Citation Nr: 1504607 Decision Date: 01/30/15 Archive Date: 02/09/15 DOCKET NO. 06-01 395 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUE Entitlement to an increased rating, greater than 20 percent for postoperative duodenal ulcer with gastroesophageal reflux disease (GERD) and chronic pancreatitis. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Amanda Christensen, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, had active service from May 1975 to May 1979. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2004 decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, which granted an increased rating for service-connected postoperative duodenal ulcer with GERD and established a 20 percent evaluation. The Veteran appealed from the assigned evaluation. The Board remanded this matter for additional development in May 2010. Such development was conducted, and in an August 2012 decision, the Board denied entitlement to a rating of higher than 20 percent for postoperative duodenal ulcer with GERD. In April 2013 the United States Court of Appeals for Veterans Claims (Court) granted the parties' Joint Motion for Remand and remanded the matter to the Board for action consistent with the motion. The Board again denied a higher rating in a January 2014 decision. The parties filed a Joint Motion for Remand with the Court, and in December 2014 the Court again remanded the matter to the Board for action consistent with that motion. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C.A. § 7107(a)(2) (West 2014). FINDINGS OF FACT 1. From January 1, 2005 to December 31, 2005 the Veteran's postoperative duodenal ulcer with GERD and chronic pancreatitis manifest with four typical attacks of abdominal pain per year and good remission between attacks. 2. Prior to January 1, 2005 and after December 31, 2005, the Veteran's postoperative duodenal ulcer with GERD and chronic pancreatitis did not manifest with at least four typical attacks of abdominal pain per year. 3. Throughout the period on appeal, the Veteran's postoperative duodenal ulcer with GERD and chronic pancreatitis did not result in 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. CONCLUSIONS OF LAW 1. The criteria for an evaluation of 30 percent, but no higher, for service-connected postoperative duodenal ulcer with GERD and chronic pancreatitis have been met from January 1, 2005 to December 31, 2005. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§3.102 , 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.21, 4.111, 4.112, 4.113, 4.114, Diagnostic Codes 7347 (2014). 2. The criteria for an evaluation in excess of 20 percent for service-connected postoperative duodenal ulcer with GERD and chronic pancreatitis have not been met prior to January 1, 2005 or after December 31, 2005. 38 U.S.C.A. §§ 1155 , 5107 (West 2014); 38 C.F.R. §§3.102 , 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.21, 4.111, 4.112, 4.113, 4.114, Diagnostic Codes 7305, 7308, 7346, 7347 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSION Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects the ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (rating schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10 (2014). When all the evidence is assembled, the Board is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3 (2014). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2014). Additionally, the evaluation of the same disability under several Diagnostic Codes, known as pyramiding, must be avoided. Separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). On a claim for increased rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found; such separate disability ratings are known as staged ratings. In Hart v. Mansfield, the Court extended entitlement to staged ratings to claims for increased disability ratings where "the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings." Hart v. Mansfield, 21 Vet. App. 505, 511 (2007). Generally, lay evidence is competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308 -09 (2007). In the September 2004 decision on appeal, the Veteran was granted an increased rating of 20 percent for postoperative duodenal ulcer with GERD, effective April 6, 2004. The Veteran's disability is rated under 38 C.F.R. § 4.114, Diagnostic Code (DC or Code) 7305. Under this Code, a 20 percent evaluation is assigned for moderate duodenal ulcer characterized by either recurring episodes of severe symptoms two or three times a year averaging 10 days in duration or continuous moderate manifestations. A 40 percent evaluation for a moderately severe duodenal ulcer requires a duodenal ulcer that is less than severe but that is characterized by either 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. The highest evaluation of 60 percent is reserved for a severe duodenal ulcer characterized by pain being only partially relieved by standard ulcer therapy, periodic vomiting, recurrent hematemesis or melena, and manifestations of anemia and weight loss productive of definite impairment of health. 38 C.F.R. § 4.114 (2014). "Substantial weight loss" means a loss of greater than 20 percent of the individual's baseline weight sustained for three months or longer. "Minor weight loss" means a weight loss of 10 to 20 percent of the individual's baseline weight sustained for three months or longer. An "inability to gain weight" means that there has been substantial weight loss with inability to regain it despite appropriate therapy. "Baseline weight" is the average weight for the two-year-period preceding onset of disease. 38 C.F.R. § 4.112 (2014). Two other Diagnostic Codes are also potentially applicable to the Veteran's postoperative duodenal ulcer with GERD. The Veteran underwent an in-service subtotal gastrectomy as a result of his duodenal ulcer, and Diagnostic Code 7308 addresses postgastrectomy syndromes. A 20 percent evaluation is for mild postgastrectomy syndrome characterized by infrequent episodes of epigastric distress with characteristic mild circulatory symptoms or continuous mild manifestations. Moderate postgastrectomy syndrome characterized by less frequent episodes of epigastric distress (than are present with severe postgastrectomy syndrome) with characteristic mild circulatory symptoms after meals but with diarrhea and weight loss is needed for a 40 percent evaluation. The highest evaluation of 60 percent requires severe postgastrectomy syndrome associated with nausea, sweating, circulatory disturbance after meals, diarrhea, hypoglycemic symptoms, and weight loss with malnutrition and anemia. 38 C.F.R. § 4.114 (2014). Various postgastrectomy symptoms may occur following anastomotic operations of the stomach. When present, those occurring during or immediately after eating and known as "dumping syndrome" are characterized by gastrointestinal complaints and generalized symptoms simulating hypoglycemia. Those occurring from one to three hours after eating usually present definite manifestation of hypoglycemia. 38 C.F.R. § 4.111 (2014). GERD is rated analogously to hiatal hernia because it does not have its own Diagnostic Code, and as such the Board considers whether a rating is warranted under 38 C.F.R. § 4.114, DC 7346 which relates to rating hiatal hernia. Under this Code, a 30 percent evaluation is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis and regurgitation accompanied by substernal or arm or shoulder pain and productive of considerable impairment of health. Symptoms of pain, vomiting, material weight loss, and hematemesis or melena with moderate anemia or other symptom combinations productive of severe impairment of health equate to the highest evaluation of 60 percent. 38 C.F.R. § 4.114 (2014). Pyramiding, rating the same disability or the same manifestation of a disability under different Codes is to be avoided. 38 C.F.R. § 4.14. 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 digestive diseases do not lend themselves to distinct and separate evaluations without violating the fundamental principle against pyramiding. Id. Ratings under DCs 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive, will not be combined with each other. 38 C.F.R. § 4.114. Rather, a single evaluation instead will be assigned under the Diagnostic Code which reflects the predominant disability picture. Id. In light of the above, one other Diagnostic Code is for consideration. Service connection for hepatitis C has been granted, as has service connection for chronic pancreatitis secondary to hepatitis C. Under DC 7347, a 30 percent evaluation is assigned for moderately severe pancreatitis with at least four to seven typical attacks of abdominal pain per year and good remission between attacks. A 60 percent evaluation requires frequent attacks of abdominal pain, loss of normal body weight, and other findings showing continuing pancreatic insufficiency between attacks. A total evaluation is reserved for frequently recurrent disabling attacks of abdominal pain with few pain free intermissions and with steatorrhea, malabsorption, diarrhea, and severe malnutrition. Id. Note 1 following Diagnostic Code 7347 directs that abdominal pain in this condition must be confirmed as resulting from pancreatitis by appropriate laboratory and clinical studies. Note 2 directs that a minimum rating of 30 percent must be assigned under DC 7347 for symptoms following total or partial pancreatectomy. The Board finds that a rating of greater than 20 percent under DC 7305 is not warranted. VA treatment records show some evidence of anemia during the period on appeal. Specifically, the Veteran had iron deficiency anemia in January 2004, had anemia characterized as microcytic and mild between September and November 2005, and was anemic in February 2010. Anemia disease additionally was referenced on occasion to include in December 2005 and July 2006. Treatment records also show fluctuations with respect to the Veteran's target weight and his actual weight. His target weight was 214 pounds in early 2005 but adjusted to 193 in March 2009. The Veteran's weight ranged from the low 200s to the low 210s in 2004, to include 210 pounds at his May 2004 VA medical examination. The Veteran's weight then began to decrease, with a low of 169 pounds recorded in January 2005. Nonetheless, his weight was in the high 180s and low 190s by March 2005 and was back over 200 pounds by August 2005. Some weight loss was noted in early 2006, but the Veteran's weight remained above 200 pounds throughout the rest of the year. It was generally in the high 180s in 2007 and 2008 despite a note indicating weight loss in 2008. The Veteran's weight was in the low 170s to low 180s in 2009 -back to the high 180s by February 2010 - and was above 190 in May 2010. At the October 2010 VA examination, the Veteran's weight was 184 pounds. It thereafter ranged from the low 190s to the high 190s. The Veteran reported weight fluctuated between five and 10 pounds in a December 2011 statement. However, the record reflects that the Veteran has had no impairment of health manifested by anemia and weight loss due to a moderately severe duodenal ulcer. Rather, the Board finds that the Veteran's anemia and weight loss are referable to service-connected hepatitis C, and not postoperative duodenal ulcer with GERD. Anemia was noted only sporadically, and at times, including during the Veteran's May 2004 VA examination, was not present at all. However, the Veteran's anemia - when present - followed treatment of hepatitis C involving medications causing significant side effects. The same is true of the Veteran's weight loss and weight fluctuation. Indeed, the most substantial decrease in the Veteran's weight began in late 2004 after he started taking hepatitis C related medication, and increased in early 2005 once he stopped taking such medication. Thus, the Board finds that the Veteran's anemia and weight are not related to his duodenal ulcer. The Veteran's weight loss in particular has been rated as part of the Veteran's evaluation for service-connected hepatitis C under 38 C.F.R. § 4.114, DC 7354. The Board acknowledges that weight loss from 2007, 2008, and 2009 was determined to be secondary to pancreatitis which, like the Veteran's duodenal ulcer, is for consideration here. Nonetheless, the Veteran has had a normal body mass index despite this weight loss, and has sometimes been characterized during the period on appeal as "thin," but frequently as "well developed" and "well nourished." Finally, the Board notes that the Veteran's anemia and weight loss have not coincided - with instances of anemia, other than in February 2010, occurring when the Veteran weighed 200 pounds or more. VA treatment records reflect that the Veteran has reported symptoms including abdominal pain, cramping, heartburn, nausea, vomiting, loss of or decreased appetite, loose stool, diarrhea, and fatigue. He has indicated that these symptoms are rare or occasional in that they occur a few to several times per month and last only a few days. The Veteran has also indicated that some of these symptoms are mild and are controlled by prescription medications with some supplementation of over-the-counter medication. The Veteran has denied hematemesis, melena, and blood in his stool. In December 2004 the Veteran reported two days of symptoms. He was subsequently hospitalized for five days in late January 2005 into February 2005, and for three days in March 2005 as a result of his symptoms. In April 2005, he reported symptoms for three days, and for two days in November 2005. Qualitative fecal fat was present in the Veteran's stool in September 2008, though the Veteran was otherwise asymptomatic. He was hospitalized for four days due to his symptoms in March 2009, and in November 2009 he complained of symptoms with no duration recorded. The Veteran described these last two episodes as incapacitating at the October 2010 VA medical examination. The Veteran finally was hospitalized for his symptoms for pancreatitis for four days in April 2012. Based on the foregoing, the Board finds that that recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year have not occurred at any point during the period on appeal. The Board recognizes that the Veteran had more than four symptomatic episodes in 2005. Nonetheless, this fact alone does not indicate that a 40 percent rating is warranted under DC 7305. With regard to the Veteran's report of symptoms including abdominal pain, cramping, heartburn, nausea, vomiting, loss of or decreased appetite, loose stool, diarrhea, and fatigue, occurring a few to several times per month, such symptoms are not incapacitating, and thus do not warrant a 40 percent rating under DC 7305. Rather, the Veteran has described such symptoms as only rare or occasional, and as controlled by medication. Without evidence of associated anemia and weight loss, such occurrences do not meet the criteria for a rating of greater than 20 percent. Turning to Diagnostic Code 7308, a 40 percent evaluation is not warranted as there is no indication of episodes of epigastric distress with characteristic mild circulatory symptoms after meals. In fact, there is no indication whatsoever of circulatory symptoms, whether mild or otherwise, after meals. Given the failure to find the "characteristic" symptoms, there is no need to discuss diarrhea or reiterate the previous discussion regarding weight loss. With respect to DC 7346, the Board has acknowledged that the Veteran has experienced epigastric distress, regurgitation (i.e. vomiting), and pyrosis. Yet there is no indication of accompanying substernal pain, arm pain, shoulder pain or dysphagia. Rather, the Veteran has affirmatively denied chest pain in VA treatment records throughout the period on appeal. With regard to symptoms which are present, the Board finds that such symptoms have not been "productive of considerable impairment of health," as described by the DC 7346. The Board notes that the Veteran only been hospitalized for a few days, and only a few times. Further evidence that the Veteran has not suffered from a "considerable impairment of health," includes that the Veteran has not reported any change in his ability to perform usual daily activities with the exception of modification of his diet to exclude fried and fatty foods and to limit caffeine intake. Turning lastly to Diagnostic Code 7347, the Board finds that a rating of 30 percent is warranted under this Code, but only for the period from January 1, 2005 to December 31, 2005. A rating greater than 20 percent is not warranted for any other period. Under Diagnostic Code 7347, a 30 percent evaluation is assigned for moderately severe pancreatitis with at least four to seven typical attacks of abdominal pain per year and good remission between attacks. 38 C.F.R. § 4.114 (2014). The record shows that the Veteran was hospitalized for pancreatitis from January 31, 2005, to February 4, 2005. He was also admitted to the hospital for chronic pancreatitis in March 2005. In April 2005, the Veteran sought medical attention for abdominal pain and stated that his symptoms felt the same as previous exacerbations of the condition. A diagnostic impression of pancreatitis was noted. In November 2005, the Veteran complained of pancreatitis and the medical treatment record showed a diagnostic impression of pancreatitis. Thus, giving the Veteran the benefit of the doubt, the evidence suggests he had four attacks of pancreatitis during the year 2005. However, the evidence does not show at least four typical attacks of abdominal pain over the span of any other year. The Veteran reported only occasional abdominal pain his May 2004 VA examination. At his October 2010 VA examination the Veteran specifically reported only intermittent episodes of abdominal pain that are mild, rare, and self-limiting. Thus, the Board finds that the criteria for a 30 percent rating is met only from January 1, 2005 to December 31, 2005, but not any other time during this appeal. As this is an instance where the facts show distinct time periods where the Veteran's condition exhibits symptoms warranting different ratings, a staged rating is appropriate. Hart, 21 Vet. App. 505. The Board further finds that a 100 percent rating is not warranted under DC 7347 for any period on appeal. The Board acknowledges the September 2008 finding of qualitative fecal fat in the Veteran's stool; however it is unclear whether this amounts to steatorrhea, one of the criterions for a 100 percent evaluation under DC 7347. Nonetheless, even assuming that the Veteran had steatorrhea, the Board finds that his overall disability picture is not consistent with a 100 percent rating. Specifically, only a single finding of fat in the Veteran's stool has been made - a finding inconsistent with the rating criteria's description of "frequently recurrent disabling attacks of abdominal pain with . . . steatorrhea." Furthermore, the Veteran has not manifested the remaining criterion and, as previously noted, the Veteran has been characterized as well nourished - not suffering from "severe malnutrition" or malabsorption. The Board has also considered whether the severity of the Veteran's overall disability warrants elevation to the next higher evaluation under 38 C.F.R. § 4.114, but finds that it does not. While the Veteran's condition includes diagnoses of postoperative duodenal ulcer, GERD, and chronic pancreatitis, the symptoms even when considered as a whole, do not at any time more closely approximate a severity such that a rating higher than 30 percent from January 1, 2005 to December 31, 2005 or higher than 20 percent for any other time is warranted. The Board has carefully considered the severity of all of the Veteran's symptoms. While the Veteran's symptoms at various times have included abdominal pain, nausea, vomiting, heartburn, loss of or decreased appetite, loose stool, diarrhea, and fatigue, they have not coincided or occurred with such frequency or severity that higher ratings are warranted. The Veteran has had anemia only sporadically and the Board has found it to be associated with his hepatitis C. Although he has at other times had some weight fluctuation, it has not been such marked weight loss that it suggests a significant impairment of health. The Board finds that the overall disability caused by the Veteran's postoperative duodenal ulcer with GERD and chronic pancreatitis does not warrant a higher evaluation than that which is discussed above. Accordingly, the Board concludes that the Veteran's postoperative duodenal ulcer with GERD and chronic pancreatitis warrants a 30 percent rating from January 1, 2005 to December 31, 2005, but does not warrant a rating in excess of 20 percent for the remainder of the time period on appeal. Extraschedular Consideration The Board has also considered whether referral for an extraschedular rating is warranted for the Veteran's postoperative duodenal ulcer with GERD. The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Thun v. Peake, 22 Vet. App. 111, 115 (2008). Here the schedular rating criteria used to rate the Veteran's service-connected disability above, reasonably describe and assess the Veteran's disability level and symptomatology. The criteria rate the disability on the basis of symptomatology such as episodes of pain, cramping, heartburn, nausea, vomiting, fatigue, anemia, weight loss, loose stool, and diarrhea; thus the demonstrated manifestations - including periodic symptomatic episodes - are contemplated by the provisions of the rating schedule. As the Veteran's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is adequate. The schedular rating criteria also include analogous symptoms that are "like or similar to" listed schedular rating criteria. Mauerhan, 16 Vet. App at 442; see also 38 C.F.R. § 4.21 (2014). For these reasons, the Board finds that the schedular rating criteria is adequate to rate the Veteran's postoperative duodenal ulcer with GERD, and referral for consideration of an extra-schedular evaluation is not warranted. Finally, the record does not reveal that the Veteran is claiming that he is rendered unemployable by virtue of postoperative duodenal ulcer with GERD, and the Board finds that the record has not raised an implied claim for a total disability rating based on individual unemployability due to service-connected disabilities pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009); thus no discussion or remand of such a claim in warranted. Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. A notice letter was sent to the Veteran in April 2004, and he was supplied with additional information in a statement of the case provided in December 2005. Although VA's duty to notify was satisfied subsequent to the initial adjudication of the issue on appeal, the issue was readjudicated, most recently, with the issuance of a supplemental statement of the case in December 2011, thus curing any timing defect. Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant notification followed by readjudication of the claim, such as a statement of the case or supplemental statement of the case, is sufficient to cure a timing defect). Notice sent to the Veteran included descriptions of what information and evidence must be submitted to substantiate the claim, including a description of what information and evidence must be provided by the Veteran and what information and evidence would be obtained by VA. The Veteran was also advised to inform VA of any additional information or evidence that VA should have, and to submit evidence in support of the claim to the RO. The content of the letters complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). VA also has a duty to assist a veteran in the development of the claim. To that end, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159 (2014); see Golz v. Shinseki, 590 F.3d 1317, 1320-21 (2010) (stating that the "duty to assist is not boundless in its scope" and "not all medical records . . . must be sought - only those that are relevant to the veteran's claim"). The Board finds that VA has satisfied its duty to assist by acquiring service records as well as records of VA treatment in addition to those records of private treatment provided by the Veteran. These pertinent records have been associated with the Veteran's claims file and reviewed in consideration of the issues before the Board. The duty to assist was further satisfied by VA examinations in May 2004 and October 2010 during which examiners conducted physical examinations of the Veteran, were provided the claims file for review, took down the Veteran's history, considered the lay evidence presented, laid factual foundations for the conclusions reached, and reached conclusions and offered opinions based on history and examination that are consistent with the record. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4) (2014); Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of their opinion). Based on the foregoing, VA has fully met its duties to notify and assist the claimant with the development of the claim and no further notice or assistance is required. Finally, in May 2010 the Board remanded the immediate issue for additional development, including obtaining VA treatment records and affording the Veteran a VA examination to evaluate the Veteran's service-connected postoperative duodenal ulcer with GERD. Since that time, the sought treatment records have been associated with the claims file and in October 2010 a VA examination was completed. Therefore, the Board finds that the RO substantially complied with the Board's prior remand directives. See Stegall v. West, 11Vet. App. 268, 271 (1998) (noting the Board's duty to "insure [the RO's] compliance" with the terms of its remand orders). ORDER A rating of 30 percent, but no higher, for postoperative duodenal ulcer with GERD and chronic pancreatitis is granted from January 1, 2005 to December 31, 2005, subject to the laws and regulations controlling the disbursement of monetary benefits. A rating in excess of 20 percent for the period prior to January 1, 2005 and after December 31, 2005 for postoperative duodenal ulcer with GERD is denied. ____________________________________________ M. TENNER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs