MIGRAINE

DAVID A. BRENNINGMEYER · 2026 · Case ID: A26029472

GRANTED

Summary

The veteran, who served in the U.S. Air Force from July 2007 to September 2016, including service in Bahrain and earning the Global War on Terrorism Expeditionary Medal, appeals the rating decisions for migraines, anemia, and service connection for peptic ulcers. The veteran sought a higher rating for migraines, contending that the maximum 50 percent rating was warranted due to very frequent, completely prostrating, and prolonged attacks causing economic inadaptability. For anemia, the veteran sought a higher rating, arguing that under the pre-December 2018 criteria (DC 7700), a 70 percent rating was appropriate due to a hemoglobin level of 6.8 gm/100ml and tachycardia, and under the post-December 2018 criteria (DC 7720), a 30 percent rating was warranted due to multiple intravenous iron infusions. The veteran also sought service connection for peptic ulcers, claiming an in-service onset with continuity of symptomatology. The Board granted a 50 percent rating for migraines, finding the evidence, when resolving doubt in the veteran's favor, supported the maximum rating due to the frequency, prostrating nature, and economic impact of the headaches, despite some conflicting VA examiner opinions. The Board also granted a 70 percent rating for anemia for the entire period on appeal, finding the criteria for that rating under the pre-December 2018 DC 7700 were met due to a hemoglobin level of 6.8 gm/100ml and tachycardia in March 2019, even though this was the lowest reading during the period. Service connection for peptic ulcers was granted presumptively due to chronicity, based on in-service treatment for gastritis/ulcer symptoms and subsequent diagnosis of a peptic duodenal ulcer within a year of service, with continuity of symptoms. The Board found a prior VA examiner's negative nexus opinion for ulcers to be unreliable due to factual errors.

Rationale

Evidence supports 50% rating for migraines; Migraines were very frequent, prostrating, prolonged; Caused economic inadaptability

Service Branch

AIR FORCE

Special Benefit

NO SPECIAL BENEFIT

Diagnostic Code

8100

Docket No.

200912-109413

Full Decision Text

Citation Nr: A26029472
Decision Date: 04/01/26 Archive Date: 04/01/26

DOCKET NO. 200912-109413
DATE: April 1, 2026

ORDER

A 50 percent rating is granted for migraines from February 16, 2018, subject to the law and regulations governing the award of monetary benefits.

A 70 percent rating is granted for anemia from February 16, 2018, subject to the law and regulations governing the award of monetary benefits.

Service connection for peptic ulcers is granted.

FINDINGS OF FACT

1. During the period on appeal, the evidence is at least in equipoise as to whether the Veteran's service-connected migraines were manifested by very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability.

2. During the period on appeal, the Veteran's macrocytic anemia was manifested by a hemoglobin level of 7 gm/100ml or less with findings such as tachycardia; at no time during the period on appeal was the condition manifested by a hemoglobin level of 5 gm/100ml or less.

3. The Veteran has a current disability of peptic ulcers; it is at least as likely as not that the condition had its onset during service and has continued since.

CONCLUSIONS OF LAW

1. Resolving reasonable doubt in the Veteran's favor, the criteria for a 50 percent rating for migraines have been met throughout the period on appeal. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.10, 4.124a, Diagnostic Code (DC) 8100.

2. Resolving reasonable doubt in the Veteran's favor, the criteria for a 70 percent rating for iron deficiency anemia have been met throughout the period on appeal. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.10, 4.117, DC 7700.

3. Resolving reasonable doubt in the Veteran's favor, the criteria for an award of service connection for peptic ulcers have been met. 38 U.S.C. §§ 1110, 1112, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the U.S. Air Force from July 2007 to September 2016, to include service in Bahrain. His decorations include the Global War on Terrorism Expeditionary Medal.

This matter arises from a September 2018 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran filed a legacy notice of disagreement (VA Form 21-0958) (NOD) in November 2018, and a Statement of the Case (SOC) was issued in April 2020.

The Appeals Modernization Act (AMA) allows VA claimants to opt into the modernized review system by requesting review of a SOC or supplemental SOC (SSOC) issued on or after February 19, 2019 if the opt-in is received within one year of the date of the notification of the underlying rating decision, or 60 days from the issuance of the SOC/SSOC, whichever is later. Here, the Veteran elected to appeal to the Board of Veterans' Appeals (Board) via the modernized appeal system in September 2020, after receiving the April 2020 SOC. See May 2020 VA Form 10182 (Decision Review Request: Board Appeal (Notice of Disagreement)). Although the Veteran's September 2020 NOD was not submitted within 60 days of issuance of the April 2020 SOC, he requested leniency for the late filing due to the COVID-19 pandemic in a submission that accompanied his September 2020 NOD. The Board has approved his request. In his September 2020 NOD, he selected the hearing review option. 38 C.F.R. §§ 20.201, 20.202(b)(2).

In June 2024, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing has been associated with the record. Under the hearing review option, the Board may only consider the evidence of record at the time of issuance of the agency of original jurisdiction (AOJ) decision on appeal (in this case, the April 2020 SOC), as well as any evidence submitted by the Veteran
due to the COVID-19 pandemic in a submission that accompanied his September 2020 NOD. The Board has approved his request. In his September 2020 NOD, he selected the hearing review option. 38 C.F.R. §§ 20.201, 20.202(b)(2).

In June 2024, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing has been associated with the record. Under the hearing review option, the Board may only consider the evidence of record at the time of issuance of the agency of original jurisdiction (AOJ) decision on appeal (in this case, the April 2020 SOC), as well as any evidence submitted by the Veteran or his representative at the hearing or within 90 days following the hearing. 38 C.F.R. §?20.302(a). The Board cannot consider (1) evidence submitted during the period after the AOJ issued the April 2020 SOC and before the hearing was held, or (2) evidence submitted more than 90 days after the hearing was held. 38 C.F.R. § 20.302.

If evidence was associated with the claims file during a period of time when additional evidence was not allowed, the Board has not considered it in its decision on the Veteran's claims. 38 C.F.R. § 20.300. If the Veteran would like VA to consider any evidence that was added to the claims file that the Board could not consider, he may file a Supplemental Claim (VA Form 20-0995) and submit or identify that evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim(s), considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

The Board notes that the Veteran's claims were originally adjudicated in an April 2018 rating decision. After receiving a request to reconsider the claims in July 2018, the RO readjudicated them in the September 2018 rating decision. Thereafter, as noted, the Veteran filed a legacy NOD in November 2018, within a year of both rating decisions. As such, the present appeal is most properly regarded as emanating from the claim he filed in February 2018, rather than from the request for reconsideration he subsequently filed in July 2018.

Higher Ratings

Disability evaluations are determined by the application of a schedule of ratings, which is in turn based on the average impairment of earning capacity caused by a given disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the evaluations to be assigned to the various disabilities.

The law mandates resolving reasonable doubt regarding the degree of disability in favor of the claimant. 38 C.F.R. § 4.3. If there is a question as to which of two evaluations shall be applied, 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. If different disability ratings are warranted for different periods of time over the life of a claim, "staged" ratings may be assigned. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119, 125-26 (1999).

1. Entitlement to a rating in excess of 30 percent for migraines

In an April 2018 rating decision, the AOJ granted service connection and an initial 30 percent rating for migraines, effective February 16, 2018. The Veteran contends that the maximum 50 percent rating is warranted. In his July 2018 application, he stated that he was seeking a 50 percent rating due to the number of prostrating attacks he had each month, adding that such attacks occurred more often than once per month per medical records. He stated that he was currently having eight episodes per month, and that his condition had caused him to miss work.

The Veteran's service-connected migraines have been evaluated under DC 8100. Under that diagnostic code, a 30 percent disability rating is assigned for migraine headaches with characteristic prostrating attacks occurring on an average of once a month over the last several months. A maximum 50 percent rating is assigned for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability.

The United States Court of Appeals for Veterans Claims (Court) held in Johnson v. Wilkie, 30 Vet. App. 245 (2018), that DC 8100 contains successive rating criteria, as each disability level builds on another in terms of duration and frequency, and requires that a veteran rated at a higher level satisfy all of the requirements at the lower level. While the criteria for a 50 percent rating therefore contain a frequency requirement, they additionally require that a veteran have "completely" prostrating and "prolonged" attacks which are "productive of severe economic inadaptability." 38 C.F.R. § 4.124a, DC 8100.

In determining whether the Veteran experiences the type and frequency of prostrating attacks of migraine headaches necessary for a higher rating under DC 8100, the Board observes that the rating criteria do not define "prostrating," nor has the Court. Cf. Fenderson v. West, 12 Vet. App. 119 (1999) (in which the Court quoted DC 8100 verbatim but did not specifically address the matter of what is a prostrating attack).

By way of reference, the Board notes that according to WEBSTER'S NEW WORLD DICTIONARY OF AMERICAN ENGLISH, THIRD COLLEGE EDITION (1986), page 1080, "prostration" is defined as "utter physical exhaustion or helplessness." A very similar definition is found in DORLAND'S ILLUSTRATED MEDICAL DICTIONARY (28th Ed. 1994), page 1367, in which "prostration" is defined as "extreme exhaustion or powerlessness."

The Court has also held that the phrase "productive of severe economic inadaptability" should be construed to mean either "producing" or "capable of producing" economic inadaptability. See Pierce v. Principi, 18 Vet. App. 440, 445 (2004). Moreover, in making that assessment, the ameliorative effects of medication cannot be taken into account. See Jones v. Shinseki, 26 Vet. App. 56 (2012).

The Veteran was afforded a VA examination in connection with his claim for service connection for migraines in March 2018. The examiner noted that the Veteran took sumatriptan as needed to treat the condition and indicated that he experienced headache pain in the form of pulsating or throbbing head pain. She indicated that non-headache symptoms included nausea, vomiting, and sensitivity to light, and that the typical duration of a headache was less than one day. She indicated further that the Veteran had characteristic prostrating attacks once every month, but that he did not have very prostrating and prolonged attacks. As to the impact of migraines on the Veteran's ability to work, the examiner stated that he had lost two to four weeks of work in the last 12 months due to migraines, that he had headache pain, and that it was difficult for him to concentrate.

According to an April 2018 VA treatment record, the Veteran reported to a VA provider that he could have up to eight migraines per month, with symptoms including light sensitivity, nausea, and vomiting. He also reported that his migraines were worsening since their onset several years earlier, that medications could help, and that he was missing work for the more severe migraines. The provider also noted that he kept a migraine diary and that on average he had six migraines per month.

The Veteran was afforded a VA examination in connection with his request for a higher rating in August 2018. The examiner noted the findings recorded in the April 2018 VA treatment record, but noted that the frequency of migraines had decreased since that time to just a couple in April, May, and June. She then noted the Veteran's report that the migraines seemed to be picking up again, that he had had four in just nine days in the month of July, and that they had become prostrating, prolonged, and were affecting his daily life and work. The examiner noted that the Veteran's treatment plan included taking propranolol and Imitrex and indicated that the typical duration of a headache was less than one day. She next indicated that he had characteristic prostrating attacks once every month, but that he did not have very prostr
noted the findings recorded in the April 2018 VA treatment record, but noted that the frequency of migraines had decreased since that time to just a couple in April, May, and June. She then noted the Veteran's report that the migraines seemed to be picking up again, that he had had four in just nine days in the month of July, and that they had become prostrating, prolonged, and were affecting his daily life and work. The examiner noted that the Veteran's treatment plan included taking propranolol and Imitrex and indicated that the typical duration of a headache was less than one day. She next indicated that he had characteristic prostrating attacks once every month, but that he did not have very prostrating and prolonged attacks productive of severe economic inadaptability. With respect to the impact of the disability on the Veteran's ability to work, the examiner stated that when he had a migraine, he was totally incapacitated and had to be driven home from work, and that that had been occurring from five to eight times per month.

The Veteran submitted a lay statement from a colleague, a Dr. B.B., in November 2018. Dr. B. stated that he had observed the Veteran miss several days from work and meetings, and that he also had incomplete and late work assignments due to recurrent migraines. He stated further that on occasions at work and home the Veteran had had to limit sound and light exposure in order to limit the duration, intensity, and frequency of his migraines.

The Veteran was afforded another VA examination as to the severity of his migraines in November 2019. He reported to the examiner that he had some daily headaches, but that he had learned to live with them, that he was most bothered by bad migraines that happened occasionally and could be unrelenting for a few days, and that they could cause him to be not able to do his work. He also reported that he was hoping to find telework so that if he was having a bad day, he could turn the lights down and rest, and estimated that he had about 15 migraines per month. The examiner indicated that the Veteran's treatment plan included taking medication, and that the typical duration of a headache was less than one day. She then indicated that he had characteristic prostrating attacks once per month, but that he did not have very prostrating and prolonged attacks. As to the impact on work, the examiner noted that the Veteran stated that when he had a headache he was not able to work through them, and that that occurred five to seven times per month.

The Veteran submitted a lay statement from his spouse in July 2024. She stated that the Veteran had migraines that were increasingly frequent, that they forced him to go into a dark and quiet room, and that he was frequently incapacitated and housebound.

In light of the foregoing, and resolving reasonable doubt in the Veteran's favor, the Board finds that the evidence supports the assignment of a 50 percent rating for the Veteran's migraines from February 16, 2018. Throughout the period on appeal, the evidence demonstrates that his migraines have occurred on a very frequent basis, even where he has been taking medications to help alleviate the condition. His migraines have also been completely prostrating and prolonged, inasmuch as the evidence demonstrates that when he has one, he needs to lie down in a dark room, take medications, and avoid light and/or sound. They are also severe enough to preclude him from working, which demonstrates that they are severe enough to produce and are capable of producing economic inadaptability, even taking into account the ameliorative effects of medication. Without the ameliorative effects of medication (which is how the Board must analyze the Veteran's claim), his migraines would very clearly produce economic inadaptability to a very significant degree.

While none of the VA examiners of record opined that the Veteran had very prostrating and prolonged attacks of migraine/non-migraine headache pain that was productive of severe economic inadaptability, the Board finds their conclusions in that regard to be inconsistent with the bulk of the evidence of record, and even the examiners' own examinations. VA treatment records and the Veteran's lay statements as to the frequency and severity of his headaches have been consistent throughout the appeal period, and there is no logical explanation for why the two latter VA examiners indicated that the Veteran's migraines caused him to miss work many times per month, but that they were not very prostrating, prolonged, and productive of severe economic inadaptability. Still further, none of the VA examiners evaluated the severity of the Veteran's migraines while discounting the ameliorative effects of medication. The Board finds that when such effects are discounted, the Veteran's migraines clearly meet the criteria for the maximum 50 percent rating.

the evidence of record, and even the examiners' own examinations. VA treatment records and the Veteran's lay statements as to the frequency and severity of his headaches have been consistent throughout the appeal period, and there is no logical explanation for why the two latter VA examiners indicated that the Veteran's migraines caused him to miss work many times per month, but that they were not very prostrating, prolonged, and productive of severe economic inadaptability. Still further, none of the VA examiners evaluated the severity of the Veteran's migraines while discounting the ameliorative effects of medication. The Board finds that when such effects are discounted, the Veteran's migraines clearly meet the criteria for the maximum 50 percent rating.

Given the frequency and severity of the Veteran's migraine headaches reported during the appeal period, the Board resolves doubt in his favor and finds that it is at least as likely as not that his headaches satisfied the criteria needed for the maximum 50 percent rating under DC 8100. The full benefit sought on appeal is granted.

2. Entitlement to a rating in excess of 10 percent for anemia

In an April 2018 rating decision, the AOJ granted service connection and an initial 10 percent rating for anemia, effective February 16, 2018. The Veteran seeks a higher rating. At the June 2024 Board hearing, the Veteran's representative noted that at the time the Veteran filed his application for service connection for anemia in February 2018, anemia was rated pursuant to DC 7700, but that at the time of the hearing, the condition was rated pursuant to DC 7720. In this regard, the Veteran contends that a 70 percent rating is warranted pursuant to DC 7700 inasmuch as his hemoglobin level during the period on appeal was as low as 6.8, which is consistent with a 70 percent rating under that DC. He has also contended that even pursuant to DC 7720, a 30 percent rating is warranted inasmuch he has required four or more intravenous iron transfusions during a 12-month period.

Prior to December 9, 2018, anemia was rated pursuant to DC 7700. Under that DC, a 10 percent rating was assigned for anemia with a hemoglobin level of 10 gm/100ml or less with findings such as weakness, easy fatigability, or headaches. A 30 percent rating was assigned for a hemoglobin level of 8 gm/100ml or less, with findings such as weakness, easy fatigability, headaches, lightheadedness, or shortness of breath. A 70 percent rating was assigned for a hemoglobin level of 7 gm/100ml or less, with findings such as dyspnea on mild exertion, cardiomegaly, tachycardia (100 to 120 beats per minute), or syncope (three episodes in the last six months). A 100 percent rating was assigned for anemia with a hemoglobin level of 5 gm/100ml or less, with findings such as high output congestive heart failure or dyspnea at rest. A note to DC 7700 provided that complications of pernicious anemia, such as dementia or peripheral neuropathy, should be evaluated separately. 38 C.F.R. § 4.117, DC 7700 (2017).

On October 29, 2018, VA issued a final rule revising 38 C.F.R. § 4.117, the portion of the VA Schedule for Rating Disabilities that addresses the hemic and lymphatic systems, effective December 9, 2018. See Schedule for Rating Disabilities: The Hematologic and Lymphatic Systems, 83 Fed. Reg. 54,250 (Oct. 29, 2018). The final rule updated medical terminology, added certain hematologic diseases, and provided detailed and updated criteria for evaluating conditions pertaining to the hematologic and lymphatic systems. The rule removed DC 7700 (anemia, hypochromic-microcytic and megaloblastic, such as iron-deficiency and pernicious anemia) and added separate diagnostic codes (DCs 7720-7723) for the four major types of anemia that are neither hereditary nor secondary (addressed under the diagnostic code for the causative condition). Because the rating criteria were changed during the appeal period, the old regulations are applicable both before and after the date of the change in regulations and the new regulations are applicable only on or after their effective date. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003); VAOPGCPREC 7-2003.

Under DC 7720, a 10 percent rating is
galoblastic, such as iron-deficiency and pernicious anemia) and added separate diagnostic codes (DCs 7720-7723) for the four major types of anemia that are neither hereditary nor secondary (addressed under the diagnostic code for the causative condition). Because the rating criteria were changed during the appeal period, the old regulations are applicable both before and after the date of the change in regulations and the new regulations are applicable only on or after their effective date. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003); VAOPGCPREC 7-2003.

Under DC 7720, a 10 percent rating is warranted for iron deficiency anemia requiring intravenous iron infusions at least 1 time but less than 4 times per 12-month period, or requiring continuous treatment with oral supplementation. A maximum 30 percent rating is warranted for iron deficiency anemia requiring intravenous iron infusions 4 or more times in a 12-month period. 38 C.F.R. § 4.117, DC 7720.

DCs 7721, 7722, and 7723, which relate to folic acid deficiency, pernicious and Vitamin B12 deficiency anemia, and acquired hemolytic anemia, respectively, are not relevant the Veteran's present appeal, as the claims file demonstrates that he has iron deficiency, or macrocytic, anemia.

The Veteran was afforded a VA examination in connection with his claim for service connection in March 2018. The examiner found that the Veteran had anemia, noting that the status of the condition was watchful waiting. In a later section of her report, she indicated that the Veteran did not have anemia and she did not complete the remainder of the report related to anemia. She next indicated that he did not have any complications, residuals, or treatment requiring transfusions of platelets of red blood cells, and that there were no other current findings, to include weakness, easy fatigability, light-headedness, shortness of breath, headaches, dyspnea on mild exertion, or tachycardia. Under the section on other pertinent findings, however, she indicated that he had shortness of breath with exertion, dizziness, and fatigue. The examiner cited to laboratory results, including the Veteran's hemoglobin level, from January 2016, but that was more than 2 years prior to the period on appeal. In a July 2018 VA treatment record, the Veteran was diagnosed with tachycardia.

The Veteran was afforded a VA examination in connection with his request for a higher rating in August 2018. The examiner noted that the Veteran had chronic anemia and noted his hemoglobin levels from 2016 to May 2018. Four hemoglobin readings from her examination report are dated during the period on appeal, all of which show a hemoglobin levels between 10.6 and 10.9 mg/100ml. The examiner next noted that the Veteran had been on oral iron supplements and that he had had one infusion and would be receiving a second the following month. The examiner indicated that the status of the disease was active, and that the Veteran's treatment would be indefinite. She indicated that he had easy fatigability, light-headedness, and tachycardia.

Subsequent VA treatment records show that the Veteran was hospitalized in March 2019 due to anemia. During his admission, his hemoglobin level was recorded at 6.8 gm/100ml, though it improved following treatment. He was also noted to be symptomatic with tachycardia, shortness of breath, and chest pain on exertion.

Following review of the evidence, the Board finds that the criteria for a 70 percent rating for anemia pursuant to DC 7700 have been met for the entire period on appeal. As noted, a 70 percent rating under that DC is warranted for a hemoglobin level of less than 7 gm/100ml, with symptoms such as tachycardia. The Veteran's hemoglobin level was noted to be less than that in March 2019, and the record also clearly shows that he had tachycardia during the same period. While acknowledging that the Veteran's hemoglobin level of 6.8 gm/100ml is the lowest reading during the period on appeal, and that it improved with treatment, the Board notes that there is nothing in DC 7700 which requires a hemoglobin level to be predominantly below a certain level, to be viewed in the aggregate, or to be averaged. Indeed, the plain language of DC 7700 requires only that a claimant's hemoglobin level is 7 mg/100ml or less, accompanied by other various symptoms, to
ia. The Veteran's hemoglobin level was noted to be less than that in March 2019, and the record also clearly shows that he had tachycardia during the same period. While acknowledging that the Veteran's hemoglobin level of 6.8 gm/100ml is the lowest reading during the period on appeal, and that it improved with treatment, the Board notes that there is nothing in DC 7700 which requires a hemoglobin level to be predominantly below a certain level, to be viewed in the aggregate, or to be averaged. Indeed, the plain language of DC 7700 requires only that a claimant's hemoglobin level is 7 mg/100ml or less, accompanied by other various symptoms, to include tachycardia. As each of these elements is present in the March 2019 VA treatment records, the Board finds that a 70 percent rating is warranted.

The Board has reviewed the claims file for the remainder of the period on appeal, but notes that there are no other instances in which the Veteran's hemoglobin level was less than 7 mg/100ml during that period. Still further, there is no evidence to suggest, and the Veteran does not contend, that his hemoglobin level has ever been less than 6.8 mg/100ml at any time during the period on appeal. The Board therefore finds that the evidence is persuasively against the assignment of the next highest (100 percent) rating.

The Board acknowledges that the evidence of record shows that the Veteran underwent several iron infusions during the period on appeal. An April 2018 VA treatment record shows that he underwent his first iron infusion at that time. A September 2018 VA treatment record shows that he underwent three iron infusions in August 2018. A December 2018 VA treatment record shows that he had another iron infusion in October 2018. In a July 2024 submission, the Veteran also noted that he underwent two iron infusions in 2019, and that he had several others in 2020, 2021, 2022, 2023, and 2024. In this regard, the Board notes that any iron infusions that the Veteran underwent after April 2020 are not relevant to the Board's current rating of his anemia, inasmuch as they occurred after the period on appeal ended in April 2020.

While the Veteran underwent five iron infusions in 2018, all of which occurred during the period on appeal, the Board must emphasize that all of those infusions occurred prior to December 9, 2018, when the rating criteria for anemia were revised. As noted, the new rating criteria cannot be applied retroactively to a period of time prior to when they were made effective. More importantly, the Board notes that under the new criteria, which are effective as of December 9, 2018, a 30 percent rating for iron deficiency anemia is the maximum allowable rating. Inasmuch as the Board is granting a 70 percent rating for the entire period on appeal pursuant to DC 7700, the application of DC 7720 is less favorable to the Veteran.

In light of all of the above, and applying the DC most favorable to the Veteran, the Board finds that the criteria for a 70 percent rating for anemia have been met for the entire period on appeal. To that extent, the appeal of this issue is granted.

Service Connection

Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a).

Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999).

If a Veteran serves 90 days or more of active, continuous service after December 31, 1946, and manifests certain chronic diseases, including peptic ulcers (gastric or duodenal), to a degree of 10 percent or more during the one-year period following his separation from that service, service connection for the condition may be established on a presumptive basis, notwithstanding that there is no in-service record of the disorder. See 38 U.S.C. §§ 1112, 1113; 38 C.F.R.
seki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999).

Service connection may also be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307) and (ii) subsequent manifestations of the same chronic disease, or (b) if the fact of chronicity in service is not adequately supported, by evidence of continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).

A layperson is generally incapable of opining on matters requiring medical knowledge. However, lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition, (e.g., a broken leg, separated shoulder, pes planus (flat feet), varicose veins, tinnitus (ringing in the ears), etc.), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007).

In essence, lay testimony is competent when it pertains to the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also 38 C.F.R. § 3.159(a)(2). A determination as to whether medical evidence is needed to demonstrate that a Veteran presently has the same condition he or she had in service or during a presumptive period, or whether lay evidence will suffice, depends on the nature of the Veteran's present condition (e.g., whether the Veteran's present condition is of a type that requires medical expertise to identify it as the same condition as that in service or during a presumption period, or whether it can be so identified by lay observation). See Barr v. Nicholson, 21 Vet. App. 303, 310 (2007).

Thus, medical evidence is not always or categorically required when the determinative issue involves either medical diagnosis or etiology, but rather such issue may, depending on the facts of the particular case, be established by competent and credible lay evidence under 38 U.S.C. § 1154(a). See Davidson, supra.

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. An approximate balance of the evidence includes, but is not limited to, equipoise. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). Evidence is not in "approximate balance" or "nearly equal" when the evidence persuasively favors one side or the other. Id.

3. Entitlement to service connection for peptic ulcers

The Veteran contends that he has peptic ulcers that were incurred in service and have continued since. Specifically, in his November 2018 legacy NOD, he stated that a 2008 service treatment record (STR) showed that he had complained of stomach ulcer related pain since that time, and that while it was initially regarded as gastritis, the pain continued. He added that although a definitive diagnosis of an ulcer came after his separation from service, his appointment for an endoscopy was scheduled as a result of the symptoms within a year of separation from service.

As an initial matter, the Board notes that the evidence establishes the presence of a current disability of ulcer. A January 2018 esophagogastroduodenoscopy (EGD) shows that an ulcer was found in the duodenal bulb. The first element of service connection, as to the presence of
legacy NOD, he stated that a 2008 service treatment record (STR) showed that he had complained of stomach ulcer related pain since that time, and that while it was initially regarded as gastritis, the pain continued. He added that although a definitive diagnosis of an ulcer came after his separation from service, his appointment for an endoscopy was scheduled as a result of the symptoms within a year of separation from service.

As to an in-service event, injury, or disease, the Board notes that an April 2008 STR shows that the Veteran was seen for a possible ulcer and reported that he had begun taking Mylanta and Prilosec. The provider diagnosed gastritis. Subsequently, in an August 2011 STR, a provider noted that the Veteran had a remote history of stomach ulcer, parenthetically noting that the condition had occurred on and off and was worse with stress, and that he had had his last flare around two years previously. The provider renewed a prescription of omeprazole to treat the condition. Given this evidence, the Board finds that the second element of service connection, as to an in-service event, injury, or disease, has also been established.

As to the nexus, or link, between the Veteran's current diagnosis and his in-service treatment for ulcers and/or symptoms of ulcers, the Board finds that an award of service connection on a presumptive basis, as due to chronicity, is warranted. In an April 2018 VA treatment record, a VA provider noted that the Veteran first developed hematochezia and melena in 2008, and that since then he had had numerous recurrent episodes of melena and hematochezia with normocytic anemia noted on laboratory findings. She noted that he was seen by hematology in September 2017 and referred for testing as well as a gastrointestinal consultation. She next noted that the consultation occurred in November 2017, and that he underwent an EGD in January 2018 which found a peptic duodenal ulcer.

In light of the above, and resolving reasonable doubt in the Veteran's favor, the Board finds that an award of service connection on a presumptive basis, as due to chronicity, is warranted. The Veteran was noted to have gastritis and/or an ulcer during his active service, continued to have symptoms thereof during his service (as shown by his continued use of omeprazole and other medications), and also continued to have symptoms thereof after his separation from active service in September 2016. As noted, he was seen by VA providers in September 2017 for ongoing symptoms, and treatment eventually led to an EGD in January 2018 which confirmed the diagnosis of peptic duodenal ulcer. While the diagnosis was not confirmed until January 2018, the evidence clearly demonstrates that the Veteran had the ulcer within a year of separation from his service, and likely even during service, as he had symptoms thereof and sought treatment for the same within a year of separation from his service. As the evidence reflects an onset of an ulcer during service with continuity of symptoms since, an award of service connection on a presumptive basis is warranted.

The Board acknowledges that in March 2018, a VA examiner offered a negative nexus opinion. However, the examiner's rationale was based on an erroneous finding that the Veteran did not have an ulcer, and that she only saw a diagnosis of gastritis. In that regard, the examiner cited to the January 2018 EGD, but stated that it only showed gastritis in the stomach. The examiner's conclusions suggest that she did not fully review the record, as the January 2018 EGD clearly showed a peptic duodenal ulcer. As such, the Board finds that the opinion is entitled to no probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-304 (2008).

For all of the foregoing reasons, and with resolution of reasonable doubt in the Veteran's favor, the Board finds that the criteria for an award of service connection ?

for peptic ulcers have been met. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The appeal of this issue is granted.

DAVID A. BRENNINGMEYER

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board R. Oldroyd, Counsel

The Board's decision in this case is binding
. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-304 (2008).