Citation Nr: 1624980 Decision Date: 06/21/16 Archive Date: 07/11/16 DOCKET NO. 10-38 986 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUE Entitlement to an initial disability rating in excess of 10 percent for hiatal hernia and gastroesophageal reflux disease (GERD). REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD K.C. Spragins, Associate Counsel INTRODUCTION The Veteran had active service in the United States Air Force from January 1955 to November 1958. This matter initially came to the Board of Veterans' Appeals (Board) on appeal from a July 2009 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Washington, DC. The RO in Denver, Colorado certified the case to the Board on appeal. The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge in November 2015. A transcript from that proceeding is associated with the Veterans Benefits Management System (VBMS) folder. In a February 2016 decision, the Board remanded the case to the Agency of Original Jurisdiction (AOJ) for additional development and adjudication. The case has since been returned to the Board for appellate review. This appeal was processed using the Virtual VA paperless claims processing system and VBMS. Accordingly, any future consideration of this case should take into consideration the existence of these records. 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). FINDING OF FACT During the entire period on appeal, the Veteran's hiatal hernia and GERD have not been manifested by persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. CONCLUSION OF LAW The requirements for an initial disability rating in excess of 10 percent for hiatal hernia and GERD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.1, 4.3, 4.7, 4.10, 4.14, 4.20, 4.21, 4.114, Diagnostic Code 7346 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 as amended (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). In this case, the Veteran is challenging the initial evaluation assigned following the grant of service connection for his hiatal hernia and GERD. In cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 490-91 (2006); VAOPGCPREC 8- 2003 (December 22, 2003). Thus, VA's duty to notify has been satisfied. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. 3.159(c), (d). This duty to assist contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that the VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). In this case, the AOJ obtained the Veteran's service treatment records and all identified and available post-service treatment records. The Veteran also received VA examinations in connection with his claim in June 2005, April 2009, May 2015, and March 2016. In the February 2016 remand, the Board directed the AOJ to provide the Veteran with a VA examination in connection with his claim. The record shows that such and examination was conducted in March 2016. The Board finds that this VA examination is adequate for rating purposes as it fully addresses the rating criteria and evidence of record that are relevant for rating the Veteran's hiatal hernia and GERD. Accordingly, the Board finds the AOJ has substantially complied with the instructions of the prior remand. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (concluding that a remand is not required under Stegall v. West, 11 Vet. App. 268 (1998), where there was substantial compliance with the Board's remand instructions). Moreover, there is no objective evidence indicating that there has been a material change in the severity of the Veteran's hiatal hernia and GERD since he was last examined in March 2016. The record does not reflect an allegation or evidence revealing any worsening of his disability since that time. The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11-95. As such, the Board finds that there is adequate medical evidence of record to make a determination on the claim. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In addition, the Veteran had the opportunity to testify in support of his claims during a November 2015 Board hearing. During the hearing, the undersigned Veterans Law Judge (VLJ) explained the issues on appeal, asked questions focused on the elements necessary to substantiate the claims, and sought to identify any further development that was required. These actions satisfied the duties a VLJ has to explain fully the issues and to suggest the submission of evidence that may have been overlooked. 38 C.F.R. § 3.103(c)(2). Moreover, there is no indication that the Veteran was otherwise denied due process during his Board hearing. In light of the foregoing, the Board finds that VA's duties to notify and assist have been satisfied, and, thus, appellate review may proceed without prejudice to the Veteran. II. Law and Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. Disability ratings are intended to compensate impairment in earning capacity due to a service connected disorder. 38 U.S.C.A. § 1155. The evaluation of a service-connected disorder requires a review of a veteran's entire medical history regarding that disorder. 38 U.S.C.A. § 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When a reasonable doubt arises regarding the degree of disability, 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. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. Disability ratings are intended to compensate impairment in earning capacity due to a service connected disorder. 38 U.S.C.A. § 1155. The evaluation of a service-connected disorder requires a review of a veteran's entire medical history regarding that disorder. 38 U.S.C.A. § 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When a reasonable doubt arises regarding the degree of disability, 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. Evidence to be considered in an appeal from an initial disability rating was not limited to that reflecting the then current severity of the disorder. Fenderson v. West, 12 Vet. App. 119 (1999). In cases where an initially assigned disability evaluation has been disagreed with, it is possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Fenderson, 12 Vet. App. at 126-27; Hart v. Mansfield, 21 Vet. App. 505 (2007). Such separate disability ratings are known as staged ratings. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The July 2009 rating decision assigned a 10 percent disability rating for the Veteran's service-connected hiatal hernia and GERD effective from February 8, 2005. The Veteran's disability is currently rated Diagnostic Code 7346. 38 C.F.R. § 4.114. This Diagnostic Code provides that a 10 percent disability rating is assigned for a hiatal hernia with two or more symptoms for the 30 percent evaluation of less severity. Id. A 30 percent disability rating is awarded for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. Id. A 60 percent disability rating is assigned 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. Id. With regard to coexisting abdominal conditions, VA regulation recognizes that there are diseases of the digestive system, particularly within the abdomen, which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia and disturbances in nutrition. 38 C.F.R. § 4.113 (2015). Consequently, certain coexisting diseases in this area do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in § 4.14. Id. Rather, a single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. The Board also notes that, with regard to the schedule of ratings for the digestive system, section 4.114 expressly prohibits, in pertinent part, the combination of ratings under Diagnostic Codes 7301 to 7329, inclusive, and 7345 to 7348 inclusive, which include the schedular criteria for a hiatal hernia (Diagnostic Code 7346). In a February 2005 statement, the Veteran reported that he suffered from acid reflux as a result of his hiatal hernia. He described needing to watch his food intake and sleeping with an elevated pillow to prevent the acid reflux. During a June 2005 VA examination, the examiner noted that that the Veteran had heartburn that was controlled with the use of daily medication. The diagnosis was hiatal hernia associated with GERD. In an August 2005 VA treatment record, the Veteran reported having discomfort in the back of his throat. He denied experiencing dysphagia or odynophagia. The record noted an assessment of globus sensation/GERD. The Veteran had no reflux symptoms, but sinus drainage was apparent. He also did not have hemoptysis, hoarseness, unintentional weight loss, or night sweats. Later in March 2006, the Veteran was noted to have increased gas and bloating related to his GERD. In June 2006, the Veteran opined that he was experiencing chest pain on exertion as a result of his hiatal hernia. The impression was severe aortic stenosis, moderate aortic insufficiency, and coronary artery disease. A subsequent July 2006 VA treatment record stated that the Veteran had no nausea, vomiting, constipation, or diarrhea. He also denied symptoms of abdominal pain, melena, or jaundice. He complained of occasional red blood from hemorrhoids. Although the Veteran denied angina, he stated that he could not differentiate between his GERD and chest pain. In April 2007, the Veteran complained of difficulty swallowing. On rare occasions, the Veteran would awaken feeling as though he was choking. The record noted an assessment of dysphagia. However, there was no increase in reflux symptoms. The Veteran did not have unexplained weight loss, melena, or abdominal pain. During a May 2007 follow-up visit, the record stated that Veteran was not currently experiencing dysphagia. He did complain of a cough and a sensation that his throat was closing. There was no runny nose or sinus congestion. His reflux was noted be controlled with the use of medication. The impression from a subsequent June 2007 VA barium swallow stated that there was a breaking of the primary esophageal stripping wave, esophagitis, hiatal hernia and gastroesophageal reflux stricture, and marked irregularity of the tongue base and vallecula. In July 2007, a panendoscopy (EGD) with esophageal dilation was performed at VA. The record indicated that the purpose of the procedure was to evaluate a stricture seen on the Veteran's barium swallow. However, the findings stated that the Veteran's esophagus was normal in appearance without any identifiable stricture. The findings also noted the presence of a small hiatal hernia, gastritis, a polyp versus thickened fold in the duodenum, and multiple erosions of the duodenal bulb and second portion of the duodenum. By August 2007 a VA treatment record noted that the Veteran's dysphagia had resolved with esophageal dilation, and he was currently asymptomatic. He still suffered from heartburn and slept with two pillows to elevate his head. In September 2007, the Veteran was referred to VA's ear, nose, and throat (ENT) department to evaluate the irregularity of the tongue barium enema and vallecula that was noted in the June 2007 barium swallow impression. The Veteran reported that his swallowing was better, but he still had throat issues. He suffered from reflux symptoms as well as a globus sensation and throat clearing. There was no throat or ear pain. The assessment was laryngeal irritation and laryngopharyngeal reflux. There was no evidence of malignancy. It was noted that a long uvula could be causing the Veteran's choking feeling. In November 2007, the Veteran reported some improvement as a result of a change in his medication dosage. He no longer had choking episodes. The Veteran did not was to pursue any surgery or uvulectomy at that time. The Veteran was provided with another VA examination in connection to his claim in April 2009. The Veteran informed the examiner that he had retired by choice in 1995. He described daily episodes of water brash with an acidic taste in the evening or morning that was probably related to a recumbent position. The Veteran also experienced 1 to 2 episodes of solid food regurgitation per month. In addition, breakthrough epigastric pains and dyspepsia occurred 2 to 3 times a week for 1 to 2 hours. Consistent with heartburn, these pains would occasionally extend retrosternally. He denied having hematemesis or melena. The Veteran continued to take daily prescribed medication, and he occasionally supplemented with over the counter antacids. He still elevated his head when sleeping. The Veteran was able to receive benefits from these treatment methods. The diagnosis was GERD with hiatal hernia. The examiner noted that this disability was status post GERD-induced esophageal stricture with dysphagia that had been treated successfully in October 1996. Mild anemia was also documented as a residual. The Veteran additionally reported almost daily episodes of posterior pharyngeal choking and dysphagia. However, the examiner stated that the Veteran had upper pharyngeal dysphagia that was secondary to his otolaryngology-diagnosed abnormal uvula. The examiner concluded that the Veteran had no symptoms of dysphagia that could be related to an esophageal pathology in light of his normal July 2007 endoscopy. According to the examiner, there was no documented relationship between this issue and GERD. Following this examination, a February 2010 VA treatment record stated that the Veteran's GERD was controlled with his medication. In his September 2010 VA Form 9, the Veteran reported that he had persistent epigastric distress with regurgitation, as well as substernal arm and occasional shoulder pain. He stated that even with the use of daily medication, he suffered from persistent symptoms. A subsequent November 2010 VA treatment record noted that he underwent an EGD in July 2007 for dysphagia and had chronic inflammation in the duodenum. At the time of the visit, the Veteran had minimal reflux symptoms. In March 2011, a VA treatment record reported that the Veteran had adequate symptom control of his GERD on his daily medication. In July 2013, a VA treatment record noted the Veteran's report of right flank pain. He was concerned that reflux was causing the pain. Although the Veteran was advised that stomach pain could radiate to the back, the Veteran denied having stomach pain. Later this month, the Veteran reported having a lot of heartburn at night and coughing in the morning. In August 2013, a VA treatment record's assessment stated that the Veteran's anemia was related to chronic gastrointestinal loss. Another August 2013 VA treatment record revealed that the Veteran denied having symptoms of abdominal pain, nausea, or vomiting. He continued to deny vomiting in October 2013. The Veteran later reported in January 2014 that a piece of his tooth had had broken off as a result of acid reflux. An August 2014 VA treatment record stated that the Veteran did not suffer from vomiting. Also in August 2014, the Veteran reported having constant low level pain in the upper right rib area. The record noted that the pain was most likely in his gall bladder area. A subsequent August 2014 VA treatment record documented the Veteran's report of right-sided rib pain that had been present for 5 days. The record noted that the Veteran was status post cholecystectomy. The Board notes that a cholecystectomy is the surgical removal of the gallbladder. See Dorland's Illustrated Medical Dictionary 348 (32nd ed. 2012). Later in October 2014, the Veteran complained of left arm pain that had been present for a week. He had visited the emergency room for the pain, but they were unable to find anything wrong. Approximately three days later, an October 2014 VA treatment record noted that the Veteran had a history of coronary artery disease before stating that his left shoulder pain could be an angina equivalent. The Veteran was advised to go to the emergency room. Around two days later, it was noted that the Veteran had visited a VA hospital, and the doctor did not find anything wrong with his left shoulder. In November 2014, the Veteran reported that his pain had previously been in his left shoulder, but now the pain occurred in his low back and hips. The Veteran opined that his arthritis could be bothering him. Nearly a week later, the Veteran stated that his pain was better after finishing a Medrol dose pack. In May 2015, the Veteran underwent a VA examination for his service-connected hiatal hernia and GERD. The examiner documented that the Veteran experienced the symptom of reflux. The Veteran described having almost daily acid reflux when he went to bed. He was prescribed daily medication for this issue, but it appeared to the examiner that the Veteran was not taking the medication as ordered. She noted that he had not filled his prescription since September 2014. The Veteran continued to elevate his head with multiple pillows when lying down as he could feel acid in his throat when lying flat. The examiner addressed the Veteran's contention that he had lost teeth as a result of his acid reflux. She noted that the Veteran had a full mouth of natural teeth except for 3 removed molars. In addition, there were no overt signs of acid eroding the tooth enamel. The Veteran did not have an esophageal stricture, spasm of the esophagus (cardiospasm of achalasia), or an acquired diverticulum of the esophagus. No relevant scars were present. The examiner additionally noted that the Veteran had an obese abdomen and a large abdominal ventral hernia, but he reported that he would not have surgery to repair it. Regarding the Veteran's previously documented anemia, the examiner stated that this disorder was not caused by GERD or any esophageal bleeding. The diagnoses were GERD and a hiatal hernia. The examiner opined that the Veteran's esophageal conditions did not impact his ability to work. During the November 2015 Board hearing, the Veteran testified that he experienced symptoms of regurgitation, constipation, and diarrhea. See November 2015 Board Hearing Transcript (Tr.), page 8-9. In addition, the Veteran found himself awakened by coughing almost every night. See Tr., page 10. He also reported that he avoided certain foods and monitored the size of his meals as a result of his disability. See Tr., page 9-10. In March 2016, an additional VA examination was conducted to evaluate the Veteran's disability. The Veteran had resumed his use of daily medication since the May 2015 VA examination. He reported having occasional heartburn once a week. The Veteran additionally experienced fluid in his mouth in the evening after going to bed. He reported sleeping with three pillows as a result of this problem. The examiner opined that this symptom was at least as likely as not caused by or the result of the Veteran's GERD as it was one of the classical and most frequent symptoms of the disease. The examiner determined that the Veteran's symptoms included infrequent episodes of epigastric distress, reflux, regurgitation, and sleep disturbance caused by esophageal reflux. He indicated that these symptoms occurred 4 or more times a year and lasted less than 1 day. Similar to the findings from the May 2015 VA examination, the examiner found that the Veteran did not have any relevant scars, an esophageal stricture, spasm of the esophagus, or an acquired diverticulum of the esophagus. The diagnosis was a hiatal hernia and GERD. During the examination, the examiner discussed the relevance of other symptoms that had been documented in the Veteran's treatment records. In terms of the Veteran's history of dysphagia, the examiner noted that this issue had improved after the July 2007 empiric esophageal dilation. When the Veteran again reported dysphagia during the April 2009 VA examination, the examiner had been unable to relate these symptoms to an esophageal pathology. Moreover, the Veteran denied having any dysphagia at the time of March 2016 examination. The examiner also addressed the reports of a globus sensation, occasional choking, and throat clearing from November 2007. He noted that the Veteran's diagnosis of laryngopharyngeal reflux was more likely than not related to his GERD and globus sensation. The examiner explained that the relationship between this symptom and GERD was well known. He also noted that that the globus sensation could be related to GERD as it was a known extra-esophageal condition. The examiner observed that the laryngopharyngeal reflux and globus sensation had resolved with a change in the Veteran's medication in 2007. However, the examiner also opined that the long uvula was less likely than not caused or related to GERD in any way. He repeated the observation from the April 2009 VA examination that the Veteran's posterior pharyngeal choking and dysphagia were thought to be associated with his long uvula. Regarding the Veteran's previously reported left arm and shoulder pain, the examiner opined that it was less likely than not caused by or the result of the Veteran's GERD. The examiner observed that no etiology had been found when the Veteran was evaluated in October 2014. The Veteran additionally informed the examiner that he did not have any chest pain and that there had been no further episodes of left shoulder or arm pain. The examiner explained that while esophageal conditions may cause referral pain in the left shoulder and arm, such a symptom had not been reported during the Veteran's history of GERD. According to the examiner, it would be highly unusual for GERD to cause this symptom for only a brief time in the Veteran's long history with the disease. The examiner also addressed the anemia that was documented during the April 2009 VA examination. The examiner opined that the anemia was less likely than not caused by or a result of the Veteran's GERD. The examiner determined that there was no clinical evidence to support such a relationship. The examiner acknowledged that severe esophagitis or an esophageal ulcer may lead to the development of chronic gastrointestinal blood loss and the development of anemia due to iron deficiency. However, the fact that the Veteran had chronic low grade anemia with normal mean corpuscular volume (MCV) levels and normal serum ferritin ruled out the possibility of a relationship between his anemia and chronic gastrointestinal blood loss or GERD. In addition, the endoscopic procedures of record had not documented significant esophagitis or an esophageal ulcer. The Board does not find that the evidence of record demonstrates that the Veteran's symptoms more nearly approximate a 30 percent disability rating under Diagnostic Code 7436. As noted above, a 30 percent rating contemplates persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. See 38 C.F.R. § 4.114, Diagnostic Code 7346. The Veteran was noted to experience heartburn and regurgitation during the period on appeal. However, the Veteran denied having abdominal pain in July 2006 and April 2007. In addition, the March 2016 VA examiner found that the Veteran's epigastric distress was infrequent rather than persistently recurrent. As noted in the March 2016 VA examination, the record does not suggest that the Veteran's previously reported left shoulder or arm pain was associated with the his GERD. Furthermore, the Veteran reported that he no longer experienced this symptom in March 2016. The March 2016 VA examiner also reported that the symptom of dysphagia was not present during the examination, and it had not been related to the Veteran's esophageal disability in the previous treatment records. Accordingly, the Board finds that a 30 percent disability rating is not warranted. In addition, the Board does not find that the evidence reflects that the Veteran's hiatal hernia and GERD produced symptoms of pain, vomiting, material weight loss, and hematemesis or melena with moderate anemia, or other symptom combinations productive of severe impairment of health. See 38 C.F.R. § 4.114, Diagnostic Code 7346. The record has not suggested that the Veteran experienced material weight loss as a result of his hiatal hernia and GERD. Although the Veteran testified during the November 2015 hearing that he felt as though he wanted to vomit as a result of his regurgitation, VA treatment records stated that the Veteran did not suffer from vomiting in July 2006, August 2013, October 2013, and August 2014. This symptom was also not documented during the May 2015 or March 2016 VA examinations. The Veteran was noted to not have melena in July 2006, April 2007, and April 2009. He also denied having hematemesis during the April 2009 VA examination. While the Board acknowledges the August 2013 VA treatment record's statement that the Veteran's anemia was related to chronic gastrointestinal loss, both the May 2015 and March 2016 VA examiners determined that this issue was not associated with GERD. The Board finds the March 2016 VA examiner's opinion on this matter to be more probative than the assessment from the August 2013 VA treatment record as the examiner provided an explanation for his conclusion that was based on the clinical data of record. Moreover, the record does not reflect that the Veteran experienced any other combination of symptoms that produced a severe impairment of health. As such, a 60 percent disability rating is also not appropriate in this case. In considering the potential applicability of other diagnostic codes, the Board again notes that coexisting diseases of the digestive system do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in 38 C.F.R. § 4.14. 38 C.F.R. § 4.113. In addition, the Board has considered rating the service-connected disability under other possibly applicable diagnostic codes found at 38 C.F.R. § 4.114 (containing the schedule for rating disorders of the digestive system), but finds none applicable that would grant the Veteran a higher disability rating. See Butts v. Brown, 5 Vet. App. 532, 538 (1993); see also Pernorio v. Derwinski, 2 Vet. App. 625, 629(1992). In light of the evidence discussed above, the Board thus finds that the rating criteria for an initial disability evaluation in excess of 10 percent for the Veteran's hiatal hernia and GERD have not been met at any point during the period on appeal. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 54-55. The Board has also considered the application of other various provisions, including 38 C.F.R. § 3.321(b)(1) for exceptional cases where scheduler evaluations are found to be inadequate. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available scheduler evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned scheduler evaluation is, therefore, adequate, and no referral is required. Thun v. Shinseki, 573 F.3d 1366 (Fed. Cir. 2009). Here, the rating criteria reasonably describe the Veteran's symptoms, such as infrequent episodes of epigastric distress, reflux, regurgitation, and sleep disturbances caused by esophageal reflux. In addition, the rating criteria provide for ratings higher than that assigned based on more significant functional impairment. Hence, the rating criteria clearly contemplate the Veteran's disability picture. Therefore, the threshold factor for extraschedular consideration under step one of Thun has not been met. The Board further notes that, pursuant to Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), 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 symptoms associated with the service-connected disabilities. However, in this case, even after affording the Veteran the benefit of the doubt under Mittleider v. West, 11 Vet. App. 181 (1998), there is no additional impairment that has not been attributed to a specific service-connected disability. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for disability that can be attributed only to the combined effect of multiple conditions. Based on the foregoing, the Board finds that the requirements for an extraschedular evaluation for the Veteran's service-connected hiatal hernia and GERD under the provisions of 38 C.F.R. 3.321(b)(1) have not been met. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995); Thun v. Peake, 22 Vet. App 111 (2008). ORDER Entitlement to an initial disability rating in excess of 10 percent for hiatal hernia and GERD is denied. ____________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs