Citation Nr: 0811477 Decision Date: 04/08/08 Archive Date: 04/23/08 DOCKET NO. 04-14 698 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to service connection for peripheral neuralgia, claimed as twitching of the nerves and muscles, including as due to exposure to DDT or as due to service- connected disability. 2. Entitlement to service connection for a liver problem, including as due to exposure to DDT or as due to service- connected disability. 3. Entitlement to service connection for gastrointestinal tract problems, esophageal dysmotility and dysphagia with aspiration, low back and neck pain and degenerative joint disease, muscle pain and weakness, gall bladder problem, and right kidney cyst, claimed as due to exposure to DDT or as due to service-connected disability. 4. Entitlement to an increased evaluation for erythropoietic protoporphyria, dermatitis actinica, due to sunlight, currently evaluated as 10 percent disabling. 5. Entitlement to a compensable evaluation for post- operative hemorrhoidectomy, with external tags. WITNESSES AT HEARING ON APPEAL Appellant and his son ATTORNEY FOR THE BOARD Jason R. Davitian, Counsel INTRODUCTION The veteran served on active duty from March 1944 to February 1946. This case is before the Board of Veterans' Appeals (BVA or Board) on appeal from an October 2002 rating decision of the Department of Veterans Affairs (VA) Regional Office in New Orleans, Louisiana (RO), which denied compensable evaluations for dermatitis actinica, due to sunlight, and post-operative hemorrhoidectomy, with external tags. An April 2004 rating decision denied the service connection claims on appeal. During the pendency of the appeal, a July 2007 rating decision recharacterized the veteran's service-connected dermatologic disability as including erythropoietic protoporphyria, and assigned a 10 percent evaluation for erythropoietic protoporphyria (EPP) and dermatitis actinica, due to sunlight. In his claims for service connection for a variety of ailments, including a liver disorder and gastrointestinal tract (GI) problems, the veteran contended the claimed disorders were due to in-service exposure to DDT. The veteran's claims, liberally interpreted, include a claim for service connection for each of the claimed disorders on any basis, including on the basis of secondary service connection. During the course of the appeal, the veteran sought service connection for porphyria. The medical evidence disclosed a specific type of porphyria, EPP. The evidence also disclosed that the skin disorder for which the veteran was granted service connection was a manifestation of erythropoietic protoporphyria, the RO recharacterized the veteran's service-connected disability as erythropoietic protoporphyria. The Board finds that the claims, liberally construed to include the claim for service connection as secondary to service-connected EPP, are more accurately stated as listed on the title page of this decision. The claims for service connection for GI problems, esophageal dysmotility and dysphagia with aspiration, low back and neck pain and degenerative joint disease, muscle pain and weakness, gall bladder problem, and right kidney cyst, claimed as due to exposure to DDT, to include as secondary to service-connected erythropoietic protoporphyria, are addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The competent medical evidence demonstrates that the veteran's peripheral neuralgia, claimed as twitching of the nerves and muscles, and liver disease are the result of his service-connected erythropoietic protoporphyria. 2. The competent medical evidence does not show that the dermatologic manifestations of the veteran's erythropoietic protoporphyria, for which service connection was granted under the diagnosis of dermatitis actinica, due to sunlight, result in constant exudation, itching or extensive lesions; coverage of 20 to 40 percent of the entire body or exposed areas, or the requirement of systemic therapy for a total duration of 6 weeks or more, but not constantly, during the past 12-month period. 3. The competent medical evidence does not show that the veteran's post-operative hemorrhoidectomy, with external tags, is manifest by internal or external hemorrhoids that are large or thrombotic, or irreducible with excessive redundant tissue evidencing frequent recurrences. CONCLUSIONS OF LAW 1. Service connection for peripheral neuralgia, claimed as twitching of the nerves and muscles, is warranted. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.303, 3.304, 3.310(a) (2007). 2. Service connection for a liver disorder is warranted. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.303, 3.304, 3.310(a) (2007). 3. The criteria for an evaluation in excess of 10 percent for erythropoietic protoporphyria and dermatitis actinica, due to sunlight, have not been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. § 4.118, Diagnostic Codes 7806, 7815 (prior to August 30, 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.118, Diagnostic Code 7815 (2007). 4. The criteria for a compensable evaluation for post- operative hemorrhoidectomy, with external tags, have not been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.114, Diagnostic Code 7336 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2007). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA 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; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In the case of the claims for service connection for peripheral neuralgia, claimed as twitching of the nerves and muscles, and a liver problem, the Board is granting in full the benefits sought on appeal. Accordingly, assuming, without deciding, that any error was committed with respect to either the duty to notify or the duty to assist, such error was harmless and will not be further discussed. With respect to the claims for increased evaluations, the VCAA duty to notify the veteran of VA's duties to him was partially met in July 2002 and July 2003 letters sent to the appellant prior to the respective initial AOJ decisions in this matter. The letters informed the appellant of what evidence was required to substantiate the claims and of the appellant's and VA's respective duties for obtaining evidence. Correspondence to the veteran sent in March 2004 and May 2004 provided him with adequate notice of the pertinent diagnostic codes. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). Since the claims for increased ratings were thereafter readjudicated, the 2002 and 2004 communications provided notice which fulfills the requirements of the VCAA as to the requirements that the veteran be informed of the diagnostic codes and the types of evidence which may be relevant to substantiate a claim. The appellant was not asked to submit evidence and/or information in his possession to the AOJ, or to submit evidence reflecting the effect that worsening of a disability has on a veteran's employment and daily life. Thus, the VCAA duty to notify has not been satisfied with respect to the fourth notice element of asking the claimant to provide any evidence in his possession that pertains to the claim in accordance with 38 C.F.R. § 3.159(b)(1). In Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007), the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that any error by VA in providing the notice required by 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b)(1) is presumed prejudicial, and that once an error is identified as to any of the four notice elements the burden shifts to VA to demonstrate that the error was not prejudicial to the appellant. The Federal Circuit stated that requiring an appellant to demonstrate prejudice as a result of any notice error is inconsistent with the purposes of both the VCAA and VA's uniquely pro-claimant benefits system. Instead, the Federal Circuit held in Sanders that all VCAA notice errors are presumed prejudicial and require reversal unless VA can show that the error did not affect the essential fairness of the adjudication. To do this, VA must show that the purpose of the notice was not frustrated, such as by demonstrating: (1) that any defect was cured by actual knowledge on the part of the claimant; (2) that a reasonable person could be expected to understand from the notice what was needed; or (3) that a benefit could not have been awarded as a matter of law. Although not specifically discussed by the court, some other possible circumstances that could demonstrate that VA error did not prejudice the claimant include where the claimant has stated that he or she has no further evidence to submit, or where the record reflects that VA has obtained all relevant evidence. In this case, the Board finds that the notice error did not affect the essential fairness of the adjudication and thus the purpose of the fourth notice element was not frustrated. Based on the notice letters discussed above, a reasonable person could be expected to understand from the notices what was needed to substantiate the claims. The claims file establishes that the veteran did understand, either from his representative or on the basis of the numerous communications sent to him, that he could submit evidence in his possession. The claims file demonstrates that the veteran submitted such varied evidence as medical bills and information obtained from the Internet, as well as his own written statements and oral testimony at a personal hearing. Further, there is no indication that VA has not obtained all available relevant evidence. The veteran did not submit any additional evidence when given the opportunity to do so by a September 2007 letter from the RO informing him that his claims had been certified to the Board. The veteran's lack of response to this final letter, in contrast to his previous efforts to submit statements and evidence, makes it clear that he has submitted all evidence and/or information in his possession. In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the Court of Appeals for Veterans Claims (Court) held that upon receipt of an application for a service-connection claim, VA must inform the veteran that a disability rating and an effective date will be assigned if benefits are awarded. In this case, the veteran was not provided Dingess notice. Despite this fact, the Board finds no prejudice to the veteran in proceeding with the issuance of the final decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993) (where the Board addresses a question that has not been addressed by the agency of original jurisdiction, the Board must consider whether the veteran has been prejudiced thereby). As noted above, the veteran provided lengthy testimony about the impact of his service-connected disabilities on his life and health. In this regard, the Board further notes that, as discussed below, the preponderance of the evidence is against the veteran's claims for increased ratings. Thus, any questions as to the appropriate effective dates to be assigned are rendered moot. As such, the Board finds, as a matter of fact, that the veteran was not, as to the appeals denied in this decision, prejudiced by the defects in notice as to those claims. The Board finds that any deficiency in the notice to the veteran or the timing of the notice is harmless error. See Overton v. Nicholson, 20 Vet. App. 427, 435 (2006) (finding that the Board erred by relying on various post-decisional documents to conclude that adequate 38 U.S.C.A. § 5103(a) notice had been provided to the appellant, the Court found that the evidence established that the veteran was afforded a meaningful opportunity to participate in the adjudication of his claims, and found that the error was harmless, as the Board has done in this case). VA has a duty to assist the veteran in the development of the claim. This duty includes assisting the veteran in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished with respect to the claims currently on appeal, and therefore appellate review may proceed without prejudice to the appellant. See Bernard, supra. The RO has obtained VA and private medical records. The veteran had the opportunity to testify at a personal hearing, and provide information through a witness, his son, as well. The appellant was afforded VA medical examinations in August 2002, November 2003 and October 2006 in connection with his increased evaluation claims. Significantly, the Board observes that the veteran does not report that his hemorrhoids have worsened since his most recent examination, in August 2002. Thus a remand is not required solely due to the passage of time since that examination. See Palczewski v. Nicholson, 21 Vet. App. 174, 182-83 (2007); VAOPGCPREC 11- 95 (1995), 60 Fed. Reg. 43186 (1995). VA need not conduct examinations with respect to the service connection claims. The evidence set forth and analyzed below (which shows no pertinent complaints, symptoms, findings or diagnoses during service or applicable presumptive periods, and includes no evidence linking the claimed conditions to service) contains sufficient competent medical evidence to decide the claim. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also Wells v. Principi, 326 F.3d 1381 (Fed. Cir. 2003) (there must be some evidence of a causal connection between the alleged disability and the veteran's military service to trigger VA's obligation to secure a medical opinion pursuant to 38 U.S.C.A. § 5103A(d)). Therefore, the Board is satisfied that the duty to assist has been met. 38 U.S.C.A. § 5103A. Significantly, neither the appellant nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claims that has not been obtained. In this respect, several sources of medical records identified by the veteran informed VA that no records are available. Hence, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Service Connection Claims Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. § 1131 (West 2002); 38 C.F.R. § 3.303(a) (2007). Service connection generally requires evidence of a current disability with a relationship or connection to an injury or disease or some other manifestation of the disability during service. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). A disorder may be service connected if the evidence of record reveals that the veteran currently has a disorder that was chronic in service or, if not chronic, that was seen in service with continuity of symptomatology demonstrated thereafter. 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488, 494-97 (1997). Disorders diagnosed after discharge may still be service connected if all the evidence, including pertinent service records, establishes that the disorder was incurred in service. 38 C.F.R. § 3.303(d). Where the determinative issue involves medical causation or a medical diagnosis, there must be competent medical evidence to the effect that the claim is plausible; lay assertions of medical status do not constitute competent medical evidence. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. 38 U.S.C.A. § 5107(b). Certain chronic diseases, including arthritis, may be presumed to have been incurred during service if they become disabling to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. A July 2005 report from a private physician states that the veteran has peripheral neuropathy, liver disease and pain due to EPP. As service connection has been granted for erythropoietic protoporphyria, the Board finds that secondary service connection is warranted for peripheral neuropathy, claimed as twitching of the nerves and muscles, and liver disease. There is no evidence of pertinent complaints, symptoms, findings or diagnoses of degenerative joint disease within one year of the veteran's separation from service. Because these claimed conditions were not seen during service, service connection may not be established based on chronicity in service or continuity of symptomatology thereafter. 38 C.F.R. § 3.303; Savage, 10 Vet. App. at 494-97. Because degenerative joint disease was not seen within one year of the veteran's separation from service, presumptive service connection is not warranted. In reports dated in 2003 and 2004, a private physician stated that he had been seeing the veteran as a patient since 1992 for a variety of disorders. The physician noted the veteran's history that he was exposed to DDT while on active duty, and the history of possible porphyria. The physician related the veteran's only to the development of the veteran's EPP and peripheral neuralgia (for which the Board is granting secondary service connection, see above). The veteran submitted November 2004 and January 2005 private medical statements, which related the onset of manifestations of EPP to the veteran's service or exposure to DDT during service. These private opinions, and an October 2006 VA examiner opinion, indicate that the veteran was diagnosed with porphyria during service or soon after service or that the disorder diagnosed in service was actually porphyria or EPP. These opinions linked a liver disorder to the veteran's service-connected EPP. In an October 2006 VA medical opinion, the provider related the veteran's skin manifestations to EPP, and inherited disorder which is controlled, in part, by exposure to sunlight. Resolving any reasonable doubt in the veteran's favor, the preponderance of the medical evidence establishes that peripheral neuralgia and a liver disorder. The claims are granted. Increased Evaluation Claims Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2007). 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. Reasonable doubt as to the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. While the veteran's entire history is reviewed when assigning a disability evaluation, 38 C.F.R. § 4.1, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The Court has held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the veteran, as well as the entire history of the veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). The Rating Schedule provides that when an unlisted disability is encountered, it will be permissible to rate it under a closely related disease or injury in which not only the functions affected, but also the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. 1. Increased rating for skin disability Turning to the veteran's skin condition, the Board observes that during the pendency of the veteran's appeal, VA promulgated new regulations for evaluating disability from skin disorders, effective August 30, 2002. See 67 Fed. Reg. 49,590 (July 31, 2002) (codified at 38 C.F.R. pt. 4). The timing of this change requires the Board to consider the claim under the pre-amended regulations for any period prior to the effective date of the amended diagnostic codes. Thereafter, the Board must analyze the evidence dated after the effective date of the amended regulations and consider whether a rating higher than the pre-amended rating is warranted. See VAOPGCPREC 7-2003; Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). The veteran was originally rated noncompensable for dermatitis actinica, due to sunlight, under Diagnostic Code 7817. However, the July 2007 rating decision granted service connection for erythropoietic protoporphyria, combined it with dermatitis actinica, due to sunlight, and assigned a 10 percent evaluation under Diagnostic Code 7815. Under the previous version of Diagnostic Code 7815 (pemphigus) (effective prior to August 30, 2002), conditions under that diagnostic code are to be rated as eczema, dependent upon location, extent, and repugnant or otherwise disabling character of manifestations. Under the previous version of Diagnostic Code 7806 (effective prior to August 30, 2002), eczema manifested by exfoliation, exudation, or itching, if involving an exposed surface or extensive area, warrants a 10 percent evaluation. A 30 percent evaluation requires findings of constant exudation or itching, extensive lesions, or marked disfigurement. Under the current version of Diagnostic Code 7815 (bullous disorders), a bullous disorder covering at least 5 percent, but less than 20 percent of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or requiring intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than 6 weeks during the past 12-month period warrants a 10 percent disability rating. A bullous disorder covering 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or requiring systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of 6 weeks or more, but not constantly, during the past 12-month period warrants a 30 percent disability rating. Otherwise, the disorder is rated based on disfigurement of the head, face, or neck (Diagnostic Code 7800), or scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, Diagnostic Code 7815 (2007). VA treatment records dated during the appeal periods relate that the veteran reported a diagnosis of porphyria but are negative for treatment. Private medical reports dated in 2003, 2004 and 2005 relate that the veteran has porphyria. The 2005 report provides that the disease completely disabled the veteran. The report of a November 2003 VA examination provides that on physical examination the veteran had no dermatitis or erythema or vesicles on the hands. He did have a dark purple macula on the left arm, and some scaly, erythematous dermatitis on the globella and around the ears. He had some mild distal onycholysis on a few fingernails and also had some dystrophy of the nail plate on the right first fingernail. The diagnosis was purpura simplex; seborrheic dermatitis; habit tic deformity; a nail dystrophy, possibly very mild psoriasis; and photosensitivity, by history. The report of an October 2006 VA examination provides that the veteran reported hypersensitivity to the sun, with chronic burning of his hands. He had to wear long sleeves all year long. He had to avoid direct exposure to sunlight because of severe painful stinging and burning. He had no systemic symptoms. On physical examination, the veteran had no active lesions. He indicated burning sensation of both his hands. His hand felt very warm to the touch. The face, neck and upper chest skin was erythematous in comparison to other parts of his body. Mild erythema was noted to the dorsum of both hands. Flakiness was noted to the eyebrows, nasal folds and skin. The skin area affected was 5 to 20 percent. The estimate of sun exposed skin was 5 to 20 percent. Blood test results from April 2006 suggested erythropoietic protorporphyria. The final diagnosis was erythropoietic protoporphyria and seborrheic dermatitis. The foregoing medical evidence does not support the veteran's claim for an evaluation in excess of 10 percent under the old or the revised criteria. It does not show constant exudation, itching, extensive lesions, Diagnostic Code 7806 (effective prior to August 30, 2002); coverage of 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas, or the requirement of systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of 6 weeks or more, but not constantly, during the past 12-month period, Diagnostic Code 7815. The Board recognizes that the October 2006 VA examination report shows that the veteran's head, face or neck was erythematous in comparison to other parts of his body, with flakiness in the eyebrows, nasal folds and skin. However, the record overall is negative for any opinion or evidence that the veteran was disfigured or that he has scars as a predominate disability. Therefore, Diagnostic Codes 7800 to 7805 are not applicable. The Board is aware of the veteran's own assertions as to the severity of his skin condition. However, these contentions do not support his claim. As a general matter, lay statements are considered to be competent evidence when describing the features or symptoms of an injury or illness. See Falzone v. Brown, 8 Vet. App. 398, 405 (1995). The veteran himself, as a layperson, is not competent to provide an opinion requiring medical knowledge or a clinical examination by a medical professional, such as an opinion addressing whether a service-connected disability satisfies diagnostic criteria. See Bostain, supra, citing Espiritu, supra. See also Routen, supra ("a layperson is generally not capable of opining on matters requiring medical knowledge"). Despite the veteran's testimony as to the observable symptoms of his skin disability, the medical record before the Board shows that the manifestations do not satisfy the diagnostic criteria. As a result, his assertions do not constitute evidence that this disability warrant an increased evaluation. In sum, the medical evidence demonstrates that the veteran is not entitled to the claimed increased evaluation. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See generally Gilbert, supra; Ortiz, supra. 2. Increased rating for hemorrhoids Turning to the veteran's hemorrhoids, the Rating Schedule provides that a noncompensable evaluation is warranted for internal or external hemorrhoids that are mild or moderate. A 10 percent rating is warranted for internal or external hemorrhoids that are large or thrombotic, irreducible, with excessive redundant tissue evidencing frequent recurrences. Diagnostic Code 7336. In the present case, the preponderance of the competent medical evidence of record weighs against a compensable evaluation for the veteran's internal and external hemorrhoids. The report of an August 2002 VA examination provides that the veteran had a good degrees of sphincter control and no fecal leakage or involuntary bowel movement. He had occasional bleeding from the hemorrhoid and no thrombosis. He used Preparation H for swelling and pain as needed. On physical examination, there was no colostomy or evidence of fecal leakage. The size of the rectum and anus was normal. The veteran had no signs of anemia or fistula. The veteran had internal and external hemorrhoids. There was no evidence of bleeding. The diagnosis was hemorrhoids. VA treatment records dated during the relevant appeal period are negative for complaints, symptoms, findings or diagnoses related to hemorrhoids. A treatment note dated in June 2002 provides that on rectal examination, the veteran's sphincter tone was normal and no mass was palpable. A treatment note dated in September 2005 provides that rectal examination was negative. Overall, these medical findings simply fail to show that the veteran's internal and external hemorrhoids result in the symptoms required for a 10 percent evaluation. Diagnostic Code 7336. The Board is aware that during the May 2003 hearing the veteran testified that the August 2002 VA examination report does not pain an accurate portrait of his disability. However, review of the May 2003 examination report reveals that all subjective and objective findings necessary for adjudication of the veteran's claim were observed and recorded, and thus the examination appears complete and adequate. Further, the veteran's subsequent outpatient treatment reports are negative for complaints, symptoms, findings or diagnoses related to hemorrhoids. Accordingly, a new examination is not necessary for evaluation of the veteran's hemorrhoids. The Board is also aware of the veteran's own assertions as to the severity of his internal hemorrhoids. However, these contentions do not support his claim. As a general matter, lay statements are considered to be competent evidence when describing the features or symptoms of an injury or illness. See Falzone, supra. The veteran himself, as a layperson, is not competent to provide an opinion requiring medical knowledge or a clinical examination by a medical professional, such as an opinion addressing whether a service-connected disability satisfies diagnostic criteria. See Bostain, supra, citing Espiritu, supra. See also Routen, supra ("a layperson is generally not capable of opining on matters requiring medical knowledge"). In this case, however, the veteran's outpatient treatment reports are negative for complaints, symptoms, findings or diagnoses related to hemorrhoids. As the objective medical evidence does not support the veteran's contentions, it does not constitute evidence that his hemorrhoids warrant an increased evaluation. In sum, the weight of the credible evidence demonstrates that the veteran is not entitled to a compensable evaluation for post-operative hemorrhoidectomy, with external tags. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See generally Gilbert, supra; Ortiz, supra. ORDER Service connection for peripheral neuralgia, claimed as twitching of the nerves and muscles, is granted. Service connection for liver disease is granted. An evaluation in excess of 10 percent for erythropoietic protoporphyria and dermatitis actinica, due to sunlight, is denied. A compensable evaluation for post-operative hemorrhoidectomy, with external tags, is denied. REMAND The veteran's service medical records are negative for complaints, symptoms, findings or diagnoses related to the claimed gastrointestinal tract problems, esophageal dysmotility and dysphagia with aspiration, low back and neck pain and degenerative joint disease, muscle pain and weakness, gall bladder problem, and right kidney cyst. Although there is no evidence that complaints of such disorders were noted in service, the provider who prepared a May 2003 medical statement indicated that the veteran's neck and back pain, GI tract problems, dysmotility, and gallbladder problems, among others, could have been caused by DDT. More importantly, this provider also noted that several of the veteran's diagnosed disorders could be related to porphyria. Letters provided by other physicians in November 2004 and January 2005 also indicated that several of the veteran's medical disorders, including disorders manifested by pain, could be related to EPP. However, no VA examination or opinion as to whether disorders other than skin, liver, and peripheral nerve disabilities were related to the veteran's diagnosed EPP. Further medical development is required. The veteran must be notified of the criteria for establishing secondary service connection, including as the result of service-connected disability or on the basis of aggravation of a nonservice-connected disorder by a service- connected disability or disabilities. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The veteran should be advised that, when aggravation of a nonservice-connected condition is proximately due to or the result of a service-connected disability, the veteran is compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Id. Accordingly, the case is REMANDED for the following action: 1. The veteran must be notified of the criteria for establishing that a claimed disorder is etiologically related to, secondary to, or aggravated by a service- connected disability or disabilities, including EPP. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The veteran should be advised that, when aggravation of a nonservice-connected condition is proximately due to or the result of a service- connected disability, the veteran shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. The veteran should be notified of the information or evidence needed to establish a disability rating, and an explanation as to the information or evidence needed to determine an effective date following a grant of service connection, if any of the claims for service connection at issue is granted. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). 2. The veteran should be afforded the opportunity to submit or identify any additional evidence he believes may be relevant to his claim, including any records of treatment of a claimed disorder proximate to his service, if the veteran is able to identify any such records, or opinions linking the treatment of a claimed disorder, such as operative treatment of the gallbladder, to a service-connected disability, to include EPP. The veteran should again be afforded the opportunity to identify any relevant records of any type, including the earliest evidence of treatment of a claimed disorder, including alternative types of records, such as, but not limited to, employment medical records, employment medical examinations, examinations for insurance purposes, statements from employers, fellow employees, or others who may have observed relevant symptoms, and the like. 3. The veteran's current VA clinical records should be associated with the claims file, even if there are no records of treatment of a claimed disorder. 4. The veteran should be provided with an appropriate examination(s) as necessary to determine the etiology of GI problems, esophageal dysmotility and dysphagia with aspiration, low back and neck pain and degenerative joint disease, muscle pain and weakness, gall bladder problem, and right kidney cyst. The claims file must be provided to each examiner. The examiner should, based upon review of the relevant evidence contained in the claims file, and after examining the veteran, answer the following questions: (i) Is it at least as likely as not (is there at least a 50 percent probability) or, is it unlikely, that the veteran has a current GI problem, esophageal dysmotility and dysphagia with aspiration, low back and neck pain and degenerative joint disease, muscle pain and weakness, gall bladder problem, or right kidney cyst (or residuals of treatment of such a disorder) which was either incurred or manifested in service, or within one year after his service discharge in February 1946? (ii) If the veteran does not have a current back disorder which was directly incurred in service, is it at least as likely as not (is there at least a 50 percent probability) or, is it unlikely that he has a GI disorder, esophageal dysmotility and dysphagia with aspiration, low back and neck pain and degenerative joint disease, muscle pain and weakness, gall bladder problem, or right kidney cyst (or residuals of treatment thereof) which is/was (a) caused by, or (b) permanently aggravated (increased in severity) by a service-connected disability, to include EPP? The examiner(s) should be advised that the term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. If aggravation of a claimed disorder by a service-connected disability is determined to exist, the examiner should describe the increase in severity of the claimed disorder which is proximately due to the service- connected disability, and describe the percentage or extent of increase in symptoms which may be attributed to the service- connected right knee disability. The examiner should explain the medical considerations supporting the opinion. 5. After reviewing the evidence to assure that all development is complete and that the VA examination report is complete, the claims should be readjudicated. If any benefit sought remains denied, the veteran and his representative should be issued a supplemental statement of the case (SSOC) which addresses actions taken since the issuance of the last SSOC. The veteran and his accredited representative should be given the opportunity to respond. The appellant 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. 2007). ____________________________________________ Tresa M. Schlecht Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs