Citation Nr: 1340050 Decision Date: 12/04/13 Archive Date: 12/18/13 DOCKET NO. 10-10 689 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to a rating in excess of 40 percent for residuals, antrectomy, vagotomy, and gastrojejunostomy due to duodenal ulcer. 2. Entitlement to a separate rating for peripheral neuropathy associated with residuals, antrectomy, vagotomy, and gastrojejunostomy due to duodenal ulcer. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T. Mainelli, Counsel INTRODUCTION The Veteran had active service from March 1946 to July 1952. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision issued by the Department of Veterans Affairs (VA), Regional Office (RO), in St. Louis, Missouri. This appeal was processed using the Veterans Benefits Management System (VBMS) and Virtual VA, which are two separate VA paperless claims processing systems. There is no paper claims folder associated with this appeal. While the Veteran's records are primarily housed in VBMS, there are additional VA treatment records contained in Virtual VA that are not associated with VBMS. However, all such records were considered by the agency of original jurisdiction (AOJ) in the August 2013 supplemental statement of the case. In a statement received in September 2011, the Veteran's representative withdrew the Veteran's request for a hearing before the Board. In March 2013, the Board remanded this appeal to the AOJ for additional development and it now returns for further appellate consideration. Regarding the characterization of the issues on appeal, the Board's March 2013 remand directed the AOJ to evaluate whether the Veteran has any residuals of his antrectomy, vagotomy, and gastrojejunostomy that are not contemplated in the currently assigned rating under Diagnostic Code (DC) 7308, to include peripheral neuropathy of the lower extremities. The RO has not adequately addressed this issue, which is part of the claim on appeal. Therefore, this issue will be addressed in the REMAND portion of this decision and is REMANDED to the RO via the AMC in Washington, D.C. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDING OF FACT For the entire appeal period, the Veteran's service-connected residuals, antrectomy, vagotomy, and gastrojejunostomy due to duodenal ulcer has been manifested by postgastrectomy syndrome, which is no more than moderate in degree, without substantial weight loss and malnutrition. CONCLUSION OF LAW The criteria for a rating in excess of 40 percent for residuals, antrectomy, vagotomy, and gastrojejunostomy due to duodenal ulcer have not been met. 38 U.S.C.A. §§ 1151, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.114, DCs 7305, 7308 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Proper VCAA notice must inform the claimant of any information and 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)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the appellant's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. In a claim for an increased rating, 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 the instant case, the Board finds that VA has fully satisfied the VCAA content and timing requirements. Specifically, a pre-adjudicatory RO letter dated December 2007 advised the Veteran of the evidence and information necessary to substantiate his increased rating claim, the relative duties between himself and VA in developing his claim, and the criteria for establishing a disability rating and effective date of award. With regard to the duty to assist, all pertinent, identified medical records have been obtained and considered. The RO has obtained all available VA treatment records necessary to decide these claims. There are no outstanding requests to obtain any private medical records which the Veteran has both identified and authorized VA to obtain on his behalf. The Board is unaware of any documents in the possession of the Social Security Administration. Additionally, the Veteran was afforded VA examinations in conjunction with the claim on appeal in May 2008, November 2010, December 2012 and June 2013. Such examinations, to specifically include the June 2013 VA examination, contain all findings necessary to evaluate the increased rating claim under the rating criteria for gastrointestinal disorders. As addressed in the remand below, the June 2013 VA examination is inadequate to evaluate whether the Veteran manifests additional disability of peripheral neuropathy which may be separately rated. Since the June 2013 examination, the Board finds no credible lay or medical evidence suggesting a worsening to the extent that a higher rating may be warranted under the schedular criteria for evaluating gastrointestinal disorders. Therefore, the Board finds that the June 2013 examination report the issue addressed on appeal. The Board remanded this case in March 2013 to allow the Veteran's updated VA treatment records to be obtained and provide him with a VA examination. The AOJ has obtained the Veteran's identified medical records and provided him with a new VA examination in June 2013, which is adequate for deciding the issue decided on appeal. Therefore, the Board finds that the AOJ has substantially complied with the March 2013 remand directives to the extent of the issues being decided on appeal and that no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that there must be substantial compliance with the terms of a Court or Board remand). For the foregoing reasons, the Board finds that VA has satisfied its duties to inform and assist the Veteran at every stage in this case. As such, the Veteran will not be prejudiced by a decision on the merits of his claim being decided on appeal. II. Analysis The Veteran seeks a rating greater than 40 percent evaluation for his service-connected residuals, antrectomy, vagotomy, and gastrojejunostomy due to duodenal ulcer. Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). 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 required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where an increase in the level of a disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Separate ratings may also be assigned for separate periods of time based on the facts found. 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. See generally 38 U.S.C.A. § 5110(b)(2). VA regulations provide that there are diseases of the digestive system, particularly within the abdomen, which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia and disturbances in nutrition. 38 C.F.R. § 4.113. Consequently, certain coexisting diseases in this area, as indicated in the instruction under the title "Diseases of the Digestive System," do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in § 4.14. Id. 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 diagnostic code which reflects 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. The RO has rated the Veteran's service-connected residuals, antrectomy, vagotomy, and gastrojejunostomy due to duodenal ulcer as 40 percent disabling under DC 7308. This rating contemplates moderate post gastrectomy syndrome with less frequent episodes of epigastric disorders with characteristic mild circulatory symptoms after meals but with diarrhea and weight loss. 38 C.F.R. § 4.114, DC 7308. The maximum rating of 60 percent is warranted for severe postgastrectomy syndrome associated with nausea, sweating, circulatory disturbance after meals, diarrhea, hypoglycemic symptoms, and weight loss with malnutrition and anemia. Id. The Veteran has a history of duodenal ulcer which is evaluated under DC 7305. This rating contemplates a moderately severe ulcer, which is less than severe but with impairment of health manifested by anemia and weight loss; or recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year. 38 C.F.R. § 4.114, DC 7305. A 60 percent evaluation is assignable for a severe duodenal ulcer with pain only partially relieved by standard ulcer therapy, periodic vomiting, recurrent hematemesis or melena, with manifestations of anemia and weight loss productive of definite impairment of health. The rating schedule provides guidance in the evaluation of gastrointestinal disorders. In particular, 38 C.F.R. § 4.112 highlights the importance of weight loss in the evaluation of the impairment resulting from gastrointestinal disorders. For purposes of evaluating conditions in 38 C.F.R. § 4.114, the term "substantial weight loss" means a loss of greater than 20 percent of the individual's baseline weight, sustained for three months or longer; and the term "minor weight loss" means a weight loss of 10 to 20 percent of the individual's baseline weight, sustained for three months or longer. 38 C.F.R. § 4.112. The term "inability to gain weight" means that there has been substantial weight loss with inability to regain it despite appropriate therapy. "Baseline weight" means the average weight for the two-year-period preceding onset of the disease. Descriptive words such as "slight," "moderate" and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. The use of descriptive terminology by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision. 38 U.S.C.A. § 7104(a); 38 C.F.R. §§ 4.2, 4.6. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Historically, the Veteran entered active service in March 1946 with a weight of 152 pounds. He was hospitalized for 62 days prior to discharge due to an active duodenal ulcer. He had a weight of 180 pounds upon service separation. Post-service, the Veteran received private hospital treatment for an active duodenal ulcer in July 1958. He filed his original service connection claim in August 1958. VA Compensation and Pension (C&P) examination in September 1958 reflected the Veteran's report of pain in the epigastrium and right upper quadrant of the abdomen. He weighed 165 pounds with a weight of 185 pounds in the last year. His build and nutrition was described as slender and fair. He was on a bland diet. A GI series examination was significant for a gross deformity of the duodenal bulb associated with tenderness and the characteristic appearance of a duodenal ulcer. An October 1958 RO rating decision awarded service connection for duodenal ulcer and assigned an initial 20 percent rating under DC 7305. In pertinent part, the Veteran was hospitalized at VA in March 1960 with complaint of a flare-up of peptic ulcer with nausea, vomiting and weight loss. He was diagnosed with chronic duodenal ulcer with obstruction and underwent an antrectomy and vagotomy. His post-operative complaints included occasional vomiting with a fullness sensation treated with urecholine. He weighed 165 pounds. The Veteran was hospitalized at VA in February 1990 with a history of occasional vomiting, epigastric pain and belching. An esophagogastroduodenoscopy (EGD) in November 1989 had been significant for retained bile secretions with evidence of alkaline gastritis in the stomach and duodenitis. At that time, he weighed 194 pounds. A gastric emptying study demonstrated a 95 percent retention with very delayed emptying. The Veteran underwent subtotal gastrectomy with Roux-en-Y retrocolicgastrojejunostomy. He regained weight to 176 pounds. A September 1999 VA C&P examination revealed the Veteran's complaints of having soft mushy stools and needing to use the bathroom three times within the two hours after awakening. He described bloating with drinking liquids with lemon-flavored drinks causing a dull abdominal ache. He only experienced nausea or vomiting when he ate too much. He experienced dumping syndrome three times per year accompanied by a shakiness sensation. He weighed 196 pounds with his weight ranging from 185 to 200 pounds. He was getting monthly B-12 injections. There are no signs of anemia on examination. By means of a rating decision dated October 1999, the RO increased the disability evaluation for service-connected residuals, antrectomy, vagotomy, and gastrojejunostomy due to duodenal ulcer to 40 percent under DC 7308. The Veteran filed the current increased rating claim on appeal in November 2007. At that time, he described a recent increase in stomach symptoms which included an inability to digest food with bowel and elimination problems. His contemporaneous VA clinic records included a November 2007 clinic visitation due to complaint of right upper quadrant pain (RUQ). He denied nausea or vomiting, constipation, diarrhea, blood in stool, or tarry stools. He was receiving monthly B-12 injections. He weighed 192.1 pounds. An x-ray examination of the stomach was interpreted as showing a large stool burden. He was assessed with RUQ pain with dilated biliary ducts confirmed by ultrasound and computed tomography (CT) scan. Thereafter, his weight ranged from 187.8 to 193.9 pounds. The Veteran underwent VA C&P examination in May 2008. At that time, he described nausea which occurred two to three times per month which lasted less than a day in duration. He had constipation about once every two months which lasted a week in duration. He often got diarrhea 30 minutes after a meal. He further described daily colic, belly distention and gas pattern. He denied vomiting, hematemesis, hematochezia, fever or melena within the last year. His weight had remained stable between 194 to 204 pounds. He took Vitamin B-12 every day. On examination, the Veteran was described as well-nourished and well-developed. He weighed 194 pounds. There were no signs of anemia on complete blood count testing. There was tenderness over the liver. A CT scan of the abdomen in January 2008 showed a dilated biliary duct. The examiner provided diagnoses of peptic ulcer disease not otherwise specified, B-12 deficiency, status post enterotomy vagotomy and status post gastrojejunostomy. Thereafter, a November 2008 VA gastroenterology consultation noted the Veteran's report of no longer having abdominal pain. He also denied nausea, vomiting, diarrhea, melena, hematochezia, weight loss and fever. An EGD noted a normal esophagus and duodenum. His recorded weights remained above 190 pounds. In a statement received in February 2010, the Veteran described difficulty controlling his stools requiring use of stool softeners, suppositories and enemas. The Veteran underwent additional VA examination in November 2010. In general, the Veteran reported a recent worsening of symptoms with a feeling that food did not move through his stomach fast enough, early satiety and constipation. He had symptoms of bloating, sweating and weakness 30 minutes after eating. He further reported experiencing dysesthesias and paresthesias on a daily basis. He took 20 mg. of Omeprazole per day. He denied periods of incapacitation, colic, nausea, vomiting, abdominal distention, gnawing or burning pain, hematemesis, or melena. On examination, the Veteran weighed 186 pounds, which was described as a 10% loss compared to baseline. There were no indications of significant weight loss, malnutrition, or anemia. It was noted that a November 2009 electromyography (EMG) study demonstrated electrodiagnostic evidence of a sensorimotor peripheral polyneuropathy characterized by demyelination and axonal loss as well as electrodiagnostic findings suggestive of a superimposed demyelinating right L5 radiculopathy. The examiner described the effects of the Veteran's disability on activities of daily living as "severe" due to the Veteran only eating one meal per day due to a full feeling after eating, and not eating solid food after 4 pm. The examiner also diagnosed the Veteran with a B-12 deficiency secondary to his gastrointestinal surgeries with peripheral neuropathy that was at least as likely as not secondary to the B12 deficiency. The Veteran's neuropathy impacted daily activities that involved walking, recreational activities or standing for long periods, which impacted activities such as chores, bathing and grooming. The Veteran's subsequent VA clinic records record a weight of 185.4 pounds in February 2011. An August 2011 clinic record noted a history of peripheral neuropathy due to chronic B-12 deficiency, vitamin D deficiency, and status post gastrectomy with 25 percent of the stomach left leading to nutritional deficiency. The Veteran weighed 186 pounds. Another VA examination report was issued in December 2012. This examination report was based solely on a review of records and not on an interview and/or physical examination of the Veteran pursuant to the Acceptable Clinical Evidence (ACE) protocol. The report stated that that there had been no significant change in the Veteran's condition since he was last evaluated in November 2010 citing to contemporaneous VA treatment records. The Veteran presented to the VA urgent care clinic in January 2013 due to symptoms of abdominal pain, nausea, constipation and poor appetite. Imaging studies were interpreted as showing no evidence of bowel obstruction, inflammatory process or other acute abdominal/pelvis abnormality. In a statement received in February 2013, the Veteran described food staying in his stomach too long. A February 2013 VA clinic record noted the Veteran's complaint of bloating sensation with early satiety after few bites. He had one episode of vomiting the previous month. His weight had been stable, but the Veteran described a 30 pound weight loss over the last 12 years. He weighed 186 pounds. It was noted that an EGD in 2008 showed that very little stomach remained connected to the blind and efferent loop. The Veteran was advised to eat puree and semi-solid foods. His lowest recorded weight during the appeal period, 182.6 pounds, was also recorded in February 2013. The Veteran underwent another VA C&P examination in June 2013. The Veteran primarily described having a full sensation even when eating little. For example, he had felt full at the time of examination despite only having had a yogurt and two coffees. He had an instance of vomiting in January to relieve his fullness sensation. Occasionally, he would experience brief pain when eating or drinking certain items followed by difficulty lying on his side due to stomach tenderness. The Veteran described problems with constipation, sometimes to the extent of not having a bowel movement for up to a week, which he treated with suppositories. The clinician found these problems as unrelated to the service-connected post-gastrectomy as diarrhea was a much more typical symptom. The Veteran "seldom" had diarrhea, but reported a "dump" of diarrhea fluid after one bowel movement in January 2013. This happened from time to time. He described having nausea "not too often." He had sweating nightly, but not usually during the day, which the examiner found no indication to be associated with eating. The Veteran described his circulatory disturbance after meals as feeling hot and tachycardic which he treated with metoprolol. He usually had a heart rate of 68-70 which increased to 90-100 after eating. He had additional symptoms of feeling weak and shaky prior to eating meals. The Veteran also had a history B-12 deficiency which had been attributed to low absorption due to his gastrectomy. He had no episodes of bowel disturbance with abdominal distress, exacerbations or attacks, weight loss, malnutrition, GERD symptoms, complications and other general health effects. The Veteran had "moderate" recurring episodes of ulcer symptoms which occurred 4 or more times a year and lasted less than 1 day in duration. He experienced abdominal pain which occurred at least monthly, was periodic in nature and only partially relieved by standard ulcer therapy. On examination, the Veteran weighed 184.7 pounds which was not a significant weight loss from 186 pounds on the 2010 VA C&P examination. There was evidence of mild normochromic anemia, which would be consistent with blood loss that was at least as likely as not related to the service-connected stomach condition. The Veteran's B-12 deficiency was described as well-treated with oral (p.o.) medications. The examiner opined that the Veteran's symptoms did not neatly fit into any category, but that his symptoms would be classified as "moderate" and without malnutrition. His postgastrectomy syndrome was characterized as moderate - less frequent episodes of epigastric disorders with characteristic mild circulatory symptoms after meals but with diarrhea and weight loss, and vagotomy with pyloroplasty or gastroenterostomy with demonstrably confirmative postoperative complications of stricture or continuing gastric retention. His stomach condition impacted his ability to work to the extent that the condition made the Veteran feel a little weaker. Applying the criteria to the facts of this case, the Board finds that the Veteran is not entitled to a rating in excess of 40 percent for residuals, antrectomy, vagotomy, and gastrojejunostomy due to duodenal ulcer for any time during the appeal period. In this respect, the credible lay and medical evidence establishes that the Veteran's service-connected residuals, antrectomy, vagotomy, and gastrojejunostomy due to duodenal ulcer has been manifested by postgastrectomy syndrome, which is no more than moderate in degree, without substantial weight loss and malnutrition. Here, the Veteran's service-connected post-gastrectomy syndrome demonstrates some features supporting a 60 percent rating. For example, the Veteran has described some symptoms of nausea, sweating, circulatory disturbance after meals, weight loss and anemia. The Veteran credibly describes frequent circulatory disturbance with increased heart rate after meals which, in part, supports his 40 percent evaluation under DC 7308. The VA examiner in June 2013 characterized the overall severity of these symptoms as "mild." The Veteran "seldom" experiences diarrhea or dumping syndrome. The Veteran has also self-described the frequency of his nausea as occurring only two to three times per month, and lasting only one day in duration. Thus, the Veteran's own self-report is not consistent with characterizing his nausea symptoms as "severe" when considering the frequency and duration of his symptoms. The Veteran does demonstrate signs of nutritional deficiency with B-12 and Vitamin D deficiencies as well as anemia found on VA examination in June 2013. However, the Veteran's anemia was characterized by the VA examiner as "mild" in degree while his vitamin deficiencies are treatable with vitamin supplements. The Veteran's weight has ranged from 182.6 pounds to well over 190 pounds during the appeal period. He reports a weight as high as 204 pounds. Notably, the Veteran weighed 152 pounds prior to the onset of disease in service, and left service with a weight of 180 pounds. Thus, the Veteran has not demonstrated a "substantial" weight loss from his baseline weight preceding the onset of gastrointestinal disease during the appeal period. Additionally, the VA examiner in June 2013 found no evidence of malnutrition, and there is no medical description of malnutrition in the clinic records. The Veteran also describes additional symptoms which he attributes to his service-connected residuals, antrectomy, vagotomy, and gastrojejunostomy due to duodenal ulcer. This includes a bloating sensation and early satiety requiring a diet of puree and semi-solid food, constipation, hypoglycemic symptoms prior to eating and episodes of abdominal pain. The June 2013 VA examiner medically described the totality of the Veteran's post-gastrectomy symptoms as no more than "moderate" severity in degree which includes consideration of the functional effects of the Veteran's symptoms due to weakness and interference with activities of daily living. In the opinion of the Board, the VA examiner's characterization of the severity of the Veteran's post-gastrectomy symptoms is consistent with the evidentiary record when considering the nature, severity, frequency and duration of all reported symptoms as discussed above and the absence of substantial weight loss and malnutrition. As the Veteran has a history of duodenal ulcer, the Board also considers whether a higher rating can be assigned under DC 7305. The record on appeal does not reflect active ulcer disease during service. An EGD in November 2008 was interpreted as showing a normal esophagus and duodenum. The Veteran has reported that his vomiting episode in 2013 was due to sensation of fullness rather than active duodenal ulcer. He has consistently denied hematemesis and melena. As described above, the Veteran has recently been diagnosed with "mild" anemia and has not demonstrated a significant weight loss. The record does not show that the inactive duodenal ulcer results in definite impairment of health. The Board also observes that VA's Rating Schedule contains multiple other diagnostic codes for various gastrointestinal disorders. The Board finds no lay or medical evidence of perforated ulcer or peritoneum adhesions to warrant consideration of DC 7301, hypertrophic gastritis with severe hemorrhages or large eroded or ulcerated areas to warrant consideration of DC 7307, or resection of small intestine with severe impairment of health supported by material weight loss under DC 7328. The various other diagnostic codes have no applicability to the facts of this case. In so deciding, the Board finds the Veteran's report of gastrointestinal symptomatology to be credible and consistent with the well-documented treatment history. He has reported a 30-pound weight loss over a period of a decade, but his weight during the appeal period has been above his baseline weight preceding the onset of gastrointestinal disease. There is also no evidence of sustained, dramatic weight loss during the appeal period. To the extent that he argues that his post-gastrectomy symptoms are more properly classified as "severe" with malnutrition and weight loss, or that he demonstrates active ulcer disease productive of definite impairment of health, the Board places greater probative weight to the findings of the VA clinicians and examiners who have greater expertise and training than the Veteran in evaluating the severity of a gastrointestinal disorder. The Board has also considered the propriety of a "staged" rating. See Hart, 21 Vet. App. 505 (2007). However, the Board finds that the criteria for a rating in excess of 40 percent for the service-connected gastrointestinal disorder have not been met, or more nearly approximated, for any time during the appeal period. The Board has also contemplated whether the case should be referred for extra-schedular consideration for the disabilities at issue. An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that 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. 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. Second, 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 "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto 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 to determine whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected residuals, antrectomy, vagotomy, and gastrojejunostomy due to duodenal ulcer with the established criteria found in the rating schedule. The Board finds that all of the Veteran's gastrointestinal symptoms are fully addressed by the rating criteria under which such disability is rated. In this regard, a wide range of signs and symptoms are contemplated in the applicable rating criteria for the Veteran's disability. In this regard, the Board has considered all of the gastrointestinal symptoms attributed to the Veteran's service-connected disorder and determined that such result in no more than moderate postgastrectomy syndromes. To the extent that there remains a question as to whether the Veteran has peripheral neuropathy associated with such disability, that issue is addressed in the remand section of this decision and need not be considered further at this time. Moreover, neurological impairment is addressed under 38 C.F.R. § 4.124a of the Rating Schedule. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology associated with the service-connected disability addressed above. As such, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating for either of the service-connected disabilities addressed above is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). Finally, the Board observes that there is no lay or medical evidence, or argument on appeal, that the Veteran's service-connected gastrointestinal disorder is productive of unemployability. In this regard, the June 2013 VA examiner found that such condition only impacted the Veteran's ability to work to the extent that it made him feel a little weaker. Thus, the issue of entitlement to a total disability rating based upon individual unemployability (TDIU) has not been reasonably raised. See Roberson v. Principi, 251 F.3d 1378, 1384 (2001) (once a claimant submits evidence of medical disability, makes a claim for highest possible rating, and submits evidence of unemployability, an informal claim is raised under 38 CFR 3.155(a)); Comer v. Peake, 552 F.3d 1362, 1367 (Fed.Cir.2009) (the issue of TDIU "is implicitly raised whenever a pro se Veteran, who presents cogent evidence of unemployability, seeks to obtain a higher disability rating"). In sum, the Board finds that the criteria for a rating in excess of 40 percent for service-connected residuals, antrectomy, vagotomy, and gastrojejunostomy due to duodenal ulcer have not been met for any time during the appeal period. There is no doubt of material fact to be resolved in the Veteran's favor. 38 U.S.C.A. § 5107(b). Thus, the claim for a higher schedular rating must be denied. ORDER A rating in excess of 40 percent for residuals, antrectomy, vagotomy, and gastrojejunostomy due to duodenal ulcer is denied. REMAND The Board regrets any delay in finally adjudicating all aspects of the claim on appeal, but finds that the issue of entitlement to a separate rating for peripheral neuropathy associated with residuals, antrectomy, vagotomy, and gastrojejunostomy due to duodenal ulcer must be remanded as the June 2013 VA examination is inadequate to rate this aspect of the appeal. In the March 2013 remand, the Board noted that a November 2010 VA examiner indicated that the Veteran had a B-12 deficiency secondary to his surgery (antrectomy, vagotomy, and gastrojejunostomy) and had peripheral neuropathy that was at least as likely as not secondary to the B-12 deficiency. This finding was supported by a November 2009 electromyography (EMG) study of the lower extremities which was interpreted as showing evidence of a sensorimotor peripheral polyneuropathy characterized by demyelination and axonal loss as well as a superimposed demyelinating right L5 radiculopathy. At the June 2013 VA examination, it was noted that the Veteran had a history of Vitamin B-12 deficiency, probably due to his service-connected gastric surgery. The Veteran reported a cold sensation of the bilateral upper extremities, trouble walking, and urinary urgency. Electrodiagnostic testing of the bilateral upper extremities revealed a normal study. The examiner concluded that there was no electrodiagnostic evidence of any nerve problem in the right or left upper extremity related to the Veteran's B-12 deficiency; rather, he indicated that he was highly suspicious of cervical myelopathy as the etiology of the Veteran's complaints. However, electrodiagnostic testing of the bilateral lower extremities revealed an abnormal study as there was positive electrodiagnostic evidence of peripheral polyneuropathy, involving the sensory and motor fibers. There was no electrodiagnostic evidence of myopathy. While such testing did, in fact, reveal peripheral polyneuropathy of the bilateral lower extremities, the examiner did not offer an opinion as to whether such is related to the Veteran's B12 deficiency (which, in turn, resulted from his service-connected gastrointestinal surgery) and, if so, the severity of such neurological impairment. Additionally, while the August 2013 supplemental statement of the case noted that there was no electrodiagnostic evidence of any nerve problem in the right or left upper extremities related to the Veteran's B12 deficiency, the AOJ did not consider whether there was evidence of peripheral neuropathy of the bilateral lower extremities related to the Veteran's B12 deficiency. Therefore, a remand is necessary in order to obtain a VA examination in order to evaluate the Veteran's peripheral neuropathy of the lower extremities due to B-12 deficiency caused by service-connected residuals, antrectomy, vagotomy, and gastrojejunostomy due to duodenal ulcer and, thereafter, allow the AOJ to reconsider whether a separate rating for peripheral neuropathy is warranted. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). Expedited handling is requested.) 1. The Veteran should be afforded an in-person VA examination conducted by an appropriate examiner to evaluate his potential peripheral neuropathy of the lower extremities due to B-12 deficiency caused by service-connected residuals, antrectomy, vagotomy, and gastrojejunostomy due to duodenal ulcer. In this regard, the entire claims file, to include a complete copy of this REMAND, should be provided for the examiner and review of these items should be documented in the examination report. The examiner should elicit from the Veteran lay reports regarding his lower extremity symptoms. All appropriate tests and studies should be accomplished (with all results made available to the examiner prior to the completion of his or her report), and all clinical findings should be reported in detail. The examiner should clarify the diagnosis/es of all neurologic impairment of the lower extremities present and, for each separate diagnosis, provide opinion as to whether it is at least as likely as not that such neurologic disorder is due to B-12 deficiency caused by service-connected residuals, antrectomy, vagotomy, and gastrojejunostomy due to duodenal ulcer. In providing this opinion, the examiner must consider the November 2009 EMG study of the lower extremities which was interpreted as showing evidence of a sensorimotor peripheral polyneuropathy characterized by both demyelination and axonal loss as well as a superimposed demyelinating right L5 radiculopathy; the November 2010 VA examiner's opinion that the Veteran manifested a peripheral neuropathy that was at least as likely as not secondary to the B12 deficiency caused by service-connected residuals, antrectomy, vagotomy, and gastrojejunostomy due to duodenal ulcer; and the June 2013 electrodiagnostic study demonstrating peripheral polyneuropathy, involving the sensory and motor fibers. If the examiner determines that the Veteran has peripheral neuropathy as a result of a B-12 deficiency caused by service-connected residuals, antrectomy, vagotomy, and gastrojejunostomy due to duodenal ulcer, the examiner should identify the nerve(s) involved and the severity of the impairment. A rationale for all opinions offered should be provided. 2. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claim of entitlement to a separate rating for peripheral neuropathy associated with residuals, antrectomy, vagotomy, and gastrojejunostomy due to duodenal ulcer should be readjudicated. If the claim remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The Board intimates no opinion as to the outcome of this case. The Veteran need take no action until so informed. The purpose of this REMAND is to ensure compliance with due process considerations. The Veteran has the right to submit additional evidence and argument on the matter 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). ______________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals