Citation Nr: 21028842 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 16-50 545 DATE: May 12, 2021 ORDER Service connection for right ear hearing loss is denied. An increased initial evaluation for service-connected posttraumatic stress disorder (PTSD) with anxiety, evaluated as 30 percent disabling prior to April 1, 2013, and as 50 percent disabling prior to April 16, 2019, is denied. An initial evaluation in excess of 10 percent for service-connected gastroesophageal reflux disease (GERD) with resection of the small intestine is denied. FINDINGS OF FACT 1. The Veteran does not have right ear hearing loss that is related to his military service, to include any noise exposure therein. 2. Prior to April 1, 2013, the Veteran's PTSD with anxiety was productive of symptoms that include anxiety, mild memory loss, and sleep impairment, but not occupational and social impairment with reduced reliability and productivity or worse. 3. For the period from April 1, 2013 to April 15, 2019, the Veteran's PTSD with anxiety is not shown to have resulted in total impairment or occupational and social impairment with deficiencies in most areas. 4. The Veteran's service-connected GERD with resection of the small intestine is shown to have been productive of symptoms that include GERD, but not 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 service connection for right ear hearing loss have not been met. 38 U.S.C. §§ 1131, 1154 (b), 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.385. 2. The criteria for an increased initial evaluation for service-connected PTSD, evaluated as 30 percent disabling prior to April 1, 2013, and as 50 percent disabling prior to April 16, 2019, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411. 3. The criteria for an initial evaluation in excess of 10 percent for GERD with resection of the small intestine have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.7, 4.114, Diagnostic Code 7346. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had service from September 1999 to September 2002, and from October 2005 to November 2011, to include service in Kosovo, Iraq, and Afghanistan. In January 2020, the Veteran was afforded a hearing before the undersigned. In October 2020, the Board remanded the claims for additional development. The Veteran essentially asserts that he has constipation and diarrhea that are related to his service or his service-connected GERD with small bowel resection. VA progress notes show that the Veteran has been noted to have irritable bowel syndrome. Service connection is not currently in effect for this disability. Should the Veteran wish to file a claim for this condition, he should consult his representative, as informal claims are no longer permitted under VA regulations. Service Connection The Veteran asserts that he is entitled to service connection for right ear hearing loss. During his hearing, held in January 2020, he testified that he had problems hearing and understanding speech during service in Iraq. He stated that he worked close to an airfield for about one month. He said that he was also exposed to loud noise from an improvised explosive device. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may be granted for an organic disease of the nervous system, such as a sensorineural hearing loss, when manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Applicable regulations provide that impaired hearing shall be considered a disability when the auditory thresholds in any of the frequencies of 500, 1,000, 2,000, 3,000, and 4,000 Hz are 40 decibels or greater; the thresholds for at least three of these frequencies are 26 decibels or greater; or when speech recognition scores are 94 percent or less. 38 C.F.R. § 3.385. 38 C.F.R. § 3.385 does not preclude service connection for a current hearing loss disability where hearing was within normal limits on audiometric testing at separation from service. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Rather, when audiometric test results at a veteran's separation from service do not meet the requirements of 38 C.F.R. § 3.385, a veteran may nevertheless establish service connection for current hearing disability by submitting medical evidence that the current disability is causally related to service. Hensley v. Brown, 5 Vet. App. 155 (1993). Where the requirements for hearing loss disability pursuant to 38 C.F.R. § 3.385 are not met until several years after separation from service, the record must include evidence of exposure to disease or injury in service that would adversely affect the auditory system and post-service test results meeting the criteria of 38 C.F.R. § 3.385. Hensley, 5 Vet. App at 155. If the record shows (a) acoustic trauma due to significant noise exposure in service and audiometric test results reflect an upward shift in tested thresholds while in service, though still not meeting the requirements for "disability" under 38 C.F.R. § 3.385, and (b) post service audiometric testing produces findings which meet the requirements of 38 C.F.R. § 3.385; then the rating authorities must consider whether there is a medically sound basis to attribute the post service findings to the injury in service, or whether these findings are more properly attributable to intervening causes. Id. at 159. The law provides that, in the case of any veteran who engaged in combat with the enemy in active service, satisfactory lay or other evidence of an injury incurred in service shall be accepted as sufficient proof of service incurrence of the injury if the evidence is consistent with circumstances of service and notwithstanding that there is no official record of service incurrence of the injury. 38 U.S.C. § 1154 (b); see also VAOPGCPREC 12-99, 65 Fed. Reg. 6256 - 6258 (2000). The United States Court of Appeals for Veterans Claims (Court) has held that 38 U.S.C. § 1154 does not alter the fundamental requirements of a diagnosis, and a medical nexus to service. See Brock v. Brown, 10 Vet. App. 155, 162 (1997). The Veteran's participation in combat has been conceded and the Veteran is entitled to the presumptions at 38 U.S.C. § 1154 (b). The Board notes that service connection is currently in effect for disabilities that include tinnitus, eustachian tube dysfunction and chronic serous otitis, and left ear hearing loss. The Veteran's discharges (DD Form 214s) shows that his specialties were nuclear medical specialist and health care specialist. The Veteran's service treatment records show that in 2006 and 2008 he was profiled (put on light duty) for "unilateral" hearing loss (2006) and a hearing deficit (2008). There were multiple notations of chronic hearing loss of the left ear. See e.g., reports dated in 2008. A February 2008 report notes that the Veteran's right ear hearing was within normal limits across all speech frequencies. A December 2009 audiogram was noted to shows normal auditory sensitivity; there was a notation of a complaint of worsening right ear hearing, and that the Veteran had a blocked PE tube, right ear. A September 2011 DD Form 2697 shows that the Veteran reported having hearing loss; no specific ear was identified. Multiple audiograms, dated between 1999 and 2010, do not show right ear hearing loss for VA purposes, as defined at 38 C.F.R. § 3.385. The Veteran's separation examination report, dated in September 2011, shows that his ears and drums were clinically evaluated as normal; there were no audiogram results included in this report. There was a notation of bilateral hearing loss. The Veteran denied a history of hearing loss on his medical history survey completed in conjunction with the separation physical. As for the post-service medical evidence, a VA disability benefits questionnaire (DBQ), dated in March 2012, shows that the Veteran reported a history of hearing loss prior to entering the service in 1999. He stated that during service he was exposed to loud noise, to include range fire, explosions, jet engines, and helicopters, with the use of hearing protection. On examination, the Veteran did not have right ear hearing loss for VA purposes, as defined at 38 C.F.R. § 3.385. The examiner indicated that the right ear had normal hearing. The examiner stated that there was no difference in thresholds between the Veteran's current examination and his inservice examination dated in August 2005, at all ratable frequencies. Given normal hearing sensitivity thresholds in the right ear, the examiner concluded that the Veteran does not have hearing loss that was caused by or a result of military service. A VA ear DBQ, dated in May 2012, notes a four to five-year history of intermittent eustachian tube dysfunction producing intermittent earaches and fluctuations in hearing. The Veteran was status post bilateral ear ventilation (myringotomy) tubes in 2010 for his eustachian tube dysfunction and serous otitis in the ears. The Veteran's eardrums were noted to be well-healed. A VA DBQ, dated in November 2020, shows that on examination, the Veteran did not have right ear hearing loss for VA purposes, as defined at 38 C.F.R. § 3.385. The examiner indicated the following: The Veteran was deployed to Afghanistan and Iraq, and he is presumed to have been exposed to hazardous noise. There was no right ear hearing loss prior to service. There was not a permanent positive threshold shift (worse than reference threshold) greater than normal measurement variability at any frequency between 500 and 6,000 Hz for the right ear. The right ear currently has normal hearing. The Board finds that the claim must be denied. Although the Veteran is conceded to have been exposed to loud noise during service, and participation in combat is conceded, he is not shown to have had right ear hearing loss during service, or thereafter, as defined for VA purposes. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998). Although there was a notation of "bilateral" hearing loss upon separation from service, this appears to have been based on the Veteran's verbal report of his history. In any event, there are no inservice audiograms to show right ear hearing loss. There is no evidence of right ear sensorineural hearing loss within one year of separation from service. See 38 C.F.R. §§ 3.307, 3.309. Right ear hearing loss is not currently shown. McLain v. Nicholson, 21 Vet. App. 319, 321 (2007). Accordingly, the Board finds that the preponderance of the evidence is against the claim, and that the claim is denied. Increased Ratings 1. Increased rating, PTSD. The Veteran asserts that he is entitled to an increased initial evaluation for PTSD. During his hearing, held in January 2020, he testified that he receives individual PTSD treatment at VA about once a month. He said that he takes care of his daughter, and that his symptoms include anxiety, and feeling withdrawn. He does not leave the house unless he must. He reported having sleep difficulties and nightmares. With regard to the history of the disability in issue, the Veteran had tours in Iraq and Afghanistan. His service treatment records note anxiety as of at least 2009, and an adjustment disorder with anxiety and prolonged depressed mood as of at least 2011. His separation examination report from his second period of active duty, dated in September 2011, showed that his psychiatric condition was clinically evaluated as normal; there were notations of depression, anxiety, PTSD, and insomnia. The associated report of medical history includes notations of a history of treatment for anxiety, panic attacks, and insomnia, a history of PTSD counseling, and that he would need ongoing close clinical follow-up by mental health. In April 2012, the RO granted service connection for an anxiety disorder, evaluated as 30 percent disabling, with an effective date of November 28, 2011. The Veteran appealed the issue of entitlement to an increased initial evaluation. In September 2016, the RO recharacterized the Veteran's disability as PTSD, and granted the claim to the extent that it increased the Veteran's rating to 50 percent, with an effective date of April 1, 2013. In January 2021, the RO granted the claim to the extent that it increased the Veteran's rating to 100 percent, with an effective date of April 16, 2019. The Veteran's PTSD has been evaluated under 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411, under the general rating formula for mental disorders, which became effective prior to the Veteran's claim for service connection. Under DC 9411, a 30 percent rating is assigned when a psychiatric disability causes occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactory, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; or mild memory loss (such as forgetting names, directions, recent events). Id. Under DC 9411, a 50 percent rating is warranted when a psychiatric disability causes occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks (more than once a week); difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. Under DC 9411, a 70 percent rating is warranted when an acquired psychiatric disability causes occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood, due to such symptoms as: Suicidal ideations; obsessional rituals that interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Id. That portion of VA's Schedule for Rating Disabilities ("the Schedule") that addresses service-connected psychiatric disabilities was based on the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) IV prior to a change effective August 4, 2014. 38 C.F.R. § 4.130. The regulation has been changed to reflect the current DSM, the DSM-V. As this appeal was certified to the Board in November 2016, after the effective date for this change, DSM-5 is applicable to this claim. See 70 Fed. Reg. 45,093-94 (Aug. 4, 2014). As such, the use of global assessment of functioning scores is inappropriate. Golden v. Shulkin, 29 Vet. App. 221 (2018). When determining the appropriate disability evaluation to assign, the Board's primary consideration is the Veteran's symptoms, but it must also make findings as to how those symptoms impact the Veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). Because the use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Nevertheless, as all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the Veteran's impairment must be "due to" those symptoms, a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. Prior to April 1, 2013. VA progress notes show that the Veteran received ongoing treatment for psychiatric symptoms. In October 2012, he complained of a lack of attention and focus, with a history of trials of Concerta, Adderall, Strattera, and Wellbutrin. He felt that he either did not tolerate these medications well or that they were not effective at the doses prescribed. He was to undergo a trial of short-acting methylphenidate (Ritalin). In January 2013, he reported that he was attempting to go back to school despite his history of ADD (attention deficit disorder). In March 2013, he reported that he was in school, and that he is doing very well with his medication. He had earned four A's and two B's. He had grown more confident and optimistic. He denied problems with sleep, anxiety, tremors, tics, or excessive weight loss. His mood was good. On examination, the findings tended to show that he was neat and well-groomed. He was serious, but not agitated or irritable. Mood was euthymic or anxious. Speech had a normal rate and rhythm, and was clear, coherent, and relevant. He was alert, attentive, and oriented times three. Judgment and insight were good. Memory was intact. Affect was within normal limits and congruent to mood, non-labile with psychomotor agitation. Thought processes were logical and goal directed. Thought content was within normal limits. Memory was grossly intact. Judgment and insight appeared good. The Veteran did not appear to be a significant risk of harm to self or others. There were auditory hallucinations in the form of hearing a child crying "every once in a while" (about once a month), with no signs or reports of other hallucinations, delusions, paranoia, or suicidal or homicidal, intent or plan. A VA PTSD examination report, dated in April 2012, shows that the diagnosis was anxiety disorder NOS (not otherwise specified). The examination report notes the following: The Veteran has been married to his wife for seven years. This is his first marriage. He described his relationship with his wife to be "ok now", though he described some relationships difficulties during his most recent deployment. They previously participated in marital counseling for four months. They have a 3-year-old daughter. The Veteran has a few close friends, but he had limited opportunities to socialize due to financial constraints. The Veteran has been unemployed since his discharge. He was treated for psychiatric symptoms during service, but not since his discharge. The Veteran denied a history of hospitalization for psychiatric symptoms and stated that he was not taking any medications for control of psychiatric symptoms. He occasionally took over-the-counter medications for sleep. He drinks about six beers a month. He denied use of illicit substances. He denied current suicidal or homicidal ideation, plan, or intent, or a history of previous suicide attempts. The examiner indicated that the Veteran does not appear to be at risk for harming himself or others at the present time. His symptoms were noted to include anxiety, mild memory loss, irritability or outbursts of anger, difficulty concentrating, hypervigilance, and chronic sleep impairment. The examiner stated that the Veteran's anxiety symptoms appear to have only a mild impact on his social functioning at the present time, and that they were apparently more disruptive to him and to his relationship with his wife during and immediately following his deployments to Iraq and Afghanistan. The examiner indicated that the Veteran did not meet the criteria for PTSD. The Board finds that an initial evaluation in excess of 30 percent is not warranted for the Veteran's PTSD. The Veteran's symptoms were not shown to be sufficiently severe to have resulted in occupational and social impairment with reduced reliability and productivity or worse prior to April 2013. The totality of the evidence shows that the Veteran's PTSD most closely resembled the criteria for not more than an initial 30 percent evaluation during that time. The Veteran had been married for approximately seven years, and had been unemployed since his discharge. However, there was no history of hospitalization for psychiatric symptoms, and was not taking any medications for control of psychiatric symptoms at that time. The Veteran's symptoms have been discussed. They did not include a history of psychosis or suicidal or homicidal ideation, plan or attempt. The April 2012 VA examiner characterized the Veteran's symptoms as being productive of occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or, symptoms controlled by medication. This most closely conforms to the language for no more than a 10 percent evaluation under the General Rating Formula. See 38 C.F.R. § 4.130. That is, after examining the Veteran, the examiner found that the criteria descriptive of a 10 percent rating was most indicative of the Veteran's impairment from his psychiatric disorder. In summary, there is insufficient evidence of such symptoms as flattened affect; irregular speech; difficulty in understanding complex commands; impairment of short- and long-term memory; and impaired abstract thinking, nor are other psychiatric symptoms shown to have resulted in the required level of impairment. Vazquez-Claudio. Given the foregoing, the Board finds that the Veteran's symptoms are not of such severity to approximate, or more nearly approximate, the criteria for a 50 percent evaluation or worse under DC 9411, and that the findings do not support a conclusion that his symptoms are productive of a "similar severity, frequency, and duration" as those required for a 50 percent evaluation. See 38 C.F.R. § 4.7; Vazquez-Claudio. April 1, 2013 to April 16, 2019. A VA PTSD examination report, dated in April 1, 2013, completed by J.L, M.D., and submitted by the Veteran, shows that Dr. J.L. indicated that the Veteran was experiencing avoidance of stimuli associated with the trauma and numbing of general responsiveness, and persistent symptoms of increased arousal, not present before the trauma. His symptoms were indicated to include depressed mood, anxiety, suspiciousness, chronic sleep impairment, panic attacks more than once a week, mild memory loss, memory loss for names of close relatives, own occupation, or own name, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a work like setting, obsessional rituals which interfere with routine activities, persistent flash backs, persistent danger of hurting self or others, and an inability to establish and maintain effective relationships, and suicidal ideation. The diagnoses were PTSD, depression, and anxiety. The examiner indicated that the Veteran's symptoms were productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. A VA PTSD examination report, dated in April 8, 2013, submitted by the Veteran, and completed by E.S, LCSW., shows that the Veteran was noted to have been separated from his wife since September 2012 and that he was in the process of getting a divorce. The Veteran had been unemployed since his discharge. He was enrolled in college. He was currently smoking marijuana once or twice a day "to self-medicate." His symptoms were indicated to include depressed mood, anxiety, suspiciousness, chronic sleep impairment, impairment of short and long term memory, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a work like setting, and an inability to establish and maintain effective relationships. The diagnoses were PTSD, depression, and anxiety. A VA PTSD DBQ, dated in June 2016, shows that the Veteran reported that he and his wife separated about three years earlier, and had been officially divorced for two years, and that they had a history of fighting and that she was not supportive of his mental health symptoms. He had custodial and joint custody of their daughter, age seven. The Veteran reported having a good relationship with his mother, but not his father, and that he had a few close friends. He brews beer and plays video games in his spare time. He felt motivated but directionless. He had not worked since his discharge. He had been in school and did "okay," but it was somewhat harder after he discontinued Ritalin about a year before due to difficulties obtaining it. He complained that he was often restless and filled with nervous energy. He reported feeling very uncomfortable in crowded settings and avoided them if possible. He said that he typically has a generally cheerful demeanor but that he has some ongoing anxiety related to his finances and his health. He drinks beer daily, but he denied that he drinks to the point of incapacitation, or that his alcohol use causes any problems or functional impairment. He said that he smokes marijuana about once a week. The examiner noted that the Veteran had not received VA outpatient treatment for psychiatric symptoms since October 2015. His symptoms were noted to include anxiety, suspiciousness, and chronic sleep impairment. There were no noteworthy behavioral observations. The diagnosis was PTSD. VA progress notes show ongoing treatment for psychiatric symptoms. In July 2013, the Veteran reported that he was able to make all A's in school and that he was majoring in business. He said that found that his medication had been very helpful, and he denied any untoward side effects. He was having difficulty sleeping. In December 2013 the Veteran reported that he was in good spirits. It appears that he was provided with Mirtazapine between July and December of 2013. He said that if he works out on a regular basis, his sleep is good and that he has joined a gym and tried to integrate this into his lifestyle. In June 2015, the Veteran stated that he was currently living with his six-year old daughter stated that he has one more semester and two classes to go in order to be graduated from college with a degree in business administration. He stated that he is doing well on his current medication, getting most of the time A's and that he currently has a 3.2 GPA (grade point average) "compared to before where he was approximately 1." He denied any depressive symptoms, neurovegetative symptoms, psychosis, suicidal thinking, and side effects from the medication. A June 2015 report notes that he was to continue with Methylphenidate 10 milligrams (mg.) daily until he graduated from school in December 2015. There were notations of reduced/difficulty with concentration. Reports dated between 2016 and 2019 show that the Veteran reported using marijuana, drinking two drinks/beers a day, and that he works out four times a week. His PTSD was noted to be stable. Overall, VA progress notes contain findings tending to show that he was alert and oriented times three. He had fair grooming and hygiene or was well-groomed. Speech was adequate, or normal in rate, rhythm, quantity tone, or normal in volume, articulation, and prosody. Mood was euthymic neutral, or happy. Memory was intact for immediate, recent, and remote events. He was coherent and logical. There was no evidence of delusions or hallucinations, or psychosis (including paranoia). There was no suicidal or homicidal ideation, obsessions, compulsions, or preoccupations. Thought processes were logical, goal-directed, and coherent without tangentiality. Insight and judgment were fair or "fairly good." Cognition was grossly intact. His medications included Effexor and Venlafaxine. The Board finds that an evaluation in excess of 50 percent is not warranted for the Veteran's PTSD prior to April 2019. The Veteran's symptoms were not shown to be sufficiently severe to have resulted in occupational and social impairment, with deficiencies in most areas. The totality of the evidence shows that the Veteran's PTSD most closely resembled the criteria for not more than a 50 percent evaluation. The Veteran is divorced, with custody of his daughter. He has been unemployed since his discharge. However, he was enrolled in a college business program and appears to have done well. He had a few close friends and he apparently went to the gym several times a week. There is no history of hospitalization for psychiatric symptoms. The Veteran's symptoms have been discussed. They do not include a history of suicidal or homicidal ideation, plan or attempt, or evidence of psychotic symptoms. The June 2016 VA examiner indicted that the Veteran's symptoms were productive of occupational and social impairment with reduced reliability and productivity. This most closely conforms to the language for no more than a 50 percent evaluation under the General Rating Formula. See 38 C.F.R. § 4.130. The Board has considered the April 2013 report from Dr. J.L., which indicates that the Veteran's symptoms include panic attacks more than once a week, "memory loss for names of close relatives, own occupation, or own name," obsessional rituals which interfere with routine activities, persistent flash backs, persistent danger of hurting self or others, and suicidal ideation. These findings are significantly inconsistent with, and are not corroborated by, the weight of the other medical evidence of record, which does not show such symptomatology. Similarly, the Board has considered the April 2013 findings of difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a work like setting, and an inability to establish and maintain effective relationships. However, these findings are not accompanied by explanations or citations to corroborating or supporting facts. When these findings are viewed in context with the other medical evidence of record, to they are insufficient to show that the criteria for a 70 percent evaluation have been met. Therefore, this evidence is insufficiently probative to warrant a grant of the claim. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). In summary, the evidence is insufficient to show that the Veteran has such symptoms as suicidal ideation with plan or intent, obsessional rituals, defects in speech, near-continuous panic or depression which affect his ability to function independently, appropriately, and effectively; impaired impulse control (other than as noted), spatial disorientation, neglect of personal appearance and hygiene, or difficulty in adapting to stressful circumstances, nor are there other psychiatric symptoms shown to have resulted in such impairment, such that a 70 percent evaluation is warranted. See 38 C.F.R. § 4.130; Vazquez-Claudio. Accordingly, an evaluation in excess of 50 percent is not warranted prior to April 2019. GERD and resection of the small intestine. The Veteran asserts that he is entitled to an initial evaluation in excess of 10 percent for his GERD and resection of the small intestine. During his hearing, held in January 2020, it was argued that the Veteran has problems with nutrition and absorption, and that he lost weight during service, from about 210 pounds to 135 pounds. The Veteran testified that he takes supplements, to include lactobacillus so that he can process dairy products more easily. He said that he currently weighs 170 pounds and that he cannot gain weight. He said that he either has diarrhea and constipation. The Veteran's representative argued that he should be evaluated under Diagnostic Code 7328 (as opposed to Diagnostic Code 7346), because it more accurately covers his condition. The Veteran's service treatment records show that he was noted to have esophageal reflux as of at least 2010. In July 2010, he underwent an exploratory laparotomy small bowel resection of about three inches for a small bowel abscess that formed after an injection of Neupogen for bone marrow donation. His postoperative course complicated by pneumonia and sepsis. He was discharged from the hospital, but he was readmitted for about five days later that month with postoperative bowel obstruction versus ileus. Upon readmission, his weight was noted to be 178 pounds. In August 2010, he was noted to be doing well, although he reported weight loss. He was advanced to a regular diet. The Veteran's separation examination report, dated in September 2011, shows that he was noted to have GERD, and a history of hospitalization for status post bowel obstruction. He weighed 168 pounds. In April 2012, the RO granted service connection for GERD and resection of the small intestine, evaluated as 10 percent disabling, with an effective date of November 28, 2011. The Veteran has appealed the issue of entitlement to an initial evaluation in excess of 10 percent. Under 38 C.F.R. § 4.114, ratings under Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive, will not be combined with each other. 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. The Veteran's disability has been evaluated under 38 C.F.R. § 4.114, DC 7346 (hiatal hernia). Under DC 7346, a 10 percent rating is warranted for two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent evaluation is assigned for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. Id. To the extent that DC 7346 lists the criteria conjunctively, all of the listed symptoms must be shown. See e.g., Melson v. Derwinski, 1 Vet. App. 334 (1991). 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. Use of terminology such as "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. A VA esophageal conditions DBQ, dated in March 2012, shows the following: The diagnosis was GERD, with an onset in 2006. No medication had been needed since 2010. The Veteran experienced self-resolving symptoms approximately once a month on average. His symptoms consisted of infrequent episodes of epigastric distress, pyrosis (heartburn), and reflux. The examiner opined that the Veteran's esophageal condition did not affect his ability to work. A VA intestinal surgery DBQ, dated in March 2012, indicates the following: The Veteran has a history of resection of the small intestine (exploratory laparotomy) for small bowel obstruction in 2010. Specifically, following donation for bone marrow transplant, the Veteran developed small bowel obstruction. He required exploratory laparotomy and resection of small bowel. He required postoperative readmission for distention that resolved with conservative measures. His intestinal condition did not require an ileostomy or colostomy. There have been no further interventions. He does not require continuous medication for control of his intestinal condition. The Veteran does not have weight loss or inability to gain weight attributable to intestinal surgery. The Veteran does not have any interference with absorption and nutrition attributable to resection of the small intestine. The Veteran does not now have, and has never had, a persistent intestinal fistula attributable to a surgical intestinal condition. The Veteran's residuals of intestinal surgery do not affect his ability to work. A VA esophageal conditions DBQ, dated in June 2016, shows the following: The diagnosis was GERD, with an onset in 2006. The Veteran reported that his GERD acts up about once a week, causing reflux. He tried to avoid certain food which would trigger it. He was not currently taking any medication. He experienced infrequent episodes of epigastric distress, pyrosis, and reflux. He also has sleep disturbance caused by esophageal reflux, with four or more recurrences per year and an average duration of symptoms of less than one day. He was not found to be experiencing any esophageal stricture, spasm of esophagus (cardiospasm or achalasia), or an acquired diverticulum of the esophagus. The Veteran's esophageal condition did not affect his ability to work. VA progress notes show that the Veteran complained of diarrhea and constipation. In 2013, the Veteran's esophageal condition was noted to be stable. He reported having joined a gym. In October 2015, his GERD /bowel resection was noted to be stable, with no current symptomatology. He denied nausea, vomiting, or diarrhea. In November 2018, he denied dysphagia, indigestion, heartburn, current abdominal pain, nausea or vomiting, bright red blood/rectum or melena. In December 2018, he underwent a colonoscopy with results that were consistent with diverticulosis. The results were noted to show no mucosal abnormalities to suggest inflammatory bowel disease, with negative biopsies. In January 2019, he reported running at least 20 miles a week. In February 2019, his impressions noted status post recent colonoscopy unremarkable other than diverticulosis, and possible irritable bowel syndrome. He was recommended for a stepwise approach for possible irritable bowel syndrome with diarrhea. He was to start with high fiber and probiotics. There was a low suspicion for inflammatory bowel disease, given the reassuring colonoscopy with biopsies. An upper GI (gastrointestinal study) with small bowel follow-through resulted in no significant findings. The report notes that the Veteran's esophagus is normal in course, caliber, and contractility and that the gastroesophageal junction is normal. There was mild reflux of barium into the esophagus. The Veteran reported an unplanned weight change of more than ten pounds in the last three months (loss of ten pounds or more), with no loss of appetite or decrease in food intake over the last three days, no difficulty with swallowing or chewing. He reported that he goes running and that his appetite is fine. There were findings of anemia. A March 2019 report shows that he denied having a recent weight gain or loss; he reported that he has diarrhea and that he exercises five days a week. He said that he does not follow a special diet. It appears that his symptoms and treatment are complicated by use of alcohol. See e.g., March 2019 report (noting alcohol dependence, ongoing issue, offered counseling, patient declined"). Reports dated in 2020 show that the Veteran reported that he was running from between a few times a week to on a daily basis, and that he had the goal of completing a marathon. This evidence notes stable irritable bowel disease. Overall, his weight was noted to be between 170 pounds and 193 pounds. The Veteran was repeatedly recommended for the MOVE program (a national weight management and exercise program designed by VA). The Board finds that a rating in excess of 10 percent is not warranted. The evidence shows that the Veteran has repeatedly complained of such symptoms as diarrhea, constipation, and GERD. He will get self-resolving esophageal symptoms once a month on average. His symptoms consist of infrequent episodes of epigastric distress, pyrosis (heartburn), and reflux. The Veteran does not have weight loss or inability to gain weight attributable to intestinal surgery. The Veteran does not have any interference with absorption and nutrition attributable to resection of the small intestine. The Veteran's residuals of intestinal surgery do not affect his ability to work. The June 2016 DBQ shows that he was not currently taking any medication. He has infrequent episodes of epigastric distress, pyrosis, and reflux. All the DBQs indicate that the Veteran's condition does not affect his ability to work. Thereafter, it appears that he was restarted on Omeprazole, followed by lactobacillus acidophilus and psyllium. Beginning in 2019, there are findings of anemia, however, there is no medical evidence to show that his symptoms are productive of a considerable impairment of health. The Veteran has reported that he enjoys running between several times a week to daily, or that he otherwise exercises five days a week. There is no evidence of malnutrition. It appears that the Veteran has repeatedly been determined to be overweight, e.g., he has repeatedly been recommended for the MOVE program. There is no competent evidence associating substernal arm or shoulder pain with the disability in issue. Based on the foregoing, the Board finds that the evidence is insufficient to show that the Veteran's disability 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. Melson. Accordingly, the Board finds that the criteria for a rating in excess of 10 percent under DC 7346 have not been met, and that the claim must be denied. As for the possibility of a rating in excess of 10 percent under any other potentially applicable diagnostic code, see Schafrath v. Derwinski, 1 Vet. App. 589 (1991), under 38 C.F.R. § 4.114, DC 7328, a 20 percent rating is warranted for: Intestine, small, resection of: Symptomatic with diarrhea, anemia, and inability to gain weight. The aforementioned evidence does not show that the Veteran has all of the required symptoms for a 20 percent rating under DC 7328. Melson. Specifically, in addition to the noted range of weight, VA progress notes show that the Veteran has repeatedly been determined to be overweight, e.g., he has repeatedly been recommended for the MOVE program. The evidence is insufficient to show that he has an inability to gain weight. Therefore, the severity of his disability is not shown to be in excess of that contemplated by the 10 percent rating currently in effect. The regulations clearly contemplate the assignment of a single rating in order to avoid violating the fundamental principle relating to pyramiding as outlined in 38 C.F.R. § 4.14. The rating schedular specifically precludes separate ratings for certain co-existing abdominal conditions. 38 C.F.R. § 4.113. There are 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. Consequently, certain coexisting diseases in this area do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in § 4.14. 38 C.F.R. § 4.113. Ratings under DCs 7301 to 7329, inclusive, 7331, 7342 and 7345 to 7348, inclusive, are not to be combined with each other. Rather, a single rating is to be assigned under the DC reflecting the predominant disability picture with elevation to the next higher rating where the severity of the overall disability warrants such rating. 38 C.F.R. § 4.114. As such, the Board can find no basis to assign separate ratings for the Veteran's gastrointestinal disabilities. The Board has considered the Veteran's statements. The Veteran served as a medic and he is presumed to have medical knowledge from his training and experience that exceeds that of a lay person. However, with regard to the service connection claim, an opinion may be reduced in probative value even where the statement comes from someone with medical training, if the medical issue requires special knowledge. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). The probative value of his opinion is reduced due to his lesser level of expertise, as compared to the reports of the VA audiologists based on audiometric testing, supra. He is not competent to report that he had, or has, a certain level of hearing impairment as measured in Hertz, and he is not competent to report that he has a hearing loss disability for VA purposes. With regard to the increased initial evaluation claims, the Veteran is competent to report on factual matters of which he has first-hand knowledge. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). However, he is not competent to identify a specific level of disability under the appropriate diagnostic codes. Accordingly, the preponderance of the evidence is against the Veteran's claims and they are denied. MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T.S.E., 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.