Citation Nr: 1314517 Decision Date: 05/02/13 Archive Date: 05/15/13 DOCKET NO. 08-02 411 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for Addison's disease. 2. Entitlement to an initial rating higher than 10 percent for gastroesophageal reflux disease (GERD) with history of hiatal hernia. 3. Entitlement to service connection for an acquired psychiatric disorder, to include depression and anxiety. WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD L. Edwards, Associate Counsel INTRODUCTION The Veteran had active service from September 1988 to December 1999 and from March 2000 to March 2002 with additional periods of inactive and active duty for training served in the Navy Reserves. This matter comes before the Board of Veterans' Appeals (BVA or Board) from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. The Veteran requested a hearing before the Board. The requested hearing was conducted in October 2011 by the undersigned Veterans Law Judge. A transcript is associated with the claims file. In Bryant v. Shinseki, the U.S. Court of Appeals for Veterans Claims held that 38 C.F.R. § 3.103(c)(2) requires that the "hearing officer" who chairs a hearing fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki 23 Vet. App. 488 (2010). In regard to the first duty, during the hearing, the Veterans Law Judge enumerated the issues on appeal. In regard to the second duty, the duty to suggest the submission of evidence that may have been overlooked was also accomplished throughout the hearing. The Veteran was informed of the type of evidence that would be supportive of her claim. In February 2012, the Board remanded these claims for additional development. A review of the claims file shows that there has been substantial compliance with the Board's remand directives in regard to the claim for Addison's disease and GERD because the Board directed the AOJ to: (1) assist the Veteran in obtaining any additional evidence she identified, which was accomplished in February 2012, and (2) afford the Veteran VA examinations for her Addison's disease and GERD, which was accomplished in March 2012. See Stegall v. West, 11 Vet. App. 268 (1998); see also Dyment v. West, 13 Vet. App. 141 (1999) (holding that another remand is not required under Stegall where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). In November 2012, the Board referred the claim of entitlement to service connection for Addison's disease for an independent medical opinion; an opinion was received in December 2012. That development having been completed, the claims of entitlement to service connection for Addison's disease and entitlement to an increased rating for GERD are now ready for appellate review. The record suggests that the Veteran has maintained employment during the appellate period, as evidenced in the October 2011 Hearing Transcript, page 3, which would render her ineligible for consideration of a TDIU rating. See Jackson v. Shinseki, 587 F.3d 1106 (Fed. Cir. 2009) (TDIU is part of an increased rating or initial rating only when there is evidence of unemployability). The issue of entitlement to service connection for bilateral pes planus has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). See August 2010 statement. Therefore, the Board does not have jurisdiction over it, and it is REFERRED to the AOJ for appropriate action. The issue of entitlement to service connection for an acquired psychiatric disorder, to include depression and anxiety, is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's Addison's disease is not causally or etiologically due to service. 2. The Veteran's GERD with history of hiatal hernia is manifested by symptoms of persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment to health. CONCLUSIONS OF LAW 1. Service connection for Addison's disease is not established. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.309 (2012). 2. The criteria for an initial rating of 30 percent, but no higher, for GERD with history of hiatal hernia are met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.14, 4.114, Diagnostic Code 7346 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist As set forth in the Veterans Claims Assistance Act of 2000 (VCAA), the Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012). Under the VCAA, when VA receives a claim, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim; that VA will seeks to provide; and that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the regional office. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (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. The Veteran's claim for an increased initial rating arises from her disagreement with the initial evaluation following the grant of service connection. It has been held that once service connection is granted, the claim is substantiated and additional notice is not required. Any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Concerning the service connection claim, the VCAA duty to notify was satisfied by letters sent to the Veteran in April 2006 and February 2008 that fully addressed the entire notice element. The letters informed her of what evidence was required to substantiate her claims and of her and the VA's respective duties for obtaining evidence. In any event, in her statements the Veteran demonstrated her actual knowledge of the elements necessary to substantiate her claims. See Short Bear v. Nicholson, 19 Vet. App. 341, 344 (2005). The claim was subsequently adjudicated in an August 2012 supplemental statement of the case (SSOC). There is no allegation from the Veteran that she has any evidence in her possession that is needed for full and fair adjudication of these claims, and the Board finds that the notification requirements of the VCAA have been satisfied as to timing and content. To fulfill Dingess requirements, in April 2006, the regional office provided the Veteran with notice as to what type of information and evidence was needed to establish a disability rating and the possible effective date of the benefits. The regional office successfully completed the notice requirements with respect to the issues on appeal. Therefore, adequate notice was provided to the Veteran prior to the transfer and certification of his case to the Board and complied with the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b). Additionally, VA has a duty to assist the Veteran in claim development. This includes assisting in the procurement of service treatment and hospitalization records and pertinent medical records, as well as providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In this case, 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 regional office has obtained service treatment records, VA outpatient medical records, private medical records, and the Veteran has been afforded VA examinations. An independent medical opinion was obtained in December 2012. Virtual VA records have also been reviewed. Therefore, the available medical evidence and records have been obtained in order to make an adequate determination. The Veteran has not identified any additional existing evidence that has not been obtained or is necessary for a fair adjudication of the claims. The VA's duty to assist in the development of the claim is complete, and no further notice or assistance to the Veteran is required to fulfill the duty. Smith v. Gober, 14 Vet. App. 227 (2000), Dela Cruz v. Principi, 15 Vet. App. 143 (2001). II. Entitlement to Service Connection for Addison's Disease The Veteran seeks entitlement to service connection for Addison's disease. She asserts she contracted Addison's disease during service after using a steroidal cream. The Board observes that, with respect to the Veteran's Reserves service, the applicable laws and regulations permit service connection only for a disability resulting from disease or injury incurred in or aggravated coincident with active duty for training, or for disability resulting from injury during inactive duty training. See 38 U.S.C.A. § 101(22),(23),(24); 38 C.F.R. § 3.6. The Board notes that it has thoroughly reviewed the record in conjunction with this case. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). Rather, the Board's analysis below will focus specifically on what the evidence shows, or fails to show, on the claims. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant). Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage, 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). With chronic diseases shown as such in service (or within the presumptive period under § 3.307), so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however, remote, are service connected, unless clearly attributable to intercurrent causes. For a showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. When the disease entity is established, there is no requirement of evidentiary showing of continuity. If the condition noted during service (or in the presumptive period) is not shown to be chronic or where the diagnosis of chronicity may be legitimately questioned, then generally a showing of continuity of symptomatology after discharge is required to support the claim. 38 C.F.R. § 3.303(b). In Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), the Federal Circuit recently limited the applicability of the theory of continuity of symptomatology in service connection claims to those disabilities explicitly recognized as "chronic diseases" in 38 C.F.R. § 3.309(a). Because endocrinopathies are specifically listed as a chronic disease under 38 C.F.R. § 3.309(a), the theory of continuity of symptomatology is for application in the Veteran's claim of service connection for Addison's disease. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To do so, the Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Appellant. See Masors v. Derwinski, 2 Vet. App. 181 (1992). A lay witness is competent to testify as to the occurrence of an in-service injury or incident where such issue is factual in nature. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). In some cases, lay evidence will also be competent and credible on the issues of diagnosis and etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Specifically, lay evidence may be competent and sufficient to establish a diagnosis where (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d at 1377; see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009. A layperson is competent to identify a medical condition where the condition may be diagnosed by its unique and readily identifiable features. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Additionally, where symptoms are capable of lay observation, a lay witness is competent to testify to a lack of symptoms prior to service, continuity of symptoms after in-service injury or disease, and receipt of medical treatment for such symptoms. Charles v. Principi, 16 Vet. App 370, 374 (2002). When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). However, although the Veteran is competent in certain situations to provide a diagnosis of a simple condition such as a headache, varicose veins, or tinnitus, the Veteran is not competent to provide evidence as to more complex medical questions, such as the etiology of psychiatric, respiratory, or orthopedic disorders. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Service records were reviewed. The Veteran's entrance examination from February 1988 did not indicate any abnormalities other than pes planus. She had repeated treatment for dizziness, dyspepsia, and dehydration. See April 1993, May 1993, and January 1994 treatment records. In March and June 2001, she was prescribed topical steroids for an eye condition. Possible Addison's disease was first documented on July 1, 2003, when the Veteran admitted to the hospital while in the Reserves, but not serving on active duty for training. It was noted that the Veteran's low serum cortisol level was suggestive of adrenal insufficiency. After discharge from the hospital, several weeks later, on July 15, 2003, it was noted that the Veteran would have a primary endocrinology workup for possible Addison's disease. In March 2004, during a Fitness for Duty physical, the physician stated that based on her clinical presentation and pre-treatment cortisol value, the Veteran developed adrenal insufficiency during or prior to 2003. She was medically disqualified from the Reserves in September 2005. In the Veteran's VA Form 9 from January 2008 and in an additional statement submitted in October 2009, the Veteran reported her own research concerning Addison's disease. She related that she discovered Addison's disease can occur through drug induction. She indicated that a cream she was prescribed while she was on active duty, triamcinolone acetonide cream, caused adrenal gland suppression. Later, during her October 2011 Board hearing, the Veteran testified that her research showed that Addison's disease is acquired in one of three ways. She said that a person is either born with it, acquires it through tuberculosis, or a medication causes it. She stated that to the best of her knowledge, she was not born with Addison's disease and she had never tested positive for tuberculosis. She indicated that while she was on active duty, she was prescribed a steroidal cream for a three-year period, and after she discontinued use of the cream, she experienced fatigue. The Veteran was afforded a VA examination in March 2012. The Veteran reported that she was always a tired child and had to take iron pills, she was also very thin and required vitamins during her childhood. The examiner opined that the Veteran's Addison's disease was not incurred in active duty service, to include as secondary to prescription steroid cream and was not aggravated during service. The examiner stated that based on a review of medical records and the Veteran's history, the Veteran had waxing and waning signs and symptoms of primary adrenal insufficiency/Addison's disease beginning in childhood, through early adulthood and throughout her military career. The examiner stated that the fact she requires mineralcorticoid replacement makes primary adrenal insufficiency more likely. The examiner noted that the Veteran was prescribed Topicort cream for her eyes on one occasion and had one refill in 2001, but her symptoms of primary adrenal insufficiency began prior to her treatment with topical corticosteroids. The examiner explained that the Veteran's prescription of topical steroids does not appear to be a sufficient amount of medication, or a long enough exposure to lead to an Addison's crisis. In December 2012, a specialist's opinion was obtained. The examiner noted that the initial diagnosis of possible Addison's' disease was suspected based on the initial low random cortisol in July 2003. The examiner opined that since the diagnosis of Addison's disease may be suspected from the records but cannot be confirmed, the probability that Addison's disease was first manifest during the Veteran's active service or within the first year following service discharge is less than 50 percent. The examiner noted that topical steroids may on occasion suppress cortisol values, but do not cause Addison's disease. The Veteran's lay statements in support of her claim have been considered. The Board notes that the Veteran is competent to comment on any symptoms, such as pain. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). However, although laypersons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011), as to the specific issue in this case, Addison's disease falls outside the realm of common knowledge of a layperson. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). To date, there is no medical evidence demonstrating a causal relationship between the Veteran's time in service and her currently diagnosed Addison's disease. Because of the absence of a medical nexus between her current diagnosis and her time service, the Board finds that the evidence is against a grant of service connection. Importantly, the VA examiners from March 2012 and December 2012 opined that the Veteran's Addison's disease is less likely than not related to service. In summary, the weight of the evidence reflects that the Veteran was diagnosed with Addison's disease during a period of inactive duty. As such, service connection may not be granted on a presumptive basis for chronic disability. See 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Furthermore, VA examiners have opined that the Veteran's Addison's disease is less likely than not due to service. Consequently, the Board finds that the preponderance of the evidence is against entitlement to service connection for Addison's disease. As the preponderance of the evidence is against his claim, the doctrine of reasonable doubt is not for application. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Accordingly, the appeal is denied. III. Entitlement to an Initial Rating Higher than 10 Percent for Gastroesophageal Reflux Disease (GERD) with History of Hiatal Hernia The Veteran seeks an increased rating for her GERD with history of hiatal hernia. Disability ratings are based on the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations shall be applied, the higher evaluations will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The determination of whether an increased evaluation is warranted is to be based on a review of the entire evidence of record and the application of all pertinent regulations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Board notes that the appeal for higher evaluations arises from the initial rating decision that established service connection for the disabilities and assigned the initial disability evaluations. Therefore, the entire rating period is to be considered, including the