Citation Nr: 1337856 Decision Date: 11/19/13 Archive Date: 12/06/13 DOCKET NO. 07-25 420 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to service connection for pain in the bilateral elbows, to include fibromyalgia. 2. Entitlement to service connection for pain in the bilateral wrists, to include fibromyalgia. 3. Entitlement to service connection for pain in the bilateral ankles, to include fibromyalgia. 4. Entitlement to a higher initial evaluation for discogenic disease of the lumbar spine (low back disability), currently rated as 40 percent disabling. 5. Entitlement to a higher initial evaluation for gastroesophageal reflux disease (GERD), currently rated as noncompensable prior to August 30, 2012, and as 10 percent disabling from August 30, 2012, forward. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C. Fields, Counsel INTRODUCTION The Veteran had active service from March 2004 to June 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California. This case was previously before the Board in June 2012, at which point these issues were remanded for further development. The issue of service connection for amenorrhea was also before the Board previously, and was remanded for further development, to include whether the Veteran had primary or secondary amenorrhea. In a December 2012 rating decision (with notice provided in February 2013), service connection was granted for secondary amenorrhea. This was a full grant of this benefit sought on appeal, and the Veteran has not disputed the rating or effective date. As such, this issue is no longer on appeal. See Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997). Additionally, the Veteran was awarded a partial increased rating for GERD in the December 2012 rating decision, as indicated on the first page of this decision. As this was not a full grant of the benefit sought on appeal, and the Veteran has not expressed satisfaction with this determination, her appeal proceeds from the initial unfavorable rating decision. See AB v. Brown, 6 Vet. App. 35, 39 (1993). The paper claims file and Virtual VA paperless claims file, which includes additional VA treatment records, have been considered. To the extent that any records in the Virtual VA system may not have been considered by the agency of original jurisdiction (AOJ), the Veteran waived initial review of such evidence by the AOJ in a February 2013 statement. Therefore, the Board may properly consider such evidence at this time. See 38 C.F.R. §§ 20.800, 20.1304(c) (2013). The first three issues on appeal were previously characterized as entitlement to individual disabilities of the elbows, wrists, and ankles. Nevertheless, the Veteran has repeatedly asserted that she does not have a specific disability of these joints but, rather, has pain in multiple joints and muscles that began in service, and that her service provider indicated may be fibromyalgia. See, e.g., August 2006 notice of disagreement. This aspect of the claim has not been adjudicated by the AOJ. Accordingly, the issues of entitlement to service connection for pain in the bilateral elbows, wrists, and ankles, to include fibromyalgia, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's low back disability has not manifested by unfavorable ankylosis of the spine, bowel or bladder impairment, or incapacitating episodes due to the low back disability with a duration of at least 6 weeks during any 12-month period. 2. The Veteran has had neurological abnormalities of the right and left lower extremities associated with the low back disability that most nearly approximated moderate incomplete paralysis of the sciatic nerve throughout the appeal. 3. Throughout the appeal, the Veteran's gastrointestinal disability has manifested by multiple small erosions in the gastric antrum and fundus with persistent gastrointestinal symptoms; with no diagnosed ulcer, and no substernal, arm, or shoulder pain, or symptoms productive of considerable impairment of health. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 40 percent for low back disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242 (2013). 2. The criteria for an initial rating of 20 percent, but no higher, for left lower extremity radiculopathy have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.3, 4.7, 4.10, 4.123, 4.124, 4.124a, Diagnostic Code 8520 (2013). 3. The criteria for a separate initial rating of 20 percent, but no higher, for right lower extremity radiculopathy have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.3, 4.7, 4.10, 4.123, 4.124, 4.124a, Diagnostic Code 8520 (2013). 4. The criteria for an initial rating of 30 percent, but no higher, for GERD/gastritis have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.3, 4.7, 4.10, 4.113, 4.114, Diagnostic Codes 7307, 7346 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) requires VA to notify and assist claimants in substantiating a claim. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Proper notice must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). The notice requirements apply to all elements of a service-connection claim, including the degree of disability and the effective date. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). VCAA notice should be provided prior to an initial unfavorable decision. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Veteran was provided adequate notice in a May 2006 letter, prior to the adjudication of her service connection claims in June 2006. The claims for a higher rating arise from the initial ratings assigned following the grant of service connection in that rating decision. As such, the service connection claim was substantiated, and the initial rating is a downstream element for which no further notice is required. See Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). There is also no allegation of prejudice concerning notice as to the downstream element of a higher initial rating. VA's duty to assist includes assisting the claimant in the procurement of service and other relevant records, and obtaining a medical examination and opinion when necessary for a fair adjudication. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran has received adequate assistance in this case. The RO obtained all identified, available treatment records, and records in the paper claims file and the paperless Virtual VA system have been reviewed and considered. As directed in the prior remand, the AOJ obtained copies of VA treatment records dated from June 2006 forward, which are primarily contained in the Virtual VA paperless claims file. The AOJ also requested the Veteran to identify any outstanding non-VA records in a June 2012 letter; however, the Veteran did not respond or authorize VA to obtain any non-VA outstanding records. VA's duty to assist in developing the pertinent facts and evidence in connection with a claim is not a one-way street, and the Veteran has a responsibility to cooperate in such development. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Therefore, in light of the Veteran's failure to cooperate fully, this remand directive was substantially completed. The Veteran was also provided VA examinations to determine the nature and severity of her claimed disabilities, including in August 2012 as directed in the prior remand. There is no argument or indication that this VA examination is inadequate. Rather, the examiner measured and recorded all manifestations of the service-connected low back disability, associated neurological abnormalities, and GERD. In sum, another remand for further notice or development as to the issues decided herein would serve no useful purpose, as it would unnecessarily impose additional burdens on VA with no benefit to the Veteran. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). VA has satisfied its duties to inform and assist at every stage in this case, at least insofar as any errors were not harmful to the essential fairness of the proceedings. Therefore, the Veteran will not be prejudiced by a decision on the merits. II. Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, the higher evaluation 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. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology or manifestations of the conditions is not duplicative or overlapping. 38 C.F.R. § 4.14; Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009). In determining the propriety of the initial rating assigned after a grant of service connection, the evidence since the effective date of the grant of service connection must be evaluated and staged ratings must be considered. Staged ratings are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods during the course of the appeal. Fenderson v. Brown, 12 Vet. App. 119, 126-27 (1999). To avoid unnecessary repetition, general considerations as to extraschedular referral under § 3.321(b), unemployability, and the benefit-of-the-doubt doctrine will be discussed after the schedular rating criteria for the disabilities on appeal. Low back disability The Veteran is currently assigned a 40 percent initial rating for her low back disability, as well as a separate 10 percent rating for associated radiculopathy, left lower extremity, with sensory changes. The Board explained in the prior remand that the Veteran did not appeal from the rating assigned for the radiculopathy and, therefore, this issue was not before the Board. Nevertheless, the Board will consider any neurological findings in determining the appropriate ratings. Under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula), a 40 percent rating will be assigned for a low back disability where there is forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a, DC 5242. There must be unfavorable ankylosis to warrant a higher rating of 50 or 100 percent. Id. These ratings are to be assigned with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. Id. (preliminary note). Under the General Rating Formula, any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under appropriate diagnostic codes. Id. at Note (1). When evaluating musculoskeletal disabilities based on limitation of motion, a higher rating must be considered where the evidence demonstrates additional functional loss due to pain, pursuant to 38 C.F.R. §§ 4.40 and 4.45. The diagnostic codes pertaining to range of motion do not subsume sections 4.40 and 4.45, and the rule against pyramiding does not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including use during flare-ups. DeLuca, 8 Vet. App. 202; see also Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Here, the Veteran primarily complains of pain in the low back with reduced range of motion, as well as radiating pain and other symptoms in the lower extremities. The AOJ assigned a 40 percent rating for the low back disability based on the Veteran's measured forward flexion to 20 degrees during a June 2006 VA examination. This is the maximum available rating based on measured limitation of motion of the lumbar spine, and there have been no findings of ankylosis. See 38 C.F.R. § 4.71a, DC 5242; see also Johnston v. Brown, 10 Vet. App. 80 (1997) (stating that once a particular joint is evaluated at the maximum level in terms of limitation of motion, there can be no additional disability due to pain). Further, the Veteran retains range of motion even during flare-ups, and the limitation is not analogous to unfavorable ankylosis in any portion of the spine. As such, a higher rating of 50 or 100 percent is not warranted under the General Rating Formula. The Board has also considered whether a separate or higher rating is warranted for the any associated neurological impairment. See General Rating Formula, Note (1). The Veteran has generally denied any bowel or bladder impairment. Although she has had constipation and/or diarrhea at various times, these have been noted to be due to pain medications to treat various conditions, not specifically related to the low back disability. As such, a separate rating is not warranted on this basis. The Veteran is currently assigned a 10 percent initial rating for radiculopathy of the left lower extremity. As discussed below, the Board also finds that a separate rating is warranted for associated radiculopathy of the right lower extremity. Further, the appropriate rating for both lower extremities is 20 percent for moderate impairment. Under 38 C.F.R. § 4.124a, diseases of the peripheral nerves are rated on the basis of degree of paralysis, neuritis, or neuralgia. The term "incomplete paralysis" indicates a degree of impaired function substantially less than the type of picture for "complete paralysis" given for each nerve, whether due to varied level of the nerve lesion or to partial regeneration. Id. at Note. When the involvement is wholly sensory, the rating for incomplete paralysis should be for the mild, or, at most, the moderate degree. Id. Neuritis characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. 38 C.F.R. § 4.123. The maximum rating which may be assigned for neuritis not characterized by such organic changes will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. Id. Neuralgia characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124. Under DC 8520, an 80 percent rating will be assigned where there is complete paralysis of the sciatic nerve where the foot dangles and drops, there is no active movement possible of muscles blow the knee, and flexion of the knee is weakened or (very rarely) lost. A 60 percent rating is warranted where there is severe incomplete paralysis of the sciatic nerve with marked muscular atrophy. A 40 percent rating is warranted for moderately severe incomplete paralysis of the sciatic nerve. A 20 percent rating is warranted for moderate incomplete paralysis of the sciatic nerve. A 10 percent rating is warranted for mild incomplete paralysis of the sciatic nerve. 38 C.F.R. § 4.124a. Neuritis and neuralgia of the sciatic nerve are rated using these criteria under DCs 8620 and 8720, respectively. Here, the Veteran has repeatedly complained of pain radiating from the back into both lower extremities, as well as numbness, weakness, and tingling or paresthesias down the length of the extremities into the feet. These complaints were noted several times in service during the year prior to discharge, which are relevant to establishing the level of disability as of the date of service connection. See, e.g., December 2005 service treatment record, June 2006 VA examination prior to discharge. VA and private treatment records and examinations since that time generally reflect similar complaints, except for the August 2012 VA examination. The Board notes that the Veteran has also been diagnosed with myoclonus, which is service-connected and currently assigned a noncompensable rating. She has been noted to have possible other reasons for her complaints of pain in various joints including in the lower extremities. Nevertheless, an October 2006 EMG study showed bilateral lower lumbar radiculopathy based on her complaints of pain and other symptoms in the lower extremities. VA rheumatology clinic notes dated in September 2007 record that the Veteran had a history of sciatica-like symptoms, with lumbar radiculopathy that began during service, along with myoclonic jerks, and chronic pain syndrome with some symptoms suggestive of fibromyalgia. The evidence does not clearly show that the Veteran's symptoms are due to nonservice-connected disability; therefore, they will be included in the rating for radiculopathy in the lower extremities. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). Although the October 2006 EMG was interpreted to show mild bilateral lower lumbar radiculopathy, when resolving doubt in the Veteran's favor, the Board finds that her recorded symptoms most nearly approximated moderate impairment of the sciatic nerve in both lower extremities throughout the appeal. As noted above, she has reported sensory changes of pain, numbness, weakness, and tingling or paresthesias. Testing during and after service has also shown intermittent organic changes in both lower extremities, including measurable decreases in sensation, motor strength, and reflexes at the knees, ankles, and feet at various times. For example, during service, there were no objective abnormalities when the Veteran complained of pain and other symptoms in December 2005, but she had decreased reflexes in both knees and ankles, decreased sensation on the right, and muscle strength of 3-4 out of 5 at multiple levels bilaterally in January 2006. She then had normal reflexes, but decreased flexion in both hips due to back pain, in March 2006. Shortly after discharge from service, in August 2006, the Veteran had normal motor, sensory, and reflex testing bilaterally with the exception of decreased ankle jerks bilaterally. She then had decreased sensation to pain in the feet and reduced reflexes in the knees and ankles in October 2006. A few months later, in December 2006, the Veteran denied any radicular pain, and her reflexes were intact. The Veteran and her husband continued to describe pain, numbness, and shaking or weakness in the legs and feet in statements dated in July 2007. VA and private treatment records and examinations dated in 2007 and 2008 continued to show intermittent measurable decreases in reflexes, motor strength, and sensation. See, e.g., May 2007 private neurology consult (noting improvement of lower extremity numbness and weakness, with normal motor, sensory, and reflex testing other than absent reflexes at the left ankle); March 2008 VA physical therapy note (complained of shooting pain and numbness down the legs, with normal reflexes); October 2008 private record (complaints of numbness and tingling, with normal reflexes and strength, except for give way weakness in ankles, and decreased light touch and pinprick sensation bilaterally). The Veteran denied any weakness or numbness during an October 2009 VA routine examination for treatment, and she had normal motor strength of 5 out of 5. Similarly, during the August 2012 VA examination, she primarily complained of low back pain and denied any radicular pain, and she was found to have full muscle strength, sensation, and reflexes. Although there are some inconsistencies, the Board finds that the evidence most nearly approximates moderate incomplete paralysis of the sciatic nerve in both lower extremities throughout the appeal, which warrants a 20 percent rating for the right and left lower extremities. In particular, the Veteran's sensory and organic symptomatology were only intermittent, and there was no evidence of muscle atrophy or other moderately severe or severe symptoms. As such, the evidence does not more nearly approximate moderately severe incomplete paralysis of the sciatic nerve, and a rating of 40 percent or higher is not warranted. See DC 8520. The Board notes that the Veteran's discogenic disease of the lumbar spine has been alternately referred to as degenerative disc disease, such as in the MEB proceedings, which is a type of intervertebral disc syndrome (IVDS). Spinal disabilities involving IVDS should be rated under the General Rating Formula or the Formula for Rating IVDS Based on Incapacitating Episodes (IVDS Formula), whichever results in the highest overall rating when all disabilities are combined. See 38 C.F.R. § 4.71a, Preliminary Notes to General Rating Formula and DC 5243. As the Board has granted higher ratings of 20 percent for neurological impairment in each lower extremity for the entire period on appeal, in addition to the 40 percent rating for limitation of motion, the Veteran's combined rating under the General Rating Formula is greater than 60 percent. See 38 C.F.R. § 4.25, Table I (combined ratings table), and § 4.26 (bilateral factor). As the maximum available rating under the IVDS Formula is 60 percent, no further discussion of these provisions is necessary. See 38 C.F.R. § 4.71a, DC 5243. The Board notes, however, that there is no indication of incapacitating episodes due to the low back disability that totaled at least six weeks in any 12-month period, as required for a 60 percent rating under the IVDS Formula. Id. GERD The Veteran is currently assigned a noncompensable rating for GERD prior to August 30, 2012, and a 10 percent rating for such disability from August 30, 2012, forward. As there is no diagnostic code directly applicable to GERD, these ratings were assigned under DC 7346, which pertains to hiatal hernia. See 38 C.F.R. § 4.114; see also 38 C.F.R. § 4.27 (concerning analogous ratings for unlisted conditions). Hiatal hernia warrants a maximum 60 percent rating where there are symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia, or other symptom combinations productive of severe impairment of health. A 30 percent rating is assigned for symptoms of persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 10 percent rating is warranted where there are two or more of the symptoms for the 30 percent evaluation of less severity. 38 C.F.R. § 4.114, DC 7346. Here, the Veteran does not appear to meet the criteria for a higher rating of 30 percent or higher for hiatal hernia under DC 7346. The evidence establishes persistently recurrent epigastric distress with frequent abdominal pain, pyrosis (heartburn), and nausea, as well as occasional dysphagia and regurgitation. Dysphagia was only noted in August 2006 when the Veteran underwent and endoscopy, and occasional or mild regurgitation was noted in the May 2007 and August 2012 VA examinations. She has otherwise denied dysphagia and regurgitation. The Veteran has also complained of vomiting several times, although she repeatedly noted that nausea and vomiting were a side effect of her pain medications. See, e.g., April 2006 service treatment record, July 2007 statement. Further, the Veteran denied nausea or vomiting in a January 2012 VA treatment record, as well as during the August 2012 VA examination, when she reported being on no continuous medications and using only acupuncture and a bland diet for treatment. The Veteran has consistently denied hematemesis or melena. In July 2007, the Veteran also complained of pain or pressure in the shoulder like carrying heavy bags on top of it, but she was unsure if this was due to her GERD or to her separately diagnosed shoulder disorder. There were no other reports of shoulder pain before or after that time. Further, there is no other lay or medical evidence relating the Veteran's shoulder pain to her gastrointestinal disability, and there is no indication of any substernal or arm pain related to this disability. Additionally, it does not appear that the Veteran has considerable impairment of health due to gastrointestinal symptomatology, as opposed to her other medical conditions. In this regard, the Veteran was treated for low weight during service in April 2006, when her weight had declined to 98 pounds from a previous weight of 105 pounds, which had been stable for two years. In August 2006, she reported losing 20 pounds due to nausea and vomiting from pain medications after her back surgery in January 2006. The Board notes that this could constitute minor weight loss, as the loss of between 7 and 20 pounds would be between 10 and 20 percent of her average weight over the prior two years of 105 pounds. It would not be material weight loss, as it was not more than 20 percent if the baseline weight. See 38 C.F.R. § 4.112 (defining substantial and minor weight loss, and baseline weight). The Veteran's weight was noted to be stable during the May 2007 VA examination. Subsequent records also indicate that she eventually regained weight, with measurements ranging from 111 to 123 pounds from May 2011 to February 2012. Further, although the Veteran was noted to have anemia during service, she reported in April 2006 that this had present since childhood. More recently, VA records dated in January 2012 indicate that the Veteran had severe iron deficiency due to anemia that began in August 2010, but there was no obvious source of gastrointestinal blood loss. The Veteran denied any hematochezia or hematuria, and the provider noted that anemia could be associated with autoimmune disease. In sum, the Veteran has persistently recurrent epigastric distress with frequent pain, pyrosis, nausea, and occasional dysphagia, regurgitation, and vomiting. There does not, however, appear to be substernal, arm, or shoulder pain; or considerable impairment of health due to anemia, weight loss, or otherwise, due to such symptoms, as required for the next higher rating of 30 percent under DC 7346. See 38 C.F.R. § 4.114. Further, the disability picture does not more nearly approximate the next higher rating. See 38 C.F.R. § 4.7. The Board observes that ratings of 10 to 100 percent are available for gastric ulcer (DC 7304) and marginal (gastrojejunal) ulcer (DC 7306), which contemplate many of the Veteran's symptoms. See 38 C.F.R. § 4.114. Further, the Veteran has reported having a history of peptic ulcer, such as in February 2006 and April 2006 for the purposes of her MEB proceedings in service. In an August 2006 notice of disagreement, she reported being diagnosed with an ulcer in July 2005. Nevertheless, although the Veteran is competent to report what providers told her, she is not competent as lay witness to identify her particular diagnosis. Rather, specialized medical knowledge, training, or experience is necessary to respond to this question, given the complex nature of her gastrointestinal disability and multiple other medical conditions. See Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Indeed, VA regulations expressly recognize that coexisting diseases of the digestive system, and particularly within the abdomen, produce a common disability picture characterized by varying degrees of abdominal distress or pain, anemia, and disturbances in nutrition. Consequently, certain diseases do not lend themselves to distinct and separate disability evaluations without violating the principle of pyramiding set forth in 38 C.F.R. 4.14. See 38 C.F.R. § 4.113. As such, ratings under DCs 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive, will not be combined with each other. Rather, a single evaluation will be assigned under the code that reflects the predominant disability picture. 38 C.F.R. § 4.114. Here, the medical evidence is not consistent with a diagnosis of any type of ulcer during the course of the appeal. Rather, the June 2006 VA examiner noted that a July 2005 gastroscope during service showed reflux and gastritis, but no specific ulcer diagnosis. Similarly, an August 2006 VA endoscopy showed diffuse erythema and erosions in the gastric antrum and fundus, with a normal duodenum and esophagus. The Board finds this medical evidence to be more probative than the Veteran's lay reports of what her providers told her. Further, the diagnostic code for gastritis, or DC 7307, contemplates erosions. As such, the more probative evidence does not establish a diagnosed ulcer, and a rating is not appropriate under the codes for gastric ulcer (DC 7304) or marginal (gastrojejunal) ulcer (DC 7306). Nevertheless, the Veteran clearly meets the criteria for a 30 percent rating for her diagnosed gastritis. Hypertrophic gastritis (identified by gastroscope) warrants a 60 percent rating with chronic symptoms of severe hemorrhages, or large ulcerated or eroded areas. A 30 percent rating is warranted for chronic symptoms of multiple small eroded or ulcerated areas, and symptoms. 38 C.F.R. § 4.114, DC 7307. As noted above, the August 2006 endoscopy showed multiple small erosions in the gastric antrum and fundus, and the Veteran has had gastrointestinal symptoms as summarized above throughout the appeal. This meets the criteria for 30 percent for gastritis. Id. A higher rating of 60 percent is not warranted because there is no indication of chronic severe hemorrhages or large ulcerated or eroded areas. Id. The Board finds that DC 7307 for gastritis is the most appropriate diagnostic code, and is more appropriate than DC 7346. This is based on consideration of the Veteran's symptomatology and the medical evidence establishing gastritis, but not ulcers, as discussed above. Further, it allows for a higher rating under the circumstances of this case than the code used by the AOJ. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992) (stating that when the regulations do not provide diagnostic codes for specific disorders, the Board should explain the code under which the claim is evaluated, as well as any change in the code from what was used by the AOJ); Stankevich v. Nicholson, 19 Vet. App. 470, 472 (2006) (stating that the Board must provide an adequate statement of reasons or bases for its selection of a diagnostic code and explain why other codes are not analogous). The Board notes that the Veteran's ratings under DC 7346 were in effect as of June 2006, or less than 20 years. As such, they were not protected, and there is no possibility of reduction in rating or severance of service connection. Cf. Murray v. Shinseki, 24 Vet. App. 420 (2011) (holding that a change in diagnostic code for a protected disability rating that was in effect for 20 years or more could constitute an impermissible reduction in rating under 38 C.F.R. § 3.951(b)); see also Read v. Shinseki, 651 F.3d 1296 (Fed. Cir. 2011) (holding that service connection is not severed simply because a diagnostic code associated with a disability is corrected to determine more accurately the benefit to which a veteran may be entitled). In sum, an initial rating of 30 percent, but no higher, is warranted for the Veteran's gastrointestinal disability throughout the period on appeal under DC 7307. General considerations All potentially applicable diagnostic codes have been considered in determining the appropriate ratings for the Veteran's low back disability, associated neurological impairment in the extremities, and gastrointestinal disability. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). Although the AOJ assigned staged ratings for GERD, the Board finds that staging is not appropriate for any disability on appeal, as the Veteran's symptomatology remained relatively stable. Any increases or decreases in severity were not sufficient for a higher or lower rating as discussed above. See Fenderson, 12 Vet. App. at 126-127. The Board has considered whether this case should be referred for extra-schedular consideration pursuant to 38 C.F.R. § 3.321(b)(1). In this regard, the Veteran's low back disability manifested by pain and decreased range of motion, with associated sensory and organic changes in the bilateral lower extremities. Her GERD or gastritis manifested by multiple small erosions and varying degrees of gastrointestinal symptoms. Such symptomatology is fully contemplated by the schedular criteria. Therefore, the rating schedule is adequate, and it is not an exceptional or unusual disability picture. Referral for consideration of an extra-schedular rating is not necessary. See Thun v. Peake, 22 Vet. App. 111, 115-16 (2008) (discussing the three-pronged analysis as to whether extra-schedular referral is necessary under § 3.321). The Veteran was granted a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) in June 2012 rating decision. This is not currently before the Board and need not be further addressed at this time. Higher ratings are being granted as discussed above; however, the preponderance of the evidence is against a higher rating for the Veteran's low back disability, or an even higher rating for the associated neurological impairment in the lower extremities and for GERD/gastritis. As such, the benefit-of-the-doubt doctrine is inapplicable and the claims must be denied in this regard. 38 C.F.R. § 4.3. ORDER An initial evaluation in excess of 40 percent for low back disability is denied. An initial evaluation of 20 percent, but no higher, for radiculopathy in the left lower extremity is granted. A separate initial evaluation of 20 percent, but no higher, for radiculopathy in the right lower extremity is granted. An initial evaluation of 30 percent, but no higher, for GERD/gastritis is granted. REMAND The Veteran seeks service connection for pain in the bilateral elbows, wrists, and ankles, which she states began in service or, alternatively, are secondary to her service-connected low back and/or bilateral knee conditions. Service connection has already been granted for myoclonus due to complaints of jerking or twitching in multiple parts of the body. Based on several VA examinations, including most recently in August 2012, the Veteran was found to have no specific diagnosable disability of either elbow, wrist, or ankle. Imaging studies showed no abnormalities in these joints, to include arthritis, in August 2012. Nevertheless, the Veteran has reported that providers during service indicated that her complaints of pain in multiple muscles and joints may be due to fibromyalgia. The Veteran was treated for pain in multiple joints in service, and there are some references to possible fibromyalgia in her service treatment records. There are also several post-service rheumatological consults. The Veteran was noted to have no signs of rheumatologic or inflammatory disease on several occasions, including in the May 2007 VA examination. A January 2008 VA rheumatology clinic note, however, records a diagnosis of chronic pain syndrome for complaints of "hurting all over" and evidence upon physical examination of diffuse soft tissue tenderness all over, including in the ankles. The August 2012 VA examiner found that the Veteran had normal ankles, elbows and wrists, stating that her complaints were vague, and all of her joint complaints appeared to be somatic. The examiner noted that the Veteran had metabolic problems, which could contribute to her complaints. The Board observes that service connection generally may not be granted where there is no current disability. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999) (stating that pain alone, without a diagnosed or identifiable underlying condition, does not constitute a disability for which service connection may be granted). Nevertheless, it is unclear whether the Veteran has a non-orthopedic diagnosable disability, fibromyalgia or otherwise, to account for her complaints of pain in multiple joints and muscles, including in the elbows, wrists, and ankles. As the Veteran was treated for pain in these areas during service, the Board finds that further development and adjudication is necessary for a fair adjudication of these claims. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for an appropriate VA examination to determine if there is any diagnosable disability to account for her complaints of pain in multiple joints and muscles, including in the elbows, wrists, and ankles, to include fibromyalgia. The entire claims file should be made available to the examiner for review, and all necessary tests and studies should be conducted. The examiner should respond to the following: (a) Is it at least as likely as not (probability of 50 percent or more) that the Veteran has fibromyalgia, or any other diagnosable disability, to account for her complaints of pain in multiple joints and muscles, including in the elbows, wrists, and ankles? Further, is this disability different from the service-connected myoclonus? Please indicated what, if any, symptoms are duplicative or overlapping with the myoclonus diagnosis. (b) For any currently diagnosed disability affecting the elbows, wrists, or ankles, to include fibromyalgia, is it at least as likely as not that such disability was incurred or aggravated by the Veteran's active service, to include her complaints and treatment for pain in multiple joints? (c) If not, is it at least as likely as not that any currently diagnosed disability affecting the elbows, wrists, or ankles, to include fibromyalgia, was either caused or worsened beyond its natural progression (aggravated) by the service-connected low back or bilateral knee disabilities? Please provide an explanation for each opinion offered. All lay and medical evidence during the course of the appeal, or since 2006, as well as during service, should be considered. If any requested opinion cannot be given without resorting to speculation, explain why. State what, if any, information is needed to offer an opinion. 2. Thereafter, readjudicate the claims for entitlement to service connection for pain in the elbows, wrists, and ankles, to include fibromyalgia. If the appeal is not fully granted, issue a supplemental statement of the case before returning the case to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. All claims 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. 2013). ____________________________________________ James L. March Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs