Citation Nr: 20070177 Decision Date: 10/29/20 Archive Date: 10/29/20 DOCKET NO. 16-25 210 DATE: October 29, 2020 ORDER Entitlement to an initial disability rating in excess of 10 percent for the Veteran’s service-connected left ankle disability is denied. Entitlement to an initial compensable disability rating prior to November 4, 2019, and in excess of 10 percent thereafter, for the Veteran’s service-connected gastroesophageal reflux disease (GERD) is denied. REMANDED Entitlement to an initial disability rating in excess of 10 percent for the Veteran’s service-connected right wrist/hand disability is remanded. FINDINGS OF FACT 1. During the appellate period, the Veteran has not experienced left ankle ankylosis, subastragalar or tarsal joint ankylosis, or malunion of the os calcis or astragalus, and his left ankle limitation of motion has most closely approximated a moderate degree of impairment. 2. Prior to November 4, 2019, the Veteran’s service-connected GERD was characterized by infrequent complaints of epigastric distress, pyrosis, and reflux, but two or more symptoms for the 30 percent evaluation of less severity, including persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health, have not been shown. 3. Since November 4, 2019, the Veteran’s service-connected GERD has resulted in dysphagia, pyrosis, reflux, and substernal pain, but has not resulted in persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial disability rating in excess of 10 percent for the Veteran’s service-connected left ankle disability have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Code 5002-5271 2. The criteria for entitlement to an initial compensable disability rating prior to November 4, 2019, and in excess of 10 percent thereafter, for the Veteran’s service-connected GERD have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.114, Diagnostic Code 7399-7346. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1999 to March 2004. These matters come before the Board of Veterans Appeals (Board) on appeal from an October 2014 rating decision issued by a Regional Office (RO) of the United States Department of Veterans Affairs (VA). In the February 2016 VA form 9, Substantive Appeal, the Veteran requested a Board videoconference hearing. In October 2018, the Veteran, through a written statement received from his former representative, withdrew his request for a Board hearing. As such, the Veteran has waived his right to a hearing and this case is properly before the Board for appellate disposition. See 38 C.F.R. § 20.704(e) (formerly 38 C.F.R. § 20.702(e)). The undersigned Veterans Law Judge has been assigned to consider these matters pursuant to 38 C.F.R. § 20.106(a) (formerly 38 C.F.R. § 19.3(a)). In correspondence received in October 2020, the Veteran’s representative waived initial RO consideration of all evidence received since the claims were last adjudicated by the RO. As such, the Board may proceed with its appellate review. In the October 2014 rating decision, the Veteran was granted service connection for a left ankle disability (10 percent rating effective July 14, 2014), a right wrist/hand disability (10 percent rating effective October 13, 2011), and GERD (noncompensable rating effective March 20, 2004). The Veteran filed a VA form 21-0958, Notice of Disagreement, in October 2014, where in pertinent part, he requested higher initial ratings for these three disabilities, as well as earlier effective dates for the left ankle and right wrist/hand disabilities. In a January 2016 rating decision, the Veteran was awarded an earlier effective date of March 20, 2004—the date he filed his first VA claim—for the claims of entitlement to service connection for a left ankle and right wrist/hand disabilities. The January 2016 rating decision fully resolved the Veteran’s earlier effective date claims, and thus the only matters ripe for appellate consideration are his claims seeking higher initial disability ratings for his service-connected left ankle, right wrist/hand, and GERD disabilities. The appeal period for all increased rating claims on appeal dates back to March 20, 2004. Regarding the Veteran’s service-connected GERD, the Board notes that its November 2015 decision mistakenly listed the issue as “entitlement to an initial disability rating higher than 10 percent for GERD” when it remanded the claim for issuance of a Statement of the Case pursuant to Manlincon v. West, 12 Vet. App. 238 (1999). According to the October 2014 rating decision, the Veteran was granted service connection for GERD and assigned an initial noncompensable rating dating back to March 20, 2004. In a June 2020 rating decision, the RO implemented a staged rating for the Veteran’s service-connected GERD, where an initial compensable rating was denied prior to November 4, 2019, and an initial 10 percent rating was awarded thereafter. Accordingly, the issue has been adjusted to reflect this partial grant of benefits. Neither the Veteran nor his representative has raised any issues with VA’s duty to notify or VA’s duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); see also Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Thus, the Board need not discuss any potential issues in this regard. Under 38 U.S.C. § 7104, Board decisions must be based on the entire record, with consideration of all the evidence. The law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran. Timberlake v. Gober, 14 Vet. App. 122, 128-29 (2000). The Board must review the entire record but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1381 (Fed. Cir. 2000). The analysis below focuses on the most salient and relevant evidence within the period on appeal and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake, supra. Increased Rating Claims Disability ratings are determined by application of the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. The Veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.”). Moreover, the provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). 1. Entitlement to an initial disability rating in excess of 10 percent for the Veteran’s service-connected left ankle disability is denied. The Veteran’s service-connected left ankle disability is currently rated under Diagnostic Code 5271-5002, 38 C.F.R. § 4.71a. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the rating assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.2. Diagnostic Code 5271 refers to ankle limitation of motion and Diagnostic Code 5002 refers to rheumatoid arthritis (which is analogous to the Veteran’s diagnosis of reactive arthritis). The Veteran seeks a higher initial disability rating on appeal. Initially, the Board notes that the evidence fails to substantiate the presence of left ankle ankylosis, including the subastragalar and tarsal joints; mal union of os calcis or astragalus in the left ankle; or astragalectomy in the left ankle. Consequently, Diagnostic Codes 5270, 5272, 5273, and 5274 are not for application. 38 C.F.R. § 4.71a. Under Diagnostic Code 5271, a 10 percent rating is assigned for moderate limitation of motion in the ankle, and a maximum 20 percent rating is assigned for marked limitation of motion in the ankle. Normal range of ankle motion is defined as dorsiflexion from zero to 20 degrees and plantar flexion from zero to 45 degrees. 38 C.F.R. § 4.71, Plate II. The Board notes that the terms “moderate” or “marked” as used in Diagnostic Code 5271 are not defined in VA’s Schedule for Rating Disabilities. Therefore, the Board finds it appropriate to utilize definitions provided by a general-purpose dictionary. Terry v. Principi, 340 F.3d 1378, 1382-83 (Fed. Cir. 2003) (in the absence of an express definition, words are given their ordinary meaning). “Moderate” is defined as “limited in scope or effect... not seriously or permanently disabling or incapacitating.” Webster’s Third International Dictionary (1986) at 1451. “Marked” is defined as “distinctive... strongly pronounced... noticeable.” Id. at 1383. Further, guidance from VA’s M21-1 Adjudication Procedures Manual (M21-1) states that moderate limitation of ankle motion is present when there is less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion. See VA Manual M21-1, III.iv.4.A.6.m. Marked limitation of motion is demonstrated when there is less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion. Id. The M21-1 is not binding on the Board and, to rely on the M21-1, the Board must conduct an independent analysis before determining whether the provisions may be relied upon as a factor to support its decision. Overton v. Wilkie, 30 Vet. App. 257 (2018). The Board finds that the M21-1 may be relied upon as a factor based on VA’s proposed revisions to DC 5271 made in February 2003 and August 2017. See 68 Fed. Reg. 6998 (Feb. 11, 2003); 82 Fed. Reg. 35719 (Aug. 1, 2017). In February 2003, VA hired an outside consultant, who convened a panel of non-VA specialists, to review the portion of the rating schedule dealing with the musculoskeletal system to formulate recommendations. VA proposed to adopt many of the recommendations, including defining “moderate” and “marked” similarly to the current M21-1 guidelines to ensure consistent evaluations. See 68 Fed. Reg. at 7018. In August 2017, VA proposed to redefine “moderate” and “marked” exactly as listed in the M21-1 and the proposal noted that “as VA currently uses these standards to define marked and moderate, this change is intended as a clarification of current policy and would ensure consistent application of these criteria among rating personnel.” See 82 Fed. Reg. at 35723. As such, the Board finds that ranges of motion listed in the M21-1 were based on expert recommendations, and it is appropriate to consider them for adjudicative purposes. The Veteran was afforded an initial VA examination to assess the severity of the Veteran’s left ankle disability in July 2004. Musculoskeletal examination of the left ankle showed mild swelling of the left heel with mild tenderness. The Veteran’s left ankle exhibited pain on dorsiflexion at 15 degrees and pain on plantar flexion at 40 degrees. The VA examiner noted additional fatigue, weakness, and lack of endurance/coordination in the left ankle, but noted that the Veteran’s pain had the most impact on function. The VA examiner found no left ankle deformity or any ankylosis in the left ankle. The VA examiner further stated that the Veteran’s left ankle disability contributed to the Veteran’s limited ability to stand and walk due to pain. The Veteran’s gait was normal. The Veteran attended a second VA examination to assess the severity of his left ankle disability in October 2011. The Veteran reported that during flare-ups he was limited to ambulating no more than 5 blocks and that flare-ups typically occurred during the morning. Range of motion testing showed complete left ankle dorsiflexion through 20 degrees, with pain starting at 15 degrees; and complete left ankle plantar flexion of 45 degrees or greater, with pain starting at 45 degrees. The Veteran performed repetitive use testing with three repetitions and post-test dorsiflexion in the left ankle ended at 20 degrees or greater, and post-test plantar flexion in the left ankle was further limited to 35 degrees. The VA examiner stated that less movement than normal, excess fatiguability, pain on movement, swelling, disturbance of locomotion, and interference with sitting, standing, and weight-bearing contributed to functional loss. The VA examiner elicited localized tenderness or pain to palpation on the left ankle. Muscle strength testing was normal in the left ankle during plantar flexion (5/5), but was slightly decreased during dorsiflexion (4/5). The VA examiner found no evidence of joint instability or ankylosis. The VA examiner noted that the Veteran constantly used bilateral shoe inserts to assist with locomotion, and that the Veteran had to frequently elevate his feet while performing his desk job due to swelling. The Veteran attended a third VA examination to assess the severity of his left ankle disability in July 2014. The Veteran reported that his left ankle disability limited his ability to perform prolonged walking, prolonged standing, running, and hiking. During flare-ups, the Veteran’s left ankle disability impacted his ability to stand, walk, and run for extended periods. Range of motion testing showed complete left ankle dorsiflexion to 20 degrees. Left ankle plantar flexion was limited to 20 degrees. The VA examiner estimated that the Veteran experienced an additional 5 degrees of range of motion loss in both the plantar flexion and dorsiflexion planes due to pain or functional loss during flare-ups. The VA examiner noted pain during weight-bearing and nonweight-bearing. The Veteran declined repetitive use testing due to pain. The VA examiner elicited no localized tenderness or pain on palpation in the left ankle. The VA examiner stated that less movement than normal, pain on movement, swelling, disturbance of locomotion, and interference with standing contributed to functional loss and the Veteran’s limitation of motion. Muscle strength testing of the left ankle was slightly decreased (4/5) in both the plantar flexion and dorsiflexion planes. There was no muscle atrophy, ankylosis, or joint instability. The VA examiner opined that the Veteran’s disability would limit activities requiring weight-bearing, standing, and locomotion for extended periods of time. The Veteran attended a final VA examination to assess the severity of his left ankle disability in November 2019. The Veteran reported that flare-ups occur daily with morning awakenings, causing stiffness. He also reported that weather changes result in a throbbing, burning, sharp pain and he notices swelling on and off throughout the day. He stated that he is unable to run, stand for more than 5 minutes or walk for more than 5 minutes without severe left ankle pain. Range of motion testing of the left ankle showed dorsiflexion limited to 10 degrees and plantar flexion limited to 20 degrees. Pain was noted on examination during testing of both planes and it resulted in functional loss. The VA examiner explained that the range of motion findings demonstrated the Veteran’s degree of functional loss due to pain and weakness and accurately reflected the Veteran’s functional ability during flare-ups. The VA examiner did not distinguish whether the range of motion findings were from active or passive testing, and thus, the Board infers that no difference was observed between active or passive range of motion testing. There was evidence of pain with weight-bearing, and evidence of localized tenderness or pain on palpation of the left ankle. Repetitive use testing was performed and did not result in any additional loss of function after three repetitions. The VA examiner stated that the Veteran’s left ankle was also manifested by swelling. Muscle strength testing of the left ankle was slightly decreased (4/5) in both the plantar flexion and dorsiflexion planes. There was no muscle atrophy, ankylosis, or joint instability. The VA examiner stated that the Veteran occasionally used orthotics. In considering this appeal, the Board has fully considered the medical treatment records during the entire appellate period. Generally, the Veteran reported left ankle pain, swelling, tenderness, and discomfort. Records consistently documented full range of motion, and never contained range of motion findings more severe than the results elicited at the Veteran’s VA examination. At worst, the evidence of record shows that the Veteran’s left ankle has resulted in dorsiflexion limited to less than 10 degrees or plantar flexion limited to less than 15 degrees in each plane (which are the most severe range of motion findings from the VA examinations). Based on the above findings, the Veteran has exhibited, at worst, moderate limitation of motion in the left ankle during the appellate period. Conversely, the Board finds that the Veteran’s left ankle disability did not demonstrate marked limitation of motion during the appellate period. While the evidence shows a decrease in range of motion for dorsiflexion and plantar flexion, his muscle strength results remained either within normal limits or mildly impaired (i.e., 4/5). Dorsiflexion was never limited to more than half of normal range of motion in the left ankle, and plantar flexion was not limited to less than 10 degrees, as referenced in the M21-1. The Board finds that the bases underlying VA’s proposed rules, which were created with non-VA specialists, are persuasive reasons to rely on M21-1 in rating ankle disabilities under Diagnostic Code 5271. As the evidence shows dorsiflexion at no worse than 10 degrees and plantar flexion no worse than 15 degrees, even when considering the factors discussed in 38 C.F.R. §§ 4.40, 4.45, and 4.59, the Veteran’s left ankle range of motion has most closely approximated moderate impairment pursuant to the M21-1 throughout the appellate period. In adjudicating this claim, the Board acknowledges the Veteran’s competent and credible reports of experiencing chronic pain, swelling, and discomfort in the left ankle, as reported at various VA treatment visits and VA examinations. In the October 2020 appellate brief, the Veteran’s representative has correctly argued that symptoms must be considered in compliance with Deluca and C.F.R. §§ 4.40, 4.45, 4.59. The Veteran’s complaints of chronic pain, swelling, and discomfort in the left ankle are fully compensated by his current 10 percent rating for the left ankle under Diagnostic Code 5271, which accounts for limitation of motion caused by pain and swelling, among other factors. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca, 8 Vet. App. at 204-07; see also Thompson, 815 F.3d at 785. At the April 2010 Board hearing, the Veteran’s previous representative stated that the Veteran suffered from decreased range of motion in the left ankle. To the extent that this statement can be attributed to the Veteran, it is competent and credible; however, the Board affords more weight to the explicit objective range of motion findings in the medical evidence, versus the Veteran’s generalized statement describing reduced limitation of motion. Likewise, to the extent that the Veteran reported flare-ups of left ankle pain, he described them in terms of the activities he could not fully complete or as stiffness, but he did not indicate that flare-ups resulted in additional limitation of motion. Sharp v. Shulkin, 29 Vet. App. 26 (2017). The Veteran’s left ankle disability is caused by reactive arthritis (analogous to rheumatoid arthritis), which may be rated under Diagnostic Code 5002; however, the VA treatment records indicate that the Veteran’s reactive arthritis has been largely in remission since 2008 (see December 2013 VA treatment records). More recent VA treatment records characterize the Veteran’s reactive arthritis as a historical diagnosis with chronic residuals. Diagnostic Code 5002 states that chronic residuals such as limitation of motion or ankylosis are to be rated under the appropriate diagnostic condes for the specific joints involved. Moreover, a note under Diagnostic Code 5002 states that “the ratings for the active process will not be combined with the residual ratings for limitation of motion or ankylosis;” instead, the regulation directs that the higher rating should be assigned. In the instant case, the Veteran has been awarded separate ratings based on limitation of motion of each joint affected by reactive arthritis. The Veteran’s combined rating for chronic residuals of his reactive arthritis has been at minimum, 50 percent, since March 20, 2004, and there is no evidence of symptomatology productive of severe impairment of health, severely incapacitating exacerbations, or total incapacitation sufficient to warrant a higher 60 or 100 percent rating under Diagnostic Code 5002 during the appellate period, in lieu of the combined rating assigned for limitation of motion affecting his individual joints service-connected as due to reactive arthritis. While the November 2019 VA examiner did not expressly address how many exacerbations of reactive arthritis occur in the left ankle per year, or whether a well-established diagnosis of reactive arthritis is present, these questions may be resolved by the Veteran’s contemporaneous VA treatment records, which do not indicate symptoms of reactive arthritis correlating to a higher 60 or 100 percent rating under Diagnostic Code 5002. The VA examiner’s failure to address these inquiries as directed by the Board’s November 2018 decision amounts to harmless error under the circumstances of this case. Based on the foregoing analysis, the criteria for an initial disability rating in excess of 10 percent for the Veteran’s service-connected left ankle disability have not been met, and the Veteran’s claims for initial increased rating is denied. 2. Entitlement to an initial compensable disability rating prior to November 4, 2019, and in excess of 10 percent thereafter, for the Veteran’s service-connected GERD is denied. The Veteran is currently assigned a noncompensable rating prior to November 4, 2019, and a 10 percent rating thereafter, for his service-connected GERD under Diagnostic Code 7399-7346, 38 C.F.R. § 4.114. In this matter, the Veteran’s GERD is rated under Diagnostic Code 7399-7346. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the evaluation assigned. The additional code is shown after a hyphen. 38 C.F.R. § 4.27. Furthermore, codes ending in “99” are for all unlisted conditions. As there is no diagnostic code for GERD, the RO rated GERD analogous to hiatal hernia under Diagnostic Code 7346. When an unlisted condition is encountered, it is permissible to rate under a closely related disease which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. Here, the Board finds that GERD is most closely analogous to a hiatal hernia in terms of symptomatology, resulting disability pictures, and anatomical localization in the upper gastrointestinal tract. Neither the Veteran nor his representative has the challenged the use of Diagnostic Code 7346 to rate this disability, nor have they identified a more appropriate diagnostic code. In light of the above considerations, the Board finds that Diagnostic Code 7346 is the most appropriate diagnostic code for rating the Veteran’s GERD. Under Diagnostic Code 7346, a 10 percent rating is warranted where hiatal hernia manifests with two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent rating is warranted for hiatal hernia that manifests as persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. The highest schedular rating of 60 percent rating under such code is warranted for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114. A. Prior to November 4, 2019 The evidence of record establishes that the Veteran experienced gastroenteritis during service, but there is very little probative evidence of GERD-related symptomatology from the start of the appellate period to November 4, 2019. The Veteran’s VA treatment records are largely silent regarding GERD-related symptoms during this time period, aside from rare notations that the Veteran’s medications may result in gastrointestinal discomfort. The Veteran attended a VA examination in July 2004 to assess his claims of gastrointestinal symptoms. At the time of examination, the Veteran denied gastrointestinal complaints; he denied any gastrointestinal treatment; and he denied any symptoms regarding his stomach. The VA examiner opined that the Veteran’s in-service gastroenteritis was resolved. The Veteran denied any residual gastrointestinal symptoms and abdominal examination was benign without pallor, anemia, or malnutrition. VA treatment records from October 2009 document complaints of dysphagia and pharyngeal swelling, however these symptoms were not attributed to GERD or any other gastro condition, but were instead believed to be symptoms related to a throat infection. In written argument received in May 2009 and June 2010, the Veteran’s prior attorney alleged that the Veteran suffered from symptoms similar to those he experienced during service on a recurrent basis. The attorney cited to no lay or medical evidence of record to support this assertion. When the Veteran testified at his April 2010 Board hearing, a different Veterans Law Judge questioned the Veteran regarding his gastrointestinal symptoms. The Veteran focused his testimony on the fact that he experienced gastroenteritis during service, but he provided very little information regarding the presence of contemporaneous symptoms. The Veterans Law Judge specifically asked the Veteran what his present symptoms were, and the Veteran deflected by discussing his in-service symptoms. He noted that his doctors have told him his medications could cause gastrointestinal problems, but he did not testify regarding specific symptoms he personally experienced. He stated that he had not seen a doctor recently regarding any gastrointestinal complaints. He vaguely asserted that he experienced some sort of gastro condition, but it was not a serious issue. This hearing testimony directly from the Veteran far outweighs the uncorroborated assertions made by his previous attorney. There is no evidence to support to the contention that the Veteran experienced recurrent gastrointestinal complaints during the period prior to November 4, 2019 that were akin to the symptomatology exhibited during his bout of in-service gastroenteritis. The Veteran attended a VA examination in October 2011 to assess his complaints of gastrointestinal distress. The VA examiner completed a disability benefits questionnaire (DBQ) for a stomach and duodenal condition (not including GERD or esophageal disorders). It was noted that the Veteran did not take continuous medication for gastrointestinal complaints. The VA examiner stated that the Veteran exhibited recurring episodes of symptoms that were not severe, with a frequency of 4 or more episodes per year, with an average duration of 1 to 9 days per episode. The Veteran’s symptoms included periodic abdominal pain, mild nausea for less than 1 day in duration, and recurrent melena (4 or more episodes per year, with an average duration of 1 to 9 days per episode). The Veteran did not have anemia, weight loss, or hematemesis. The VA examiner found no incapacitating episodes due to signs or symptoms of a stomach/duodenum condition. The Veteran attended another VA examination in July 2014 to assess his claimed gastro condition. Based on the undersigned’s review of the record, it was at this VA examination that the Veteran was first formally diagnosed with GERD. The Veteran lay reported a history of occasional GERD since his 2002 in-service gastroenteritis. It was noted that the Veteran did not take continuous medication for gastrointestinal complaints. The VA examiner found that the Veteran’s GERD was manifested by infrequent episodes of epigastric distress, pyrosis, heartburn, recurrent nausea (4 or more times per year lasting less than 1 day in duration per episode), and mild melena (4 or more episodes per year lasting less than 1 day in duration per episode). The Veteran did not exhibit persistently recurrent epigastric distress, dysphagia, regurgitation, substernal arm or shoulder pain, anemia, weight loss, vomiting, or hematemesis. The Veteran did not have an esophageal stricture, spasm of esophagus, or an acquired diverticulum of the esophagus. The July 2014 VA examiner also completed a DBQ for intestinal conditions. The Veteran’s primary symptoms identified were diarrhea (at least once per month), recurrent nausea, occasional black stools, and occasional episodic bowel disturbance with abdominal distress. The Board has fully reviewed the electronic claims file and finds no probative evidence that the Veteran’s service-connected GERD has resulted in two or more of the symptoms for a 30 percent rating of less severity, sufficient to warrant a compensable 10 percent rating or higher during the period prior to November 4, 2019. As noted, the Veteran’s VA treatment records are generally silent regarding GERD complaints during the relevant time period. The most probative evidence is the July 2014 VA examination, and it only showed the presence of infrequent episodes of epigastric distress, pyrosis, heartburn, recurrent nausea, and mild melena. These findings do not include two or more of the symptoms delineated in Diagnostic Code 7346 for a 30 percent evaluation. Consequently, as the record lacks probative evidence of two or more symptoms (such as persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, and/or substernal arm or shoulder pain), a compensable rating is not warranted for this period on appeal. Likewise, since the evidence does not show two or more symptoms of the 30 percent evaluation of less severity to support a 10 percent rating under Diagnostic Code 7346, it also does not show symptomatology sufficient to support a 30 percent rating. Lastly, the Veteran’s GERD has not resulted in symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health sufficient to warrant the maximum 60 percent rating under Diagnostic Code 7346 prior to November 4, 2019. Accordingly, the Veteran’s request for an initial compensable rating prior to November 4, 2019 for his service-connected GERD must be denied. B. Since November 4, 2019 Since November 4, 2019, the Veteran has been assigned a 10 percent rating under Diagnostic Code 7346 for his service-connected GERD based on the results on his November 4, 2019 VA examination. The Board finds that the RO correctly staged the Veteran’s increased rating effective November 4, 2019, as this is the first date in the record where it was factually ascertainable the Veteran satisfied the criteria for a 10 percent rating under Diagnostic Code 7346 for the Veteran’s service-connected GERD. See Swain v. McDonald, 27 Vet. App. 219, 224 (2015). Neither the Veteran nor his representative have argued for or cited any evidence establishing that a higher 10 percent rating is warranted at any time prior to November 4, 2019. At the November 2019 VA examination, the examiner noted that the Veteran took Prilosec to medically manage his GERD. The Veteran lay reported substernal chest pain, reflux, burning sensation in the esophagus, and dysphagia. The primary signs and symptoms of the Veteran’s GERD were documented by the VA examiner as dysphagia, reflux, substernal pain, sleep disturbances (twice per year lasting 1 to 9 days per episode), and nausea (4 or more times per year lasting 10 days or more per episode). The Veteran did not exhibit symptoms productive of considerable impairment of health, symptoms productive of severe impairment of health, persistently recurrent or infrequent episodes of epigastric distress, pyrosis, regurgitation, arm or shoulder pain, material weight loss, vomiting, hematemesis, or melena with moderate anemia. The Veteran did not have an esophageal stricture, spasm of esophagus, or an acquired diverticulum of the esophagus. The Veteran’s VA treatment records since November 4, 2019 have been reviewed and they do not document signs and symptoms of GERD that correlate with a rating in excess of 10 percent during this time period. There is no probative evidence of record since November 4, 2019 which shows that the Veteran’s GERD is manifested by persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health sufficient to warrant a higher 30 percent rating under Diagnostic Code 7346. Additionally, there is no probative evidence showing that the Veteran’s GERD has resulted in symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health since November 4, 2019 to support a higher 60 percent rating during this time period. Accordingly, the Veteran’s request for an initial disability rating in excess of 10 percent since November 4, 2019 for his service-connected GERD must be denied. Additional Considerations The Board has considered whether the evidence of record has reasonably raised an inferred claim of entitlement to a total disability rating based on individual unemployability (TDIU) in conjunction with the initial increased rating claims adjudicated above. See Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). For the duration of the appellate period, the evidence does not indicate that the Veteran was incapable of securing or following substantially gainful employment due solely to his service-connected disabilities. At the start of the appellate period, the Veteran was gainfully employed as a systems engineer for a large defense contractor, he then left full-time employment to undertake post-graduate studies at a prominent university, and following graduation the evidence suggests that the Veteran has been employed as an investment banker. At an April 2010 Board hearing (for claims other than those currently on appeal), the Veteran indicated that his service-connected disabilities limited his ability to travel for his past employment, and that he chose to attend graduate school to broaden his skill set and change careers with his limitations in mind. Despite this, the Veteran remained physically capable of successfully undertaking full-time educational endeavors, and he remained fully capable of performing a variety of occupations consistent with his past educational and occupational history. There is no indication that any of the Veteran’s jobs have been marginal in nature or performed in a protected work environment. Accordingly, the Board declines to infer a claim of entitlement to a TDIU based on the current evidentiary record. Rice, supra. The Board has considered the various lay statements of record submitted by the Veteran and his friends, to include those received in October 2005, June 2008, and April 2010. To the extent that these lay statements describe the Veteran’s reduced functional capacity, they do not contain information sufficient to rate the Veteran’s left ankle and GERD disabilities under the pertinent diagnostic codes. Consequently, these lay reports are of little to no probative value in this appeal. Aside from the contentions addressed above, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). In sum, the evidence does not support the Veteran’s allegations that he is entitled to initial disability ratings higher than those already in effect for his service-connected left ankle and GERD disabilities. As such, the preponderance of the evidence is against the claims, the benefit-of-the-doubt doctrine is not for application, and the Veteran’s appeals must be denied. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Board is grateful to the Veteran for his honorable service and regrets that a more favorable outcome could not be reached. REASONS FOR REMAND Although the Board regrets the additional delay, the Veteran’s claim seeking entitlement to an initial disability rating in excess of 10 percent for his service-connected right wrist/hand disability must be remanded for additional evidentiary development. In the November 2018 Board decision, the Veteran’s claim was remanded for an updated VA examination to address the current severity of the Veteran’s right wrist/hand disability. A VA examination was conducted in November 2019, but regrettably, only the Veteran’s right wrist was evaluated. The VA examiner did not assess the Veteran’s right hand and fingers, as requested by the Board. The Board shall not request that the VA examiner address how many exacerbations of reactive arthritis occur in the right wrist/hand per year, as this is an adjudicative determination that can be justly resolved through evaluation of the Veteran’s contemporaneous treatment records. Accordingly, the Veteran’s claim seeking an initial disability rating in excess of 10 percent for his service-connected right wrist/hand disability is remanded for an additional VA examination. Upon remand, the RO is also requested to obtain any additional VA treatment records generated since August 2020. See 38 C.F.R. § 3.159(c)(2) and (3). The matter is remanded for the following action: 1. Obtain the Veteran’s VA treatment records for the period from August 2020 to the present. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected right wrist/hand disability. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The VA examiner must assess both the Veteran’s right wrist and his right hand, and answer all questions relevant to rating these disabilities under the appropriate rating criteria. The examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. To the extent possible, the examiner should identify any symptoms and functional impairments due to his right wrist/hand disability and discuss the effect of the Veteran’s disability on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). Cynthia M. Bruce Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Galante, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.