Citation Nr: 19128233 Decision Date: 04/11/19 Archive Date: 04/11/19 DOCKET NO. 18-46 748 DATE: April 11, 2019 ORDER Entitlement to service connection for a left foot disability is denied. Entitlement to service connection for a cervical spine disability is denied. Entitlement to service connection for Buerger's disease is denied. Entitlement to service connection for constipation is denied. Entitlement to service connection for headaches is denied. Entitlement to an initial rating in excess of 10 percent for gastroesophageal reflux disease (GERD) is denied. Entitlement to an initial rating in excess of 10 percent for primary insomnia is denied. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the claimed left foot disability began during active service or is otherwise related to an in-service injury or disease. 2. The preponderance of the evidence is against finding that a cervical spine disability, diagnosed primarily as degenerative disc disease, manifested during service or to a compensable degree within the initial post service year; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease. 3. The appellant’s thrombo angitis obliterans (Buerger’s disease) was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease. 4. The preponderance of the evidence is against finding that constipation began during active service or is otherwise related to an in-service injury or disease. 5. The preponderance of the evidence is against finding that headaches began during active service or is otherwise related to an in-service injury or disease. 6. During the appeal period, the appellant’s GERD, manifested primarily by pyrosis and regurgitation, was not more nearly productive of considerable impairment of health. 7. During the appeal period, the appellant’s primary insomnia was productive of no more than occupational and social impairment due to mild or transient symptoms which decreased work efficiency and his ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. CONCLUSIONS OF LAW 1. The criteria for service connection for a left foot disability are not met. 38 U.S.C. §§ 1110, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for a cervical spine disability are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for service connection for Buerger’s disease are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. The criteria for service connection for constipation are not met. 38 U.S.C. §§ 1110, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for service connection for headaches are not met. 38 U.S.C. §§ 1110, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for an initial rating in excess of 10 percent for GERD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.20, 4.114, Diagnostic Code 7399-7346. 7. The criteria for an initial rating in excess of 10 percent for primary insomnia have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.20, 4.130, Diagnostic Code 9499-9413. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant served on active duty from April 1982 to April 1986 and from March 1987 to October 1993. He also had subsequent service in the Reserve and National Guard. He participated in Operation Desert Shield/Desert Storm, (including the period from December 1990 through March 1991) while serving on board the U.S.S. THOMAS S. GATES (CG51) in the Red Sea. In March 2018, the appellant had a hearing at the Agency of Original Jurisdiction (AOJ) before a VA Decision Review Officer. His wife also testified as a witness. A hearing transcript is associated with the record . REFERRED In December 2013, the Agency of Original Jurisdiction (AOJ) denied the appellant’s claims of entitlement to service connection for a left foot disability, a cervical spine disability, Buerger’s disease, constipation, and headaches. In his substantive appeal, received in October 2018, the appellant raised contentions to the effect that those decisions involved clear and unmistakable error (CUE). Those contentions are referred to the AOJ for appropriate action. Service Connection The appellant seeks service connection for a left foot disability, a cervical spine disability, Buerger’s disease, constipation, and headaches. He contends that the claimed left foot disability, cervical spine disability, Buerger’s disease, headaches, and constipation are related to an in-service injury, event, or disease, including his participation in the Persian Gulf War. In the alternative he contends that they are proximately due to or have been aggravated by a disability for which service connection has already been established. As a preliminary matter, the appellant has submitted numerous medical articles which he contends support his claims. However, none or those articles identify the appellant or his specific case, and neither he nor his wife is competent to provide a nexus opinion regarding any of those issues or to interpret those articles as applicable to the appellant’s claims. The issues are medically complex and require knowledge of anatomy, the interaction between multiple organ systems in the body, pathology, and/or interpretation of complicated diagnostic medical testing. Therefore, rendering such opinions is outside the competence of the appellant and his wife, because the record does not show that either has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Certain chronic diseases, such as arthritis and Buerger’s disease (thromboangiitis obliterans), will be presumed to be related to service if they were shown as chronic (reliably diagnosed) in service; or, if they manifested to a compensable degree within one year of his separation from service; or, if they were noted in service, with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013); Fountain v. McDonald, 27 Vet. App. 258 (2015); 38 C.F.R. §§ 3.303, 3.307, 3.309. Service connection may also be granted when the evidence shows that a particular disability is proximately due to or has been aggravated by a disability for which service connection has already been established. 38 C.F.R. § 3.310(a). In addition, service connection may be established for a Persian Gulf veteran who has a qualifying chronic disability that became manifest during service or to a degree of 10 percent or more not later than December 31, 2021. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. A “qualifying chronic disability” includes: (A) an undiagnosed illness, or (B) a medically unexplained chronic multi-symptom illness, such as chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal disease). 38 U.S.C. § 1117 (a)(2); 38 C.F.R. § 3.317 (a)(2)(i). Disabilities that have existed for six months or more, and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period, will be considered chronic. 38 C.F.R. § 3.317 (a)(4). A qualifying chronic disability shall be considered service connected. 38 C.F.R. § 3.317 (a)(6). Compensation shall not be paid for a qualifying chronic disability if there is affirmative evidence that the disability was caused by a supervening condition or event that occurred between a veteran’s most recent Southwest Asia duty and the onset of the disability. 38 C.F.R. § 3.317 (a)(7)(ii). Signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic multi-symptom illness include, but are not limited to: (1) fatigue, (2) signs or symptoms involving skin, (3) headache, (4) muscle pain, (5) joint pain, (6) neurological signs or symptoms, (7) neuropsychological signs or symptoms, (8) signs or symptoms involving the upper or lower respiratory system, (9) sleep disturbances, (10) gastrointestinal signs or symptoms, (11) cardiovascular signs or symptoms, (12) abnormal weight loss, or (13) menstrual disorders. 38 C.F.R. § 3.317 (b). The foregoing law and regulations notwithstanding, service connection may be granted for any disease that is initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303. The question for the Board is whether the appellant has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes however that the appellant does not have a current diagnosis of a chronic, identifiable foot left foot disability. The Board further concludes that, while the appellant has a current diagnosis of degenerative disc disease of the cervical spine, Buerger’s disease, constipation, and migraine/cluster headaches, the preponderance of the evidence weighs against finding that any of those disorders began during service or is otherwise related to an in-service injury, event, or disease. Additionally, the preponderance of the evidence is against finding that cervical spine arthritis and/or Buerger’s disease had its/their onset during active service or manifested to a compensable degree within the initial post separation year. 1. Entitlement to service connection for a left foot disability The appellant contends that he has a left foot disability as a result of physical training in service. In the alternative, he contends that it is the result of his experiences during the Persian Gulf War, including his exposure to toxic substances. During his January 1982 service entrance examination, the appellant denied that he then had, or had ever had, foot trouble. During his March 1986 service separation examination and during his November 1986 service entrance examination, he was found to have bilateral pes planus which was asymptomatic. In June 1987, the appellant sprained his left ankle playing volleyball, and there was slight edema in the area of the lateral malleolus. In November 1990, he tripped on a set of stairs and sustained a soft tissue injury to the lateral edge of his left foot. At his five-year examination in November 1992, the appellant again reported pes planus; however, his feet were found to be normal. In fact, during his November 1993 service separation examination and during an April 2004 examination prior to his entry into the Reserve, he denied that he then had, or had ever had foot trouble. Such evidence weighs against a finding that the inservice injuries were productive of a chronic, identifiable left foot disability. Nevertheless, in November 2013, VA examined the appellant VA to determine the nature and etiology of any left foot disability found to be present. During the November 2013 VA examination, the appellant reported left foot and toe pain, and it was noted that X-rays the previous month had shown slight soft tissue swelling in the area of the left lateral malleolus. It was also noted that he had the residuals of a left ankle sprain for which service connection had been granted. However, the examiner opined that the left foot and toe pain were associated with the appellant’s nonservice-connected Buerger’s disease. A separate, identifiable left foot disability related to service was not identified. The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The only evidence to the contrary comes from the appellant. As noted above, however, he does not have the training or experience to render a competent opinion of a nexus to service. Jandreau. Absent a current, identifiable left foot disability related to service, the appellant does not meet the criteria for service connection. It is noted that the existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. §§ 1110, 1131; Degmetich v. Brown, 104 F. 3d 1328 (1997). In the absence of proof of a present disability due to disease or injury, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Accordingly, service connection is not warranted. There is no doubt to resolve. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to service connection for a cervical spine disability The appellant contends that his currently diagnosed degenerative disc disease of the cervical spine disability is a result of physical training in service and notes that he was treated in service for neck strain. In the alternative, he contends that it is the result of his experiences during the Persian Gulf War, including his exposure to toxic substances. He maintains that the cervical spine degenerative disc disease is associated with fibromyalgia, a chronic, multi-symptom illness. The reports of the appellant’s examinations at the time of his entry into and separation from his first period of active duty and the report of examination prior to his second period of active duty show that his neck and spine were normal. In June 1992, the appellant was treated for a four-hour history of neck pain. The assessment was muscle strain; however, by the time of his November 1992 5-year examination, his neck and spine were found to be normal. His September 1993 service separation examination and his April 2004 examination prior to his entry into the Reserve were similarly normal. During treatment at Bull Run Family Practice in April 2001, the appellant complained of bilateral shoulder and upper arm pain, as well as numbness, tingling, and a burning sensation in hands. He reported that he had been in a motor vehicle accident 2 months earlier with some neck pain, but that it had never totally resolved. Such evidence suggests that the appellant’s neck pain resulted from an intervening injury outside of his active military service. Nevertheless, in October 2013 and May 2018, the appellant was examined by VA to determine the nature and etiology of any chronic identifiable neck disability found to be present. Following the examinations, the diagnosis was degenerative disc disease in the cervical spine. Although the appellant reported a history of intermittent muscle pain in his neck since experiencing neck muscle pain after a physical training on active duty, the examiners noted that there were no documented complaints of such in his medical records. A second VA examiner concurred, opining that that there was no indication in service that the appellant had a sustained a neck disability of such a nature that it would lead to the development of degenerative changes many years later. Following the May 2018 VA examination, a third VA examiner agreed that it was less likely than not that the appellant’s degenerative changes of the cervical spine were related to service. The examiner acknowledged the appellant’s neck injury in service; however, after reviewing the relevant medical literature showing that degenerative disc disease was caused by spinal degeneration which occurred during the aging process, she opined that the disorder was less likely than not related to in-service injury or disease. Taken together, the VA examiners’ opinions weigh heavily against the appellant’s claim. They are probative, because they are based on an accurate medical history and provide explanations that contain clear conclusions and supporting data. Nieves-Rodriguez. As to the appellant’s contentions that his cervical spine disability had its onset as a result of his experiences in the Persian Gulf War, the Board notes that degenerative disc disease cervical spine constitutes chronic, identifiable pathology. In addition, the October 2013 examiner found that the appellant did not then have, nor had he ever had, fibromyalgia associated with his complaints of cervical spine pain. Given those findings, the appellant does not meet the criteria for service connection for an undiagnosed illness or multi-symptom illness associated with his participation in the Persian Gulf War. The more persuasive evidence of record shows that the appellant’s currently shown neck disability did not have its onset during active service; or manifest to a compensable degree within one year after any period of active service; or that it is otherwise etiologically related to disease or injury incurred during a period of active service, including Gulf War service. Accordingly, the appeal is denied. There is no doubt to resolve. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Entitlement to service connection for Buerger's disease During his hearing, the appellant testified that there was a relationship between the onset of Buerger’s disease and smoking. He acknowledged that he smoked in service and that he was around second-hand smoke every day. He notes that he stopped smoking when he found out that he had Buerger’s disease but questions why he continues to have Buerger’s disease, even though he has stopped smoking. Therefore, he contends that there may be another cause, such as his participation in the Persian Gulf War. He also notes that it is a vascular disorder and may be related to heart disease. In any event, he contends that service connection is warranted. Generally, for claims filed after June 9, 1998, service connection may not be granted on the basis of tobacco use, even if such tobacco use began in service. 38 U.S.C. § 1103; 38 C.F.R. § 3.300. Thus, service connection cannot be warranted on this basis as a matter of law. However, that does not preclude the Board from considering service connection on other bases. During the appellant’s entry and separation examinations from both periods of active duty and during his April 2004 examination prior to his entry into the Reserve, he denied that he then had or had ever had, a vascular disability of any kind. Indeed, the associated physical examinations of his arteries and veins were normal. Buerger’s disease was first reported in February 2009 at Center Grove Family Medicine. The appellant reported a two-year history of left foot soreness and a dusky color in his fingers and toes, especially in winter. However, the normal medical findings at the time of the appellant’s separation from service, as well as the absence of any medical records of a diagnosis or treatment for many years after service is probative evidence against the claim. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Nevertheless, VA examined the appellant in October 2013 to determine the etiology of his Buerger’s disease. It was noted that the appellant had developed a sore on his left second and third toes and what looked like a bruise at the base of those toes. Those manifestations reportedly followed a move to Indiana from Florida in 2006. It was noted that the diagnosis of Buerger’s Disease had been confirmed in 2009; and the appellant was told to stop smoking which he did. Following the October 2013 VA examination, the examiner opined that Buerger’s disease was a condition that had specific etiologies and diagnosis and, as such was unrelated to an exposure event experienced by the appellant during service in Southwest Asia. In January 2017, the appellant contended that because Buerger’s disease is a circulatory disorder, it is associated with his heart disability, primarily diagnosed as atrial fibrillation. Therefore, he suggested that service connection is warranted on a secondary basis. However, a review of the record shows that service connection has not been established for heart disease of any kind. Therefore, it does not provide a basis for secondary service connection. Absent competent, credible evidence of Buerger’s disease in service; during the first year after the appellant’s separation from a period of active service; or secondary to a disability for which service connection has already been established, the appellant does not meet the criteria for service connection for Buerger’s disease on any basis. Accordingly, service connection is not warranted. There is no doubt to resolve. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 4. Entitlement to service connection for constipation The appellant contends that he has chronic constipation, primarily as a result of an undiagnosed illness or multi-symptom illness following his exposure to toxic substances during the Persian Gulf War. The appellant’s service medical records, including the reports of his service entry into and separation from his first period of active duty show that he denied that he then had or had ever had, a frequent indigestion or stomach, liver, or intestinal trouble of any kind. Indeed, the associated physical examinations of his abdomen and viscera and anus and rectum were normal. During service in December 1991 the appellant reported rectal pain/discomfort associated with prostatitis, and in December 1992, he reported perineal pain and rectal discomfort. However, an examination was normal. There were no reports or findings of constipation on either occasion or throughout the remainder of his service. Indeed, the reports of his November 1993 service separation examination and his April 2004 Reserve entrance examination show that his abdomen and viscera and anus and rectum were normal. The appellant’s constipation was first manifested in January 2010 during treatment at or through Center Grove Family Medicine. To the examiner, it appeared to be related to medication the appellant was taking for his nonservice-connected Buerger’s disease. He was reportedly taking a stool softener every evening. He reported constipation again in December 2011 and was treated for an anal fissure in June 2012. The appellant contends that his constipation is the result of his exposure to toxic substances during the Persian Gulf War. However, even if constipation has been chronic in nature, the evidence shows that it is less than 10 percent disabling. It is rated by analogy to irritable bowel syndrome. 38 C.F.R. §4.114, Diagnostic Code 7319. A noncompensable rating is warranted for constipation that is productive of mild impairment and manifested by disturbances of bowel function with occasional episodes of abdominal distress. A 10 percent rating is warranted if constipation is productive of moderate impairment, manifested by frequent episodes of bowel disturbance with abdominal distress. However, during treatment at Center Grove Family Medicine in February 2013, it was noted that the appellant’s constipation was occasional in nature. Moreover, during his October 2013 VA examination, the examiner noted that the appellant did not have episodes of bowel disturbance with abdominal distress. Indeed, the appellant acknowledged that stool softeners had corrected the constipation. Such findings did not meet or more nearly approximate the schedular criteria for a 10 percent rating. In addition, the VA examiner noted that constipation had a specific etiology unrelated to a specific exposure event experienced by the appellant during service in Southwest Asia. During a May 2018 VA examination by a different VA examiner, the appellant reported constipation two to three times a week and abdominal distention. However, the examiner noted that the appellant had no evidence of weight loss, malnutrition, or serious complications or other general health effects attributable to his intestinal condition. Following the examination, the examiner opined that it was less likely than not that chronic constipation was incurred in or caused by the claimed in-service injury, event, or illness. The only evidence to the contrary comes from the appellant, but, as noted above, he is not qualified to render such an opinion. Jandreau. Taken together, the VA examiners’ opinions weigh heavily against the appellant’s claim. They are probative, because they are based on an accurate medical history and provide explanations that contain clear conclusions and supporting data. Nieves-Rodriguez. Absent evidence of constipation in service or of a nexus to a service-related disease, injury, or event, the appellant does not meet the criteria for service connection for constipation. Accordingly, service connection for constipation is not warranted, and the appeal is denied. There is no doubt to resolve. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 5. Entitlement to service connection for headaches The appellant suggests that his headaches are the result of a head injury sustained in a 1990 motor vehicle accident (MVA) in service. In the alternative, he contends that they are the residuals of his experiences in the Persian Gulf War. The reports of the appellant’s medical history at the time of his entry into his first period of active duty shows that he denied that he then had or had ever had, frequent or severe headaches of any kind. Physical examinations of his head, face, neck, and scalp, as well as his neurologic processes were normal. In August 1984, the appellant complained of a headache in association with a viral syndrome and, in May 1985, he complained of a headache in association with coryza. However, there were no findings of a chronic, identifiable headache disability during the remainder of his first period of service, and during his service separation examination, his head, face, neck, and scalp, as well as his neurologic processes were, again, found to be normal. The entrance examination prior to his second period of active duty was, similarly, normal. During his second period of active duty, the appellant reported that he had headaches in September 1988 following a typhoid shot and again in association with a viral syndrome. Sinus headaches were noted in December 1988 in association with an upper respiratory infection. As above, however, there were no findings of a chronic, identifiable headache disability. Indeed, during his 5-year examination in November 1992, his September 1993 service separation examination, and his April 2004 entry examination for the Reserve, the appellant denied that he then had, or had ever had frequent or severe headaches. Each time, his head, face, neck, and scalp and neurologic processes were found to be normal. Following his VA examinations in October 2013 and May 2018, the relevant diagnoses were migraine headaches and cluster headaches. It was noted that they had first been manifested years after service and that it was less likely than not that they were related to service. While the appellant contends that his headaches are the residuals of a head injury sustained in service in 1990, his service medical records are negative for any such accident. Indeed, the May 2018 examiner noted that the appellant’s headaches were not post-traumatic in nature. In this regard, the Board notes that, in May 2015, VA examined the appellant to determine whether he had the residuals of a traumatic brain injury (TBI). Following the examination, the examiner found that the appellant did not then have, nor had he ever had, a TBI. The AOJ subsequently denied entitlement to service connection for the residuals of a TBI, which is not on appeal to the Board at this time. Although the appellant contends that his headaches are related to his exposure to toxic substances during the Persian Gulf War, the VA examiners concurred that migraine headaches and cluster headaches are chronic, diagnosable disabilities with clear and specific etiologies. Accordingly, they do not meet the criteria for service connection as undiagnosed disabilities resulting from the appellant’s participation in the Persian Gulf War. The Veteran does not contend nor does the evidence suggest that headaches are part of a medically unexplained chronic multisymptom illness. The appellant also contends that his headaches are proximately due to or have been aggravated by his service-connected sleep disorders. However, he is not competent to render such an opinion and has neither provided nor identified any outstanding competent, credible evidence to substantiate that claim. The appellant also contends that his headaches are proximately due to or have been aggravated by a heart disorder or traumatic brain injury. However, service connection has not been established for either of those disabilities and, therefore, service connection is not warranted on a secondary basis. Absent a nexus to service or to a service-connected disability, the appellant does not meet the criteria for service connection for headaches. Accordingly, service connection is not warranted, and the appeal is denied. There is no doubt to resolve. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Increased Rating The appellant contends that he is entitled to a higher initial rating for his service-connected GERD and primary insomnia because they do not adequately reflect the severity of those disorders. Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The percentage ratings contained 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. Any reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. A disability may require re-evaluation in accordance with changes in a veteran’s condition. It is thus essential, in determining the level of current impairment, that the disability be considered in the context of the entire recorded history. 38 C.F.R. § 4.1. 6. Entitlement to an initial rating in excess of 10 percent for GERD In December 2013, the AOJ granted service connection for GERD and assigned an initial rating of 10 percent, effective January 7, 2013. During his hearing, the appellant and his wife testified that his GERD was manifested primarily by heartburn and regurgitation requiring daily medication and that it had been productive of a considerable impairment of his health since service connection had become effective. Therefore, he maintained that an initial rating in excess of 10 percent was warranted. There is no Diagnostic Code specifically applicable to rating GERD. It is rated by analogy to 38 C.F.R. § 4.114, Diagnostic Code 7346. 38 C.F.R. § 4.20. Diagnostic Code 7346 provides a structured scheme of specific, successive, cumulative criteria. Each higher rating includes the same criteria as the lower rating plus distinct new criteria. Middleton v. Shinseki, 727 F.3d 1172, 1178 (Fed. Cir. 2013). A 60 percent rating is warranted for GERD, when it is manifested by symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of a severe impairment of health. A 30 percent rating is warranted when it is manifested by persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal arm or shoulder pain, which is productive of considerable impairment of health. A 10 percent rating is warranted for two or more of the symptoms for the 30 percent evaluation of less severity. 38 C.F.R. § 4.114, Diagnostic Code 7346. After reviewing the record, the Board finds that the appellant’s GERD is not more nearly manifested by symptoms, as above, that are productive of “considerable impairment of health.” The evidence such as the report of the October 2013 VA examination, shows that it is manifested, primarily, by pyrosis and regurgitation, and outpatient treatment records show that he takes daily medication. However, throughout the appellate period, such as during VA treatment in September 2014, July 2017, and July 2018, it was noted that the appellant was well-developed and well-nourished. He was 71 inches tall and weighed approximately 200 pounds. As late as November 2018, it was noted that he had not experienced weight loss or a change in appetite. As above, the appellant is competent to report elements that are capable of lay observation, such as symptoms of heartburn or regurgitation. Jandreau. However, he does not assert, and his treatment records do not show, that his GERD is productive of dysphagia, or substernal shoulder or arm pain. To the extent that lay evidence reports that there is considerable impairment of health, it has not identified with any specificity the nature of the considerably impaired health (e.g, anemia, weight loss, etc.). Whether a disability meets the schedular criteria for the assignment of a higher evaluation is a factual determination by the Board based on the complaints coupled with the medical evidence. Here, although the Veteran believes that he meets the criteria for a higher disability rating, his complaints and the medical findings do not meet the schedular requirements for the higher rating, as explained and discussed above. Both the lay and the medical evidence are probative here. However, it does not more nearly reflect the criteria for a higher rating under the assigned diagnostic code or any other potentially relevant code, or entitlement to a separate evaluation. Also, there is no basis to stage the rating as the evidence shows no distinct period where the disability exhibited symptoms that would warrant different ratings than assigned. See Hart v. Mansfield, 21 Vet. App. 505 (2007) (staged ratings are appropriate when the factual findings show distinct period where the service-connected disability exhibits symptoms that would warrant different ratings); see also Fenderson v. West, 12 Vet. App. 119, 126 (2001). Therefore, the preponderance of the evidence is against a finding that he met or more nearly approximated the schedular criteria for an initial rating in excess of 10 percent at any time since service connection became effective January 7, 2012. Accordingly, the initial 10 percent rating for GERD is confirmed and continued. 7. Entitlement to an initial rating in excess of 10 percent for primary insomnia The appellant contends that the initial 10 percent rating for primary insomnia did not adequately reflect all his sleep problems and that an increased initial rating has been warranted since service connection became effective January 7, 2012. Therefore, he maintains that an increased initial rating is warranted. Parenthetically, the Board notes that service connection has also been established for obstructive sleep apnea, evaluated as 50 percent disabling. However, that rating is not at issue here and will not be considered below. As above, there is no Diagnostic Code specifically applicable to rating primary insomnia. It is a psychiatric disorder and is rated by analogy to an unspecified anxiety disorder. 38 C.F.R. §§ 4.20, 4.130, Diagnostic Code 9413, General Rating Formula for Mental Disorders. Diagnostic Code 9413 also provides a structured scheme of specific, successive, cumulative criteria. Each higher rating includes the same criteria as the lower rating plus distinct new criteria. Middleton. Under the General Rating Formula for Rating Mental Disorders, a 10 percent rating is warranted for primary insomnia when there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. 38 C.F.R. § 4.130, Diagnostic Code 9413. A 30 percent rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. Id. A 100 percent disability rating is warranted when there are such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. The symptoms listed in the General Rating Formula are examples, not an exhaustive list and that any suggestion that the Board is required to find the presence of all, most, or even some of the enumerated symptoms is unsupported by a reading of the plain language of the regulation. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Rather, the Board must conduct a “holistic analysis” that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. When determining the appropriate rating to be assigned for a service-connected mental health condition, the focus is on how the frequency, severity, and duration of the symptoms affect a veteran's occupational and social impairment, rather than on an absence of particular symptoms listed in the schedular criteria. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013) The issue in this appeal is whether the appellant’s associated symptoms caused the level of impairment required for a disability rating of 30 percent or higher. The Board concludes that the appellant’s symptoms did not cause the level of impairment required for a disability rating of 30 percent or higher for primary insomnia. The appellant’s symptoms more closely approximated the symptoms associated with a 10 percent rating. VA and private treatment records, such as those from Center Grove Family Medicine, the reports of VA psychological examinations in an October 2013 and June 2015, and the appellant’s lay statements show that his primary insomnia was manifested by no more than mild, transient symptoms and/or symptoms controlled by continuous medication. Indeed, following the VA examinations, the examiner found that while an insomnia disorder had been formally diagnosed, the symptoms were not severe enough either to interfere with occupational and social functioning. Although the appellant reported low energy and frequent ruminations (especially at night) about whether he was going to keep his job, neither VA examiner reported findings of a depressed mood, anxiety, suspiciousness, panic attacks, or memory loss associated with the next higher rating. Taken together, the Board finds that the severity, frequency, and duration of the appellant’s primary insomnia symptoms more closely approximated those contemplated by the current 10 percent rating. Those symptoms are less severe, less frequent, and shorter in duration than those contemplated by a 30 percent rating. In sum, the preponderance of the evidence weighs against the claim for an   increased rating for primary insomnia. Accordingly, the initial 10 percent rating for is confirmed and continued, and the appeal is denied. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Harold A. Beach, Counsel