possibility of staged ratings (i.e., separate ratings for separate periods of time) based on the facts found. See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The issue has been characterized accordingly. The Board has considered the entire record, including the Veteran's VA clinical records and private treatment records. These show complaints and treatment, but will not be referenced in detail. The Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000). Therefore, the Board will discuss the evidence pertinent to the rating criteria and the current disabilities. Service connection for GERD with history of hiatal hernia was established by a March 2007 rating decision, at which time a 10 percent rating was assigned, effective April 2006. The Veteran contends that her disability is more severe than what is represented by a 10 percent rating. The Veteran is currently rated as 10 percent disabled under 38 C.F.R. § 4.114, Diagnostic Code 7346. A 10 percent rating is warranted when there is a hiatal hernia with two or more of the symptoms present for the 30 percent evaluation with less severity. 38 C.F.R. § 4.114, Diagnostic Code 7346. A rating of 30 percent is warranted when there is persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. Id. A rating of 50 percent is warranted when there are symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. Id. In April 2006, the Veteran sought treatment for medically resistant GERD secondary to medium hiatus hernia. She reported symptoms of reflux, and constant epigastric and substernal non-radiating pain with occasional emesis of foodstuffs. It was also noted that she tried elevation of her bed and change in diet. Examination revealed she was tender to deep palpation in the right lower quadrant, with mild epigastric tenderness. The Veteran underwent a Nissen fundoplication procedure to improve her symptoms of GERD in May 2006. The Veteran was afforded a VA examination in March 2007. She reported significant reflux, including nocturnal reflux that wakes her at night. She underwent a Nissen fundoplication in 2006, but continued to require medication. She reported problems with food catching in the esophagus, but no regurgitation of food. There was no hematemesis or melena or nausea or vomiting. There was no indication of pyrosis, epigastric or other pain. Examination revealed the liver and spleen were not felt, and she was noted to be moderately obese. She was diagnosed with GERD, status post Nissen fundoplication. The Veteran sought treatment for abdominal pain in May 2007. It was noted that she had a history of GERD, but no melena, hematochezia or hematemesis. In January 2009, the Veteran sought treatment at a VA outpatient center for sore throat due to acid reflux. It was noted that her symptoms had improved since the May 2006 Nissen fundoplication. It was also noted that she underwent an upper esophagogastroduodenoscopy (EGD) in June 2007 with dyspepsia and abdomen pain, with no established diagnosis. The Veteran was described to have a history of epigastric pain and nausea but no vomiting, and these symptoms were noted to have resolved since the Nissan procedure. The Veteran reported that since the year 2000, she has been experiencing abdominal bloating and pain. She was diagnosed with GERD, which was noted to be controlled on medication, and epigastric abdominal pain. VA outpatient records indicate the Veteran was seen in June 2010 for complaints of abdominal pain with eating. She indicated she could only eat little bits at a time and had lost 23 pounds since February, which was not intentional. She was diagnosed with gastrointestinal upset and intermittent diarrhea, which the physician noted might be secondary to severe GERD and/or irritable bowel syndrome. The Veteran was afforded a VA examination in March 2012. The Veteran reported that after her Nissen fundoplication in 2006, she was asymptomatic until 2010, and now experiences recurrent belching, scratchy throat, and coughing when lying down. It was noted that she takes continuous medication for her GERD and that she experiences persistently recurrent epigastric distress, dysphagia, pyrosis, reflux, regurgitation, sleep disturbances caused by reflux, and recurrent nausea. It was noted that the Veteran's GERD affected her ability to work in that when she talks, she coughs recurrently and has to clear her throat. The Board finds the Veteran is entitled to a rating of 30 percent. As stated previously, a rating of 30 percent is warranted when there is persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. Id. In April 2006, the Veteran indicated that she experienced substernal pain. VA examinations have indicated the Veteran suffers from persistently recurrent epigastric distress, dysphagia, pyrosis, reflux, and regurgitation. Additionally, the Veteran indicated an unintentional weight loss of more than 20 pounds since February 2010, due to the inability to eat. The Board notes that the Veteran is competent to give evidence about what she experiences; for example, he is competent to discuss current pain and other experienced symptoms. See Layno v. Brown, 6 Vet. App. 465 (1994). Furthermore, the Board finds the Veteran's statements to be credible. See Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). The Veteran is not entitled to a rating higher than 30 percent, however, as the evidence of records does not demonstrate that she has material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. In fact, on multiple occasions it has been noted that the Veteran has not suffered from anemia, vomiting, hematemesis, or melena. See VA examinations from March 2007 and March 2012. The Board has also considered whether any alternate Diagnostic Codes allow for a higher evaluation. However, the Board finds that the most appropriate rating criteria is Diagnostic Code 7346, as the Veteran's symptoms more closely approximate that rating criteria. Extraschedular Consideration The VA Schedule of Disability Ratings will apply unless there are exceptional or unusual factors that would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the service-connected GERD with history of hiatal hernia is inadequate. A comparison of the level of severity and symptomatology of the Veteran's disability with the established criteria found in the rating schedule for GERD shows that the rating criteria reasonably describes the Veteran's disability level and symptomatology. The Board further observes that, even if the available schedular evaluation for the disability is inadequate (which it manifestly is not), the Veteran does not exhibit other related factors such as those provided by the regulation as "governing norms." The record does not show that the Veteran has required frequent hospitalizations for her GERD. Additionally, although the Veteran has indicated her GERD affects her throat and ability to talk, there is not shown to be evidence of marked interference with employment due to the disability. Moreover, there is no evidence in the medical records of an exceptional or unusual clinical picture. In short, there is nothing in the record to indicate that this service-connected disability on appeal causes impairment with employment over and above that which is contemplated in the assigned schedular rating of 30 percent. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). The Board therefore has determined that referral of this case for extraschedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. ORDER Service connection for Addison's disease is denied. Entitlement to an initial rating of 30 percent, but no higher, for GERD with history of hiatal hernia, is granted, subject to statutory and regulatory provisions governing the payment of monetary benefits. REMAND The Veteran seeks entitlement to service connection for an acquired psychiatric disorder, to include depression and anxiety. She asserts she began experiencing anxiety attacks and depression during service. See October 2011 BVA Hearing Transcript, page 11. Medical evidence indicates the Veteran was admitted to Bremerton Naval Hospital in October 2000 and diagnosed with major depressive disorder. She currently has a diagnosis of depressive disorder, not otherwise specified. See February 2009 VA examination. To date, no medical opinion has been obtained regarding the nature and etiology of her current psychiatric disorder. A remand is necessary to obtain a medical opinion. Additionally, during the October 2011 BVA Hearing, the Veteran indicated she received psychiatric treatment at Maria Parham Hospital in 2005. These records should be obtained and associated with the claims file. Accordingly, the case is REMANDED for the following actions: 1. Obtain and associate with the claims file all medical records from Maria Parham Hospital, particularly those from 2005. All attempts to secure this evidence must be documented in the claims file. If the records are not obtainable, the AMC must notify the Veteran and (a) identify the specific records the AMC is unable to obtain; (b) briefly explain the efforts that the AMC made to obtain those records; and (c) describe any further action to be taken by the AMC with respect to the claim. The Veteran must then be given an opportunity to respond. 2. After any additional records have been received, obtain an addendum opinion to the February 2009 VA examination. If deemed necessary, afford the Veteran a VA psychiatric examination. The examiner should review the claims file and the examination report should note that the claims file was reviewed, including service treatment and personnel records. For each psychiatric disorder noted in the claims file (anxiety disorder, depression), the examiner should specifically offer an opinion as to whether it is more likely than not (i.e., probability greater than 50 percent), at least as likely as not (i.e., probability of 50 percent), or less likely than not (i.e., probability less than 50 percent), that: a) the current psychiatric disorder is causally or etiologically related to service; and b) the current psychiatric disorder is proximately due to or aggravated by her service-connected disabilities (patellofemoral syndrome of the bilateral knees and GERD). In doing so, the examiner must acknowledge symptoms experienced during and after discharge from service, and discuss lay and medical evidence of a continuity of symptomatology. In particular, review the lay statements as they relate to the development of her psychiatric disorder and provide information as to how the statements comport with generally accepted medical norms. If it is not possible to provide the requested opinion without resort to speculation, the examiner should state why speculation would be required in this case (e.g., if the requested determination is beyond the scope of current medical knowledge, actual causation cannot be selected from multiple potential causes, etc.). If there are insufficient facts or data within the claims file, the examiner should identify the relevant testing, specialist's opinion, or other information needed to provide the requested opinion. All opinions should be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. The claims folder must be provided to the examiner for review. The examiner must state in the examination report that the claims folder has been reviewed. 3. The Veteran is hereby notified that it is her responsibility to report for the examinations scheduled in connection with this REMAND and to cooperate in the development of her case. 4. After all of the above actions have been completed, readjudicate the claims. If the claims remain denied, issue to the Veteran a supplemental statement of the case, and afford the appropriate period of time within which to respond thereto. Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ WAYNE M. BRAEUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs