Citation Nr: 1211866 Decision Date: 04/02/12 Archive Date: 04/11/12 DOCKET NO. 09-46 536 ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUE Entitlement to a rating in excess of 20 percent for duodenal ulcer with gastroesophageal reflux disease (GERD). REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD David A. Brenningmeyer, Counsel INTRODUCTION The Veteran served on active duty from March 1981 to March 1988. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a May 2009 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) that, in pertinent part, denied a rating in excess of 20 percent for duodenal ulcer. In December 2011, while the appeal to the Board was pending, the RO granted service connection for GERD, effective from March 1, 2011. In a December 2011 supplemental statement of the case, the RO recharacterized the issue on appeal as entitlement to an evaluation in excess of 20 percent for duodenal ulcer with GERD. The RO determined that a higher rating was not warranted, to include under the provisions of 38 C.F.R. § 4.114, Diagnostic Code 7346. In December 2011, the Veteran and his representative were notified of the date and time of a Board hearing the Veteran had requested in connection with his appeal. In January 2012, the Veteran asked that the hearing be rescheduled. In March 2012, his representative indicated that a Board hearing was no longer desired. The Board was asked to make a decision based on the evidence of record. In a written submissions dated in February 2009 and September 2009, the Veteran appears to assert that a bowel disorder should be service connected. Inasmuch as service connection for a bowel disorder has not been adjudicated by the Agency of Original Jurisdiction (AOJ), the Board does not have jurisdiction to consider that matter. It is referred to the AOJ for appropriate action. FINDING OF FACT The Veteran's duodenal ulcer with GERD is manifested by more or less continuous moderate manifestations that include epigastric pain and gastroesophageal reflux; the greater weight of the competent, credible, and probative evidence establishes that his disability is not manifested by recurrent hematemesis, melena, anemia, significant weight loss, recurrent incapacitating episodes of symptoms averaging 10 days or more at least four times per year, symptom combinations productive of severe impairment of health, or dysphagia or stricture of the esophagus. CONCLUSION OF LAW The criteria for a disability rating in excess of 20 percent for duodenal ulcer with GERD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.113, 4.114, Diagnostic Codes 7305, 7346 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran seeks to establish a rating in excess of 20 percent for his service-connected duodenal ulcer and GERD. In February 2009, he asserted that he had persistent incapacitating episodes of symptoms; that his reflux flared up "constantly," with little to no relief, despite taking Zantac; that he was often unable to function normally; that he had taken off work several days due to the severity of his condition; that it was difficult to go to work some days; that he was on "constant" medication because he often got "infections"; and that he had vomited so many times he lost over five pounds in a week. He said that it was difficult to move his bowels at times, and that he also had diarrhea with urgency 4 to 5 times per week or more, which caused fatigue. He complained that fast foods irritated his stomach, causing him pain and vomiting, and that he got dizzy and even confused. He argued that the condition had impaired his health, that he could no longer have an exciting personal life with his wife because of pain and flare-ups, and that it was stressful. In June 2009, the Veteran asserted that he got "sick" nearly every day, feeling awful all but about one of out every seven days, and that his condition had caused him to lose weight. He said that he had to be careful about what he ate, due to nausea and discomfort associated with reflux; that he had sour breath; that over-the-counter and prescription medications offered little relief; and that his condition could be embarrassing. His wife asserted that he threw up two to three times per day, with some days being better than others; that his breath smelled horrible; that he had loose bowels; and that he had had to take off several days from work due to his symptoms. She stated, "He lost so much weight." In September 2009, the Veteran indicated that he was on several medications for his stomach, but that they afforded little help. He said that he still experienced a burning sensation, vomiting, diarrhea, and chest, throat, and stomach pain. I. The Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002)) redefined VA's duty to assist a claimant in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2011). The notice requirements of the VCAA require VA to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2011). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the AOJ. Id; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, insufficiency in the timing or content of VCAA notice is harmless if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). In this case, the Veteran was provided VCAA notice letters in March 2009 and March 2011. The March 2009 letter advised the Veteran of what information and evidence is needed to substantiate a claim for an increased rating, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. Both letters provided examples of pertinent medical and lay evidence that the Veteran could submit (or ask the Secretary to obtain) relevant to establishing entitlement to a disability evaluation. See Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (VCAA notice in a claim for increased rating need not be "veteran specific"). The letters further advised the Veteran of how effective dates are assigned, and the type of evidence which impacts those determinations. The claim was last readjudicated in December 2011. The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran. Specifically, the information and evidence that have been associated with the claims file include the Veteran's service treatment records, as well as VA and private treatment records and examination reports, and a statement from the Veteran's spouse. The Veteran has not identified and/or provided release(s) for any additional evidence that needs to be procured. As discussed above, the VCAA provisions have been considered and complied with. The Veteran was notified and aware of the evidence needed to substantiate his claim, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. The Veteran was an active participant in the claims process by submitting evidence and argument. Thus, he was provided with a meaningful opportunity to participate in the claims process and did so. Any error in the sequence of events or content of the notices is not shown to have affected the essential fairness of the adjudication or to cause injury to the Veteran. Therefore, any such error is harmless and does not prohibit consideration of this matter on the merits. See Conway, 353 F.3d at 1374, Dingess, 19 Vet. App. 473; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history; reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Gastric and duodenal ulcers are evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.114, Diagnostic Code 7305 (2011). A mild gastric or duodenal ulcer, manifested by recurring symptoms once or twice yearly, warrants a 10 percent evaluation. A moderate gastric or duodenal ulcer, manifested by recurring episodes of severe symptoms two or three times per year averaging 10 days in duration, or with continuous moderate manifestations, warrants a 20 percent rating. A 40 percent rating is warranted where the gastric or duodenal ulcer is moderately severe and characterized by recurrent incapacitating episodes four or more times per year averaging 10 days or more in duration, or with impairment of health manifested by anemia and weight loss. The highest available schedular evaluation, 60 percent, is warranted where the gastric or duodenal ulcer is severe, with pain only partially relieved by standard therapy, and characterized by periodic vomiting, and recurrent hematemesis or melena, with manifestations of anemia and weight loss productive of definite impairment of health. Id. GERD is evaluated as analogous to hiatal hernia, in accordance with the criteria set forth in 38 C.F.R. § 4.114, Diagnostic Code 7346 (2011). 38 C.F.R. § 4.20 (2011). If the condition is manifested by symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia, or by other symptom combinations productive of severe impairment of health, a 60 percent rating is warranted. If the condition is manifested by persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, and is productive of considerable impairment of health, a 30 percent rating is warranted. A 10 percent rating is warranted where two or more of the symptoms for a 30 percent rating are present and of less severity. Id. 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. 38 C.F.R. § 4.112 (2011). 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. Id. Under governing law, ratings under Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive, are not be combined with one another. 38 C.F.R. §§ 4.14, 4.113, 4.114 (2011). Rather, a single evaluation is to 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 evaluation. 38 C.F.R. § 4.114 (2011). In the present case, the record shows that service connection for duodenal ulcer was established in March 2007, effective from June 2006. The disability was evaluated as 20 percent disabling under Diagnostic Code 7305. The Veteran filed the current claim for increase in February 2009. The evidence obtained in connection with the Veteran's claim for increase includes a May 2007 VA clinical record showing that he weighed 179.3 lbs. at that time, with a BMI (body mass index) of 28. A June 2007 VA treatment record shows that the Veteran reported a history of duodenal ulcer dating back to the 1980s, with past episodes of melena. He indicated that he had taken Zantac since, and that he had issues with nausea, vomiting, epigastric burning, and abdominal pain if he did not use Zantac. He complained of severe episodes 4 to 5 times per week, and said that greasy foods, fatty foods, alcohol, and tobacco made it worse. He indicated that he limited fat and salt in his diet, and that he did not currently use alcohol or tobacco. He denied current diarrhea, hematemesis, melena, BRBPR (bright red blood per rectum), history of hepatitis jaundice or liver disease, loss of appetite, unintentional weight loss, fatigue, dysphagia, odynophagia, and anemia. It was noted that hemoccults (fecal blood tests) were negative. On examination, he was noted to be well nourished and developed and to appear his stated age. His abdomen was mildly tender in the mid-abdomen to epigastrium, but otherwise soft, with bowel sounds present, and no bruits, hepatosplenomegaly, or ascites. He weighed 179 lbs., with a BMI of 28.1. His RBC (red blood cell count) was found to be within normal limits, as was his HCT (hematocrit). The clinical impression was that he had a duodenal ulcer with GERD that was poorly controlled on Zantac. He was started on omeprazole (Prilosec). Later in June 2007, the Veteran was treated with clarithromycin and amoxicillin as a result of a positive test for Helicobacter Pylori. He reported that his stomach was less sore. In August 2007, the Veteran complained that he had been having 7/10 stomach pain for the last two days. He indicated that the pain was just below the umbilicus, in the center of the lower abdomen. He reported that he had been placed on omeprazole and antibiotics last month, and expressed his belief that his discomfort was coming from a new blood pressure medication he had been given by a private provider. In July 2008, the Veteran reported that his GERD and abdominal discomfort had improved without symptoms on omeprazole, but that he had discontinued it after the first round, thinking it a limited drug, and his symptoms then returned. On examination, he was noted to be well nourished and developed and to appear his stated age. His abdomen was mildly tender in the mid-abdomen to epigastrium, but otherwise soft, with bowel sounds present, and no bruits, hepatosplenomegaly, or ascites. He weighed 183.7 lbs., with a body mass index (BMI) of 28.8, and his RBC and HCT were found to be within normal limits. The clinical impression was that he had a duodenal ulcer with GERD, and that he had done well on omeprazole, but had stopped taking it. In August 2008, it was noted that the Veteran, who had a history of recurrent dyspepsia and GERD, had been treated for H. Pylori, but that his symptoms had returned. An esophagogastroduodenoscopy (EGD) was performed, which revealed the presence of short-segment Barrett's esophagus, esophagitis, gastritis, and edema, deformity, and diverticulum in the duodenal bulb. Testing was also positive for H. Pylori. It was noted that the Veteran would be treated for H. Pylori, that his Prilosec would be increased, and that another EGD was recommended in two months to document recovery of H. Pylori and to biopsy Barrett's, if still present after treatment. The Veteran underwent another EGD in October 2008. It revealed an irregular "Z line" in the esophagus; localized esophagitis in the lower third of the esophagus, without bleeding; a normal stomach; and a normal duodenal bulb and normal second portion of the duodenum. A biopsy taken at the EG (esphagogastric) junction was interpreted to reveal chronic active gastritis. Even though pathology did not show any evidence of H. Pylori, a more sensitive CLO (Campylobacter-like organism) test was positive for H. Pylori. As a result, it was noted that he needed to be treated with another course of anti-H. Pylori therapy with a different regimen, including amoxicillin, calrithromycin, and omeprazole. In December 2008, the Veteran reported that he was feeling better since being twice treated for H. Pylori. He indicated that he was still having GERD symptoms on a nightly basis, with bloating, and that he was still taking omeprazole. On nutrition screening, it was noted that he had no chewing or swallowing difficulties, no unplanned weight loss or gain greater than 10 lbs. in the past three months, and no weight loss greater than 10 lbs. in the past three months associated with poor appetite. On examination, he was noted to be well nourished and developed and to appear his stated age. His abdomen was soft and non-tender with bowel sounds present, and there were no bruits, hepatosplenomegaly, or ascites. A diastasis recti was noted. He weighed 190 lbs., with a BMI of 29.8. The clinical impression was that the Veteran had a duodenal ulcer with GERD, status post EGD with a positive CLO test, treated a total of three times with triple therapy. The examiner noted that symptoms were better, but the Veteran still had GERD symptoms nightly. As a result, a decision was made to change his ppi (proton pump inhibitor) from omeprazole to pantoprazole (Protonix). A January 2009 VA treatment record shows that the Veteran complained of frequent formed stools (6 to 7 per day) after pantoprazole was prescribed. He denied chest pain, nausea/vomiting, diarrhea, dizziness, and shortness of breath. An appointment was scheduled for February 2009. The report of the Veteran's February 2009 VA appointment shows that he presented for treatment with complaints of frequent stools and rectal urgency with formed stool for the past month. He reported having six formed stools daily, and said that it woke him up in the middle of the night. He said that the problem started after going off the antibiotics for H. Pylori and being started on Protonix. He indicated that the Protonix controlled the acid better. He denied any hematochezia, melena, mucous in the stool, diarrhea, nausea, vomiting, fevers, chills, and change in his chronic abdominal pain. On examination, he was noted to be well nourished and developed and to appear his stated age. His abdomen was mildly tender to palpation in the epigastric area, but otherwise soft, with bowel sounds present, and no bruits, hepatosplenomegaly, or ascites. He weighed 192 lbs., with a BMI of 30.1. The clinical impression was that he had frequent stooling of questionable etiology. The examiner indicated that he would like to rule out C. Diff. (Clostridium difficile) versus other infection process, and that Protonix could also be the culprit. The treatment plan was to get stool studies and start the Veteran on probiotics and Loperamide. Subsequent treatment records show that stool studies were negative for salmonella and shigella. The Veteran was examined for VA compensation purposes in March 2009. He complained of constant abdominal pain, precipitated by stress and food and alleviated by time and rest. He also complained of fatigue and frequent stool urgency, with symptoms of both diarrhea and constipation. He reported having passed black tarry stools a total of 10 times, the last time in March 2009. He reported that he treated the condition with Zantac and Mylanta, and that indicated that it was an occupational hindrance for him in that he had to make excessive use of sick leave as a result of stomach pain and bowel movements. He denied nausea, vomiting (including vomiting blood), anemia, and abdominal distention. He also denied that his condition affected his body weight and stated that it did not cause incapacitation. On examination, it was noted that the Veteran's nutritional status was good. He was well developed and well nourished, weighing in at 189.6 lbs. He had mild epigastric tenderness with no rebound or guarding, and there was no evidence of liver enlargement, distention of superficial veins, striae on the abdominal wall, splenomegaly, or ascites. An upper GI (gastrointestinal) series showed significant intermittent gastroesophageal reflux without reflux esophagitis or other complications related to chronic reflux disease. There was a thickening of the rugal folds that could be associated with gastritis; a deformity of the duodenal bulb and pyloric region secondary to previous peptic ulcer disease; and two focal collections of barium near the duodenal bulb that had a morphology suggestive of ulcer niches. The CBC (complete blood count, including RBC and HCT) was within normal limits. The diagnostic assessment was that the Veteran's diagnosis of duodenal ulcer should be changed to peptic ulcer disease with GERD. The examiner noted that the Veteran's condition did not cause significant anemia, that there were no findings of malnutrition, and that the condition did not result in any limitations associated with the Veteran's daily activity or occupation. An October 2009 report from the Sleep Disorders Center of Virginia contains a notation that the Veteran's history included gastroesophageal reflux, and that his weight was stable. On examination, he weighed 174.8 lbs. He was found to suffer from obstructive sleep apnea. A February 2010 VA treatment record reflects that the Veteran reported that he was doing okay in general. He indicated that he had less bloating, and that his GERD was very well controlled on Protonix. He reported that he continued to have rectal urgency, but that he had no diarrhea or loose stools and no hematochezia or melena. He also reported that he has recently been diagnosed with sleep apnea, and that he was borderline for diabetes, and that he had made some major changes in terms of diet and exercise. On examination, he was noted to be well nourished and developed and to appear his stated age. His abdomen was mildly tender to palpation in the epigastric area, but otherwise soft, with bowel sounds present, and no bruits, hepatosplenomegaly, or ascites. He weighed 184 lbs., with a BMI of 28.9. The examiner noted that the Veteran's duodenal ulcer with GERD was doing well on pantoprazole. The examiner also noted the Veteran had chronic rectal urgency, likely irritable bowel syndrome (IBS) type symptoms. The examiner recommended the Veteran increase his fiber intake, and monitor the response, and also asked GI to see if there was any intracolonic pathology. The Veteran was again examined for VA compensation purposes in July 2011. He complained of duodenal ulcer and GERD manifested by dysphagia, heartburn, epigastric pain, scapular pain, arm pain, reflux and regurgitation of stomach contents, nausea and vomiting, diarrhea, chronic cough, loss of breath, and inability to sleep. He indicated that his symptoms generally occurred intermittently, as often as two times per month (24 per year), with each occurrence lasting 10 to 15 minutes, and that he had nausea and vomiting as often as three times per week. He reported that his epigastric pain was constant, that it was precipitated by stress, and that it was alleviated by rest. He also reported that he had lost 20 lbs. over the past two months. He indicated that he was treated with Zantac, Mylanta, and Nexium, and that he did not experience any overall functional impairment from his condition, but complained that his condition affected his ability to perform daily functions during flare-ups in terms of uncontrolled bowel movement and excess use of sick leave. He denied hematemesis, constipation, and abdominal distention; denied that his duodenal ulcer caused incapacitation; and denied his GERD affected his body weight or that duodenal ulcer affected general body health. Contradictory information was provided as to whether or not he had passed black tarry stools. On examination, it was noted that the Veteran's nutritional status was good. He was well developed and well nourished, weighing in at 181 lbs. There were no signs of malaise. He had mild epigastric tenderness with no rebound or guarding, and there were no findings of hepatomegaly, distention of superficial veins, striae on the abdominal wall, flank tenderness to palpation, splenomegaly, or ascites. An upper GI series was abnormal, with findings of disordered esophageal motility with esophageal reflux; gastroesophageal reflux; thickened rugal folds in the stomach consistent with gastritis; and scarring and deformity of the duodenal bulbs and postbulbar segment of the duodenum. The CBC was abnormal in that there were insignificant deviations from normal for MCHC (mean corpuscular hemoglobin concentration), RDW (red cell distribution width), and absolute monocytes; otherwise, CBC was normal (including for RBC and HCT). The final diagnostic assessment was that the Veteran had GERD with peptic ulcer disease, gastritis and healed (quiescent) duodenal ulcer. The examiner opined that the GERD and gastritis did not cause anemia, that there were no findings of malnutrition, that the Veteran's conditions did not affect his usual occupation or daily activities. Following a review of the record in this case, and the applicable laws and regulations, the Board finds that the preponderance of the evidence is against the assignment of a rating in excess of 20 percent for the Veteran's service-connected duodenal ulcer with GERD. It appears clear from the results of multiple upper GI studies that the Veteran has medically significant pathology. However, none of the objective evidence shows that his condition is presently manifested by recurrent hematemesis or anemia. Neither does the evidence reflect that he has suffered any significant weight loss as a result of his condition. Indeed, the evidence dated between 2007 and 2011 appears to reflect a fairly stable pattern of recorded weights, ranging from a low of 174.8 to a high of 192 lbs., with a weight of 181 lbs. reported on the most recent VA examination in July 2011, and no suggestion of malnutrition. On the most recent VA examination, the Veteran reported a litany of symptoms, including dysphagia (difficulty swallowing) and possible melena. However, there is no current objective evidence of dysphagia or melena in the record on appeal. To the contrary, a June 2007 VA treatment record indicates that hemoccults were negative. In addition, the Veteran specifically denied current dysphagia and/or melena during treatment on multiple occasions, to include in June 2007, December 2008, February 2009, and February 2010. In this regard, the Board gives greater weight to the statements the Veteran made during clinical visits, when he was seeking treatment, than to statements made during examinations conducted for purposes of procuring greater compensation. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed.Cir.2006) (Board can consider bias in lay evidence and conflicting statements of the veteran in weighing credibility). As for the Veteran's claim that he suffers "incapacitating" episodes, the totality of the evidence reflects only that he has had to take several days off work over time, but has otherwise been able to work. There is no indication in the record that his condition renders him bedridden, or otherwise incapacitated, for 10 days or more at a time, four or more times a year. Indeed, the Veteran specifically denied incapacitation on VA examination in March 2009 and July 2011, and the reports of his March 2009 and July 2011 VA examinations contain medical conclusions to the effect that the Veteran's condition does not result in any significant limitations associated with his daily activities or occupation. The Veteran has repeatedly been described as well nourished and developed, to include on evaluations in June 2007, July 2008, December 2008, February 2009, March 2009, February 2010, and July 2011. In February 2010, it was noted that his GERD was very well controlled on medication. Under the circumstances, and considering the evidence in its totality, the Board finds that the greater weight of the evidence is against a finding that the Veteran's duodenal ulcer can properly be described as "moderately severe" or "severe," or that his duodenal ulcer and/or GERD is/are productive of considerable, severe, or definite impairment of health, as those terms are used in Diagnostic Codes 7305 and 7346. The Board concludes that the medical findings are of greater probative value than the Veteran's allegations regarding the severity of his condition, and that the severity of his overall disability does not warrant elevation to a higher evaluation pursuant to 38 C.F.R. § 4.114. In arriving at this conclusion, the Board has considered whether the Veteran might be entitled to a higher evaluation under alternative or additional diagnostic codes, such as those pertaining to the esophagus (Diagnostic Codes 7203 to 7205) or gastritis (Diagnostic Code 7307). However, none of the evidence suggests that the Veteran's condition results in any obstruction or stricture of the esophagus, so as to warrant an evaluation under Diagnostic Codes 7203 to 7205. Additionally, objective evidence of multiple small eroded or ulcerated areas of the stomach have not been shown to warrant a higher rating based on gastritis under Diagnostic Code 7307. Moreover, while he has reported experiencing bowel difficulties, service connection has not been established for such, and a claim for service connection for that disorder has been referred to the AOJ in the Introduction. See 38 C.F.R. § 4.14 (the use of manifestations not resulting from service-connected disability to determine an evaluation for a service-connected disability is to be avoided). For the reasons set forth above, the Board finds that the preponderance of the probative evidence is against an evaluation in excess of 20 percent. The Board has also considered whether the Veteran's disability presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards, such that referral to the appropriate officials for consideration of an extra-schedular rating is warranted. See 38 C.F.R. § 3.321(b)(1) (2011); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology for the claimed condition and provide for additional or more severe symptoms than currently shown by the evidence; thus, his disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extraschedular consideration is not warranted. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b) (West 2002); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). ORDER A rating in excess of 20 percent for duodenal ulcer with GERD is denied. ____________________________________________ K. A. BANFIELD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs