Citation Nr: 1324100 Decision Date: 07/29/13 Archive Date: 08/07/13 DOCKET NO. 05-08 147 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUE Entitlement to an increased rating, in excess of 10 percent, for gastroesophageal reflux disease (GERD) with hiatal hernia and esophageal spasms (gastrointestinal disability). ATTORNEY FOR THE BOARD Christine C. Kung, Counsel INTRODUCTION The Veteran served on active duty from March 1975 to July 1998. This matter comes on appeal before the Board of Veterans' Appeals (Board) from an April 2003 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon. In April 2013, the RO granted service connection for esophageal spasms, and recharacterized the Veteran's gastrointestinal disability as gastroesophageal reflux disease with hiatal hernia and esophageal spasms. The Veteran testified at a March 2007 hearing before a Decision Review Officer (DRO) at the RO. The hearing transcript has been associated with the claims file. The Board remanded the case in January 2007, January 2008, July 2008, and most recently in March 2013. In March 2013, the Board remanded the appeal for readjudication of the claim in light of the receipt of additional evidence and the Veteran's request that such evidence to be considered by the agency of original jurisdiction. The Board finds that the development requested in both the March 2013 remand and in prior remands has been accomplished, and the Board concludes that it may proceed with a decision at this time. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002). As noted in a March 2013 Board decision and remand, the Board finds that a claim for a total disability rating based on individual unemployability (TDIU) has not been raised by the record or has become moot in light of the Veteran's 100 percent schedular rating. See Rice v. Shinseki, 22 Vet. App. 447 (2009). While the Veteran asserts in a December 2007 statement that he could no longer work due to service-connected disabilities, the Veteran has not alleged at that any one service-connected disability interfered with employability, but instead, has argued that the totality of his service connected disabilities have rendered him unable to work. As the Veteran has been in receipt of a total schedular rating since May 2007, the Board finds that an informal claim for TDIU has been not been raised within the confines of the appeal of his gastrointestinal disability claim, or if one was, it has become moot by virtue of the fact that the Veteran is both receiving a 100 percent schedular rating and has not sought special monthly compensation. See Bradley v. Peake, 22 Vet. App. 280 (2008). The Board must note that in reviewing this case the Board has not only reviewed the Veteran's physical claims file, but also his file on the "Virtual VA" system to insure a total review of the evidence. Earlier effective date and CUE claims were raised by the Veteran in December 2007 and May 2010 statements, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over these issues, and they are referred to the AOJ for appropriate action. FINDINGS OF FACT 1. For the entire rating period, the Veteran's gastrointestinal disability has been manifested by recurrent epigastric distress or dyspepsia with symptoms of dysphagia, pyrosis, regurgitation, and substernal pain but it has not been shown to be productive of considerable impairment of health. 2. For the entire rating period, the Veteran's gastrointestinal disability has been manifested by moderate esophageal spasm, but not stricture and is not amenable to dilation. CONCLUSIONS OF LAW 1. For the entire rating period, the criteria for an evaluation in excess of 10 percent for gastroesophageal reflux disease with hiatal hernia have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.114, Diagnostic Code 7346 (2012). 2. Resolving reasonable doubt in the Veteran's favor, for the entire rating period, the criteria for a separate 30 percent evaluation for esophageal spasms associated with gastroesophageal reflux disease with hiatal hernia have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.114, Diagnostic Code 7203-7204 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.326(a) (2012). The notice requirements of VCAA require VA to notify the 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, the VA will attempt to obtain. Id. In a claim for increase, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). In an October 2002 letter, the RO provided preadjudicatory notice to the Veteran regarding what information and evidence is needed to substantiate his claim, as well as what information and evidence must be submitted by the Veteran, and what evidence VA would obtain. A March 2006 notice letter included information regarding how disability ratings and effective dates are assigned. While the March 2006 letter was not received prior to the initial rating decision, the Board finds that the RO cured any deficiency in notice timing when it readjudicated the case in an August 2007 supplemental statement of the case (SSOC) and in subsequent SSOCs. The United States Court of Appeals for the Federal Circuit (Federal Circuit) held that a statement of the case (SOC) or SSOC can constitute a "readjudication decision" that complies with all applicable due process and notification requirements if adequate VCAA notice is provided prior to the SOC or SSOC. See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). As a matter of law, the provision of adequate VCAA notice prior to a readjudication "cures" any timing problem associated with inadequate notice or the lack of notice prior to an initial adjudication. Id. The Veteran was afforded VA examinations in November 2002, April 2005, and September 2009 to address his service-connected gastrointestinal disability. An August 2012 medical opinion from the Veterans Health Administration (VHA) was also obtained. 