Citation Nr: 1331630 Decision Date: 10/01/13 Archive Date: 10/07/13 DOCKET NO. 07-15 061 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to a rating in excess of 30 percent for patellofemoral arthralgia of the left knee. 2. Entitlement to a rating in excess of 10 percent for bronchitis. 3. Entitlement to an initial compensable rating for gastrointestinal reflux disease (GERD) with gastritis from June 14, 2007 to September 23, 2008, and in excess of 10 percent disabling from September 24, 2008. 4. Entitlement to a total rating based on individual unemployability due to service connected disabilities (TDIU). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Joseph P. Gervasio, Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from October 1985 to August 1988. This case comes to the Board of Veterans' Appeals (Board) on appeal of rating decisions of the Cleveland, Ohio, Regional Office (RO) of the Department of Veterans Affairs (VA). In September 2010, a videoconference Board hearing was held before the undersigned. A transcript of the hearing is associated with the Veteran's claims file. The case was remanded by the Board in December 2010 for further development of the evidence. This was accomplished and the case was returned to the Board for appellate consideration. The issue of TDIU 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. VA will notify the appellant if additional action is required on her part. FINDINGS OF FACT 1. Throughout the appeal, patellofemoral syndrome of the left knee has been manifested by pain, crepitus, weakness, stiffness, fatigability and instability, with a range of motion from 0 degrees extension to 64 degrees flexion that is productive of severe impairment of the left knee. 2. On pulmonary function testing in October 2007, Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) was 80 percent predicted. 3. On March 18, 2009, DLCO (SB) was shown to be 59 percent predicted. 4. Throughout the appeal, the Veteran's GERD with gastritis has been primarily manifested by epigastric pain, nausea, vomiting, heartburn, intermittent anemia, dyspepsia, chronic constipation, and weight loss. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent for patellofemoral syndrome of the left knee have not been met for any period. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code (Code) 5257 (2012). 2. The criteria for a rating in excess of 10 percent for bronchitis were not met prior to March 18, 2009. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.97, Code 6600 (2012). 3. As of March 18, 2009, the criteria for an increased rating of 30 percent (but no higher) for bronchitis were met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.97, Code 6600 (2012). 4. The criteria for an initial rating of 30 percent (but no higher)for GERD with gastritis have been met for the entire appeal period. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.114, Code 7346 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VCAA notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between a veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). 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). The Veteran was advised of VA's duties to notify and assist in the development of the claim prior to the initial adjudication of the claims. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). May 2006, March 2008, and November 2008 letters explained the evidence necessary to substantiate the claims for increase, the evidence VA was responsible for providing, and the evidence the Veteran was responsible for providing. The Veteran has had ample opportunity to respond or supplement the record. Regarding the initial rating for GERD with gastritis, as the rating decision on appeal granted service connection and assigned a disability rating and effective date for the award, statutory notice had served its purpose, and its application was no longer required. See Dingess 19 Vet. App. At 490. A February 2010 statement of the case (SOC) provided notice on the "downstream" element of initial rating; while a May 2012 supplemental SOC (SSOC) readjudicated the matter after the Veteran and his representative responded and further development was completed. 38 U.S.C.A. § 7105 (West 2002); see Mayfield v. Nicholson, 20 Vet. App. 537, 542 (2006). The Veteran has had ample opportunity to respond/supplement the record. With regard to the duty to assist, the Veteran's service treatment records (STRs) and pertinent post-service treatment records have been secured. The Veteran was afforded VA medical examinations, most recently in February 2011. The Board finds that the opinions obtained are adequate. The opinions were provided by a qualified medical professional and were predicated on a full reading of all available records. The examiners also provided a detailed rationale for the opinions rendered. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Neither the Veteran nor the representative has challenged the adequacy of the examinations obtained. Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of his opinion). Accordingly, the Board finds that VA's duty to assist, including with respect to obtaining a VA examination or opinion, has been met. 38 C.F.R. § 3.159(c)(4) (2012). Rating Laws and Regulations Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C.A. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2012). Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.3 (2012). The United States Court of Appeals for Veterans Claims (Court) has held that "staged" ratings are appropriate for an increased rating claim where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). In the case of initial rating for GERD with gastritis, the Board has considered the entire period of the initial rating claim, from the effective date of service connection, to see if the evidence warrants the assignment of different ratings for different periods of time during these claims, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). The Board notes that it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to these appeals. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims decided herein. The Board is required to render a finding with respect to the competency and credibility of the lay evidence of record. See Coburn v. Nicholson, 19 Vet. App. 427, 433 (2006). Competent, credible lay evidence could be, in and of itself, sufficient to establish an elemental fact necessary to support a finding of service connection. Jandreau v. Nicholson, 492 F.3d 1372, 1376 (Fed. Cir. 2007). As a fact finder, the Board is obligated to determine whether lay evidence is credible in and of itself. The Board cannot determine that lay evidence lacks credibility solely because it is unaccompanied by contemporaneous medical evidence, but it may consider a lack of contemporaneous medical evidence as one factor in determining the credibility of lay evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). Credibility is a factual determination going to the probative value of the evidence, to be made after the evidence has been admitted or deemed competent. Cartwright v. Derwinski, 2 Vet. App. 24 (1991). Board determinations with respect to the weight and credibility of evidence are factual determinations going to the probative value of the evidence. Layno v. Brown, 6 Vet. App. 465, 469 (1994). A veteran is competent to describe symptoms that he experienced in service or at any time after service when the symptoms he perceived, that is, experienced, were directly through the senses. 38 C.F.R. § 3.159 (competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience; lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person.); Layno, 6 Vet. App. at 469-71 (lay testimony is competent as to symptoms of an injury or illness, which are within the realm of one's personal knowledge; personal knowledge is that which comes to the witness through the use of the senses; lay testimony is competent only so long as it is within the knowledge and personal observations of the witness, but lay testimony is not competent to prove a particular injury or illness); see Barr 21 Vet. App. at 303 (lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau, 492 F.3d at 1377. Also, a veteran as a layperson is competent to offer an opinion on a simple medical condition. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (citing Jandreau). VA must consider the competency of the lay evidence and cannot outright reject such evidence on the basis that such evidence can never establish a medical diagnosis or nexus; however, this does not mean that lay evidence is necessarily always sufficient to identify a medical diagnosis, but rather only that it is sufficient in those cases where the layman is competent and does not otherwise require specialized medical training and expertise to do so, i.e., the Board must determine whether the claimed disability is a type of disability for which a layperson is competent to provide etiology or nexus evidence. See Davidson, 581 F.3d at 1316 (recognizing that, under 38 U.S.C.A. § 1154(a), lay evidence can be competent and sufficient to establish a diagnosis of a condition when a layperson is competent to identify the medical condition; the person is reporting a contemporaneous medical diagnosis; or lay testimony describing symptoms at the time supports a later diagnosis by a medical professional). Left Knee The Veteran contends that her left knee disability is more disabling than currently evaluated. The Veteran asserted at her hearing before the undersigned that she has instability, weakness, popping, locking, and pain of the left knee for which she does not believe she is being fully compensated. Service connection for patellofemoral syndrome of the left knee was granted by the RO in a May 1989 rating decision. Initially, a noncompensable (0 percent) rating was assigned, effective August 25, 1988. By rating decision in November 2003, that rating was increased to 10 percent under the provisions of Code 5257, effective September 7, 2000. The rating was again increased to 20 percent in April and September 2006 rating decisions, effective September 7, 2000, which became part of this appeal rating decision and to 30 percent in the June 2008 rating, effective January 30, 2006 that, in part, gave rise to this appeal, under the same diagnostic code. (The 20 percent rating was assigned prior to and the 30 percent rating was assigned prior and subsequent to a temporary total rating under 38 C.F.R. § 4.30, effective February 28, 2006 through July 31, 2006, which is not a subject of this appeal). An examination was conducted by VA in August 2006. At that time, it was noted that the Veteran had had surgery for patellofemoral syndrome of the left knee in February 2006, but that she had not had significant relief of her symptoms. Prolonged standing and repetitive use at work at the post office seemed to irritate her knee. She wore a knee brace, but was able to perform her normal daily activity and normal job. Climbing, squatting, and crawling were hard and difficult. Left knee motion was from 0 degrees extension to 110 degrees flexion. There was retropatellar pain and guarding with lateral luxation of the patella that was described as mild. Her pain was worse at the extremes of flexion. There was pain and tenderness and retropatellar crepitation of both patellae with any attempts of lateral luxation of the patellae. Repetitive use did not cause increased ache, pains, soreness, tenderness, or fatigability . No flare-ups were noted. The knee was stable to medial and lateral as well as anterior and posterior testing. There was pain, tenderness, and guarding with lateral luxation that was mild to moderate in nature. The pertinent diagnosis was postoperative patellofemoral syndrome of the left knee. An examination was conducted by VA in October 2007. At that time, subjective complaints included pain, weakness, stiffness, fatigability and instability. The Veteran used a left knee brace. She had missed seven months from work in 2006 for left knee surgery and about two months during 2007 for pain in all of her joints, including the left knee. She had taken a light job at the Post Office. She was able to accomplish her daily activities, but had pain on stair climbing and could not run, jump or wear heels. Range of motion of the left knee was from 0 degrees flexion to 80 degrees flexion, with pain between 64 and 80 degrees. There was additional limitation of the left knee after repetitions with the Veteran unable to flex the knee more than 64 degrees due to anterior patellar pain. Knee flare-ups were reported as increases of pain from levels of from 5/10 to 10/10. These occurred approximately every week and lasted for two days. The knees were stable on examination, without warmth or effusion. Anterior and posterior drawer signs were negative. Lachman's and McMurrays's signs were also negative. The knees were stable to varus and valgus stress. The diagnosis was patellofemoral syndrome, status post left knee surgery. An examination was conducted by VA in March 2009. At that time, it was noted that the Veteran had undergone a surgical procedure, a lateral release and scoping of the left knee, which had not helped. Prolonged standing and walking bothered and irritated her knee and she had some endurance issues. She wore a knee brace and, stood all day while working at the Post Office. Her knee bothered her at the end of a work day. Range of motion of the left knee was from 0 degrees extension to 140 degrees flexion. Repetitive use increased pain, but did not further limit range of motion. Flare-ups occurred with prolonged standing or use. The pertinent diagnosis was postoperative patellofemoral syndrome of the left knee. VA outpatient treatment records, dated through September 2012, show that the Veteran continues to receive treatment for knee disability, including patellofemoral syndrome of the left knee. In July 2012, her knees were cool with no effusion. Range of motion was from 0 degrees extension to 130 degrees flexion. When last examined, it was noted that her knees were also cool with no effusion. Normal ranges of motion of the knee are to 0 degrees in extension, and to 140 degrees in flexion. 38 C.F.R. § 4.71, Plate II. Diagnostic Code 5003 provides that degenerative arthritis that is established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When there is no limitation of motion of the specific joint or joints that involve degenerative arthritis, Diagnostic Code 5003 provides a 20 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, and a 10 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. Note (1) provides that the 20 pct and 10 pct ratings based on X-ray findings will not be combined with ratings based on limitation of motion. Note (2) provides that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be utilized in rating conditions listed under Diagnostic Codes 5013 to 5024, inclusive. When there is some limitation of motion of the specific joint or joints involved that is noncompensable (0 percent) under the appropriate diagnostic codes, Diagnostic Code 5003 provides a rating of 10 percent for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. When there is limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate diagnostic codes, the compensable limitation of motion should be rated under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a. Separate disability ratings are possible for arthritis with limitation of motion under Diagnostic Codes 5003 and instability of a knee under Diagnostic Code 5257. See VAOPGCPREC 23-97. When x-ray findings of arthritis are present and a veteran's knee disability is rated under Diagnostic Code 5257, the veteran would be entitled to a separate compensable rating under Diagnostic Code 5003 if the arthritis results in noncompensable limitation of motion and/or objective findings or indicators of pain. See VAOPGCPREC 9-98. Diagnostic Code 5256 provides ratings for ankylosis of the knee. Favorable ankylosis of the knee, with angle in full extension, or in slight flexion between zero degrees and 10 degrees, is rated 30 percent disabling. Unfavorable ankylosis of the knee, in flexion between 10 degrees and 20 degrees, is to be rated 40 percent disabling; unfavorable ankylosis of the knee, in flexion between 20 degrees and 45 degrees, is rated 50 percent disabling; extremely unfavorable ankylosis is to be rated 60 percent disabling. 38 C.F.R. § 4.71a. Diagnostic Code 5257 provides ratings for other impairment of the knee that includes recurrent subluxation or lateral instability. Slight recurrent subluxation or lateral instability of the knee is rated 10 percent disabling; moderate recurrent subluxation or lateral instability of the knee is rated 20 percent disabling; and severe recurrent subluxation or lateral instability of the knee is rated 30 percent disabling. 38 C.F.R. § 4.71a. Separate disability ratings are possible for arthritis with limitation of motion under Diagnostic Codes 5003 and instability of a knee under Diagnostic Code 5257. See VAOPGCPREC 23-97. When x-ray findings of arthritis are present and a veteran's knee disability is rated under Diagnostic Code 5257, the veteran would be entitled to a separate compensable rating under Diagnostic Code 5003 if the arthritis results in noncompensable limitation of motion and/or objective findings or indicators of pain. See VAOPGCPREC 9-98. Diagnostic Code 5258 provides a 20 percent rating for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a. Diagnostic Code 5259 provides a 10 percent rating for removal of semilunar cartilage that is symptomatic. 38 C.F.R. § 4.71a. Diagnostic Code 5260 provides ratings based on limitation of flexion of the leg. Flexion of the leg limited to 60 degrees is rated noncompensably (0 percent) disabling; flexion of the leg limited to 45 degrees is rated 10 percent disabling; flexion of the leg limited to 30 degrees is rated 20 percent disabling; and flexion of the leg limited to 15 degrees is rated 30 percent disabling. 38 C.F.R. § 4.71a. See VAOPGCPREC 09-04 (separate ratings may be granted based on limitation of flexion (Diagnostic Code 5260) and limitation of extension (Diagnostic Code 5261) of the same knee joint). Diagnostic Code 5261 provides ratings based on limitation of extension of the leg. Extension of the leg limited to 5 degrees is rated noncompensably (0 percent) disabling; extension of the leg limited to 10 degrees is rated 10 percent disabling; extension of the leg limited to 15 degrees is rated 20 percent disabling; extension of the leg limited to 20 degrees is rated 30 percent disabling; extension of the leg limited to 30 degrees is rated 40 percent disabling; and extension of the leg limited to 45 degrees is rated 50 percent disabling. 38 C.F.R. § 4.71a. See VAOPGCPREC 09-04 (separate ratings may be granted based on limitation of flexion (Diagnostic Code 5260) and limitation of extension (Diagnostic Code 5261) of the same knee joint). Diagnostic Code 5262 provides ratings based on impairment of the tibia and fibula. Malunion of the tibia and fibula with slight knee or ankle disability is rated 10 percent disabling; malunion of the tibia and fibula with moderate knee or ankle disability is rated 20 percent disabling; and malunion of the tibia and fibula with marked knee or ankle disability is rated 30 percent disabling. Nonunion of the tibia and fibula with loose motion, requiring a brace, is rated 40 percent disabling. 38 C.F.R. § 4.71a. The Veteran's left knee disability is shown to be manifested, at worse, by range of motion from 0 to 64 degrees after repetition, with pain that flares up for two days once per week. For a rating in excess of the current 30 percent rating, extension would have to be shown to be limited to 30 degrees or non-union of the tibia would have to be shown. While a separate rating could be assigned for limitation of motion as a result of arthritis, there is no evidence of arthritis or non-union of the tibia or fibula in the Veteran's left knee. As such, there is no basis upon which to assign either a rating in excess of 30 percent or a separate rating for separate knee disability. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claim for increased rating for patellofemoral syndrome of the left knee, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. Bronchitis Service connection for bronchitis was granted by the RO in a May 1989 rating decision that awarded a noncompensable rating, effective August 25, 1988. The rating was increased to the current 10 percent evaluation under the criteria of Code 6600 by rating decision of November 2003, effective September 7, 2000. Diagnostic Code 6600 provides ratings for chronic bronchitis. Forced Expiratory Volume in one second (FEV-1) of 71- to 80-percent predicted value, or; the ratio of Forced Expiratory Volume in one second to Forced Vital Capacity (FEV-1/FVC) of 71 to 80 percent, or; Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) is 66- to 80-percent predicted, is rated 10 percent disabling. FEV-1 of 56- to 70-percent predicted, or; FEV-1/FVC of 56 to 70 percent or; DLCO (SB) 56- to 65-percent predicted, is rated 30 percent disabling. FEV-1 of 40- to 55-percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; DLCO (SB) of 40- to 55-percent predicted, or; maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit), is rated 60 percent disabling. FEV-1 less than 40 percent of predicted value, or; FEV-1/FVC less than 40 percent, or; DLCO (SB) less than 40-percent predicted, or; maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation), or; cor pulmonale (right heart failure), or; right ventricular hypertrophy, or; pulmonary hypertension (shown by Echo or cardiac catheterization), or; episode(s) of acute respiratory failure, or; requires outpatient oxygen therapy, is rated 100 percent disabling. 38 C.F.R. § 4.97. An examination was conducted by VA in October 2007. At that time it was noted that she had been diagnosed with bronchitis during service and had now developed wheezing in addition to her productive cough. She had been diagnosed as having asthma about three years earlier. Pulmonary function testing showed FEV-1 97 percent predicted, FEV-1/FVC 114 percent predicted and DLCO (SB) 80 percent predicted. An examination was conducted by VA on March 18, 2009. At that time, she stated that her symptoms consisted of a chronic dry cough and that she would have exacerbations of upper respiratory infections with the last being one year ago. She had a prescription for Albuterol inhaler, which she used about once per day. He had a prescription for an additional inhaler, but did not use it because it made her feel "jumpy." On examination she was not in respiratory distress and did not use accessory muscles. The lungs were clear without wheezes or rhonchi. There was no evidence of cor pulmonale or right ventricle hypertrophy. There was no evidence of edema of the extremities. Pulmonary function testing was performed. This showed FEV-1 to be 106 percent predicted, FEV-1/FVC 112 percent predicted, and DLCO (SB) 59 percent predicted. The diagnosis was chronic bronchitis. VA outpatient treatment records show that the Veteran continues to receive treatment for her respiratory disability. In March 2011, it was noted that she continued to have symptoms of night cough and hoarseness. She continued to take her mediation. In September 2011, she complained of having shortness of breath after exercise and occasional chest discomfort. She continued to take the medication Albuterol and did not have any recent asthma attacks. In the absence of such symptoms of cardiac or respiratory limitation, cor pulmonale (right heart failure), right ventricular hypertrophy, pulmonary hypertension (shown by Echo or cardiac catheterization), episodes of acute respiratory failure, or where outpatient oxygen therapy is required, the Veteran's bronchitis is primarily rated on the basis of pulmonary function testing. Testing during the appeals period shows FEV-1 and FEV-1/FVC to be in excess of the percent predicted for a compensable evaluation. DLCO (SB) was consistent with a 10 percent evaluation on testing in October 2007, but on March 18, 2009, DLCO (SB) was shown to be 59 percent predicted. This corresponds to a rating of 30 percent. As such, with the resolution of reasonable doubt, an increased rating of 30 percent is warranted as of March 18, 2009. GERD With Gastritis Service connection for GERD with gastritis was granted by the RO in a July 2008 rating decision. A noncompensable (0 percent) initial disability rating was awarded under the provisions of Code 7346 as analogous to hiatal hernia from the date of claim in June 2007. By rating decision dated in April 2009, the rating was increased to 10 percent disabling, effective September 24, 2008, the date accepted as the date a claim for increased rating was received. When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the function affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. Nor will ratings assigned to organic diseases and injuries be assigned by analogy to conditions of functional origin. 38 C.F.R. § 4.20. Diagnostic Code 7346 provides ratings for hiatal hernia. Hiatal hernia with two or more of the symptoms for the 30 percent rating of less severity is rated 10 percent disabling. Hiatal hernia with persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health, is rated 30 percent disabling. Hiatal hernia 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, is rated 60 percent disabling. 38 C.F.R. § 4.114. Ratings under Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive, will not be combined with each other. A single rating will be assigned under the diagnostic code that reflects the predominant disability picture, with elevation to the next higher rating where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. The Veteran's claim for service connection for a gastrointestinal disorder was received by VA in June 2007. In a July 2007 statement, the Veteran's private physician stated that she had seen the Veteran in May 2007 for symptoms of epigastric pain, nausea, and vomiting daily for six months; and heartburn for one year. The Veteran was treated with medication, but the symptoms were refractory. The Veteran was also noted to be iron deficient and had 16 pounds of weight loss since August 2006. The physician described the likely cause of the Veteran's gastritis and noted that she continued to have dyspepsia. VA outpatient treatment records show that in January 2008 the Veteran was seen for evaluation of nausea, vomiting, weight loss, and constipation. She had changed her eating habits to avoid fatty food, red sauce, and fruits. She reported that her weight loss was related to a lower fat diet, but continued to have pyrosis that was not controlled by medication. In April 2008, the Veteran returned for a follow-up regarding dyspepsia, chronic constipation, weight loss, and gastroparesis. Since here last visit, she had reported one bowel movement daily without bright red blood or melena. She was taking a new medication that was helping, but if she did not take it she noted her symptoms of dyspepsia and nausea seemed to be worse. The assessments were GERD, constipation, and nausea without vomiting. On VA examination in July 2008, the Veteran had complaints of nausea, heart burn, but no vomiting. There was no hematemesis or melena and she denied heartburn as long as she was using her medication. She experienced excessive constipation and increased gas. It was noted that the Veteran had a history of iron deficiency anemia. An upper gastrointestinal series study showed mild gastroesophageal reflux. The diagnosis was gastritis/GERD. In December 2009, the Veteran was noted to have constipation, nausea with occasional vomiting, bloating, and gastroparesis. The assessment was refractory GERD complicated by symptomatic gastroparesis, epigastric pain, and fluctuating anemia. The statement from the Veteran's private physician, which was submitted in support of her claim for compensation for gastrointestinal disability described symptoms of epigastric pain, nausea, vomiting, and heartburn. The Veteran's disability was noted to be treatable with medication, but the symptoms were described as refractory (unmanageable). The Board finds that these symptoms are described among the criteria for a 30 percent rating. In addition, symptoms such as anemia, dyspepsia, chronic constipation, and weight loss were described. Resolving reasonable doubt in the Veteran's favor, the Board finds that a rating of 30 percent has been warranted since the Veteran first claimed service connection in June 2007 and continued to be warranted throughout the appeal. To this extent, the appeal is allowed. The Board does not find that the Veteran has met the criteria for the 60 percent rating as the Veteran's weight loss and anemia have not been shown to be consistently moderate, or to be productive of severe impairment of health. As such, a rating of 60 percent is not demonstrated. ORDER An increased rating in excess of 30 percent for patellofemoral arthralgia of the left knee is denied. An increased rating in excess of 10 percent for bronchitis is denied prior to March 18, 2009. An increased rating of 30 percent for bronchitis is allowed as of March 18, 2009, subject to controlling regulations applicable to the payment of monetary benefits. An initial rating of 30 percent for GERD with gastritis is allowed from June 14, 2007, subject to controlling regulations applicable to the payment of monetary benefits. REMAND Having awarded increased ratings for the Veteran's bronchitis and GERD with gastritis, the Board believes that the issue of TDIU should be re-adjudicated. Accordingly, the issue of TDIU is REMANDED for the following action: The RO/AMC should readjudicate the issue of TDIU. If the determination remains unfavorable to the Veteran, she and her representative should be provided with a supplemental statement of the case (SSOC) that addresses all relevant actions taken on the claim for benefits. They should be given an opportunity to respond to the SSOC prior to returning the case to the Board for further review. The appellant 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). ____________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs