Citation Nr: 1340191 Decision Date: 12/05/13 Archive Date: 12/20/13 DOCKET NO. 09-26 078 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas THE ISSUE Entitlement to an increased (compensable) rating for service-connected hiatal hernia with gastroesophageal reflux. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. L. Wasser, Counsel INTRODUCTION The Veteran had active duty training from November 2001 to March 2002, and served on active duty from October 2003 to April 2005. He had additional reserve service. This case comes to the Board of Veterans' Appeals (Board) on appeal from September 2008 and October 2008 rating decisions of the RO in North Little Rock, Arkansas. In the September 2008 rating decision, the RO denied an increase in a noncompensable evaluation for hiatal hernia with gastroesophageal reflux. In the October 2008 rating decision, the RO denied entitlement to service connection for adjustment disorder with mixed anxiety and depressed mood. The Veteran testified at an April 2010 videoconference hearing before the undersigned Veterans Law Judge. A transcript of that proceeding has been associated with the claims file. In a January 2011 decision and remand, in pertinent part, the Board remanded the issues of entitlement to service connection for a psychiatric disorder, and entitlement to an increased rating for hiatal hernia with gastroesophageal reflux to the Appeals Management Center (AMC), for additional development. In a March 2012 rating decision, the AMC granted entitlement to service connection and a 50 percent rating for major depressive disorder, claimed as adjustment disorder with mixed anxiety, depressed mood and anxiety. Since the Veteran did not appeal the rating or effective date assigned in this decision, this claim is no longer in dispute. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (indicating he must separately appeal for a higher rating and earlier effective date since these are "downstream" issues from his initial claim for service connection). Thus, the only remaining issue on appeal is entitlement to an increased rating for hiatal hernia with gastroesophageal reflux. FINDINGS OF FACT Resolving reasonable doubt in his favor, the evidence of record shows that the Veteran's hiatal hernia with gastroesophageal reflux is manifested by pyrosis and dysphagia; the condition is controlled with medication, but does not demonstrate persistently recurrent epigastric distress that is productive of considerable impairment of health. CONCLUSION OF LAW The criteria for an increased 10 percent rating (and no higher) for hiatal hernia with gastroesophageal reflux have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.114, Diagnostic Code 7346 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist As provided by the Veterans Claims Assistance Act (VCAA), VA has duties to notify and assist a claimant in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Proper notice from VA 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 obtain and assist the claimant in obtaining; and (3) that the claimant is expected to provide. See 38 C.F.R. § 3.159(b)(1); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Charles v. Principi, 16 Vet. App. 370, 373-74 (2002). These VCAA notice requirements apply to all five elements of a claim: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). Further, this notice must include information that a downstream disability rating and an effective date for the award of benefits will be assigned if service connection is granted. Id. at 486. Ideally, VCAA notice should be provided prior to an initial unfavorable decision on a claim by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). If it was not, or the notice provided was inadequate, this timing error can be effectively "cured" by providing any necessary VCAA notice and readjudicating the claim - such as in a statement of the case (SOC) or supplemental SOC (SSOC), such that the intended purpose of the notice is not frustrated and the Veteran is given an opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, notice letters dated in June and July 2008 were sent to the Veteran prior to the September 2008 rating decision on appeal, i.e., in the preferred sequence. This letter informed him of the type of information and evidence required to substantiate this claim for an increased rating for hiatal hernia with gastroesophageal reflux, and apprised him of his and VA's respective responsibilities in obtaining this supporting evidence. He was also advised to provide evidence showing that his service-connected disabilities had worsened, and was advised of the downstream disability rating and effective date elements of this claim in these letters. See Dingess/Hartman, supra. In addition, these letters and an April 2009 letter advised the Veteran of the necessity of providing medical or lay evidence demonstrating the nature and symptoms of his condition, the severity and duration of the symptoms, and the impact of the condition and symptoms on his employment. See Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (VCAA notice in a claim for increased rating need not be "veteran specific"). The claim was most recently readjudicated in a March 2012 supplemental statement of the case. Mayfield IV, supra; Prickett, supra. As the pleading party attacking the agency's decision, the Veteran, not VA, has the evidentiary burden of proof of showing there is a VCAA notice error in timing or content and that the error is unduly prejudicial, meaning outcome determinative of his claim. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). There is no such pleading or allegation in this instance. VA also fulfilled its duty to assist the Veteran with this claim by obtaining all potentially relevant evidence, which is obtainable, and therefore appellate review may proceed without prejudicing him. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159; see also Bernard v. Brown, 4 Vet. App. 384 (1993). To this end, the RO and AMC have obtained his service treatment records (STRs), private medical records, and VA outpatient treatment records, and arranged for VA compensation examinations in July 2008 and January 2011. The mere passage of time since an examination does not, in and of itself, necessitate another examination. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007). A medical opinion is adequate when it is based upon consideration of the appellant's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's "evaluation of the claimed disability will be a fully informed one." Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). These examinations were conducted by medical professionals, and the associated reports reflect review of the appellant's prior medical history. The examinations included a report of the symptoms for the hiatal hernia with gastroesophageal reflux and demonstrated objective evaluations. The examiners were able to assess and record the clinical status of the Veteran's hiatal hernia with gastroesophageal reflux. Physical examination was accomplished. The Board finds that the examination reports were each sufficiently detailed with recorded history, impact on employment and daily life, and clinical findings. In addition, it is not shown that the examinations were in any way incorrectly conducted. Further, the VA examination reports addressed the applicable rating criteria. As a result, the Board finds that additional development by way of another examination would be redundant and unnecessary. See 38 C.F.R. § 3.326; 38 C.F.R. § 3.327; Green v. Derwinski, 1 Vet. App. 121 (1991). A Court or Board remand confers upon a veteran the right to substantial, but not strict, compliance with that order. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). In this case, the AMC arranged for a VA medical examination as directed by the Board's January 2011 remand, and the AMC sent the Veteran a letter in January 2011, asking him to send or identify any available treatment records for his condition. In response, he submitted duplicate copies of medical records dated during his active service. Additional VA medical records were obtained. Therefore, substantial compliance has been achieved. In an April 2012 statement, the Veteran said he had no additional information or evidence to submit. VA has complied with the notice and assistance requirements and the appellant is not prejudiced by a decision on the claim at this time. Analysis The Veteran contends that his hiatal hernia with gastroesophageal reflux is more disabling than currently evaluated. He asserts that he has difficulty swallowing as a result of this disorder, that his medications have been increased or changed, and that he sometimes regurgitates his medication. In addition, his representative has recently contended that this disability should be rated under Diagnostic Code 8210, which pertains to paralysis of the 10th cranial nerve. See October 2013 written brief. Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Both the use of manifestations not resulting from service-connected disease or injury and the evaluation of the same manifestation under different diagnoses are to be avoided. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259 (1994). In Esteban, the United States Court of Appeals for Veterans Claims (Court) found that when a Veteran has separate and distinct manifestations from the same injury he should be compensated under different Diagnostic Codes. When rating the Veteran's service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). That being said, given unintended delays during the appellate process, VA's determination of the current severity of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period that the increased-rating claim has been pending. And in those instances, it is necessary to "stage" the rating to compensate the Veteran for this variance. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Disabilities involving the digestive system are evaluated under the regulatory criteria found at 38 C.F.R. §§ 4.110 - 4.114. Ratings under Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other. A single 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. Throughout the rating period on appeal, the RO has rated the Veteran's service-connected hiatal hernia with gastroesophageal reflux as noncompensable under 38 C.F.R. § 4.114, Diagnostic Code 7346, pertaining to hiatal hernia. Under Diagnostic Code 7346, a 60 percent evaluation is warranted for hiatal hernia with symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. A 30 percent evaluation is assigned when there is evidence 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 evaluation is assigned when there is evidence of two or more of the symptoms for the 30 percent evaluation of less severity. 38 C.F.R. § 4.114, Diagnostic Code 7346. "Hematemesis" is defined as vomiting of blood. See Stedman's Medical Dictionary, 27th ed., 2000, at 796). "Melena" is defined as passage of dark-colored, tarry stools, due to the presence of blood altered by the intestinal juices. Id. at 1084. "Pyrosis" is defined as substernal pain or burning sensation, usually associated with regurgitation of acid-peptic gastric juice into the esophagus. Id. at 1494. "Dysphagia" is difficulty in swallowing. Id. at 554. Historically, during service in November 2004, the Veteran was seen in a private emergency room for complaints of chest pain and pain in the back of his throat. No active cardiopulmonary process was seen on chest X-ray study. He was given a "gastrointestinal (GI) cocktail" and Pepcid, and reported receiving relief from this. On VA general medical examination in September 2005, the Veteran was diagnosed with musculoskeletal chest wall pain, and gastroesophageal reflux disease. The Veteran reported that he had occasional regurgitation and a lot of pyrosis and indigestion, but that this was now controlled on Prevacid. His weight was stable and he did not have any hematemesis or melena. An upper gastrointestinal (UGI) series showed a small sliding type of hiatal hernia with minimal reflux, and possible antral gastritis and duodenitis. The Veteran filed the instant claim for an increased rating in June 2008. In this claim and in a July 2008 statement, he did not identify any symptoms of his hiatal hernia with gastroesophageal reflux. VA medical records reflect treatment, primarily medication, for hiatal hernia with gastroesophageal reflux. A July 2008 VA primary care note reflects that the Veteran was previously taking Prevacid (lansoprazole) for gastroesophageal reflux disease (GERD), and currently ranitidine (Zantac) was stopped and omeprazole (Prilosec) was started. On examination, the Veteran denied chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, heartburn/reflux, blood in stool or recent weight gain or loss. He was taking omeprazole 20 milligrams once daily in the morning. On examination, his abdomen was soft, flat, non-tender and non-distended, with no organomegaly. Bowel sounds were normoactive. On subsequent VA compensation examination in July 2008, the Veteran reported that he took 20 milligrams of omeprazole daily for his symptoms. He said that when he took his pills in the morning, he then regurgitated them and had to re-swallow them. He also complained of some anorexia, but the examiner noted that his weight had been fairly stable. He had gained and lost a few pounds but there had been no significant change in his weight. He had no hematemesis or melena. He had occasional chest pain but no upper arm pain. He had occasional indigestion. He denied other symptoms. On examination, the abdomen was soft, and bowel sounds were active. There were no abdominal masses or tenderness. The diagnosis was hiatal hernia with gastroesophageal reflux. In his September 2008 notice of disagreement, the Veteran reported that he took 20 milligrams of omeprazole every morning "just to be able to swallow." He said he had a hard time swallowing all of his medication. An October 2008 emergency department note reflects that the Veteran was seen for sinus congestion and cough. The Veteran denied loss of appetite, nausea, vomiting, dysphagia, diarrhea, bright red blood per rectum, jaundice, constipation, melena and hematemesis. Current medications included 20 milligrams of omeprazole by mouth every morning before breakfast. On examination of the abdomen, it was soft, non-distended, non-tender, and bowel sounds were positive. A March 2009 VA primary care note reflects that the Veteran was still taking 20 milligrams of omeprazole by mouth every morning before breakfast. He reported that Prevacid worked better for him than omeprazole. He said that in the past three weeks he had bright red blood and pain with bowel movements, and some black stools, which he attributed to hemorrhoids. On examination, there was an external hemorrhoidal tag. Stool guaiac tests were planned. On abdominal examination, there was no tenderness and no masses. In May 2009, the Veteran reported that pantoprazole was not working, and wanted to start Prevacid. A June 2009 note reflects that a lansoprazole prescription was pending and that the Veteran was told to pick up pantoprazole at the pharmacy. A July 2009 primary care note reflects that trials of omepramazole and pantoprazole for GERD had failed, and a request for lansoprazole was pending. The physician noted that the Veteran had no repeat of hematochezia (bloody stools), and that guaiac tests were needed. The physician noted that both shoulders had chronic pain that was worsened by his job at UPS which involved a lot of lifting. He had intermittent chest pains in the left axilla and left anterior chest that were not correlated to activity, and which he attributed to acid reflux. A lansoprazole request was pending. On abdominal examination, there was no tenderness or masses. An August 2009 physical medicine note reflects that the Veteran had pain in both shoulders which was worsened by his work activities. He received physical therapy for myofascial shoulder pain. In October 2009, it was noted that his work loading trucks increased his bilateral shoulder pain. A September 2009 primary care note reflects that the Veteran was taking lansoprazole and doing better. His active medications included 15 milligrams of lansoprazole daily for reflux. Subsequent treatment notes reflect ongoing use of this medication, as well as ongoing alcohol abuse. At his April 2010 Board hearing, the Veteran testified that his medication for his reflux symptoms had been changed. He reported daily symptoms. He reported chest and shoulder pain, but said he was told it was angina. He said that if not for the medication, he would not be able to eat, and as it was, he took his medication once daily, in the morning, and could not really eat until 1:00 or sometimes 3:00. He said his current medication did not clear up the clogged feeling he had in his throat, as the prior medication did. He said that doctors had not placed him on a restricted diet, but there were some foods he felt he could not eat. He said he had to cut up his food into very small pieces. He saw his doctor every three to six months. He reported shoulder pain which "rotates from each shoulder," and regurgitation of his pills. A September 2010 VA outpatient treatment record reflects that he had no recurrence of hematochezia, but had hemorrhoids. On VA examination in January 2011, the examiner stated that the claims file was reviewed. The Veteran reported that previously, he took Prevacid for his hiatal hernia with gastroesophageal reflux until he was discharged from service, and this medication was effective. However, when his prescription ran out, he was given a different medication that did not work as well and did not last as long. He complained of decreased appetite, and often avoided eating within an hour before bed. He said that with respect to his sleep disturbances, they were related to his enlarged prostate and bladder fullness, and also had right arm discomfort, numbness and pain following a fracture and ganglion excision. With respect to swallowing, he said that lately he sometimes had difficulty with salads and potato chips, and had to crush the potato chips and cut his salad into small bites. He said that his food would do better if it was pureed or soupy, but had not required this in the past. He reported that his throat felt clogged up all day long, and was improved by drinking extra water or fluids. He also reported feeling a sensation as if something were stuck in his throat. He said he had discomfort in the midline area just below the lower part of the sternum. He stated that since service, he had been evaluated for substernal pain, and was told it was angina, but it was not bad enough to require nitrate therapy. The examiner indicated that he appeared well-nourished. On examination, the Veteran was well-developed and well-nourished, in no acute distress. The oral cavity and oropharynx appeared normal. Palpation of the neck revealed no subcutaneous mass. He had been placed on multiple medications in the past. He said that his original medication, apparently Prevacid, worked best, but he was presently on lansoprazole 15 milligrams daily. The examiner stated that the Veteran had no history of regurgitation or hematemesis, and there was no increased erythema of the oral pharynx mucosa as is sometimes seen in severe gastroesophageal reflux disease. The diagnostic impression was gastroesophageal reflux disease, and hiatus hernia. The examiner indicated that the Veteran had symptoms of gastroesophageal reflux disease since 2004. He stated that on his initial emergency room visit in 2004, he was evaluated for possible cardiac causes but the electrocardiogram findings were negative, and he was given a GI cocktail to drink which gave him great relief and a prescription for Prevacid which he used until it ran out after discharge. He said that the Veteran felt that his throat was clogged up all day long, and a sensation that something was stuck in his throat and that he had to drink extra fluids to relieve his throat symptoms. In an October 2013 written brief, the Veteran's representative contended that a higher rating should be assigned for hiatal hernia with gastroesophageal reflux under Diagnostic Code 7346, and a separate or increased rating should be awarded under Diagnostic Code 8210, based on his difficulties with dysphagia, including eating and swallowing food. Under Diagnostic Code 8210, paralysis of the 10th (pneumogastric, vagus) cranial nerve is rated 50 percent when complete, 30 percent for severe incomplete paralysis, and 10 percent for moderate incomplete paralysis, dependent upon the extent of sensory and motor loss to organs of voice, respiration, pharynx, stomach, and heart. 38 C.F.R. § 4.124a, Diagnostic Code 8210. In this regard, the Board observes that the Veteran's cranial nerves were normal on VA neurological examination in August 2008, and in September 2010. The Veteran has never been diagnosed with paralysis of the 10th (pneumogastric, vagus) cranial nerve, and moreover, he is not service-connected for such a disability. To the extent that the Veteran's representative is arguing that the Veteran's service-connected hiatal hernia with gastroesophageal reflux should be rated by analogy to paralysis of the 10th cranial nerve, the Board finds that such an analogous rating is not appropriate here. See 38 C.F.R. § 4.20 (permitting evaluation, by analogy, where the rating schedule does not provide a specific diagnostic code to rate the disability). As noted above, the Veteran's condition, hiatal hernia with gastroesophageal reflux, does have a specific Diagnostic Code under the Schedule for Rating Disabilities, Diagnostic Code 7346, and thus the disability is properly rated under that code. Finally, assigning multiple ratings for the Veteran's dysphagia, based on the same symptoms or manifestations, would constitute prohibited pyramiding. 38 C.F.R. § 4.14. The Board finds that Diagnostic Code 8210 is not for application here. The Veteran, as a lay person, is competent to provide such evidence of how his hiatal hernia with gastroesophageal reflux disability affects his everyday life. See Layno v. Brown, 6 Vet. App. 465, 469-470 (1994) (finding lay testimony competent when it concerns features or symptoms of injury or illness). He is competent to report that which he can experience or observe and is deemed credible, in this regard. However, as a lay person lacking in medical training and expertise, the Veteran cannot provide a competent medical opinion regarding the severity of his disability including clinical evaluation and laboratory studies, and to that extent, his reports are outweighed by the detailed opinions provided by the medical professionals who evaluated the Veteran's service-connected disability and provided the relevant clinical testing to rate the claim. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The Board finds that the VA examination reports and treatment records reflect that the Veteran's hiatal hernia with gastroesophageal reflux is mostly controlled by prescription medication, specifically Prevacid (lansoprazole). The record reflects that he was taking this medication in service, and he has repeatedly stated, and testified, that this medication works well for his reflux symptoms. The evidence also shows that other medications previously prescribed for reflux by VA (omepramazole and pantoprazole) did not work as well. However, his VA medical records demonstrate that since September 2009, he has once again been taking lansoprazole and doing better. Since that time, his active medications include 15 milligrams of lansoprazole daily for reflux. As detailed above, the July 2008 VA examination report reflects that the Veteran said he experienced regurgitation of his pills, occasional chest pain and indigestion, and no upper arm pain. He denied other symptoms. The VA outpatient treatment records are entirely devoid of reports of regurgitation, and in fact he has repeatedly denied this symptom during treatment. The January 2011 VA examination report reflects that the Veteran experiences substernal pain, a feeling that his throat is clogged up, and difficulty swallowing which requires him to cut his food into small pieces. Based on the subjective complaints, and objective findings in the record, the Board has determined that an increased disability rating of 10 percent, and no higher, is warranted for the Veteran's hiatal hernia with gastroesophageal reflux, throughout the rating period on appeal, based on symptoms of dysphagia and pyrosis, i.e., two of the symptoms for a 30 percent rating but of less severity than that required for the higher rating. 38 C.F.R. § 4.114, Diagnostic Code 7346. An even higher 30 percent rating is not warranted under Diagnostic Code 7346, as the weight of the competent and credible evidence does not show that there is persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, that is productive of considerable impairment of health. The record does not suggest any impairment of health due to the service-connected hiatal hernia with gastroesophageal reflux. Although the Veteran has been treated for right arm pain and bilateral shoulder pain, these complaints have been related to unrelated orthopedic conditions, including a service-connected right elbow disability and a non-service-connected shoulder disability, and may not be considered when evaluating his service-connected hiatal hernia with gastroesophageal reflux. 38 C.F.R. § 4.14. Again, while he has experienced pyrosis and dysphagia, these symptoms are mostly controlled with medication, and he is not shown to be in persistent recurrent epigastric distress due to his hiatal hernia with gastroesophageal reflux. Impairment from the hiatal hernia with gastroesophageal reflux more closely approximates the criteria for a 10 percent rating than the next higher rating, and thus the lower 10 percent rating is to be assigned. 38 C.F.R. § 4.7. An even higher 60 percent rating is also not warranted under Diagnostic Code 7346, as the evidence does not show that the Veteran's hiatal hernia with gastroesophageal reflux is manifested by pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. He apparently had a single unwitnessed episode of black stools in March 2009, but the preponderance of the medical evidence does not show that he has hematemesis or melena with moderate anemia due to his hiatal hernia with gastroesophageal reflux. His hematochezia (bloody stools), has been related to his non-service-connected hemorrhoids, and symptoms from this may not be considered when evaluating his service-connected hiatal hernia with gastroesophageal reflux. 38 C.F.R. § 4.14. The Veteran has specifically denied any vomiting, hematemesis, or melena, and moderate anemia or weight loss is not shown. There is no other diagnostic code which could provide for a higher disability rating. In sum, an increased 10 percent rating is warranted for service-connected hiatal hernia with gastroesophageal reflux, throughout the rating period on appeal. The benefit-of-the-doubt rule has been applied. 38 U.S.C.A. § 5107(b) (West Supp. 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Extraschedular Considerations The Board has considered whether this case should be referred for extra-schedular consideration pursuant to 38 C.F.R. § 3.321(b)(1). An extra-schedular rating is warranted if a case presents such an exceptional or unusual disability picture, with such related factors as marked interference with employment or frequent periods of hospitalization, that it would be impracticable to apply the schedular standards. Analysis under this provision involves a three-step inquiry, and extra-schedular referral is necessary only if analysis under the first two steps reveals that the rating schedule is inadequate to evaluate the claimant's disability picture and that such picture exhibits such related factors as marked interference with employment or frequent periods of hospitalization. Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). Here, the manifestations of the Veteran's hiatal hernia with gastroesophageal reflux are fully contemplated by the schedular rating criteria of Diagnostic Code 7346. Thus, the evidence does not support referring this case for an extraschedular evaluation. ORDER Throughout the rating period on appeal, an increased 10 percent rating for service-connected hiatal hernia with gastroesophageal reflux is granted, subject to the regulations governing monetary benefits. ______________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs