Citation Nr: 1402992 Decision Date: 01/24/14 Archive Date: 01/31/14 DOCKET NO. 10-30 947 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Manila, the Republic of the Philippines THE ISSUES 1. Entitlement to service connection for coronary artery disease. 2. Entitlement to service connection for sleep apnea. 3. Entitlement to service connection for diabetes mellitus, type II. 4. Entitlement to service connection for benign prostatic hypertrophy. 5. Entitlement to a rating in excess of 40 percent for the service-connected bilateral hearing loss. 6. Entitlement to a rating in excess of 10 percent for the service-connected tinnitus. 7. Entitlement to a rating in excess of 10 percent for the service-connected sinusitis. 8. Entitlement to an initial rating in excess of 10 percent for the service-connected rhinitis. 9. Entitlement to an increased rating for the service-connected hemorrhoids, rated 10 percent disabling prior to December 21, 2011 and 20 percent disabling beginning on that date. 10. Entitlement to a compensable rating for a the service-connected rectal polyp, status post (s/p) polypectomy. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD M. Turner, Counsel INTRODUCTION The Veteran served on active duty from May 1969 to February 1990. This matter comes before the Board of Veterans' Appeals (Board) on an appeal from July 2009 and March 2010 rating decisions issued by the RO. The Board notes that, while the Veteran's claim of service connection for coronary artery disease was considered under a new and material evidence standard by the RO, it is actually to be considered as a new claim at this time because there was a liberalizing change in the law since the prior denial. While an increased rating claim includes a claim for a total rating based on individual unemployability (TDIU) by reason of service-connected disability when a Veteran alleges, or the evidence shows, an inability to work due to the service connected disability, here the Veteran separately submitted two TDIU claims which were pending during this appeal. Thus, his claims were addressed, and he did not appeal the adverse decisions at this time. The issues of service connection for benign prostatic hypertrophy and an increased rating for the service-connected residuals of a rectal polypectomy are being remanded to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran who is shown to have served on land or on the inland waterways of the Republic of Vietnam during the Vietnam War Era is presumed to have been exposure to herbicides incident to this service. 2. The Veteran is shown to be currently diagnosed as suffering from coronary artery disease. 3. The Veteran is not shown to suffer from sleep apnea or diabetes mellitus. 4. The service-connected bilateral hearing loss is not shown to be manifested by worse than a level VI impairment in the right ear and level IX impairment on the left. 5. The service-connected tinnitus is not shown to be productive of exceptional or unusual disability picture that is not contemplated by the currently assigned 10 percent rating. 6. The service-connected sinusitis is not shown to be productive of a disability picture manifested by more than three incapacitating episodes or more than six non-incapacitating episodes per year; nor is he shown to have nasal polyps. 7. Prior to December 11, 2011, the service-connected hemorrhoids were shown to be manifested by persistent bleeding or fissures. 8. The service-connected hemorrhoids were not shown to be productive of exceptional or unusual symptoms not contemplated by the rating schedule at any time. CONCLUSIONS OF LAW 1. By extending the benefit of the doubt to the Veteran, his disability manifested by coronary artery disease is due to his presumed exposure to herbicides that was incurred in active service in the Republic of Vietnam. 38 U.S.C.A. §§ 1110, 5013, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2013). 2. The Veteran does not have a disability manifested by sleep apnea due to disease or injury that was incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 5013, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2013). 3. The Veteran does not have diabetes mellitus due to presumed exposure to herbicides or other disease or injury that was incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 5013, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2013). 4. The criteria for the assignment of a rating in excess of 40 percent for the service-connected bilateral hearing loss disability are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.40, 4.45, 4.86 including Diagnostic Code 6100 (2013). 5. The criteria for the assignment of a rating in excess of 10 percent for the service-connected tinnitus are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.40, 4.45, 4.87 including Diagnostic Code 6260 (2013). 6. The criteria for the assignment of a rating in excess of 10 percent for the service-connected sinusitis are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.40, 4.45, 4.97 including Diagnostic Code 6510 (2013). 7. The criteria for the assignment of a rating in excess of 10 percent for the service-connected rhinitis are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.40, 4.45, 4.97 including Diagnostic Code 6522 (2013). 8. Prior to December 21, 2011, the criteria for the assignment of a 20 percent rating for the service-connected hemorrhoids were met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.40, 4.45, 4.114 including Diagnostic Code 7336 (2013). 9. Beginning on December 21, 2011, the criteria for the assignment of a rating in excess of 20 percent for the service-connected hemorrhoids were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.40, 4.45, 4.114 including Diagnostic Code 7336 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duty to Notify and Assist The Veterans Claims and Assistance Act of 2000 (VCAA) describes VA's duties to notify and assist claimants with substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. § 3.102, 3.156(a), 3.159. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant of any information, and any medical or lay evidence, that is necessary to substantiate his or her claim. 38 U.S.C.A. § 5103(a), 38 C.F.R § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183, 186-187 (2002). In accordance with 38 C.F.R. § 3.159(b)(1), proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. The Board notes that 38 C.F.R. § 3.159 was revised in part, effective May 30, 2008. See 73 Fed. Reg. 23,353-23,356. The third sentence of 38 C.F.R. § 3.159(b)(1), which stated that "VA will also request that the claimant provide any evidence in the claimant's possession that pertains to the claim," was removed. This amendment applies to all applications pending on, or filed after, the regulation's effective date. VCAA notice should be provided to a claimant before the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Pelegrini v. Principi, 18 Vet. App. 112, 115 (2004). However, the VCAA notice requirements may be satisfied notwithstanding errors in the timing or content of the notice if such errors are not prejudicial to the claimant. Id at 121. Further, a defect in the timing of the notice may be cured by sending proper notice prior to a re-adjudication of the claim. Mayfield v. Nicholson, 444 F.3d 1328, 1333-1334 (Fed. Cir. 2006). The VA General Counsel issued a precedential opinion interpreting Pelegrini as requiring the Board to ensure that proper notice is provided unless it makes findings regarding the completeness of the record or other facts that would permit the conclusion that the notice error was harmless. See VAOGCPREC 7-2004. The United States Court of Appeals for the Federal Circuit reaffirmed the importance of proper VCAA notice in Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Mayfield and its progeny instruct that a comprehensive VCAA letter, as opposed to a patchwork of other post-decisional documents, is required to meet the VCAA's notification requirements. Id at 1320. However, VCAA notification does not require a pre-adjudicatory analysis of the evidence already contained in the record. See, e.g. Mayfield v. Nicholson, 20 Vet. App. 537, 541 (2006). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), aff'd sum nom Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007), the United States Court of Appeals for Veterans Claims (Court) held that VCAA notice requirements are applicable to all five elements of a service connection claim. Thus, the Veteran must be notified that a disability rating and effective date for the award of benefits will be assigned if service connection for a claimed disability is awarded. Id at 486. In this case, the Veteran was sent letters which contained the requisite notices in March 2009 and January 2010 VA also must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In connection with the current appeal, VA has of record evidence including service treatment records, service personnel records, VA treatment records, private treatment records, and the written contentions of the Veteran. The Veteran was afforded VA examinations addressing his hearing loss and tinnitus, sinus disability, nasal disability, and hemorrhoids, all of which adequately documented the symptoms and functional effects of those disabilities. The Veteran was not afforded a VA examination with respect to his claims for service connection for diabetes and sleep apnea. In this regard, the Board notes that VA is required to provide a medical examination or medical opinion when such an examination or opinion is necessary to make a decision on the claim. 38 U.S.C.A. § 5107A(d). An examination is considered necessary if the record contains competent evidence that (a) the Veteran has a current disability or persistent or recurrent symptoms of a disability; (b) the disability or symptoms may be associated with the Veteran's service; and (c) the record does not contain sufficient medical evidence for VA to make a decision on the claim. Id. In this case VA was not required to provide an examination with respect to these issues because there is no competent evidence of a current disability. While the Veteran is competent to report a diagnosis that he was told by a health care provider and to report his symptoms, in this case the Veteran did not describe any symptoms of either sleep apnea or diabetes and there is no evidence that the Veteran has ever been diagnosed with either sleep apnea or diabetes. The Board finds that VA satisfied its obligations under the VCAA with respect to the issues that are decided hereinbelow. Service connection The Veteran contends that he developed coronary artery disease, sleep apnea, and diabetes as a result of his military service. Service connection may be granted for a disability resulting from disease or injury that was incurred in, or aggravated by, service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection for some chronic diseases, including coronary artery disease and diabetes, may be granted if manifest to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted for any disease diagnosed after discharge if all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"-the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The requirement that a current disability exist is satisfied if the claimant had a disability at the time his claim for VA disability compensation was filed or during the pendency of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). However, in the case of the chronic diseases set forth in 38 C.F.R. § 3.309, the requisite nexus may also be provided by evidence of continuity of symptoms. Walker v. Shinseki, 708 F.3d 1331 (2013). With regard to claims alleging disability due to exposure to herbicides, a Veteran who served in active military, naval, or air service in Vietnam during the Vietnam era is presumed to have been exposed to a herbicide agent during such service, unless there is affirmative evidence that the Veteran was not exposed to any such agent during that service. Service in Vietnam includes service in the waters offshore Vietnam and service in other locations if the conditions of service required the Veteran to perform duty in, or visit, Vietnam. 38 U.S.C.A. § 1116(f), 38 C.F.R. § 3.307(a)(6)(iii). However, service in Vietnam does not include service that took place exclusively in the territorial waters offshore Vietnam, if the Veteran never set foot on land there. See Haas v. Peake, 544 F.3d 1306, 1308-1309 (Fed. Cir. 2008), cert. den. 129 S.Ct. 1002 (2009). If a Veteran was exposed to a herbicide agent, certain diseases listed at 38 C.F.R.§ 3.309(e) will be considered service connected even though there is no record of such disease in service. These include coronary artery disease and diabetes. VA determined that there is no positive association between exposure to herbicides and any condition other than those for which the Secretary specifically determined that a presumption of service connection is warranted. See 59 Fed. Reg. 341-346 (1994), 61 Fed. Reg. 41442-41449,. 57586-57589 (1996). Notwithstanding the foregoing, a Veteran is not precluded from establishing service connection with proof of direct causation. See Combee v. Brown, 34 F.3d 1039, 1044 (Fed. Cir. 1994). A. Coronary Artery Disease The Veteran's service records show that he served aboard the U.S.S. Schenectady (LST 1185) during the 1974-1975 time period. During this time, it appears that the ship was deployed to Vietnam as evidenced by the Veteran's receipt of the Vietnam Service Medal and the Vietnam Campaign Medal for his participation in the war effort. VA has recognized that all ships with a "LST" designation are presumed to have been present on the inland waterways of Vietnam. Therefore, exposure to herbicides is conceded. Ischemic heart diseases including coronary artery disease are subject to service connection for any herbicide-exposed Veteran. The Veteran's private and VA treatment records show a diagnosis of coronary artery disease. Therefore, on this record, service connection for coronary artery disease is warranted. B. Diabetes Diabetes is also subject to presumptive service connection for herbicide exposed Veterans. However, in this case the evidence does not show that the Veteran has diabetes. VA and private treatment records do not show a diagnosis of diabetes. While the Veteran may believe that he has diabetes, he lacks the requisite medical expertise that is necessary in order to diagnose this condition. Although he is competent to report a diagnosis that was made by a medical professional as well as his symptoms, here the Veteran has not alleged that anyone has told him that he had diabetes mellitus or identified any symptoms of diabetes. He does not identify any reason why he believes that he has diabetes. Since the Veteran is not shown to have diabetes mellitus, an element that is necessary in order to establish entitlement to service connection is absent, specifically, there is no showing of a current diabetes disability. Hence, on this record, service connection must be denied. C. Sleep Apnea Similarly, while the Veteran alleges that he suffers from sleep apnea as a result of his military service, neither his private treatment records nor his VA treatment records show any diagnosis of sleep apnea or document any symptoms or complaints of difficulty sleeping or lack of restful sleep. The Veteran does not indicate that any health care professional ever told him that he had sleep apnea or identified any claimed symptoms of sleep apnea. The Veteran lacks the medical expertise that is necessary to diagnose a sleep-related respiratory disorder such as sleep apnea. Without competent evidence that the Veteran actually has sleep apnea, there is no basis for service connection. Additionally, the Veteran has not identified any basis for his belief that his claimed sleep apnea is related to his military service or identified any treatment records to suggest that he has sleep apnea due to service. Hence, on this record, service connection must be denied. Increased Ratings The Veteran seeks higher ratings for his service-connected hearing loss and tinnitus, sinusitis and rhinitis, and hemorrhoids. Disability ratings are determined by applying criteria that are set forth in the VA's Schedule for Rating Disabilities (38 C.F.R. Part 4). Ratings are based on average impairments of earning capacity resulting from particular diseases and injuries and the residuals thereof in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities are described utilizing diagnostic codes set forth in 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Where entitlement to compensation for a service-connected disease or injury already has been established and entitlement to an increase in the disability rating is at issue, the present level of disability is of primary importance. See, e.g., Franciso v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. See generally Hart v. Mansfield, 21 Vet. App. 505 (2007). A. Hearing loss and Tinnitus The Veteran is currently rated 40 percent disabled for hearing loss and 10 percent disabled for tinnitus. Hearing loss is rated using tables located at 38 C.F.R. § 4.85, diagnostic code 6100. Recurrent tinnitus is rated 10 percent disabling under 38 C.F.R. § 4.87, diagnostic code 6260. This is the highest scheduler rating for this disability. A single rating is assigned for recurrent tinnitus, whether the sound is perceived in one ear, both ears, or in the head. 38 C.F.R. § 4.87, Diagnostic Code 6260, note 2. The Veteran was afforded a VA audiological examination in May 2009. The examiner noted that the Veteran used hearing aids. His chief complaint was difficulty hearing in the presence of background noise. He described his tinnitus as a loud high pitched sound that occurred about five times per day and lasted about 30 minutes. At that time his pure tone thresholds, in decibels, were: HERTZ 1000 2000 3000 4000 RIGHT 55 65 80 90 LEFT 60 70 85 90 The average pure tone threshold in decibels was 72 for the right ear and 76 for the left ear. The Veteran's speech recognition ability was 92 percent in the right ear and 92 percent in the left ear. The diagnosis was moderate to severe sensorineural hearing loss with sloping on high frequency, both ears. The Veteran's hearing loss constitutes an exceptional pattern of hearing impairment pursuant to 38 C.F.R. § 4.86. Thus, the numeric designation of his hearing loss is determined by applying the higher of the result from Table VI, which considers speech discrimination scores in combination with pure tone threshold averages, or the result from Table VIA, which considers pure tone threshold averages only. In this case, application of Table VIA produces a higher numerical designation. Applying that table, the Veteran has a level VI impairment in the right ear and a level VI impairment in the left ear. This equates to a 30 percent rating using Table VII. The Veteran's hearing was reexamined in February 2012. The Veteran reported that his tinnitus was a loud high pitched ringing that occurred three to four times per week and lasted 10 to 15 minutes per episode. At that time his pure tone thresholds, in decibels, were: HERTZ 1000 2000 3000 4000 RIGHT 60 70 90 85 LEFT 70 80 95 95+ The average pure tone threshold in decibels was for 76 the right ear and 85 for the left ear. The Veteran's speech recognition ability was 92 percent in the right ear and 92 percent in the left ear. The diagnosis was that of bilateral sensorineural hearing loss in the frequencies of 500 to 4000 Hertz and 6000 Hertz and above. The Veteran's hearing loss constitutes an exceptional pattern of hearing impairment pursuant to 38 C.F.R. § 4.86. Application of Table VIA yields higher numerical designations of VI for the right ear and IX for the left ear. This yields a 40 percent rating. In June 2012 a VA examiner opined that the Veteran's impaired hearing and tinnitus could affect his employment because the Veteran would have difficulty communicating with others such as hearing directions. However, he had used hearing aids for more than six years. With continued hearing aid use, the ability to maintain gainful employment would not be affected by the hearing loss and tinnitus. The Veteran's hearing was examined again in April 2013. He complained of having difficulty understanding spoken words in conversation. He reported that his tinnitus was a loud high pitched ringing in both ears which was intermittent, occurring two or three times per week and lasting several minutes per episode. At that time his pure tone thresholds, in decibels, were: HERTZ 1000 2000 3000 4000 RIGHT 50 50 75 75 LEFT 40 65 80 85 The average pure tone threshold in decibels was 62 for the right ear and 68 for the left ear. The Veteran's speech recognition ability was 68 percent in the right ear and 36 percent in the left ear. The diagnosis was sensorineural hearing loss in the frequency range of 500 to 4000 Hertz. The Veteran's hearing loss did not meet the criteria for an exceptional pattern of hearing impairment at this time. Application of table VI yields a level V impairment in the right ear and a level IX impairment in the left ear. This yields a 40 percent rating. The treatment records reflect continuing complaints of tinnitus and the Veteran received hearing aids to help with his hearing loss. The Veteran did not identify any symptoms or functional effects of his hearing loss and tinnitus which were not documented on the examination reports, although in the past he had claimed that he was unable to work due to hearing loss and tinnitus. However, he did not at that time explain how hearing loss and tinnitus prevented him from working. The evidence does not show that the Veteran meets the criteria for a rating in excess of 40 percent for his hearing loss. Application of the tables at 38 C.F.R. § 4.85 yield a 40 percent rating or less each time that the Veteran's hearing was tested. The Board finds that the Veteran's symptoms do not present such an exceptional disability picture as to render the schedular rating inadequate. 38 C.F.R. § 3.321(b). See also Thun v. Peake, 22 Vet. App. 111, 115 (2008) (the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the schedular evaluation is inadequate). The Veteran's symptom of decreased hearing is specifically contemplated by the rating schedule. There is no evidence that the Veteran was hospitalized at any relevant time for hearing loss related complaints. While the Veteran had in the past claimed that he was unable to work due to hearing loss and tinnitus, all of the examiners who tested the Veteran found that there was no interference with employment if he used his hearing aids and the Veteran did not offer any evidence, other than his own statement, that hearing loss prevented him from working. The evidence also does not show material interference with employment since the Veteran could and did use hearing aids to improve his hearing. The evidence also does not show any exceptional or unusual factors warranting an extraschedular rating for tinnitus. The 10 percent rating for tinnitus contemplates recurrent ringing in the ears and the Veteran did not identify any other tinnitus related symptoms. The Veteran was never hospitalized for tinnitus, and although in the past he had claimed that hearing loss and tinnitus prevented him from working, there was no evidence of this other than the Veteran's own statements. The examiners did not find that the Veteran's tinnitus materially interfered with his employment. The Veteran in any event had not been employed since having heart surgery some years earlier and there was no showing that his failure to return to work had anything to do with hearing loss or tinnitus. B. Sinusitis and Rhinitis Sinusitis, at 38 C.F.R. § 4.97, Diagnostic Codes 6510-6514, are rated pursuant to a general rating formula for sinusitis. Pursuant to this formula, sinusitis is 10 percent disabling when there are one or two incapacitating episodes of sinusitis per year requiring prolonged (lasting four to six weeks) antibiotic treatment, or three to six non-incapacitating episodes of sinusitis characterized by headaches, pain, and purulent discharge or crusting. It is rated 30 percent disabling when there are three or more incapacitating episodes or more than six non-incapacitating episodes per year. It is rated 50 percent disabling following radical surgery with chronic osteomyelitis, or when there is near constant sinusitis characterized by headaches, pain and tenderness of the affected sinus, and purulent discharge or crusting after repeated surgeries. 50 percent is the highest scheduler rating for this disability. Allergic or vasomotor rhinitis is rated pursuant to 38 C.F.R. § 4.97, diagnostic code 6522. A 10 percent rating applies without polyps but with greater than 50 percent obstruction of the nasal passage on both sides or complete obstruction on one side. A 30 percent rating applies with polyps. 30 percent is the highest rating for this disability. The VA treatment record show complaints of recurrent sinusitis with headaches and congestion; however, these episodes are not shown to be incapacitating in nature. The Veteran was examined with respect to these complaints in February 2012. At that time, the Veteran had been diagnosed with maxillary sinusitis and rhinitis. At the time of the examination, there were no sinus symptoms. The Veteran had not had any incapacitating episodes of sinusitis in the past year and had three episodes of non-incapacitating sinusitis. He never had surgery on his sinuses. There was greater than 50 percent obstruction of the nasal passage on one side due to rhinitis. There were no polyps. The examiner noted that the Veteran's sinusitis and rhinitis caused him irritation and discomfort. The rhinitis problem often complicated and caused sinus infection. However, there were no signs of sinus infection during the examination. In May 2012, the Veteran filed another claim alleging that difficulty breathing due to sinusitis and rhinitis prevented him from working. However, he also attributed his breathing difficulties to his heart problems. In June 2012 a VA examiner opined that the chronic maxillary sinusitis would mildly to moderately affect his employment since he was experiencing almost daily nasal congestion, sneezing, post nasal drip, cough, throat itchiness and occasional headaches requiring treatment with antihistamines and nasal spray. He got recurrent sinus infections requiring the use of antibiotics at least one or twice per year. These symptoms caused irritation and discomfort. The Veteran could not work in an environment where he would be exposed to dust or other pollutants or allergens. The Veteran's sinusitis and rhinitis were reexamined in April 2013. He was again noted to be diagnosed with chronic sinusitis and allergic rhinitis. He had frontal and maxillary sinusitis that caused headaches and pain and tenderness of the affected sinuses. He had not had any incapacitating episodes of sinusitis in the past year. He had five non-incapacitating episodes of sinusitis in the past year. He had no history of sinus surgery. Examination of the nose showed greater than 50 percent obstruction of the nasal passage on both sides due to rhinitis. There was permanent hypertrophy of the nasal turbinates. There were no polyps. The Veteran reported that his sinusitis and rhinitis affected work because during exacerbations he got severe headaches that made him unable to move around and he would opt to rest until the pain subsided. The evidence does not show that the Veteran meets the criteria for a rating in excess of 10 percent for his service-connected sinusitis. The Veteran was not shown to have more than six non-incapacitating episodes of sinusitis per year and had no incapacitating episodes of sinusitis. Similarly, the evidence does not show that the Veteran meets the criteria for a rating in excess of 10 percent for allergic rhinitis because there are no polyps. The Board finds that the Veteran's symptoms of sinusitis and rhinitis do not present such an exceptional disability picture as to render the schedular rating inadequate. 38 C.F.R. § 3.321(b). See also Thun 22 Vet. App. 111at 115. The 10 percent rating for sinusitis contemplates six or less non-incapacitating episodes of sinusitis and symptoms such as headaches and pain which were reported by the Veteran. The Veteran's chronic nasal congestion and allergy symptoms are contemplated by the 10 percent rating for rhinitis. The congestion produced chronic greater than 50 percent obstruction of both nasal passages which is described in the criteria for a 10 percent rating for allergic rhinitis. While the Veteran also complained of allergy symptoms such as post-nasal drip and coughing/sneezing, these symptoms are not so severe as to warrant a higher rating. Moreover, the Veteran has not been hospitalized for sinusitis or rhinitis and the evidence does not show material interference with employment. Although the Veteran experienced discomfort and avoided inhaling irritants, this was not shown to have any substantial effect on his employment. The Veteran has not been employed since a heart operation several years ago, and there is no indication that this situation is due to sinusitis or rhinitis. C. Hemorrhoids Hemorrhoids are rated pursuant to 38 C.F.R. § 4.114, Diagnostic Code 7336. Large or thrombotic irreducible hemorrhoids with excessive redundant tissue, evidencing frequent recurrences, are 10 percent disabling. Internal or external hemorrhoids with persistent bleeding and with secondary anemia or fissures are rated 20 percent disabling. Here, the RO rated the Veteran's hemorrhoids 10 percent disabling prior to December 21, 2011 and 20 percent disabling thereafter. The treatment records show intermittent complaints of bleeding hemorrhoids. At his examination in April 2009, the Veteran described having anal pain and blood streaked stools. This had been on and off since the 1980's. He had a prior hemorrhoidectomy. He took Metamucil daily and used hot sitz baths and dulcolax when constipated. A proctosigmoidoscopy in April 2008 showed grade II internal hemorrhoids. The Veteran described recurrent gas, anal itching, pain, and difficulty passing stool. He had occasional bleeding from the hemorrhoids. He had four or more recurrences per year without thrombosis and four or more recurrences per year with thrombosis. The examination showed internal hemorrhoids. They were reducible. There was no evidence of prolapse, thrombosis, bleeding, fissures or redundant tissue. The examiner assessed that anal pain and blood streaked stools had mild to moderate effects on the Veteran's usual daily activities. In December 2011, the Veteran was reexamined with respect to his hemorrhoids. He claimed to continue to have blood streaked stools when constipated. He used to take Metamucil but now took lactulose. The examination showed mild to moderate hemorrhoids but still with prolapse; he often pushed it back and had persistent bleeding. Internal and external hemorrhoids were palpated, but there was no blood. He had anal pruritus due to hemorrhoids. The Veteran reported that, whenever he walked, the hemorrhoid would go down or outside of his anus. The examiner did not diagnose any anemia. In March 2012, the Veteran reported to an examiner that he had on and off bloody stools and sought regular treatment for this. He had three hemorroidectomies in the past. He took dulcolax and lactulose. Blood tests were done and anemia was not diagnosed. In June 2012, an examiner assessed that hemorrhoids mildly restricted the Veteran's ability to work because he had episodes of rectal bleeding four times per month secondary to constipation requiring treatment with stool softener and laxatives. He also had occasional prolapse of anal tissue requiring manual reduction one or two times per week. Episodes of bleeding and especially episodes of prolapse with associated rectal pain would prevent him from exerting physical effort such as lifting heavy objects as well as he would not be able to tolerate sitting for prolonged periods. The Veteran's hemorrhoids were reexamined in April 2013. At that time the Veteran continued to complain of occasional constipation with rectal bleeding. He took dulcolax as needed. He had mild or moderate reducible hemorrhoids. Exam showed small or moderate external hemorrhoids. They affected the Veteran's ability to work because he had to frequently manually reduce the hemorrhoids. The Veteran did not make any specific contentions about his hemorrhoids other than what he stated to the examiners. The Board finds that a 20 percent rating should extend back to the date of claim because there is no showing of a change in the disability since that time. In reaching this determination, we have considered the lay evidence. The Veteran presented lay evidence that he was worse than evaluated prior to the recent examination. In addition, nothing during the subsequent examination establishes that he became worse at that time. Rather, the evidence at that time provided a historic prospective of on-going disability. However, the criteria for a rating in excess of 20 percent for hemorrhoids have not been met. This is the highest rating for hemorrhoids and there has been no showing of exceptional factors that make application of the rating schedule inadequate. The assigned 20 percent rating contemplates even more severe symptoms than the Veteran has such as anemia and fissures. He had three hemrroidectomies in the past but the most recent was in the 1990's. The examiners assessed the hemorrhoids as having some effect on employment due to factors such as rectal pain, but this was not shown to be so severe as to constitute material interference with employment. In any event, the Veteran has not been employed for several years since he had heart surgery and there is no indication that his decision not to go back to work was caused by hemorrhoids. The Board acknowledges that VA is statutorily required to resolve the benefit of the doubt in favor of the Veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. ORDER Service connection for coronary artery disease is granted. Service connection for diabetes mellitus is denied. Service connection for sleep apnea is denied. A rating in excess of 40 percent for the service-connected bilateral hearing loss is denied. A rating in excess of 10 percent for the service-connected tinnitus is denied. A rating in excess of 10 percent for the service-connected sinusitis is denied. A rating in excess of 10 percent for the service-connected rhinitis is denied. An increased rating of 20 percent for the service-connected hemorrhoids for the period prior to December 21, 2011 is granted, subject to the regulations controlling disbursement of VA monetary benefits. An increased rating in excess of 20 percent for the service-connected hemorrhoids beginning on December 21, 2011 is denied. REMAND With regard to the claim of service connection for benign prostatic hypertrophy, his treatment records show that the Veteran is currently diagnosed with this condition. He claims that he developed benign prostatic hyperplasia as a result of exposure to herbicides. While benign prostatic hyperplasia is not a disease subject to presumptive service connection, entitlement to service connection may still be established on a direct basis. A medical opinion should be obtained as to whether his benign prostatic hypertrophy is related to herbicides or any other disease or injury in service. Additionally, more development is needed with respect to the Veteran's claim for a higher rating for the service-connected rectal polyp, s/p polypectomy. First, there appears to be a conflict between the examinations. A proctosigmoidoscopy in April 2008 did not show any recurrence of rectal polyps. Yet, symptoms of anal pain and blood streaked stools were ascribed to the rectal polyp at the April 2009 examination. These same symptoms were also ascribed to the Veteran's hemorrhoids making it difficult to differentiate the symptoms of these two disabilities. The examiner assessed the rectal polypectomy as having mild to moderate effects on daily activities but did not explain the nature of these restrictions and there is no way to differentiate them from the restrictions due to the Veteran's hemorrhoids. At the January 2012 examination the examiner assessed that the polypectomy caused abdominal pain, diarrhea, and bloody stools. She assessed that symptoms of the polypectomy caused mild restriction in work activities but provided no explanation of what these restrictions were. Again, bloody stools is a symptom that has also been ascribed to the Veteran's hemorrhoids. The examiner did not indicate whether any polyps were actually present. A proctosigmoidoscopy was deferred because the Veteran was leaving the country soon. In June 2012, an examiner noted that the polyp status post polypectomy caused no effect on employment since the polyp had not recurred. It does not appear that the proctosigmoidoscopy that was needed in January 2012 to fully evaluate the Veteran's symptoms ever occurred. It is not clear whether the Veteran actually has a polyp or current symptoms of a polypectomy other than the symptoms for which he is already being compensated by his 20 percent rating for hemorrhoids. Therefore, the Veteran should be given a new examination with any appropriate testing to determine whether he has any recurrence of the polyp or symptoms due to the polypectomy. Accordingly, these remaining matters are REMANDED for the following action: 1. The RO should take appropriate action to obtain a VA opinion concerning the likely etiology of the claimed benign prostatic hyperplasia. The examiner should review the claims file and, if necessary, examine the Veteran. He or she should indicate whether it is at least as likely as not (at least 50 percent likely) that the Veteran's benign prostate hyperplasia or any other prostate disorder had its clinical onset during service or otherwise is due to the exposure to herbicides or another event or incident of his period of active service. A complete rationale should be provided in support of the opinion that is rendered. If the examiner is unable to provide the requested opinion without resort to undue speculation, he or she should explain why this is the case. 2. The RO also should have the Veteran scheduled for a VA examination to determine the nature and severity of the service-connected anorectal polyp, s/p polypectomy. The examiner should review the claims file in conjunction with the examination. All necessary tests and studies should be performed, including a proctosigmoidoscopy if that is deemed necessary by the examiner. The examiner should determine whether the Veteran presently has any recurrence of the polyp or any other residuals of the rectal polyp s/p polypectomy. The examiner should document all the symptoms and functional effects of the polyp s/p polypectomy, to the extent any such symptoms are present. If symptoms are identified, the examiner should fully document those symptoms and to the extent possible differentiate these symptoms from the symptoms of the Veteran's hemorrhoids. 3. After completing all indicated development, the RO should readjudicate claims remaining on appeal in light of all the evidence of record. If any benefits sought on appeal remains denied, the Veteran and his representative should be furnished a fully responsive Supplemental Statement of the Case (SSOC) and afforded a reasonable opportunity for response. Thereafter, if indicated, the case should be returned to the Board for the purpose of appellate disposition. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ STEPHEN L. WILKINS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs