Citation Nr: 21003364 Decision Date: 01/21/21 Archive Date: 01/21/21 DOCKET NO. 15-00 480A DATE: January 21, 2021 ORDER Entitlement to service connection for a low back disorder is denied. Entitlement to a compensable evaluation for folliculitis prior to June 20, 2014 is denied. Entitlement to an increased 60 percent rating from June 20, 2014 to July 3, 2019 for folliculitis is granted, subject to the regulations governing the award of monetary benefits. Entitlement to an evaluation in excess of 10 percent for gastroesophageal reflux disease (GERD) is denied. REMANDED Entitlement to service connection for residuals of gallbladder removal, as secondary to service-connected GERD, is remanded. Entitlement to a compensable evaluation prior to January 24, 2020 and in excess of 10 percent from that date for right knee patellofemoral tendonitis is remanded. Entitlement to a compensable evaluation prior to January 24, 2020 and in excess of 10 percent from that date for left knee patellofemoral tendonitis is remanded. FINDINGS OF FACT 1. The Veteran’s back impairment treated in service was acute and resolved; a chronic low back disorder was not manifested in service and no current low back disorder is shown to be etiologically related to service. 2. Prior to June 20, 2014, it is not factually ascertainable that the Veteran’s folliculitis affected at least 5 percent of her entire body or exposed areas, required intermittent or longer systemic therapy during the past 12-month period or resulted in disfigurement. 3. From June 20, 2014 to July 3, 2019, it is factually ascertainable the Veteran’s folliculitis affected greater than 40 percent of the entire body. 4. Throughout the appeal period, the Veteran’s service-connected GERD is shown to have been manifested by dysphagia, pyrosis (heartburn), chest pain, reflux, regurgitation, nausea and sleep disturbance; symptoms productive of considerable impairment of health is not shown. CONCLUSIONS OF LAW 1. Service connection for a back disorder is not warranted. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.304. 2. A compensable rating for folliculitis prior to June 20, 2014 is denied; from June 20, 2014 to July 3, 2019, the criteria for an increased (maximum) 60 percent rating for folliculitis from have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.118, Diagnostic Code (Code) 7806. 3. Throughout the appeal period, the criteria for a rating in excess of 10 percent for GERD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.114, Code 7399-7346. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1997 to December 2004. These matters come before the Board of Veterans’ Appeals (Board) from a February 2013 rating decision of a Department of Veterans Affairs (VA), Regional Office/Agency of Original Jurisdiction (RO/AOJ). In January 2019, the Board (reopened the claim of service connection for a low back disorder) remanded the claims of service connection for a low back disorder and increased ratings for bilateral knee patellofemoral syndrome, GERD and folliculitis to obtain additional VA and private treatment records and afford the Veteran VA examinations in connection with her claims. The Board finds there has been substantial compliance with its remand directives. See D’Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only substantial and not strict compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)); see also Dyment v. West, 13 Vet. App. 141, 14647 (1999) (holding that there was no Stegall violation when the examiner made the ultimate determination required by the Board’s remand). In August 2019, VA received a June 2017 letter from the Veteran’s private physician stating that the Veteran’s hiatal hernia and chronic gastritis treated with chronic Proton Pump Inhibitor contributed to her gallbladder dysfunction. In Bailey v. Wilkie, 2021 U.S. App. Vet. Claims LEXIS 13, 35, the United States Court of Appeals for Veterans Claims (Court) held that “VA is required to develop and adjudicate related claims for secondary service connection for disabilities that are reasonably raised during the adjudication of a formally initiated claim for the proper evaluation level for the primary service-connected disability.” Accordingly, the claim of entitlement to an increased rating for GERD has been expanded to include the claim of service connection for residuals of gallbladder removal under the theory of secondary service connection, and has been characterized as stated on the title pate. See also, Roberson v. Principi, 251 F. 3d 1378, 1384 (2001) (“VA must determine all potential claims raised by the evidence, applying all relevant laws and regulations.”). In addition, based on the additional development completed pursuant to the January 2019 Board remand, a June 2020 rating decision granted staged increased ratings for bilateral patellofemoral syndrome of the knee, each rated noncompensable prior to January 24, 2020 and 10 percent from that date, and folliculitis involving the neck, rated noncompensable prior to July 3, 2019 and 30 percent from that date. Regarding the bilateral patellofemoral syndrome of the knee, the Veteran has not expressed satisfaction with staged increased ratings assigned and is presumed to be seeking the maximum benefit. AB v. Brown, 6 Vet. App. 35 (1993). Therefore, the claims for increased ratings for right and left knee patellofemoral syndrome throughout the appeal period remain before the Board. Regarding folliculitis, in a July 2020 statement, the Veteran expressed her agreement and satisfaction with the rating but requested the effective date should be the date she filed her claim, which she identified as November 20, 2008. As the Veteran has expressed satisfaction with the 30 percent rating for folliculitis from July 3, 2019, the appeal period after this date has been resolved and is no longer before the Board. The claim as to the matter of an increased rating for folliculitis is characterized to reflect that “staged” ratings are assigned, and that the rating prior to July 3, 2019 remains on appeal. Id. Review of the record shows that, subsequent to the June 2020 Supplemental Statements of the Case (SSOCs), the Veteran submitted copies of additional medical records pertaining to her claim for an increased rating for GERD. In addition, subsequent to the January 2019 Board remand, additional VA treatment records and a January 2020 VA knee examination report were added to the claims file. However, although the June 2020 rating decision addressed the knee increased rating claims, as noted by the Veteran in her July 2020 statement, she has not been provided an SSOC addressing these issues (the June 2020 SSOCs do not include these claims.) Initial AOJ review is automatically waived for evidence submitted by the Veteran or her representative when the VA Form 9 is received after February 2, 2013, as is the case here; however, the automatic waiver does not apply to VA-generated evidence not submitted by the Veteran. 38 U.S.C. § 7105 (e). Further, waiver of a supplemental statement of the case is only applicable to evidence submitted by the Veteran or her representative. See 38 C.F.R. § 20.1305. Accordingly, initial AOJ review of the treatment records submitted by the Veteran in connection with her GERD increased rating claim is automatically waived and will be considered by the Board in the decision herein. However, the knee increased rating claims will be addressed in the remand portion of the decision below, to ensure proper procedural steps as is required by 38 C.F.R. § 19.31(b)(1), and 19.37 are followed. Service Connection Service connection may be granted for current disability arising from disease or injury incurred or aggravated by active service. 38 U.S.C. § 1110. Service connection may 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). Service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010). The determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. 38 U.S.C. § 7104 (a); Baldwin v. West, 13 Vet. App. 1 (1999); see 38 C.F.R. § 3.303 (a). First, it is not in dispute the Veteran has been treated for low back pain and has a current diagnosis of a low back disorder. Specifically, VA treatment records during the appeal period show complaints of low back pain and the January 2020 VA thoracolumbar spine examination report includes a diagnosis of lumbosacral strain. Second, the service treatment records (STRs) show the Veteran reported no history of recurrent back pain and her spine was clinically normal on December 1996 enlistment examination. These records show the Veteran sought treatment for complaints of low back pain for one month in July 1998, which was treated with a muscle relaxer for weak paravertebral muscles and for which she was given a profile. On September 2004 service separation examination, the Veteran reported a history of recurrent back pain since 1998 due to carrying heavy equipment which was treated with physical therapy and a back brace. Pain with flexion of the spine was noted on clinical evaluation. Since the Veteran’s December 2005 separation from service, private treatment records dated in 2005 and 2006 are silent as to complaints of or treatment for low back symptoms. In addition, a September 2006 VA examination notes the Veteran’s complaint of low back pain with cooking and doing her usual household chores. It was not severe. Examination of the back showed tight paraspinal muscles with standing normally which relaxed with extension or sitting. The diagnosis was “[n]o evidence of low back abnormality.” Subsequent VA treatment records note the Veteran’s March 2017 complaint of back pain, October 2019 complaint of a 2 week history of low back pain and diagnosis of acute lumbar strain and November 2019 treatment with aquatic therapy. A January 2020 VA back examination report notes the Veteran reported she started having back pain during military service “secondary to the increased physical demands of the military from fitness training and ruck marches while carrying heavy equipment.” She also reported experiencing continued low back pain after military discharge. The diagnosis was lumbosacral strain. X-ray examination showed normal thoracolumbar spine series. After interview and examination of the Veteran and review of her claims file, the examiner opined that the Veteran’s low back disorder was less likely than not related to service. The examiner was “unable to identify a diagnosis for a back disability or back symptoms that [were] incurred in or was related to active service.” The examiner acknowledged the Veteran’s reports of back pain after service and noted that diagnosis of acute lumbar strain was in October 2019. Review of the record shows that the Veteran’s back complaints have been diagnosed as lumbosacral strain. However, the preponderance of the medical evidence shows that the Veteran’s current back disorder is unrelated to service. Although she reported experiencing low back pain on September 2006 VA examination, there was no evidence of a low back abnormality on clinical evaluation and her initial post-service treatment for low back complaints was in March 2017, more than 12 years after her December 2004 separation from service). The question in this case is whether the Veteran’s low back disorder is related to her service. Whether there is a nexus between her diagnosed lumbosacral strain and service or complaints therein is a medical question that requires medical expertise, which the Veteran has not been shown to possess. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428 (2011). Therefore, the Veteran’s opinion that her current back disorder is related to her military service is merely lay speculation and is not competent evidence. It is without probative value in this matter. The only medical opinion as to this matter is the opinion of the January 2020 VA examiner and is against the Veteran’s claim. The examiner reviewed the record and opined that it is less likely than not that the Veteran’s low back disorder is related to service. The opinion reflects familiarity with the record, the Veteran’s lay statements, and the Veteran’s medical history and includes rationale that cites to supporting factual data. It is probative evidence in this matter and, in the absence of competent evidence to the contrary, persuasive. For the foregoing reasons, the preponderance of the evidence is against the claim of service connection for a low back disorder. The benefit-of-the-doubt doctrine is, therefore, not for application and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Increased Ratings Disability evaluations are based upon the average impairment of earning capacity as contemplated by the schedule for rating disabilities. 38 U.S.C. § 1155; 38 C.F.R. § Part 4. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran’s condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). The Court has held that “staged” ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). As such, the Board will consider whether staged ratings are appropriate to the pending appeals. In addition, an effective date for an increased rating should not be assigned mechanically based on the date of a diagnosis. Rather, all the facts should be examined to determine the date the disability first manifested. Accordingly, the effective date for an increased rating, initial rating, or staged rating is predicated on when the increase in the level of disability can be ascertained. Swain v. McDonald, 27 Vet. App. 219, 224 (2015); DeLisio v. Shinseki, 25 Vet. App. 45, 56 (2011). In determining when an increase is “factually ascertainable,” all of the evidence must be considered, including testimonial evidence and expert medical opinions, and an effective date must be assigned based on that evidence. See McGrath v. Gober, 14 Vet. App. 28, 35-36 (2000); VAOPGCPREC 12-98. Thus, “it is the information in a medical opinion, and not the date the medical opinion [that] was provided that is relevant when assigning an effective date.” Tatum v. Shinseki, 24 Vet. App. 139, 145 (2010); see also Young v. McDonald, 766 F.3d 1348 (Fed. Cir. 2014). Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Folliculitis The Veteran’s service-connected folliculitis is currently rated zero percent prior to July 3, 2019 and 30 percent from that date pursuant to Code 7806 for dermatitis or eczema. 38 C.F.R. § 4.118. Under Code 7806, a noncompensable rating is assigned for dermatitis or eczema affecting less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12 months. A 10 percent rating is assigned where there is involvement of at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating requires involvement of 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent rating is assigned with involvement of more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. 38 C.F.R. § 4.118, Code 7806. During the pendency of the claim, effective August 13, 2018, Code 7806 was amended and provides that dermatitis or eczema is to be evaluated under the General Rating Formula for the Skin. See 38 C.F.R. § 4.118, Code 7806. However, the amendments did not change the substance of the criteria for evaluation in this case. See 38 C.F.R. § 4.118; 83 Fed. Reg. 32592 (Jul. 13, 2018). Under the new criteria, a note preceding 38 C.F.R. § 4.118 provides that, for the purposes of this section, “systemic therapy is treatment that is administered through any route (orally, injection, suppository, intranasally) other than the skin, and topical therapy is treatment that is administered through the skin.” With regard to the meaning of “systemic therapy” prior to the new definition of the term in the revised criteria, the Court held that “[c]ompensation is available for all systemic therapies that are like or similar to corticosteroids or other immunosuppressive drugs.” Warren v. McDonald, 28 Vet. App. 194, 197-99 (2016). Further, in Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017), the Federal Circuit found that “systemic therapy” means “treatment pertaining to or affecting the body as a whole.” As applied in the instant matter, Code 7806 prior to August 13, 2018 and under the revised General Rating Formula for the Skin also provides that folliculitis may be rated under Codes 7800-7805, depending on the predominant disability. Such Codes provide compensable ratings for disfigurement of the head, face, or neck (Code 7800), scars that are at least six square inches (39 sq. cm) (Codes 7801 and 7802), or scars that are unstable or painful (Code 7804). Additionally, Code 7805 provides that any disabling effect not considered in a rating provided under Codes 7800-04 should be evaluated under an appropriate Code. VA treatment records throughout the appeal period are silent as to complaints of or treatment for skin impairment, including folliculitis. Private treatment records note the Veteran complained of facial folliculitis in May 2012. A June 20, 2014 VA skin examination report shows diagnoses of rosacea and folliculitis. The Veteran reported the condition had gotten worse over the years, she has daily pus filled bumps on the face and neck, she had had laser and topical treatment during the last couple of years but the bumps come back, her face and neck were tender. Examination of the skin showed no scarring or disfigurement. Treatment consisted of topical medications (Finacea, Ammonium Lactate) for 6 weeks or more, but not constant. The examiner noted that the Veteran “has Folliculitis/rosacea. Raised bumps with erythematous base and pustules to face, neck, torso and limbs. Exposed area 5-20%, total body area >40%.” On July 3, 2019 VA skin examination, the Veteran skin disorder was diagnosed as folliculitis involving the neck. The Veteran reported “the condition had gotten worse and spreads to her neck and then throughout her body (face, neck, scalp, upper arms, legs, abdomen). She reported constant symptoms with flare-ups 4 times per year (painful), she was seen by a dermatologist in 2017 and was given antibiotic (once a month for 7-10 days) and Diflucan (for yeast infections). The examiner noted treatment with oral medication for less than 6 weeks. Physical examination showed 5 percent to less than 20 percent of the exposed area was affected and 20 percent to less than 40 percent of total body area was affected. There was no scarring or disfigurement. Similarly, January 2020 VA skin examination showed diagnoses of folliculitis and rosacea with no scarring or disfigurement. Regarding rosacea, the examiner noted “no treatment notes, evaluations or referrals noted in the medical records to confirm this condition existed.” Based on the foregoing, the Board finds that it is factually ascertainable that the Veteran’s folliculitis affected greater than 40 percent of her total body area from June 20, 2014, the date of VA examination which initially reported such finding, to July 3, 2019, the date of VA examination which showed the Veteran’s folliculitis affected between 20 percent and less than 40 percent of her total body area. Notably, in addition to service-connected folliculitis, the record also shows a diagnosis of rosacea, which is not service-connected; however, as the area of the Veteran’s body affected by folliculitis and the area of her body affected by rosacea has not been differentiated, the Board will consider all the identified skin findings as part of her service-connected folliculitis. See Mittleider v. West, 11 Vet. App. 181 (1998) (when it is not possible to separate the effects of the service-connected condition from any nonservice-connected condition, 38 C.F.R. § 3.102 requires that reasonable doubt be resolved in the claimant’s favor and that such manifestations be attributed to the service-connected disability). Therefore, an increased (maximum) rating of 60 percent under Code 7806 as in effect prior to August 13, 2018 and under the revised General Rating Formula for the Skin is warranted from June 20, 2014 to July 3, 2019. As 60 percent is the maximum rating assignable under Code 7806 prior to August 13, 2018 and under the General Rating Formula for the Skin, a rating in excess of 60 percent is not permitted. The Board notes that, in her July 2020 communication, the Veteran asserted that an effective date of November 20, 2008, the date she recalls having filed her claim, is warranted. However, the initial finding of the Veteran’s skin disorder affecting more than 40 percent of her body is June 20, 2014. It is not factually ascertainable that a higher rating is warranted prior to this date. A close review of VA and private treatment records prior to this date do not include findings to support a compensable rating and the Veteran has not argued that the evidence otherwise supports a compensable rating; a compensable rating for folliculitis prior to June 20, 2014 is not warranted. In addition, as noted above, in her July 2020 communication, the Veteran expressed her agreement and satisfaction with the increased 30 percent rating for folliculitis effective July 3, 2019 assigned by the RO in the June 2020 rating decision. [The Board notes that the evidence of record as of July 3, 2019, does not indicate that a higher rating is warranted for this period as the preponderance of the evidence is against a finding that the criteria for the next higher, 60 percent rating, are more nearly approximated. The July 3, 2019 VA examination clearly states that less than 40 percent of the total body area is affected.] As such, the matter of entitlement to a rating in excess of 30 percent after July 3, 2019 has been resolved and is no longer before the Board. The Board has also considered the applicability of other potential Codes referable to the evaluation of skin disabilities. However, as the evidence of record fails to demonstrate that the Veteran’s folliculitis has resulted in scarring, disfigurement or additional disabling effects, she is not entitled to a higher or separate rating under Codes 7800-7805. Importantly, Code 7800 is the only potentially applicable diagnostic code which offers a higher rating than Code 7806. However, such a rating requires 6 characteristics of disfigurement, visible or palpable tissue loss, or gross distortion or asymmetry of three or more features or paired sets of features. The record does not reflect that the Veteran’s folliculitis is manifested by such findings. Further, neither the Veteran nor her representatives have raised any other issues, nor have any other issues been reasonably raised by the record, in regard to the claim adjudicated herein. See Doucette v. Shulkin, 28 Vet. App. 366 (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). Therefore, based on the foregoing, the Board finds that an increased rating of 60 percent, but no higher, for the Veteran’s skin disability is warranted from June 20, 2014 to July 3, 2019. In reaching such conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, insofar as the Board has denied higher or separate ratings, the preponderance of the evidence is against such aspects of the Veteran’s claim, and the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. GERD During the appeal period, the Veteran’s service-connected GERD has been evaluated as 10 percent disabling pursuant to the criteria found at 38 C.F.R. § 4.114, Code 7399-7346. See 38 C.F.R. § 4.27 (hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned, the additional code is shown after the hyphen; unlisted disabilities requiring rating by analogy will be coded first by the numbers of the most closely related body part and then “99”). The hyphenated diagnostic code assigned for GERD in this case indicates that a miscellaneous digestive disease, under Code 7399, is the service-connected disorder, while the residual condition (to which the Veteran’s disability is rated by analogy) is hiatal hernia, which is evaluated under Code 7346. Under Code 7346, a 10 percent evaluation is warranted when there is at least one recurring attack of typical severe abdominal pain in the past year. 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 60 percent evaluation contemplates a level of impairment which includes 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, Code 7346. The terms “mild,” “moderate,” and “severe” are not defined in the schedule for rating disabilities. However, mild is generally defined as not severe. Merriam-Webster's Collegiate Dictionary, 787 (11th ed. 2003). Moderate is generally defined as tending toward the mean or average amount. Id. at 798. Severe is generally defined as of a great degree. Id. at 1140. Similarly, the term “considerable” is not defined in the rating schedule. Merriam-Webster's Dictionary defines considerable as worth consideration, or large in extent or degree. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. The use of terminology such as “moderate” or “severe” by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. On June 2014 VA esophageal conditions examination, the diagnoses were GERD, esophageal stricture with dysphagia status post dilation and reflux/eosinophilic esophagitis. The Veteran reported her current symptoms were “severe reflux, heartburn and belching. Treated with Dexilant and Omeprazole with favorable response somedays. Has constant burning sensation in throat. Feels like there is a fire in chest. Had 2 endoscopies in 2010 and Nov. 2013. Has difficulty swallowing food sometimes; gets stuck and comes up. Had dilation done last year.” The signs and symptoms due to GERD were listed as pyrosis (heartburn), reflux, regurgitation, mild nausea (4 or more times per year, lasting less than 1 day). The examiner also noted the Veteran has “mild” “difficulty swallowing solid food.” On January 2020 VA esophageal conditions examination, the diagnoses were GERD and hiatal hernia. The Veteran reported “increased burning in her throat and chest, belching, and nausea with vomiting.” She also reported shortness of breath and chest pain (denied cardiac history) with her indigestion. She reported treatment with Prevacid and Dexilant. The signs and symptoms due to GERD were listed as pyrosis, sleep disturbance (4 or more times per year, lasting 10 days or more), nausea and vomiting (each occurring 4 or more times per year, lasting 1-9 days). VA and private treatment records during the appeal period show treatment for GERD symptoms and are consistent with the VA examination reports. These treatment records do not indicate any symptoms of worse severity than those noted during the VA examinations. Upon review of the record, the Board finds that the preponderance of the evidence is against a finding that the Veteran is entitled to the next higher 30 percent rating for her service-connected GERD at any time during the appeal period. Specifically, a persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health, is required for a 30 percent rating. Here, while the Veteran reported experiencing dysphagia, pyrosis (heartburn), chest pain, reflux, regurgitation, nausea and sleep disturbance. The frequency and severity of these symptoms were not found to result in persistently recurrent epigastric distress or symptoms productive of considerable impairment of health. The Court has held that the ameliorative effects of medication cannot be considered when evaluating service-connected GERD. See Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). However, the Veteran's GERD symptoms have not been found to be stable and controlled with medication. She reported at the time of her 2014 VA examination that she only had favorable responses to her medication “somedays” and reported severe reflux, heartburn, and belching. Given her statements about her medication only working part of the time, the Board has considered her descriptions of her most severe symptoms to equate to her symptomatology without the ameliorative effects of medication. Thus, without considering the ameliorative effects of medication, the evidence shows symptoms of severe reflux, heartburn, belching, nausea and vomiting without considerable or severe impairment of health so as to support the currently assigned 10 percent evaluation for GERD with hiatal hernia under Code 7346. Accordingly, the criteria for a rating in excess of 10 percent for the Veteran’s service connection GERD have not been met (or approximated). The Board acknowledges the Veteran’s reported history of symptomatology related to the service-connected GERD. She is competent to report such symptoms and observations because this requires only personal knowledge as it comes through one’s senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). In this case, although the descriptions of her symptoms are competent, they do not show that the criteria for a 30 percent rating for her GERD have been met at any time during the appeal period. The Board has considered the possibility of staged ratings and finds that the proper rating of 10 percent for GERD has been in effect for the entire period on appeal. Accordingly, staged ratings are inapplicable. See Hart, 21 Vet. App. at 505. Further, with the exception of secondary service connection for a gallbladder disorder addressed in the remand, below, neither the Veteran nor her representative have raised any other issues, nor have any other issues been reasonably raised by the record adjudicated herein. See Doucette v. Shulkin, 28 Vet. App. 366 (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). As such, the preponderance of the evidence is against the Veteran’s claim of entitlement to a disability rating for GERD in excess of 10 percent. There is no reasonable doubt to be resolved. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). The appeal of this issue is denied. REASONS FOR REMAND As noted above, in Bailey v. Wilkie, 2021 U.S. App. Vet. Claims LEXIS 13, 35, the Court recently held that “VA is required to develop and adjudicate related claims for secondary service connection for disabilities that are reasonably raised during the adjudication of a formally initiated claim for the proper evaluation level for the primary service-connected disability.” In August 2019, VA received a June 2017 letter from the Veteran’s private physician stating that the Veteran’s hiatal hernia and chronic gastritis treated with chronic Proton Pump Inhibitor contributed to her gallbladder dysfunction. As such, the claim of entitlement to an increased rating for GERD has been expanded to include the claim of service connection for residuals of gallbladder removal under the theory of secondary service connection. Also as noted above, since the January 2019 Board remand and prior to the transfer of the appeal to the Board, additional VA treatment records and a January 2020 VA knee examination report were added to the claims file. However, the Veteran has not been furnished a SSOC that addresses the newly added medical records and examination report in connection with her knee increased rating claims. As these records are not duplicative of evidence previously received and are relevant to the Veteran’s knee increased rating claims, the appeal as to these matters must be remanded to the AOJ for issuance of a SSOC. 38 C.F.R. §§ 19.31, 20.1304(c). The matters are REMANDED for the following action: 1. Please undertake appropriate development to obtain any outstanding records pertinent to the Veteran’s gallbladder and knee disorder claims. 2. After the development in paragraph 1 has been completed to the extent possible, please arrange for a medical opinion (with examination only if feasible and deemed necessary by the opinion provider) to determine whether it is at least as likely as not that the Veteran has a gallbladder disorder that is caused or aggravated by her service-connected GERD. Based on review of the record (and, if necessary and deemed feasible, interview and examination of the Veteran), the examiner should provide opinions that respond to the following: a) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s gallbladder disorder is caused by her service-connected GERD? c) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s gallbladder disorder is aggravated (i.e. worsened in degree of severity) by her service-connected GERD? If aggravation is present, the opinion provider should indicate, to the extent possible, the approximate level of impairment (i.e., a baseline) before the onset of the aggravation. In responding to this request, in addition to the Veteran’s competent assertions as to additional impairment associated with her service-connected GERD, the examiner should consider and discuss as necessary the June 2017 letter from the Veteran’s private physician stating that the Veteran’s hiatal hernia and chronic gastritis treated with chronic Proton Pump Inhibitor contributed to her gallbladder dysfunction and she has “dumping syndrome issues post op.” Detailed rationale is requested for all opinions provided. If an opinion cannot be provided without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. 3. Thereafter, review the expanded record and readjudicate the issues on appeal, to include the increased rating claims for the left and right knee. If any benefit sought on appeal remains denied provide the Veteran and her representative with a SSOC M. C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Hughes, Kshama 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.