Citation Nr: 1606002 Decision Date: 02/17/16 Archive Date: 03/01/16 DOCKET NO. 08-38 141 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to an initial evaluation in excess of 10 percent for the service-connected gastrointestinal disorder with dyspepsia from December 27, 2007 to July 7, 2010. 2. Entitlement to a disability rating in excess of 10 percent for the service-connected gastrointestinal disorder with dyspepsia since August 11, 2011. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD L. B. Cryan, Counsel INTRODUCTION The Veteran served in the Nebraska Army National Guard including a period of active duty for training (ACDUTRA or ADT) from April 2006 to August 2006 and a period of service performed under Title 10 orders from November 2006 to December 2007, and from July 2010 to August 2011. This case is before the Board of Veterans' Appeals (Board) on appeal from a March 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. In that rating decision, in pertinent part, the RO granted service connection for a gastrointestinal disorder with dyspepsia and assigned an initial 10 percent disability rating, effective from December 27, 2007. The Veteran disagreed with the initial 10 percent rating assigned, and this appeal ensued. In February 2010, the Veteran and his wife testified at a video conference hearing at the RO before a Veterans Law Judge (VLJ) sitting in Washington, DC. A transcript of the testimony is associated with the electronic record. The matter was remanded in April 2010 and October 2014 for additional development of the record. Meanwhile, in July 2010, during the pendency of the appeal, the Veteran was recalled to active duty and served from July 2010 to August 2011. During this time period, his compensation payments were suspended. See October 2011 RO rating decision code sheet. For this reason, and for the reasons set forth in the remand section of this document, the Board finds it more efficient to bifurcate the issue on appeal and address the time period prior to the most recent period of active duty separately from the period since that deployment. This recharacterization is reflected on the Cover Page of this decision. In December 2015, the Board notified the Veteran that he had the option of appearing for another Board hearing because the VLJ who conducted the February 2010 video conference hearing had since retired from the Board. He did not respond; therefore the Board presumes that another hearing is not requested. This appeal was processed using the Virtual Benefits Management System (VBMS) paperless claims processing system. Accordingly, any future consideration of this Veteran's case should take into consideration the existence of this electronic record. The issue(s) of entitlement to a disability rating in excess of 10 percent since August 11, 2011 for the service-connected gastrointestinal disorder with dyspepsia is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. For the period from December 27, 2007 to July 7, 2010, the Veteran's service-connected gastrointestinal disorder with dyspepsia is predominantly manifested by a disability picture most analogous to hiatal hernia with gastroesophageal reflux symptoms of heartburn, pyrosis, regurgitation, substernal pain, and frequent belching; but also with irritable bowel symptoms of bloating, gas, constipation with occasional diarrhea, when considered collectively, warrants elevation to the next higher rating under Diagnostic Code 7346. 2. Prior to July 7, 2010, neither anemia nor a symptom combination productive of severe impairment of health is demonstrated. CONCLUSION OF LAW Resolving all doubt in the Veteran's favor, the criteria for the assignment of a 30 percent rating, but not higher, for the service-connected gastrointestinal disorder with dyspepsia have been more nearly approximated during the period from December 27, 2007 to July 7, 2010. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.7, 4.20, 4.113, 4.114, Diagnostic Codes 7319, 7346 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist VA has a duty to provide notification to the Veteran with respect to establishing entitlement to benefits, and a duty to assist with development of evidence under 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159(b). The Veteran's claim arises from a disagreement with the initial disability rating that was assigned following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). VA also has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that with regard to the time period in question, all relevant facts have been properly developed, and that all available evidence necessary for equitable resolution of the issue has been obtained. The Veteran's service and post-service treatment records, VA examination reports, and lay statements have been obtained. VA has associated with the claims folder records of the Veteran's VA outpatient treatment, dated since 2007. He was also afforded two VA examinations, which are adequate because the examiners discussed his medical history, described his disabilities and associated symptoms in detail, and supported all conclusions with analyses based on objective testing and observations. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Veteran was also afforded an opportunity to testify before the VLJ who would ultimately decide his case. A hearing was conducted in April 2010. The VLJ who conducted the hearing noted the current appellate issue at the beginning of the hearing, and asked questions to clarify the appellant's contentions and treatment history. The appellant provided testimony in support his claims and expressed his contentions clearly. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Moreover, neither the appellant nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2), nor have they identified any prejudice in the conduct of the hearing. As noted in the Introduction section above, the VLJ who conducted the April 2010 hearing has since retired from the Board. The Veteran was provided an opportunity to testify at another hearing, but he did not indicate a desire for such. The record to decide the appeal for the time period December 27, 2007 to July 7, 2010 is complete. Thus, the Board may proceed without prejudice. II. Increased Rating prior to July 7, 2010 The Veteran seeks a disability rating in excess of 10 percent for the service-connected gastrointestinal disorder with dyspepsia (GI disorder) since the effective date of service connection. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3. Staged ratings must be considered, which are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods during the appeal. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). See also Fenderson v. West, 12 Vet. App. 119, 126 (1999) (applying this concept to initial ratings). It is the Board's responsibility to determine whether a preponderance of the evidence supports the claim or whether the evidence is in relative equipoise, with the veteran prevailing in either event, or whether there is a preponderance of evidence against the claim, in which case the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In this case, the Veteran is competent to testify on factual matters of which he has first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362 (2005). The Veteran is competent to provide evidence of observable symptoms, including pain. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). See also Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). The Veteran is competent to describe his symptoms and their effects on employment or daily activities. His statements have been consistent with the medical evidence of record, and are probative for resolving the matters on appeal. The Board will consider not only the criteria of the currently assigned diagnostic codes, but also the criteria of other potentially applicable diagnostic codes governing conditions of the digestive system. 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. Consequently, certain coexisting diseases in that area, do not lend themselves to distinct and separate disability ratings without violating the fundamental principle relating to pyramiding as outlined in 38 C.F.R. § 4.14. 38 C.F.R. § 4.113 (2015). Ratings under diagnostic codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive, will not be combined with each other. A single rating will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher rating where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114 (2015). Gastroesophageal reflux disease (GERD) is rated by analogy to hiatal hernia under Diagnostic Code 7346. When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. Under Diagnostic Code 7346, the maximum rating of 60 percent is warranted for symptoms of pain, vomiting, material weight loss, and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. A 30 percent rating is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 10 percent rating is assigned for two or more symptoms associated with the 30 percent rating, but of less severity. 38 C.F.R. § 4.114, Diagnostic Code 7346 (2015). The evidence of record, as discussed below establishes that the Veteran's predominant symptoms are associated with GERD, but he also has definite IBS symptoms as well. Irritable Bowel Syndrome (IBS) is rated by analogy to irritable colon syndrome under Diagnostic Code 7319. Under that code, a noncompensable rating is assigned for mild IBS, with disturbances of bowel function with occasional episodes of abdominal distress. A 10 percent rating is assigned for moderate IBS, with frequent episodes of bowel disturbance with abdominal distress. A maximum schedular rating of 30 percent is assigned for severe IBS, with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. 38 C.F.R. § 4.114, Diagnostic Code 7319 (2015). At a General Medical VA examination in January 2008, the Veteran reported symptoms of increased burping and bloating, gas, and daily gurgling and bubbling of the stomach. He reported mild constipation, occasional heartburn/pyrosis. He was prescribed omeprazole for the heartburn, but it only had minimal benefit. According to the Veteran, he has pyrosis one or two times per week, typically when lying down in bed at night. He has occasional nausea and rarely vomits. His weight was stable and his appetite was good. The diagnosis was dyspepsia, and the examiner found the Veteran's symptoms affected the Veteran's ability to feed to a moderate degree on a daily basis. A more in-depth study of the Veteran's digestive system was conducted between August 2008 and November 2008 by his VA primary care providers. These reports note that the Veteran continues to belch throughout the day, and in August 2008, he was belching over 1000 times per day. It intensifies after he eats and if he lays down. Even drinking water will make him belch and he finds it very embarrassing in social settings. The examiner confirmed that belching was witnessed when the Veteran initially sat down at his appointment in November 2008. The examiner noted that the Veteran had been switched from omeprazole to ranitidine. He also referred to an October 2008 upper GI endoscopy (EGD) which was normal. In addition to the belching, the Veteran reported reflux and bloating. A February 2010 outpatient treatment record notes that the Veteran has had chronic belching since being deployed to Iraq in 2007. His belching is frequent and loud, and causes the Veteran a great deal of social embarrassment. The examiner referred to the 2008 negative EGD and indicated that the Veteran was negative for H-pylori. No cause could be identified for the chronic belching, but it was believed that it might be slow motility or bacterial overgrowth. The examiner also noted that the Veteran had acid regurgitation after eating which caused substernal chest pain and sleep impairment. Finally, the examiner indicated that the Veteran had constipation which was likely IBS brought on by stress or perhaps a GI infection in Iraq that altered the mucosa. The examiner concluded that the Veteran's GI problems cause significant impairment in life and none of them appear to be easily or successfully treated. At his video conference in April 2010, the Veteran testified that he had pyrosis (heartburn), regurgitation, with difficulty swallowing back down when this occurs. The Veteran testified that he had pain under the sternum that rises up into his throat. He reported constant burping, both day and night. The burping keeps him up at night and prevents him from getting a full night of sleep. The Veteran believes this is productive of considerable impairment of health. The Veteran also testified that he has frequent constipation with episodes of diarrhea in between. The Veteran underwent a VA examination in May 2010. The examiner reviewed the Veteran's claims file and medical records. The examiner noted symptoms of belching and burping, as well as pyrosis (heartburn). The Veteran reported daily nausea and a history of vomiting two to three times per week. The Veteran reported weekly diarrhea and occasional blood in the stool with constipation issues. The examiner found no signs of significant weight loss, no signs of malnutrition, and no anemia. The examiner did note that the Veteran burped quite often, every few minutes. The examiner also noted that the Veteran regurgitated once or twice daily. He denied chest pain and abdominal pain. The Veteran indicated that medication helps with his pyrosis, but not with his burping. The burping does not interfere with his occupation, other than the social embarrassment it causes. The Veteran denied pain, but did report some stomach fullness, diarrhea and constipation which occurs weekly. He reportedly vomits two or three times per week, but may go a couple of weeks without vomiting at all. The Veteran denied material weight loss, hematemesis and anemia, although he does have occasional blood in his stool and occasional epigastric discomfort. He denied substernal pain and dysphagia, but had pyrosis and regurgitation daily. Upon a discussion with the Veteran, the examiner opined that the Veteran's symptoms cause less than considerable impairment of health. The examiner explained that despite the Veteran's symptoms, he is able to go about his daily chores, and the upper gastrointestinal issues do not interfere with his job or his daytime activities, other than causing considerable social issues due to belching, burping, regurgitation and occasional vomiting. According to the Veteran's most recent DD Form 214, the Veteran returned to active duty on July 8, 2010. He was deployed to Iraq from August 18, 2010 through June 4, 2011. He was released from active duty on August 10, 2011. In summary, the Veteran's gastrointestinal symptoms prior to his second period of active service (from July 2010 to August 2011) were fairly consistent and consisted of the following symptoms: daily regurgitation, frequent pyrosis, occasional substernal pain, occasional vomiting, occasional blood in the stool, frequent constipation, with alternating diarrhea on occasion, and, significantly, constant belching without relief. The Veteran's treating primary VA doctor and the VA examiner in May 2010 both specifically noted that the Veteran belched frequently during the examination(s), and other VA outpatient treatment records note that the Veteran belches every few minutes, totalling thousands of burps daily, without relief. The Veteran's primary care doctor in February 2010 indicated that the Veteran's gastrointestinal symptoms cause considerable impairment in life and his symptoms were not successfully treated. The VA records show that the Veteran's health care providers admittedly do not know what is causing the constant belching or how to successfully treat it. Further, while the Veteran has said that medication helps control the heartburn somewhat, he still experiences the pyrosis/heartburn and regurgitation frequently which is not under control. In contrast to the February 2010 treating provider, the VA examiner in May 2010 concluded that the Veteran's symptoms did not cause considerable impairment of health. He reasoned that, despite his symptoms, the Veteran was able to work and conduct activities of daily living without much limitation, if any. Additionally, the examiner noted that the Veteran did not exhibit outward signs of significant health impairment such as anemia and/or significant weight loss; and, he did not look malnourished. After a review of the evidence of record, the Board finds that the evidence for and against the claim for a higher rating prior to July 11, 2010 is in equipoise; that is, the evidence demonstrating that the Veteran's overall gastrointestinal disability picture is productive of considerable impairment of health is equally weighted against the evidence demonstrating otherwise. The evidence in support of the Veteran's claim includes the Veteran's competent and credible lay statements, as well as the February 2010 opinion of the Veteran's treating health care provider. Weighing against the Veteran's claim is the May 2010 opinion of the VA examiner. Therefore, the Board must resolve all doubt in the Veteran's favor and find that the criteria for the assignment of a 30 percent rating for the service-connected gastrointestinal disorder are more nearly approximated. The Veteran is therefore entitled to the benefit of the doubt. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Even if the Board were to place greater weight on the May 2010 opinion, and find that an actual considerable impairment of health is not outwardly demonstrated, the criteria for the assignment of a 30 percent are more nearly approximated pursuant to 38 C.F.R. § § 4.113, 4.114. As noted above, the Veteran's gastrointestinal disorder is predominantly manifested by GERD symptoms (frequent heartburn, regurgitation, nausea, vomiting), but is also manifested by IBS symptoms (gas, bloating, constipation, some diarrhea, and constant belching). The symptoms of GERD are rated by analogy to hiatal hernia under Diagnostic Code 7346, and the symptoms of IBS are rated analogous to irritable colon syndrome under Diagnostic Code 7319. The regulations instruct that ratings under diagnostic codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive, will not be separately rated and combined with each other; thus, the Veteran's IBS symptoms (Diagnostic Code 7319) and GERD symptoms (Diagnostic Code 7346) cannot be separately rated and combined. Rather, a single evaluation is 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 picture warrants such elevation. See 38 C.F.R. §§ 4.113, 4.114 (2015). Here, the Board finds that the severity of the Veteran's overall GI disability picture indeed warrants elevation from 10 percent to the next higher evaluation of 30 percent. The Veteran's symptoms of gas, bloating, constipation, and constant belching are contemplated in an IBS diagnosis, but are not considered in the criteria under Diagnostic Code 7346. Because the IBS symptoms cause frequent episodes of bowel disturbance with abdominal distress, the criteria for the assignment of a compensable rating would be more nearly approximated if a separate rating were assignable. Certainly the IBS symptoms are evident and frequent such that the overall gastrointestinal disability picture is more severe than what is contemplated by the symptoms associated with the criteria under Diagnostic Code 7346 alone. Thus, even if the Veteran's overall disability picture is not productive of "considerable impairment of health," as explained by the VA examiner in May 2010, his overall disability picture warrants elevation from 10 percent under Diagnostic Code 7346 to the next higher rating of 30 percent given the IBS symptoms not accounted for under Diagnostic Code 7346. In this regard, at no time prior to July 8, 2010 did the overall gastrointestinal disability picture more nearly approximate the criteria for the assignment of a disability rating in excess of 30 percent under Diagnostic Code 7346. The Veteran routinely denied pain, material weight loss, hematemesis, and melena. No anemia was demonstrated and severe impairment of health has never been shown. As noted by the May 2010 examiner, the Veteran is well enough to work and was well enough prior to July 2010 such that he was found fit for deployment. For the foregoing reasons, the criteria for the assignment of a 30 percent rating, but not higher, are more nearly approximated for the period from December 27, 2007 through July 7, 2010. The Board also has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). If the Veteran's symptoms are contemplated in the rating criteria then consideration of whether an extraschedular rating is not warranted. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Thun v. Peake, 22 Vet App 111 (2008). Here, as noted above, the schedular criteria contemplate all of the Veteran's symptoms because the rating for the GERD under Diagnostic Code 7346 is elevated to the next higher 30 percent rating to account for the IBS symptoms, which by regulation, may not be separately rated and combined with the rating under Diagnostic Code 7346. Thus, it cannot be said that the schedular rating is inadequate in this case. The evidence does not show such an exceptional disability picture that the available schedular evaluation for the Veteran's service-connected gastrointestinal disorder is inadequate. A comparison between the level of severity and symptomatology of the Veteran's gastrointestinal disorder with the established criteria found in the rating schedule for that disability shows that the rating criteria reasonably describes the Veteran's disability level and symptomatology. The Board also notes that a Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014). In this case, all of the Veteran's symptoms caused by service-connected disabilities are accounted for in the rating schedule and the Veteran's gastrointestinal disorder does not result in further impairment when viewed in combination with his other service-connected disabilities. In light of this discussion, the Board concludes that the schedular rating criteria adequately contemplate the Veteran's symptomatology, and the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In addition, the Board observes that the Court has held that a request for an increase in benefits should be inferred as a claim for special monthly compensation (SMC) regardless of whether it has been raised by the Veteran or previously adjudicated. See Akles v. Derwinski, 1 Vet. App. 118, 121 (1991). Moreover, VA's governing regulations direct the Board to review a claim for SMC in the first instance if reasonably raised by the record. In this case, however, the Board concludes that the issue of entitlement to SMC has not been raised by the record. The record does not reflect, nor does the Veteran argue, that she has loss of function that requires additional compensation under 38 C.F.R. § 3.350. Finally, the May 2010 VA examination report indicates that the Veteran was employed at that time and there is no indication that the Veteran was unemployed prior to that time. Further, the Veteran was found fit for deployment in July 2010. Accordingly, a claim for a total rating based on individual unemployability due to service-connected disabilities (TDIU) is not raised by the record prior to July 7, 2010. ORDER An initial 30 percent rating is granted prior to July 11, 2010 for the service-connected gastrointestinal disorder, subject to the law and regulation governing the payment of monetary benefits. REMAND After the Veteran returned from deployment in August 2011, he was scheduled for orthopedic and psychiatric examinations to assess any change in his service-connected psychiatric disorder and orthopedic disabilities. The RO did not, however, order a VA examination with regard to the gastrointestinal disorder. In an October 2011 rating decision, the RO reinstated the 10 percent rating that was previously assigned prior to his second deployment, but did so without first examining him. Then, in September 2013 correspondence, the Veteran reported that his gastrointestinal condition had worsened and requested a VA examination. To date no post-deployment VA examination has been conducted. A new examination is appropriate when there is an assertion (and indication) of an increase in severity since the last examination. 38 C.F.R. § 3.159; see also Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007). Also, where the Veteran claims that a disability is worse than when originally rated, VA must provide a new examination. See Olsen v. Principi, 3 Vet. App. 480, 482 (1992), citing Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). Additionally, VA's duty to assist the Veteran includes obtaining a thorough and contemporaneous examination where necessary to reach a decision on the claim. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Reexamination will be requested whenever VA determines that there is a need to verify the current severity of a disability. 38 C.F.R. § 3.327(a). Prior to the examination, up-to-date treatment records should be obtained. Furthermore, it does not appear that the Veteran's service treatment records from his second deployment period (July 2010 to August 2011) were requested or obtained, and these records may be probative in determining the severity of the Veteran's service-connected gastrointestinal disorder following his second period of active service. In light of the foregoing, the Board finds that the record with respect to the period of time from August 11, 2011 forward is incomplete. Accordingly, the case is REMANDED for the following action: 1. Obtain and associate with the electronic record all VA treatment records from August 2011 forward that are not currently of record. 2. With appropriate authorization, obtain and associate with the electronic record all private treatment records dated since August 2011 identified by the Veteran as pertinent to his claim. 3. Request from all potential sources, including the NPRC and the Adjutant General's office of the Nebraska Army National Guard, all of the Veteran's service treatment records from July 2010 forward. 4. Upon completion of the above directives, schedule the Veteran for a VA examination to determine the severity of his gastrointestinal disorder as of August 2011. The entire electronic record must be reviewed by the examiner. The examiner is to conduct all indicated tests and obtain a history from the Veteran as to the severity of his symptoms since August 2011. The examiner should describe all pertinent GERD symptomatology, to include whether there is pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health; or, whether there is persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health; or with two or more of the above symptoms of less severity. In addition, the examiner should describe all pertinent IBS symptoms, including whether there are frequent episodes of bowel disturbance with abdominal distress; or whether the IBS symptoms are severe, resulting in diarrhea or alternating diarrhea and constipation, with more or less constant abdominal distress. The examiner should opine whether the Veteran's overall gastrointestinal disability picture is productive of severe impairment of health. 5. Finally, readjudicate the issue remaining on appeal. If any of the benefits sought remain denied, issue a supplemental statement of the case and return the case to the Board. 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). ______________________________________________ BETHANY L. BUCK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs