Citation Nr: 21023063 Decision Date: 04/20/21 Archive Date: 04/20/21 DOCKET NO. 09-03 386 DATE: April 20, 2021 ORDER Entitlement to a separate, compensable rating of 20 percent for right knee patellofemoral syndrome dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion under Diagnostic Code 5258 is granted. Entitlement to an increased disability rating in excess of 10 percent for patellofemoral syndrome of the right knee under Diagnostic Code 5257 is denied. For the period from September 25, 2012 to July 31, 2017, entitlement to an increased disability rating of 60 percent, but no higher, for GERD, Barrett’s esophagus, IBS, and esophageal adenocarcinoma residuals is granted. Entitlement to an increased disability rating in excess of 10 percent from July 11, 2007 to December 6, 2009; 30 percent from December 7, 2009 to September 24, 2012; and 60 percent from September 25, 2012 to present for GERD, Barrett’s esophagus, IBS, and esophageal adenocarcinoma residuals is denied, to include on an extraschedular basis. REMANDED Entitlement to an initial rating in excess of 10 percent for right sacroiliitis prior to September 25, 2012 is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. FINDINGS OF FACT 1. The Veteran’s right knee patellofemoral syndrome is characterized by dislocated semilunar cartilage frequent episodes of locking, pain, and effusion. 2. From July 11, 2007 to December 6, 2009, the Veteran’s GERD, Barrett’s esophagus, and IBS is characterized by pyrosis, regurgitation, and gassy pain. 3. From December 7, 2009 to September 24, 2012, the Veteran’s GERD, Barrett’s esophagus, and IBS is characterized by substernal pain, pyrosis, and regurgitation. 4. From September 25, 2012, the Veteran’s GERD, Barrett’s esophagus, IBS, and esophageal adenocarcinoma residuals is characterized by pyrosis, regurgitation, substernal arm or shoulder pain, sleep disturbance caused by reflux, abdominal distension, crampy abdominal pain, occasional episodes of bowel disturbance with abdominal distress, and episodes of exacerbation and/or attacks of the intestinal condition occurring 7 times or more in the past year. CONCLUSIONS OF LAW 1. The criteria for a separate, compensable rating of 20 percent for right knee patellofemoral syndrome dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5258. 2. The criteria for an increased rating in excess of 10 percent for right knee patellofemoral syndrome have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 3. The criteria for a disability rating of 60 percent, but no higher, for service-connected GERD, Barrett’s esophagus, IBS, and esophageal adenocarcinoma residuals have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.21, 4.113, 4.114, Diagnostic Code 7346. 4. The criteria for a disability rating in excess of 10 percent from July 11, 2007 to December 6, 2009; 30 percent from December 7, 2009 to September 24, 2012; and 60 percent from September 25, 2012 to present for service-connected GERD, Barrett’s esophagus, IBS, and esophageal adenocarcinoma residuals have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.21, 4.113, 4.114, Diagnostic Code 7346. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran seeks higher ratings for service-connected right knee patellofemoral syndrome and GERD. Right Knee Patellofemoral Syndrome The Veteran contends that he is entitled to a rating in excess of 10 percent for right knee patellofemoral syndrome. Legal Criteria The criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The Veteran’s right knee patellofemoral syndrome is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5260, for limitation of flexion of the leg. Diagnostic Code 5260 assigns ratings based on limitation of flexion and provides a noncompensable rating where flexion is limited to 60 degrees; a 10 percent rating where flexion is limited to 45 degrees; a 20 percent rating where flexion is limited to 30 degrees; and a 30 percent rating where flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. Normal ranges of motion of the knee are to 0 degrees in extension, and to 140 degrees in flexion. 38 C.F.R. § 4.71, Plate II. Diagnostic Code 5003 provides that degenerative arthritis, when established by x-ray findings, will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is, for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. Under DC 5003, X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups warrants a 10 percent rating; involvement of 2 or more major joints or 2 or more minor joint groups with occasional incapacitating exacerbations warrants a 20 percent rating. 38 C.F.R. § 4.71a, DC 5003. The 20 percent and 10 percent ratings based on X-ray findings will not be combined with ratings based on limitation of motion. 38 C.F.R. § 4.71a, DC 5003, Note (1). Diagnostic Code 5258 assigns a rating of 20 percent based on dislocation of semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint. 38 C.F.R. § 4.71a, DC 5258. Diagnostic Code 5259 assigns a rating of 10 percent based on symptomatic removal of semilunar cartilage. 38 C.F.R. § 4.71a, DC 5259. Diagnostic Code 5261 assigns ratings based on limitation of extension of the leg and provides a noncompensable rating where extension is limited to 5 degrees; a 10 percent rating where extension is limited to 10 degrees; a 20 percent rating where extension is limited to 15 degrees; a 30 percent rating where extension is limited to 20 degrees; a 40 percent rating where extension is limited to 30 degrees; and a 50 percent rating where extension is limited to 45 degrees. During the pendency of the appeal, Diagnostic Code 5257, which assigns ratings based on other impairment of knee, was amended effective February 7, 2021. 85 Fed. Reg. 76453 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5257). If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). Therefore, the Board will consider the Veteran’s claim under the old criteria prior to February 7, 2021. Both the old and new rating criteria under Diagnostic Code 5257 will be considered for the period from February 7, 2021, and the criteria that is more favorable to the Veteran will be applied. Prior to the regulatory change, Diagnostic Code 5257 for other impairment of knee provides a 10 percent rating for slight recurrent subluxation or lateral instability; a 20 percent rating for moderate recurrent subluxation or lateral instability; and a 30 percent rating for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. As of February 7, 2021, under the amended criteria, Diagnostic Code 5257 provides the following for recurrent subluxation or instability. A 10 percent rating is warranted for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 20 percent rating is warranted for one of the following: (a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation or (b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 30 percent rating is warranted for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. Additionally, the amended criteria under Diagnostic Code 5257 provides the following for patellar instability. A 10 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. A 20 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane, or walker. A 30 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. For patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (1). A surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). 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; 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 criteria.”). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). Analysis The Veteran’s right knee patellofemoral syndrome is currently evaluated as 10 percent disabling under Diagnostic Code 5260. Having reviewed the record, the Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for right knee patellofemoral syndrome under Diagnostic Code 5260. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to pain, stiffness, pain during flare-ups, pain during repetitive use over time, and excess fatigability. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that flare-ups occur daily to monthly and result in painful ambulation, would not result in limitation of motion more nearly approximating flexion limited to 30 degrees. The evidence of record indicates that the Veteran’s right knee flexion was limited to, at most, 80 degrees during the period on appeal. VA examination reports indicated that flexion was limited to 112 degrees in September 2007, 125 degrees in December 2009 per a January 2010 addendum opinion, 80 degrees in September 2012, 105 degrees in March 2016, 105 degrees in December 2017, and 90 degrees in November 2020. The Board notes that the March 2016 and December 2017 examinations did not estimate the loss of range of motion, in degrees, during flare-ups. However, a December 2020 retrospective opinion determined that the loss of range of motion during a flare-up would be in the range of 5 to 10 degrees for flexion. This indicates that flexion would be limited to, at most, 95 degrees. Treatment records are consistent with the above VA examination findings. A January 2017 VA orthopedic record noted passive range of motion with flexion to 130 degrees without pain. Of note, private treatment records note restriction in range of motion with respect flexion for the extremities. However, these records do not provide an estimated degree of motion lost or identify the specific joint exhibiting loss of range of motion. Accordingly, these findings within private treatment records are outweighed by VA examination reports and treatment records. For these reasons, a rating higher than 10 percent for limitation of flexion under Diagnostic Code 5260 is not warranted. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). A separate, compensable rating is warranted under Diagnostic Code 5258 for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion of the joint. There is evidence of a meniscal tear in the right knee with frequent episodes of locking, pain, and effusion. A September 2012 VA examination revealed a history of a meniscal tear with frequent episodes of joint locking, pain, and effusion. March 2016 VA examination noted a meniscal tear and cited to treatment records noting effusion. A December 2017 VA examination revealed meniscal tear and frequent episodes of joint pain and effusion. November 2020 VA examination noted a history of a meniscal tear. A January 2017 VA treatment record noted falls because his knee was locking up. For these reasons, the Board finds that the preponderance of the evidence establishes dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion of the joint. A separate, compensable evaluation of 20 percent under Diagnostic Code 5258 is warranted for the entire period on appeal. A separate, compensable rating is not warranted under Diagnostic Code 5257 for other impairment of the knee. September 2007, September 2012, March 2016, December 2017, and November 2020 VA examinations do not reveal reports of instability, giving away or locking of joints, or patellar subluxation/dislocation. Joint stability tests were normal during the examinations. Additionally, private treatment records do not reveal instability. August 2014 and August 2015 private treatment records determined there was no evidence of joint laxity, subluxation, or dislocation of the musculoskeletal system. VA treatment records, to include a January 2017 record, indicate that joint stability testing was normal. The Veteran has not reported giving away of the knee. The old criteria and amended criteria have been considered. The Board notes that the Veteran reported falling in a January 2017 VA treatment record. However, there is no indication that falls were due to giving away or subluxation of the knee. Rather, the Veteran reported that his falls are due to locking up of the knees, or already service-connected lower extremity radiculopathies. Of note, locking of the knee is already contemplated by the above grant of a separate rating for dislocated semilunar cartilage with frequent episodes of locking under Diagnostic Code 5258. The evaluation of the same symptom under several diagnostic codes, known as pyramiding, must be avoided. 38 C.F.R. § 4.14. Separate ratings may be assigned for distinct disabilities resulting from the same injury only where the symptomatology for one condition is not duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Here, the Veteran’s falls are contemplated and compensated by the evaluation under Diagnostic Code 5258. An additional separate rating under Diagnostic Code 5257 for instability of the knee would violate the rule against pyramiding in this case as the Veteran’s falls are due to locking of the knee. Accordingly, a separate rating is not warranted under Diagnostic Code 5257. A separate, compensable rating is not warranted under Diagnostic Code 5261for limitation of extension. Though the Veteran reported pain, stiffness, pain during flare-ups and with prolonged use, the evidence does not show degree of additional limitation reflected by his statements that flare-ups occur daily to monthly and result in painful ambulation would more nearly approximate extension limited to at least 10 degrees. The preponderance of the evidence indicates that the Veteran’s right knee extension was limited to, at most, 5 degrees during the period on appeal. The November 2020 VA examination revealed extension limited to 5 degrees during flare-ups. The September 2007, December 2009 (per a January 2010 addendum opinion), September 2012, March 2016, and December 2017 VA examinations do not reveal limitation of extension; extension was normal and measured at 0 degrees. Additionally, VA treatment records do not indicate that the Veteran’s extension was limited. A January 2017 VA orthopedic record noted passive range of motion with extension to 0 degrees without pain. As previously noted, private treatment records note restriction in range of motion with respect extension for the extremities. However, these private records do not provide an estimated degree of motion lost or identify the specific joint exhibiting loss of range of motion. Accordingly, these findings within private treatment records are outweighed by VA examination reports and treatment records. For these reasons, the preponderance of the evidence reveals right knee extension was limited to, at most 5 degrees. Consequently, a separate compensable rating under Diagnostic Code 5261 for limitation of extension is not warranted as the evidence does not show extension limited to 10 degrees. Separate, compensable ratings are not warranted under Diagnostic Codes 5256 (for ankylosis of the knee), 5259 (symptomatic, removal of semilunar cartilage); 5262 (impairment of the tibia and fibula); or 5263 (genu recurvatum). VA treatment records, private treatment records, and the September 2007, December 2009, September 2012, March 2016, December 2017, and November 2020 VA examination reports do not reveal ankylosis; removal of the semilunar cartilage; nonunion or malunion of the tibia and fibula, or medial tibial stress syndrome; or genu recurvatum. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for a rating for right knee patellofemoral syndrome in excess of 10 percent under Diagnostic Code 5260. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. However, a separate, compensable rating of 20 percent is granted for right knee patellofemoral syndrome under Diagnostic Code 5258 for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion for the entire period on appeal. GERD By way of history, the issue was previously before the Board. A November 2014 Board decision denied entitlement to an increased rating in excess of 10 percent prior to December 7, 2009 and 30 percent from December 7, 2009. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In February 2016, the Court issued a Memorandum Decision that vacated and remanded the Board’s November 2014 decision because the Board failed to provide an adequate statement of reasons or bases for its conclusion that referral for extraschedular consideration was not warranted. The Veteran’s GERD with Barrett’s esophagus and symptoms of IBS is currently rated as 10 percent disabling from July 11, 2007 to December 6, 2009 and 30 percent disabling from December 7, 2009 to August 1, 2017. His associated esophageal adenocarcinoma was rated as 100 percent disabling from August 4, 2011 to July 31, 2017. From August 1, 2017, the rating for GERD was combined with esophageal adenocarcinoma because medical evidence no longer showed active malignancy; GERD was rated as a residual of esophageal adenocarcinoma to afford the Veteran the highest rating available. See May 2017 Rating Decision. His disabilities were thereafter recharacterized as esophageal adenocarcinoma and GERD with Barrett’s esophagus and symptoms of IBS, evaluated as 60 percent disabling from August 1, 2017. The issue presently before the Board is whether an increased rating is warranted for GERD, Barrett’s esophagus, IBS, and esophageal adenocarcinoma residuals in excess of 10 percent from July 11, 2007 to December 6, 2009; in excess of 30 percent disabling from December 7, 2009 to August 1, 2017; and in excess of 60 percent from August 1, 2017, to include on an extraschedular basis. Legal Criteria Pursuant to 38 C.F.R. § 4.114, Diagnostic Code 7346, for hiatal hernia, a 10 percent disability rating is warranted for two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent evaluation is warranted for persistently recurring epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. The maximum 60 percent evaluation 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. “Considerable” is defined as “large in extent or degree.” Merriam-Webster’s Collegiate Dictionary 267 (11th ed. 2012). “Severe” is defined as “very painful or harmful.” Id. at 1140. Pursuant to Diagnostic Code 7343, a 100 percent disability rating is warranted for malignant neoplasms of the digestive system, exclusive of skin growths. A rating of 100 percent shall continue beyond the cessation of any surgical, X-ray, antineoplastic chemotherapy or other therapeutic procedure. 38 C.F.R. § 4.114, Diagnostic Code 7343, Note. Six months after discontinuance of such treatment, the appropriate disability rating shall be determined by mandatory VA examination. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of §3.105(e) of this chapter. If there has been no local recurrence or metastasis, rate on residuals. Pursuant to Diagnostic Code 7323, ulcerative colitis, a 10 percent rating is warranted for moderate; with infrequent exacerbations. A 30 percent rating is warranted for moderately severe; with frequent exacerbations. A 60 percent rating is warranted for severe; with numerous attacks a year and malnutrition, the health only fair during remissions. A 100 percent rating is warranted for pronounced; resulting in marked malnutrition, anemia, and general debility, or with serious complication as liver abscess. Period from July 11, 2007 to December 6, 2009 Because follow, the Board finds that for the period from July 11, 2007 to December 6, 2009, the Veteran’s GERD with Barrett’s esophagus and symptoms of IBS was manifested by pyrosis, regurgitation, and gassy pain. This more nearly approximates the criteria for a 10 percent rating under Diagnostic Code 7346. After resolving doubt in the Veteran’s favor, the preponderance of the evidence reveals symptoms of pyrosis, regurgitation, and gassy pain. A September 2007 VA examination revealed that the Veteran previously had symptoms of pyrosis, reflux regurgitation, and gassy pain, but no longer experienced those symptoms with medication. As the ameliorative effects of medication were considered, the Board will resolve doubt in the Veteran’s favor and find that the Veteran had symptoms of pyrosis, reflux regurgitation, and abdominal/gassy pain during this examination. See Jones v. Shinseki, 26 Vet. App. 56 (2012). July 2007 and December 2008 federal treatment records noted no abdominal pain. Consequently, the Board finds that the Veteran’s symptoms of more nearly approximate a rating of 10 percent under Diagnostic Code 7346 as there are two of the symptoms (pyrosis and regurgitation) for the 30 percent evaluation of less severity. A rating in excess of 10 percent is not warranted because there is no evidence that the Veteran’s symptoms were accompanied by substernal, arm or shoulder pain, productive of considerable impairment of health. Pain was reported during the September 2007 VA examination, but was described as a gassy pain rather than a substernal pain. Federal and private treatment records and lay statements do not document or describe any substernal, arm, or shoulder pain. The Board acknowledges the Veteran’s July 2008 statement indicating that he has had to change his diet and could not go to most restaurants because it would cause intense, prolonged reflux/burning with regurgitation. However, this does not establish that these symptoms were accompanied with substernal, arm, or shoulder pain. For these reasons, a rating in excess of 10 percent is not warranted from July 11, 2007 to December 6, 2009 for GERD, Barrett’s esophagus, and symptoms of IBS. Period from December 7, 2009 to September 24, 2012 For the reasons that follow, the Board finds that for the period from December 7, 2009 to September 24, 2012, the Veteran’s GERD, Barrett’s esophagus, and symptoms of IBS was manifested by substernal pain, pyrosis, and regurgitation. This more nearly approximates the criteria for a 30 percent rating under Diagnostic Code 7346. A December 2009 VA examination revealed symptoms of substernal pain, pyrosis, regurgitation, and esophageal distress. An August 2011 private treatment record noted abdominal pan. A rating in excess of 30 percent is not warranted during this period as the Veteran did not have symptoms that would approximate the criteria for a 60 percent rating: pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. Though pain was noted during this period, it is already contemplated by the 30 percent rating, which specifically considers substernal pain. Additionally, there is no evidence of material weight loss. The Veteran was observed by his private provider to be well developed and well-nourished in September 2011 and April 2012 private treatment records. There is no evidence of vomiting related to gastrointestinal disabilities. Though an April 2012 private treatment record noted 5 days of nausea and vomiting accompanied with sinus congestion, there is no indication this was related to GERD because the Veteran was ultimately assessed with acute bronchitis. Further, there is no evidence of hematemesis or melena with moderate anemia. The December 2009 VA examination revealed that there was no history of hematemesis or melena and no signs of anemia. For these reasons, a rating in excess of 30 percent is not warranted from December 7, 2009 to September 24, 2012 for GERD, Barrett’s esophagus, and symptoms of IBS. Period from September 25, 2012 to present For the reasons that follow, the Board finds that for the period from September 25, 2012 to present, the Veteran’s GERD with Barrett’s esophagus and symptoms of IBS was manifested by symptoms of pyrosis, regurgitation, substernal arm or shoulder pain, sleep disturbance caused by reflux, abdominal distension, crampy abdominal pain, occasional episodes of bowel disturbance with abdominal distress, and episodes of exacerbation and/or attacks of the intestinal condition occurring 7 times or more in the past year. Resolving doubt in the Veteran’s favor, the Board finds that the combination of these symptoms is productive of severe impairment of health, which corresponds to the criteria for a 60 percent rating under Diagnostic Code 7346. Collectively, VA examinations during this period establish symptoms of pyrosis, regurgitation, substernal arm or shoulder pain, sleep disturbance caused by reflux, abdominal distension, crampy abdominal pain, occasional episodes of bowel disturbance with abdominal distress, and episodes of exacerbation and/or attacks of the intestinal condition occurring 7 times or more in the past 12 months. A September 2012 VA esophageal examination revealed symptoms of persistently recurrent epigastric distress, dysphagia, pyrosis, reflux, regurgitation, substernal arm or shoulder pain, and sleep disturbance caused by esophageal reflux. A September 2012 irritable bowel syndrome examination revealed symptoms of infrequent abdominal distension, crampy abdominal pain, occasional episodes of bowel disturbance with abdominal distress, and episodes of exacerbation and/or attacks of the intestinal condition occurring 7 times or more in the past year. A June 2013 VA examination revealed symptoms of persistently recurrent epigastric distress, dysphagia, pyrosis, reflux, regurgitation, substernal arm or shoulder pain, and sleep disturbance caused by esophageal reflux. Symptom recurrence occurred 4 times or more a year. Weight loss of 6 pounds was noted. A November 2015 VA examination revealed symptom combinations productive of severe impairment of health, persistently recurrent epigastric distress, substernal pain, and sleep disturbance caused by esophageal reflux. A December 2017 VA esophageal examination revealed symptoms of dysphagia, reflux, regurgitation, and substernal pain. A December 2017 VA intestinal examination revealed abdominal distension, frequent episodes of bowel disturbance with abdominal distress, and episodes of exacerbations or attacks of the intestinal condition occurring 7 times or more in a year. There was no evidence of weight loss or malnutrition. The Board notes that the rating criteria for a 60 percent rating under Diagnostic Code 7346 requires symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. The Board acknowledges that the record does not establish material weight loss or hematemesis or melena with moderate anemia. However, the Board finds that the Veteran’s symptoms, in combination, are productive of considerable impairment of health. For these reasons, the Board finds that a rating of 60 percent under Diagnostic Code 7346 is more nearly approximated for this period. This is the highest schedular rating allowed under Diagnostic Code 7346. The Board has considered other relevant Diagnostic Codes. However, diseases of the digestive system, particularly within the abdomen, which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia and disturbances in nutrition. 38 C.F.R. § 4.113. Consequently, certain coexisting diseases in this area, as indicated in the instruction under the title “Diseases of the Digestive System” of the Rating Schedule, do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in § 4.14. Notably, ratings under Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other. 38 C.F.R. § 4.114. A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. Id. In the present case, analysis of the Veteran’s combined symptoms (other than active malignancy) due to GERD, Barrett’s esophagus, IBS, and residuals of adenocarcinoma under other Diagnostic Codes would result in no higher than a 60 percent rating. A higher rating would not be warranted under Diagnostic Code 7323 (ulcerative colitis) as there is no evidence of malnutrition, anemia, or serious complication as liver abcess. VA examination testing has not revealed anemia. Likewise, there is no evidence of malnutrition. The Veteran was frequently observed to be well-nourished. There is no evidence indicating serious complication as liver abcess associated with his service-connected disability. Other pertinent Diagnostic Codes such as 7319 (irritable colon syndrome) would not avail the Veteran to a higher rating as the maximum schedular rating is less than 60 percent. For these reasons, a rating of 60 percent for GERD with Barrett’s esophagus and symptoms of IBS for the period from December 7, 2009 to August 1, 2017 is granted. However, a rating in excess of 60 percent for esophageal adenocarcinoma and GERD with Barrett’s esophagus and symptoms of IBS for the period from August 1, 2017 to present is denied. Additional Considerations The issue of consideration of an extraschedular rating was raised by the record. A November 2020 advisory opinion by the Director of VA’s Compensation Service determined that the medical evidence does not support a higher evaluation on an extraschedular basis for GERD with IBS. Consideration of an extraschedular rating requires a three-step inquiry. The first question is whether the schedular rating criteria adequately contemplate the Veteran’s disability picture. If the schedular evaluation does not contemplate the level of disability and symptomatology shown and is found inadequate, then the second inquiry is whether the exceptional disability picture exhibits other related factors, such as marked interference with employment or frequent periods of hospitalization. See Thun v. Peake, 22 Vet. App. 111 (2008). The first Thun element compares a claimant’s symptoms to the rating criteria, while the second addresses the resulting effects of those symptoms. Thus, the first and second Thun elements, although interrelated, involve separate and distinct analyses. Yancy v. McDonald, 27 Vet. App. 484, 495 (2016). Regarding the first element, comparison of the Veteran’s symptoms and associated functional impairment does not show that the rating criteria are inadequate to describe his disability picture. The Veteran’s GERD, Barrett’s esophagus, and IBS is rated under Diagnostic Code 7346. The record shows that from July 11, 2007 to December 6, 2009, he had complaints and findings of pyrosis, regurgitation, and gassy pain. Diagnostic Code 7346 does not specifically list gassy pain, but this symptom is reasonably similar to two or more of the symptoms for the 30 percent evaluation (epigastric distress) of less severity, which is contemplated by the 10 percent evaluation. Here, the manifestations of Veteran’s GERD, Barrett’s esophagus, IBS, and adenocarcinoma from July 11, 2007 to December 6, 2009 are reasonably contemplated by Diagnostic Code 7346. The threshold issue under Thun is thus not met, and further consideration of an extraschedular rating is not warranted for this period. The record shows that from December 7, 2009 to September 2, 2012, he had complaints and findings of substernal pain, pyrosis, and regurgitation. Diagnostic Code 7346 specifically lists substernal pain, pyrosis, and regurgitation in the rating criteria. Here, the manifestations of Veteran’s GERD, Barrett’s esophagus, IBS, and adenocarcinoma from July 11, 2007 to December 6, 2009 are reasonably contemplated by Diagnostic Code 7346. The threshold issue under Thun is thus not met, and further consideration of an extraschedular rating is not warranted for this period. The record shows that from September 25, 2012 to present, he has complaints and findings of pyrosis, regurgitation, substernal arm or shoulder pain, sleep disturbance caused by reflux, abdominal distension, crampy abdominal pain, occasional episodes of bowel disturbance with abdominal distress, and/or episodes of exacerbation and attacks of the intestinal condition occurring 7 times or more in the past year. Diagnostic Code 7346 does not specifically list all the Veteran’s symptoms during this period. Nonetheless, sleep disturbance caused by reflux, abdominal distension, crampy abdominal pain, occasional episodes of bowel disturbance with abdominal distress, and/or episodes of exacerbation and attacks of the intestinal condition occurring 7 times or more in the past year are reasonably similar to “symptom combinations productive of severe impairment of health” which is listed under Diagnostic Code 7346. Additionally, these unlisted symptoms were used to assign the highest schedular rating allowed under Diagnostic Code 7346. Further, the Board notes that the medical evidence reveals esophageal adenocarcinoma was associated with the Veteran’s GERD and Barrett’s esophagus. A separate, compensable rating was granted for adenocarcinoma effective from August 4, 2011 to until August 1, 2017, when was determined that there was no longer any active malignancy. From August 1, 2017, the Veteran’s GERD, Barrett’s esophagus, IBS, and adenocarcinoma were combined, and rated based on residuals of the adenocarcinoma, pursuant to Diagnostic Code 7343. Here, the Veteran’s GERD, Barrett’s esophagus, IBS, and adenocarcinoma manifestations are reasonably contemplated by Diagnostic Code 7346. The threshold issue under Thun is thus not met, and further consideration of an extraschedular rating is not warranted for this period. In sum, for the period from September 25, 2012 to July 31, 2017 a rating of 60 percent, but no higher, for GERD, Barrett’s esophagus, and IBS is granted. However, a rating in excess of 10 percent from July 11, 2007 to December 6, 2009; 30 percent from December 7, 2009 to September 24, 2012; and 60 percent from September 25, 2012 to present is denied, to include on an extraschedular basis. REASONS FOR REMAND Having reviewed the record, the Board finds remand is warranted with respect to the issues of an increased rating for sacroiliitis for the period prior to September 25, 2012 and TDIU. With respect to sacroiliitis, remand is warranted for an addendum opinion. The issue was remanded in a May 2019 Board decision for a retrospective opinion regarding whether there was additional limitation of motion and functional loss during flare-ups, pursuant to Sharp v. Shulkin, 29 Vet. App. 26 (2017). A November 2020 VA examiner opined that there would be little to no functional loss due to sacroiliitis as sacroiliitis would involve only local symptoms and does not impact, directly, the range of motion. The examiner further stated the bulk of the Veteran’s limitations are due to degenerative spine disease, separate from the sacroiliitis joint condition. However, the Board notes that a February 2015 VA examination revealed that the Veteran’s sacroiliitis was a diagnosis error and the correct diagnosis was spondylolisthesis at L5-S1 with mild degenerative changes. It is unclear whether the November 2020 VA examiner considered this corrected diagnosis, which includes degenerative changes. As such, remand is warranted for clarification. On remand, the examiner should provide an addendum opinion estimating the amount in degrees of range of motion lost, and functional impairment, due to flare-ups experienced by the Veteran at the time of the December 2009 examination. In doing so, the examiner should clarify whether the Veteran’s corrected diagnosis of spondylolisthesis at L5-S1 with mild degenerative changes was considered. As the increased rating claim is being remanded, the outcome of which could affect whether the Veteran meets the criteria for TDIU benefits, the Board finds that the claim for TDIU is inextricably intertwined with the increased rating claim and must be remanded as well. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Finally, any outstanding VA treatment records for the period from June 2020 to present should be obtained and associated with the record. The matters are REMANDED for the following actions: 1. Obtain the Veteran’s VA treatment records for the period from June 2020 to present. 2. Forward the claims file to November 2020 VA examiner, or an appropriate substitute, to assess the severity of the Veteran’s service-connected right sacroiliitis disability prior to September 25, 2012. Following a review of the record, the examiner should provide retrospective findings in regard to pain on range of motion testing and an estimation of functional loss, per Sharp. (a) The examiner should estimate the amount in degrees of range of motion lost due to flare-ups experienced by the Veteran at the time of the examination in December 2009. (b) The examiner should comment upon the functional impairment resulting from the Veteran’s right sacroiliitis disability prior to September 25, 2012. The examiner should clarify whether the Veteran’s corrected diagnosis of spondylolisthesis at L5-S1 with mild degenerative changes was considered. The examiner is advised that a February 2015 VA examination revealed that the Veteran’s sacroiliitis was a diagnosis error and the correct diagnosis was spondylolisthesis at L5-S1 with mild degenerative changes. If the examiner cannot provide some or all such retrospective opinions, the examiner must make clear that he or she has considered all relevant, procurable data, but that any member of the medical community at large could not provide such an opinion without resorting to speculation. Saudiee Brown Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Vang, Stephanie 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.