Citation Nr: 21041147 Decision Date: 07/08/21 Archive Date: 07/08/21 DOCKET NO. 16-33 369 DATE: July 8, 2021 ORDER Entitlement to service connection for rheumatoid arthritis (RA) is denied. Entitlement to service connection for hiatal hernia is denied. Entitlement to a rating in excess of 10 percent for right foot plantar warts is denied. Entitlement to a separate 10 percent rating for left foot plantar warts is granted, subject to the controlling regulations applicable to the payment of monetary benefits. Prior to September 17, 2015, entitlement to an initial rating in excess of 10 percent for gastroesophageal reflux disease (GERD) and irritable bowel syndrome (IBS) is denied. Effective September 17, 2015, entitlement to a rating in excess of 30 percent for GERD and IBS is denied. FINDINGS OF FACT 1. The Veteran's RA was not manifested in service or during the first post-service year and the evidence shows it is not related to service. 2. The Veteran's hiatal hernia manifested many years after service and is not related to service. 3. Throughout the appeal period, the Veteran has had plantar warts on each foot that have been manifested by pain; he has no more than two warts on each foot, they cover an area less than 5 percent of the entire body and no part of an exposed area, did not require more than topical therapy during the past 12-month period, and did not involve disfigurement. 4. Prior to September 17, 2015, the Veteran's GERD was the predominant digestive disability; his IBS was mild and manifested by intermittent diarrhea and constipation without evidence of occasional abdominal distress; the overall disability picture was not productive of symptoms accompanied by substernal or arm or shoulder pain productive of considerable impairment of health. 5. Effective September 17, 2015, the Veteran's IBS was the predominant gastrointestinal disability and was severe with alternating diarrhea and constipation, weight loss, and more or less constant abdominal distress. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for RA have not been met. 38 U.S.C. § 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for entitlement to service connection for hiatal hernia have not been met. 38 U.S.C. § 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for entitlement to a rating in excess of 10 percent for right foot plantar warts have not been met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes 5284; 4.118, Diagnostic Code 7820. 4. The criteria for entitlement to a separate 10 percent rating left foot plantar warts have been met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes 5284; 4.118, Diagnostic Code 7820. 5. Prior to September 17, 2015, the criteria for entitlement to an initial rating in excess of 10 percent for GERD and IBS have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.114, Diagnostic Code 7319. 6. Effective September 17, 2015, the criteria for entitlement to a rating in excess of 30 percent for GERD and IBS have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.114, Diagnostic Code 7319. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1982 to June 2007. This appeal to the Board of Veterans' Appeals (Board) is from August 2014, December 2014, and June 2015 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). In a November 2018 decision, the Board decided some of the issues on appeal and remanded the rest. Regarding the remanded issues, a September 2020 rating decision granted service connection for erectile dysfunction, headaches, restless leg syndrome, and fibromyalgia, so those matters are no longer on appeal. An October 2020 rating decision granted service connection for GERD and combined it with the Veteran's service-connected IBS; the rating for the latter is on appeal. That decision also granted a staged rating for GERD and IBS. Service Connection Generally, to establish service connection, there must be lay or medical evidence of (1) a current disability, (2) incurrence or aggravation of a disease or injury in service, and (3) a nexus between the in-service injury or disease and the current disability. See 38 U.S.C. §§ 1110, 1131; Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); 38 C.F.R. § 3.303. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To deny a claim for benefits on its merits, the preponderance of the evidence must be against the claim. See Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). 1. Entitlement to service connection for rheumatoid arthritis (RA). The Veteran's service treatment records show he had left knee, low back, and left ankle complaints. In January 1983, he had left ankle and knee complaints after a fall during basic training. The assessment was early MTP stress reaction. He eventually had left knee surgery and was given a physical profile in June 1985, but subsequent records continued to note knee complaints. In October 1988, he complained of low back pain and cold symptoms. A February 1990 record also notes low back pain complaints with other symptoms and he was diagnosed with an upper respiratory infection. In November 1992, he complained of right foot/toe pain after walking into a child's toy. See July 2007 STR Medical. Service treatment records also include a December 2006 post-deployment health assessment that shows the Veteran gave a negative response for having swollen, stiff, or painful joints during his deployment and currently. His January 2007 retirement examination does not contain any indications of rheumatoid arthritis, and his spine and musculoskeletal system were normal. The retirement medical history report shows he gave negative responses to having had swollen or painful joints or rheumatism. Lab work that month and in March 2007 also contain no evidence of rheumatoid arthritis. See July 2007 and June 2009 STR Medical. In October 2011, the Veteran indicated that his post-deployment concerns included swollen, stiff, and painful joints. See January 2014 Correspondence. An October 2014 VA treatment record shows the Veteran was seen by a non-VA clinician in September 2014 and that the physician had recommended a rheumatology consult. The November 2014 rheumatology consultation included a complete joints examination that revealed decreased flexion in his elbows with some synovitis; there was bilateral wrist tenderness and trace swelling. His lab work revealed a RF (rheumatoid factor) of 537. The assessment was seropositive rheumatoid arthritis. The physician noted there was elbow and wrist involvement but not small joint involvement of the hands, which could be consistent with RA. A September 2015 record notes that RA was discovered incidentally while being worked-up for fibromyalgia. The Veteran never had synovitis on examination, so the physician was unsure if seropositivity was related to any real disease. See December 2015 CAPRI records. Although a December 2015 VA examiner was asked to opine on whether the Veteran's arthritis due to trauma was secondary to left knee surgery, the physician offered comments regarding the Veteran's RA in the discussion of the Veteran's left knee. He noted that RA is a chronic, systemic, inflammatory disorder of unknown etiology that primarily involves synovial joints. The arthritis is typically symmetrical, and usually leads, if uncontrolled, to destruction of joints due to erosion of cartilage and bone, causing joint deformities. The disease onset in RA is usually insidious, with the predominant symptoms being pain, and stiffness (especially morning stiffness). Synovial joints of the upper and lower limbs, such as the elbows, shoulders, ankles, and knees, are also commonly affected. Persistent single joint arthritis (monoarthritis), frequently of a large joint such as the wrist, knee, shoulder, hip, or ankle, may be the sole manifestation of RA or may herald the onset of polyarticular disease. There may be a history of joint trauma as an apparent initiating event. The physician noted that in the present case the diagnosis of rheumatoid arthritis was made approximately 30 years from his initial injury s/p arthroscopic surgery. See January 2016 C&P Exam. A September 2020 VA treatment record shows the Veteran's RA was in his elbows, hands, and knees. The VA physician opined that the Veteran's RA less likely than not had its onset during service, manifested in the first post-service year, or is otherwise related to service to include complaints of joint pain. The Veteran's joint pains while in service have specific etiologies unrelated to the claimed RA. The Veteran was diagnosed with having RA in November 2014 based on positive RF and CCP findings. A May 1995 record noted that the Veteran had a 10 year history of left knee pain and pseudo locking while in service. The Veteran also underwent surgery on the hand in November 1989. In February 2018, the Veteran's VA records show bilateral contracture of the elbows related to RA. His RA did not have its onset during service. See September 2020 C&P Exam. In light of the opinion and other pertinent evidence, the record tends to show that the Veteran's RA is not related to service. Although the Veteran had some joint-related complaints in service, the VA examiner attributed them to other causes and found they were not affiliated with RA. The RA diagnosis was made in November 2014, seven years after he separated from service. Since the November 2014 record indicates the Veteran was referred to rheumatology due to his polyarthralgia, the record suggests his RA was not suspected up until that point. Thus, the evidence weighs against an onset during service or the first post-service year and service connection on a presumptive basis as a chronic disease is not available. The unfavorable nexus evidence is also probative evidence that weighs against the claim. No favorable evidence was submitted or obtained to suggest the Veteran's RA is in any way related to service. As a preponderance of the evidence is against the claim, service connection for RA is denied. 2. Entitlement to service connection for hiatal hernia. The Veteran's service treatment records are silent for any complaints, findings, or diagnosis of hiatal hernia. His January 2007 retirement examination and medical history report contain no evidence related to hiatal hernia. See 2007 STR Medical. The earliest evidence of hiatal hernia is a July 2014 esophagram that revealed the presence of a small hiatal hernia. See December 2015 CAPRI records. The Board obtained an opinion in September 2020 to determine whether the Veteran's hiatal hernia is related to service and the clinician offered an inconsistent opinion; however, when read in its entirety the Board finds the clinician's intent reasonable to construe. The clinician's initial opinion reads as follows, "The Gastroesophageal reflux disease/hiatal hernia at least as likely as not 50 percent or greater probability had its onset during service." The rationale, however, went on to only address the Veteran's GERD. The clinician then offered what appears to be clarification of the prior opinion and states "Gastrointestinal reflux disease is at least as likely as not 50 percent or greater probability had its onset during service. However, hiatal hernia less likely than not had its onset during service." The clinician added that there is no diagnostic evidence of a hiatal hernia until 2014, which was seven years after service. See September 2020 C&P Exam. Thus, while the first opinion combined the two disorders, the clinician then separated them and provided an opinion for each. The Board finds the opinion to be probative and consistent with the record. The Veteran has not reported an onset during service or shortly thereafter and as there is no evidence of the disorder until seven years after service, the evidence weighs against the claim. As there is no evidence of hiatal hernia in service or linking it to service, a preponderance of the evidence is against the claim. Increased Rating A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule). See generally 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can practicably be determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. 38 C.F.R. § 4.27. VA has a duty to acknowledge and to consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. See Schafrath v. Derwinski, 1 Vet. App. 589, 592-93 (1991). The Board will consider whether separate ratings may be assigned for separate periods of time based on the facts found, a practice known as "staged ratings," regardless of whether a case involves an initial rating. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126-27 (1999). The words "mild," "moderate," "moderately severe," and "severe" as used in the various Diagnostic Codes are not defined in the VA Schedule for Rating Disabilities. 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. Where there is a question as to which of two ratings to apply, VA will assign the higher rating if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. Otherwise, it will assign the lower rating. Id. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. 3.-4. Entitlement to a rating in excess of 10 percent rating for bilateral plantar warts. Service connection for bilateral plantar warts was established in an August 2007 rating decision and a noncompensable rating was assigned. The RO received his claim for an increased rating in February 2013 and an October 2020 rating decision increased the rating to 10 percent, effective the date the claim was received. In Scott v. Wilkie, the Federal Circuit expressly adopted the Court's holding that disabilities specifically listed in the rating schedule may only be rated under Diagnostic Codes which specifically pertain to them. Scott v. Wilkie, 920 F.3d 1375 (Fed. Cir. 2019) (citing Copeland v. McDonald, 27 Vet. App. 333, 336 (2015)). The Federal Circuit also expressly adopted the Court's holding that unlisted conditions may be rated by analogy to Diagnostic Codes that may not describe the unlisted disability but addresses disabilities that may be productive of similar symptoms. Scott, 920 F.3d 1375 (citing Yancy v. McDonald, 27 Vet. App. 484, 493 (2016)). Here, the disability is rated by analogy under Diagnostic Codes 5284-7820. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. Typically, the additional diagnostic code that is the basis for the rating is shown after the hyphen; however, in the present case the October 2020 rating decision has the first diagnostic code listed before the hyphen, Diagnostic Code 5284, as the basis for the rating. Under Diagnostic Code 5284, moderate residuals of other foot injuries warrant a 10 percent rating. A 20 percent rating requires moderately severe residuals. A 30 percent rating requires severe residuals. 38 C.F.R. § 4.71a, Diagnostic Code 5284. A note to Diagnostic Code 5284 provides that a 40 percent disability evaluation will be assigned for actual loss of use of the foot. See 38 C.F.R. § 4.71a. Diagnostic Code 7820 relates to infections of the skin not listed elsewhere and provides that the disability should be rated as disfigurement of the head, face, or neck (Diagnostic Code 7800), scars (Diagnostic Codes 7801-7805), or dermatitis (Diagnostic Code 7806) depending on the predominant disability. See 38 C.F.R. § 4.118. During the appeal, the rating criteria related to skin disabilities have undergone a revision, effective August 13, 2018. See 38 Fed. Reg. 32,592 (July 13, 2018). Prior to August 13, 2018, the Board will consider the former version of the diagnostic codes only, but for the period beginning August 13, 2018 the Board will consider both the former and amended version of the diagnostic code and rate based on whichever is most favorable to the Veteran. Prior to August 13, 2018, Diagnostic Code 7806 provided a 10 percent rating when the skin disability covered at least 5 percent, but less than 20 percent of the entire body, or at least 5 percent, but less than 20 percent of exposed areas affected, or; when intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs was required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating was warranted if the skin condition covered 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; when systemic therapy such as corticosteroids or other immunosuppressive drugs was required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent evaluation was assigned if the skin condition covered more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. 38 C.F.R. § 4.118, Diagnostic Code 7806. The amendment that became effective August 13, 2018, in pertinent part, added a "General Rating Formula for the Skin" for Diagnostic Codes 7806, 7809, 7813-7816, 7820-7822, and 7824, and amended Diagnostic Codes 7801, 7802, 7817, 7819, 7825, 7826, 7827, 7829. See 83 Fed. Reg. 32,592 (July 13, 2018). Under the new General Rating Formula for the Skin, a noncompensable rating is assigned when no more than topical therapy is required over the past 12-month period and at least one of the following: characteristic lesions involving less than 5 percent of the entire body affected; or characteristic lesions involving less than 5 percent of exposed areas affected. 38 C.F.R. § 4.118, Diagnostic Code 7806 (2018). A 10 percent rating will be assigned if the disability meets one of the following: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. Id. A 30 percent rating will be assigned if the disability meets one of the following: characteristic lesions involving 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. Id. A 60 percent rating will be assigned if the disability meets one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required over the past 12-month period. Id. Also, under the new General Rating Formula for the Skin, the rating criteria notes that for the purposes of that section, systemic therapy is treatment that is administered through any route (orally, injection, suppository, intranasally) other than the skin, and topical therapy is treatment that is administered through the skin. The Federal Circuit Court has held that within the purview of Diagnostic Code 7806 in effect prior to August 13, 2018, systemic therapy meant "treatment pertaining to or affecting the body as a whole," whereas topical therapy meant treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it was applied, and that nothing in Diagnostic Code 7806 displaced the accepted understanding of systemic therapy and topical therapy to permit a topical therapy that affected "only the area to which it [was] applied" to count as a systemic therapy under that code. Prior to August 13, 2018, the use of a topical corticosteroids could be considered either systemic therapy or topical therapy based on the factual circumstances of each case. The use of topical corticosteroids did not automatically mean systemic therapy because Diagnostic Code 7806 distinguished between systemic and topical therapy. Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017) (The use of "such as" in Diagnostic Code 7806 does not mean that all forms of treatment with "cortico-steroids and other immunosuppressive drugs," no matter how narrowly localized in their impact, count as "systemic therapy."). Alternatively, the General Rating Formula states to rate the disability as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7804, or 7805), depending upon the predominant disability. This rating instruction does not apply to Diagnostic Code 7824. The 2018 revisions did not substantively change the Codes applicable to rating the Veteran's warts by analogy under the criteria for scars. Pursuant to Diagnostic Code 7804, a rating of 10 percent is warranted for one or two scars that are unstable or painful, and a 20 percent evaluation is warranted for three or four scars that are unstable or painful. A 30 percent evaluation is warranted for five or six scars that are unstable or painful. 38 C.F.R. § 4.118. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. 38 C.F.R. § 4.118, Diagnostic Code 7804, Note (1). Note (2) states that if one or more scars are both unstable and painful, 10 percent is added to the evaluation that is based on the total number of unstable or painful scars. The Veteran had a VA examination in April 2014 that showed he had no complaints since his last VA examination, which was in 2010. There were no systemic manifestations due to any skin disease and he was not treated with oral or topical medications during the past 12 months. An examination of the feet did not reveal any lesions and the examiner indicated that the disability did not cause any functional impairment. See June 2014 VA Examination. On September 2020 VA examination, the Veteran's current symptoms for plantar warts were pain and difficulty walking. His current treatment was to shave them, and they were most recently shaved in August 2020. If the Veteran did not shave his warts, then he had difficulty walking. On examination, the clinician found two warts on each foot and noted that they covered less than 5 percent of his total body. See September 2020 C&P Exam. On October 2020 VA examination, the Veteran reported having sharp pain on the bottom of his feet that was worse with movement and weight bearing. The functional impairment the warts produced was difficulty walking for long periods due to pain. His symptoms were moderate in severity for both feet and they did not chronically compromise weight bearing or require arch support or any custom orthotic or shoe modification. Pain was noted on examination and contributed to functional loss, bilaterally. There was pain with movement and weight bearing, resulting in a limp during walking. He had decreased walking and running distances due to pain, bilaterally. There was no pain with non-weight bearing, bilaterally. He had pain with active and passive dorsiflexion, bilaterally. See October 2020 C&P Exam. Due to the small area affected, it is not advantageous to the Veteran to rate the plantar warts as a skin disability under Diagnostic Code 7806 or under the current General Rating Formula For The Skin, since it would result in a noncompensable rating. The RO assigned a 10 percent rating based on the criteria for other foot injuries under Diagnostic Code 5284. However, since the Veteran had painful plantar warts on both feet, a 10 percent rating is assignable for each lower extremity. Thus, the Board finds that the current 10 percent rating may be applied to the right foot and a separated 10 percent rating is granted for the plantar warts on the left foot. Ratings greater than 10 percent for each foot is not assignable since moderately severe disability is not shown. In this regard, the evidence shows that it impacts him mostly with prolonged walking and limits the distance he can walk or run. Limitations such as these are more indicative of moderate rather than moderately severe impairment as the Veteran appears to function well under normal circumstances. In short, a separate 10 percent rating is assigned for the right lower extremity plantar warts and a preponderance of the evidence is against a rating in excess of 10 percent for either foot. The disability could have also been rating alternatively by analogy under the criteria for scars but since the Veteran is shown to have a total of four warts that cause pain their rating would be no higher than what he is being compensated for under Diagnostic Code 5284. 5.-6. Entitlement to an initial rating in excess of 10 percent for GERD and IBS prior to September 17, 2015 and in excess of 30 percent thereafter. A May 2015 rating decision granted service connection for IBS and assigned a zero percent rating, effective February 10, 2015; the Veteran appealed the initial rating. The Board notes that an October 2020 rating decision granted service connection for GERD and assigned a 10 percent rating, effective February 16, 2013. That rating decision also increased the rating for IBS to 30 percent, effective September 17, 2015. Thus, the Veteran has two service-connected disabilities that are part of the digestive system. Regulation 38 C.F.R. § 4.113 states that 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, as indicated in the instruction under the title ''Diseases of the Digestive System,'' do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in § 4.14. 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. In the present case, the RO found that the Veteran's GERD was the more predominant of the two disabilities prior to September 17, 2015 as it was 10 percent disabling and IBS already had a zero percent rating in effect. Beginning September 17, 2015, the RO found that the Veteran's IBS increased in severity and, therefore, became the more predominant disability; the 30 percent rating was based on Veteran's IBS disability. The Board notes for clarification that the predominant disability is the one that is more disabling. Although the initial rating for GERD is not on appeal it is in a sense part and parcel to the rating of IBS. In this regard, the Board cannot discuss when and if the IBS disability is the predominant disability without discussion of the Veteran's GERD symptoms as well. In Urban, the Court stated in reference to 38 C.F.R. § 4.114 that "the phrase "with elevation to the next higher evaluation" is reasonably interpreted as referring to the next higher evaluation level of the predominant disability DC" and noted that signs and symptoms of either or both coexisting disabilities must be considered. See Urban v. Shulkin, 29 Vet. App. 82, 88 (2017). In other words, all symptoms attributed to the coexisting condition being rated will be considered in assigning the rating, but the criteria under the applicable, predominant disability's diagnostic code will determine the appropriate rating to be assigned. Since IBS was noncompensable prior to September 17, 2015, GERD is obviously the predominant disability during this period as the RO found it to be 10 percent disabling. The Veteran's IBS is rated analogously to irritable colon syndrome under Diagnostic Code 7319, which provides a maximum 30 percent rating for severe; diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. A 10 percent rating is assigned for moderate; frequent episodes of bowel disturbance with abdominal distress. A 0 percent rating is assigned for mild; disturbances of bowel function with occasional episodes of abdominal distress. See 38 C.F.R. § 4.114, Diagnostic Code 7319. The Veteran's GERD is rated analogously to hiatal hernia pursuant to Diagnostic Code 7346. Under this criteria, a 60 percent rating assigned 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; a 30 percent rating 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; and 10 percent is assigned with two or more of the symptoms for the 30 percent evaluation of less severity. See 38 C.F.R. § 4.114, Diagnostic Code 7346. Generally, a higher rating may be assigned if the predominant disability is severe enough to warrant it. There is no evidence prior to September 17, 2017 to suggest that the Veteran's GERD met or approximated the criteria for a 30 percent rating or greater. Even though the December 2014 VA examination shows he had multiple symptoms associated with GERD, it did not indicate he had substernal or arm or shoulder pain and that the disability was productive of considerable impairment of health. See April 2014 CAPRI records. Two ways to assign a higher rating prior to September 17, 2015 are if the Veteran's IBS is the predominant disability by warranting a rating in excess of 10 percent under Diagnostic Code 7319, or when the overall disability for both IBS and GERD warrants elevating the predominant disability (GERD) to the next higher level. See 38 C.F.R. § 4.114. The higher rating achieved by either method would result in a 30 percent rating. After reviewing the evidence, the Board finds that a higher rating is not assignable prior to September 17, 2015. On April 2015 VA examination, the Veteran reported having intermittent diarrhea and intermittent constipation, alternating with few normal bowel movements. He also had nausea three to four times a week and vomiting twice a week. The examiner indicated the Veteran did not have episodes of bowel disturbance with abdominal distress or exacerbations or attacks. The Veteran also did not have weight loss, malnutrition, serious complications, or other general health effects attributable to his intestinal disability. See April 2015 C&P Exam. While the Veteran experienced alternating diarrhea and constipation, which is contemplated in a 30 percent rating, these symptoms were reported as intermittent, so the disability does not rise to the level of severe. Furthermore, nether the medical nor lay evidence shows that he experienced anything close to constant abdominal distress. The term "abdominal distress" is not defined, but the VA examiner found that the Veteran did not have bowel disturbance with abdominal distress. The examiner is a medical professional who is competent to make this determination, so it is highly probative. Consequently, the Veteran's IBS does not meet or approximate the criteria for a 30 percent rating under Diagnostic Code 7319. Therefore, due to the intermittent nature of his symptoms and the absence of bowel disturbance with abdominal distress, the disability during this period is no worse than mild. Looking at the evidence in light of 38 C.F.R. § 4.114, the symptoms associated with the IBS are not sufficient to assign the next higher evaluation under the criteria used to rate the Veteran's GERD. Even when the symptoms reported on the April 2015 VA examination are considered alongside the Veteran's GERD symptoms that were reported on the December 2014 VA examination, the overall disability picture is not consistent with the criteria for a 30 percent rating under Diagnostic Code 7346. Most notably, there is no evidence that with the additional symptoms of diarrhea, constipation, vomiting, and nausea that the Veteran had substernal arm or shoulder pain or that the disability was productive of considerable impairment of health. The April 2015 VA examination shows the Veteran did not have weight loss, malnutrition, serious complications, or other general health effects attributed to his disability. On September 17, 2015, a treatment record shows the Veteran reported having alternating diarrhea and occasional constipation with frequent abdominal cramping. See December 2015 CAPRI records. In April and November 2016, the Veteran denied having abdominal pain and irregular bowel movements. There are also multiple occasions from March 2017 to September 2019 when the Veteran denied having diarrhea and constipation. See July 2019 and September 2019 CAPRI records. In November 2019, he complained of loose stools alternating with constipation and abdominal discomfort. See May 2020 CAPRI records. On September 2020 VA examination, his current symptoms consisted of stomach cramps, diarrhea, and constipation. He had alternating diarrhea and constipation, and he was on continuous medication. He also had bowel disturbance with more or less constant abdominal distress. Exacerbations were manifested by abdominal cramping and pain that was relieved with bowel movements. He had seven exacerbations during the past 12 months. The Veteran had related weight loss; his baseline weight was 145 pound and his current weight was 134 pounds. There was no malnutrition, serious complications, or other general health effects. See September 2020 C&P Exam. The September 2020 VA examination findings are consistent with the 30 percent rating that has been in effect since September 17, 2015. As discussed previously, there is no evidence prior to that effective date indicating a 30 percent rating was assignable and the current 30 percent rating in the maximum schedular rating allowed under Diagnostic Code 7319. A higher schedular rating may only be assigned during this period if GERD was the predominant disability since Diagnostic Code 7346 has a higher rating of 60 percent. However, when considering the GERD symptoms along or the overall disability picture of both disabilities combined, the evidence does not support such finding. VA treatment records from September 2015 to May 2020 do not contain evidence that the digestive disabilities produced material weight loss and hematemesis or melena with moderate anemia, or other symptom combinations that are productive of severe impairment of health. A September 2019 record shows he denied having blood in his stools. See September 2019 CAPRI records. A December 2017 records shows he had no anorexia, heartburn, constipation, nausea, diarrhea, rectal bleeding, melena, or vomiting. See July 2019 CAPRI records. Since the Veteran's IBS is rated by analogy, the Board considered whether it could be assigned a higher rating under a different diagnostic code. Looking at the other digestive system diagnostic codes that could potentially afford the Veteran a disability rating in excess of 30 percent, the Board finds that none are applicable in this particular case. The evidence of record does not reflect that the Veteran has loss of whole or part of the tongue, stricture of the esophagus, marginal (gastrojejunal) ulcer, cirrhosis of the liver, ulcerative colitis, fistula of the intestine, tuberculous peritonitis, an anal or rectal disability, hemorrhoids, pruritus ani, inguinal, ventral, or femoral hernia, malignant neoplasms of the digestive system, chronic liver disease, pancreatitis, vagotomy, liver transplant, or hepatitis C; therefore, Diagnostic Codes 7202, 7203, 7306, 7312, 7323, 7330 to 7340, 7343, 7345, 7347, 7353, and 7354 do not apply. (Continued on the next page) Here, there is no greater rating under Diagnostic Code 7319 or evidence that the Veteran's GERD was predominant to permit consideration of the criteria for a 60 percent rating under Diagnostic Code 7346. Thus, a preponderance of the evidence is against a rating greater than 10 percent prior to September 17, 2015 and greater than 30 percent for GERD and IBS beginning September 17, 2015. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Bredehorst 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.