38 C.F.R. § 3.159(c)(4) (2012). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examinations and opinions, considered along with the medical evidence of record, are adequate because they were performed by a medical professional, and were based on a review of the record and history and symptomatology from the Veteran and a thorough examination of the Veteran. The Board finds that the rating examinations reported findings pertinent to the rating criteria. Nieves-Rodriguez v. Peake, 22 Vet. App 295 (2008); see Barr v. Nicholson, 21 Vet. App. 303 (2007) (holding that VA must provide an examination that is adequate for rating purposes). The Board is also satisfied that VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes VA and private treatment records, VA examinations, a VHA opinion, and the Veteran's statements and testimony. In light of the foregoing, the Board finds that VA has provided the Veteran with every opportunity to submit evidence and arguments in support of his claims, and to respond to VA notices. The Veteran and representative have not identified any outstanding evidence that needs to be obtained. For these reasons, the Board finds that VA has fulfilled the duties to notify and assist the Veteran. Increased Rating Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. The United States Court of Appeals for Veterans Claims (Court or CAVC) has also held that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Id. The Board has considered whether a staged rating is warranted; however, the Board finds that symptoms related to the Veteran's gastrointestinal disability, to include esophageal spasms have not changed in severity over the course of the appeal to warrant a staged rating. The Veteran is in receipt of a 10 percent evaluation for gastroesophageal reflux disease with a hiatal hernia and esophageal spasms with under Diagnostic Code 7204-7346. 38 C.F.R. § 4.114; see also 38 C.F.R. § 4.27 (hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen). Diagnostic Code 7204 addresses spasm of the esophagus (cardiospasm). Diagnostic Code 7204 provides that if spasm of the esophagus is not amenable to dilation, rate based on the degree of obstruction (stricture). 38 C.F.R. § 4.114. Diagnostic Code 7203 (stricture of the esophagus) provides for a 30 percent rating for moderate stricture, a 50 percent rating for severe stricture permitting liquids only, and an 80 percent rating for stricture permitting passage of liquids only with marked impairment of general health. 38 C.F.R. § 4.114. The Schedule of Ratings of the Digestive System at 38 C.F.R. § 4.114 provides that ratings under Diagnostic Codes 7301 to 7329, inclusive 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other. A single evaluation will be assigned under the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. Diagnostic Code 7346 (hiatal hernia) assigns a 10 percent evaluation where there are two or more of the symptoms of a 30 percent evaluation with less severity. A 30 percent rating for a hiatal hernia is assigned with 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 assigned with symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114. In rendering a decision on appeal the Board must also 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. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). After a review of all the evidence, lay and medical, the Board finds that, for the entire rating period, the Veteran's gastrointestinal disability has been manifested by recurrent epigastric distress with symptoms of dysphagia, pyrosis (heartburn), regurgitation, and substernal pain; but is not, and has not been, productive of considerable impairment of health. However, the Board also finds that, for the entire rating period, esophageal spasms associated with the Veteran's gastrointestinal disease have not amenable to dilation and therefore approximate a rating based on moderate disability under Diagnostic Code 7203-7204, thus warranting a separate compensable rating. See 38 C.F.R. § 38 C.F.R. § 4.114. Turning first to Diagnostic Code 7346, for the entire rating period, the Board finds that the Veteran's GERD with hiatal hernia has been manifested by recurrent epigastric distress or dyspepsia with symptoms of dysphagia, pyrosis, and regurgitation but is not productive of considerable impairment of health. The evidence of record, lay and medical, shows that the Veteran has had symptoms of recurrent epigastric distress or dyspepsia with symptoms of pyrosis and substernal pain, and more recently reports problems with regurgitation. The Board finds, however, that the criteria for a higher 30 percent rating under Diagnostic Code 7346 have not been met or more nearly approximated for any portion of the rating period as the Veteran's gastrointestinal disability is not shown to be productive of considerable impairment of health at any time during the course of the appeal. See 38 C.F.R. § 4.114. During a November 2002 VA examination, the Veteran reported that he was on medication for his gastrointestinal disability, but still had breakthrough heartburn a few times of week, particularly if he ate a big meal. He reported pain with swallowing which he related to esophageal stricture as well as epigastric pain. He denied having problems with vomiting. He was diagnosed with GERD and hiatal hernia with recurrent esophageal strictures requiring balloon dilations in the past, pain with swallowing, and breakthrough heartburn. During an April 2005 VA examination, the examiner noted that the Veteran had developed esophageal stricture or a Schatzki's ring in the lower esophagus, requiring occasional dilation. The Veteran reported that his symptoms required him to eat smaller meals to reduce heartburn. The VA examiner stated that the Veteran's gastrointestinal disability did not cause functional or occupational impairment apart from the need to take medication to control the discomfort of heartburn. A September 2009 VA examination also reflects increasing symptoms of discomfort with swallowing and occasional stomach upset. GERD was stated to be stable with no evidence of weight loss. A hiatal hernia demonstrated on esophagoduodenoscopy was noted not to have resulted in any functional impairment. A November 2009 letter from the Veteran's private physician shows that the Veteran has dysphagia, esophageal spasm, reflux, and chest pain due to his gastrointestinal disability. In various lay statements, the Veteran reported that he had esophageal stricture, reported difficulty with eating solid foods, problems with vomiting, painful pressure on the diaphragm, and heartburn. In a December 2007 statement, the Veteran reported fluctuations in weight, substernal pain, regurgitation. A March 2007 statement from the Veteran's coworker also noted periods of weight loss. The Board finds that the Veteran and his coworker are competent to describe observable symptoms related to his gastrointestinal disability and finds that these statements are credible as they are consistent with medical evidence of record. However, these statements do not establish that the Veteran's gastrointestinal symptomatology has been productive of considerable impairment in health. While the evidence of record described above reflects symptoms of recurrent epigastric distress with symptoms of dysphagia, pyrosis, and regurgitation, the Board finds that the Veteran's disability has not resulted in considerable impairment of health at any time during the rating period. VA examinations dated in November 2002, April 2005 and September 2009 show no impairment of health due to the Veteran's gastrointestinal disability. The Veteran denied melena or hematochezia, was found to be adequately nourished on physical examinations, and was noted to be somewhat overweight. His physical examinations were otherwise unremarkable. Additionally, laboratory testing, completed in conjunction the September 2009 VA examination, shows that the Veteran's complete blood count, electrolytes, BUN, creatinine, liver function tests, and thyroid stimulating hormone were all within normal limits and a urinalysis was normal. While the Veteran has provided lay evidence describing fluctuations in weight, the Board finds that, as the Veteran has been noted in the record to be overweight, that these fluctuations are not indicative of considerable impairment of health where laboratory testing is shown to be normal during a September 2009 VA examination. VA and private treatment records do not otherwise reflect considerable impairment in health due to a gastrointestinal disability. Additionally, the examiner in 2005 concluded that Veteran's gastrointestinal disability did not cause functional or occupational impairment; likewise, the examiner in 2009 stated that the Veteran's gastrointestinal disability had not resulted in any functional impairment. These findings directly address the impairment caused by the Veteran's gastrointestinal disability, and clearly show the medical consensus that it was not causing considerable impairment in health. For these reasons, the Board finds that the weight of the evidence does not establish considerable impairment of health due to the service-connected gastrointestinal disability, and for these reasons, a higher 30 percent rating is not warranted under Diagnostic Code 7346. See 38 C.F.R. § 4.114. The Board has considered whether a 50 percent rating is warranted as well, noting that the Veteran submitted a copy of Diagnostic Code 7346 with pain, and vomiting underlined. As noted the Board explained above why a 30 percent rating was not warranted. In some cases it is possible to obtain a higher schedular rating without meeting the next higher criteria. See Tatum v. Shinseki, 23 Vet. App. 152, 155 (2009). The Court has held that where rating criteria are worded in the conjunctive with the use of the word "and," each of the specified criteria must be present to warrant the specified percentage requirements. Camacho v. Nicholson, 21 Vet. App. 360 (2007). However, the holding in Camacho only applies where the rating criteria are "successive," meaning that the criteria for the lower rating plus additional criteria are required before the next higher rating is warranted. Tatum v. Shinseki, 23 Vet. App. 152, 156 (2009). In this case, the criteria for a 30 percent rating under DC 7346 incorporate those required for the 10 percent rating, and are "successive." As such, all of the additional criteria would be required for the next higher rating. See Tatum, 23 Vet. App. at 156; Camacho, 21 Vet. App. at 360. It is true that the 50 percent rating lists a slightly different set of symptoms than does the 30 percent rating. However, both rating levels contemplate the impact the symptoms have on the Veteran's overall health. That is a 50 percent rating essentially requires that the symptoms are productive of severe impairment of health, whereas the 30 percent rating requires considerable impairment of health. As noted here, the medical evidence does not show that the symptoms cause even considerable impairment of health, and for the same reason, severe impairment of health is not shown. The Board has closely reviewed the Veteran's credible reports of symptoms he experiences, but has placed greater weight on the findings of the medical professionals as they have more training on the impact of various symptoms on a person's overall health and well-being. The Schedule of Ratings of the Digestive System at 38 C.F.R. § 4.114 provides that ratings under the relevant Diagnostic Codes (Diagnostic Codes 7301 to 7329, inclusive 7331, 7342, and 7345 to 7348 inclusive) will not be combined with each other, and a single evaluation will be assigned based on the predominant disability picture. The Board notes, however, that limitation does not does not apply to Diagnostic Codes 7203 and 7204. See 38 C.F.R. § 4.114. The Board finds that Diagnostic Code 7346 best represents the Veteran's predominant disability picture due to GERD with hiatal hernia based on the system or body parts involved, and his symptoms and presentation. Thus, the Board finds that consideration of ratings under alternate schedular rating criteria is not warranted for the evaluation of GERD with hiatal hernia; however, because service connection for esophageal spasm is also in effect, the Board has considered whether a separate rating is warranted under Diagnostic Codes 7203 and 7204. See 38 C.F.R. § 4.114. The Board finds that for the entire rating period, the Veteran has experienced esophageal spasms that are not amenable to dilation. The Board finds that the esophageal spasms are moderate in degree and do not result in severe stricture or spasm, permitting passage of liquids only, at any time during the rating period. The Veteran is shown to have esophageal spasms associated with his service-connected gastrointestinal disability. An August 2012 VHA opinion shows that the Veteran did not have aclasia, but did experience dysphagia and esophageal spasms or strictures which were a manifestation of his service-connected gastrointestinal disability. The Board notes that while the Veteran has reported a history of esophageal stricture and stricture was noted during course of VA treatment, an April 2012 VA endoscopy shows that the Veteran had dysphagia with no evidence stricture. For these reasons, the Board finds that the weight of the evidence reflects a current diagnosis of esophageal spasms, which has been service-connected as a part of the Veteran's gastrointestinal disability. The Board finds that for the entire rating period, esophageal spasms are moderate in degree and are not amenable to dilation. VA treatment records show that the Veteran reported increasing symptoms during a December 2004 GI consult, to include dysphagia with solid food and problems with swallowing pills. He had esophageal dilations in February 2004, January 2005 and April 2012. In January 2007, the Veteran had Botox injected into the distal esophagus during an esophagoduodenoscopy. For these reasons, the Board finds that the evidence of record shows that the Veteran has esophageal spasms which are not amenable to dilation and are moderate in degree. Resolving reasonable doubt in the Veteran's favor, for the entire rating period, the Board finds that a separate 30 percent rating is warranted for esophageal spasms under Diagnostic Code 7203-7204. See 38 C.F.R. §§ 4.3, 4.7, 4.114. The Board finds that esophageal spasms do not result in severe stricture or spasm, permitting passage of liquids only, at any time during the rating period. The Veteran has provided lay evidence describing difficulty with eating solid foods and regurgitation. The Veteran's esophageal spasm is shown to be symptomatic and contributes to his difficulty with eating, requiring treatment such as dilation and Botox injections. The Board finds, however, that these symptoms are adequately considered by the Veteran's separate ratings under both Diagnostic Code 7346 and Diagnostic Code 7203-7204. See 38 C.F.R. § 4.114. While the Board finds that the Veteran is credible in describing difficulty eating, the Board finds that his esophageal spasms are not severe in degree and his disability is not of such a severity that he cannot eat solid foods. In a December 2007 statement, the Veteran reported that he used energy drinks such as Ensure when he had difficulty getting food down and that he never knew when his esophagus was going to constrict such that he could not eat solid food. During a March 2007 DRO hearing, the Veteran described a history of esophageal dilations which were not ultimately effective. He described problems with regurgitation after dilation and problems with getting solid food down. However, he specified that he would drink Ensure during the periods after receiving dilation or Botox treatment and while he reported that he ate mostly liquids or purees, he also indicated that he ate small pieces of solid food, or finely ground food, such as hamburger. This would suggest that his condition was not manifested by an inability to consume any solids (i.e. liquid only). In a March 2007 statement, the Veteran's co-worker reported that the Veteran had difficulty with consuming soup and drinking water at lunch. He reported that the Veteran improved after his medical procedure, but reported that he began having problems again a few weeks later. In support of his claim, the Veteran has also submitted several previous decisions by the Board which he believes are relevant to his claim in that they suggest that slurry was sufficient to constitute liquid only. However, Board decisions are not precedential and are decided on the individual facts of the case. 38 C.F.R. § 20.1303. The Board will consider general comments and opinions that were relevant but not unique to the specific Veteran's case. Here, while the Veteran contends that he cannot get food down, or that he could not eat solid food, the Board finds that the difficulties described by the Veteran are limited to periods shortly after dilation or Botox treatment, or occur only on occasion, as indicated during a March 2007 DRO hearing. Similarly, the Board finds that Veteran's difficulties with eating described by his co-worker focus on a specific time period, and do not account for the Veteran's own lay reports of being able to eat solid foods at other times. While the Veteran has credibly reported difficulty with eating solid food at times, the Board finds that disability is not shown to permit the passage of liquids only and is not indicative of severe stricture or spasm. In that regard, during a November 2002 VA examination, the Veteran reported that he had breakthrough heartburn if he ate a big meal, and in April 2005 VA examination he reported that his symptoms required him to eat smaller meals to reduce heartburn, indicating that the Veteran was able to consume meals with solid food. During a March 2007 DRO hearing, the Veteran indicated that he was able to eat solid foods such as fast food chicken or hamburger that had been finely ground or processed. In a more recent January 2013 statement, he described having to chew his food to a pulp and having to take a drink to assist in swallowing with eating. He reported that he had to eat foods that were easily chewed, such as pasta, potatoes, or bread, that he had to take small bites, and that he had to chew for a long time. For these reasons, the Board finds that the weight of the evidence shows that the Veteran has consistently been able to eat at least some solid foods. This is not to minimize the difficulty that the Veteran has with eating due to esophageal spasms, but the fact remains that a 30 percent rating is being assigned as a result of those symptoms. However, the Board finds for the reasons elaborated above that the Veteran's esophageal spasms are not severe, such that they permit "liquids only" to warrant the next higher 50 percent rating under Diagnostic Code 7203-7204. See 38 C.F.R. § 4.114. Based on the evidence as discussed above, the Board finds that for the entire rating period, the criteria for evaluation in excess of 10 percent for gastroesophageal reflux disease with hiatal hernia under Diagnostic Code 7346 have not been met, and resolving reasonable doubt in the Veteran's favor, for the entire rating period, the criteria for a separate 30 percent evaluation is warranted for esophageal spasms under Diagnostic Code 7203-7204. See 38 C.F.R. §§ 4.3, 4.7, 4.114. Extraschedular Consideration The Board has considered whether referral for an extraschedular evaluation is warranted. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). 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. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has 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 for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's gastrointestinal disability is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, including Diagnostic Codes 7203, 7204, and 7346, specifically provide for disability ratings for esophageal spasms and GERD with hiatal hernia based on symptoms which include moderate stricture or spasm, epigastric distress, dysphagia, pyrosis, regurgitation, and substernal pain. See 38 C.F.R. § 38 C.F.R. § 4.114. The 10 percent rating under Diagnostic Code 7346 was granted based on recognition of the Veteran's symptomatic disability characterized by recurrent epigastric distress, pyrosis and dysphagia. Additionally, the Board has granted a separate 30 percent rating based on evidence of moderate esophageal spasm which is not amenable to dilation. These symptoms are part of or similar to symptoms listed under the schedular rating criteria. See 38 C.F.R. § 4.20 (schedular rating criteria provides for rating by analogy based on similar functions, anatomical location, and symptomatology). Moreover, because the assigned Diagnostic Code requires the Board to consider whether the Veteran's symptoms cause impairment of his health, the Board is essentially tasked with considering of all of the Veteran's GERD related symptoms within the parameters of the schedular rating that is assigned. For these reasons, the Board finds that the schedular rating criteria is adequate to rate the gastroesophageal reflux disease with hiatal hernia and esophageal spasm, and referral for consideration of an extraschedular evaluation is not warranted. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In this case, the problems reported by the Veteran are specifically contemplated by the criteria discussed above, including the effect on his occupation and daily life. In the absence of exceptional factors associated with the Veteran's gastrointestinal disability, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER An increased rating for a gastrointestinal disability, in excess of 10 percent, based on gastroesophageal reflux with hiatal hernia, is denied. A separate 30 percent disability rating for a gastrointestinal disability based on esophageal spasm is granted, subject to the laws and regulations governing the award of monetary benefits. ____________________________________________ MATTHEW W. BLACKWELDER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs