Citation Nr: 1332566 Decision Date: 10/21/13 Archive Date: 10/24/13 DOCKET NO. 11-02 515 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to an increased disability rating for gastroesophageal reflux disease (GERD). 2. Entitlement to service connection for irritable bowel syndrome, to include as secondary to a service-connected major depressive disorder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Christine C. Kung, Counsel INTRODUCTION The Veteran, who is the appellant in this case, served on active duty from January 1992 to December 1994. This matter comes on appeal before the Board of Veterans' Appeals (Board) from January 2009 and June 2009 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. The Veteran testified at May 2013 Board videoconference hearing before the undersigned. The hearing transcript has been associated with the claims file. A claim to reopen service connection for a dental disorder, claimed as erosion of teeth, secondary to gastroesophageal reflux disease has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over that issue, and it is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. For the entire rating period, GERD has been manifested by recurrent epigastric distress with symptoms of dysphagia, pyrosis (heartburn), regurgitation or vomiting, and substernal, arm, or shoulder pain, productive of at least some degree of impairment in health. 2. Irritable bowel syndrome is related to a service-connected major depressive disorder. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, for the entire rating period, the criteria for a 30 percent rating for gastroesophageal reflux disease are 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 (2013). 2. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for irritable bowel syndrome, secondary to a service-connected major depressive disorder, are met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.210 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes 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) (2013). 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. Because Board is granting the claim for service connection for irritable bowel syndrome, no further discussion regarding VCAA notice or assistance duties is required with respect to that issue. 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 a September 2008 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. The September 2008 notice letter included information regarding how disability ratings and effective dates are assigned. The Veteran was afforded a VA authorized examination in October 2008 to address service-connected GERD. 38 C.F.R. § 3.159(c)(4) (2013). 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 examination was adequate because it was performed by a medical professional, and was 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 examination 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). While the Veteran indicated in a January 2011 substantive appeal and May 2013 hearing testimony that GERD had worsened since he had surgery for this condition; the Veteran has specified that he had surgery in 2006, prior to the June 2008 claim for an increase, and he testified in 2013 that has not had additional surgery for GERD. Accordingly, the Board finds that the Veteran is asserting that his condition has worsened since his last rating decision, and this case may be distinguished from a case, where a claimant asserts that the disability in question has increased in severity since the most recent rating examination. See VAOPGCPREC 11-95. Moreover, the Board finds that VA treatment records dated since the October 2008 VA authorized examination, which include comprehensive gastrointestinal (GI) evaluations and an esophagogastroduodenoscopy (EGD), adequately address the current severity of GERD since the previous examination, and adequately report findings pertinent to the rating criteria. Cf. Allday v. Brown, 7 Vet. App. 517, 526 (1995) (where the record does not adequately reveal current state of claimant's disability, fulfillment of statutory duty to assist requires a contemporaneous medical examination - particularly if there is no additional medical evidence that adequately addresses the level of impairment of the disability since the previous examination). Accordingly, the Board finds that a remand for an additional VA examination is not necessary. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). The Board is 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 treatment records, VA and VA authorized examinations, 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 GERD 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 GERD with under Diagnostic Code 7346. 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 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"). The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate. After a review of all the evidence, lay and medical, the Board finds that, for the entire rating period, GERD has been manifested by recurrent epigastric distress with symptoms of dysphagia, pyrosis (heartburn), regurgitation or vomiting, and substernal (chest), arm, or shoulder pain productive of at least some degree of impairment in health. See 38 C.F.R. § 4.114. The evidence of record, lay and medical, shows that the Veteran has had symptoms of recurrent epigastric distress with symptoms of pyrosis, and substernal, arm, and/or shoulder pain, as well as symptoms of regurgitation or vomiting. The Board finds that the Veteran's symptoms and presentation approximate the criteria for a higher 30 percent rating under Diagnostic Code 7346. See 38 C.F.R. § 4.114. During an October 2008 VA authorized examination, the Veteran reported symptoms of dysphagia, heartburn, epigastric pain, scapular and arm pain, reflux, regurgitation of stomach contents, nausea, and vomiting. The condition was stated to affect general body health in terms of chest pain, coughing problems, problems with bending and swallowing, and headaches. The Veteran had no hematemesis and GERD did not affect body weight. The Veteran reported that symptoms of GERD had returned since a procedure for Nissan fundoplication in 2006. A physical examination shows that the Veteran was well developed, well nourished, and was in no acute distress. Complete blood count results were within normal limits. The examiner stated that the Veteran's GERD was symptomatic with reflux, heartburn, pain behind the breastbone, arm pain, difficulty swallowing, chest pain, and headaches. The Veteran had abdominal tenderness in the left upper quadrant. He was being treated with medication. The examiner opined that hiatal hernia and GERD did not cause significant anemia and there were no findings of malnutrition. GERD had a moderate affect on the Veteran's daily activities. VA treatment records also reflect symptoms of recurrent epigastric distress with symptoms of dysphagia, pyrosis, substernal or chest pain, and regurgitation or vomiting. A July 2008 EGD indicates recurrent of cough and GERD symptoms since Nissen fundoplication in October 2006. The Veteran had grade A esophagitis secondary to recurrent GERD. A December 2008 GI note reflects an increase in heart burn and chest discomfort since the Veteran ran out of medication, with no nausea, vomiting, dysphagia, or weight loss. A March 2009 GI consult shows that GERD symptoms were adequately controlled on medication, with no nausea, vomiting, dysphagia, or weight loss. A March 2012 GI consult showed intermittent reflux symptoms. An August 2012 GI consult shows that acid reflux symptoms were controlled with medication; however, the Veteran had dysphagia with harder solid foods, approximately twice per month, and that he endorsed symptoms of gagging and substernal burning/sharp chest pain with these episodes. He also had dry heaves and pain with these episodes. The Veteran denied melena, hematochezia, hematemesis, and weight loss. It was noted that May 2012 pH monitoring showed that the Veteran had 26 reflux episodes in 24 hours, with no evidence of gastroesophageal reflux while he was on medication. Nissen fundoplication with wrap was intact on a November 2009 EGD, but a January 2012 EGD showed relaxed Nissen. A May 2013 GI follow up noted shows that the Veteran had increased nausea and vomiting secondary to "acid" for the past three weeks. He had symptoms of almost daily intolerance to most liquids and solids with increased acid reflux symptoms and substernal chest pain. The Veteran denied melena, hematochezia, hematemesis, dysphagia, and weight loss. During May 2013 hearing testimony, the Veteran reported that his appetite had gone down due to GERD, but that he had weight gain due to other medications. He reported that he did not have issues with vomiting when he was on medication, but had five or six episodes where he vomited in the past couple of months. He also reported having a continuous cough. The Veteran reported using 50 hours of sick leave due to his combination of disabilities, to include depression and GERD. For the entire appeal period, the evidence discussed above reflects symptoms of recurrent epigastric distress with symptoms of dysphagia, pyrosis, substernal or chest pain, and occasional regurgitation or vomiting. The Veteran has identified at least some degree of impairment in health due to GERD and GERD symptoms, indicating that he had loss of appetite, coughing problems, and headaches due to GERD. Additionally, a VA authorized examination shows that GERD symptoms result in moderate impairment in activities of living, and has required both past surgical intervention as well as continuous medication for control of current reflex symptoms. Resolving reasonable doubt in the Veteran's favor, the Board finds that disability due to service-connected GERD approximates a higher 30 rating under Diagnostic Code 7346. See 38 C.F.R. § 4.114. The Board has considered whether the next higher 60 percent rating is warranted for service-connected GERD. A 60 percent rating essentially requires that gastrointestinal symptoms are productive of severe impairment of health with either pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. The Board finds, however, that GERD is not productive of severe impairment of health, and does not approximate a 60 percent rating under Diagnostic Code 7346. For the entire rating period, the Veteran's GERD has not been manifested by symptoms such as pain (other than substernal, shoulder, or arm pain already considered in his 30 percent rating), vomiting, material weight loss, and hematemesis or melena with anemia. The Veteran had reported vomiting or regurgitation, but there was no evidence of weight loss, hematemesis, melena, or anemia. An October 2008 VA authorized examination shows that the Veteran was well developed and well nourished with no weight loss, hematemesis, anemia, or malnutrition. VA treatment records dated from 2008 to 2013 show that the Veteran had no melena, hematochezia, hematemesis, or weight loss. GERD is not otherwise shown by VA treatment records to be productive of severe impairment of health, and the Veteran had no hospitalizations due to GERD. For these reasons, the Board finds that the Veteran's GERD does not more nearly approximate the criteria for a 60 percent rating under Diagnostic Code 7346. 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 finds that Diagnostic Code 7346 best represents the Veteran's predominant disability picture due to GERD 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. See 38 C.F.R. § 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 (2013). 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, Diagnostic Code 7346, specifically provides for disability ratings for GERD or hiatal hernia based on symptoms which include epigastric distress, dysphagia, pyrosis, regurgitation, and substernal pain, and impairment of health. See 38 C.F.R. § 38 C.F.R. § 4.114. The 30 percent rating under Diagnostic Code 7346 was granted based on recognition of the Veteran's symptomatic disability characterized by his recurrent epigastric distress, pyrosis and dysphagia, regurgitation, and substernal pain. These symptoms are part of or similar to symptoms listed under the schedular rating criteria. 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 and referral for consideration of an extraschedular evaluation is not warranted. The Veteran has identified some loss of time from work due to his combination of disabilities, to include GERD, during a May 2013 Board hearing and GERD was stated by a VA authorized examiner to result in moderate impairment in activities of living. However, 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). Service Connection Law and Analysis Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). Service connection may be granted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2013). In addition, a claimant is entitled to service connection on a secondary basis when it is shown that a service-connected disability has chronically aggravated a nonservice-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Under the current version of 38 C.F.R. § 3.310(b) which is applicable to this appeal, the regulation provides that any increase in severity of a nonservice-connected disease or injury proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the disease, will be service connected. In reaching this determination as to aggravation of a nonservice-connected disability, consideration is required as to the baseline level of severity of the nonservice-connected disease or injury (prior to the onset of aggravation by service-connected condition), in comparison to the current level of severity of the nonservice-connected disease or injury. These evaluations of baseline and current levels of severity are to be based upon application of the corresponding criteria under the VA rating schedule for evaluating that particular nonservice-connected disorder. See Notice, 71 Fed. Reg. 52,744 -47 (Sept. 7, 2006), later codified at 38 C.F.R. § 3.310(b). The Veteran contends that service connection is warranted for irritable bowel syndrome, and more recently contends that irritable bowel syndrome is secondary to his service-connected psychiatric disorder with claimed depression and anxiety symptoms. After reviewing all the lay and medical evidence, including the Veteran's statements and testimony, the Board finds that the weight of the evidence shows that currently diagnosed irritable bowel syndrome is related to service-connected major depressive disorder. Because the Board is granting the Veteran's claim on a secondary basis, the Board need not address whether service connection is warranted on a direct basis. The Veteran contends, in a January 2011 substantive appeal and May 2013 Board videoconference hearing that irritable bowel syndrome is aggravated by service-connected depression and anxiety and contends that VA treatment providers have provided opinions to that affect. The Veteran is currently service-connected for major depressive disorder and the Board has attributed symptoms of depression, anxiety, and stress identified in VA treatment records to his service-connected psychiatric disorder. See 38 C.F.R. § 3.102 (2013); Mittleider v. West, 11 Vet. App. 181 (1998) citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996) (the Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence which does so.) VA treatment records show that the Veteran has currently diagnosed irritable bowel syndrome. A May 2009 VA examiner provided an opinion indicating that irritable bowel syndrome was not incurred in service; however, the examiner did not address the question of secondary service connection. A February 2010 treatment report from the Veteran's VA treating physician, a specialist in internal medicine and gastrointestinal disabilities, shows that the Veteran had diarrhea likely secondary to irritable bowel syndrome with depression and stress playing a significant role. An October 2012 treatment report, completed by a VA gastroenterologist, shows that the Veteran presented with chronic diarrhea most likely secondary to irritable bowel syndrome given negative workup including EGD, C scope, CT of the abdomen and pelvis, infectious workup, celiac panel, THS, and SBFT. With respect to irritable bowel syndrome, the VA physician stated that the Veteran had a strong psychiatric component to his current comorbidities. According to the Court, "the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches." Guerrieri v. Brown, 4 Vet. App. 467, 470 (1993). The credibility and weight to be attached to these opinions is within the province of the Board. Id. In this case, two of the Veteran's treating physicians have related current irritable bowel syndrome to a service-connected psychiatric disorder. The record shows that the Veteran receives both mental health treatment and treatment for GERD at VA. As such, the Board finds that VA treating physicians are familiar with his medical history and have knowledge of the Veteran's disabilities as they relate to both irritable bowel syndrome and major depressive disorder. See Owens v. Brown, 7 Vet. App. 429, 433 (1995) (holding that VA may favor the opinion of one competent medical expert over that of another when VA gives an adequate statement of reasons and bases). Moreover, the VA physicians providing the opinions in this case are both specialists in gastroenterology, and the opinions were provided during the course of treatment for diagnostic purposes. For these reasons, the Board finds that they provide probative evidence with respect to the etiology of irritable bowel disease. Resolving reasonable doubt in the Veteran's favor, the Board finds that the combination of February 2010 and October 2012 VA opinions provide competent, credible, and probative evidence which relates irritable bowel syndrome to a service-connected psychiatric disorder. The Board notes that because the October 2012 VA gastroenterologist found that the Veteran's disabilities were comorbid, the Board need not consider the baseline level of severity of irritable bowel syndrome prior to aggravation in this case. Cf. Allen v. Brown, 7 Vet. App. 439 (1995). The Board finds that the weight of the evidence, to include medical opinions from VA treating physicians, shows that irritable bowel syndrome is proximately due to, the result of, or aggravated by a service-connected major depressive disorder. For these reasons and resolving reasonable doubt in the Veteran's favor, the Board finds that service connection for irritable bowel syndrome is warranted. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. §§ 4.3, 4.7 (2013). ORDER A 30 percent disability rating for GERD is granted, subject to the laws and regulations governing the award of monetary benefits. Service connection for irritable bowel syndrome, secondary to a service-connected major depressive disorder is granted. ____________________________________________ MATTHEW TENNER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs