Citation Nr: 1826041 Decision Date: 04/27/18 Archive Date: 05/07/18 DOCKET NO. 10-35 061 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for hemorrhoids. 2. Entitlement to service connection for migraine headaches. 3. Entitlement to service connection for irritable bowel syndrome (IBS). 4. Entitlement to an initial compensable evaluation for right ear hearing loss, with residuals of stapedectomy, for the period after September 10, 2015. 5. Entitlement to an extraschedular disability rating for post-operative residuals, right (dominant) wrist. 6. Entitlement to an initial compensable rating for gastroesophageal reflux disease (GERD) prior to November 17, 2017, and in excess of 10 percent from that date. REPRESENTATION Veteran represented by: Lisa A. Lee, Attorney ATTORNEY FOR THE BOARD J. Costello, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1978 to July 1981 and from January 1987 to March 2004. This case comes before the Board of Veterans' Appeals (Board) on appeal from an April 2008 rating decision and a November 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. The Board notes the Veteran did not request a hearing. The Board previously remanded this claim for additional development in January 2013 and May 2016. As the actions specified in the remand have been completed, the matter has been properly returned to the Board for appellate consideration. See Stegall v. West, 11 Vet. App. 268 (1998). FINDINGS OF FACT 1. The Veteran does not have a current diagnosis of hemorrhoids. 2. A headache disorder disability was not manifest during service, within one year of separation, and is not attributable to or related to service. 3. The Veteran does not have a current diagnosis of IBS. 4. From September 10, 2015, at worse, the Veteran had Level III hearing in his right ear. 5. The symptomatology associated with the Veteran's service-connected right wrist disability is contemplated by the current schedular rating. 6. From March 15, 2016, the Veteran's GERD has caused persistently recurrent epigastric distress with dysphasia, pyrosis, and regurgitation, accompanied by substernal pain, but has not caused hematemesis or melena, anemia, or other symptom combinations productive of severe impairment of health. CONCLUSIONS OF LAW 1. The criteria for service connection for hemorrhoids have not been met. 38 U.S.C. §§ 1101, 1110, 1131 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.306 (2017). 2. A headache disorder was not incurred in or aggravated by service and may not be presumed to have been incurred or aggravated therein. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137 (2012); 38 C.F.R. §§ 3.303, 3.306, 3.307, 3.309 (2017). 3. The criteria for service connection for IBS have not been met. 38 U.S.C. §§ 1101, 1110, 1131 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.306 (2017). 4. From September 10, 2015, the criteria for a compensable rating for a right ear hearing loss disability are not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.85, Part 4, Diagnostic Code 6100 (2017). 5. The criteria for an extraschedular evaluation for the Veteran's service-connected right wrist disability have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5215 (2017). 6. The criteria for a schedular rating of 30 percent, but no higher, for GERD are met from March 15, 2016. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.20, 4.7, 4.10, 4.114, Diagnostic Codes 7399-7346 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS With respect to the Veteran's claim herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126(2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326; see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Service Connection Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 1153; 38 C.F.R. §§ 3.303, 3.304, 3.306. Service connection may also be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Medical evidence is not always or categorically required when the determinative issue involves either medical diagnosis or etiology, but rather such issue may, depending on the facts of the particular case, be established by competent and credible lay evidence under 38 U.S.C. § 1154(a). See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). In addition, service connection for certain chronic diseases, including organic disease of the neurological systems, will be presumed to have been incurred in or aggravated by service if it had become manifest to a degree of 10 percent or more within one year of a Veteran's separation from service. 38 U.S.C. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. With chronic diseases shown as such in service or within the presumptive period so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. This rule does not mean that any manifestation of joint pain, any abnormality of heart action or heart sounds, any urinary findings of casts, or any cough, in service will permit service connection of arthritis, disease of the heart, nephritis, or pulmonary disease, first shown as a clearcut clinical entity, at some later date. Continuity of symptomatology is required only where the condition noted during service or the presumptive period is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after service is required to support the claim. 38 C.F.R. § 3.303(b). This regulation pertains to "chronic diseases" enumerated in 38 C.F.R. § 3.309(a) (listing named chronic diseases). Walker v. Shinseki, 708 F.3d 1331, 1336-37 (Fed. Cir. 2013). The United States Court of Appeals for the Federal Circuit (Federal Circuit) noted that the requirement of showing a continuity of symptomatology after service is a "second route by which a veteran can establish service connection for a chronic disease" under subsection 3.303(b). Walker, supra. Showing a continuity of symptoms after service itself "establishes the link, or nexus" to service and also "confirm[s] the existence of the chronic disease while in service or [during the] presumptive period." Id. (holding that section 3.303(b) provides an "alternative path to satisfaction of the standard three-element test for entitlement to disability compensation"). Service connection may also be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Reasonable doubt concerning any matter material to the determination is resolved in the Veteran's favor. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Hemorrhoids and IBS The Veteran's service treatment records (STRs) do not reflect any complaints, findings, treatment, or diagnoses for hemorrhoids or IBS. The Veteran's September 2003 separation medical history indicated that the Veteran did not have any rectal disease, hemorrhoids, blood from the rectum, stomach or intestinal trouble, frequent indigestion or heartburn, or stomach trouble. The Veteran's January 2004 retirement examination indicated that he had a normal rectum. A February 2005 treatment note indicated that the Veteran reported rectal bleeding. He reported increased gas and cramping. On examination, bowel sounds were normal, there were no lesions or abnormalities, and stool guaiac was negative. He was diagnosed with a recent change in bowel habits. In March 2005, the physician indicated that the Veteran likely had IBS, but the Veteran was not treated for his symptoms. A March 2009 VA physical examination revealed that the Veteran did not have external hemorrhoids. In June 2013, the Veteran stated that he had frequent bowel movements during periods of high stress, to include diarrhea. Also, he believed that hemorrhoids were secondary to his non-service-connected IBS. In September 2016, the Veteran underwent a disability benefits questionnaire (DBQ) for rectum and anus conditions. His claims file was reviewed. He was diagnosed with hemorrhoids, by history, but not currently active. His treatment did not include taking continuous medication. His examination was normal and no external hemorrhoids, anal fissures, or other abnormalities were found. The Veteran reported that he had hemorrhoids when his IBS acted up. Also, he stated that he had loose stools nightly and blood in his stool when his IBS flared. In September 2016, the Veteran underwent a DBQ for intestinal conditions. His claims file was reviewed. The Veteran reported a history of IBS, but not treatment. He noticed in 2005 that he had really bad diarrhea and cramps. He stated that a gastrointestinal specialist diagnosed him with IBS. He reported flare-ups with loose stools 5 to 8 times per day several times a month. He reported diarrhea nightly that was worse with stress and spicy foods. Symptoms got better when he relaxed. The VA examiner found that the Veteran did not demonstrate current evidence of IBS. A precise diagnosis was not rendered as there was no objective data to support such a diagnosis. The Veteran's reported history and symptomatology was not consistent with IBS. Nocturnal diarrhea is not a feature of IBS. The United States Court of Appeals for Veterans Claims (Court) consistently has held that, under the law, "[a] determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or a disease incurred in service." Watson v. Brown, 4 Vet. App. 309, 314 (1993). This principle has been repeatedly reaffirmed by the United States Court of Appeals for the Federal Circuit (Federal Circuit), which has stated, "a Veteran seeking disability benefits must establish . . . the existence of a disability [and] a connection between the Veteran's service and the disability." Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997) (holding that the VA's and the Court's interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary and therefore the decision based on that interpretation must be affirmed). In Brammer v. Derwinski, 3 Vet. App. 223 (1992), the Court noted that Congress specifically limited entitlement for service-connected disease or injury to cases where such incidents had resulted in a disability. See also Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998) (service connection may not be granted unless a current disability exists). A "current disability" means a disability shown by competent evidence to exist. Chelte v. Brown, 10 Vet. App. 268 (1997). In this case, there are no current diagnoses of hemorrhoids or IBS. Therefore, in the absence of proof of a present disability, there can be no valid claim. Rabideau v. Derwinski, 2 Vet. App. 141, 143- 44 (1992). Therefore, service connection for hemorrhoids or IBS is not warranted. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. The preponderance is against the Veteran's claim, and it must be denied. Headaches The Veteran's STRs do not reflect any complaints, findings, treatment, or diagnoses for headaches. The Veteran's September 2003 separation medical history indicated that the Veteran did not have frequent or severe headaches. The Veteran's January 2004 retirement examination indicated that he had a normal neurologic function. A September 2002 annual evaluation revealed that the Veteran denied ever having migraine headaches. In a July 2007 correspondence, the Veteran stated that his headaches began in 1994 due to the high stress of recruiting. The first time he sought treatment for a headache was in September 2005. A February 2013 buddy statement indicated that the Veteran complained of several headaches from 1997 to 2004. In September 2016, the Veteran underwent a DBQ for headaches. His claims file was reviewed. The Veteran was diagnosed with headaches in September 2005. He reported onset in 1994, brought on by stress and dehydration. He reported experiencing 2 to 3 headaches a month. They started with pain, then light sensitivity and noise sensitivity, and then irritability. He reported treating his headaches with Maxalt. Typically he had pain on both sides of his head that lasted less than a day. He did not have prostrating attacks. The VA examiner opined that it was less likely than not that any diagnosed headache disorder had its onset in active service or is otherwise causally related to service. The Veteran indicated on his separation examination that he did not have frequent or severe headaches. Also, he listed twelve current medical conditions upon retirement, but did not list headaches. Post service, in 2004, the Veteran sought service connection for the twelve medical conditions and he did not seek service connection for headaches or vision changes. VA records from May 2004 to March 2005 indicated that the Veteran denied having headaches. His first complaint of a headache was in September 2005, more than one year after separation from service. He received medication for a headache in December 2005. The objective evidence showed that the Veteran was not diagnosed with headaches in service or within one year of service. In this case, the examiner was aware of the Veteran's medical history, provided a fully articulated opinion, and also furnished a reasoned analysis. The Board therefore attaches significant probative value to this opinion, and the most probative value in this case, as it is well reasoned, detailed, consistent with other evidence of record, and included an access to the accurate background of the Veteran. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (Factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). The Board has considered the Veteran's own opinion that his headaches are related to his active duty service. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition; (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay testimony is competent as to matters capable of lay observation, but not with respect to determinations that are "medical in nature" Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). The Veteran, as is his friend, is competent in this case to report the Veteran's symptoms, but nothing in the record demonstrated that he has received any special training or acquired any medical expertise in evaluating and determining causal connections for the claimed condition. Therefore, a medical expert opinion would be more probative regarding the causation question in this case and has been obtained as set forth above. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Thus, the Veteran's opinion is outweighed by the findings to the contrary by the VA examiner, a medical professional who considered the pertinent evidence of record and found against such a relationship. See id.; see also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (affirming the Court's conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert's opinion more probative on the issue of medical causation). The most probative evidence establishes that headaches are not related to service. Accordingly, service connection is not warranted. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The preponderance is against the Veteran's claim, and it must be denied. Increased Ratings Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in the VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making disability evaluations. See generally, 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Hearing Loss Where, as here, a Veteran appeals the denial of a claim for an increased disability rating for a disability for which service connection was in effect before he filed the claim for increase, the present level of disability is the primary concern, and past medical reports should not be given precedence over current medical findings. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994). Where factual findings show distinct time periods where the service-connected disability exhibits symptoms which would warrant different ratings, different or "staged" ratings may be assigned for such different periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). In evaluating service-connected hearing impairment, disability ratings are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered. See Acevedo-Escobar v. West, 12 Vet. App. 9, 10 (1998); Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). The schedule provides a table (Table VI) to determine a Roman numeral designation (I through XI) for hearing impairment. Testing for hearing loss is conducted by a state-licensed audiologist, including a controlled speech discrimination test (Maryland CNC). The evaluation is based upon a combination of the percent of speech discrimination and the puretone threshold average which is the sum of the puretone thresholds at 1000, 2000, 3000 and 4000 Hertz, divided by four. See 38 C.F.R. § 4.85. Table VII in the schedule is used to determine the percentage evaluation by combining the Roman numeral designations for hearing impairment of each ear, the horizontal rows representing the ear having better hearing and the vertical columns the ear having the poorer hearing. The percentage evaluation is indicated where the row and column intersect. Table VIa is used when the examiner certifies that the use of speech discrimination test is not appropriate because of language difficulties, inconsistent speech discrimination scores, etc., or when indicated under the provisions of 38 C.F.R. § 4.86. See 38 C.F.R. § 4.85(c). When the puretone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. Each ear will be evaluated separately. See 38 C.F.R. § 4.86(a). When the puretone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. That numeral will then be elevated to the next higher Roman numeral. See 38 C.F.R. § 4.86(b). Lastly, 38 C.F.R. § 4.85 (f) provides that if a Veteran's impaired hearing is service-connected in only one ear, in order to determine the percentage evaluation from Table VII, the non-service-connected ear will be assigned a Roman Numeral designation for hearing impairment of I, subject to the provisions of section 3.383 of the chapter. In conjunction with his claim for an increased rating, the Veteran was afforded a VA audiological examination in September 2016. On the authorized audiological evaluation, puretone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 average RIGHT 70 55 50 65 60 Speech audiometry tested speech recognition ability and revealed 90 in the right ear. The examiner indicated that the Veteran had mixed hearing loss in his right ear and it affected his daily life including difficulty hearing when there was background noise. Under the rating criteria, the examination results constitute Level III hearing in the right ear. The result is a noncompensable or 0 percent disability evaluation as the non-service-connected left ear is considered to be at Level I in the absence of total deafness. Further, the Board finds that 38 C.F.R. § 4.86(a) is not for application because the puretone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is not 55 decibels or more. The Board further finds that 38 C.F.R. § 4.86(b) is not for application as the puretone threshold is not 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz. The Veteran asserts that he is entitled to a higher rating for his hearing loss disability. As evidenced above, however, notwithstanding the Veteran's complaints, the audiology examination yielded results warranting a noncompensable rating from September 10, 2015. To the extent that his hearing is impaired, the fact that the Veteran's hearing acuity is less than optimal does not by itself establish entitlement to a higher disability rating. To the contrary, it is clear from the Rating Schedule that a higher rating can be awarded only when loss of hearing has reached a specified measurable level. The medical evidence does not support the assignment of ratings higher than those assigned during the entire appeals period. The Board in no way discounts the difficulties that the Veteran experiences as a result of his hearing loss. However, as was explained above, the assignment of disability ratings for hearing impairment is derived by a mechanical application of the rating schedule to the numeric designation assigned after audiometry results are obtained. Hence, the Board has no discretion in this matter and must predicate its determination on the basis of the results of the audiology results of record. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). In other words, the Board is bound by law to apply VA's rating schedule based on the Veteran's audiometry results. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. For all the foregoing reasons, the Board finds that the evidence does not support the assignment of ratings higher than 0 percent from September 10, 2015. Therefore, entitlement to an increased rating for the impairment associated with right ear hearing loss is not warranted. In determining whether a higher rating is warranted for service-connected disability, VA must determine whether the evidence supports the Veteran's claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107(a); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In this case, the preponderance of the evidence is against ratings higher than 0 percent from September 10, 2015. Lastly, consideration of a compensable rating on an extraschedular basis pursuant to 38 C.F.R. 3.321 (b)(1) is not warranted because (1) the schedular criteria for hearing loss contemplate the functional effects of difficulty hearing and understanding speech, which are the type/nature of complaints reported by the Veteran in this case; and (2) there is no general requirement on the Board to engage in extraschedular analysis in all hearing loss rating cases. See Doucette v. Shulkin, 28 Vet. App. 366 (2017); and Martinak v. Nicholson, 21 Vet. App. 447 (2007). See also, Yancy v. McDonald, 27 Vet. App. 484 (2016). Right Wrist According to Thun v. Peake, 22 Vet. App. 111 (2008), there is a three-step inquiry for determining whether an appellant is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a claimant's disability picture and that picture includes related factors, such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director to determine whether, to accord justice, the appellant's disability picture requires the assignment of an extraschedular rating. See 38 C.F.R. § 3.321 (b)(1) (2015). In May 2016, the Board denied a schedular rating in excess of 10 percent for post-operative residuals, right (dominant) wrist and remanded the claim for consideration of a possible extraschedular rating by the Director of Compensation Service. A decision was obtained in August 2016 from the Director of Compensation Service, of the Veterans Benefits Administration, who concluded that the evidentiary record fails to show an exceptional disability pattern for the service-connected residuals of a right wrist surgery that renders application of the regular rating criteria as impractical, citing Thun, supra. The Director summarized pertinent evidence, and found that the Veteran's manifestations of pain, loss of motion, and weakness of the right wrist have been appropriately considered and evaluated under the regular rating criteria of Diagnostic Code 5215. The Director stated that the record showed that the residual symptoms of the right wrist surgery are clearly consistent with the criteria under Diagnostic Code 5215, and, accordingly, entitlement to an extraschedular evaluation for the residuals of a right wrist surgery was denied. Finally, the Board has considered whether the Veteran may be entitled to an extraschedular rating pursuant to 38 C.F.R. § 3.321 (2017). The Veteran's case has already been referred to the Director of the C&P Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. It was determined that an extraschedular rating was not warranted. The Board agrees. The Veteran's functional loss as difficulty with opening and closing a school bus door or gripping a steering wheel is consistent with a 10 percent evaluation for a right wrist disability that is based upon loss of motion and pain, which is part of the regular rating criteria under Diagnostic Code 5215. In a December 2015 statement, the Veteran's representative asserted that the Veteran's wrist pain required the use of a brace to drive a school bus. A February 2017 VA occupational therapy note indicated that the Veteran continued to have right wrist pain, but showed improvement due to his new wrist splint, which increased wrist function and decreased symptoms. He reported his pain as 0/10 and in the past month worst pain was 5/10. After a review of all of the evidence of record, the Board finds that the applicable diagnostic codes contemplate the Veteran's claimed symptoms related to his service-connected right wrist disability, as described above. Higher ratings are available for greater levels of disability. As the rating criteria are considered adequate, an extraschedular rating is not warranted. Thun, supra. The Board notes that the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that the combined effects of a veteran's service-connected disabilities must also be considered in determining whether the schedular evaluations are adequate under § 3.321(b)(1). Johnson v. McDonald, 762 F.3d 1362, 1365 (Fed. Cir. 2014). In this regard, the Federal Circuit observed that "§ 3.321(b)(1) performs a gap-filling function [that] accounts for situations in which a veteran's overall disability picture establishes something less than total unemployability, but where the collective impact of a veteran's disabilities are nonetheless inadequately represented." However, in this case there are no additional service-connected disabilities that have not been attributed to a specific service-connected condition. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. Therefore, entitlement to an extraschedular rating pursuant to 38 C.F.R. 3.321 (b)(1) is not warranted. GERD Before proceeding with its analysis of the Veteran's claim, the Board finds that some discussion of Fenderson v. West, 12 Vet. App 119 (1999) is warranted. In that case, the Court emphasized the distinction between a new claim for an increased evaluation of a service-connected disability and a case (such as this one) in which a veteran expresses dissatisfaction with the assignment of an initial disability evaluation where the disability in question has just been recognized as service-connected. VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim-a practice known as "staged rating." See also Hart v. Mansfield, 21 Vet. App. 505 (2007). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is not allowed. See 38 C.F.R. § 4.14. A claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993) (interpreting 38 U.S.C. § 1155). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. However, if a Veteran has separate and distinct manifestations attributable to the same injury, they should be compensated under different diagnostic codes. See Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225, 230 (1993). In July 2013, the Veteran underwent a DBQ for esophageal conditions. The Veteran was diagnosed with GERD. During service, he took tums to relieve heartburn, but did not report his symptoms. Shortly after service, the Veteran was diagnosed with erosive esophagitis. He reported taking Nexium for years and that he had been asymptomatic while taking Nexium. In March 2016, the Veteran stated that he had GERD symptoms during periods of high stress while on medication. He reported difficulty swallowing, a constant burning sensation in his upper abdomen, belching, and occasionally he regurgitated food. In November 2017, the Veteran underwent a VA examination of esophageal conditions. The Veteran was diagnosed with GERD. His symptoms included pyrosis, pain mid-chest, reflux, and belching. He reported taking Nexium, which controlled his symptoms. The VA examiner found that the Veteran's GERD did not impact his ability to work. The Veteran's GERD is rated under Diagnostic Code 7399-7346. Diagnostic Code 7346 provides a 60 percent evaluation for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia, or other symptom combinations productive of severe impairment of health. A 30 percent evaluation is warranted when there is persistently recurrent epigastric distress with dysphasia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 10 percent evaluation when the evidence shows two or more of the symptoms for the 30 percent evaluation of less severity. 38 C.F.R. § 4.114. The Veteran's GERD symptoms more nearly approximate a 30 percent rating from March 15, 2016. In his March 15, 2016 statement, the Veteran reported difficulty swallowing, a constant burning sensation in his upper abdomen, belching, and regurgitation. Prior to this date, the Veteran reported that he was asymptomatic while on medication during his July 2013 VA examination. However, although the Veteran has some symptoms which are listed among those for 60 percent criteria, the rating criteria requires that the Veteran have not only pain and vomiting, but also weight loss and hematemesis which he does not have. Moreover, he does not alternatively have melena with moderate anemia, or other symptom combinations productive of severe impairment of health. In determining whether a higher rating is warranted for service-connected disability, VA must determine whether the evidence supports the Veteran's claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107 (a); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In this case, the evidence supports a higher rating of 30 percent but no higher, for GERD from March 15, 2016. ORDER Service connection for hemorrhoids is denied. Service connection for migraine headaches is denied. Service connection for IBS is denied. Entitlement to an increased rating higher than 0 percent for right ear hearing loss from September 10, 2015, is denied. Entitlement to an extraschedular disability rating for post-operative residuals, right wrist is denied. Entitlement to a 30 percent rating, but not higher, for GERD is granted from March 15, 2016, subject to the law and regulations governing the payment of monetary benefits. S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs