Citation Nr: 1805020 Decision Date: 01/25/18 Archive Date: 02/05/18 DOCKET NO. 13-19 484 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to service connection for a back disorder, to include degenerative disk disease from C7 to T1, to include as secondary to service-connected posttraumatic stress disorder (PTSD) with symptoms of depression, fatigue, and insomnia; and as due to Gulf War environmental hazards. 2. Entitlement to service connection for hypertension, to include as secondary to service-connected bronchial asthma; gastroesophageal reflux disease (GERD), PTSD with symptoms of depression, fatigue, and insomnia; degenerative joint disease of the right foot with history of fracture of the fifth metatarsal; and/or chronic recurrent chalazion of the right upper eyelid; and as due to Gulf War environmental hazards and/or undiagnosed illness. 3. Entitlement to an initial disability rating in excess of 30 percent for bronchial asthma. 4. Entitlement to a rating in excess of 10 percent for GERD. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J.A. Williams, Associate Counsel INTRODUCTION The Veteran had active service in the United States Air Force from February 1976 to February 2004. This matter comes to the Board of Veterans' Appeals (Board) on appeal from March 2005, July 2010, and June 2011 rating decisions from the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. The Board notes that a March 2005 rating decision initially granted entitlement to service connection for bronchial asthma and assigned a 10 percent disability rating effective from March 1, 2004. The Veteran subsequently filed an increased rating claim for his bronchial asthma on March 6, 2007. The July 2010 rating decision found clear and unmistakable error (CUE) with respect to the March 2005 rating decision and assigned a 30 percent evaluation for bronchial asthma effective from March 1, 2004. The Veteran then timely appealed the assigned 30 percent rating. As the March 2005 rating decision contained CUE, it is not considered final as it relates to the Veteran's increased rating claim for bronchial asthma. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Thus, the Veteran's claim is appropriately characterized as an initial increased rating claim in accordance with Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Veteran testified at a Travel Board hearing before a Veterans Law Judge in April 2016. A transcript from that proceeding is associated with the claims file. In September 2017, the Veteran was advised that the VLJ who conducted the Travel Board hearing was no longer employed by the Board. He was afforded an opportunity to testify at another hearing. In December 2017 the Veteran indicated that he did not want another hearing. In July 2016, the Board remanded the claims for additional development. The Board finds that the RO substantially complied with the remand instructions. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). The Board also notes that the March 2005 rating decision granted service connection for GERD and assigned a noncompensable rating. The Veteran did not file a notice of disagreement (NOD) as to his disability evaluation for GERD. In July 2009 the Veteran filed an increased rating claim with respect to his GERD. A July 2010 rating decision increased the Veteran's disability evaluation for GERD to 10 percent effective July 20, 2009. The Veteran filed a timely NOD in June 2011. In the July 2016 remand, the Board incorrectly characterized the Veteran's increased rating claim for GERD to include a claim of increase for the Veteran's initial noncompensable rating. However, as the Veteran did not file an NOD with respect to his initial evaluation for GERD, that issue is not on appeal. Thus, the issue has been corrected to properly reflect the claim before the Board. FINDINGS OF FACT 1. The Veteran's back disability did not have its onset in service, did not manifest to a compensable degree within one year of separation, and is not otherwise related to service, to include Gulf War service. 2. The Veteran's back disability was not caused or aggravated by his service-connected disabilities. 3. The Veteran's hypertension did not have its onset in service, did not manifest to a compensable degree within one year of separation, and is not otherwise related to service, to include Gulf War service. 4. The Veteran's hypertension was not caused or aggravated by his service-connected disabilities. 5. Throughout the appeal period, the Veteran's bronchial asthma has manifested in no worse than an FEV-1of 66 percent predicted and FEV-1/FVC of 71 percent. 6. Throughout the appeal period, the Veteran's GERD has manifested in no worse than mild pyrosis, regurgitation, and epigastric distress; substernal, arm, or shoulder pain productive of considerable impairment of health is not shown. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a back disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310, 3.317 (2017). 2. The criteria for entitlement to service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310, 3.317 (2017). 3. The criteria for the assignment of disability rating in excess of 30 percent for bronchial asthma have not been met. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.96, 4.97 Diagnostic Code 6602 (2017). 4. The criteria for the assignment of disability rating in excess of 10 percent for GERD have not been met. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.114, Diagnostic Code 7399-7346. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection Claims Establishing service connection requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Moreover, pursuant to 38 C.F.R. § 3.309, where a veteran served continuously for ninety (90) days or more during a period of war, or during peacetime service after December 31, 1946, and certain chronic diseases, such as arthritis and hypertension, becomes manifest to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309(a). Service connection may also be established on a secondary basis for a disability which is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2017). Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was either caused by or aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a) (2017); Allen v. Brown, 7 Vet. App. 439 (1995). Service connection may be established on a presumptive basis for a Persian Gulf Veteran who exhibits objective indications of chronic disability resulting from an undiagnosed illness that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). In claims based on undiagnosed illness, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Notably, laypersons are competent to report objective signs of illness. Id. In the present case, the Veteran served in the Southwest Asia Theater of Operations during the Gulf War as shown by service personnel records. Thus, the Board finds that the Veteran is a "Persian Gulf Veteran" for the purposes of 38 C.F.R. § 3.317. See 38 C.F.R. § 3.317(e)(1). Back Disability The Veteran asserts that his current back disability had its onset in service or is secondary to service-connected posttraumatic stress disorder (PTSD) with symptoms of depression, fatigue, and insomnia, and is due to Gulf War environmental hazards. The evidence is clear that the Veteran has a current disability of degenerative arthritis of the spine. See October 2016 VA Examination Report. Thus, the issue that remains disputed is whether the Veteran's current back disability had its onset in service, manifested to a compensable degree within one year of service or is secondary to a service-connected disability or Gulf War service. The Veteran's service treatment records show that he complained of lumbar spine pain in June 1976. It was noted that he had mild tenderness in the lower right lumbar muscle, and the assessment was strain. Later in January 1980, the impression from a lumbar spine x-ray stated that the Veteran had a normal lumbosacral spine. In the September 1980 Report of Medical History, the Veteran reported having recurrent back pain. The physician's summary noted that this symptom was present despite the negative January 1980 lumbar spine x-ray. The record added that the Veteran had recurrent pain in the middle of his lower back when sitting for a long period without back support. The record further indicated that the problem began in 1977, but the Veteran had not received treatment. In the corresponding September 1981 service examination, the Veteran's spine was noted to be normal in the clinical evaluation. In June 1987, the Veteran reported sharp pain in his lower back. The record noted that the previous month, the Veteran had fallen while playing with his kids. The record also stated that the Veteran had an OCD (osteochondritis dissecans) injury. The assessment was a recurrent lumbar spasm that was recurrent for one month, secondary to strain. The Veteran's spine was later marked as normal in the October 1987 service examination. The Veteran also reported low back pain in March 2002. He described running a 5K the previous day, but he denied experiencing any injury to the area. The assessment was low back pain with radiation. The Veteran later complained of upper back pain in May 2003. Private treatment records contain a May 2005 MRI report showing multi-level disc herniation. In his March 2006 notice of disagreement, the Veteran reported that he was being treated for pinched nerves that caused numbness and chronic pain in his back. During a January 2011 VA examination the Veteran reported that his low back pain began in service 7 years prior. He reported no history of injury. He reported that in service he was treated with Motrin and had physical therapy, which helped his symptoms initially. He reported the pain got progressively worse with increased pain, frequency and intensity. After a physical examination and review of the claims file the examiner reported that although the Veteran was seen one time in service for lumbar pain, there was no objective evidence of chronicity of care and it is less likely as not that the Veteran's current degenerative arthritis is related to complaints of back pain during service. The Veteran also asserted that his lumbar spine condition is due to Gulf War service. During the January 2012 VA Gulf War general medical examination, the examiner noted that the Veteran had degenerative joint disease and degenerative disc disease of the back. He opined that these disorders met the criteria for a disease with a specific etiology and diagnosis and thus was less likely as not caused by or related to Gulf War environmental exposure. He opined that the degenerative disk disease was at least as likely as not caused by the process of aging and genetics. The Veteran was afforded another VA examination in October 2016. The Veteran reported back pain that is sharp at times and dull at times. He denied any injury to the back. The examiner opined that the Veteran's current back disability did not have its onset in service. The examiner reasoned that the Veteran's service treatment records indicated treatment for acute back complaints such as muscle spasms and muscle strain. There was no evidence of chronic back complaints in service and the Veteran's separation physical did not indicate any reports or complaints related to the back. Medical reports after separation indicate neck and back complaints related to a 2010 motor vehicle accident as well as neck and back complaints and evaluation after a motorcycle accident in 2011. The examiner further indicate thee Veteran currently has a diagnosis of degenerative disc disease (DDD) and degenerative change based on x-rays and CT scans. These findings are consistent with age related changes and during the examination the Veteran reported that his back symptoms were probably from getting old. The Veteran's service treatment records did not indicate any findings consistent with degenerative changes of the back and no x-rays were found with DDD or other degenerative changes of the spine until 2011. Based on these findings and the Veteran's history his current back symptoms did not begin in service. DDD is a medical condition with a clear and specific etiology and diagnosis is less likely than not due to his service in Southwest Asia. There is no nexus between a diagnosis of PTSD (with symptoms of depression, fatigue, and insomnia) and the development of DDD of the spine and PTSD also would not aggravate DDD beyond the natural progression. In a January 2017 addendum opinion, the examiner indicated that he reviewed additional medical records that had been associated with the claims file and that there was no change in his medical opinion regarding the Veteran's lumbar spine claim. The Board finds that the VA examiners' opinions adequate and highly probative to the question at hand. The examiners possessed the necessary education, training, and expertise to provide the requested opinions. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). In addition, the VA examiners provided adequate rationales for their opinions, and their opinions were based on an examination and interview of the Veteran, as well as on a review of the service treatment records, the post-service treatment records and examinations, and the lay statements of the Veteran. The opinions considered an accurate history, were definitive and supported by a detailed rationale that considered the lay and medical evidence. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Significantly, the Veteran has not presented or identified any contrary medical opinion that supports the claim for service connection. VA adjudicators are not free to ignore or disregard the medical conclusions of a VA physician, and are not permitted to substitute their own judgment on a medical matter. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Willis v. Derwinski, 1 Vet. App. 66 (1991). The Board has also considered the Veteran's assertions that his current back disability in related to back pain in service or is secondary to service-connected disabilities. The Veteran is competent to testify to facts or circumstances that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2); Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). It is also well established that lay persons without medical training, such as the Veteran, are not competent to provide medical opinions on matters requiring medical expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). Whether the Veteran's current back disability is related to service requires medical expertise to determine. Thus, the Board finds the VA medical opinions more probative than the Veteran's statements. The Board has also considered whether service connection is warranted on a presumptive basis. However, the evidence does not show that the Veteran's back disability to include degenerative disc disease manifested to a compensable degree within 1 year of separation. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). Hypertension The Veteran contends that his hypertension began in service. He also contends that his hypertension is secondary to an environmental hazard from the Gulf War as well as his service-connected GERD; bronchial asthma; PTSD with symptoms of depression, fatigue, and insomnia; degenerative joint disease of the right foot with history of fracture of the fifth metatarsal; and/or chronic recurrent chalazion of the right upper eyelid. See February 2016 Application for Disability Compensation and Related Benefits; April 2016 Hearing Transcript. The record reflects that the Veteran has a current diagnosis of hypertension. See January 2009 and August 2009 treatment records from Dr. J.B. Thus, the issue that remains disputed is whether the Veteran's hypertension is related to service to include Gulf War environmental exposure, manifested to a compensable degree within one year of separation, or is related to a service-connected disability. The Veteran's service treatment records are silent for complaints of or treatment for hypertension. In addition, private treatment records from 2005 and 2006 show blood pressure readings within normal range. A February 2007 private treatment records shows an elevated blood pressure of 142/83. The medical evidence of record does not show treatment for hypertension until January 2009. The Veteran was afforded a VA examination in October 2016. The Veteran reported that he was diagnosed with hypertension between 2004 and 2006. The examiner noted that medical records do not show a diagnosis of hypertension until 2009. The examiner opined that the Veteran's hypertension was less likely as not related to service. The examiner reasoned that the Veteran's service treatment records did not indicate a diagnosis of hypertension or findings of chronically elevated blood pressure. In addition, medical records after the Veteran's left service did not find elevated blood pressure readings or a diagnosis of hypertension until 2009 - 5 years after the Veteran left service. The examiner further explained that hypertension is a condition with a clear and specific etiology and diagnosis and is less likely than not due to or caused by a specific environmental exposure even during his service in Southwest Asia. The Veteran has a family history of hypertension and his diagnosis of hypertension is more likely than not due to both his family history, his age, tobacco use, and elevated body mass index. There is also no nexus between the development of hypertension, and his service-connected disabilities including bronchial asthma, GERD, PTSD with depression, fatigue and insomnia, degenerative joint disease of the right foot and/or chronic recurrent chalzion of the right upper eyelid. In addition, the Veteran's hypertension was not aggravated by any of his service-connected disabilities. In a January 2017 addendum medical opinion, the examiner reported that he had reviewed the additional medical treatment records associated with the claims file and that his opinion regarding the Veteran's hypertension did not change. Based on the foregoing the Board finds that the preponderance of the evidence is against a find that the Veteran's hypertension had its onset in service, is related to Gulf War service, or is secondary to a service connected condition. The Board finds that the VA examiner's opinion adequate and highly probative to the question at hand. See Grottveit, 5 Vet. App. at 93. The only evidence in support of the Veteran's claim is his statements that his hypertension is related to service. However, the etiology of his hypertension requires medical expertise to determine. Thus, the Board finds the VA medical opinion more probative than the Veteran's statements. The Board has also considered whether service connection is warranted on a presumptive basis. However, the Veteran does not show elevated blood pressure until February 2007 and was not diagnosed with hypertension until 2009 - over 4 years after separation. Thus, service connection on a presumptive basis is not warranted. 38 C.F.R. §§ 3.307, 3.309. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). Increased Rating Claims Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The assignment of a particular Diagnostic Code (DC) depends wholly on the facts of the particular case. Butts v. Brown, 5 Vet. App. 532, 538 (1993). The Veteran is presumed to be seeking the maximum possible evaluation. AB v. Brown, 6 Vet. App. 35 (1993). When a question arises as to which of two ratings applies under a particular code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). The evaluation of the same disability under various diagnoses, known as "pyramiding," is to be avoided. 38 C.F.R. § 4.14. Where functional loss due to pain on motion is alleged, 38 C.F.R. §§ 4.40 and 4.45 must be considered. DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995). A finding of functional loss due to pain must be supported by adequate pathology, and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. However, § 4.14 does not preclude the assignment of separate evaluations for separate and distinct symptomatology where none of the symptomatology justifying an evaluation under one diagnostic code is duplicative of or overlapping with the symptomatology justifying an evaluation under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Bronchial Asthma The Veteran's bronchial asthma is currently rated as 30 percent disabling under 38 C.F.R. § 4.97, Diagnostic Code 6602 (2015) for bronchial asthma. Diagnostic Code 6602 provides for a 10 percent disability rating where pulmonary function tests (PFTs) show any of the following: FEV-1 of 71 to 80 percent predicted, FEV-1/FVC of 71 to 80 percent, or where intermittent inhalational or oral bronchodilator therapy is required. A 30 percent disability evaluation is warranted where PFTs show any of the following: FEV-1 of 56 to 70 percent predicted, FEV-1/FVC of 56 to 70 percent; or daily inhalational or oral bronchodilator therapy, or inhalational anti-inflammatory medication. A 60 percent disability evaluation is warranted where PFTs show any of the following: FEV-1 of 40 to 55 percent predicted, FEV-1/FVC of 40 to 55 percent; or at least monthly visits to a physician for required care of exacerbations, or intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. A 100 percent evaluation is warranted where PFTs show any of the following: FEV-1 less than 40 percent predicted, FEV-/FVC less than 40 percent; or more than one attack per week with episodes of respiratory failure, or where the use of systemic high dose corticosteroids or immuno-suppressive medications are required on a daily basis. 38 C.F.R. § 4.97, Diagnostic Code 6602 (2017). A February 2005 VA examination report shows the Veteran had no history of productive cough, sputum, hemoptysis or anorexia. Regarding dyspnea he reported that he can run sometimes and is not very restricted as a result of his asthma. He reported having an emergency room visit about every three months. He had been admitted three times due to reactions to his asthma medication. On physical examination the examiner noted lungs clear to auscultation. Mild restrictive disease in addition to mild obstructive defect of the small airways was present and associated with air trapping. The FEF 25/75 (FEV-1 is 75 percent predicated?) percent improved by 33 percent post bronchodilator. The examiner noted that the Veteran's bronchial asthma FEV1 pre and post bronchodilator most accurately reflects the Veteran's current respiratory condition. An October 2009 VA examination report indicates that the Veteran reported cold symptoms six to seven times a year and a productive cough with yellow sputum. The Veteran showed no hemoptysis. He reported shortness of breath, dyspnea on exertion, especially with walking or with any physical activity. He reported he is not able to run. He walks four times a month when previously he would walk two to three times a week. He reported getting short of breath with walking. He reported asthma attacks two to three times a month. He reported being on steroid oral medication twice in 2009. In between bad episodes two to three times a month he also reported attacks with cold symptoms with coughing and wheezing. The Veteran's pulmonary function test showed mild restrictive disease. The FEF 25-75 percent improved by 33 percent post-bronchodilator. A July 2010 VA pulmonary function report show an FEV1/FVC of 72.49 percent. The Veteran was afforded and additional VA respiratory examination in July 2014. The Veteran denied asthma symptoms. The Veteran reported smoking a half pack of cigarettes per day for 20 years. His pulmonary function tests were normal and the Veteran showed no functional limitations due to asthma. The Veteran's condition did not require use of oral or parenteral corticosteroid medications but did require use of an inhalational bronchodilator therapy, and inhalational anti-inflammatory medication. The Veteran reported that he did not have any asthma attacks with episodes of respiratory failure in the prior 12 months. A pulmonary function test revealed FEV-1 of 91 percent predicted and FEV-1/FVC of 92 percent. During an October 2016 VA examination, the Veteran reported shortness of breath, coughing, and wheezing. He reported having a good response to medication. The Veteran's asthma did not require use of oral or parenteral corticosteroid medications, oral bronchodilators, antibiotics, or outpatient oxygen therapy. The Veteran's asthma did require the use of inhaled medications. The Veteran did not have asthma attacks with episodes of respiratory failure in the previous 12 months. The Veteran also did not require any physician visits for required care of exacerbations. There was no wheezing noted on auscultation of the lung during examination. Pulmonary function test showed FEV-1 of 66 percent predicted and FEV-1/FVC of 71 percent. The examiner reported no obstruction, no bronchodilator response, mild restriction, and a normal DLCO. Based on the foregoing evidence, the Veteran's bronchial asthma symptoms more nearly approximate the criteria for a 30 percent rating. Throughout the appeal period, the Veteran's asthma manifested in no worse than an FEV-1of 66 percent predicted and FEV-1/FVC of 71 percent. The evidence also shows daily use of inhalational anti-inflammatory medication but only intermittent use of inhalational bronchodilator therapy. The evidence does not show the Veteran's FEV-1 predicted or FEV-1/FVC at 55 percent or below as required by the higher ratings. Additionally, the record indicates the Veteran has not had at least monthly visits to a physician for required care of exacerbations. The Veteran has not suffered more than one attack per week with episodes of respiratory failure. He also has not required use of systemic corticosteroids or immuno-suppressive medications to warrant a higher rating under Diagnostic Code 6602. The Board has also considered whether a higher rating is warranted under another Diagnostic Code for the respiratory system. However, the record is negative for bronchitis, bronchiectasis, emphysema, or chronic pulmonary disease to warrant a rating under Diagnostic Codes 6600, 6601, 6603, or 6604, respectively. In sum, a disability rating in excess of 30 percent for the Veteran's bronchial asthma is not warranted. GERD The Veteran's service-connected GERD is rated 10 percent disabling, under 38 C.F.R. § 4.114, Diagnostic Code 7399-7346. As there is no Diagnostic Code for GERD, the disability is rated by analogy under the Schedule of Ratings for the digestive system. 38 C.F.R. § 4.114, Diagnostic Code 7399-7346. Under Diagnostic Code 7346, a 10 percent evaluation is warranted when there are two or more of the symptoms required for a 30 percent evaluation, but with less severity. A 30 percent evaluation is warranted when 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. A 60 percent evaluation is warranted when there are 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 (2017). During a December 2009 VA examination the Veteran reported pain, epigastric burning radiating substernal at least 3 times a day at a pain level of 7 out of 10 lasting 2 hours. Pain did not radiate into his arm. The Veteran denied dysphagia to solids or liquids. He reported no hematemesis or melanotic stools. He reported that he refluxes twice a day. He reported nausea twice a week and denied vomiting and dilation. During the November 2011 VA examination the Veteran reported severe pyrosis. He denied a history of surgery. He reported heartburn occurring on a daily basis. He reported reflux complaints once a week. The Veteran's treatment plan included continuous medication. The Veteran denied epigastric distress, dysphagia, regurgitation, substernal arm or shoulder pain, and sleep disturbance. The examination was also negative for esophageal stricture, spasm if the esophagus, and acquired diverticulum of the esophagus. During the July 2014 VA examination, the Veteran reported reflux when he lies down. He reported avoiding acidic food at night. The examiner noted that there was no radiographic finding of GERD as the Veteran had negative upper gastrointestinal series in 2005, 2010, and 2011. The Veteran had not required a gastrointestinal consult despite continued gastrointestinal complaints. The examination report indicates that the Veteran takes continuous medication of GERD. The Veteran reported reflux and sleep disturbance caused by esophageal reflux. He reported symptoms occurring 4 times a year or more with the average duration of symptoms being less than one day. The examination was negative for esophageal stricture, spasm of the esophagus, and acquired diverticulum of the esophagus. During an October 2016 VA examination the Veteran reported having symptoms of heartburn and regurgitation. He reported citrus foods and salsa make his symptoms worse. The examiner noted that the Veteran has not had positive findings by x-ray. The Veteran was taking continuous medication for his GERD. The examination was negative for esophageal stricture, spasm of the esophagus, and acquired diverticulum of the esophagus. Based on the medical evidence of record, the Board finds the Veteran's GERD more nearly approximates the criteria contemplated by a 10 percent disability rating. Although on the November 2011 VA examination the Veteran consistently reported experiencing pyrosis (heartburn), he only occasionally experiences epigastric distress and regurgitation. The Veteran's symptoms are not sufficient to warrant a rating in excess of 10 percent as the evidence does not show persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health to warrant a 30 percent rating. A rating in excess of 10 percent for GERD is not warranted. ORDER Entitlement to service connection for a back disorder is denied. Entitlement to service connection for hypertension is denied. (CONTINUED ON NEXT PAGE) Entitlement to an initial disability rating in excess of 30 percent for bronchial asthma is denied. Entitlement to a rating in excess of 10 percent for GERD is denied. ____________________________________________ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs