Citation Nr: 1312689 Decision Date: 04/17/13 Archive Date: 05/02/13 DOCKET NO. 10-31 051 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for tinnitus. 3. Entitlement to an increased rating (evaluation) in excess of 30 percent for service-connected gunshot wound residuals of the right shoulder with involvement of Muscle Group III. 4. Entitlement to an increased (compensable) rating (evaluation) for service-connected hemorrhoids. 5. Entitlement to a higher initial rating (evaluation) than 10 percent for service-connected coronary artery disease (CAD) status post LAD stent. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Appellant (Veteran) ATTORNEY FOR THE BOARD C. Ferguson, Counsel INTRODUCTION The Veteran had active service from July 1967 to July 1969 and is in receipt of the Purple Heart Medal, among other awards and decorations. This matter comes before the Board of Veterans' Appeals (Board) on appeal from May 2008 and August 2011 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois. The Board has reviewed the physical claims file, as well as the electronic file on the "Virtual VA" system, to ensure a complete review of the evidence in this case. During the course of this appeal, in a September 2012 rating decision, the RO granted two separate 10 percent ratings for a painful scar on the right superior deltoid and a deep scar on the right superior deltoid as residuals of the gunshot wound of the right shoulder. In February 2013, the Veteran presented testimony from the RO relevant to the appeal via videoconference before the undersigned Veterans Law Judge in Washington, DC. A transcript of the Board hearing is of record. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that the Veterans Law Judge who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the February 2012 Board hearing, the undersigned specifically identified the issues on appeal and the Veteran testified regarding the current severity of his hemorrhoids, gunshot wound residuals and coronary artery disease, as well as his history of in-service noise exposure and tinnitus symptomatology. The undersigned also sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claims, to include suggesting that the Veteran obtain a medical opinion from a private audiologist or any VA audiologist from whom he is receiving treatment relating any current hearing loss that he may have to service; therefore, in consideration thereof, the undersigned substantially complied with the requirements of Bryant. During the course of this appeal, the Court held that a TDIU claim is part of an increased rating claim when such claim is reasonably raised by the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, the Veteran was awarded a TDIU in a July 2010 rating decision. As the benefit has already been granted, the issue of entitlement to a TDIU is not reasonably raised and, therefore, is not considered part of the increased rating claims on appeal to the Board. The issues of service connection for hearing loss and service connection for tinnitus 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. For the entire rating period, the service-connected residuals of a gunshot wound of the right shoulder with involvement of Muscle Group III have been manifested by subjective intermittent pain and stiffness with objective limitation of right arm motion well above shoulder level and without muscle atrophy. 2. The service-connected hemorrhoids have been manifested by pain, itching, and bleeding associated with frequent recurrences. 3. The service-connected coronary artery disease is manifested by a workload of 8 METS and is treated with continuous medication. CONCLUSIONS OF LAW 1. The criteria for a disability rating higher than 30 percent for service-connected gunshot wound residuals of the right shoulder with involvement of Muscle Group III are not met or approximated for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.21, 4.56, 4.73, Diagnostic Code 5303 (2012). 2. Resolving reasonable doubt in the Veteran's favor, the criteria for a 10 percent disability rating for service-connected hemorrhoids are approximated throughout the period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.21, 4.114, Diagnostic Code 7336 (2012). 3. The criteria for a disability rating higher than 10 percent for coronary artery disease are not met or approximated for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.21, 4.104, Diagnostic Code 7005 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative 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). 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; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In a claim for increase, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). If complete notice is not provided until after the initial adjudication, such a timing error can be cured by subsequent legally adequate VCAA notice, followed by readjudication of the claim, as in a Statement of the case or Supplemental Statement of the Case. Moreover, where there is an uncured timing defect in the notice, subsequent action by the RO which provides the claimant a meaningful opportunity to participate in the processing of the claim can prevent any such defect from being prejudicial. Mayfield v. Nicholson, 499 F.3d 1317, 1323-24 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Regarding the Veteran's initial rating appeal for service connection for coronary artery disease, the Veteran is challenging the initial disability rating assigned following the grant of service connection in the August 2011 rating decision. The Court has held that, 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 in fact been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. See Dingess v. Nicholson, 19 Vet. App. 473, 490-91; Dunlap v. Nicholson, 21 Vet. App. 112, 117 (2007). Furthermore, under 38 C.F.R. § 3.159(b)(3)(i), there was no duty to provide the Veteran with VCAA notice upon receipt of a Notice of Disagreement, such as in this case. For these reasons, the Board finds that no further notice, beyond that afforded in the context of the claim for service connection, is needed under the VCAA. Regarding the increased rating claims for gunshot wound residuals of the right shoulder and hemorrhoids, VCAA notice requirements were satisfied prior to the initial denial of the increased rating claims by way of the November 2007 and January 2008 notice letters, collectively. In the November 2007 and January 2008 notice letters, the RO advised the Veteran that he may submit evidence showing that his claimed service-connected gunshot wound residuals and hemorrhoids had increased in severity, and described the types of information and evidence that he should submit in support of his claims. The RO also explained what evidence VA was responsible for obtaining or would assist in obtaining on the Veteran's behalf in support of his increased rating claims. The RO further explained how VA determines the disability rating and the effective date. In addition to the notice letters sent above, the Veteran and his representative have been provided with copies of the above rating decisions, the Statements of the Case, and the Supplemental Statements of the Case, which collectively include discussion of the facts of the claims, pertinent laws and regulations, notification of the bases for the decisions, and a summary of the evidence considered. In consideration of the foregoing, the Board concludes that the requirements of the notice provisions of the VCAA have been met, and there is no outstanding duty to inform the Veteran that any additional information or evidence is needed. Regarding VA's duty to assist in claims development, the RO afforded the Veteran with VA medical examinations in connection with his increased rating claims in January 2008, June 2010, and September 2012. Collectively, the medical examination reports include all relevant findings and medical opinions needed to evaluate fairly the Veteran's claims. The VA examiner took a thorough history of the disabilities from the Veteran, including history of onset, diagnosis, report of pain, worsening of pain, other symptoms and limitations, and treatment. The VA examiners had adequate facts and data regarding the history and condition of the Veteran's disabilities. See VAOPGCPREC 20-95 (interpreting that in some cases an accurate history by a veteran may be a valid basis for an examination report rather than claims file review); see also Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran). The VA medical examiners also considered the Veteran's subjective complaints as it related to his current symptomatology and its effects on his daily life and performed a thorough physical evaluation of the Veteran's right shoulder, to include x-rays, and the rectal area. There has been no allegation or indication that there has been a material change in condition of the Veteran's service-connected disabilities since the most recent examinations. For these reasons, the Board finds that the medical examination reports of record are adequate for rating purposes, and there is no need for further medical examination. Also, post-service treatment records adequately identified as relevant to the Veteran's claims have been obtained or otherwise submitted, and are associated with the record. Although the records from Loyola University Medical Center were not obtained, the Veteran was advised that the facility charged a fee for copies of their records, that VA had no funds to pay the charges for the records, and the Veteran was advised to send a copy of these records to VA to have them considered. Further requests for these records from Loyola University Medical Center would not result in obtaining the records; therefore, there is no further duty to request these records. The Veteran had ample opportunity to submit the records himself, but the records have not been received. There are additional treatment records pertinent to the Veteran's claims found in the Virtual VA folder, which were considered by the Agency of Original Jurisdiction (AOJ) in the first instance. The Veteran has not made the RO or the Board aware of any other evidence relevant to the appeal that needs to be obtained. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal, and no further development is required to comply with the duty to assist in developing the facts pertinent to the claims decided herein. In view of the foregoing, the Board will proceed with appellate review. Rating Gunshot Wound Residuals, Hemorrhoids, and Coronary Artery Disease Disability Rating Criteria It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C.A. § 7104(a) (West 2002). The Board has thoroughly reviewed all the evidence in this case. The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to a veteran). Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. In determining the disability evaluation, VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Governing regulations include 38 C.F.R. §§ 4.1 and 4.2, which require the evaluation of the complete medical history of a veteran's condition. In a September 1969 rating decision, service connection was established for residuals of a gunshot wound to the right shoulder and hemorrhoids, with a 20 percent rating and 0 percent rating, respectively, effective July 4, 1969. In an August 2004 rating decision, the rating for the Veteran's residuals of a gunshot wound to the right shoulder was increased to 30 percent effective April 14, 2004. The current increased rating claims for gunshot wound residuals and hemorrhoids were filed in October 2007. Where an increase in an existing disability rating based on established entitlement to compensation is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). VA's determination of the "present level" of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased rating claim has been pending and, consequently, staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). In the August 2011 rating decision on appeal, service connection was established for coronary artery disease status post LAD stent (i.e., groin), with a 10 percent disability rating effective November 14, 2006. The Veteran has appealed the initial rating assigned by the RO for the service-connected coronary artery disease. In a claim for a higher original rating after an initial award of service connection, such as for coronary artery disease in this case, all the evidence submitted in support of a veteran's claim is to be considered. An appeal from the initial assignment of a disability rating requires consideration of the entire time period involved and contemplates staged ratings where warranted. Fenderson v. West, 12 Vet. App. 119 (1999). Rating Gunshot Wound Residuals with involvement of Muscle Group III The Veteran's gunshot wound residuals of the right shoulder with involvement of Muscle Group III are currently rated as 30 percent disabling under 38 C.F.R. § 4.73, Diagnostic Code 5303 for rating muscle injuries of Group III. The Veteran is right arm dominant and the currently assigned 30 percent rating represents moderately severe impairment of Muscle Group III. The functions of Muscle Group III are elevation and abduction of arm to level of shoulder; and the pectoralis major I (clavicular) and deltoid acting with Group II in forward and backward swing of the arm. The muscles involved include the pectoralis major I (clavicular) and deltoid. Concerning injury to the dominant arm, a slight injury warrants a noncompensable (zero percent) rating. A moderate injury is rated as 20 percent disabling. A moderately severe injury is rated as 30 percent disabling. A severe injury is evaluated as 40 percent disabling. 38 C.F.R. § 4.73, Diagnostic Code 5303. Muscle group damage is categorized as mild, moderate, moderately severe, and/or severe, and evaluated accordingly. 38 C.F.R. § 4.56. Disability of a muscle group is based on impaired joint motion and its ability to perform its full work. Principal symptoms are weakness and fatigability, and coordination, swelling, deformity, and atrophy. The principal factors are impairment of delicate coordination, strength of scar bound muscles, and lowering of fatigue threshold. Skin scars are incidental and negligible but allow for envisaging the whole track of the missile, including any bony or nerve involvement. It is the deep intra-and inter-muscular scarring that is disabling. Through-and-through or other wounds of the deep structure almost invariably cause scarring so that muscles pull against other muscles causing incoordination and loss of strength. Prolonged exertion brings about fatigue and pain, thus interfering with function. 38 C.F.R. §§ 4.47, 4.48, 4.49, 4.50, 4.51, 4.54 (2012). Moderately severe disability of muscles--(i) Type of injury. Through and through or deep penetrating wound by small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. (ii) History and complaint. Service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section and, if present, evidence of inability to keep up with work requirements. (iii) Objective findings. Entrance and (if present) exit scars indicating track of missile through one or more muscle groups. Indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side. Tests of strength and endurance compared with sound side demonstrate positive evidence of impairment. 38 C.F.R. § 4.56(d). Severe disability of muscles--(i) Type of injury. Through and through or deep penetrating wound due to high-velocity missile, or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intermuscular binding and scarring. (ii) History and complaint. Service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements. (iii) Objective findings. Ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track. Palpation shows loss of deep fascia or muscle substance, or soft flabby muscles in wound area. Muscles swell and harden abnormally in contraction. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side indicate severe impairment of function. If present, the following are also signs of severe muscle disability: (A) X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile. (B) Adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle. (C) Diminished muscle excitability to pulsed electrical current in electrodiagnostic tests. (D) Visible or measurable atrophy. (E) Adaptive contraction of an opposing group of muscles. (F) Atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle. (G) Induration or atrophy of an entire muscle following simple piercing by a projectile. In the interest of providing historical background on the Veteran's muscle injury, the Board notes that the service treatment records show that he was hit in the right shoulder by enemy fire during a mortar attack in March 1968 while serving in the Republic of Vietnam. The injury showed no evidence of artery or nerve involvement and was initially treated with debridement and irrigation of the lacerated wound followed by debridement and primary closure of the lacerated wound of the right shoulder three days later. The Veteran was hospitalized for a period of eight days and then discharged to duty. Later that month, he was determined to be medically qualified for duty with limitations until May 1969. At the May 1969 service separation examination, the Veteran's upper extremities were clinically evaluated as normal, with scars on the right shoulder noted. On the service separation report of medical history, the Veteran checked "No" when asked if he had a painful or "trick" shoulder and the service medical examiner wrote that the Veteran's right shoulder was "ok" after having been wounded in Vietnam. When the Veteran underwent a VA medical examination in August 1969 in connection with the original service connection claim for residuals of the gunshot wound to the right shoulder, he complained of aching and pain in the right shoulder and arm after prolonged use (i.e., from three to four hours) and reported that he worked as a machinist handling tools and heavy wire. Objectively, the Veteran demonstrated right shoulder abduction reduced by 50 percent (i.e., to 90 degrees) and external and internal rotations reduced by 25 percent. X-rays were negative. At the February 1983 VA medical examination performed in connection with a prior increased rating claim, the Veteran complained of pain in the right shoulder from time to time, limited motion/mobility of the right arm intermittently, numbness in the deltoid region, loss of strength of the right arm, and itching with very cold and damp weather. The Veteran was able to abduct to 120 degrees with pain and forward flex to 160 degrees with pain. The Veteran also demonstrated normal motor strength of the right arm and the x-rays showed no abnormalities. The noted impression was status post shell fragment wound of the right shoulder with loss of muscle mass and power and loss of cutaneous sensation. When the Veteran underwent a VA medical examination in February 2002 performed in connection with a prior increased rating claim, he complained of ache and pain in the right shoulder with occasional itching during cold weather, as well as intermittent limited range of motion and weakness. The VA examiner noted that the disability may effect the Veteran's household related activities and chores but had no effect on his occupation. Objectively, the Veteran demonstrated normal motor strength (5/5) with limited range of motion on abduction (140/180), forward flexion 160/180), internal rotation (70/90) and external rotation (80/90). Also demonstrated was minimal tissue loss with minimal tenderness. X-rays of the shoulder showed degenerative joint disease of the acromioclavicular joint with spur formation. After review of the lay and medical evidence of record as it is relevant to the current rating period, the Board finds that the weight of the evidence demonstrates that the Veteran's right shoulder disability has been productive of no more than moderately severe impairment of muscle group III throughout the period, which is commensurate with the current 30 percent rating assigned under Diagnostic Code 5303. At the outset, the Board notes that the Veteran is diagnosed with degenerative arthritis of the acromioclavicular joint and rotator cuff tendinopathy of the right shoulder. The Court has held that, when a claimant has both service-connected and non-service-connected disabilities, the Board must attempt to discern the effects of each disability and, where such distinction is not possible, attribute such effects to the service-connected disability. Mittleider v. West, 11 Vet. App. 181, 182 (1998). In consideration of the foregoing, and in an effort to give the Veteran the benefit of the doubt in this case, the Board has considered all the Veteran's symptoms and diagnoses involving the right shoulder in reaching its decision regarding entitlement to an increased rating when not easily distinguished. The Board notes that the Veteran underwent medical examination in September 2012. Despite the Veteran's complaints of intermittent anterior right shoulder pain several times per week and intermittent stiffness without flare-ups, the Veteran was able to lift the right arm well above shoulder level on both abduction and forward flexion. Indeed, he was able to abduct to 120 degrees (out of 180 degrees) with pain beginning at 120 degrees, and was able to forward flex to 130 degrees (out of 180 degrees) with pain beginning at 130 degrees. On repetition, the Veteran was still able to abduct to 120 degrees and forward flex to 130 degrees. The Veteran also demonstrated normal muscle strength on right shoulder abduction and shoulder forward flexion and showed no muscle atrophy. Although the Hawkin's Impingement Test was positive, which may signify rotator cuff tendinopathy, all other tests for rotator cuff conditions were negative. The VA examiner also noted that there was a tender acromioclavicular joint with positive cross body adduction test and positive Neer impingement sign. However, the VA examiner checked "No" when asked if there was functional impairment to the degree that no effective function remained in the right shoulder other than that which would be equally well served by an amputation with prosthesis. The VA examiner also checked "No" when asked if the Veteran's Muscle Group III injury affected muscle substance or function, as well as when asked if the Veteran had any signs or symptoms such as loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, and uncertainty of movement attributable to muscle injury. There was no X-ray evidence of retained shell fragment(s) and/or shrapnel. The VA medical examiner noted that the Veteran demonstrated some loss of subcutaneous tissue but no apparent muscle loss and the deltoid had normal strength. The VA examiner further noted that there was no appreciable bone, tendon, joint, or neurovascular injury which could be attributed to the wound to the right shoulder and checked "No" when asked if the shoulder condition impacted the Veteran's ability to work. Upon review of the treatment records relevant to the rating period, the Board notes that they contain no findings contrary to those articulated in the September 2012 VA examination report above. The treatment records only include reference to the Veteran's complaint of chronic shoulder pain. After reviewing the evidence, the Board notes that the Veteran has complained of intermittent pain and stiffness affecting the right upper extremity and has demonstrated limitation of motion of the right arm on physical examination. In evaluating musculoskeletal disability, VA must determine whether pain could significantly limit functional ability during flare-ups, or when the joints are used repeatedly over a period of time. See DeLuca v. Brown, 8 Vet. App. 202, at 204-206, 208 (1995); 38 C.F.R. §§ 4.40, 4.45, 4.59. Although pain may cause a functional loss, pain itself does not constitute functional loss. Pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Even considering additional limitations of motion and function due to pain demonstrated on examination in this case, the motion of the Veteran's right arm is shown to be limited to, at worst, 120 degrees, which does not meet or more nearly approximate the criteria for a rating in excess of 30 percent based on limitation of shoulder and arm motion (Diagnostic Code 5201). The pain associated with the Veteran's scar is already separately compensated under Diagnostic Code 7804. 38 C.F.R. § 4.14 (2012). The evidence does not show ankylosis of the scapulohumeral articulation or impairment of the humerus such that an increased rating under either Diagnostic Code 5200 or Diagnostic Code 5202 is warranted. While there is degenerative joint disease at the acromioclavicular joint, the evidence does not show dislocation, nonunion, or malunion of the clavicle or scapula to warrant evaluation under Diagnostic Code 5203. The Board notes that the Veteran is in receipt of two separate 10 percent evaluations for residual scars of the right shoulder due to the in-service gunshot wound; however, upon review of the evidence, the Board finds that the Veteran is not entitled to a higher rating for either scar. Neither scar is shown to result in functional impairment or demonstrates any of the characteristics, to include size and location, necessary for a higher rating. For these reasons, the Board finds that the lay and medical evidence is against finding that the Veteran's right shoulder gunshot residuals demonstrate more than a moderately severe level of impairment. There is no additional disability as a result of functional impairment, including no limitation of flexion or abduction to warrant a rating in excess of 30 percent; therefore, a rating in excess of 30 percent is not warranted for any period. 38 C.F.R. §§ 4.3, 4.7. The Board has further considered whether the increased rating claim warrants referral for consideration of an extraschedular rating under 38 C.F.R. § 3.321. Under Thun v. Peake, 22 Vet. App. 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, it must be determined whether the disability picture is such that the schedular criteria are inadequate, i.e., whether there are manifestations or impairment that are not encompassed by the schedular criteria. If those criteria are not inadequate, the analysis does not need to proceed any further. In this case, the Board does not find any symptoms or functional impairment caused by the right shoulder gunshot wound disability that is not already encompassed by the 30 percent schedular schedular disability rating. As stated above, the Veteran's right shoulder disability is manifested by intermittent pain and stiffness and limitation of motion of the right arm. Although the schedular criteria under Diagnostic Code 5303 does not delineate the symptomatology in the criteria and, instead, more generally considers the overall disability picture, without limitation of factors for consideration, these more specific findings and impairments may be considered when assessing the overall degree of severity for a rating under Diagnostic Code 5303. The criteria and factors at 38 C.F.R. §§ 4.40, 4.45, 4.59, and Deluca are incorporated as part of the schedular rating criteria and are considered in the currently assigned schedular rating. Despite the Veteran's complaint of right arm numbness at the January 2008 VA medical examination, he made no mention of numbness at the September 2012 VA medical examination. Furthermore, the September 2012 VA examiner noted that there was no appreciable neurovascular injury attributable to the gunshot wound and there is no competent medical opinion to the contrary of record; therefore, the Veteran's complaint of right arm numbness is not shown to be a symptom of the service-connected right shoulder disability. The September 2012 VA medical examiner also opined that the Veteran's right shoulder disability did not impact his ability to work. In consideration of the foregoing, the Board finds that the Veteran's right shoulder gunshot wound residuals are appropriately considered to more nearly approximate a moderately severe level of impairment and, accordingly, contemplates all of the encompassed symptomatology. For these reasons, the Board finds that the schedular criteria are adequate to rate the Veteran's disability, and referral for consideration of extraschedular rating is not necessary. In consideration of the foregoing, the Board finds that a preponderance of the evidence is against the Veteran's claim for increased rating in excess of 30 percent for residuals of a gunshot wound to the right shoulder, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. Rating Hemorrhoids The Veteran is presently assigned a zero percent rating for his service-connected hemorrhoids under Diagnostic Code 7336, which is reflective of mild or moderate external or internal hemorrhoids. 38 C.F.R. § 4.114, Diagnostic Code 7336. The Veteran complains of bleeding, fecal leakage, pain, and itching associated with his service-connected hemorrhoids and seeks a compensable evaluation on such basis. Under the diagnostic code, a 10 percent rating is warranted when there is evidence of external or internal hemorrhoids that are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. A 20 percent rating, which is the maximum disability rating available under the diagnostic code, is warranted when there is evidence of external or internal hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. Id. After review of the lay and medical evidence of record relevant to the rating period, the Board resolves reasonable doubt in the Veteran's favor in finding that the disability picture associated with the Veteran's hemorrhoids more closely approximates the criteria for a 10 percent rating throughout the period. In this regard, the Board recognizes that the September 2012 VA medical examiner specifically noted that the Veteran's hemorrhoids were mild to moderate, which is consistent with the currently assigned 10 percent rating. The Board also notes that the evidence relevant to the rating period does not show that the Veteran's hemorrhoids have been large, irreducible, or manifested by excessive redundant tissue at any time. Nonetheless, the evidence shows that the Veteran's hemorrhoids are manifested by symptoms analogous to frequent recurrences, which is a symptom delineated in the criteria for the10 percent rating under Diagnostic Code 7336. At the Board hearing, for example, the Veteran testified that he had problems with his hemorrhoids "pretty constantly of late." See February 2013 Board hearing transcript, page 6. Also, at the June 2010 VA medical examination, the Veteran testified that he had recurring episodes of hemorrhoids that he self treated with over-the-counter medication (i.e., preparation H) and rectal steroid suppositories. The Board considers the Veteran competent to report the frequency of his hemorrhoids and finds no evidence in the record to show that the Veteran's account of hemorrhoids is not credible. The Board also observes that the Veteran objectively demonstrated hemorrhoids at both the June 2010 and September 2012 VA medical examinations, and VA treatment records show that the Veteran has objectively demonstrated and received medical treatment for hemorrhoids during the period. See, e.g., December 2007 VA general medicine attending note (noting the presence of external nontender hemorrhoids). The Veteran is also shown to have episodes of bleeding associated with the hemorrhoids. At the September 2012 VA medical examination, the VA examiner noted that the Veteran reportedly had some bleeding a few times per week. The Veteran is competent to report having bleeding associated with the hemorrhoids and the VA medical examiner found the competent account of frequent bleeding to be credible. See also December 2007 VA general medicine attending note (noting that the Veteran noticed blood in his stool when he wipes). Bleeding is a symptom contemplated by the highest schedular rating of 20 percent under Diagnostic Code 7336. The evidence does not, however, show that the Veteran has persistent bleeding, as required for the 20 percent rating. Despite the Veteran's complaints, the June 2010 VA medical examiner specifically wrote that no current bleeding was observed at the time of the rectal examination and the September 2012 VA medical examiner similarly noted that no gross blood was shown on examination, which is evidence against finding that hemorrhoids are manifested by persistent bleeding. The objective medical evidence as it relates to the persistency of the bleeding is deemed more credible and of greater probative value than the Veteran's assertion of constant bleeding at the June 2010 VA medical examination, particularly as the assertion is inconsistent with the Veteran's later statement at the September 2012 VA medical examination that the bleeding was only occasional or a few times per week. The Board has further considered the Veteran's complaints of itching and pain associated with his service-connected hemorrhoids, which are not symptoms specifically contemplated under Diagnostic Code 7336. However, the Court has defined thrombosis as the formation or presence of a thrombus. See Hayes v. Brown, 9 Vet. App. 67, 70 (1996). A thrombus is defined as a "stationary blood clot along the wall of a blood vessel, frequently causing vascular obstruction." DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1949 (31st ed. 2007). In this case, the Veteran's rectal pain and itching, considered together with the frequent bleeding discussed above, is found to be analogous to a thrombotic hemorrhoid, which is a symptom contemplated by the 10 percent schedular rating. Thus, while not all the elements for a 10 percent schedular evaluation under Diagnostic Code 7336 are demonstrated, the overall disability picture associated with the Veteran's hemorrhoid disability more closely approximates the level of impairment contemplated for the 10 percent evaluation under Diagnostic Code 7336 throughout the rating period. See 38 C.F.R. § 4.21. The disability picture approximates or is most analogous to thrombotic hemorrhoids with frequent recurrences manifested by bleeding, itching, and pain. A higher rating of 20 percent is not warranted under Diagnostic Code 7336, however, because the evidence weighs against finding that the Veteran's hemorrhoids are manifested by persistent bleeding, as explained above, and there is no evidence of secondary anemia or fissures during the time relevant to the rating period. The Board has further considered whether the increased rating appeal warrants referral for consideration of an extraschedular rating under 38 C.F.R. § 3.321. In this case, the Board does not find any symptoms or functional impairment that is not already encompassed by the currently assigned 10 percent rating. The Veteran's pain, itching, and bleeding associated with frequent recurrences of the service-connected hemorrhoids were specifically contemplated when the Board found that the disability picture more closely approximated the criteria for the 10 percent rating under Diagnostic Code 7336. Although the September 2012 VA medical examiner noted that the Veteran's disability impacted his ability to work on the bases that it was occasionally hard to sit or stand for prolonged periods before having to change positions and the Veteran was unable to left heavy objects due to the worsening of the hemorrhoids, the Veteran acknowledged that the hemorrhoid disability was only partly contributing to his unemployability and his service-connected PTSD was the primary reason for his unemployability. As noted above, the Veteran is in receipt of a TDIU and, therefore, the extent to which the hemorrhoid disability contributes to the Veteran's unemployability has already been contemplated in the award of TDIU benefits. As it relates to the Veteran's complaint of fecal leakage, the Board notes that fecal leakage and/or impaired sphincter control is not shown by the evidence to be a symptom of service-connected hemorrhoids and, therefore, is not considered part of the service-connected hemorrhoid disability. Impairment of sphincter control is a different disability with different rating criteria from the disability of hemorrhoids. The evidence of record does not show that the Veteran's service-connected hemorrhoid disability is manifested by impairment of sphincter control. In this case, the Board finds that the Veteran's hemorrhoid disability is appropriately considered to more nearly approximate a level of impairment commensurate with a 10 percent schedular evaluation and, accordingly, contemplates all the encompassed symptomatology. For these reasons, the Board finds that the schedular criteria are adequate to rate the Veteran's disability, and referral for consideration of extraschedular rating is not necessary. Thus, a preponderance of the evidence is against the increased rating claim and it must be denied. 38 C.F.R. §§ 4.3, 4.7. Rating Coronary Artery Disease The Veteran was initially assigned a 10 percent rating for his service-connected coronary artery disease, status post under Diagnostic Code 7005. A 10 percent rating is prescribed when there is evidence of workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required. In order for the Veteran to receive the next higher evaluation of 30 percent under Diagnostic Code 7005 (arteriosclerotic heart disease/coronary artery disease), the evidence must show that manifestations of his cardiac disability more closely approximate a workload of greater than 5 METs but not greater than 7 METs which results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. 38 C.F.R. § 4.104, Diagnostic Code 7005. After reviewing the lay and medical evidence relevant to the rating period, the Board concludes that the weight of the evidence is against finding that the disability picture associated with the Veteran's coronary artery disease more closely approximates the schedular criteria for a higher disability rating. The VA treatment records show that the Veteran was on continuous medication to treat coronary artery disease but has otherwise been asymptomatic throughout the rating period. See, e.g., September 2006 VA cardiology progress note (noting that the Veteran was totally asymptomatic for cardiac diseases); and March 2007 VA general medicine note (noting that the Veteran's symptoms had resolved since the August 2006 placement of the stent). In this regard, the Board recognizes that the Veteran had presented for medical treatment in June 2009 with noted exertional shortness of breath at the prior visit; however, the VA medical providers considered the complaints and specifically noted that the Veteran was asymptomatic and without angina symptoms. A VA cardiologist noted that the Veteran was not having symptoms of unstable angina and it was okay to proceed with the dental work. See June 2009 VA addendum. This evidence weighs against finding that the disability picture more closely approximates a rating higher than the assigned 10 percent. Also, when the Veteran underwent a medical examination in connection with the claim in June 2010, the VA heart examiner noted that the Veteran took medication to treat the coronary artery disease, demonstrated a workload of 8 METs, and had no recurrence of symptoms since the 2006 placement of the stent. This evidence provides further evidence against finding that the criteria for a higher rating for coronary artery disease have been met for any period. Thus, the probative evidence of record shows that the disability picture associated with the Veteran's coronary artery disease is commensurate with the schedular criteria for a 10 percent rating throughout the rating period. Therefore, an increased rating is not warranted on a schedular basis at any time during the period and the appeal is denied. The Board has considered whether the initial rating appeal warrants referral for consideration of an extraschedular rating under 38 C.F.R. § 3.321. However, in this case, the Board does not find any symptoms or functional impairment that is not already encompassed by the 10 percent rating. The Veteran's use of medication to treat coronary artery disease and the demonstrated workload of 8 METs are symptoms specifically contemplated in the schedular criteria for a 10 percent rating under Diagnostic Code 7005. The coronary artery disease is otherwise shown to be asymptomatic during the rating period. The June 2010 VA heart examiner specifically noted that the Veteran's coronary artery disease does not affect his usual occupation and daily activities, and there is no competent medical opinion to the contrary of record. For these reasons, the Board finds that the schedular criteria are adequate to rate the Veteran's disability, and referral for consideration of extraschedular rating is not necessary. ORDER An increased rating in excess of 30 percent for service-connected gunshot wound residuals of the right shoulder with involvement of Muscle Group III, is denied. A 10 percent rating for service-connected hemorrhoids is granted. An initial rating higher than 10 percent for service-connected coronary artery disease (CAD) status post LAD stent is denied. REMAND Service Connection for Hearing Loss and Tinnitus The Board finds that the issues of service connection for hearing loss and tinnitus must be remanded. The Veteran contends that he was exposed to the loud noise of artillery while performing his duties as an automatic weapons crewman in the Army and that such exposure caused hearing loss and tinnitus. The Veteran's account of having been exposed to the loud noise of artillery is consistent with the circumstances, hardships, and conditions of his combat service and is, therefore, deemed credible. The RO has denied the Veteran's service connection claim for hearing loss primarily on the bases that the results of the January 2008 VA audiological examination showed no hearing loss for VA compensation purposes. However, at the February 2013 Board hearing, the Veteran's representative asserted that the Veteran's hearing loss may have worsened since the January 2008 VA audiological examination so that he now meets the criteria for hearing loss. In consideration of the foregoing, the Board finds that another VA medical examination for the Veteran's claimed hearing loss is warranted. Regarding the service connection claim for tinnitus, the RO has denied the claim primarily on the basis that the January 2008 VA audiological examiner opined that tinnitus was not related to military noise exposure. In providing the rationale for the opinion, the VA audiological examiner noted that the service separation examination showed normal hearing and tinnitus reportedly first began after service. However, the VA audiological examiner did not adequately address the likelihood in terms of relative probability of whether in-service combat noise exposure caused tinnitus to develop after service. As the January 2008 medical opinion is inadequate, another medical opinion is needed. Accordingly, the issues of service connection for hearing loss and tinnitus are REMANDED for the following actions: 1. Schedule the Veteran for a VA audiology and/or ear disease examination for the claimed hearing loss and tinnitus. All relevant documents (i.e., the paper claims file and any medical records contained in Virtual VA, CAPRI, and AMIE) should be made available to and reviewed by the examiner in rendering the opinion. The examiner should confirm that the record was reviewed. Based on review of the record, the examiner should provide the following opinion: A. Is it at least as likely as not (i.e., to at least a 50 percent degree of probability) that the Veteran's current hearing loss of either ear is causally or etiologically related to in-service combat noise exposure? B. Is it at least as likely as not (i.e., to at least a 50 percent degree of probability) that the Veteran's tinnitus, which began after service, is causally or etiologically related to in-service combat noise exposure? Note: The term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather that the weight of evidence both for and against a conclusion is so evenly divided that it is as sound to find in favor of causation as it is to find against it. Note: A rationale should be provided for all opinions given, and the factors upon which each medical opinion is based must be set forth in the report. If the examiner cannot answer any question posed without resorting to speculation, the examiner should so state, and explain why that is so. 2. After any additional notification and/or development deemed necessary is undertaken, adjudicate the issues of service connection for hearing loss and service connection for tinnitus. If any benefit sought on appeal remains denied, provide a Supplemental Statement of the Case with an appropriate period of time for response by the Veteran and the representative. Thereafter, return the case to the Board for further appellate consideration, if in order. This case is REMANDED for further evidentiary development. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs