Citation Nr: 23006291 Decision Date: 02/01/23 Archive Date: 02/01/23 DOCKET NO. 18-23 290 DATE: February 1, 2023 ORDER Entitlement to a 60 percent rating for duodenal ulcer, duodenitis, gastritis, and gastroesophageal reflux disease (GERD) is granted, from July 8, 2022, to November 8, 2022. Entitlement to a 30 percent rating, but not higher, for duodenal ulcer, duodenitis, gastritis, and GERD is granted, from June 23, 2020, to July 7, 2022. Entitlement to a rating in excess of 10 percent for duodenal ulcer, duodenitis, gastritis, and GERD is denied, prior to June 23, 2020. FINDINGS OF FACT 1. From July 8, 2022, to November 8, 2022, the Veteran's gastrointestinal disabilities, specifically the GERD, were manifested by a burning sensation in his stomach almost every day, regurgitation two to three times a week, vomiting "once in a blue moon," a swallowing/sticking sensation every couple of weeks, and occasional chest pain. 2. From June 23, 2020, to July 7, 2022, the Veteran's gastrointestinal disabilities were manifested by persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain. 3. Prior to June 23, 2020, the Veteran's gastrointestinal disabilities were not manifested by moderate duodenal ulcer with recurring episodes of severe symptoms two or three times a year averaging 10 days in duration, or with continuous moderate manifestations; chronic gastritis with multiple small eroded or ulcerated areas, and symptoms; or 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. From July 8, 2022, to November 8, 2022, the criteria for a 60 percent rating for duodenal ulcer, duodenitis gastritis, and GERD are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.7, 4.114. 2. From June 23, 2020, to July 7, 2022, the criteria for a 30 percent rating, but not higher, for duodenal ulcer, duodenitis gastritis, and GERD are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.7, 4.114. 3. Prior to June 23, 2020, the criteria for a rating in excess of 10 percent for duodenal ulcer, duodenitis gastritis, and GERD are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.7, 4.114. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1999 to December 2002. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2016 rating decision by a Department of Veteran Affairs (VA) Regional Office (RO) that denied entitlement to a disability rating in excess of 10 percent for the Veteran's service-connected duodenal ulcer, duodenitis and gastritis. In March 2022, the Board granted entitlement to service connection for gastroesophageal reflux disease (GERD) and remanded the claim for an increased rating for duodenal ulcer, duodenitis and gastritis for additional development. Thereafter, the RO implemented the Board's award of service connection for GERD, effective January 26, 2016, and recharacterized the Veteran's service-connected gastrointestinal disorder as duodenal ulcer, duodenitis gastritis, and GERD. In a November 2022 rating decision, the RO assigned an increased 60 percent rating for this condition, effective November 9, 2022. In a November 2022 statement, the Veteran stated that he agreed with the assignment of the 60 percent rating assigned for his service-connected duodenal ulcer, duodenitis gastritis, and GERD. Accordingly, the scope of the appeal is limited to the issue of entitlement to a disability rating in excess of 10 percent prior to November 9, 2022. See Ab v. Brown, 6 Vet. App. 35, 39 (1993). Further, in his November 2022 statement the Veteran indicated that he disagreed with the effective date of November 9, 2022, that was assigned for the 60 percent rating and that the effective date should be "at the start of my claim." While the Veteran phrased the issue as an effective date claim, the Board finds that it more properly characterized as a staged rating. See Fenderson v. West, 12 Vet. App. 119, 126 (2001). 1. Entitlement to a 60 percent rating for duodenal ulcer, duodenitis, gastritis, and gastroesophageal reflux disease (GERD) is granted, from July 8, 2022, to November 8, 2022. 2. Entitlement to a 30 percent rating, but not higher, for duodenal ulcer, duodenitis, gastritis, and GERD is granted, from June 23, 2020, to July 7, 2022. 3. Entitlement to a rating in excess of 10 percent for duodenal ulcer, duodenitis, gastritis, and GERD is denied, prior to June 23, 2020. Disability ratings are determined by applying the criteria set forth in 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. Part IV. 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. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. 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. See 38 C.F.R. § 4.114. The Veteran's gastrointestinal conditions are rated by analogy to 38 C.F.R. § 4.114, Diagnostic Codes (DC) 7305 for duodenal ulcer; 7307 for gastritis; and 7346 for hiatal hernia. Pursuant to DC 7305, a 10 percent evaluation is warranted for mild duodenal ulcer, defined as with recurring symptoms once or twice yearly; a 20 percent evaluation is warranted for moderate duodenal ulcer, defined as with recurring episodes of severe symptoms two or three times a year averaging 10 days in duration, or with continuous moderate manifestations; a 40 percent evaluation is warranted for moderately severe duodenal ulcer, defined as with less than severe but with impairment of health manifested by anemia and weight loss, or recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year; and the maximum 60 percent evaluation is warranted for severe duodenal ulcer, defined as with pain only partially relieved by standard ulcer therapy, periodic vomiting, recurrent hematemesis or melena, with manifestations of anemia and weight loss productive of definite impairment of health. Pursuant to DC 7307, a 10 percent evaluation is warranted for chronic gastritis with small nodular lesions, and symptoms; a 30 percent evaluation is warranted for chronic gastritis with multiple small eroded or ulcerated areas, and symptoms; and the maximum 60 percent evaluation is warranted for chronic gastritis with severe hemorrhages, or large ulcerated or eroded areas. Pursuant to DC 7346, a 10 percent evaluation 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 recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health; and the maximum 60 percent evaluation is warranted for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. For the purpose of determining what encompasses "symptoms" of the Veteran's duodenal ulcer, duodenitis, gastritis, and GERD, as referenced in the pertinent diagnostic codes, the Board will consider all of the Veteran's gastrointestinal symptoms reported in the lay and medical evidence. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam). BACKGROUND For procedural clarity, a May 2003 rating decision granted service connection for duodenal ulcer, duodenitis and gastritis with an initial disability rating of 10 percent, effective December 6, 2002, an evaluation of 100 percent, effective January 9, 2003, based on surgical or other treatment necessitating convalescence, and an evaluation of 10 percent from March 1, 2003. The Veteran was notified of that decision and his appellate rights in a May 2003 letter. See 38 U.S.C. § 5104; 38 C.F.R. §§ 3.103, 19.25. He did not appeal. See 38 C.F.R. §§ 20.200, 20.201, 20.302 (setting forth procedures for appealing a decision under VA's then applicable legacy appeal system). More recently, in a May 2013 rating decision the RO denied entitlement to a disability rating in excess of 10 percent for the Veteran's duodenal ulcer, duodenitis and gastritis. The Veteran was notified of that decision and his appellate rights in a June 2013 letter. See 38 U.S.C. § 5104; 38 C.F.R. §§ 3.103, 19.25. He did not appeal. See 38 C.F.R. §§ 20.200, 20.201, 20.302 (setting forth procedures for appealing a decision under VA's then applicable legacy appeal system). The Veteran filed a claim for an increased rating for his service-connected duodenal ulcer, duodenitis, and gastritis on January 26, 2016. See February 2016 VA Form 21-526EZ (Veteran's Application for Disability for Compensation and Related Compensation Benefits); January 2016 VA Notification Letter of Intent to File on January 26, 2016. As noted above, during the course of the appeal he was awarded service connection for GERD in conjunction with his service-connected gastrointestinal disorder and assigned a 60 percent rating as of November 9, 2022. He has expressed satisfaction with the 60 percent rating; therefore, the issue on appeal is characterized as entitlement to a disability rating in excess of 10 percent for duodenal ulcer, duodenitis, gastritis, and GERD, prior to November 9, 2022. The Veteran submitted a statement in June 2020. In the June 2020 Statement, the Veteran reported: I am currently service connected for my Duodenal Ulcer, Duodenitis, and Gastritis at 10%. I am requesting an increase as I do not believe that my current rating accurately reflects my level of disability. I continue to have issues with abdominal pain, indigestion, bloating, burning in my stomach, heartburn, regurgitation, acid reflux, and chest pain at least once a week. I have previously been prescribed Omeprazole for my condition, but I now have to take just over-the-counter medications like Pepto Bismol, Rolaids, or Tums 3-4 times a week to help control my symptoms. I have to avoid certain foods that aggravate my symptoms, especially spicy foods, tomato-based sauces, and citrus juices. This condition makes it difficult to sleep, and I have to sleep propped up in order to prevent some of the burning from regurgitation during the night. I find that I can only get about five hours of sleep at night, on average. See June 2020 Statement. Regarding the Veteran's claim for an increased rating related to his ulcer, in September 2021 the Veteran testified at a hearing with the undersigned. The Veteran testified that he had burning like sensations in his stomach, and that if he does not eat anything, it feels as though he has acid in his stomach and starts burning with heartburn-like chest pain. See September 2021 Hearing Transcript. The Veteran testified that he experiences the stomach burning approximately three or four times a month, usually when his stomach is empty and that he cannot eat foods such as pasta, anything with sauces or anything acidic. Id. The Veteran testified that he sometimes experienced regurgitation in his mouth in tandem with the associated stomach and chest pain. Id. The Veteran testified that he takes over the counter medicines and tries to manage the symptoms on his own. Id. The Veteran testified that since 2003 he was not followed by any doctors for outpatient evaluation, or checkups, nor had he been admitted to a hospital due to the gastrointestinal symptoms he experiences. Id. The Veteran testified that the symptoms he experiences occur sporadically but are impacted by and limits the food he may eat. Id. For example, he testified that he ate hot wings for breakfast on an empty stomach and then within an hour regurgitated the entire meal, due to the hot sauce. Id. Regarding the GERD condition, the Veteran testified that he was diagnosed with GERD in 2003 by a VA medical professional but stated that he did not have any more recent doctor or medical evaluations for GERD. Id. The Veteran testified that he continues to have the same symptoms associated with GERD as he had in 2003, specifically the reflux. Id. The Veteran testified that he did not have any medical evidence to submit regarding the GERD condition since the 2003 diagnosis. In April 2016 the Veteran was afforded a VA Stomach and Duodenal Conditions DBQ, Medical Opinion DBQ. He complained of stomach pain, dark stools and some vomiting. He stated that he takes omeprazole, which helps. The Veteran was diagnosed with duodenal ulcer, with symptoms of abdominal pain (occurring less than monthly), vomiting (mild, occurring four or more times per year with an average duration of episodes of vomiting less than one day), and no incapacitating episodes due to signs or symptoms of any stomach or duodenum conditions. See April 2016 VA Stomach and Duodenal Conditions DBQ; Medical Opinion DBQ. In April 2016 the Veteran was also afforded a VA Intestinal Conditions DBQ, in which the medical examiner noted that the Veteran complained of constipation, described hard stool, reported a bowel movement every 3 to 4 days since "6 years or maybe more" and stated that when he takes laxatives, he has a watery bowel movement every other day, and claims taking laxative for years. See April 2016 VA Intestinal Conditions DBQ. The medical examiner opined that there were no diagnosed intestinal conditions, although the Veteran's symptoms require continuous over the counter medication, specifically, stool softeners. Id. In June 2016, the Veteran copies of his April 2016 DBQs with his own mark-ups stating that his vomiting was recurrent, still 4 times a year but lasting 10 days or more; that he had incapacitating episodes due to signs and symptoms of his stomach condition; and that he had episodes of bowel disturbance with abdominal distress, or exacerbations or attacks of the intestinal condition. On July 8, 2022, the Veteran was afforded a VA Esophageal Conditions DBQ (including GERD, hiatal hernia, and other esophageal disorders), in which the medical examiner diagnosed the Veteran only with GERD and hernia hiatal, with symptoms of pyrosis, reflux, and regurgitation due to any esophageal conditions including GERD. See July 2022 VA Esophageal Conditions DBQ. At the July 2022 VA medical examination, the Veteran reported that he gets a burning sensation in his stomach almost every day and that it occurs if he hasn't eaten for several hours, lasts up to two hours, and resolves with eating. Id. The Veteran also reported that he uses over the counter medication "every couple days," with no changes in years." Id. The Veteran did not report other types of abdominal pain and reported that GERD "to me is like when I eat acidic foods, pizza, spaghetti, chicken wings I'm kind of throwing it back up." Id. The Veteran stated that food feels like it's coming up his throat and reported "regurgitation" 2-3 times a week. Id. The Veteran reported that vomiting after hot wings occurs "once in a blue moon," and is relieved with over-the-counter medication. Id. The Veteran reported that he uses a lot of antacids and can't lay down or play basketball because he feels bad. Id. The Veteran reported having a swallowing/sticking sensation "every couple weeks if [his] throat is dry," and that he has dysphagia to solid foods and "can't sleep" if he eats late. Id. The Veteran reported occasional chest pain which he attributed to indigestion. Id. The medical examiner noted that "despite alleged limitations in activity," the Veteran reported that he has not visited a doctor for a gastrointestinal follow up in years because he doesn't like to see doctors. Id. The medical examiner also noted that "objective clinical notes" contradict the Veteran's subsequent statements regarding the symptoms and severity of those symptoms he experiences due to his gastrointestinal conditions, and cited the following examples: (a) 04/04/16: COPC follow up for constipation noted now having daily bowel movements with miralax. The Veteran denied nausea, vomiting, abdominal pain, diarrhea and reported no reflux. (b) 4/21/16: MEDVAMC C&P reports in which the Veteran reported abdominal pain less than monthly, mild vomiting more than 4x/year for less than one day each episode. (c) 12/06/16: COPC PCP follow up noted recent visit for bronchitis. The Veteran reported no gastrointestinal (GI) symptoms, and no reflux reported. No reflux meds. (d) 4/26/17: COPC PCP follow up noted current complaint of abdominal pain with the Veteran reporting "constipation, bloating, abdominal pain on and off since he was 21 years old. It is also noted that he was scheduled for colonoscopy in the past, but he did not show up for the procedure, he was offered to reschedule the colonoscopy, but he refused. No GERD symptoms, diagnosis of GERD or medications noted, and benign abdominal exam. (e) 10/26/17: CBOC PCP note indicated routine visit for labs/meds. No GI symptoms, no diagnosis of GERD, no GERD medication noted. (f) 1/08/18: CBOC PCP no GI complaints. (g) 9/20/18: CBOC PCP routine follow up for labs/meds did not document any GI symptoms. (h) 6/30/19: CBOC PCP follow up noted no GI symptoms of abdominal pain/dysphagia/hematemesis /melena/hematochezia. No GI meds ordered. (i) 4/13/21: COPC PCP follow up noted routine visit, no GI symptoms reported. No GI meds noted. PE unrevealing. (j) 10/22/21: COPC PCP follow up noted no diagnosis of GERD, no GI symptoms. (k) 1/24/22: Per most recent TOPC PCP note, PMH included a diagnosis of duodenal ulcer. No diagnosis of GERD or gastritis documented. The Veteran denied using any non-VA or over-the-counter medications. The Veteran denied nausea, vomiting, abdominal pain, diarrhea, melena. See July 2022 VA Esophageal Conditions DBQ. The medical examiner also noted that none of the medical VAMC PCP notes documented complaints of chronic constipation treated with Miralax, and no other gastrointestinal symptoms, including GERD, nausea, vomiting, dysphagia, hematemesis, melena, bright red blood per rectum (BRBPR), appetite or weight changes were noted. Id. The medical examiner noted that the only medical VAMC gastrointestinal notes are for routine screening and a colonoscopy, otherwise there are no other medical VAMC notes available. Id. Regarding the Veteran's claim that his symptoms have worsened since his April 2016 VA examination, the July 2022 medical examiner opined, in pertinent part: There is no objective evidence [the] Veteran has had recurrent UGIB [Upper Gastrointestinal Bleeding] since 2003. At the time of the most recent 2003 EGD, [the] Veteran had histologic evidence of gastritis and ulcers. He was found to have hiatal hernia. According to references below, gastritis was most likely caused by H. Pylori infection which was treated in 2003. There is no evidence [the]Veteran has had recurrent gastritis symptoms since then. Based on review of references below, the symptoms reported by [the]Veteran in more recent years are most likely attributable to GERD, not gastritis or duodenal ulcers. [The] Veteran has given conflicting information on severity and frequency of symptoms when compared/contrasted with objective clinical notes and his self-report during 9/20/21 BVA Hearing. Given the discrepancies in [the] Veteran's self-report of symptoms and documentation [the] Veteran sought care in remote past when he had worsening symptoms, I am concerned Veteran's recall of symptoms more recently may not be accurate. Based on this I am inclined to give more probative value to objective records. It does not appear [the] Veteran has worsening of his GERD condition. See July 2022 VA Esophageal Conditions DBQ. (Emphasis added). In November 2022 VA received a Private Esophageal Conditions DBQ, which included a November 2022 Esophagogastroduodenoscopy with Biopsy Operative Report (November 2022 Operative Report). The private medical examiner diagnosed the Veteran with GERD, hernia hiatal, spasm of esophagus, and severe esophagitis, with symptoms of persistently recurrent epigastric distress, dysphagia, reflux, regurgitation, pain substernal, sleep disturbance, nausea, vomiting, hematemesis, melena with moderate anemia and severe esophagus stricture. See. November 2022 Private Esophageal Conditions DBQ; November 2022 Operative Report. Additionally, in the November 2022 Operative Report, the private medical examiner reported that "no gross masses, ulcers, or lesions, bleeding or obstruction" were noted. Id. The private medical examiner noted that the second portion of the duodenum was observed to be normal in appearance. Id. The Board finds that the criteria for the assignment of a 60 percent disability evaluation for the Veteran's gastrointestinal disabilities are met, effective July 8, 2022. The Board finds it probative that the July 8, 2022, VA medical examiner's findings note GERD symptoms contemplated at the 60 percent disability evaluation which are consistent, to that extent, with the November 2022 Private Esophageal Conditions DBQ and Operative Report. Therefore, the record shows that the criteria for a 60 percent rating under DC 7346 were met as of July 8, 2022. As explained above, the Veteran has expressed satisfaction with the assignment of a 60 percent rating. Further, the Board finds that the criteria for the assignment of a 30 percent disability evaluation for the Veteran's gastrointestinal disabilities are met, effective June 23, 2020. In his statement dated June 23, 2020, the Veteran reported symptoms of abdominal pain, indigestion, bloating, burning in his stomach, heartburn, regurgitation, acid reflux, and chest pain at least once a week. He was taking over-the-counter medications such as Pepto Bismol, Rolaids, or Tums three to four times a week to help control his symptoms. The Board finds that these symptoms approximate the criteria for the assignment of a 30 percent rating under DC 7346. However, the criteria for a rating in excess of 30 percent rating under DC 7305, 7307 or 7346 were not met or more nearly approximated from June 23, 2020, to July 7, 2022. With respect to DC 7346, the Veteran was not shown to have anemia; nor was there any evidence showing that his gastrointestinal symptoms were productive of severe, i.e., "very great [or] intense" or "of a great degree" impairment of health, so as to warrant the assignment of a 60 percent rating. See NEW OXFORD AMERICAN DICTIONARY 1599 (3d ed. 2010) and MERRIAM-WEBSTER DICTIONARY online (internal citation omitted)). The Veteran's VA treatment records dated in 2020 and 2021 are of record, but they show no complaints, findings or treatment related to his gastrointestinal disorders. With respect to DC 7305, the Veteran's ulcer has not been shown to be active. Even if it was active, he was not shown to have impairment of health manifested by anemia and weight loss; nor was he shown to have recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year so as to warrant the assignment of a 40 percent rating. There was no evidence of anemia or weight loss, and the Veteran stated that his symptoms occurred at least once a week and that he took such as Pepto Bismol, Rolaids, or Tums three to four times a week to help control his symptoms. There was no indication that the Veteran had any incapacitating episodes. Rather, his symptoms reportedly occurred on a regular basis and he obtained some relief with over-the-counter medications. DC 7305 contemplates the use of treatment/medication, as the 60 percent criteria references relief by standard ulcer therapy. Further, with respect to DC 7307, the Veteran was not shown to have chronic gastritis with severe hemorrhages, or large ulcerated or eroded areas, so as to warrant the assignment of a 60 percent rating. There was no evidence of any hemorrhages, or large ulcerated or eroded areas. Accordingly, the evidence persuasively weighs against the assignment of a rating in excess of 30 percent under DC 7305, 7307 or 7346 from June 23, 2020, to July 7, 2022. For the appellate period prior to June 23, 2020, the Board finds that the criteria for a rating in excess of 10 percent rating under DC 7305, 7307 or 7346 were not met or more nearly approximated. During this time, the Veteran's symptoms included stomach pain, dark stools, some vomiting, and constipation. He had symptoms of abdominal pain (occurring less than monthly), vomiting (mild, occurring four or more times per year with an average duration of episodes of vomiting less than one day), and no incapacitating episodes due to signs or symptoms of any stomach or duodenum conditions. With respect to DC 7346, the Veteran was not shown to have persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health, so as to warrant the assignment of a 30 percent rating. He did not report any dysphagia, pyrosis, or regurgitation, and the symptoms he did have were not persistently recurrent. Rather, his abdominal pain occurred less than monthly and his vomiting occurred four or more times per year with an average duration of episodes of vomiting for less than one day. With respect to DC 7305, again, the Veteran's ulcer was not shown to be active. Further, he was not shown to have recurring episodes of severe symptoms two or three times a year averaging 10 days in duration, or continuous moderate manifestations, so as to warrant the assignment of a 20 percent rating. While periodic vomiting is listed as a one of the symptoms of a severe condition under DC 7305, he experienced none of the other listed symptoms, i.e., pain only partially relieved by standard ulcer therapy or recurrent hematemesis or melena. Also, the Veteran's symptoms, even if moderate, were not continuous. Again, his abdominal pain occurred less than monthly and his vomiting occurred four or more times per year with an average duration of episodes of vomiting for less than one day. Finally, with respect to DC 7307, while the Veteran was shown to experience gastrointestinal symptoms, i.e., stomach pain, dark stools, some vomiting, and constipation, there was no evidence of any small eroded or ulcerated areas, so as to warrant the assignment of a 30 percent rating. There has been no evidence of any ulcerated or eroded areas. The Board has considered copies of the April 2016 DBQs with the Veteran's own mark-ups stating that his vomiting was recurrent, still 4 times a year but lasting 10 days or more; that he had incapacitating episodes due to signs and symptoms of his stomach condition; and that he had episodes of bowel disturbance with abdominal distress, or exacerbations or attacks of the intestinal condition; as well as his September 2021 testimony and other lay statements on record. His statements are competent because the Veteran may report the symptoms he experiences and any diagnosis and or treatment he may have received relating to his gastrointestinal conditions. However, the Veteran's statements are not credible because they are inconsistent with the evidence of record. The evidence of record indicates that the Veteran did not report any of the more severe symptoms he contends he experiences in follow up medical appointments and has at times downplayed his symptoms and seemingly exaggerated the same symptoms at other times as discussed above. For example, during the period on appeal the Veteran has contended that symptoms he experiences due to his gastrointestinal disabilities have existed, continued, and worsened since his military service and reflect the symptoms and severity contemplated at the highest disability rating for his conditions, however, at the September 2021 hearing when asked whether his symptoms have stayed the same or worsened since his 2016 VA medical examination, the Veteran testified that his symptoms were "about the same, maybe little bit worse." See September 2021 Hearing Transcript. Further, when asked whether he sought medical attention for the gastrointestinal symptoms he experiences, the Veteran testified that "I haven't been bleeding. So, I feel like maybe there's almost no point of going. [...] I try to manage it myself," with over-the-counter medicines he can get at a drugstore. Id. The Board finds it probative that despite the Veteran's contention that the severity of the gastrointestinal symptoms he experiences is reflected by higher disability evaluations since service, he did not seek medical attention for the gastrointestinal conditions except the VA DBQs and private medical opinion ordered to form the basis of his claims. His VA treatment records show minimal, if any, complaints or findings related to his gastrointestinal conditions. See VA treatment records dated April 2016 to January 2022. Accordingly, the Board affords low probative value to the Veteran's lay statements that his symptoms have worsened to a severity as contemplated by ratings in excess of those assigned above. The medical evidence of record discussed above is competent because the medical examiners have the skill and training necessary to diagnose and opine on the Veteran's gastrointestinal disabilities. The medical evidence is credible because it is consistent with other medical evidence of record, and the medical examiners indicated, and their opinions reflect, that they reviewed the Veteran's entire claims file including the Veteran's lay statements. Accordingly, the Board affords high probative value to the medical evidence of record. In sum, the Board finds that a 60 percent rating, but not higher, for the Veteran's duodenal ulcer, duodenitis, gastritis, and GERD is warranted from July 8, 2022, to November 9, 2022 and that a 30 percent rating, but not higher, is warranted from June 23, 2020, to July 7, 2022. However, the weight of the evidence is against the assignment of a rating in excess of 10 percent prior to June 23, 2020. Finally, the Veteran has asserted that his gastrointestinal disorders make it difficult to sleep and that he can only get five hours of sleep per night on average. He stated that his lack of sleep causes difficulty with concentration, daytime fatigue, forgetfulness, irritability, trouble thinking and a low sex drive. See Statement from the Veteran, dated June 23, 2020. The Board notes that the Veteran has been awarded service connection for a major depressive disorder, sleep apnea and erectile dysfunction, and that the ratings assigned for these conditions contemplate his symptoms of poor sleep, difficulty with concentration, daytime fatigue, forgetfulness, irritability, trouble thinking and a low sex drive. See 38 C.F.R. §§ 4.97, 4.115b, 4.130, DCs 9434, 6847 and 7522. Thus, they are not for consideration in assigning a higher and/or separate rating for his gastrointestinal disorders. P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board H.E. Brand, Associate 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.