Citation Nr: 1229501 Decision Date: 08/27/12 Archive Date: 09/05/12 DOCKET NO. 02-08 414 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for residuals of left great toe injury. 3. Entitlement to service connection for polycythemia. 4. Entitlement to a disability rating in excess of 10 percent for hemorrhoids. 5. Entitlement to an initial disability rating in excess of 10 percent for hiatal hernia with gastroesophageal reflux disorder (GERD). 6. Entitlement to an initial disability rating in excess of 10 percent for right knee degenerative joint disease (DJD). 7. Entitlement to an initial disability rating in excess of 10 percent for left knee DJD. 8. Entitlement to an effective date prior to October 17, 2000, for the grant of service connection for hiatal hernia with GERD. 9. Entitlement to an effective date prior to June 29, 2000, for the grant of service connection for right knee DJD. 10. Entitlement to an effective date prior to June 29, 2000, for the grant of service connection for left knee DJD. 11. Entitlement to a total disability rating for compensation purposes based upon individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. Barone, Counsel INTRODUCTION The Veteran had active duty service from November 1969 to May 1971. This issue pertaining to service connection for an acquired psychiatric disability comes before the Board of Veterans' Appeals (Board) on appeal from a May 2006 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran testified at a Board hearing before the undersigned in June 2010. The issue of entitlement to an initial rating in excess of 10 percent for hemorrhoids comes before the Board on appeal from an August 2002 rating decision. A Travel Board hearing in front of another Veterans' Law Judge was held in September 2005. A transcript of the hearing has been associated with the claim file. In May 2006, the Board denied the Veteran's claim for a compensable rating for hemorrhoids. In October 2006, the Court of Appeals for Veterans Claims (Court), pursuant to a Joint Motion for Remand, vacated the Board's decision and remanded the case for readjudication. In March 2007, the Board again denied the Veteran's claim for a compensable rating for hemorrhoids. In May 2008 the Court, pursuant to a Joint Motion for Remand, vacated the Board's decision and remanded the claim for readjudication. Subsequently, in April 2009, the Board granted an initial 10 percent rating, which was effectuated in a June 2009 rating decision. Thereafter, the Veteran again appealed this determination to the Court, which again pursuant to another Joint Motion for Remand, vacated the Board's decision with respect to its denial of a rating in excess of 10 percent, and remanded the case for readjudication. The Board observes that the Veterans' Law Judge who conducted the September 2005 hearing is no longer employed at the Board. In October 2010, the Board sent notice to the Veteran giving him the right to request a new hearing before another Veterans' Law Judge. However, the Veteran responded that he did not want to appear at an additional hearing. The issues of entitlement to service connection for residuals of left great toe injury and service connection for polycythemia come before the Board from multiple rating decisions of RO. In December 2001, the RO denied entitlement to service connection for the residuals of a left great toe injury. The Veteran testified at a personal hearing at the RO in April 2002. In June 2005, the RO denied service connection for polycythemia. Again, in September 2005, the Veteran testified before another Veterans Law Judge at a personal hearing conducted at the Waco RO. The Veteran testified before the undersigned in June 2010 with respect to these issues as well. The issues of entitlement to service connection for PTSD, for residuals of left great toe injury, and for polycythemia, together with the issue of entitlement to an increased disability rating for hemorrhoids, were all most recently before the Board in December 2010, when they were all remanded for additional development. The introduction section of that remand further explains certain characterization and jurisdiction matters with regard to these issues. When this case was remanded by the Board in December 2010, it additionally included the issues of entitlement to service connection for a bilateral knee disability, a hiatal hernia with GERD, disability manifested by spitting up blood, and disability manifested by bilateral tunnel vision. However, these issues are no longer in appellate status and are not before the Board at this time. The issue of service connection for the knees is no longer in appellate status because during the processing of the Board's December 2010 remand, the RO issued a May 2012 rating decision granting service connection for DJD of each knee. The issue of service connection for hiatal hernia with GERD is no longer in appellate status because the May 2012 RO rating decision also granted service connection for that disability. The Board has determined that no distinct issue of entitlement to service connection for 'a disability manifested by spitting up blood' remains in appellate status in light of the details of the Veteran's contentions and the grant of service connection for hiatal hernia with GERD that includes the symptom of spitting up blood. The basis of the May 2012 grant of service connection for hiatal hernia and GERD featured a March 2011 VA examination report which attributed the Veteran's complaints of spitting up blood to hiatal hernia with GERD, and the Board views the grant of service connection for hiatal hernia with GERD as encompassing the claimed 'disability manifested by spitting up blood.' The Veteran has otherwise contended that his claimed symptoms of spitting up blood may be linked to polycythemia, and a claim for service connection for that issue remains in appellate status at this time. The Board finds that the Veteran's contentions regarding 'disability manifested by spitting up blood' are subsumed by the grant of service connection for hiatal hernia with GERD, which contemplates his complaints of spitting up blood. The Veteran's contentions with regard to spitting up blood are fully addressed in the grant of service connection for hiatal hernia with GERD and the ongoing appeal for service connection for polycythemia; there remains no need to individually adjudicate an individual issue for 'disability manifested by spitting up blood' under these circumstances where the pertinent contentions are addressed in other issues and the claimed symptoms have already been the subject of a grant of service connection. As to the issue of entitlement to service connection for disability manifested by bilateral tunnel vision, the Veteran expressly withdrew that issue from appeal with a signed statement in April 2012. The Board finds that the RO has complied with the directives of the Board's December 2010 remand with regard to the issues addressed with final decisions by the Board at this time. Specifically, the Board notes that the claims-file contains documentation of a negative response from the Shreveport VAMC in February 2011 regarding the availability of treatment records from 1971 to 1975 which had been sought in an effort to assist the Veteran. Additionally, a March 2011 VA examination report is of record and addresses the questions pertinent to the issue decided by the Board at this time. Appeals of the issues of entitlement to higher initial ratings and earlier effective dates for the May 2012 grants of service connection for hiatal hernia with GERD and DJD of both knees were initiated by the Veteran's recently filed notice of disagreement received in June 2012. Although the Board in the past has referred such matters to the RO for appropriate action, the Court has now made it clear that the proper course of action is to remand the matter to the RO. Manlincon v. West, 12, Vet. App. 238 (1999). The Board acknowledges the judicial holding in Rice v. Shinseki, 22 Vet. App.447, 453-54 (2009). In that decision, the United States Court of Appeals for Veterans Claims held that a request for a total rating based on individual unemployability (TDIU), whether expressly raised by the Veteran or reasonably raised by the record, is not a separate 'claim' for benefits, but rather, can be part of a claim for increased compensation. In other words, if the claimant or the evidence of record reasonably raises the question of whether the Veteran is unemployable due to a disability for which an increased rating is sought, then part and parcel with the increased rating claim is the issue whether a TDIU is warranted as a result of that disability. In the present case, the Board finds that certain statements of record, including in the June 2012 correspondence, reasonably raise a claim of entitlement to a TDIU. Although not entirely clear, the Veteran's statements included with the notice of disagreement received in June 2012 appear to possibly raise claims of entitlement to service connection for several disabilities (or petitions to reopen previously denied claims of entitlement to service connection) that are not on appeal nor pending adjudication by the Agency of Original Jurisdiction (AOJ). Additionally, the correspondence received in June 2012 alleges that the RO has incorrectly calculated the Veteran's combined disability rating. The Board does not have jurisdiction over such claims, and the matter of obtaining clarification of the Veteran's intentions and completing any other necessary action is referred to the AOJ. The issues of entitlement to service connection for an acquired psychiatric disability, entitlement to service connection for polycythemia, entitlement to a disability rating in excess of 10 percent for hemorrhoids, entitlement to higher initial disability ratings for hiatal hernia with GERD and DJD of both knees, entitlement to earlier effective dates for the grants of service connection for hiatal hernia with GERD and DJD of both knees, and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran does not have any residuals of injury to his left great toe. 2. The Veteran's diagnosed hallux valgus / bunion of the left great toe was not manifested during active duty service or for many years thereafter. CONCLUSION OF LAW Disability of the left great toe was not incurred in or aggravated by the Veteran's active duty service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 Under the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107 and 5126; see also 38 C.F.R. §§ 3.102, 3.156(a), and 3.326(a), VA has a duty to notify the claimant of any information and evidence needed to substantiate and complete a claim, and of what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain for the claimant. 38 U.S.C.A. § 5103(a); 38 C.F.R § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Duty to Notify After reviewing the claims folder, the Board finds that the claimant has been notified of the applicable laws and regulations which set forth the necessary criteria for the benefits currently sought. The claimant was most recently informed of the information and evidence necessary to warrant entitlement to the benefits sought in a letter dated in June 2006 (pertaining to the claim addressed with a final decision by the Board below). Moreover, in the June 2006 letter, the appellant was advised of the types of evidence VA would assist him in obtaining as well as his own responsibilities with regard to identifying relevant evidence. See Quartuccio v. Principi, 16 Vet. App. 183 (2002); Charles v. Principi, 16 Vet. App. 370 (2002). The Board notes that this letter was sent to the appellant prior to the most recent RO-level readjudication of the case, as evidenced by the May 2012 supplemental statement of the case. The VCAA notice was therefore effectively timely. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). Further, the notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In the present appeal, the appellant was provided with notice of what type of information and evidence was needed to substantiate the claim for service connection. The June 2006 VCAA letter further gave notice of the types of evidence necessary to establish a disability rating and effective date for the disability on appeal. In sum, the Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). In any event, the Veteran has not demonstrated any prejudice with regard to the content of the notice. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009) (Reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination.) See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). Duty to Assist Furthermore, the Board finds that there has been compliance with the assistance provisions set forth in the law and regulations. The record in this case includes service treatment records, post-service VA and private treatment records, and VA examination reports. The Board notes that the claims-file contains documentation of a negative response from the Shreveport VAMC in February 2011 regarding the availability of treatment records from 1971 to 1975 which had been sought in an effort to assist the Veteran. The Board finds that the record as it stands includes adequate competent evidence to allow the Board to decide the case and no further action is necessary. See generally 38 C.F.R. § 3.159(c)(4). No additional pertinent evidence has been identified by the claimant. The Veteran has been afforded a VA examination addressing the issue decided by the Board at this time, and the pertinent March 2011 VA examination report is of record. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The Board finds that the March 2011 VA examination report contains sufficiently specific clinical findings, medical opinions, and informed discussion of the facts of record to provide probative medical evidence adequately addressing the issue decided below. The examination report obtained contains sufficient information to decide the issue on appeal. See Massey v. Brown, 7 Vet. App. 204 (1994). Thus, the Board finds that a further examination is not necessary with regard to this issue. For all the foregoing reasons, the Board concludes that VA's duties to the claimant have been fulfilled with respect to the issue on appeal decided by the Board at this time. Service Connection The Veteran seeks entitlement to service connection for residuals of a left great toe injury, which he contends was caused or began during active duty. Applicable law provides that service connection will be granted if it is shown that the veteran suffers from disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury or disease in line of duty, in the active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. That an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic disabilities, such as arthritis, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. The Board notes that it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. Residuals of Left Great Toe Injury To the extent that the Veteran claims entitlement to a left foot disability specifically featuring residuals of an injury during military service, the Board finds that the claim must be denied because the evidence shows that the Veteran has no residuals of any injury involving his left foot. To the extent that the Veteran otherwise has any disability of the left foot, the Board finds that such disability has no etiological nexus to his military service. A pertinent March 2011 VA examination report is of record, and was prepared in connection with the development of evidence for this appeal. The Veteran's claims-file was reviewed and discussed by the examiner in connection with the preparation of the report. The report discusses the Veteran's account of having suffered an injury to the left great toe during an in-service motorcycle accident in 1971. The Veteran reported that he experienced significant pain of the left great toe. The examiner noted that the Veteran's service treatment records associated with the event only reflect and report a right leg laceration. The Veteran described that he experiences intermittent swelling and pain in the left great toe since 1971, and referred to a "large knot" in the left great toe area. After direct examination of the Veteran's left foot, in addition to diagnostic imaging of the left foot, the examining medical doctor diagnosed the Veteran with "[m]ild hallux valgus deformity, left great toe, non traumatic, non military related." The examiner opined that "the Veteran's diagnosis of mild hallux valgus deformity of the left great toe and claim for residuals of left toe injury are not consistent with an injury nor residual of an injury." Significantly, the examining doctor explained that the "defect that he is claiming as a residual of the left toe injury is simply a bunion." The examining doctor concluded that it was not at least as likely as not that the left great toe disability was related to the Veteran's military service." The Board notes that the Veteran's medical records do not present any findings contrary to those presented in the detailed medical information in the March 2011 VA examination report. There is no medial finding or opinion of record indicating the presence of disability in the left great toe of a nature that would be consistent with residuals of an injury. Thus, to the extent that the Veteran claims entitlement to service connection for the residuals of injury of the left great toe, the claim must be denied because the evidence shows that there is no disability of a nature which may be medically considered a residual of injury or trauma of the left great toe. As the most probative evidence shows that there is no current clinical diagnosis of any residuals of injury of the left great toe, service connection for residuals of injury of the left great toe must be denied. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (in the absence of proof of the presently claimed disability, there can be no valid claim). The Board has further considered whether service connection may otherwise be warranted for the diagnosed disability of hallux valgus / bunion of the left great toe which is shown to be actually responsible for the Veteran's claimed symptoms. The Board finds that service connection for hallux valgus / bunion of the left great toe is not warranted. This disability is shown by the evidence to have had onset many years after service, and it is not shown to be otherwise related to service. The Board notes that there is no contemporaneous evidence of any left great toe symptoms or disability during service; the Veteran's service treatment records are silent for any suggestion of left great toe disability. The Veteran's May 1971 service separation examination report shows that trained medical professionals found that the Veteran's feet were clinically normal with no pertinent abnormalities. Significantly, the Veteran responded to a medical history questionnaire in May 1971 by specifically denying having experienced any foot problems. Furthermore, the Veteran sought VA disability benefits proximate to his separation from service and made no indication of a left great toe disability. Moreover, it is highly significant that the Veteran underwent a VA examination in August 1972 with the resulting report specifically stating: "Feet appear to be normal throughout without any bunion formation or abnormalities." There is no contrary evidence from around the time of the Veteran's service indicating the existence of any left great toe hallux valgus / bunion during service or for many years following service. The contemporaneous evidence for during and proximately following the Veteran's service is highly probative evidence featuring the findings of trained medical professionals examining the Veteran as well as featuring the Veteran's own statements concerning his own health. This probative evidence indicates that neither the Veteran himself nor trained medical professionals believed that the Veteran had hallux valgus / bunion of the left great toe. The Board again emphasizes that the August 1972 VA examination report specifically stated that the Veteran was "without any bunion formation or abnormalities" on his feet at that time. In sum, the most probative evidence shows that the Veteran has no residuals of any injury to the left great toe, and the only diagnosed disability of the left great toe is not related to the Veteran's military service. Service connection is not warranted for a left great toe disability in this case. Conclusion The Board finds that the preponderance of the evidence is against the claim of entitlement to service connection for a left great toe disability. In reaching this decision, the Board has reviewed the entirety of the evidence of record but finds that there is no other evidence of record which probatively contradicts the findings presented in the most probative evidence discussed above with regard to the issue decided at this time. The Board acknowledges that the claims file contains a quantity of other documents, including medical records referring to the claimed medical problem (without etiology opinions), but none of the information in these records substantially supports the Veteran's claim or otherwise contradicts the evidence deemed to be most probative in the discussion above. Here, the evidence does not support finding that the Veteran's left great toe disability is related to his military service. The Veteran has been afforded a VA examination with an adequate VA examination report in connection with this claim; the examiner provided clear findings and opinion with persuasive discussion of rationale weighing against the claim. The examiner's pertinent findings and opinions are uncontradicted by the rest of the competent evidence of record. No medical professional has provided any opinion indicating that the Veteran's current left great toe disability is related to his military service. None of the Veteran's post-service medical records indicate that the Veteran's current left great toe disability is related to his military service. The Board acknowledges that service connection may indeed be granted when a chronic disease or disability is not present in service, but there is evidence of continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). In accordance with Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006), the Board concludes that the lay evidence presented by the Veteran concerning his continuity of symptoms after service does not provide a persuasive basis to award service connection in this case because the Veteran's testimony in this regard is not credible. As discussed above, contemporaneous medical evidence shows clearly that neither the Veteran nor trained medical professionals believed that the Veteran had any symptoms, abnormalities, or disabilities involving the left great toe during service, at separation, and proximately following separation. The only current diagnosed disability of the left great toe features a bunion, and the August 1972 VA examination report expressly and directly states that the Veteran did not have a bunion at that time nor did the Veteran report any left great toe symptoms at that time or during service; the Veteran denied foot problems at the time of his separation, and was found by the medical examiner to have no foot problems. The Board finds that there is no credible evidence in this case establishing continuity of pertinent symptomatology from the time of active duty military service. The Board acknowledges the Veteran's belief that his claimed disability is related to his military service. However, there is no evidence of record showing that the Veteran has the specialized medical education, training, and experience necessary to render a competent medical opinion as to the diagnosis and etiology of a disability. Espiritu v. Derwinski, 2 Vet. App. 492 (1992); 38 C.F.R. § 3.159(a) (1). Consequently, the Veteran's own assertions as to diagnosis and etiology of a disability have no probative value. Lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. §§ 3.303(a), 3.159(a); see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). See also Robinson v. Shinseki, 312 Fed. Appx. 336 (Fed. Cir. 2009) (non-precedential) (confirming that, 'in some cases, lay evidence will be competent and credible evidence of etiology'). However, a determination concerning the possibility of a causal relationship between military service and a chronic acquired disability which the evidence shows did not manifest until many years after service requires specialized training, and may therefore not be established by lay opinions on etiology. As the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for a left great toe disability, the benefit-of-the-doubt rule does not apply and this claim is denied. See 38 U.S.C.A § 5107. ORDER Entitlement to service connection for residuals of left great toe injury is not warranted. To this extent, the appeal is denied. REMAND Polycythemia Polycythemia is a blood disease manifested by a sustained abnormally elevated red blood cell count. (See Dorland's Illustrated Medical Dictionary, 30th edition (2003), p. 1479.) The Board observes that although polycythemia is in some respects essentially a laboratory finding, it appears to be recognized as a diagnosable disability for VA compensation purposes and is rated under 38 C.F.R. § 4.117, Diagnostic Code 7704. The Board observes that certain evidence of record suggests that the Veteran may have polycythemia. For instance, a February 2011 VA outpatient treatment record (available for review in the Virtual VA electronic claims-file) makes reference to the Veteran having polycythemia, and then indicates that testing showed "Elevated hgb (polycythemia)." At that time, the Veteran was advised to check with a blood bank to determine if he can donate blood. The Board finds that the March 2011 VA examination report prepared in connection with the development of the evidence in this appeal fails to adequately address the medical questions central to this appeal. In pertinent part, the examiner comments that "the Veteran is filing a claim for polycythemia but he relates this to 'spitting up blood' while he was on active duty." The Veteran denied any history of sickle cell disease. The examiner noted that the Veteran had iron-deficiency anemia attributable to bleeding hemorrhoids and esophagitis. The examiner noted a history of fatigability but noted there was no history of generalized weakness. The examiner noted a remote history of headaches but noted that the Veteran did not have a chronic headache disorder. The examiner noted that there was no history of transfusions, recurrent infections, bone marrow transplant, myelo-suppressant therapy, or congestive heart failure. In the section for diagnostic findings in the March 2011 VA examination report, the examiner found that polycythemia was "not related to the military as there was no evidence of polycythemia while the Veteran was on active duty." However, in the section of the report explaining the bases for the examiner's conclusion, the examiner offers an explanation that fails to adequately address the essential questions at issue. In the opinion section, the examiner first states: "The Veteran was not found to have a diagnosis of polycythemia. He primarily has an iron-deficiency anemia." However, the same examiner listed "Polycythemia" in the "Final Diagnoses" section. This contradiction is important, as analysis of entitlement to service connection cannot reasonably proceed without a clear determination as to whether the Veteran has or does not have the claimed disability. The examiner does not discuss the other medical evidence suggesting that the Veteran has polycythemia and abnormal blood test results, nor does the examiner indicate that any new diagnostic testing has ruled out a diagnosis of polycythemia. In the event that the Veteran may be properly diagnosed with polycythemia, the Board finds that the portions of the March 2011 VA examination report which attempt to address the etiology of such a diagnosis are inadequate. In the opinion section, the March 2011 VA examiner stated that "[t]here was no CNC to confirm that the Veteran had polycythemia in the military." The examiner then proceeds to discuss how the Veteran's belief that his symptoms of spitting up blood were a result of polycythemia was probably incorrect. However, regardless of whether the Veteran's lay sensibilities have correctly attributed specific symptoms to the claimed diagnosis, there are indications of potentially pertinent symptoms in the service treatment records which must be addressed by the medical expert to provide an adequate basis for concluding that the Veteran did not have polycythemia during service. The Board notes that multiple publicly available medical websites identify the key symptoms associated with polycythemia as including: Headache; Dizziness; Itchiness, especially following a warm bath or shower; Redness of your skin; Shortness of breath; Breathing difficulty when you lie down; Numbness, tingling, burning or weakness in your hands, feet, arms or legs; A feeling of fullness or bloating in your left upper abdomen due to an enlarged spleen; Fatigue. Mayo Clinic: Polycythemia vera - Symptoms (http://www.mayoclinic.com/health/polycythemiavera/DS00919/DSECTION=symptoms). The Veteran endorsed dizziness and fainting spells both on his entrance examination in June 1969 and at separation in May 1971. The May 1971 separation examination also shows that the Veteran additionally endorsed experiencing shortness of breath (and palpitation or pounding heart). A November 1969 service treatment record includes "sense of fatigue" among complaints at that time. A March 1970 service treatment record shows that the Veteran complained of a "tickling" sensation under his left armpit for two months. Another March 1970 service treatment report shows complaint of "itching" under the left armpit for the prior two months. A December 1970 service treatment report shows the Veteran "gets tight in the head and feels like he is going to pass out." Another December 1970 service treatment report shows that the Veteran experienced sense of pressure in his head and dizziness when lying down in bed. A February 1971 report shows that the Veteran continued to complain of reoccurring headaches. In April 1971 the Veteran complained of "feeling bad all over, pressure in head," and then later "numb feeling in head." Although the focus of many of the documented in-service symptom complaints was potential psychiatric pathology, if the Veteran is currently diagnosed with polycythemia then it is necessary for the Board to turn to competent medical evidence to determine whether these potentially pertinent symptom complaints during service represented manifestations of polycythemia during service. Accordingly, the Board must seek clarification of the March 2011 VA examination report to obtain a clear determination as to whether the Veteran is currently diagnosed with polycythemia and, if so, to opine as to whether it is at least as likely as not that current polycythemia is etiologically linked to the Veteran's potentially pertinent in-service symptomatology. Service Connection for Psychiatric Disability The Veteran underwent a VA psychiatric examination in February 2011 in connection with this claim. The VA examiner diagnosed the Veteran with generalized anxiety disorder and dysthemia and specifically confirmed that these were both acquired Axis I psychiatric diagnoses. The VA examiner opined that the acquired Axis I psychiatric diagnoses "are not supported by any of the medical evidence of record while the Vet was active duty military." The examiner opined that the Axis II diagnosis of personality disorder was shown during service. As a matter of law, it is not possible to establish service connection for a personality disorder on any basis. 38 C.F.R. §§ 3.159, 3.303(c). The VA examiner's opinion regarding the acquired Axis I psychiatric diagnoses is of critical importance in this case. The Board must find that the February 2011 VA examination report does not present an adequate etiology opinion allowing for informed appellate review of this issue. The fact that the Veteran's service treatment records contain significantly conflicting indications on this question requires a rationale for the VA examiner's bare conclusion that there is no support for finding a chronic acquired psychiatric disability manifested during service. Significantly, a March 1971 Application for Humanitarian Reassignment states that a Dr. Baker "made a diagnosis of psychogenic symptoms secondary to anxiety neurosis." Furthermore, "Dr. Blair, the base psychiatrist, ... agreed with the diagnosis of anxiety neurosis." Additionally, a December 1970 service treatment record shows that the Veteran presented with symptoms assessed to be "anxiety hyperventilation." Another December 1970 service treatment record shows that the Veteran was assessed to be experiencing "anxiety neurosis." A January 1971 service medical examination report shows that the Veteran was diagnosed with "depression reaction." Another January 1971 consultation request refers to the Veteran's "recurring ... anxiety neurosis." A February 1971 service treatment record refers to the Veteran's continuing difficulties with "anxiety," consistent with other February 1971 documentation of consultations concerning consistent symptom problems. A March 1971 service consultation report describes repeated visits involving psychiatric difficulties. An April 1971 service treatment record shows that the Veteran presented with symptoms assessed at that time to be "psychosomatism." The May 1971 service separation examination report stated that the Veteran's character and behavior disorder was best diagnosed as psychopathic personality, and an August 1972 VA neuropsychiatric report repeated this finding. However, the Veteran's service treatment records indicate that competent medical and psychiatric professionals had diagnosed an anxiety pathology. This evidence would seem to contradict the February 2011 VA examination report's conclusion that the currently diagnosed anxiety disorder is "not supported by any of the medical evidence of record while the Vet was active duty military." Some discussion of the service treatment records expressly referring to the Veteran being diagnosed with an anxiety disorder is necessary for the Board to be able to understand and evaluate the probative value of the February 2011 VA examination report's conclusion in appellate review of this case. Accordingly, the Board must seek clarification of the February 2011 VA psychiatric examination report to reconcile its conclusion with the apparently contrary evidence of record. Increased Rating for Hemorrhoids As relevant to this appeal, the RO has rated the Veteran's hemorrhoids as 10 percent disabling under Diagnostic Code 7336, which is applicable to both external and internal hemorrhoids. A 10 percent rating is warranted for hemorrhoids that are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. A maximum 20 percent rating is warranted for hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. See 38 C.F.R. § 4.114, Diagnostic Code 7336. The Board previously remanded this issue to afford the Veteran a new VA examination (in accordance with the terms of a prior JMR) to ascertain to current severity of the Veteran's hemorrhoids. Unfortunately, the Board finds that the resulting March 2011 VA examination report contains conflicting indications and lack sufficient clarity concerning the pertinent aspects of the Veteran's hemorrhoids to permit informed appellate review at this time. The March 2011 VA examination report refers to a documented October 2010 "severe complete hemorrhoidal prolapsed episode." The report also documents the Veteran's own report of "periodically" seeing "bright red blood" when wiping after a bowel movement. Pertinent examination findings describe observation of hemorrhoids that "are not severely prolapsed and actually are only mildly prolapsed." However, when the same VA examiner discusses the Veteran's possible hemic disorder, the examiner stated that the Veteran "does have a history of iron-deficiency anemia and has reason to have this due to the fact that he has severely prolapsed hemorrhoids which periodically bleed and the esophagitis." The pertinent rating criteria for a higher disability rating for hemorrhoids could be met if the Veteran is shown to have anemia due to persistent bleeding of his hemorrhoids. The March 2011 VA examination report indicates that the Veteran has iron-deficiency anemia due possibly to his "severely prolapsed hemorrhoids which periodically bleed" and also possibly due to his esophagitis. The March 2011 VA examiner acknowledges that there is documentation of a recent episode involving severely prolapsed hemorrhoids, but also indicates that on current examination the Veteran's hemorrhoids were found to be only mildly prolapsed. No clear statement indicating the likely frequency of bleeding is presented, and the Board is unable to determine whether the VA examiner believed that the Veteran's iron-deficiency anemia was secondary to his hemorrhoids after completion of the objective examination. Additionally, to any extent that the March 2011 VA examination report, once clarified, may indicate that the Veteran's hemorrhoids cause anemia through persistent bleeding, the Board must determine at what point during the many years of the period on appeal that the Veteran's hemorrhoids are first shown to have manifested in disability of this severity. The Board notes that the period of time on appeal for this issue dates back to the effective date for the grant of service connection for hemorrhoids in 2002. Accordingly, the Board must seek clarification of the March 2011 VA examination report to adequately determine whether the Veteran's hemorrhoids manifest in persistent bleed with secondary anemia and, if so, at what point such severity was first shown. The Notice of Disagreement Received in June 2012 The Board also notes that by rating decision in May 2012, the RO granted service connection for hiatal hernia with GERD, for right knee DJD, and for left knee DJD. While this case has been at the Board, the Veteran filed a notice of disagreement received in June 2012 which expressed disagreement with the disability ratings and effective dates assigned in the May 2012 RO rating decision. Appropriate action, including issuance of a statement of the case, is therefore necessary pursuant to 38 C.F.R. § 19.26. Although the Board in the past has referred such matters to the RO for appropriate action, the Court has now made it clear that the proper course of action is to remand the matter to the RO. Manlincon v. West, 12, Vet. App. 238 (1999). TDIU With respect to the issue of entitlement to TDIU, the Court has held that a request for TDIU, whether expressly raised by a Veteran or reasonably raised by the record, is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities, either as part of the initial adjudication of a claim or, if the disability upon which entitlement to TDIU is based has already been found to be service-connected, as part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). In the instant case, the Veteran's statements, including his recent June 2012 written correspondence, have repeatedly included references to have lost job opportunities or having been rendered incapable of working at times due to service-connected disabilities. Accordingly and in light of the Court's decision in Rice, the Board finds that a claim for TDIU has been raised by the record. In order to ensure due process, the RO will be directed to conduct the initial adjudication of this issue (following resolution of all issues with which the TDIU issue is inextricably intertwined). Bernard v. Brown, 4 Vet. App. 384, 393 (1993). Accordingly, the case is REMANDED for the following action: 1. The claims file should be forwarded to the author of the March 2011 VA examination report addressing the Veteran's claim of entitlement to service connection for polycythemia, if available, otherwise forwarded to an appropriate specialist for an opinion to clarify: a) Does the Veteran have polycythemia? (In answering this question, please address the Veteran's VA treatment records referring to polycythemia. Also, please reconcile the conflicting evidence of record, including that the March 2011 VA examination report lists polycythemia as a diagnosis, later states that the Veteran was not found to have polycythemia, and then states that the diagnosis was not likely related to military service.); b) If the Veteran currently has a diagnosis of polycythemia, please opine as to whether it is at least as likely as not (a 50% or higher degree of probability) that the Veteran had polycythemia during his military service? (In answering this question, please specifically discuss the documentation in the Veteran's service treatment records, including the items noted in the remand discussion above, showing the Veteran's complaints involving headaches, dizziness, itchiness, shortness of breath, numbness, tingling, and fatigue.); c) If the Veteran currently has a diagnosis of polycythemia, is it at least as likely as not (a 50% or higher degree of probability) that the current polycythemia is causally related to military service? The reviewing specialist should explain the rationale for all opinions given. 2. The claims file should be forwarded to the author of the February 2011 VA psychiatric examination report, if available, otherwise forwarded to an appropriate psychiatric specialist for an opinion to clarify whether it is at least as likely as not (a 50% or higher degree of probability) that the Veteran had any currently diagnosed chronic acquired psychiatric disability (such as any anxiety disorder) during his military service. The reviewing specialist should explain the rationale for all opinions given. The VA opinion provider should be sure to specifically discuss the evidence in the claims file indicating anxiety disorder, including the multiple items (discussed above), indicating a diagnosis of anxiety neurosis or other anxiety-related disorders in service. The opinion provider should explain why it is the case, or is not the case, that the documented in-service anxiety diagnoses represent manifestations of the currently diagnosed generalized anxiety disorder (or dysthemic disorder or any other current chronic acquired psychiatric disability). All opinions and conclusions expressed must be supported by a complete rationale in a report. 3. The claims file should be forwarded to the author of the March 2011 VA examination report addressing the severity of the Veteran's hemorrhoids, if available, otherwise forwarded to an appropriate medical specialist for an opinion to clarify whether the Veteran's iron-deficiency anemia is considered to be secondary to persistent bleeding of the Veteran's hemorrhoids. If any additional examination or testing is required, such should be accomplished. The claims file should be made available to the examiner / opinion-provider for review. The examiner / opinion-provider should expressly report: a) Is there evidence of persistent bleeding with secondary anemia or fissures? If it is found that the Veteran has one of these two elements (persistent bleeding or anemia associated with hemorrhoids) but not the other, the examiner / opinion provider should clearly state this. b) If so, based upon the available evidence and information of record, what is the earliest date upon which it can be factually ascertained that the Veteran's hemorrhoids manifested in anemia due to persistent bleeding? The examiner / opinion provider is asked to specifically discuss the pertinent evidence in the claims file, including the findings in the March 2011 VA examination report concerning hemorrhoids and anemia, and including documentation of exacerbations and treatment of hemorrhoid problems such as in October 2010. 4. To avoid further remand, the RO/AMC should review the examination reports obtained and ensure that the requested findings and opinions have been reported, and that all opinions and conclusions expressed are supported by a complete rationale. 5. After completion of the above and any additional development which the RO may deem necessary, the RO should then review the expanded record and readjudicate the issues of entitlement to service connection for polycythemia and an acquired psychiatric disability and entitlement to an increased disability rating for hemorrhoids. The RO should also adjudicate the TDIU issue (when appropriate with regard to other pending inextricably intertwined issues). The RO should issue an appropriate supplemental statement of the case, and give the Veteran and his representative the opportunity to respond. The case should then be returned to the Board, if in order, for further review. 6. The RO should take appropriate action pursuant to 38 C.F.R. § 19.26, including issuance of a statement of the case, on the appeal initiated by the Veteran from the May 2012 rating decision which assigned ratings and effective dates for grants of service connection for hiatal hernia with GERD and for DJD of both knees. The Veteran and his representative should be advised of the need to file a timely substantive appeal if the Veteran wishes to complete an appeal from that determination. If a timely substantive appeal is received in response to the statement of the case, then the case should be returned to the Board for appellate review. 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. 2011). ______________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs