Citation Nr: 1318309 Decision Date: 06/05/13 Archive Date: 06/11/13 DOCKET NO. 05-38 078 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York THE ISSUE Entitlement to an initial rating in excess of 30 percent for the service-connected gastroesophageal reflux disease (GERD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. Postek, Associate Counsel INTRODUCTION The Veteran served on active duty from March to July 1983 and June 2002 to July 2004. This case initially came before the Board of Veterans' Appeals (Board) on appeal from a July 2004 rating decision by the RO. In an August 2012 decision, the Board granted a 30 percent rating for the service-connected GERD for the period prior to November 23, 2011, and the case was remanded for further development on the remaining issue of an initial rating in excess of 30 percent for the entire period of the appeal. That development was completed, and the case has since been returned to the Board for appellate review. During the pendency of the appeal, the evaluation for the service-connected GERD has been increased on multiple occasions, such that the rating for the entire appeal period is currently 30 percent, effective on July 6, 2004. While the Veteran has been granted rating increases during the pendency of his appeal, this rating does not represent the highest possible benefit, and therefore, this issue remains in appellate status. See AB v. Brown, 6 Vet. App. 35, 38 (1993). In addition to the paper claims file, there is a Virtual VA electronic claims file associated with the claim. A review of the documents in the electronic file reveals that some are non-duplicative of those in the paper claims file, to include evidence of the Veteran's ongoing VA treatment. However, those outstanding records were obtained and considered by the RO prior to the issuance of the most recent Supplemental Statement of the Case in February 2013. Therefore, the Board finds that there is no prejudice in proceeding with consideration of the evidence in the Virtual VA file. FINDING OF FACT For the period of the appeal, the service-connected GERD is shown to have been manifested by persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health; neither pain, vomiting, material weight loss nor hematemesis or melena with moderate anemia is demonstrated; nor is the symptom combination productive of severe impairment of health. CONCLUSION OF LAW The criteria for the assignment of an initial rating in excess of 30 percent for the service-connected GERD have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.7, 4.21, 4.114 including Diagnostic Code 7346 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's 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. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Under VCAA, VA must inform the claimant of any information and medical or lay evidence not of record: (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004); Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002); 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In addition, the notice requirements of VCAA apply to all elements of a service-connection claim. 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. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). The claim on appeal arises from the Veteran's disagreement with the rating assigned in connection with the grant of service connection for this disability. The courts have held, and VA's General Counsel has agreed, that where an underlying claim for service connection has been granted and there is disagreement as to "downstream" questions, the claim has been substantiated and there is no need to provide additional VCAA notice or prejudice from absent VCAA notice. Hartman v. Nicholson, 483 F.3d 1311, 1314-15 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112, 116-17 (2007); VAOPGCPREC 8-2003 (2003). The Court has elaborated that filing a notice of disagreement begins the appellate process, and any remaining concerns regarding evidence necessary to establish a more favorable decision with respect to downstream elements (such as a disability rating) are appropriately addressed under the notice provisions of 38 U.S.C.A. §§ 5104 and 7105. Goodwin v. Peake, 22 Vet. App. 128, 137 (2008). Consequently, further discussion of VCAA's notification requirements with regard to this claim is unnecessary. VCAA also requires VA to make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The record reflects that all pertinent available service treatment records and all available post-service medical evidence identified by the Veteran have been obtained. The Board notes that the Veteran reported that he received care from a non-VA facility (Albany Medical Center) from 2008 to 2011. In a January 2012 response to the RO's request for these treatment records, the facility indicated that there was no record of treatment for the Veteran; the physician should be contacted directly for results of private outpatient testing or treatment. In accordance with the Board's remand instructions, the RO sent the Veteran a letter in November 2012 explaining the need for the name of the treating physician at Albany Medical Center to obtain the records, along with a blank authorization form. The Veteran did not respond to this letter. As such, the Board finds that the RO substantially complied with the remand directive, and additional development is not necessary in this regard. The Veteran's written statements are also of record. Neither the Veteran nor his representative has identified any outstanding evidence that could be obtained to substantiate the claim; the Board is also unaware of any such evidence. In addition, the Veteran was afforded appropriate VA examinations in connection with his claim. The Board finds that the examinations were adequate, in that the exams were conducted by medical professionals who reviewed the claims files, solicited history from the Veteran, and performed thorough examinations. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (noting that even if not statutorily obligated to do so, if VA provides the veteran with an examination in a service connection claim, the examination must be adequate); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Moreover, the Board has reviewed the report of the most recent November 2011 examination and finds that this opinion provides adequate medical evidence to decide the claim and substantially complies with the requirements articulated in the remand request. See D'Aries v. Peake, 22 Vet. App. 97 (2008); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Based on the foregoing, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. Bernard v. Brown, 4 Vet. App. 384 (1993). Legal Principles and Analysis Disability ratings are determined by application of the criteria in the VA Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R., Part 4 (2012). Each disability must be viewed in relation to its history, and there must be emphasis upon the limitation of activity imposed by the disabling condition. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Separate evaluations may be assigned for separate periods of time based on the facts found. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. It is not expected that all cases will show all the findings specified by the Rating Schedule, but findings sufficiently characteristic to identify the disease and disability therefrom, and above all, coordination of rating with impairment of function, will be expected in all cases. 38 C.F.R. § 4.21. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the weight of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The Veteran contends that he is entitled to a higher rating for his service-connected GERD, which is currently assigned a 30 percent disability rating from July 6, 2004 pursuant to 38 C.F.R. § 4.114, Diagnostic Code 7346 (hiatal hernia). Historically, as noted, the Veteran has been granted a series of rating increases for this disability throughout the pendency of his appeal. A September 2005 Decision Review Officer decision increased the initial noncompensable rating to 10 percent effective on July 6, 2004. An April 2012 rating decision increased the initial rating to 30 percent effective on November 23, 2011. Thereafter, an August 2012 Board decision (implemented in an October 2012 rating decision) increased the initial rating prior to November 23, 2011 to 30 percent. As such, the remaining question before the Board is whether the Veteran is entitled to a disability rating in excess of 30 percent for the service-connected GERD at any time during the appeal period. Under this criteria, a 30 percent rating is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 60 percent 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. The service treatment records showed that the Veteran complained of burning and pressure after eating. A November 2003 service treatment record showed an assessment of GERD, for which he was prescribed Aciphex. In a report of medical history that same day, the Veteran denied a history of recent unexplained weight loss, as well as stomach, liver, intestinal trouble, or ulcer problems, but noted frequent indigestion or heartburn. The Veteran established care with the VA Medical Center (VAMC) in July 2004 for ongoing treatment of several medical conditions, to include GERD. At that time, he reported that he was treated with medication for his GERD during service and denied nausea, vomiting, diarrhea, loss of weight, and chest pain. An October 2004 VA treatment record showed that the Veteran denied having abdominal symptoms, to include pain, nausea, vomiting, diarrhea, constipation, melena or hematochezia; he also denied having any black, tarry stools. A November 2004 VA treatment record showed that the Veteran denied any weight loss or bowel habit changes, but reported occasional bouts of chest pain. A January 2005 VA treatment record showed that the Veteran reported having difficulty swallowing and esophageal discomfort. He denied any chest pain since the first episode about 1.5 months earlier. The Veteran was afforded a VA examination in August 2005 and reported having symptoms of occasional dysphagia to solids and liquids in the epigastrium and infrequent water brash. He denied hematemesis. He maintained his weight and was in general good health, with no signs or symptoms of anemia. It was noted that his esophagus and hiatal hernia problems started after use of nonsteroidals to control pain from an injury to the back and knee during service. He took Omeprazole, but did not use it use when asymptomatic. Following examination, the diagnosis was that of GERD. An October 2005 VA treatment record showed that the Veteran was receiving ongoing treatment and medication for reflux esophagitis. A notation was made as to his previous cardiac evaluation for chest pain, which was negative; the pain was described as "atypical" and might have been symptomatic of GERD. Aside from his orthopedic conditions, he was feeling well. The diagnosis continued as GERD, controlled on medication. In the Veteran's November 2005 Substantive Appeal (VA Form 9), he listed ongoing GERD symptoms, to include regurgitation, persistent epigastric distress, water brash, and related arm and shoulder pain. A January 2006 VA treatment record showed that the Veteran complained of some intermittent swallowing difficulty and choking spells, relieved by standing and walking a few steps, as well as some heartburn. He denied nausea and vomiting. An esophagram performed later that month showed evidence of a small nonpersistent diaphragmatic hernia, associated with esophageal reflux. A February 2006 VA treatment record showed that the Veteran reported having intermittent dysphagia which began after he returned from Bosnia a few years earlier, and lately occurred with slightly more frequency (once every two weeks or so). He stated that it did not matter what he was eating, it felt like his throat was tightening up and he would not be able to pass solids or liquids. He would sometimes regurgitate his food. He reported that he took reflux medication in the past, but not lately. The physician recommended that he stay on antireflux medication in addition to making some lifestyle changes (lifestyle conducive to reflux), such as a reduction in caffeine consumption. A March 2006 VA treatment record for an initial gastroenterology consult (GI clinic) showed that the Veteran reported having intermittent symptoms, including a progressively worsening dysphagia to solid foods and occasional epigastric burning; he denied dysphagia to liquid foods, odynophagia or weight loss. Following examination, the physician noted that an esophagram did not show evidence of stricture; however, an upper endoscopy was recommended to rule out esophagitis, malignancy, or other causes of dysphagia. The Veteran underwent an endoscopy in April 2006. The final diagnosis was that of LA Grade B esophagitis, suspected Barrett's with a suspicious nodule, and hiatal hernia. The Veteran underwent an esophagogastroduodenoscopy in July 2006. He was diagnosed with LA Grade B reflux esophagitis. A July 2008 VA treatment record showed that the Veteran complained of two episodes of chest pain, one the past December and one several weeks before, each lasting about two minutes. The incidents were not associated with nausea or vomiting. He acknowledged some modest weight gain and recalled recent symptoms that sounded like dysphagia and odynophagia. The impression was that of atypical chest pain that was likely due to a gastrointestinal process. An August 2008 VA treatment record noted that the Veteran began experiencing chest pain about one or twice per month, lasting three minutes or so, and occasional dysphagia with bolus arrest to liquids and solids that had spontaneously cleared in the past. A notation was made of a normal esophagram except for a small hiatal hernia in 2006 and normal stress test in February 2008. An October 2008 VA treatment record following endoscopy showed a diagnosis of esophagitis with associated narrowing of gastroesophageal junction and a small hiatal hernia. A September 2009 VA treatment records showed that the Veteran denied having chest pain, nausea and vomiting. He reported feeling GERD symptoms and acknowledged eating unfavorable foods. The assessment/plan included considering use of a PPI (proton pump inhibitor) and dietary changes. In accordance with the September 2009 remand, the Veteran was afforded a VA examination in March 2010 and complained of dysphagia, pyrosis, epigastric pain, regurgitation, and reflux (three times each month); he denied having arm pain, hematemesis or melena. He described treatment using Prevacid with partial improvement. On examination, the abdomen was noted to be soft and showed no masses or tenderness; the state of health was normal with no weight loss or anemia. The diagnosis was that of GERD with dysphagia. The examiner noted there was no severe impairment of health, epigastric pain, vomiting, hematemesis or melena. A September 2010 VA treatment record showed that the Veteran reported choking episodes happening more frequently (2-3 times each month); he was not taking any PPIs. He denied having chest pain, nausea or vomiting. He again reported feeling GERD symptoms and acknowledged eating unfavorable foods. He was advised to use the PPIs and was referred to the GI clinic. A December 2010 VA treatment record from the GI clinic showed that the Veteran continued to complain of sporadic dysphagia. His prescription for Omeprazole had run out, and he was using Tums and Rolaids for reflux-type symptoms. The dysphagic episodes were characterized by a sense of fullness and pressure in the epigastrium, followed by forceful regurgitation if Veteran did not stop eating. He was able to relieve his symptoms by walking around. A March 2011 VA treatment record showed that the Veteran's medications and active problem list were reviewed. At that time, he was advised to reduce his current daily caffeine intake of 1.5 to 2 pots of coffee in half. There was no recent chest pain or GI/GU complaints. The assessment included a note for Omeprazole to be taken daily, with an instruction to follow-up with the GI clinic. A May 2011 VA treatment note showed a GI consult for evaluation of regurgitation and atypical chest pain; the Veteran was last seen in the clinic for similar symptoms of regurgitation of solid food and reflux symptomatology in December 2010. A notation was made that the Veteran had a long history of similar symptoms that led to an upper endoscopy in 2008 that showed "acute chronic inflammation" treated with a PPI over an extended period of time with little to no improvement; the endoscopy also showed slight narrowing of the distal esophagus. Thereafter, escalating symptoms led to evaluation at the Medical Center for esophageal manometry, which found evidence of apparently decreased peristalsis in the upper esophageal body, as well as diminished tone in the lower esophageal sphincter. At the current appointment, it was noted that the Veteran had difficulty eating solids more than drinking liquids. The impression was that of chronic dysphagia with very extensive workup in the past, revealing inflammatory, anatomical, and motility abnormalities. A November 2011 VA treatment record noted the Veteran's history of chronic pain localized to his lower back, as well as a chronic left knee problem. The physician further noted that, because of these two issues, the Veteran had been chronically on oxycodone and was unable to take nonsteroidal anti-inflammatory medications on a regular basis due to his GERD. He was continuing to take Omeprazole, with no problems with chest pain or GI or GU symptoms. Following examination, the impression was that of GERD controlled on medication. Another November 2011 VA treatment record showed that the Veteran had an endoscopy after complaints of difficulty swallowing; the test revealed esophagitis, small hiatal hernia, and gastropathy. In accordance with the October 2011 remand, the Veteran was afforded a VA examination in November 2011 when the following symptoms were noted: persistently recurrent epigastric distress; dysphagia; pyrosis (heartburn); reflux; regurgitation; mild nausea; mild esophageal narrowing. The Veteran took continuous medication for the condition, noted as Omeprazole and Sucralfate. He denied symptoms including substernal arm or shoulder pain, anemia, weight loss, vomiting, hematemesis, and melena. The diagnoses of GERD, hiatal hernia, esophageal stricture, and esophageal spasm were noted, as well as a brief history of treatment including the recent endoscopy and GI work-up earlier that month. The examiner noted that the esophageal conditions impaired the Veteran's ability to work, to include discomfort after eating requiring the Veteran to go home and rest several times per week. A December 2011 VA treatment record from the GI clinic showed that the Veteran was dealing with his symptoms reasonably well until the last year when the symptom of regurgitation and dysphagia increased; unfortunately, his several orthopedic issues required narcotic pain medication for treatment. On examination, pain was noted to be orthopedic. The assessment was that of chronic dysphagia/regurgitation, GERD, esophagitis, and gastritis. A February 2012 VA treatment record showed that the Veteran reporting continuing GI issues, but that they were intermittent; sometimes, he went for two weeks with no problems, and then he would start having difficulty with swallowing and some regurgitation. Following examination, the assessment was that of dysphagia and GERD, with a recommendation for a trial of Protonix each day before a meal. A May 2012 VA treatment record showed that the Veteran reported no positive impact with Protonix or sucralfate. Following examination, the assessment was that of chronic dysphagia with occasional vomiting episodes, GERD. In a June 2012 written brief, the Veteran's representative indicated that, while some of the Veteran's severe symptoms were intermittent, they had not diminished, and his GERD was chronic in nature. As such, the representative asserted that the Veteran's symptoms demonstrated severe impairment of health. In a June 2012 written submission, the Veteran indicated that he was entitled to a 60 percent rating for his GERD, as he experienced pain and vomiting at times. He also stated that he was prescribed oxycodone and hydrocodone by VA. An August 2012 VA treatment record following an endoscopy showed an impression of suspected Barrett's Esophagus, esophagitis and hiatal hernia. An October 2012 VA treatment record for follow-up post-endoscopy showed that the biopsies taken were benign and consistent with the Veteran's pre-existing Barrett's esophagus. His symptoms were noted to be improved somewhat, and he remained on PPI. At that time, the Veteran indicated that he did not want surgical repair of his hiatal hernia, having had "enough surgery" on his back. The physician noted that the Veteran continued to be dependent on narcotics to remain fully functional, while fully aware of the effect that they could have on his digestive system, constipation and gastroparesis. The impression was that of Barrett's esophagus, hiatal hernia, and chronic narcotic dependence. The plan was to continue noted medical therapy (PPI/cytoprotectant), repeat endoscopy three years for surveillance of Barrett's, and return to GI clinic for any progression of symptoms. In considering the evidence of record in light of the law and regulations, the Board finds that a rating in excess of 30 percent for the service-connected GERD is not assignable, as the Veteran's disability picture does not meet the criteria of symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. Throughout the period on appeal, the service-connected GERD had been manifested by symptoms productive of considerable impairment of health, to include persistently recurrent epigastric distress with dysphagia, pyrosis (heartburn), regurgitation, water brash and some chest pain. Such symptoms were generally intermittent in nature, and the Veteran was able to self-remedy in some instances (e.g., walking when feeling problems while eating to get relief) and generally control symptoms with medication. During some VA appointments, he would deny GI/GU symptoms. See, e.g., November 2011 and February 2012 VA treatment records. The evidence as discussed establishes that the Veteran has not had material weight loss, hematemesis, or melena with anemia or symptom combinations indicative of severe impairment of health. In fact, the March 2010 examiner noted that there was no severe impairment of health. The symptomatology has remained relatively constant throughout the appeal period, with no real indication of a permanent increase in severity. See, e.g., May and December 2011 VA treatment records. As such, the effects of this symptomatology are contemplated in the 30 percent rating currently assigned in that severe impairment of health is not demonstrated. The Board notes that it has also considered the lay evidence of record, to include the Veteran's reports during VA examinations and his written submissions, in deciding this case. The Veteran is competent to report as to the symptoms he experiences and their history. Layno v. Brown, 6 Vet. App. 465 (1994); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). In this regard, the Veteran did report having occasional pain (with other significant pain attributed to the separately service-connected back and knee disabilities), as well as occasional vomiting. As noted, however, he did not have the other listed symptoms in the combination associated with the 60 percent rating or another combination of symptoms productive of severe impairment of health to warrant a higher rating. See 38 C.F.R. §§ 4.7, 4.21. As such, affording this and the remainder of the lay evidence full competence and credibility, such statements do not support a schedular rating higher than the one currently awarded. The Board recognizes that the Veteran has certainly been burdened by the ongoing maintenance of this disability and has undergone numerous diagnostic tests. Nevertheless, the weight of the evidence does not support a higher rating. Thus, on this record, the Board concludes that the weight of the evidence is against the Veteran's claim for an initial rating in excess of 30 percent for the service-connected GERD. As such, the benefit-of-the-doubt rule does not apply, and the claim is denied. Gilbert, 1 Vet. App. at 53. The Board has also considered other possible diagnostic codes for rating this disability, but finds that no other diagnostic code pertaining to the digestive system provides a basis for a higher rating. See Schafrath, 1 Vet. App. at 595; see also 38 C.F.R. § 4.114. The disability also has not been shown to involve any factors that warrant evaluation under any other provision of VA's rating schedule. Consideration has also been given regarding whether the schedular evaluation in this case is inadequate, thus requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the veteran or reasonably raised by the record). An extraschedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. Floyd v. Brown, 9 Vet. App. 88, 94 (1996). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Thun, 22 Vet. App. at 115-16. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. In this regard, the schedular criteria in this case are not shown to be inadequate. A rating in excess of 30 percent is provided for certain manifestations of the service-connected GERD, but the evidence reflects that those manifestations are not present in this case. The diagnostic criteria adequately describe the severity and symptomatology of the service-connected GERD. Accordingly, this issue need not be referred for consideration of an extraschedular rating. ORDER An increased, initial rating in excess of 30 percent for the service-connected gastroesophageal reflux disease (GERD) is denied. ____________________________________________ STEPHEN L. WILKINS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs