Citation Nr: 21028880 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 16-37 532 DATE: May 12, 2021 ORDER Entitlement to an effective date earlier than December 18, 2009, for the grant of service connection for anxiety, major depressive disorder (MDD) and panic disorder with insomnia is denied. Entitlement to an effective date earlier than May 22, 2012, for the grant of service connection for right patellar femoral pain syndrome is denied. Entitlement to an effective date earlier than May 22, 2012, for the grant of service connection for left patellar femoral pain syndrome is denied. Entitlement to an initial rating of 50 percent, but no higher, prior to June 6, 2011, for anxiety, MDD, panic disorder with insomnia, is granted. Entitlement to a rating in excess of 70 percent since June 6, 2011, for anxiety, MDD, panic disorder with insomnia is denied. Entitlement to an initial rating in excess of 10 percent for gastroesophageal reflux disease (GERD) with irritable bowel syndrome (IBS) prior to January 24, 2011, is denied. Entitlement to a rating of 30 percent, but no higher, for GERD with IBS from January 24, 2011, to July 8, 2015, is granted. Entitlement to a rating of 60 percent for GERD with IBS from July 9, 2015, is granted. REMANDED Entitlement to an initial compensable rating for striae distensae of the right lower extremity from steroid therapy is remanded. Entitlement to an initial compensable rating for striae distensae of the left lower extremity from steroid therapy is remanded. Entitlement to service connection for a cervical spine disability is remanded. FINDINGS OF FACT 1. The Veteran filed her initial claim for depression on December 18, 2009; date entitlement arose was prior to the date of claim. 2. The Veteran was notified of a December 2010 rating decision which denied service connection for bilateral patellar femoral pain syndrome in a December 29, 2010, letter; as she did not submit a notice of disagreement (NOD) and VA did not receive new evidence within one year of this notification, the December 2010 rating decision is final. 3. On May 22, 2012, the Veteran requested that her claim for service connection for a bilateral knee condition be reopened; date entitlement arose was prior to the date of claim. 4. Prior to June 6, 2011, the severity, frequency, and duration of the Veteran's anxiety, MDD, panic disorder with insomnia symptoms more closely approximated occupational and social impairment with reduced reliability and productivity; it was not manifested by occupational and social impairment with deficiencies in most areas or total occupational and social impairment. 5. Since June 6, 2011, the severity, frequency, and duration of the Veteran's anxiety, MDD, panic disorder with insomnia symptoms did not more closely approximate total occupational and social impairment. 6. Prior to January 24, 2011, the Veteran's GERD was manifested by persistently recurring epigastric distress with dysphagia and regurgitation; it was not manifested by pyrosis or substernal, arm, or shoulder pain. 7. From January 24, 2015 to July 8, 2015, at its worst, the Veteran's GERD with IBS was manifested by persistent severe nausea, pyrosis, and occasional constipation. 8. Since July 9, 2015, the Veteran's GERD with IBS has been manifested by predominant constipation with frequent abdominal distension, occasional diarrhea, frequent nausea, and occasional vomiting. CONCLUSIONS OF LAW 1. The criteria for an effective date prior to December 18, 2009, for the grant of service connection for anxiety, MDD and panic disorder with insomnia have not been met. 38 U.S.C. § 5110; 38 C.F.R. §§ 3.160, 3.400. 2. The criteria for an effective date earlier than May 22, 2012, for the grant of service connection for right patellar femoral pain syndrome have not been met. 38 U.S.C. § 5110; 38 C.F.R. §§ 3.160, 3.400. 3. The criteria for an effective date earlier than May 22, 2012, for the grant of service connection for left patellar femoral pain syndrome have not been met. 38 U.S.C. § 5110; 38 C.F.R. §§ 3.160, 3.400. 4. Prior to June 6, 2011, with resolution of reasonable doubt in the Veteran's favor, the criteria for a rating of 50 percent, but no higher, for service-connected anxiety, MDD, panic disorder with insomnia were met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9434. 5. Since June 6, 2011, the criteria for a rating in excess of 70 percent for service-connected anxiety, MDD, panic disorder with insomnia have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9434. 6. Prior to January 24, 2011, the criteria for a rating in excess of 10 percent for service-connected GERD were not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.21, 4.114, Diagnostic Code 7319-7346. 7. From January 24, 2011 to July 8, 2015, the criteria for a rating of 30 percent, but not higher, for service-connected GERD with IBS have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.21, 4.114, Diagnostic Code 7319-7346. 8. Since July 9, 2015, the criteria for a rating of 60 percent, but not higher, for service-connected GERD with IBS have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.21, 4.114, Diagnostic Code 7319-7346. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 2003 to August 2005. This matter comes to the Board of Veterans' Appeals (Board) on appeal of rating decisions by a U.S. Department of Veterans Affairs (VA) Regional Office (RO). In March 2019 and March 2020, the Board remanded the claims on appeal for additional development. The case is again before the Board for appellate review. Effective Date The assignment of effective dates of awards is generally governed by 38 U.S.C. § 5110 and 38 C.F.R. § 3.400. Unless specifically provided otherwise, the effective date of an award based on an original claim for service connection "shall be fixed in accordance with the facts found but shall not be earlier than the date of receipt of application therefor." 38 U.S.C. § 5110 (a). The implementing regulation clarifies this to mean that the effective date of an evaluation and an award of compensation based on an original claim "will be the date of receipt of the claim or the date entitlement arose, whichever is the later." 38 C.F.R. § 3.400. Thus, with a claim for service connection, the effective date of an award will be (1) the day following separation from active service or the date entitlement arose if the claim is received within one year after separation from service or (2) the date of receipt of claim or date entitlement arose, whichever is later. 38 C.F.R. § 3.400 (b)(2)(i). The effective date for a reopened claim, after a final disallowance, shall be the date of receipt of the new claim or date entitlement arose, whichever is later. 38 C.F.R. § 3.400 (q)(2), (r). A final decision cannot be reopened unless new and material evidence is presented. 38 U.S.C. § 5108. Pursuant to 38 C.F.R. § 3.156 (c), a final decision will be reconsidered when new and material evidence, in the form of service records, results in the reopening of a claim and a retroactive evaluation may be assigned. See Mayhue v. Shinseki, 24 Vet. App. 273, 277 (2011); 38 C.F.R. § 3.156 (c)(1). Additionally, the Board notes that it has no equitable powers to assign an effective date other than that required by applicable law. See 38 C.F.R. § 2.7; Zimick v. West, 11 Vet. App. 45, 50-51 (1998). 1. Entitlement to an effective date earlier than December 18, 2009, for the grant of service connection for anxiety, major depressive disorder (MDD) and panic disorder with insomnia The Veteran filed her initial claim for service connection for depression on December 18, 2009. The first evidence of any psychiatric disability in the record is during the Veteran's active duty service. The controlling regulation in this case is clear that the effective date for an award of service connection based on an original claim "will be the date of receipt of the claim or the date entitlement arose, whichever is the later." 38 C.F.R. § 3.400. The later date in this case is clearly the date of the claim, December 18, 2009. The Veteran contends that an implied or inferred claim for depression was raised in her initial claim in April 2005 but was not addressed in the September 2005 rating decision, but that depression was mentioned in the narrative portion of the rating decision. Under the regulations in effect prior to March 24, 2015, a claim for benefits is defined broadly to include a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1 (p); see also Brannon v. West, 12 Vet. App. 32, 34-35 (1998); Servello v. Derwinski, 3 Vet. App. 196, 199 (1992). As noted above, an effective date of a reopened claim cannot be earlier than the date the request to reopen the claim was filed. See 38 C.F.R. § 3.400 (r). With regard to the Veteran's contention an implied claim for service connection for a psychiatric disability existed in April 2005, the Board finds that the evidence of record dated prior to December 18, 2009, does not constitute a claim. Indeed, prior to December 18, 2009, the evidence of record includes service treatment records indicating treatment for anxiety and depressive symptoms with a diagnosis of anxiety disorder, NOS. In addition, the Veteran filed a claim for, inter alia, pretibial myxedema scars. During the May 2005 VA examination, the Veteran stated, "As horrible as my legs look, makes me depressed and I don't ever want to show my legs again." This was noted in the December 2010 rating decision. The Board finds that the evidence pertaining to anxiety diagnosis and depressive symptoms in the service treatment records and as relayed to the May 2005 VA examiner do not constitute a claim. It is well established that the mere presence of medical evidence does not establish an intent to seek service connection. See Brannon, 12 Vet. App.at 32, 34-35 (holding that the mere receipt of medical records could not be construed as an informal claim); see also Criswell v. Nicholson, 20 Vet. App. 501, 503 (2006) ("[W]here there can be found no intent to apply for VA benefits, a claim for entitlement to such benefits has not been reasonably raised."). Moreover, the Board notes that the provisions of former 38 C.F.R. § 3.157, which provide that a report of examination or hospitalization may be accepted as an informal claim for an increased rating or claim to reopen, are not applicable as the claim at issue is one for service connection. In short, the Veteran does meet the criteria for establishing an effective date earlier than August 26, 2011, for the grant of service connection for anxiety, MDD and panic disorder with insomnia. The pertinent legal authority governing effective dates is clear and specific, and the Board is bound by such authority. Accordingly, the Board concludes that the preponderance of the evidence is against the claim of entitlement to an effective date prior to December 18, 2009, for the grant of service connection for anxiety, MDD and panic disorder with insomnia. As such, the benefit-of-the-doubt rule enunciated in 38 U.S.C. § 5107 (b) is not for application. 2. Entitlement to an effective date earlier than May 22, 2012, for the grant of service connection for right patellar femoral pain syndrome 3. Entitlement to an effective date earlier than May 22, 2012 for the grant of service connection for left patellar femoral pain syndrome The Veteran filed her original claim for service connection for knee pain as secondary to service-connected thoracolumbar disability in July 2010. By rating decision in December 2010, service connection for patellar femoral pain syndrome was denied on the basis that patellar femoral pain syndrome was not caused by the thoracolumbar disorder. The Veteran did not appeal the decision, so it became final. The Veteran requested to reopen her claim for service connection for a bilateral knee disorder on May 22, 2012. At that time, the Veteran submitted service treatment records which showed problems with the back and knees for two weeks in October 2004. In a January 2013 rating decision, the RO granted service connection for right and left patellar femoral pain syndrome effective from May 22, 2012. The Board is unable to locate any claim to reopen the previously denied claim for service connection for a knee disability prior to May 22, 2012. There is no provision in either the statute or the regulations that allows for an earlier effective date based on a reopened claim unless a clear and unmistakable error was committed in a prior decision, or unless the new and material evidence resulted from receipt of additional relevant military records. See 38 U.S.C. § 5110 (i); 38 C.F.R. §§ 3.105, 3.156(c). The Veteran does not argue that relevant service records were the basis for reopening, and the record would not support any such argument. The service treatment records submitted by the Veteran in May 2012 were of record at the time of the December 2010 rating decision. In August 2013, the Veteran submitted a statement claiming CUE on the effective date for both knees. The Veteran noted that the C&P exam indicated that "review of service treatment records shows no complaint of any knee ... problem during active military duty." The Veteran noted that the narrative that service connection indicated in the reason for denial that "nor is there any evidence of the disability during active military service." That month, the Veteran was informed that VA was unable to process her claim for Clear and Unmistakable Error (CUE) as it did not meet the criteria and was not a valid claim for review based on CUE. The Veteran did not appeal that decision. As such, a claim for CUE in a prior rating decision is not currently before the Board. In short, the Veteran does meet the criteria for establishing an effective date earlier than May 22, 2012, for the grant of service connection for patellar femoral pain syndrome. The pertinent legal authority governing effective dates is clear and specific, and the Board is bound by such authority. Accordingly, the Board concludes that the preponderance of the evidence is against an effective date prior to May 22, 2012, for the grant of service connection for right and left patellar femoral pain syndrome. Thus, the benefit-of-the-doubt rule enunciated in 38 U.S.C. § 5107 (b) is not for application. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Veteran is appealing the original assignments of disability ratings following awards of service connection for anxiety, MDD, panic disorder with insomnia and GERD with IBS. As such, it is not the present level of disability which is of primary importance, but rather the entire period is to be considered to ensure that consideration is given to the possibility of staged ratings; that is, separate ratings for separate periods of time based on the facts found. Fenderson v. West, 12 Vet. App. 119 (1999). 4. Entitlement to an initial rating in excess of 30 percent prior to June 6, 2011, and in excess of 70 percent since June 6, 2011, for anxiety, MDD, panic disorder with insomnia The Veteran contends that her service-connected psychiatric disability warrants higher ratings than assigned. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). A 50 percent rating is assigned when symptoms such 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; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name. A private treatment record beginning in December 2009 indicates that the Veteran had diagnoses of depressive disorder NOS with anxiety as well as passive dependent and avoidant traits. The Veteran underwent VA examination in May 2010 at which time she reported being employed as a legal administrative specialist, that she missed about five to six days from work over the prior year, and that she had panic attacks on the job. The Veteran also noted that she got irritable on the job but was able to manage her irritability by walking away. She also reported having problems with concentration. The Veteran reported that she was working on her MBA but was having problems with focus and concentration. The Veteran was having a fairly good relationship with her husband but denied having close friends. She noted that she had two casual friends that she saw weekly but that she was withdrawing more from them. Mental status examination was unremarkable except that her mood appeared to be sad, basically depressed, and anxious and that she was tearful for most of the evaluation which affected her speech. The examiner noted that the Veteran appeared to be exhibiting moderate to considerable symptoms associated with anxiety and depression. The examiner noted that the Veteran described low energy, low motivation, and fatigue with decreased interest and activities, a tendency to isolate, and panic attacks several times a week. The examiner noted that in terms of her ability to maintain employment, perform job duties in a reliable and efficient manner, as well as social adaptability and interactions with others, these appear to be moderately impaired. The findings of record indicate that prior to June 6, 2011, the Veteran's anxiety, MDD, panic disorder with insomnia symptoms match some of the rating criteria for a 30 percent rating (depressed mood, anxiety, chronic sleep impairment) and some of the rating criteria for a 50 percent rating (panic attacks more than once a week; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships). The Board acknowledges that the Veteran does not meet all of the criteria for a 50 percent evaluation. The specified factors for each incremental psychiatric rating are not, however, requirements for a particular rating but are examples providing guidance as to the type and degree of severity, or their effects on social and work situations. Thus, any analysis should not be limited solely to whether the symptoms listed in the rating scheme are exhibited; rather, consideration must be given to factors outside the specific rating criteria in determining the level of occupational and social impairment. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Resolving reasonable doubt in the Veteran's favor, the Board finds that prior to June 6, 2011, the Veteran's anxiety, MDD, panic disorder with insomnia was productive of occupational and social impairment with reduced reliability and productivity. Therefore, the Veteran's symptoms due to anxiety, MDD, panic disorder with insomnia prior to June 6, 2011, exceeded the criteria for the 30 percent rating and more nearly approximate the criteria for the 50 percent rating. However, at no time prior to June 6, 2011, did the Veteran's anxiety, MDD, panic disorder with insomnia symptoms approach the severity contemplated for the 70 or 100 percent ratings. As set forth above, the criteria for a 70 percent rating are met when the Veteran experiences occupational and social impairment with deficiencies in most areas, and the criteria for a 100 percent rating are met when the Veteran experiences total occupational and social impairment, which is clearly not demonstrated in this case. Although the Veteran has consistently reported depression, there is no evidence that it was ever near continuous or that it affected her ability to function independently, appropriately, and effectively. The Veteran has been able to maintain minimal personal hygiene and other basic activities of daily living, she has been oriented to person, place, and time, and she has demonstrated normal speech. There has been no impairment of thought process or communication, suicidal ideation, delusions, hallucinations, inappropriate behavior, obsessive or ritualistic behavior, or panic attacks. Although the Veteran reported irritability, there has been no evidence of any impaired impulse control. Accordingly, a 50 percent evaluation, but no higher, is warranted for the period prior to June 6, 2011. 38 C.F.R. § 4.130, Code 9434. Psychiatric disability has been rated 70 percent disabling since June 6, 2011. The question before the Board is whether the next-highest rating of 100 percent has been approximated since then. At no time during the appeal period has the Veteran's psychiatric symptoms approached the severity contemplated for the 100 percent rating. As set forth above, the criteria for a 100 percent rating are met when the Veteran experiences total occupational and social impairment, which is clearly not demonstrated in this case. There has never been any indication of gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, disorientation as to time or place, or memory loss for names of close relative, own occupation or own name. VA treatment records during the appeal period indicate that there was no impairment in thought process, thought content, or suicidal or homicidal ideations. Rather, the records indicate that the Veteran has fully and competently participated in the medical treatment of her several disorders. In addition, the Veteran's insight and judgment have been at least fair. The Veteran underwent VA examination in October 2012 at which time she reported considerable impairment at work with decreased productivity, frequent errors, and conflict with supervisors due to her irritability. She also reported that she no longer performed activities of daily living routinely. The examiner noted symptoms of neglect of personal appearance and hygiene and intermittent inability to perform activities of daily living. At that time, she reported frequent conflicts with her husband due to her "wanting to be left alone." The examiner found that the Veteran's psychiatric symptoms caused occupational and social impairment with deficiencies in most areas. Although the Veteran reported symptoms of neglect of personal appearance and hygiene and intermittent inability to perform activities of daily living, VA treatment records from 2011 to 2020 show the Veteran's hygiene to be from fair to good. Importantly, the Veteran is still working. The Board notes that the Veteran was on FMLA for a number of years due to needing to leave work early or miss days because of anxiety and depression as well as after childbirth and after foot surgery. In January 2016, the Veteran reported missing days from being up all night. The last outpatient record in the file, dated August 13, 2020, notes that she was working full time. In addition, although she socially isolates, she still had contact with a couple of friends. In August 2015, the Veteran disclosed having social support networks but indicated that she did not actively engage with friends in her community. Veteran briefly discussed positive support offered by her sister. The Board notes that the last VA examination was conducted in October 2012; however, the record contains mental health records since that examination. There is no indication of a material change in the Veteran's service-connected psychiatric disability since the VA examination in October 2012. Thus, the Board finds that the VA examination reports of record are adequate for rating purposes, and there is no need for further examination. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Upon consideration of all of the relevant current evidence of record, the Board finds that the Veteran's anxiety, MDD, panic disorder with insomnia has not been manifested by total occupational and social impairment. In short, the preponderance of the evidence weighs against finding that the severity, frequency, and duration of the Veteran's symptoms resulted in the level of impairment required for a 100 percent rating. The criteria for a 100 percent rating have not been met and the appeal must be denied. 5. Entitlement to a rating in excess of 10 percent for GERD with IBS The Veteran contends that she is entitled to a higher rating for her service-connected gastrointestinal (GI) disability. On a Notice of Disagreement form received in March 2014, the Veteran indicated that she sought a 30 percent rating for her IBS. The Veteran's GERD with IBS has been rated pursuant to 38 C.F.R. § 4.114, Diagnostic Codes 7319-7346. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the evaluation assigned. The additional code is shown after a hyphen. 38 C.F.R. § 4.2. Pursuant to Diagnostic Code 7319, for irritable colon syndrome, a zero percent rating is warranted for mild symptoms described as disturbances of bowel function with occasional episodes of abdominal distress; a 10 percent is warranted for moderate symptoms described as frequent episodes of bowel disturbance with abdominal distress; and the highest rating of 30 percent is warranted for severe symptoms, described as diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. 38 C.F.R. § 4.114, Diagnostic Code 7319. Pursuant to 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. A 60 percent rating is warranted under DC 7346 for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114. Disability ratings assigned under Diagnostic Codes 7301 to 7329 (inclusive), 7331, 7342, and 7345 to 7348 (inclusive) will not be combined with each other. Instead, a single disability rating will be assigned under the diagnostic code which reflects the predominant disability picture with elevation to the next higher rating where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. The Veteran underwent VA examination in September 2010 at which time she reported near-constant nausea; reflux-type symptoms occurring approximately 10 to 20 times per day, worse at night; regurgitation of acid occurring approximately 10 times a day; and a mid-abdominal type pressure pain extending to the mid chest with no specific precipitating or alleviating factors. She denied consistent vomiting, dysphagia; and there was no history of hematemesis, melena, diarrhea, constipation, or peritoneal adhesions. The examiner noted that the Veteran stated that both her work and activities of daily living were affected by her nausea and also her decreased ability to sleep at night secondary to her worsening reflux symptoms at night. The examiner noted that he felt her level of severity was moderate to severe. The Veteran was diagnosed as having GERD. In February 2011, the Veteran was seen to establish care at a private medical facility at which time it was noted that on January 24, 2011, she presented at that facility's urgent care with complaints of epigastric discomfort and nausea after eating without vomiting as well as long-standing history of constipation averaging one to two bowel movements a week along with chronic bloating and abdominal discomfort. The Veteran was started on MiraLax. She presented for follow up in March 2011 with report that MiraLax did not alleviate her symptoms; she was started on Colace and Amitiza. The Veteran underwent VA examination in February 2011 at which time she reported persistent severe nausea, a steady burn in her epigastric region with some pressure, and occasional constipation. The Veteran denied hematemesis, melena, weight gain or loss. The examiner noted that the Veteran reported that there were periods where she felt like the pain was to a point that incapacitated her in that she missed work. The examiner stated that it appeared that the Veteran's abdominal pain had worsened rendering her incapable of completing her work because of the nausea. The Veteran underwent VA examination in November 2012 at which time she was pregnant. She reported nausea and constipation and noted that because of the pregnancy, she was taking on MiraLax. There was no weight loss, malnutrition, serious complications, or other general health effects. The examiner noted that only nausea and constipation were the only signs or symptoms attributable to the Veteran's GI condition. There were no signs or symptoms of diarrhea, alternating diarrhea and constipation, abdominal distension, anemia, or vomiting. The examiner noted that the Veteran did not report episodes of bowel disturbance with abdominal distress or episodes of exacerbations and/or attacks. The Veteran reported that she had missed work because of her GI symptoms. VA treatment records indicate that on July 9, 2015, the Veteran reported a nearly ten-year history of constipation, bloating, and occasional diarrhea with no weight changes. The Veteran underwent VA examination for this disability in July 2015 at which time she reported predominant constipation with frequent abdominal distension, occasional diarrhea, frequent nausea, and occasional vomiting. The examiner noted that the Veteran reported frequent episodes of bowel disturbance with abdominal distress as well as seven or more exacerbations and/or attacks in the prior 12-month period of diarrhea, constipation, bloating, abdominal pain, and nausea. The Veteran also reported a 10-pound weight loss, but there was no malnutrition, serious complications, or other general health effects. In August 2016 and November 2017, the Veteran denied heartburn, abdominal pain, constipation, diarrhea, hematochezia, and hematuria; and in April 2020, she did not report any new onset of diarrhea. The Board finds that a 30 percent rating is warranted from January 24, 2011, when the Veteran was seen at urgent care with complaint of epigastric discomfort and nausea after eating without vomiting and long-standing history of constipation averaging one to two bowel movements a week along with chronic bloating and abdominal discomfort. As noted above, disability ratings assigned under Diagnostic Codes 7319 and 7346 will not be combined with each other; instead, a single disability rating will be assigned under the diagnostic code which reflects the predominant disability picture with elevation to the next higher rating where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. As such, the Board finds that an elevation to 30 percent is warranted from January 24, 2011, as the Veteran's GERD symptoms warranted a higher rating as did her IBS symptoms. Prior to January 24, 2011, however, the Veteran's service-connected GI disability did not meet or approximate the criteria for a 30 percent rating or higher. Prior to January 24, 2011, although the Veteran had some of the symptoms associated with a higher rating of 30 percent under Diagnostic Code 7346, such as persistently recurring epigastric distress with dysphagia and regurgitation, there has never been reports of pyrosis or substernal, arm, or shoulder pain. In addition, there was no complaints of IBS symptoms. The Board also finds that from July 9, 2015, a 60 percent rating is warranted. At that time, the Veteran reported constipation, bloating, and occasional diarrhea. At the VA examination conducted that same month, the Veteran reported frequent nausea and occasional vomiting. The Board notes that there have been fluctuations in the Veteran's reports of abdominal distress over the years; however, and nausea was noted to be nearly constant in September 2010 and persistently severe in February 2011. As such, the Board finds that an elevation to 60 percent is warranted from July 9, 2015 the Veteran's GERD and IBS symptoms militate in favor of assigning the higher rating. Accordingly, the Board finds that the Veteran's GERD with IBS warrants a 30 percent rating, but no higher, from January 24, 2011, and a 60 percent rating since July 9, 2015. REASONS FOR REMAND 1. Entitlement to a compensable rating for striae distensae of the right lower extremity from steroid therapy 2. Entitlement to a compensable rating for striae distensae of the left lower extremity from steroid therapy The Veteran contends that she is entitled to a higher rating for her service-connected striae distensae, also known as stretchmarks, of the lower extremities noted to be from the hip to the knee on bilateral inner thighs as well as on her calves. The Veteran underwent VA examination in November 2012 at which time the examiner noted that one scar on the trunk or extremities was painful and that the Veteran stated that they hurt sometimes but not always. The Veteran's stretchmarks on both legs were superficial and non-linear and measured 10 centimeters by 20 centimeters. The Board notes that the VA examiner did not identify which scar was painful. In addition, the Veteran stated on her Notice of Disagreement received in December 2013 that the VA examiner did not properly examine her scars, that the examiner did not actually look at her scars or take any measurements. The Veteran also stated that she has scars on other parts of her body which were not considered. The Veteran also said that she had several scars that were deeper and hurt all the time and some that were not as deep and that hurt on occasion. She stated that she also has one area of scars that will on occasion split some and blood can be seen under the skin. As such, an additional examination should be performed to assess the current severity of the Veteran's striae distensae of the lower extremities. With respect to scars identified by the Veteran on other parts of her body, if she desires consideration for service connection for these scars, she should file a claim for them. 3. Entitlement to service connection for cervical myofascial pain syndrome The Veteran seeks service connection for a cervical spine disability. Service treatment records indicate that the Veteran presented with being lightheaded/dizzy/vertigo, nausea, and stiff/sore neck; the Veteran reported "starts low back [goes up] through neck. In August 2005, the Veteran underwent MRI of the cervical spine after complaints of burning left upper arm and pain/numbness with upper back pain over the prior year. Findings included (1) minimal early disc desiccation at C3-4 and C4-5 without any disc bulging or focal protraction; (2) no evidence of any cervical disc abnormality otherwise. There was no focal cervical disc herniation or significant central canal or foraminal stenosis; and (3) mild straightening of the normal upper cervical lordosis. The Veteran underwent VA examination in November 2013 at which time the Veteran denied any specific injury and that she just began having pain in her cervical spine over time. The Veteran stated that when the pain got bad, it radiated down to her shoulder and sometimes to her hands. Physical examination demonstrated limitation of all cervical spine motion. After physical examination, the examiner noted that the Veteran had never been diagnosed with a cervical spine condition. The examiner stated, I see no evidence of a current cervical condition. Her MRI findings are incidental and do not typically cause pain. There is also no evidence that she would have a radiculopathy or neuropathy from this. The Veteran underwent VA examination in May 2015 at which time she reported onset of neck pain in 2004/2005 after she was hit with a water balloon in her neck during physical training. The Veteran reported daily neck pain, occasional numbness at the dorsal aspect of the left hand (middle, ring, and little finger) as well as similar symptoms around her shoulder blades. She denies right upper extremity symptoms. Physical examination demonstrated limitation of all cervical spine motion. The examiner opined that the Veteran's current cervical spine symptoms were less likely than not due to or aggravated beyond their normal progression by her chronic lower back disability. The examiner noted that the Veteran's cervical pain was myofascial in nature and not exacerbated by her lumbar strain diagnosis. The Veteran was diagnosed as having cervical myofascial syndrome. VA sought an additional opinion as to whether the cervical myofascial pain syndrome was related to the neck pain noted during active service. In a June 2015 Addendum opinion, the examiner opined that the Veteran's cervical myofascial pain syndrome condition was less likely as not caused by service factors/neck pain noted in service since there is no specific "STR cervical myofascial pain syndrome DIAGNOSIS NOR STR RECORDS TO SUPPORT SUCH A CHRONIC MEDICAL DISABILITY." The examiner also opined that the Veteran's claimed cervical myofascial pain syndrome condition was less likely as not aggravated beyond its natural progression by service factors/neck pain noted in service since there is no specific "STR cervical myofascial pain syndrome DIAGNOSIS NOR STR RECORDS TO SUPPORT SUCH A CHRONIC MEDICAL DISABILITY." The Board finds the November 2013 and June 2015 opinions inadequate for adjudication purposes. The November 2013 examiner found no evidence of a current cervical condition; however, a condition which manifests in symptoms that cause functional impairment is considered a "disability." The examiner noted that the Veteran did not have any functional loss and/or functional impairment of the cervical spine, yet there was clearly limitation of motion of the cervical spine on examination. In addition, the June 2015 VA examiner stated, "less likely as not" and "50 percent or greater probability" with respect to the etiology of the Veteran's cervical spine disorder; these statements are inconsistent. As such, an additional examination should be performed to address the nature and etiology of the Veteran's current cervical spine disability. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician, preferably a dermatologist, to determine the current severity of her service-connected striae distensae of the lower extremities. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. 2. Schedule the Veteran for a VA examination by an appropriate clinician, preferably an orthopedist, to address the nature and etiology of the Veteran's cervical spine complaints. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: Is the cervical spine disability at least as likely as not (probability of 50 percent or more) related to service, including symptoms documented during such service? Provide a rationale to support the opinion(s). In providing the requested opinion, consider the Veteran's description of her in-service injury and symptoms as well as her post-service symptoms. Moreover, discuss the significance of the August 2005 MRI findings indicating minimal early disc desiccation at C3-4 and C4-5 and indicating mild lordosis. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of her current disability, this should be noted. Stated another way, do the Veteran's reports about her symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? C. J. McEntee Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Olson, Patricia 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.