Citation Nr: 1307946 Decision Date: 03/11/13 Archive Date: 03/20/13 DOCKET NO. 09-04 726 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to service connection for musculoskeletal pain in shoulders, hips and knees. 2. Entitlement to service connection for muscle weakness. 3. Entitlement to service connection for multiple joint pain due to undiagnosed illness. 4. Entitlement to service connection for arthritis of multiple joints, including hands, legs and arms due to exposure to Agent Orange. 5. Entitlement to service connection for gout. 6. Entitlement to service connection for pyoderma. 7. Entitlement to service connection for night sweats and sleep problems. 8. Entitlement to service connection for abnormal skin texture with scales and facial disfigurement due to scarring 9. Entitlement to service connection for scattered follicular papules. 10. Entitlement to service connection for acne keloid. 11. Entitlement to service connection for hair loss. 12. Entitlement to service connection for fatigue syndrome. 13. Entitlement to an increased rating for service-connected erectile dysfunction. 14. Entitlement to an increased rating for sleep apnea. 15. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). 16. Entitlement to an initial compensable evaluation for service-connected hemorrhoids. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. Stephen Eckerman, Counsel INTRODUCTION The Veteran served on active duty from January 1969 to January 1971. This matter comes before the Board of Veterans' Appeals (the Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas. In February 2008, the RO denied all of the above-listed claims for service connection except PTSD, and sleep apnea. In December 2008, the RO denied the claim for service connection for PTSD, and sleep apnea. In April 2010, the RO granted service connection for hemorrhoids, evaluated as 0 percent disabling (noncompensable). In July 2010, the RO denied a claim for service connection for sleep apnea. In June 2012, the Veteran was afforded a videoconference hearing before Jonathan B. Kramer, who is the Veterans Law Judge rendering the determination in this claim and was designated by the Chairman of the Board to conduct that hearing, pursuant to 38 U.S.C.A. § 7102(b) (West 2002). The Board must review all issues reasonably raised from a liberal reading of all documents in the record. EF v. Derwinski, 1 Vet. App. 324, 326 (1991). In this case, the Veteran has raised the issues of entitlement to service connection for a clothing allowance, tinnitus, polyps, hearing loss, a shoulder disability, pseudofolliculitis barbae, and ischemic heart disease. See Veteran's statements, dated in February, August, September and October of 2010, and August 2011. It appears that the RO has begun development on at least several of these issues. In any event, these issues have not been adjudicated by the RO, and are referred to the RO for appropriate action. FINDINGS OF FACT 1. The Veteran has indicated that he desires to withdraw his appeal of the issues of entitlement to service connection for a disability manifested by musculoskeletal pain in shoulders, hips and knees, muscle weakness, multiple joint pain, arthritis of multiple joints, including hands, legs and arms, gout, pyoderma, night sweats and sleep problems, abnormal skin texture with scales and facial disfigurement due to scarring, scattered follicular papules, acne keloid, hair loss, fatigue syndrome, erectile dysfunction, and sleep apnea. 2. The Veteran does not have an acquired psychiatric disorder, to include PTSD, that was caused by his service. 3. The Veteran's service-connected hemorrhoids are productive of internal and external hemorrhoids, but not irreducible, large, or thrombotic hemorrhoids with excessive redundant tissue and frequent recurrences. CONCLUSIONS OF LAW 1. The criteria for a withdrawal of the Veteran's substantive appeal on the issues of entitlement to service connection for a disability manifested by musculoskeletal pain in shoulders, hips and knees, muscle weakness, multiple joint pain, arthritis of multiple joints, including hands, legs and arms, gout, pyoderma, night sweats and sleep problems, abnormal skin texture with scales and facial disfigurement due to scarring, scattered follicular papules, acne keloid, hair loss, fatigue syndrome, erectile dysfunction, and sleep apnea, have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002 & Sup. 2011); 38 C.F.R. §§ 20.200, 20.202, 20.204(b), (c) (2012). 2. An acquired psychiatric disorder, to include PTSD, was not caused by service. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304(f), 3.310 (2012). 3. The criteria for an initial compensable evaluation for service-connected hemorrhoids have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.114, Diagnostic Code 7336 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Dismissal An appeal consists of a timely filed Notice of Disagreement in writing, and after a Statement of the Case has been furnished, a timely filed Substantive Appeal. 38 U.S.C.A. § 7105(a) (West 2002 & Supp. 2012); 38 C.F.R. § 20.200 (2012). Under 38 U.S.C.A. § 7105, the Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. Further, a Substantive Appeal may be withdrawn in writing at any time before the Board promulgates a decision. 38 C.F.R. §§ 20.202, 20.204(b) (2012). Except for appeals withdrawn on the record at a hearing, appeal withdrawals must be in writing. 38 C.F.R. § 20.204(b) (2012). The record shows that the Veteran perfected an appeal of a February 2008 decision of the RO which inter alia denied entitlement to service connection for a disability manifested by musculoskeletal pain in shoulders, hips and knees, muscle weakness, multiple joint pain, arthritis of multiple joints, including hands, legs and arms, gout, pyoderma, night sweats and sleep problems, abnormal skin texture with scales and facial disfigurement due to scarring, scattered follicular papules, acne keloid, hair loss, fatigue syndrome, and erectile dysfunction. The Veteran also perfected an appeal of a July 2010 decision of the RO which denied a claim for service connection for sleep apnea. However, during his hearing, held in June 2012, the Veteran and his representative indicated that the Veteran desired to withdraw his appeal with respect to these issues. See Tomlin v. Brown, 5 Vet. App. 355 (1993) (when oral remarks (i.e., hearing testimony) are transcribed, a statement becomes written). In this regard, it was specifically agreed to that the issues, which were noted in a January 2009 Statement of the Case, and a (February 2012) VA Form 646 reflecting those issues, are not on appeal. It was also specifically stated that the claim for service connection for sleep apnea was withdrawn. The Board finds that these statements qualify as valid withdrawals of the issues of entitlement to service connection for a disability manifested by musculoskeletal pain in shoulders, hips and knees, muscle weakness, multiple joint pain, arthritis of multiple joints, including hands, legs and arms, gout, pyoderma, night sweats and sleep problems, abnormal skin texture with scales and facial disfigurement due to scarring, scattered follicular papules, acne keloid, hair loss, fatigue syndrome, erectile dysfunction, and sleep apnea. Accordingly, these claims will be dismissed. II. Service Connection The Veteran asserts that he is entitled to service connection for an acquired psychiatric disorder, to include PTSD. With regard to his claim for PTSD, he essentially asserts that he has this condition as a result of participation in combat during service in Vietnam. See e.g., May 2008 and August 2009 VA outpatient treatment reports. He has reported that he has had psychiatric symptoms since 1970. See e.g., May 2008 VA outpatient treatment report. He has also argued that he has depression that was caused or aggravated by a service-connected disability, specifically, his service-connected hiradenitis suppurativa. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d). Applicable regulations provide that service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a), a link, established by medical evidence between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. See 38 C.F.R. § 3.304(f); 75 Fed. Reg. 39843 (July 13, 2010). Service connection may be granted, on a secondary basis, for a disability, which is proximately due to, or the result of an established service-connected disorder. 38 C.F.R. § 3.310 (2012). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities (38 C.F.R. part 4) and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. 38 C.F.R. § 3.310(b). If the evidence establishes that a veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. See 38 C.F.R. § 3.304(f)(2); see also 38 U.S.C.A. § 1154(b) (West 2002). Otherwise, the law requires verification of a claimed stressor. Service connection is currently in effect for hiradenitis suppurativa, and internal and external rectal hemorrhoids, grade 2/4, status post hemorrhoidectomy. The Veteran's service treatment reports do not show any relevant complaints, treatment, or diagnoses. The Veteran's separation examination report, dated in December 1970, shows that his psychiatric condition was clinically evaluated as normal. In an associated "report of medical history" he denied having had frequent trouble sleeping, frequent or terrifying nightmares, "nervous trouble of any sort," or "depression or excessive worry." The report notes, "No significant medical problem." As for the post-service medical evidence, it consists of VA and non-VA reports, dated between 1974 and 2012. This evidence includes service treatment reports associated with Army Reserve duty, which show that he was examined in September 1974, and in July 1978. In both cases, the Veteran's psychiatric condition was clinically evaluated as normal. Also in both cases, associated "reports of medical history" show that he denied having had "nervous trouble of any sort," "depression or excessive worry," or "frequent trouble sleeping." The Veteran's personnel records, to include his discharge (DD Form 214) show the following: his military occupation specialty was cargo handler. He served in Vietnam between July 1969 and June 1970. His awards include the Vietnam Service Medal, and the Republic of Vietnam Campaign Medal with "60" device. While in Vietnam, his principal duty was boat crewman (July to late August of 1969) with HHD (headquarters and headquarters detachment), 71st Transportation Battalion, USARPAC, and wheeled vehicle repairman (late August 1969 to June 1970) with 372nd Transportation Company (Tm Trf) USARPAC. The Veteran has submitted a copy of an electronic mail from J.O.K., who indicated that he was commander of the Veteran's unit in Vietnam until March 1970. He states, "The company and the Battalion did not participate in any direct combat operations during the this [sic] time period other than going to work each day at Newport." He noted that the Long Binh post had been attacked in February 1969 (prior to the Veteran's service in Vietnam), and that he did not know what had happened after March 1970, although he thought he would have heard about it, since he stayed in the Army for another 25 years and served with fellow battalion members again. The Board initially finds that the evidence does not show that the Veteran participated in combat. The Veteran is not shown to have received commendations or awards that warrant the conclusion that he participated in combat, nor is the other evidence of record sufficient to show participation in combat. See VAOPGCPREC 12-99 at 12; 65 Fed. Reg. 6256 -6258 (2000); VBA's Adjudication Procedure Manual, M21- 1MR (hereinafter "M21- 1MR"), Part III.iv.4.H.29.b, c. The Board therefore finds that the Veteran did not participate in "combat" for the purposes of the combat presumption. See Cohen v. Brown, 10 Vet. App. 128, 145 (1997). In reaching this determination, the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against a finding of participation in combat, the doctrine is not for application. See 38 U.S.C.A. § 5107(b); VAOPGCPREC 12-99. As a final preliminary matter, the Board finds that the Veteran is not a credible historian. In the Veteran's "statement in support of claim" (VA Form 21-4138), received in June 2008, he asserted that he had PTSD due to "exposure to life threatening events in combat in Vietnam." He stated that he was in a transportation unit in Vietnam, and that he drove all over the country delivering supplies and equipment. He stated that he saw men, women and children without arms or legs, and dead bodies. In a stressor statement (VA Form 21-0781), received in September 2008, the Veteran reported his stressors as: being shot at while in a convoy, seeing "several body bags and the enemy soldiers dead," and, "I have seen bodies with no head and missing arms, legs, bodies with their organs cutoff." During a VA PTSD examination in April 2010, the Veteran stated that his position got overrun while in "Long Bend" (presumably Long Binh), Vietnam, but "that nothing had happened but it was just the idea." He also reported a second stressor in which the Viet Cong "broke our perimeter," and that he helped chase them, but that no one was injured or killed. In a third stressor, he asserted that his daughter died shortly after birth while he was in Vietnam. The examiner concluded that the Veteran's reported on examination "are not consistent with those reported previously." In memorandums, dated in December 2008, and February 2010, the RO's coordinator for the U. S. Army & Joint Services Records Research Center (JSRRC) determined that the Veteran had not provided sufficient information to warrant an attempt to verify the claimed stressors. In summary, the Veteran has claimed that he participated in combat, however, the Board has determined that participation in combat is not shown. The Veteran's reported stressors are uncorroborated by any service records, and are shown to have been inconsistently reported to a significant degree. In addition, he has received treatment for hallucinations, to include medications (Risperidone). See e.g., VA outpatient treatment reports, dated in July 2009 and October 2010. This is evidence that his memory and perception are unreliable. He has also repeatedly complained of financial problems, and this is evidence of financial interest. See e.g., VA outpatient treatment reports, dated in January and March of 2009, January and May of 2011; Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (interest may affect the credibility of testimony). The Board therefore finds that he is not a credible historian. See Wilson v. Derwinski, 2 Vet. App. 16, 19-20 (1991); Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (in determining whether documents submitted by a Veteran are credible, the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant). The relevant medical evidence is summarized as follows: A VA PTSD examination report, dated in April 2010, shows that the examiner (Dr. T.A.) stated that the Veteran's claims file had been reviewed. The examiner recorded the Veteran's subjective history, and performed an examination. The examiner concluded that the Veteran did not have PTSD. She explained that although the Veteran had been diagnosed with PTSD during VA mental health treatment, that she had done a thorough review of his record. She noted that although he claimed to have been symptomatic since 1997, a PTSD screen in May 2006 was 0 (zero). His first complaints of PTSD were in May 2008, at which time a diagnosis of PTSD was provided, however, that report did not show that any service stressors were elicited. She noted that his stressors were inconsistently reported, that there was a lack of sufficient symptoms, and she concluded that the criteria for PTSD were not met. A VA disability benefits questionnaire (DBQ), dated in December 2011, shows that a VA physician indicated that the Veteran's claims file had been reviewed. The physician diagnosed the Veteran with a depressive disorder NOS (not otherwise specified). The physician was asked to opine as to whether any psychiatric disorder was caused by a service-connected disability, specifically hidradenitis suppurativa. The physician determined that the Veteran's depression was less likely than not related to a skin disorder. The physician explained that the Veteran's depression was likely related to his adjustment to retirement, as well as back and shoulder pain and unexpected life situations, to include raising two grandchildren. In October 2012, the Board requested a specialist medical opinion through a Veterans Heath Administration (VHA) directive. The Board noted that the VA physician who had written the December 2011 opinion had not provided an opinion as to whether the Veteran's depressive disorder was related to his period of active service, or whether a service-connected disability aggravated an otherwise non-service-connected psychiatric disorder. The Board requested that the expert review the record, and provide an opinion as to whether it is at least as likely as not (i.e., a 50 percent probability or greater) that any current psychiatric disorder is etiologically-related to the Veteran's period of active duty service, and, if not, whether it is at least likely as not that any current psychiatric disorder was proximately aggravated by service-connected hidradenitis suppurativa. In November 2012, an opinion ("VHA opinion") was received from L.P., M.D. Dr. L.P. provided a detailed summary of the Veteran's medical history, thus indicating that the Veteran's claims file had been reviewed. Dr. L.P. concluded: Based upon all available evidence, this writer concurs with the opinions of Dr. T.A. (the April 2010 VA examiner) that the Veteran is not experiencing a psychiatric disorder etiologically related to his period of active duty service, nor from an exacerbation of the service connected hidradenitis suppurativa. Additionally, it would be highly unusual for PTSD to suddenly appear 37 years after service and then resolve within two years from only a few mental health appointments. From the records, it appears that the Veteran is doing well with respect to not only his mental health functioning, but also the skin condition, hidradenitis suppurativa. I do not believe the Veteran's depressive disorder, or any other mental disorder, was related to his period of active service and I do not believe a service connected disability aggravated an otherwise non-service connected psychiatric disorder, if one exists. A. PTSD The Board finds that the claim must be denied, as the preponderance of the evidence shows that the Veteran does not have PTSD. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998) (under 38 U.S.C.A. § 1110, an appellant must submit proof of a presently existing disability resulting from service in order to merit an award of compensation). In particular, the Board finds that the November 2012 VHA opinion is highly probative evidence against the claim. In that opinion, Dr. L.P. indicated that she had reviewed the Veteran's medical records, and her opinion is accompanied by a sufficient rationale. See Neives- Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). For the same reasons, the April 2010 VA examiner's opinion is also considered to be highly probative evidence against the claim. Id. The Board therefore finds that the preponderance of the evidence shows that the Veteran does not have PTSD, and that the claim must be denied. In reaching this decision, the Board has considered a number of diagnoses of PTSD contained in VA progress notes, dated between 2008 and 2011. However, none of these diagnoses are shown to have been based on a review of the Veteran's C-file, or any other detailed and reliable medical history, and most appear to be "by history" only. In addition, none of them discuss the criteria for PTSD, and show that they have been met. This evidence is therefore insufficiently probative to warrant the conclusion that the Veteran currently has PTSD. Id. B. Acquired Psychiatric Disorder (other than PTSD) With regard to the claim for an acquired psychiatric disorder (other than PTSD), briefly stated, the evidence includes VA progress notes, dated beginning in 2008, which show that the Veteran's diagnoses include MDD (major depressive disorder). The April 2010 VA PTSD examination report shows that the examiner concluded that the Veteran did not have PTSD, and that there was no evidence of any other psychiatric disorders. The December 2011 VA disability DBQ shows that the diagnosis was depressive disorder NOS. The November 2012 VHA opinion shows that Dr. L.P. concluded that the Veteran's depressive disorder was not caused by his service, nor was it caused or aggravated by a service-connected disability. The Board finds that the claim must be denied. The Veteran was not treated for psychiatric symptoms, or diagnosed with an acquired psychiatric disorder, during service. The earliest post-service medical evidence of an acquired psychiatric disorder is dated in 2008. This is about 37 years after service. The Veteran has asserted that his symptoms began in 1997, and in any event has been found not to be credible. Furthermore, the Veteran is not shown to have been diagnosed with a psychosis, which is the only acquired psychiatric disorder listed at 38 C.F.R. § 3.309(a) (2012), and the U.S. Court of Appeals for the Federal Circuit has recently held that the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic 38 C.F.R. § 3.309(a). Walker v. Shinseki, No. 10-2634, 2013 WL 628429 (Fed. Cir. May 25, 2011). In addition, there is no competent medical evidence to show that the Veteran has an acquired psychiatric condition that is related to his service. In this regard, the only competent opinions are contained in the December 2011 VA DBQ, and the November 2012 VHA opinion, and both of these opinions weigh against the claim on a direct basis. These opinions are considered to be highly probative evidence against the claim, as they are shown to have been based on a review of the Veteran's medical records, and they are accompanied by a sufficient rationale. Neives-Rodriguez; Prejean. Finally, with regard to the claim that the Veteran has an acquired psychiatric disorder (other than PTSD) that was caused or aggravated by service-connected disability, there is no competent evidence in support of this aspect of the claim. The only competent opinion is found in the November 2012 VHA opinion, and this opinion weighs against the claim on a secondary basis. This opinion is considered highly probative. Id. Service connection for an acquired psychiatric disorder (other than PTSD) on a secondary basis is therefore not warranted. See 38 C.F.R. § 3.310. With respect to the Veteran's own contentions, a layperson is generally not capable of opining on matters requiring medical knowledge. Bostain v. West, 11 Vet. App. 124, 127 (1998) citing Espiritu v. Derwinski, 2 Vet. App. 492 (1992) (a layperson without the appropriate medical training and expertise is not competent to provide a probative opinion on a medical matter, to include a diagnosis of a specific disability and a determination of the origins of a specific disorder). Lay testimony is competent, however, to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). When a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In this case, the issue on appeal is based on the contention that an acquired psychiatric disorder, to include PTSD, was caused by service that ended in 1971, or that an acquired psychiatric disorder (other than PTSD) was caused or aggravated by a service-connected disability. However, the Veteran has been found not to be credible. Furthermore, he does not have the requisite skills, knowledge, or training, to be competent to provide a diagnosis of an acquired psychiatric disorder, to include PTSD, or to state whether the claimed condition was caused by his service, or whether it was caused or aggravated by a service-connected disability. Id. The Veteran was not treated for psychiatric symptoms during service, nor was an acquired psychiatric disorder noted upon separation from service. The post-service medical records do not show any relevant treatment or diagnoses prior to 2008. There is no competent evidence of a nexus between an acquired psychiatric disorder, to include PTSD, and the Veteran's service, or a service-connected disability. Given the foregoing, the Board finds that the service treatment reports, and the post-service medical evidence, outweigh the Veteran's contention to the effect that he has the claimed condition that is related to his service, or a service-connected disability. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). III. Increased Initial Evaluation - Hemorrhoids The Veteran asserts that he is entitled to an increased initial evaluation for his hemorrhoids. He argues that he has flare-ups once a month, and a history of bleeding and spotting, and that he has missed up to four or five days due to his symptoms. See Veteran's appeal (VA Form 9), received in November 2011. With regard to the history of the disability in issue, the Veteran's service treatment reports do not show any relevant treatment; the Veteran's separation examination report did not note hemorrhoids, and in an associated "report of medical history," he denied a history of piles or rectal disease. Examination reports associated with Army Reserve duty (following separation from active duty) note hemorrhoids (in September 1974), and a March 1978 hemorrhoidectomy (in July 1978). Private treatment reports show that in 1983, he underwent an excision of a fistula in ano, and a hemorrhoidectomy. In 1998 and 2003, he was treated for hemorrhoids. See 38 C.F.R. § 4.1 (2012). In an April 2010 rating decision, the RO granted service connection for hemorrhoids, evaluated as noncompensable (0 percent disabling), with an effective date of March 18, 2008. The Veteran has appealed the issue of entitlement to an initial compensable evaluation. Disability evaluations are determined by comparing the veteran's present symptomatology with the criteria set forth in the VA's Schedule for Ratings Disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § Part 4 (2012). The Veteran's disability has been evaluated as noncompensable under 38 C.F.R. § 4.114, Diagnostic Code (DC) 7336. Under 38 C.F.R. § 4.114, DC 7336, which pertains to both internal and external hemorrhoids, a 0 percent (noncompensable) evaluation is warranted for mild or moderate hemorrhoids. A 10 percent evaluation is warranted for irreducible, large, or thrombotic hemorrhoids with excessive redundant tissue and evidencing frequent recurrences. Id. The Veteran is appealing the original assignment of a disability evaluation following an award of service connection. In such a case it is not the present level of disability which is of primary importance, but rather the entire period is to be considered to ensure that consideration is given to the possibility of staged ratings; that is, separate ratings for separate periods of time based on the facts found. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). A VA examination report, dated in March 2010, shows that the Veteran complained of intermittent difficulty with rectal bleeding, usually associated with having become constipated. He reported some improvement after a 1983 hemorrhoidectomy. On examination, there was evidence of previous perianal surgery, with small external hemorrhoidal tags in three areas, and one area had a small amount of internal hemorrhoidal tissue. Rectal sphincter tone was good, and there was no evidence of rectal stricture. There were no rectal masses. The diagnosis was internal and external rectal hemorrhoids, grade 2/4, status post hemorrhoidectomy in 1983. A VA examination report, dated in August 2011, shows that the Veteran complained of internal and external hemorrhoids, with pain, itching, and bleeding. He denied fecal incontinence from any cause except very acute gastrointestinal upsets. He gave a history of thrombosed hemorrhoids, and rectal bleeding, and a fissure in ano in the 1980s. He reported current use of hydrocortisone cream. On examination, there was no indication of fecal leakage. The lumen was normal in size, and he had a rectal reflex. There was no indication of anemia, and fissures were not seen. Hemorrhoids were not seen. There was no rectal prolapsed. Sphincter tone was good. The report notes that the Veteran's history of bleeding was more than 12 months ago, and therefore a CBC was not done, and that there were no other signs of anemia. The examiner stated, "[T]he patient has no current indication of hemorrhoids found by this observer at this time." VA progress notes include a May 2010 report which notes mild internal hemorrhoids. In December 2011, the Veteran sought treatment for complaints of rectal cysts and blood in his stool, which had been present for a few days. On examination, there was no visible blood. The diagnoses were recurrent gluteal abscess, and recurrent hemorrhoidal flare. He was given hydrocortisone/pramoxine cream. A statement from the Veteran's spouse, dated in November 2011, shows that she asserts that the Veteran has a history of hemorrhoids dating to at least 1985, with pain and bleeding during bowel movements. She also reports that he has pain, bleeding, and constipation, and that he requires medication for control of his symptoms. The Board finds that the criteria for an initial compensable evaluation have not been met. In this regard, the Veteran has reported that he has flare-ups once a month, and a history of bleeding and spotting, and that he has missed up to four or five days of work due to his symptoms. However, he has been found not to be credible, and his assertions are not corroborated by the medical evidence, which is insufficient to show the required symptoms for a compensable evaluation. In this regard, since the beginning of the appeal period, i.e., March 18, 2008, he has been noted to have hemorrhoids on only a few occasions, and no hemorrhoids were found during an August 2011 VA examination. Furthermore, there are no findings to show irreducible, large, or thrombotic hemorrhoids. In summary, the medical evidence does not show that the Veteran has had irreducible, large, or thrombotic hemorrhoids with excessive redundant tissue and evidencing frequent recurrences. Accordingly, the Board finds that the preponderance of the evidence is against the claim, and that the criteria for an initial compensable rating have not been met. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). IV. The Veterans Claims Assistance Act of 2000 The Board is required to ensure that the VA's "duty to notify" and "duty to assist" obligations have been satisfied. See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). The notification obligation in this case was accomplished by way of letters from the RO to the Veteran dated in December 2006, August and October of 2007, August 2008, and August 2010. Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F. 3d 1328 (Fed. Cir. 2006); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). With regard to the claim for an initial compensable evaluation for hemorrhoids, this appeal arose from a grant of service connection in April 2010. In such a case, where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice was intended to serve has been fulfilled; no additional § 5103(a) notice is required. Dingess v. Nicholson, 19 Vet. App. 473, 491 (2006). The RO also provided assistance to the appellant as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances in this case. It appears that all known and available service treatment reports, and post-service records relevant to the issue on appeal have been obtained and are associated with the Veteran's claims file. The RO has obtained the Veteran's service treatment reports, and his VA and non-VA medical records. The Veteran has been afforded examinations, and with regard to the claim for service connection, etiological opinions have been obtained, to include a VHA opinion. The Board notes that, during the Veteran's hearing, held in June 2012, it was agreed that the record would be held open for 60 days in order to allow the Veteran additional time to supplement the record with medical evidence. However, there is no record that any additional medical evidence was ever submitted. The Board concludes, therefore, that decisions on the merits at this time do not violate the VCAA, nor prejudice the appellant under Bernard v. Brown, 4 Vet. App. 384 (1993). Based on the foregoing, the Board finds that the Veteran has not been prejudiced by a failure of VA in its duty to assist, and that any violation of the duty to assist could be no more than harmless error. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). ORDER The appeal of the issues of entitlement to service connection for a disability manifested by musculoskeletal pain in shoulders, hips and knees, muscle weakness, multiple joint pain, arthritis of multiple joints, including hands, legs and arms, gout, pyoderma, night sweats and sleep problems, abnormal skin texture with scales and facial disfigurement due to scarring, scattered follicular papules, acne keloid, hair loss, fatigue syndrome, erectile dysfunction, and sleep apnea, are dismissed. Service connection for an acquired psychiatric disorder, to include PTSD, is denied. An initial compensable evaluation for service-connected hemorrhoids is denied. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs