Citation Nr: 1624173 Decision Date: 06/16/16 Archive Date: 06/29/16 DOCKET NO. 11-18 175 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to an increased rating for a left shoulder disability, rated as 20 percent disabling prior to February 14, 2013 and 30 percent disabling from that date. 2. Entitlement to a higher initial rating for chronic gastritis, gastric ulcer, and a hiatal hernia with gastroesophageal reflux disease (GERD), rated as 10 percent disabling before March 23, 2015 and 60 percent disabling from that date. 3. Entitlement to an effective date prior to June 9, 2011 for service connection for chronic gastritis, gastric ulcer, and a hiatal hernia with GERD. 4. Entitlement to service connection for an adjustment disorder with a depressed mood, claimed as secondary to the Veteran's service connected left shoulder disability. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD J. L. Prichard, Counsel INTRODUCTION The Veteran had active service from October 1956 to October 1958. This matter comes before the Board of Veterans' Appeals (Board) on appeal of rating decisions of the San Juan, Puerto Rico, regional office (RO) of the Department of Veterans Affairs (VA). The Veteran appeared at a hearing in April 2016. A transcript is in the record. Additional medical evidence pertaining to the claim for an increased rating for a left shoulder disability was received in April 2016. The Veteran's representative has submitted a waiver of initial RO review. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2015). 38 U.S.C.A. § 7107(a)(2) (West 2014). The issues of entitlement to an effective date prior to June 9, 2011 for service connection for chronic gastritis, gastric ulcer, and a hiatal hernia with GERD, and entitlement to service connection for an adjustment disorder with a depressed mood, claimed as secondary to the Veteran's service connected left shoulder disability, are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. With consideration of additional impairment due to repetitive use over time or flare-ups, the Veteran's left (minor) shoulder disability has been productive of limitation of motion to 25 degrees from the side for the entire appeal period. 2. Prior to March 23, 2015, the Veteran's chronic gastritis, gastric ulcer, and a hiatal hernia with gastroesophageal reflux disease was manifested by daily burning pain and nausea several times a week; constipation and abdominal tenderness were noted on one occasion but denied on all other occasions; without multiple eroded or ulcerated areas, weight gain or loss, loss of appetite, dysphagia, vomiting, hematemesis, diarrhea, melena, or hematochezia. 3. The Veteran has been in receipt of the highest scheduler rating available for his chronic gastritis, gastric ulcer, and a hiatal hernia with gastroesophageal reflux disease from March 23, 2015. CONCLUSIONS OF LAW 1. The criteria for entitlement to a 30 percent rating for a left shoulder disability have been met for the entire appeal period; the criteria for a rating in excess of 30 percent have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2014); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.71a, Codes 5200, 5201, 5202, 5203 (2015). 2. The criteria for an initial rating in excess of 10 percent for chronic gastritis, gastric ulcer, and a hiatal hernia with gastroesophageal reflux disease before March 23, 2015 have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2014); 38 C.F.R. §§ 4.7, 4.114, Codes 7305, 7307, 7346 (2015). 3. The criteria for a rating in excess of 60 percent for chronic gastritis, gastric ulcer, and a hiatal hernia with gastroesophageal reflux disease from March 23, 2015 have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2014); 38 C.F.R. §§ 4.7, 4.114, Codes 7305, 7307, 7346 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a) (West 2014); C.F.R. § 3.159(b)(1) (2015). Pelegrini v. Principi, 18 Vet. App. 112 (2004). The duty to notify has been met. In the claim for an increased rating for the left shoulder, the Veteran was provided with complete VCAA notification in a March 2009 letter. As for the claim for an increased rating for gastritis, the appeal arises from disagreement with the initial evaluation following the grant of service connection. The courts have held that once service connection is granted the claim is substantiated, additional VCAA 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). The Board also finds that the duty to assist has been met. The Veteran has been afforded recent VA examinations of both of the disabilities on appeal. These examinations address all rating criteria. At the April 2016 hearing, the Veteran testified that about the time he moved to Puerto Rico, he was told by a VA doctor that his left shoulder disability had become worse. The Board, however, observes that the most recent VA examination was conducted after his move, and an additional examination is not necessary. The Veteran has also submitted private examinations, and his VA treatment records have been obtained. The United States Court of Appeals for Veterans Claims (Court) has interpreted the provisions of 38 C.F.R. § 3.103(c)(2) as imposing two distinct duties on VA employees, including Board personnel, in conducting hearings: The duty to explain fully the issues and the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010) (per curiam). At the Veteran's hearing the undersigned engaged the Veteran and his representative in a discussion regarding the Veteran's left shoulder disability and gastritis. There was a discussion of the current symptomatology as well as the evidence relevant to an increased rating. The duties imposed by 38 C.F.R. § 3.103(c)(2), as explained by the United States Court of Appeals for Veterans Claims (Court) in Bryant v. Shinseki, 23Vet. App. 488 (2010) have been met. There is no indication that there is any relevant evidence outstanding in these claims, and the Board will proceed with consideration of the Veteran's appeal. Increased Rating The Veteran contends that his left shoulder disability has increased in severity to such an extent that the 30 percent evaluation is not adequate. He testified he was told that he should have shoulder replacement surgery. In addition, the Veteran argues that the initial evaluations assigned to his gastritis are also inadequate. He notes that this disability developed secondary to the pain medication he uses for the left shoulder disability, so that he is now often unable to use medication when he experiences shoulder pain. The evaluation of service-connected disabilities is based on the average impairment of earning capacity they produce, as determined by considering current symptomatology in the light of appropriate rating criteria. 38 U.S.C.A. § 1155. Consideration is given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4, whether or not they are raised by the veteran, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In addition, the entire history of the veteran's disability is also considered. Consideration must be given to the ability of the veteran to function under the ordinary conditions of daily life. 38 C.F.R. § 4.10. If there is a question as to which of two evaluations should apply, the higher rating is assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. In determining an initial rating, the entire record from the effective date of service connection to the present is of importance in determining the proper rating of disability, and staged ratings are to be considered in order to reflect the changing level of severity of a disability during this period. Fenderson v. West, 12 Vet. App. 119 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). The Board acknowledges that a claimant may experience multiple degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). Left Shoulder Entitlement to service connection for a left shoulder disability was established in a November 1969 rating decision. A 20 percent evaluation was assigned for this disability. Other than for temporary total evaluations on two occasions, the 20 percent rating remained in effect until the Veteran submitted his current claim. Subsequently, it was increased to 30 percent in an October 2015 rating decision, effective from February 14, 2013. The Veteran's left shoulder disability is evaluated under the rating code for degenerative arthritis. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate codes for the specific joint or joints involved. If the limitation of motion is noncompensable, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 20 percent evaluation is merited for X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. A 10 percent evaluation is merited for X-ray evidence of involvement of two or more major joints or two or more minor joint groups. 38 C.F.R. § 4.71a, Code 5003. The rating code that addresses limitation of motion of the Veteran's left shoulder disability is that for limitation of motion of the arm. Limitation of motion of the arm to shoulder level is evaluated as 20 percent disabling for either arm. Limitation of motion to midway between the side and shoulder level is evaluated as 30 percent disabling for the major arm, and 20 percent disabling for the minor arm. Limitation of motion to 25 degrees from the side is considered 40 percent disabling for the major arm and 30 percent disabling for the minor arm. 38 C.F.R. § 4.71a, Code 5201. For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. The Court has instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, or pain. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59. These provisions are not for consideration; however, where the veteran is in receipt of the highest rating based on limitation of motion and a higher rating requires ankylosis. Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997). The Veteran was afforded a VA examination of his left shoulder on April 15, 2009. He was right hand dominant. His symptoms included of pain and stiffness of the shoulder, which were precipitated on range of motion of the shoulder. There was no swelling, giving way or instability, locking, weakness, heat or redness, fatigability, lack of endurance or other symptoms reported. Flare-ups would result in increased pain and some additional limitation to the range of motion. There was no dislocation or recurrent subluxation. Range of motion showed 50 degrees of flexion, with pain from zero to 50 degrees; abduction was to 45 degrees, external rotation was to 45 degrees with pain from zero to 45 degrees, and internal rotation to 50 degrees with pain from zero to 50 degrees. His pain increased with repetitive movements. Repetitive motion also resulted in objective evidence of painful motion, marked tenderness, weakness, and severe guarding. There was no ankylosis. The diagnosis was severe post-traumatic osteoarthritis of the left shoulder with post-surgical changes. The examiner opined that the additional functional loss or impairment with repetitive motion and flare-ups could not be expressed without resort to mere speculation. At a February 14, 2013 VA examination, the Veteran was reported to be right handed. The Veteran said that for the past two years he had experienced severe pain and a limited range of motion of the left shoulder. He reported flare-ups, which resulted in difficulty in doing his activities of daily living due to severe limitation of movement of the left shoulder. On examination, the left shoulder had 40 degrees of flexion, with objective evidence of pain at that point. Abduction was to 20 degrees, with pain at that point. There was no additional limitation of motion following repetitive use testing, but there remained less movement than normal and pain on movement. The Veteran also had pain on palpation and guarding. Muscle strength was 4/5. There was no ankylosis. The Veteran was unable to perform impingement testing or the testing for external rotation. He reported a history of clicking and catching, but no recurrent dislocation or subluxation. There was no condition of the acromioclavicular joint or other impairment of the clavicle or scapula. He had a history of surgery in 1961 and 1994. The most recent VA examination of the left shoulder was conducted in May 2015. The Veteran's records were reviewed by the examiner, and he was noted to be right handed. He complained of being unable to use his left arm for most household activities. Range of motion of the left shoulder was 45 degrees of flexion, 45 degrees of abduction, 40 degrees of external rotation, and 90 degrees of internal rotation. The Veteran was able to perform repetitive use testing, but this did not result in any additional functional loss or loss of range of motion. The examiner opined that the results were medically consistent with the Veteran's statements describing functional loss with repetitive use over time. The examiner was unable to offer an opinion as to whether or not pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over time without mere speculation. The reason was that all musculoskeletal disorders could potentially cause functional limitations over time, but it would be speculation to describe the severity of the limitation. A similar opinion was expressed when describing the impact of flare-ups, and the examiner added that an examination would have to be conducted during a flare-up to obtain an accurate description. Muscle strength was reduced to 3/5, but there was no atrophy or ankylosis. Testing for disabilities of the rotator cuff was negative, and there was evidence of instability or dislocation. The Veteran did not have a disorder of the humerus, clavicle, scapula, acromioclavicular joint or sternoclavicular joint. The diagnosis was severe post-surgical osteoarthritis with associated capsulitis. The Veteran submitted a VA Form 21-0969M-12 Shoulder and Arm Conditions Disability Benefits Questionnaire from a private examiner in April 2016. The Veteran had a diagnosis of glenohumeral joint osteoarthritis. There was limited motion of the arm, and he was unable to do "almost nothing" with the left upper arm. Flexion was to 80 degrees, and abduction was to 20 degrees. The Veteran was unable to perform repetitive use testing due to significant pain. Other symptoms identified by the examiner included atrophy of disuse. The examiner said that pain, weakness, fatigability, or incoordination did not significantly limit functional ability during flare-ups or when the joint was used repeatedly over a period of time. Muscle strength was 4/5. There was no impairment of the humerus, clavicle, or scapula. Degenerative arthritis was documented on X-ray study. The Veteran was unable to do lifting, typing, or overhead activities. VA treatment records for the appeal period have been obtained and reviewed. While these show occasional complaints of left shoulder pain, they do not contain any additional findings regarding limitation of motion. The Board finds that the evidence supports entitlement to a 30 percent rating for the Veteran's left shoulder disability prior to February 14, 2013. The only medical evidence from this period that includes range of motion measurements is the April 2009 VA examination. Although this shows that the Veteran's range of motion was not limited to 25 degrees from his side on either flexion or abduction, the examiner also opined that there would be additional impairment with repetitive use and flare-ups but was unable to quantify this in terms of additional loss of motion without resorting to speculation. Given that additional limitation has been confirmed, and that the next highest level in the rating criteria would be the limitation to 25 degrees that warrants the 30 percent rating, the Board resolves all reasonable doubt in favor of the Veteran and finds that with consideration of the effects of pain, weakness, and fatigability his level of impairment more nearly resembled that of the limitation of motion to 25 degrees from his side that warrants a 30 percent rating. 38 C.F.R. §§ 4.40, 4.45, 4.71, Code 5201. The Board has considered entitlement to a rating in excess of 30 percent for the left shoulder for the entire appeal period, but the criteria for an increased rating were not met at any time. The 30 percent rating is the highest available under the rating criteria for limitation of motion of the minor arm. No more discussion of this rating code is necessary. 38 C.F.R. § 4.71a, Code 5201; Johnston v. Brown, 10 Vet. App. 80 (1997). The Board has considered the use of other potentially applicable rating codes, but finds that none of them are appropriate. All examinations have been negative for ankylosis, which precludes the use of the code for ankylosis of the scapulohumeral articulation. 38 C.F.R. § 4.71a, Code 5200 (2015). Similarly, all examinations have specifically stated that there is no additional impairment of the humerus such as recurrent dislocations, and no additional impairment of the clavicle or scapula. See 38 C.F.R. § 4.71a, Code 5202, 5203 (2015). It follows that the Veteran is in receipt of the highest scheduler rating available for his left shoulder disability. Gastritis The record shows that entitlement to service connection for mild gastritis claimed as a stomach condition secondary to medications taken for the Veteran's service connected left shoulder disability was granted in a December 2011 rating decision. A 10 percent rating was assigned, effective from June 9, 2011. This was increased to a 60 percent rating during the course of the current appeal, effective from March 23, 2015. The Veteran's disability has been evaluated under the rating codes for hiatal hernia and gastric ulcers. Under the rating code for a hiatal hernia, a 10 percent rating is warranted for a hiatal hernia with two or more of the symptoms for the 30 percent evaluation of less severity. 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. Lastly, a 60 percent rating 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. 38 C.F.R. § 4.114, Code 7346. A severe gastric ulcer is manifested by symptomatology including pain that is only partially relieved by standard ulcer therapy, periodic vomiting, recurrent hematemesis or melena, with manifestations of anemia and weight loss productive of definite impairment of health, and is evaluated as 60 percent disabling. A moderately severe duodenal ulcer is manifested by symptomatology that is less than severe, but with impairment of health manifested by anemia and weight loss, or recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year, and is evaluated as 40 percent disabling. A moderate duodenal ulcer has recurring episodes of severe symptoms two or three times a year averaging 10 days in duration, or with continuous moderate manifestations, and merits a 20 percent evaluation. A mild duodenal ulcer with recurring symptoms once or twice a year merits a continuation of the 10 percent evaluation currently in effect. 38 C.F.R. § 4.114, Code 7305. The Board finds that as the Veteran's current diagnoses include gastritis, it may also be appropriate to consider the rating criteria for chronic gastritis. Chronic gastritis with severe hemorrhages, or large ulcerated or eroded areas is evaluated as 60 percent disabling. Chronic gastritis with multiple small eroded or ulcerated areas, and symptoms is evaluated as 30 percent disabling. Chronic gastritis with small nodular lesions, and symptoms is evaluated as 10 percent disabling. 38 C.F.R. § 4.114, Code 7307. At this juncture, the Board notes that the most recent VA examiner has opined that the symptoms attributable to the Veteran's gastritis, hernia, and ulcer are indistinguishable. Regulations acknowledge that diseases of the digestive system may be difficult to distinguish, and do no lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding described in 38 C.F.R. § 4.14 (2015). See 38 C.F.R. § 4.113. Therefore, the Board will evaluate the Veteran under all three of the possible rating codes and apply the one that is most favorable. A January 2011 VA treatment note states that the Veteran did not have abdominal pain, nausea, vomiting, or diarrhea. VA treatment records from April 2011 show that the Veteran underwent a follow up examination in order to monitor his adenocarcinoma. There was no evidence of tumor recurrence. The diagnoses included mild gastritis with prescribed antiacid. The Veteran was afforded a VA examination of the stomach in November 2011. He has not employed, and had been retired since 1999. A history of discovery of a gastric carcinoma in December 2007 was noted, as was a partial gastrectomy in December 2010. Currently, the Veteran was treated with a restricted diet and antacids. He did not have periods of incapacitation due to stomach or duodenal disease. There were no episodes of abdominal colic, nausea, or vomiting, or abdominal distention. The Veteran did experience gnawing or burning pain on a daily or more often basis. This occurred before eating or at night, lasted about an hour, and was relieved by antacids. There were no episodes of hematemesis or melena. He experienced nausea several times a week but there was no vomiting or diarrhea. Other symptoms included constipation and abdominal tenderness. The results of a November 2010 endoscopy were reviewed, which was said to have shown no evidence of recurrence of disease and mild gastritis. The diagnoses were gastric adenocarcinoma, and mild gastritis. Private medical records include the results of a June 2014 endoscope. A nodule seen at anastomosis was visualized, unchanged from prior endoscopies. No ulcerations were described. The findings included hiatal hernia, as well as a gastric inflammatory nodule. The diagnosis was chronic active gastritis with intestinal metaplasia. July 2014 VA treatment records include a primary care note with a system review. The Veteran was there for a regular visit and laboratory work and had no new complaints. He did not have weight gain or loss, or loss of appetite. He also was negative for dysphagia, abdominal pain, nausea, vomiting, hematemesis, diarrhea, constipation, melena, and hematochezia. An October 2014 primary care note and a January 2015 primary care note were also negative for all of these symptoms. The Veteran submitted a VA Form 21-0960G-1 Esophageal Conditions Disability Benefits Questionnaire from a private doctor dated March 23, 2015. The Veteran was reported to have a long history of GERD. The doctor indicated that the treatment was not effective. The Veteran experienced four or more episodes of epigastric distress each year that lasted 10 days or more. He also experienced dysphagia, pyrosis, reflux, regurgitation, substernal or shoulder pain, and sleep disturbance. Each of these symptoms occurred four or more times each year, and each lasted for ten or more days at a time. The Veteran was not reported to have anemia, weight loss, nausea, vomiting, hematemesis, or melena. He did not have an esophageal stricture, spasm of the esophagus, or an acquired diverticulum. The history of gastric carcinoma was noted. The examiner added that GERD would be a recurrent problem given his gastric surgery, but it should not impact his ability to work. The Veteran also submitted a VA Form 21-0960G-7 Stomach and Duodenal Conditions Disability Benefits Questionnaire from his private doctor dated March 23, 2015. The examiner stated that he started treating the Veteran following his gastric surgery. He had recurring episodes of severe symptoms once a year that lasted ten days or more. Abdominal pain occurred less than once a month. However, the Veteran did experience two incapacitating episodes of intermittent epigastric pain per year, lasting from one to nine days. The examiner concluded by noting the Veteran's history of a poorly differentiated gastric carcinoma, post-surgery, with GERD and intermittent epigastric pain. The most recent VA examination of the Veteran's disability was conducted in April 2015. The record was reviewed by the examiner. His history of gastric cancer, a partial gastrectomy, and chronic gastritis was noted. Currently, the Veteran complained of severe reflux symptoms, especially during the night. He reported epigastric pain that radiated to the chest and arms, nausea, excessive bloating and burps. The Veteran reported that he ate small low fat meals every two to three hours. He was currently under treatment with Prilosec and Carafate with partial relief of his symptoms. The Veteran denied diarrhea, constipation, and significant weight loss. At the conclusion of the examination, the examiner opined that GERD was at least as likely as not also related to the Veteran's service connected medications, as was his gastric ulcers. In addition, the gastritis and gastric ulcers aggravated each other. The examiner concluded by stating that the proximity of the esophagus and the stomach, and the surgical alterations, precluded differentiation of specific organ locations of the Veteran's reported symptoms and complaints. VA treatment records from August 2015 include a primary care follow up note. The Veteran said that he was feeling well and had come in for evaluation of his right shoulder. He did not have weight gain or loss, or loss of appetite. He also was negative for dysphagia, abdominal pain, nausea, vomiting, hematemesis, diarrhea, constipation, melena, and hematochezia. The Board finds that entitlement to a rating in excess of 10 percent prior to March 23, 2015 is not shown by the evidence. The November 2011 VA examination noted gastritis, with daily burning pain and nausea without vomiting several times a week. This was also the only occasion at which he reported constipation and abdominal tenderness. The Veteran was treated with a restricted diet and antacids, and the examiner characterized the gastritis as mild. On every other occasion on which the Veteran's gastrointestinal symptoms were recorded, he did not have weight gain or loss, loss of appetite, dysphagia, abdominal pain, nausea, vomiting, hematemesis, diarrhea, constipation, melena, and hematochezia. He has bilateral shoulder pain, but this has been attributed to his service connected arthritis of the left shoulder and nonservice connected arthritis of the right shoulder. These symptoms fail to meet the criteria for a 30 percent rating for a hiatal hernia, which are persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. 38 C.F.R. § 4.114, Code 7346. They also fail to meet the standard for a 20 percent evaluation of a moderate peptic ulcer, which are recurring episodes of severe symptoms such as periodic vomiting, recurrent hematemesis or melena, and manifestations of anemia and weight loss two or three times a year averaging 10 days in duration, or with continuous moderate manifestations. 38 C.F.R. § 4.114, Code 7305. Finally, the Veteran's symptoms from this time did not show the multiple small eroded or ulcerated areas and symptoms required for a 30 percent rating for gastritis. 38 C.F.R. § 4.114, Code 7307. The Board must conclude that no more than a 10 percent rating is warranted prior to March 23, 2015 under any of the appropriate rating criteria. The Board also finds that entitlement to a rating in excess of 60 percent from March 23, 2015 is precluded. A 60 percent rating is the highest allowable under all three of the applicable rating codes. 38 C.F.R. § 4.114, Codes 7305, 7307, 7346. No additional discussion of these codes is necessary. Johnston v. Brown, 10 Vet. App. 80 (1997). The Board has considered the applicability of other rating codes that allow for a rating higher than 60 percent, but finds that none are permissible. Entitlement to service connection for the cancer of the stomach was previously denied, and is not currently before the Board. That precludes use of that rating code. 38 C.F.R. § 4.114, Code 7343 (2014). The Veteran does not have a diagnosis of ulcerative colitis, and even if he did he does not have the marked malnutrition, anemia, or debility required for a 100 percent rating. 38 C.F.R. § 4.114, Code 7323 (2015). There is also no diagnosis of a fistula, peritonitis or tuberculosis, complete loss of sphincter control, stricture of the rectum and anus, a ventral hernia, or pancreatitis. 38 C.F.R. § 4.114, Code 7330, 7331, 7332, 7333, 7339, 7347 (2015). Therefore, there is no basis for a scheduler rating in excess of 60 percent after March 23, 2015, for the Veteran's chronic gastritis, gastric ulcer, and hiatal hernia with GERD. Other Considerations Consideration has also been given regarding whether the schedular evaluation is inadequate, thus requiring that the RO refer a claim to the Under Secretary for Benefits or to the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1) (2015); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008). In determining whether an extra-schedular evaluation is for consideration, the Board must first consider whether there is an exceptional or unusual disability picture, which occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a Veteran's service-connected disability. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, the Board must next consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Thun, 22 Vet. App. at 115-16. When those two elements are met, the appeal must be referred for consideration of the assignment of an extra-schedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. The schedular evaluation in this case is not inadequate. The scheduler criteria adequately describe the Veteran's symptoms for his left shoulder disability, which are pain, weakness, and limitation of motion. These are accounted for in the rating criteria. Similarly, the Veteran does not have any gastrointestinal symptoms that are not listed in the appropriate rating criteria. Accordingly, referral for consideration of an extra-schedular rating is not warranted. Finally, the Board recognizes that a claim for an increased rating may include a claim for a total rating for compensation based upon individual unemployability due to service-connected disabilities (TDIU), if such a claim has been raised by the record and by the Veteran. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The Board finds that it has not been raised in this case. The record shows that the Veteran has been retired since the 1990s, which is well before the beginning of the current appeal period. He does not contend that his left shoulder or gastritis makes him unemployable. There is no medical opinion that states these disabilities make him unemployable. In fact, the Veteran's own private doctor opined that the GERD should not impact his ability to work. The Board concludes that TDIU is not for consideration. ORDER Entitlement to a 30 percent rating for a left shoulder disability prior to February 14, 2013 is granted. Entitlement to a rating in excess of 30 percent for a left shoulder disability is denied. Entitlement to a higher initial rating for chronic gastritis, gastric ulcer, and a hiatal hernia with gastroesophageal reflux disease, rated as 10 percent disabling before March 23, 2015 and 60 percent disabling from that date, is denied. REMAND The June 2009 rating decision that denied entitlement to an increased rating for the Veteran's left shoulder disability also denied entitlement to service connection for a psychiatric disability characterized as an adjustment disorder with depressed mood. The Veteran's June 2010 notice of disagreement indicated that he disagreed with the rating decision without distinguishing between the two issues. The Board notes that this statement can be considered a notice of disagreement with the denial of service connection just as easily as it can be interpreted as a notice of disagreement with the denial of an increased rating. The Board concludes that the Veteran must be issued a statement of the case for the denial of service connection for an adjustment disorder with depressed mood. Similarly, in the January 2012 notice of disagreement with the initial evaluation of the Veteran's chronic gastritis, the Veteran also argued that the RO did not respond to his previous claims for service connection for this disability, which he identified by date. The Board observes that these documents claiming service connection can be found in VBMS. The Board finds that this constitutes a notice of disagreement with the effective date of service connection. The Veteran must be issued a statement of the case for the issue of entitlement to an effective date for service connection for chronic gastritis, gastric ulcer, and a hiatal hernia with gastroesophageal reflux disease prior to June 9, 2011. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) Provide the Veteran a statement of the case for the issues of entitlement to service connection for a psychiatric disability claimed as an adjustment disorder with depressed mood, and entitlement to an effective date for service connection for chronic gastritis, gastric ulcer, and a hiatal hernia with gastroesophageal reflux disease prior to June 9, 2011. He must also be notified that he must submit a substantive appeal for each of these issues in order to complete his appeal to the Board. These issues should not be returned to the Board unless a substantive appeal is received. The Veteran 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 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). ______________________________________________ JAMES L. MARCH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs