Citation Nr: 1506112 Decision Date: 02/10/15 Archive Date: 02/18/15 DOCKET NO. 12-24 148 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Togus, Maine THE ISSUES 1. Entitlement to a compensable rating for hypertensive vascular disorder. 2. Entitlement to a compensable rating for residuals of subcutaneous mastectomy. 3. Entitlement to an effective date earlier than February 16, 2012, for the grant of a 100 percent rating for posttraumatic stress disorder (PTSD). 4. Whether the reduction of the 10 percent schedular rating for gastroesophageal reflux disease (GERD) with pre-ulcerative gastritis, to 0 percent, effective April 25, 2012, was proper. REPRESENTATION Appellant represented by: John S. Berry, Attorney at Law ATTORNEY FOR THE BOARD D.M. Casula, Counsel INTRODUCTION The Veteran had active service from September 1999 to January 2007. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2012 rating decision of the above Regional Office (RO) of the Department of Veterans Affairs (VA) which granted an increased, 100 percent, rating for PTSD, effective from February 16, 2012; denied a compensable rating for hypertension; and reduced the rating assigned for GERD with pre-ulcerative gastritis from 10 percent to 0 percent (non-compensable), effective from April 25, 2012. This matter further comes before the Board from a July 2012 rating decision in which the RO denied a compensable rating for residuals of subcutaneous mastectomy. The Board notes that in February 2009, a power of attorney (POA) was executed on a VA Form 21-22, Appointment of Veterans Service Organization as Claimant's Representative, naming John S. Berry as the Veteran's representative. In May 2013, the Veteran's appeal was certified to the Board. Thereafter, the Veteran's representative, John S. Berry, sent at least two letters to the Board regarding the Veteran's appeal. In March 2014, however, John S. Berry filed a document titled "Cancellation of Limited Power of Attorney", in which it was noted that he was canceling his limited power of attorney for the Veteran, and that the Veteran was sent a copy of this document. However, pursuant to 38 C.F.R. § 20.608(b)(2), after an appeal has been certified to the Board, a representative may not withdraw services as a representative in the appeal unless good cause is shown on motion, and motion must be in writing and must comply with the criteria set forth in 38 C.F.R. § 20.608(b)(2). Although the Veteran was notified of the attempted withdrawal of representation, to date a motion showing good cause to withdraw services has not been filed by John S. Berry. The Board concludes that at this time John S. Berry is still the Veteran's representative in this matter. The issue of entitlement to a compensable rating for residuals of subcutaneous mastectomy is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran's hypertension does not require continuous medication and he has a history of diastolic pressure predominately less than 100 and systolic pressure predominantly less than 160. 2. By September 2007 rating decision, the Veteran was granted service connection for PTSD and assigned a 50 percent disability rating, effective from January 31, 2007. By September 2009 rating decision, a 70 percent rating was granted for the service-connected PTSD, effective from March 2, 2009. The Veteran did not appeal these rating decisions and they became final. 3. On February 16, 2012, an informal claim for an increased rating for PTSD was received from the Veteran. 4. Prior to February 16, 2012, there were pertinent VA treatment records received, as early as December 9, 2010, that may be construed as informal unacted upon claims for an increased rating for PTSD received in the record. 5. It was not factually ascertainable that an increase in severity of the Veteran's PTSD occurred at any point prior to February 16, 2012. 6. The reduction of the rating for service-connected GERD with pre-ulcerative gastritis, from 10 percent to 0 percent, effective April 25, 2012, was improper in that it did not comport with applicable laws and regulations. CONCLUSIONS OF LAW 1. The criteria for a compensable rating for hypertensive vascular disorder have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.7, 4.104, Diagnostic Code 7101 (2014). 2. The criteria for an effective date earlier than February 16, 2012, for the assignment of a 100 percent disability rating for PTSD, have not been met. 38 U.S.C.A. §§ 1155, 5110(a) (West 2014); 38 C.F.R. §§ 3.400, 4.1, 4.2, 4.7, 4.130, Diagnostic Code 9411 (2014). 3. The reduction of the 10 percent schedular rating for GERD with pre-ulcerative gastritis, to 0 percent, effective April 25, 2012, was not proper. 38 U.S.C.A. §§ 1155, 5112 (West 2002); 38 C.F.R. §§ 3.105, 3.344 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating a claim for VA benefits, as codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.159, 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA 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 C.F.R. § 3.159(b)(1), as amended, 73 Fed. Reg. 23,353 (April 30, 2008). This notice must be provided prior to an initial decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The VCAA notice requirements apply to all five elements of a service connection claim: (1) veteran status; (2) existence of disability; (3) connection between service and the disability; (4) degree of disability; and (5) effective date of benefits where a claim is granted. Dingess v. Nicholson, 19 Vet. App. 473, 484 (2006). In a claim for increase, the VCAA requirement is for generic notice of the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening 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 this case, the VCAA duty to notify was satisfied by way of a letter sent to the Veteran in March 2012 that fully addressed the notice elements and was sent prior to the initial RO decision in this matter. The letter informed the Veteran of what evidence was required to substantiate the claim and of his and VA's respective duties for obtaining evidence. The Board also notes that in this letter, the Veteran was advised of how disability ratings and effective dates are assigned. See Dingess v. Nicholson, supra. Moreover, he has not demonstrated any error in VCAA notice, and therefore the presumption of prejudicial error as to such notice does not arise in this case. See Sanders v. Nicholson, supra. Thus, the Board concludes that all required notice has been given to the Veteran. The Board also finds VA has satisfied its duty to assist the Veteran in the development of the claims. The RO has obtained all identified and available service and post-service treatment records for the Veteran. Further, he underwent VA examinations in April 2012 regarding the severity of his hypertension, PTSD, and GERD. These VA examinations included a review of the claims folder and a history obtained from the Veteran, and examination findings were reported, along with diagnoses/opinions, which were supported in the record. These VA examination reports are adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 310-11 (2007). It appears that all obtainable evidence identified by the Veteran relative to his claims has been obtained and associated with the claims folder, and he has not identified any other pertinent evidence, not already of record, which would need to be obtained for a fair disposition of this appeal. No further notice or assistance is required to fulfill VA's duties in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). The Board concludes that VA has satisfied its duty to assist the Veteran in apprising him as to the evidence needed, and in obtaining evidence pertinent to his claims under the VCAA. II. Compensable Rating for Hypertensive Vascular Disorder Disability evaluations are determined by application of the VA Schedule for Rating Disabilities, which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Each disability must be viewed in relation to its history and there must be emphasis upon the limitation of activity imposed by the disabling condition. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to 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. In every case where the requirements for a compensable rating are not met, a zero percent evaluation may be assigned, even if the diagnostic schedule does not provide for such a noncompensable evaluation. 38 C.F.R. § 4.31. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's service-connected hypertension is rated under Diagnostic Code (DC) 7101 which provides for a 10 percent disability rating for diastolic pressure predominantly 100 or more or systolic pressure predominantly 160 or more; or as the minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is warranted for diastolic pressure predominantly 110 or more or systolic pressure predominantly 200 or more. 38 C.F.R. § 4.104, DC 7101. For purposes of this section, the term hypertension means that the diastolic blood pressure is predominantly 90mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm. or greater with a diastolic blood pressure of less than 90mm. Id. In considering the Veteran's claim, as noted above, in order to obtain a compensable, 10 percent rating, for hypertension, the evidence must indicate diastolic pressure readings predominantly 110 or more, or systolic pressure predominantly 200 or more, or a history of diastolic pressure predominantly 100 or more and requiring continuous medication for control. 38 C.F.R. § 4.104, DC 7101. Review of VA treatment records shows that in November 2007 and December 2008, it was noted that the Veteran's hypertension was controlled without medication. Also shown were the following blood pressure readings: 122/72 in June 2009; 161/97 in December 2010; 120/70 and 116/66 in January 2011; and 140/80 and 126/76 in October 2011. On a VA examination in April 2012, it was noted that the Veteran was treated with medication for hypertension in service, but that he had not been using medication for hypertension for the past several years. He reported that he continued with lifestyle changes and it was noted that he may have white coat syndrome. It was also noted that the Veteran was monitored by his primary care doctor for the intermittent elevated blood pressures, but that he did not require continuous blood pressure medication for control of his hypertension. His blood pressure readings were listed as 130/80 (April 2012), 126/76 (October 2011), and 143/89 (March 2012). Thus, review of the record shows that the Veteran has not had diastolic pressure readings predominantly 110 or more, or systolic pressure predominantly 200 or more, or a history of diastolic pressure predominantly 100 or more. Rather, the record shows that most, if not all, of the Veteran's blood pressure readings taken during the pendency of his claim, and prior, have included diastolic pressure routinely below 100 and systolic pressures routinely below 160. The preponderance of the evidence is therefore against a finding that the Veteran's hypertension has met or approximated the criteria for a compensable rating at any point. 38 C.F.R. §§ 4.7. As the preponderance of the evidence of record is against the claim; the benefit-of-the-doubt doctrine does not apply; and the claim for a compensable rating for hypertensive vascular disorder must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet.App. 49 (1990). III. Earlier Effective Date for 100 percent rating for PTSD The effective date of a grant of an increased evaluation is based upon a variety of factors, including the date of claim, date entitlement is shown, and finality of prior decisions. See U.S.C.A. § 5110; 38 C.F.R. § 3.400. Section 5110(b)(2) and 38 C.F.R. § 3.400(o)(2) provide an exception to the general rule for increased rating claims by stating that the effective date of an increased rating shall be the earliest date as of which it is factually ascertainable that an increase in disability had occurred, if application is received within one year from such date, otherwise, date of claim. See Hazan v. Gober, 10 Vet. App. 511 (1997); see also Servello v. Derwinski, 3 Vet. App. 196 (1992). Basically, the Court has held that 38 U.S.C.A. § 5110(b)(2) and 38 C.F.R. § 3.400(o)(2) are applicable only where an increase in disability precedes a claim for an increased disability rating; otherwise the general rule of 38 C.F.R. § 3.400(o)(1) applies. See Harper v. Brown, 10 Vet App 125, 126 (1997). Thus, three possible dates may be assigned depending on the facts of the case: (1) if an increase in disability occurs after the claim is filed, the date that the increase is shown to have occurred (date entitlement arose); (2) if an increase in disability precedes the claim by a year or less, the date that the increase is shown to have occurred (factually ascertainable); or (3) if an increase in disability precedes the claim by more than a year, the date that the claim is received (date of claim). 38 C.F.R. § 3.400(o)(2); see also Harper v. Brown, supra. The Court has made it clear that the date of the filing of a claim is controlling in determinations as to effective dates. A specific claim in the form prescribed by the Secretary must be filed in order for benefits to be paid to any individual under the laws administered by VA. 38 U.S.C.A. § 5101(a); 38 C.F.R. § 3.151(a). The Veteran contends he should be entitled to an earlier effective date for the assignment of the 100 percent disability rating for his PTSD. In evaluating his claim, the Board must first identify the date of claim and then identify the date entitlement arose. Received from the Veteran in June 2007 was his formal claim (VA Form 21-526) for service connection for PTSD. By September 2007 rating decision, the RO, in pertinent part, granted service connection for PTSD, and assigned a 50 percent rating, effective from January 31, 2007. The Veteran did not appeal that decision and it became final. 38 U.S.C.A. § 7105; 38 C.F.R. § 20.1103. In February 2009, the Veteran filed a claim for an increased rating for PTSD. By September 2009 rating decision, the RO granted an increased, 70 percent rating for PTSD, effective from March 2, 2009. The Veteran did not appeal the September 2009 decision and it became final. 38 U.S.C.A. § 7105; 38 C.F.R. § 20.1103. Thereafter, the Veteran next filed a claim for an increased rating for PTSD on February 16, 2012. On that date, received from the Veteran, was a statement in support of claim (VA Form 21-4138) in which he requested that "VA increase my 70 percent PTSD", noting that he was having problems keeping jobs, had not worked for the past year, had failed out of an educational program, and his personal and family relationships were failing despite his best efforts. At that time, the Veteran also filed a claim for a total disability rating based on individual unemployability due to service-connected disability (TDIU rating), claiming that his PTSD and GERD affected full time employment. In April 2012, the Veteran underwent a VA examination to assess the severity of his PTSD. The VA examiner opined that the Veteran's PTSD resulted in total occupational and social impairment. The VA examiner noted that the Veteran was divorced and living with his girlfriend and had been housebound for the last three months. He tried to stay busy around the house with projects. With regard to employment, he last worked at Maine Maritime Academy in December 2009 but was let go after missing too many days of work for sleeplessness and anxiety. Further, it was noted that in November, the Veteran had been kicked out of EMCC because he missed too many days of school and was constantly sick. His PTSD symptoms included depressed mood; anxiety; suspiciousness; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a work like setting; inability to establish and maintain effective relationships; impaired impulse control, such as unprovoked irritability with periods of violence; neglect of personal appearance and hygiene. It was also noted that the Veteran had severe nightmares and night terrors, got only 1 to 2 hours of sleeping, and would wake up screaming. He denied suicidal thoughts. The examiner opined that based on the severity of symptoms and his almost complete lack of sleep, plus chronic anxiety, this Veteran most certainly displays an inability to obtain or maintain either sedentary or physical employment. A GAF (global assessment of functioning) score of 45 was assigned. Thereafter, by May 2012 rating decision, the RO granted an increased, 100 percent, rating for the Veteran's service-connected PTSD, effective from February 16, 2012. As noted above, the Veteran's increased rating claim was received on February 16, 2012. The Board has carefully reviewed the record in order to determine whether there existed previous, unacted upon claims for an increased rating, prior to February 16, 2012, the date of the increased rating claim. Servello v. Derwinski, supra. Also, with regard to the terms "application" or "claim", once a formal claim for compensation has been allowed, receipt of a VA hospitalization report, a record of VA treatment or hospitalization will be accepted as an informal claim for increased benefits, and the date of such record will be accepted as the date of receipt of a claim. 38 C.F.R. § 3.157(b)(1); 38 C.F.R. § 3.155(a). Under the controlling law and regulations outlined above, the Board must review the evidence dating back to September 2009, to determine the "earliest date as of which," within the year prior to the claim, an increase in disability was factually ascertainable. See Hazan v. Gober, supra. In that regard, the Board finds that the earliest document in the claims folder, received after the September 2009 rating decision, that can be construed as an informal or formal claim related to PTSD, was a VA treatment record dated December 8, 2010. This VA record showed that the Veteran called from work and reported he had more difficulty coping lately and had an increase in PTSD symptoms. He was taking an old prescription and it was helping, but his sleep was horrible, he was out of Ambien, and he wanted to see his mental health provider. He reported he had a supportive girlfriend and denied suicidal and homicidal ideations. The next day he presented for an urgent visit, reporting he had not been seen for a year and had become an officer at Maine Maritime Academy. He thought he could handle PTSD symptoms on his own, but days prior his PTSD symptoms and nightmares had flared up. He reported that it was about this time of year until February when he had a flare up of PTSD symptoms because many life events had happened at that time, including his father's suicide and his divorce. He reported having a supportive girlfriend who kept him busy and helped him get through this. He also talked to close friends felt this helped. Several days later, on December 14, 2010, the Veteran stated he felt normal but then had several crying spells while talking about the ambush in Iraq. It was noted that the Veteran was high functioning and in a stable relationship, and had significant, recurrent PTSD symptoms, worse at present but probably related to approaching anniversary of being ambushed while serving in Iraq. He was not suicidal or homicidal. In January 2011, it was noted that with regard to his PTSD he was "doing well". He responded to a questionnaire and endorsed having symptoms including disturbing memories, thoughts, or images, repeated disturbing dreams, reliving of the stressful event, moderate loss of interest in activities he used to enjoy, feeling distant or cut off from other people, having trouble sleeping, feeling irritable, having difficulty concentrating, and being super alert and easily startled. He reported that these problems made it "extremely difficult" for him to work, take care of things at home, or getting along with other people. In February 2011, he reported having persistent PTSD symptoms which had interfered with his work to the extent that he had requested and been granted a leave of absence (LOA) from his job at Maine Maritime Academy. On examination he was anxious but cooperative, oriented, depressed, and had normal speech and good eye contact. His thought processes appeared logical, he denied suicidal or homicidal ideations and hallucinations, and his memory was intact. The assessment was that he had significant, recurrent, worsening PTSD symptoms, some of which is related to anniversary of being ambushed while serving in Iraq, but sufficiently acute to warrant a leave of absence from his job. It was noted that uniforms and a military atmosphere had become somewhat of a trigger for him. Further, in February 2011, the Veteran reported tremor side effects from psychiatric medications, but his mood had improved. He remained on LOA but was in the process of enrolling in an x-ray technician program and was worried about his concentration due to a history of ADHD. He was sleeping better with fewer nightmares, and his mood was euthymic and thoughts organized. He agreed to start psychotherapy with a social worker. In March 2011, he had improved focus and motivation, with medication, and denied depression or anxiety. His mental status examination was unremarkable, and the diagnosis included ADHD, described as improving with treatment, and PTSD, stable. In April 2011, he reported side effects from psychiatric medications including being jittery and paranoid. He was accepted into a medical radiology program starting in the Fall, but felt he would not succeed because of his ADHD. In June 2011, he reported no increased anxiety, and because of his medications he was able to sleep without nightmares. He reported no depressive symptoms and improved concentration, and denied social anxiety or "paranoia." The impression was PTSD, stable. In July 2011, he reported starting college to get some basic courses out of the way. His focus and attention were improved and he was getting good grades. He was planning to move to an apartment with his girlfriend, and was sleeping well with no recent episodes of depression or anxiety. His PTSD symptoms were found to be stable. In August 2011, the Veteran's diagnoses included ADHD and PTSD, and a GAF score of 71 was assigned. Later in August 2011, he reported running out of medication the day before and experiencing rebound anxiety. He was waking at night with racing thoughts, worrying about his sister who had terminal brain cancer, and was getting worse. His mental status examination was unremarkable, but it was noted that he was experiencing increased stressors related to an intensifying academic/clinical load at school, plus worries about his sister. It was noted that he was general still doing well, with minor medication adjustments needed. In October 2011, the Veteran reported that a close friend was killed yesterday in Afghanistan by a roadside bomb. His classroom work and labs were very demanding and stressful, but his grades were good. He had no increased depression, except with the bad news about his friend. The impression was his PTSD was stable for the most part, but exacerbated by a friend's death. Thereafter, the Veteran missed his next few appointments, and in a telephone call in February 2012, he reported he was doing "very good" but wanted to see his provider as soon as practical. In March 2012, he called and left an urgent message requesting a call from his provider. When his call was returned, it was noted that his voice was trembling and he was in distress, and reported that for the past week, he had been becoming increasingly anxious and felt he was having panic attacks. He started crying when he reported that tomorrow was the anniversary of his military trauma. Later in March 2012, he reported he had dropped out of school, had night terrors, woke up screaming; and was afraid to go to bed. He indicated that the only thing that stopped it was if he drank, but he wanted to stop. On mental status examination, he was extremely anxious, but oriented and without psychosis. The impression was relapse/recurrence of severe symptoms of PTSD around the anniversary of severe trauma, and attempts to self-medicate with alcohol. Review of the VA treatment records, as detailed above, dated from December 2010 through February 2012, show that although the Veteran may have experienced intermittent increases in his PTSD symptoms prior to February 2012, he continued to seek and receive treatment and medication which helped his symptoms. Further, prior to February 2012, his PTSD symptoms did not result in total social or occupational impairment as these records show he was either working or in school during this time, maintained a relationship with his girlfriend, experienced improved sleep, had minimal depression and anxiety, had unremarkable mental status examinations, and continued to deny suicidal or homicidal ideation. Review of these records, however, does show that in March 2012, the Veteran experienced a marked increase in his PTSD symptoms and had stopped working/going to school. Thus, the Board concludes that although the December 2010 VA treatment record may be considered a claim for an increased rating for the service-connected PTSD, that record and subsequent records do not suggest a change in the Veteran's PTSD disability such that the assignment of 100 percent rating would be warranted prior to February 16, 2012. Overall, the preponderance of the evidence of record does not show an increase in the severity of the Veteran's PTSD within one year before his February 16, 2012 claim; at any point during the period from December 9, 2010 to February 16, 2012, or within one year of the above-referenced VA treatment record dated in December 2010. Rather, the first indication of an increase in severity of his PTSD symptoms was in March 2012. Therefore, the Veteran's claim for an earlier effective date for the increased 100 percent rating, prior to the February 16, 2012 date of claim, must be denied. See 38 U.S.C.A. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2). IV. Propriety of Rating Reduction for GERD The Veteran contends he is entitled to restoration of the 10 percent rating originally assigned for his service-connected GERD with pre-ulcerative gastritis. VA handles cases affected by a change in medical findings so as to produce the greatest degree of stability in ratings consistent with the laws and regulations governing compensation. 38 C.F.R. § 3.344(a) . A variety of requirements thus must be met in order for a reduction to be proper. These include both procedural requirements as well as substantive requirements. Where a reduction in an evaluation of a service-connected disability is considered warranted and the lower evaluation would result in a reduction or discontinuance of compensation payments currently being made, a rating proposing the reduction or discontinuance must be prepared setting forth all material facts and reasons. 38 C.F.R. § 3.105(e). VA's General Counsel has held that the provisions of 38 C.F.R. § 3.105(e) do not apply where there is no reduction in the amount of compensation payable, finding that this regulation is only applicable where there is both a reduction in evaluation and a reduction or discontinuance of compensation payable. VAOPGCPREC 71-91 (Nov. 1991), see also VAOPGCPREC 29-97 (Aug. 1997). Substantively, a disability rating shall not be reduced unless an improvement in the disability is shown. 38 U.S.C.A. § 1155; Greyzck v. West, 12 Vet. App. 288, 292 (1999). The standard for establishing improvement varies depending on amount of time the Veteran has been in receipt of the rating. For ratings that have been in effect for five years or more, as is the case here, a reduction is warranted when reexamination discloses sustained material improvement. 38 C.F.R. §§ 3.344(a-b). Examinations usually are the comparison point for determining whether or not there has been improvement. Collier v. Derwinski, 2 Vet. App. 247 (1992). Evidence other than examinations must also be considered, however. This includes post-reduction evidence, although the reduction must be supported by the evidence at the time it is made. Dofflemeyer v. Derwinski, 2 Vet. App. 277 (1992). By way of history, the Board notes that by October 2007 rating decision, the RO granted service connection for GERD with pre-ulcerative gastritis, and assigned a 10 percent disability rating, effective from January 31, 2007. Thereafter, in March 2012, the Veteran filed an Application for Increased Compensation based on Unemployability (VA Form 21-8940), claiming his service-connected PTSD and GERD prevented him from securing or following any substantially gainful occupation. The RO then sent him a letter advising that they were working on his claims, including regarding GERD with pre-ulcerative gastritis; requesting he submit evidence showing his GERD had increased in severity; and advising him he would be scheduled for a VA examination. In April 2012, the Veteran underwent a VA examination at which he reported that his GERD had been controlled on medication for years, and that he currently had mild intermittent symptoms. It was noted that he had reflux due to GERD. The examiner opined that the Veteran's GERD did not impact his ability to work. By May 2012 rating decision, the RO reduced the rating assigned for GERD with pre-ulcerative gastritis, from 10 to 0 percent, effective from April 25, 2012 (the date of the VA examination). The RO also noted that the 10 percent rating for GERD had been in effect for more than five years, and that normally an evaluation in effect for over five years would not be reduced based on just one examination report, however, in this case, the reduction would not affect the total evaluation for PTSD, thus, the reduction was effective the date of the VA examination. In a notice of disagreement filed in August 2012, the Veteran's representative, on his behalf, argued that although a decreased evaluation (for GERD) would not immediately affect the total evaluation for PTSD, this did not qualify as a reasonable basis for a reduction in evaluation. The representative further argued that according to 38 C.F.R. § 3.344(a) it was essential that a full and complete examination, including any special examinations, be considered before a reduction in evaluation, and that analysis of one examination report was not sufficient. With regard to whether the reduction was proper, the Board initially notes that by May 2012 rating decision, the Veteran's rating for service-connected PTSD was increased from 70to 100 percent, effective February 16, 2012. Thus, the reduction of the rating assigned for GERD with pre-ulcerative gastritis, from 10 percent to 0 percent, effective April 25, 2012, did not result in a decrease in the overall amount of compensation payable to the Veteran. It follows that the procedural requirements set forth in 38 C.F.R. § 3.105(e) are not applicable. Next, because the 10 percent rating for GERD with pre-ulcerative gastritis was in effect from January 31, 2007 to April 25, 2012, a little over five years, the appropriate standard is whether there was substantial material improvement. The Board notes that the service-connected disability of GERD does not have a specific diagnostic code, but has been rated according to the analogous condition of hiatal hernia under Diagnostic Code (DC) 7346. Under DC 7346, a 30 percent rating is warranted for a hiatal hernia with persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal arm or shoulder pain, productive of considerable impairment of health. A 10 percent rating is assigned when there are two or more such symptoms of less severity. The Board notes that when the initial 10 percent rating was assigned for GERD with pre-ulcerative gastritis, by the October 2007 RO rating decision, this was based on the VA examination in October 2007, which showed that he took medication daily and had regurgitation/reflux and a burning sensation in the throat in the morning. The question is whether there was substantial material improvement in his GERD symptoms. In that regard, the Board finds that there was not substantial material improvement shown from 2007 to 2012, as the Veteran's GERD still required medication and was manifested by regurgitation/reflux, and the only symptom not noted in 2012 that was shown in 2007 was a burning sensation in the throat. Moreover, in the May 2012 rating decision, the RO noted that a 0 percent rating was being assigned based on the April 2012 VA examination (noting that the Veteran took medication for his condition and had the symptom of regurgitation) which the RO found to show that the Veteran's GERD had decreased in severity. In the statement of the case (SOC) issued in August 2012, the RO noted the findings on the VA examination in 2012, but also noted that regulations provide that evaluations will not be reduced on any one examination, except in those instances where all the evidence of record clearly warrants the conclusion that sustained improvement had been shown. The RO then noted that because the Veteran's treatment records (dated in January 2012) showed he was on medication only with no treatment or evidence of any symptoms, this was considered sustained improvement. Review of the this VA treatment record dated in January 2012 shows that the Veteran reported he had an occasional flare up of GERD and was taking Prilosec. The recommendation was to order Zantac for him and that he could alternate between Zantac or Prilosec, or take Zantac as needed and Prilosec as maintenance. Thus, the Board finds that the Veteran's GERD was essentially the same from 2007 to 2013 in that at both times he took regular medication for GERD but still had symptom(s) or flare-ups of symptoms. Thus, after reviewing the record, the Board finds that reduction of the rating assigned for GERD from 10 to 0 percent effective April 25, 2012 was improper. Although the procedural requirements set forth in 38 C.F.R. § 3.105(e) do not apply in this matter because the reduction did not result in the amount of compensation payable, the Board finds that VA failed to apply and follow all pertinent substantive requirements. The Board concludes that restoration of the 10 percent rating for the Veteran's service-connected GERD with pre-ulcerative gastritis, effective April 25, 2012, is therefore warranted. ORDER A compensable rating for hypertensive vascular disorder is denied. An effective date earlier than February 16, 2012, for the grant of a 100 percent rating for PTSD, is denied. The reduction of the 10 percent schedular rating for GERD with pre-ulcerative gastritis, to 0 percent, being void, restoration of a 10 percent rating for GERD with pre-ulcerative gastritis, effective April 25, 2012, is granted, subject to the laws and regulations governing the payment of monetary benefits. REMAND The record reflects that in July 2012, the Veteran failed to report for a scheduled VA examination to assess the severity of residuals of subcutaneous mastectomy. In August 2012, the Veteran's representative indicated that he was now available to report for a VA examination, and requested that the examination be scheduled. Although a VA examination was scheduled in September 2012, the Veteran failed to report because he had been admitted for inpatient psychiatric treatment. Thereafter, he was scheduled for a VA examination in February 2013 and he failed to report. The address listed in the examination request form was in Winterport, Maine. In a substantive appeal (VA Form 9) submitted in April 2013, the Veteran indicated he had moved and did not receive any notices for the examinations and requested that his VA examination be rescheduled; he also provided a new address in Bangor, ME. In light of the fact that the Veteran may not have received notice of this most recent VA examination, a remand of this matter is warranted. It is emphasized, however, that "the duty to assist is not always a one-way street. If a veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence." Wood v. Derwinski, 1 Vet. App. 190, 193 (1991); see also Olson v. Principi, 3 Vet. App. 480, 483 (1992). Furthermore, while VA does have a duty to assist the veteran in the development of his claim, that duty is not limitless. In the normal course of events, it is the burden of the veteran to keep the VA apprised of their whereabouts. If he does not do so, there is no burden on the VA to "turn up heaven and earth" to find him. Hyson v. Brown, 5 Vet. App. 262 (1993). Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for an appropriate VA examination to address the current severity of his service connected residuals of subcutaneous mastectomy. The examiner must review the claims folder, and then note that this review has occurred. The examiner should be asked to describe the nature and severity of any and all symptoms related to the Veteran's residuals of subcutaneous mastectomy. The examiner must explain the rationale for any opinion(s) given. If a requested opinion cannot be rendered on a medical or scientific basis without invoking processes relating to guesswork or judgment based upon mere conjecture, the examiner should clearly and specifically so state, along with an explanation as to why that is so. 3. Thereafter, readjudicate the issues on appeal. If any benefit sought on appeal is not granted to the Veteran's satisfaction, he should be provided with a Supplemental Statement of the Case (SSOC) which addresses all evidence submitted, and be afforded the appropriate opportunity to respond thereto. The appellant has the right to submit additional evidence and argument on the matter or matters 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 2014). ______________________________________________ GAYLE E. STROMMEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs