Citation Nr: 1322652 Decision Date: 07/16/13 Archive Date: 07/24/13 DOCKET NO. 09-26 399 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to an increased disability evaluation for allergic rhinitis, to include a compensable evaluation prior to November 26, 2012, and a disability evaluation in excess of 10 percent as of November 26, 2012. 2. Entitlement to a compensable disability evaluation for beta thalassemia. 3. Entitlement to an increased disability evaluation for hemorrhoids, to include a compensable evaluation prior to November 26, 2012, and a disability evaluation in excess of 10 percent as of November 26, 2012. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD B. R. Mullins, Counsel INTRODUCTION The Veteran had active service from November 1983 to November 2004. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas, denying the claims currently on appeal. In a January 2013 rating decision, the Veteran's disability evaluation for his service-connected allergic rhinitis was increased to 10 percent, effective as of November 26, 2012. The disability evaluation for his hemorrhoids was also increased to 10 percent, effective as of November 26, 2012. Since these grants did not constitute a full grant of the benefits sought on appeal, these claims are still in appellate status. AB v. Brown, 6 Vet. App. 35, 39 (1993). The Veteran was afforded a hearing before the undersigned in January 2012. A written transcript of this hearing has been prepared and incorporated into the evidence of record. FINDINGS OF FACT 1. Prior to November 26, 2012, the Veteran's allergic rhinitis was manifested by symptoms such as troubled breathing and discharge; it was not manifested by nasal obstruction of 50 percent or more on both sides or total obstruction on one side. 2. As of November 26, 2012, the Veteran's allergic rhinitis has been manifested by symptoms such as trouble breathing, discharge, and nasal obstruction of 50 percent or more on both sides; it has not been manifested by nasal polyps. 3. The Veteran's beta thalassemia has not been manifested by hemoglobin levels of 10 gram (gm)/100 milliliter (ml) or less at any time during the pendency of this claim and the condition has not required continuous medication. 4. Prior to November 26, 2012, the Veteran's hemorrhoids were mild to moderate with excessive redundant tissue and occasional bleeding; they were not large or thrombotic or irreducible. 5. As of November 26, 2012, the Veteran's hemorrhoids have been mild to moderate with occasional bleeding, irreducible and associated with excessive redundant tissue; they have not been large or thrombotic or associated with anemia or anal fissures. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to an increased disability evaluation for allergic rhinitis, to include a compensable evaluation prior to November 26, 2012, and a disability evaluation in excess of 10 percent as of November 26, 2012, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.97, Diagnostic Code 6522 (2012). 2. The criteria for establishing entitlement to a compensable disability evaluation for beta thalassemia have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.117, Diagnostic Code 7700, 7716 (2012). 3. The criteria for establishing entitlement to an increased disability evaluation for hemorrhoids, to include a compensable evaluation prior to November 26, 2012, and a disability evaluation in excess of 10 percent as of November 26, 2012, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.114, Diagnostic Code 7336 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify VA has a duty to notify and assist veterans in substantiating a claim 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 and 3.326(a) (2012). Proper notice from VA must inform the Veteran of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the Veteran is expected to provide in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). For an increased disability rating claim, VA is required to provide the Veteran with generic notice - that is, the type of evidence needed to substantiate the claim. This includes 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). In the present case, such notice was provided to the Veteran in letters dated May 2007, February 2009 and November 2012. These letters informed him of the need to show a worsening of his disabilities, how disability ratings and effective dates are assigned, and the February 2009 letter provided him with the applicable rating criteria. The claims were readjudicated in a January 2013 supplemental statement of the case. Under these circumstances, the Board finds that the notification requirements have been satisfied as to both timing and content. Adequate notice was provided to the Veteran prior to the transfer and certification of his case to the Board that complied with the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b). Duty to Assist Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). VA obtained the Veteran's service treatment records. Also, the Veteran received adequate VA medical examinations in May 2007 and November 2012. Copies of treatment records from the Lackland Air Force Base and the Brooke Army Medical Center, as well as private treatment records, have also been incorporated into the claims file. Significantly, neither the Veteran nor his representative has identified any additional existing evidence that is necessary for a fair adjudication of the claim that has not yet been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Additionally, the Board finds there has been substantial compliance with its September 2012 remand directives. The Board notes that the Court has held that "only substantial compliance with the terms of the Board's engagement letter would be required, not strict compliance." See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that there was no Stegall (Stegall v. West, 11 Vet. App. 268) violation when the examiner made the ultimate determination required by the Board's remand). The record indicates that the Appeals Management Center (AMC) obtained additional records from the Brooke Army Medical Center, contacted the Veteran about additional treatment providers and scheduled the appellant for medical examinations. The AMC later issued a rating decision and a Supplemental Statement of the Case (SSOC). Based on the foregoing, the Board finds that the AMC substantially complied with the mandates of its remand. See Stegall, supra, (finding that a remand by the Board confers on the appellant the right to compliance with its remand orders). In January 2012, the Veteran was provided an opportunity to set forth his contentions during a hearing before the undersigned. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that a "hearing officer" who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, the undersigned noted the issues on appeal and solicited information regarding his symptomatology and how it affected him. Therefore, not only were the issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim," were also fully explained. See Bryant, 23 Vet. App. at 497. Moreover, the Veteran indicated that he was still receiving medical care, and his claim was subsequently remanded so these additional records could be added to the claims file. Under these circumstances, nothing gave rise to the possibility that evidence had been overlooked with regard to the Veteran's claims. As such, the Board finds that, consistent with Bryant, the undersigned complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) and that the Board may proceed to adjudicate the claims based on the current record. Relevant Laws and Regulations Disability ratings are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings will be applied, the higher rating will be assigned if the disability picture more closely approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7 (2012). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). See also 38 C.F.R. §§ 4.1, 4.2 (2012). As such, the Board has considered all of the evidence of record. However, the most probative evidence of the degree of impairment consists of records generated in proximity to and since the claim on appeal. As is the case here, where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. Hart v. Mansfield, 21 Vet. App. 505 (2007). Allergic Rhinitis The Veteran contends that he is entitled to an increased disability evaluation for his service-connected allergic rhinitis. For historical purposes, the Veteran was originally granted service connection for allergic rhinitis in a May 2005 rating decision. A noncompensable (0 percent) disability evaluation was assigned under Diagnostic Code 6522, effective as of December 1, 2004. In February 2007, VA received a claim from the Veteran seeking a higher disability evaluation. This claim was denied in an August 2007 rating decision. A timely notice of disagreement was received from the Veteran in October 2007, but the noncompensable disability evaluation was continued in an April 2009 statement of the case. The Veteran appealed this rating to the Board in June 2009. As already noted, the Veteran's disability evaluation was increased to 10 percent in a January 2013 rating decision, effective as of November 26, 2012. Therefore, the issue before the Board is entitlement to a compensable disability evaluation for allergic rhinitis, prior to November 26, 2012, and entitlement to a disability evaluation in excess of 10 percent as of November 26, 2012. According to a March 2006 Air Force treatment note, the Veteran was having problems with congestion. Examination revealed mild hypertrophy of the nasal mucosa without swollen nasal turbinate, tenderness of the maxillary sinus or tenderness of the frontal sinus. A diagnosis of allergic rhinitis was assigned at this time. A July 2006 note also reflects that the Veteran was having problems with allergies. The Veteran reported symptoms for the past two weeks with itching and watering of the eyes, voice loss, congestion, runny nose and feeling tired. The Veteran was afforded a VA examination for this condition in May 2007. The Veteran reported sinus problems with sinusitis occurring constantly. During the attacks, he was incapacitated as often as 2 times per year with each incident lasting for 2 weeks. During these attacks, he also had headaches. No antibiotic treatment was required. The Veteran reported suffering from interference with breathing through the nose, hoarseness of the voice and shortness of breath. The Veteran's overall functional impact was noted to be limited to breathing problems. Examination of the nose revealed no nasal obstructions, no deviated septum and no nasal polyps. No sinusitis was found upon current examination. Numerous records from the Brooke Army Medical Center also reflect treatment for allergy symptoms such as congestion. A July 2007 record notes that the Veteran's rhinitis was currently stable. In September 2008, the Veteran was experiencing a sore throat associated with drainage. According to a February 2009 record, the Veteran had increased coughing and congestion for the past week. The Veteran treated his allergies with Flonase and Claritin. An October 2009 private treatment note from the Alamo City Medical Group reflects that the Veteran's allergies had been exacerbated for the past week. The Veteran was noted to be experiencing seasonal allergies with watery eyes. The Veteran was most recently afforded a VA examination in November 2012. The Veteran reported persistent sneezing, fatigue, nasal congestion, itchy eyes and watery nose. It was noted that his symptoms were seasonal rather than perennial. Examination revealed a greater than 50 percent obstruction of the nasal passage on both sides. There was no complete obstruction on one side due to rhinitis, but there was permanent hypertrophy of the nasal turbinates. However, no polyps were found upon examination. The examiner concluded that the Veteran's disability did not impact his ability to work. The preponderance of the above evidence demonstrates that the Veteran is not entitled to a compensable disability evaluation for his allergic rhinitis prior to November 26, 2012. Diagnostic Code 6522 provides ratings for allergic or vasomotor rhinitis. Allergic or vasomotor rhinitis without polyps, but with greater than 50-percent obstruction of nasal passage on both sides or complete obstruction on one side, is rated 10 percent disabling. Allergic or vasomotor rhinitis with polyps is rated 30 percent disabling. 38 C.F.R. § 4.97. According to the May 2007 VA examination, there was no evidence of obstruction or nasal polyps upon examination. Without medical evidence of obstruction greater than 50 percent on both sides, complete obstruction on one side, or nasal polyps, a compensable disability cannot be assigned. The record contains no further medical evidence demonstrating nasal obstruction until the Veteran's VA examination of November 2012. As such, the preponderance of the evidence of record demonstrates that a compensable disability evaluation is not warranted prior to November 26, 2012. The preponderance of the evidence of record also demonstrates that the Veteran is not entitled to a disability evaluation in excess of 10 percent for his service-connected allergic rhinitis at any time since November 26, 2012. According to the November 2012 VA examiner, while there was evidence of greater than 50 percent obstruction of the nasal passage on both sides due to rhinitis, there were no nasal polyps. The Veteran has not provided VA with any information demonstrating that he has ever been found to have nasal polyps either. As such, the preponderance of the evidence of record demonstrates that a disability evaluation in excess of 10 percent is not warranted at any time since November 26, 2012. The Board recognizes that the Veteran believes he is entitled to increased disability evaluations for his service-connected allergic rhinitis. The Veteran testified in January 2012 that his eyes itched a lot and that he had nasal congestion. In a November 2012 statement, he also indicated that he suffered from itchy eyes, sneezing, and lack of energy. He also noted that he was forced to wear a mask when performing actions such as lawn work. However, itchy or watery eyes associated with allergies is not evidence suggestive of a higher schedular evaluation. A higher disability evaluation is only warranted when symptoms are of such severity as to result in obstruction of 50 percent or more on both sides, total obstruction on one side or nasal polyps - the evidence of itchy eyes, sneezing and reported lack of energy fails to demonstrate that the Veteran's allergic rhinitis is of such severity as to warrant a higher disability evaluation. The Veteran is competent to report on symptoms and credible to the extent that he sincerely believes he is entitled to a higher rating. The lay evidence, however, is outweighed by competent and credible medical evidence that evaluates the true extent of the impairment based on objective data coupled with the lay complaints. In this regard, the Board notes that the VA examiners have the training and expertise necessary to administer the appropriate tests for a determination of the actual type and degree of the impairment associated with the Veteran's complaints. For these reasons, greater evidentiary weight is placed on the examination findings in regard to the type and degree of impairment. The Board has contemplated whether the case should be referred for extra-schedular consideration. In this regard, to accord justice in an exceptional case where the scheduler standards are found to be inadequate, the field station is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1). The provisions of 38 C.F.R. § 3.321(b) state as follows: Ratings shall be based as far as practicable, upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service- connected disability or disabilities. The governing norm in these exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. In Thun v. Peake, 22 Vet. App. 111 (2008), the Court specified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. The Court stated that the RO or the Board must first determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Id. If the RO or the Board finds that the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the Veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. VA's General Counsel has stated that consideration of an extra-schedular rating under 3.321(b)(1) is only warranted where there is evidence that the disability picture presented by the Veteran would, in that average case, produce impairment of earning capacity beyond that reflected in the rating schedule or where evidence shows that the Veteran's service-connected disability affects employability in ways not contemplated by the rating schedule. See VAOPGCPREC 6-96 (Aug. 16, 1996). In Thun, the Court further explained that the actual wages earned by a particular Veteran are not considered relevant in the calculation of the average impairment of earning capacity for a disability, and contemplate that Veterans receiving benefits may experience a greater or lesser impairment of earning capacity than average for their disability. The Thun Court indicated that extraschedular consideration cannot be used to undo the approximate nature of the rating system created by Congress. The Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance. However, the Board is not precluded from raising this question, see Floyd v. Brown, 9 Vet. App. 88 (1996), and addressing referral where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). The Board is aware of the Veteran's complaints as to the effects of his service-connected allergic rhinitis on his activities of work and daily living. In the Board's opinion, all aspects of this disability are adequately encompassed in the assigned schedular ratings. In this respect, the Veteran complains of trouble breathing, itching of the eyes and sneezing, as well as reported loss of energy. His 10 percent rating is meant to compensate allergies of such severity as to result in a greater than 50 percent obstruction of the nasal passages on both sides. While the Veteran was in receipt of a noncompensable evaluation prior to November 26, 2012, his allergies were not of sufficient severity at this time to result in nasal obstruction of 50 percent or more. Symptoms such as sneezing and itching of the eyes do not suggest that the Veteran's allergies were significantly worse than that envisioned by the applicable rating criteria. The complained of symptoms are not exceptional or unusual features of the disability. In short, the Board finds that the assigned schedular evaluation is adequate. As such, there is no basis for extraschedular referral in this case. See Thun, 22 Vet. App. 111, 114-15 (2008). The Board notes that, pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009), a claim for a total disability evaluation based on individual unemployability (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. The Veteran indicated in a statement dated November 2012 that he was currently employed, albeit on a contract basis. Nonetheless, according to the November 2012 VA examiner, the Veteran's allergic rhinitis had no impact on his ability to work. Since the Veteran has not argued an inability to work due to his service-connected disabilities, further consideration of TDIU is not warranted. Based upon the guidance of the Court in Hart v. Mansfield, 21 Vet. App. 505 (2007), the Board has considered whether additional staged ratings are appropriate. However, as outlined above, the evidence of record demonstrates that the Veteran's allergies did not meet the schedular criteria for a compensable disability evaluation at any time prior to November 26, 2012, nor did they meet the schedular criteria for a disability evaluation in excess of 10 percent at any time since November 26, 2012. As such, additional staged ratings are not warranted. Since the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable. The Veteran's claim of entitlement to an increased evaluation for allergic rhinitis, to include a compensable evaluation prior to November 26, 2012, and an evaluation in excess of 10 percent since November 26, 2012, must be denied. Anemia The Veteran also contends that he is entitled to an increased disability evaluation for his service-connected anemia. For historical purposes, the Veteran was originally granted service connection for beta thalassemia in an October 2005 rating decision. A noncompensable (0 percent) disability evaluation was assigned under Diagnostic Code 7799-7700, effective as of December 1, 2004. In February 2007, VA received a claim from the Veteran seeking a higher disability evaluation. This claim was denied in an August 2007 rating decision. A timely notice of disagreement was received from the Veteran in October 2007, but the noncompensable disability evaluation was continued in an April 2009 statement of the case. The Veteran appealed this rating to the Board in June 2009. The Veteran was afforded a VA examination in May 2007. The Veteran reported light-headedness, headaches, easy fatigability, weakness and shortness of breath at rest. He also described intermittent claudication after walking 25 yards on level ground at 2 miles per hour. There was also calf pain at rest but the Veteran did not feel persistent coldness of the extremities. The Veteran did not receive any treatment such as blood transfusions, myelon-supressant therapy or bone marrow transplant. Continuous treatment was not required to control this condition and the overall functional impact was limitation of physical activity and headaches. A May 2008 Brooke Army Medical Center record notes a one month history of fatigue. The Veteran denied any blurred vision, dizziness, shortness of breath or difficulty breathing at this time. According to a November 2011 private treatment record, however, the Veteran recently passed out after taking a hot bath. The Veteran was most recently afforded a VA examination in November 2012. It was noted that the Veteran was suffering from beta thalassemia that was diagnosed in 1999. This condition did not require continuous medication and the Veteran was not currently undergoing any treatment. The Veteran had anemia with hemoglobin of 13.4 gm/100ml. It was noted that there were no current findings, signs or symptoms (such as easy fatigability or dyspnea) associated with this condition. It was determined that this condition had no impact on the Veteran's ability to work. The preponderance of the above evidence demonstrates that the Veteran is not entitled to a compensable disability evaluation for this disability at any time during the pendency of his claim. Diagnostic Code 7700 provides ratings for hypochromic-microcytic and megaloblastic anemia, such as iron deficiency and pernicious anemia. Anemia with hemoglobin 10gm/100 ml or less, asymptomatic, is rated noncompensably (0 percent) disabling. Anemia with hemoglobin 10gm/100ml or less with findings such as weakness, easy fatigability or headaches, is rated 10 percent disabling. Anemia with hemoglobin 8gm/100ml or less, with findings such as weakness, easy fatigability, headaches, lightheadedness, or shortness of breath, is rated 30 percent disabling. Anemia with hemoglobin 7gm/100ml or less, with findings such as dyspnea on mild exertion, cardiomegaly, tachycardia (100 to 120 beats per minute) or syncope (three episodes in the last six months), is rated 70 percent disabling. Anemia with hemoglobin 5gm/100ml or less, with findings such as high output congestive heart failure or dyspnea at rest, is rated 100 percent disabling. A Note to Diagnostic Code 7700 provides that complications of pernicious anemia, such as dementia or peripheral neuropathy, are to be rated separately. 38 C.F.R. § 4.117. According to the November 2012 VA examination report, the Veteran had hemoglobin of 13.4 gm/100ml. The record contains no other evidence suggesting that the Veteran has ever had a hemoglobin level of 10gm/100ml or less. Therefore, a 10 percent disability evaluation is not warranted as there are no findings of hemoglobin of 10gm/100ml or less. The Veteran has also requested that his anemia be rated under Diagnostic Code 7716. Diagnostic Code 7716 provides ratings for aplastic anemia. Aplastic anemia requiring continuous medication for control is rated 10 percent disabling. Aplastic anemia requiring transfusion of platelets or red cells at least once per year but less than once every three months, or; infections recurring at least once per year but less than once every three months, is rated 30 percent disabling. Aplastic anemia requiring transfusion of platelets or red cells at least once every three months, or; infections recurring at least once every three months, is rated 60 percent disabling. Aplastic anemia requiring bone marrow transplant, or; requiring transfusion of platelets or red cells at least once every six weeks, or; infections recurring at least once every six weeks, is rated 100 percent disabling. A Note to Diagnostic Code 7716 provides that the 100 percent rating for bone marrow transplant shall be assigned as of the date of hospital admission and shall continue with a mandatory VA examination six months following hospital discharge. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of 38 C.F.R. § 3.105(e). 38 C.F.R. § 4.117. According to the November 2012 VA examiner, the Veteran's anemia did not require continuous medication for treatment. There is no history of transfusions of platelets, infections or bone marrow transplantation. As such, a higher disability evaluation would not be warranted under Diagnostic Code 7716 either. The Veteran's representative alleged during the January 2012 hearing that the Veteran did require continuous medication and multi-vitamins. However, a review of the evidence of record fails to reflect any prescribed medications for anemia and the November 2012 VA examiner explicitly noted that there was no continuous medication. The mere fact that the Veteran may take over-the-counter supplements or vitamins is not evidence of continuous medication required for treatment. The Board has also considered whether there is evidence of complications of pernicious anemia, such as dementia or peripheral neuropathy, that could be rated separately. See 38 C.F.R. § 4.117, Diagnostic Code 7700 (Note 1). Service connection is in effect for peripheral vascular disease of the right lower extremity associated with beta thalassemia. No other complications have been noted at any time during the current appeal. The Board recognizes that the Veteran believes he is entitled to a compensable disability evaluation for this disability. The Veteran testified in January 2012 that his anemia left him tired and without energy. He noted that his doctor suggested he exercise more to counteract this, but it was difficult due to his decreased energy and a decrease in strength. He also reported intermittent light-headedness and decreased physical activity and motivation due to his energy levels. In November 2012, he also indicated that his strength was diminished and that he was always tired. However, diminished energy or reports of intermittent light-headedness are not in and of themselves suggestive of a higher disability evaluation - diminished hemoglobin levels of 10gm/100ml or less are also required. In the present case, the Veteran's anemia has not been of sufficient severity to result in such a low level of hemoglobin. The Veteran is competent to report on symptoms and credible to the extent that he sincerely believes he is entitled to a higher rating. The lay evidence, however, is outweighed by competent and credible medical evidence that evaluates the true extent of the impairment based on objective data coupled with the lay complaints. In this regard, the Board notes that the VA examiners have the training and expertise necessary to administer the appropriate tests for a determination of the actual type and degree of the impairment associated with the Veteran's complaints. For these reasons, greater evidentiary weight is placed on the examination findings in regard to the type and degree of impairment. The Board has again considered whether referral for an extraschedular rating may be warranted in this case. See 38 C.F.R. § 3.321(b)(1). In the present case, however, the Veteran has complained of symptoms such as intermittent light-headedness and diminished energy. However, his symptoms are not of such severity as to result in significantly depleted hemoglobin levels or a need for continuous medication. The Veteran has not described any unusual or exceptional features of his disability. In the Board's opinion, all aspects of this disability are therefore adequately encompassed by the noncompensable disability evaluation. As such, there is no basis for extraschedular referral in this case. See Thun, 22 Vet. App. 111, 114-15 (2008). The Board has again considered whether staged ratings may be warranted in this case. See Hart, 21 Vet. App. at 505. However, the evidence of record fails to reflect that the Veteran has met the criteria for a compensable disability evaluation for anemia at any time during the pendency of his claim. As such, staged ratings are not warranted. Since the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable. The Veteran's claim of entitlement to a compensable disability evaluation for anemia must be denied. Hemorrhoids Finally, the Veteran contends that he is entitled to an increased disability evaluation for his service-connected hemorrhoids. For historical purposes, the Veteran was originally granted service connection for hemorrhoids in a May 2005 rating decision. A noncompensable (0 percent) disability evaluation was assigned under Diagnostic Code 7336, effective as of December 1, 2004. In February 2007, VA received a claim from the Veteran seeking a higher disability evaluation. This claim was denied in an August 2007 rating decision. A timely notice of disagreement was received from the Veteran in October 2007, but the noncompensable disability evaluation was continued in an April 2009 statement of the case. The Veteran appealed this rating to the Board in June 2009. As already noted, the Veteran's disability evaluation was increased to 10 percent in a January 2013 rating decision, effective as of November 26, 2012. Therefore, the issue before the Board is entitlement to a compensable disability evaluation for hemorrhoids, prior to November 26, 2012, and entitlement to a disability evaluation in excess of 10 percent as of November 26, 2012. A January 2006 Air Force treatment note reflects that the Veteran was having problems with hemorrhoids. A March 2006 examination reflected external hemorrhoids. Internal hemorrhoids were not noted at this time. There was also no residual hemorrhoidal skin tag or tenderness. The Veteran underwent a VA examination in May 2007. The Veteran reported a stool leakage problem occurring 1/3 to 2/3 of the day in moderate amounts. A pad was not required. The Veteran indicated that his hemorrhoids were constantly present and he treated them with hydrocortisone suppositories and cream. The Veteran's overall functional impairment was noted to be problems with having bowel movements. Examination revealed no evidence of ulceration, fissures, reduction of lumen or loss of sphincter control. External hemorrhoids were present and were reducible. There was no evidence of bleeding and thrombosis was absent. There was, however, evidence of frequent recurrence with excessive redundant tissue. No rectum fistula was found. The examiner concluded that this condition did not cause significant anemia or malnutrition. According to a July 2007 record from the Brooke Army Medical Center, the Veteran's hemorrhoid symptomatology was relieved by the use of suppositories. The Veteran was also treated for his hemorrhoids by the Gastroenterology Consultants in May 2009. The Veteran was complaining of dark red blood mixed in with his stool. In June 2009, the Veteran underwent a colonoscopy. It was determined that the Veteran was suffering from rectal bleeding and internal hemorrhoids. It was noted that the hemorrhoids were not significant and that there were no rectal masses. The Veteran was most recently afforded a VA examination for this condition in November 2012. The Veteran reported that he started having problems with itching and hurting in the rectal area with occasional bleeding. Colonoscopies have confirmed the existence of internal hemorrhoids. Examination revealed mild or moderate hemorrhoids resulting in rectal itching and occasional bleeding once or twice per month. They were not large or thrombotic. However, the examiner noted that the external hemorrhoid were, nonetheless, irreducible with excessive redundant tissue. There was also no persistent bleeding, secondary anemia or fissures. The examiner concluded that the Veteran's hemorrhoids did not impact his ability to work. The preponderance of the above evidence demonstrates that the Veteran is not entitled to a compensable disability evaluation at any time prior to November 26, 2012. Diagnostic Code 7336 provides ratings for internal or external hemorrhoids. Mild or moderate hemorrhoids are rated noncompensably (0 percent) disabling. Large or thrombotic hemorrhoids, irreducible, with excessive redundant tissue, evidencing frequent recurrences, are rated 10 percent disabling. Hemorrhoids with persistent bleeding and with secondary anemia, or with fissures, are rated 20 percent disabling. 38 C.F.R. § 4.114. According to the May 2007 VA examination report, the Veteran had hemorrhoids with no evidence of bleeding and thrombosis was absent. While there was evidence of redundant tissue, the hemorrhoids were not large or thrombotic and irreducible. A July 2009 record also indicates that the Veteran's hemorrhoids were not significant, further suggesting that they were not large or thrombotic. There is no medical evidence of large or thrombotic hemorrhoids at any time prior to November 26, 2012. As such, a compensable disability evaluation is not warranted. In fact, there is no medical evidence of large or thrombotic hemorrhoids at any time since November 26, 2012, either. According to the November 2012 VA examination report, the Veteran had small to moderate external hemorrhoids that were irreducible with excessive redundant tissue. Even though the Veteran's hemorrhoids were not large or thrombotic, the Veteran was afforded the benefit of the doubt that the disability more nearly approximated the next higher rating given its state as now irreducible and a 10 percent disability evaluation was assigned in a January 2013 rating decision. However, the November 2012 VA examination reflects that the Veteran does not suffer from anemia secondary to his hemorrhoids and there were no anal fissures. As such, the criteria for a 20 percent disability evaluation have not been met. See id. The Board recognizes that the Veteran believes he is entitled to increased disability evaluations for his service-connected hemorrhoids. The Veteran testified in January 2012 that he had spots of blood with itching that would come and go. The Veteran also endorsed frequent recurrence with excessive redundant tissue if he sat a lot. In a November 2012 statement, he also indicated that while he used over-the-counter medications to ease his itching and pain, it was still very difficult at times and uncomfortable. However, a noncompensable disability evaluation is prescribed for a veteran who suffers from mild or moderate hemorrhoids. A compensable evaluation is not warranted until there is evidence of irreducible large or thrombotic hemorrhoids - the medical evidence of record fails to demonstrate that the Veteran has ever suffered from large or thrombotic hemorrhoids. As such, the symptomatology described by the Veteran does not demonstrate he is entitled to a higher rating at any time during the pendency of his claim. The Veteran is competent to report on symptoms and credible to the extent that he sincerely believes he is entitled to a higher rating. The lay evidence, however, is outweighed by competent and credible medical evidence that evaluates the true extent of the impairment based on objective data coupled with the lay complaints. In this regard, the Board notes that the VA examiners have the training and expertise necessary to administer the appropriate tests for a determination of the actual type and degree of the impairment associated with the Veteran's complaints. For these reasons, greater evidentiary weight is placed on the examination findings in regard to the type and degree of impairment. The Board has again considered whether referral for an extraschedular rating may be warranted in this case. See 38 C.F.R. § 3.321(b)(1). In the present case, however, the Veteran has complained of symptoms such as itching and intermittent bleeding. Despite his reported symptomatology, the examiners of record have consistently referred to his hemorrhoids as mild or moderate. The Veteran has not described any exceptional or unusual features of his disability. In the Board's opinion, all aspects of this disability are therefore adequately encompassed by the noncompensable disability evaluation prior to November 26, 2012, and the 10 percent evaluation assigned thereafter. As such, there is no basis for extraschedular referral in this case. See Thun, 22 Vet. App. 111, 114-15 (2008). The Board has again considered whether additional staged ratings may be warranted in this case. See Hart, 21 Vet. App. at 505. However, the evidence of record fails to reflect that the Veteran has met the criteria for a compensable disability evaluation for hemorrhoids at any time prior to November 26, 2012, or the criteria for a 20 percent evaluation at any time since November 26, 2012. As such, additional staged ratings are not warranted. Since the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable. The preponderance of the evidence is against the appellant's claim. The claim must be denied. (CONTINUED ON NEXT PAGE) ORDER The claim of entitlement to an increased disability evaluation for allergic rhinitis, to include a compensable evaluation prior to November 26, 2012, and a disability evaluation in excess of 10 percent as of November 26, 2012, is denied. The claim of entitlement to a compensable disability evaluation for beta thalassemia is denied. The claim of entitlement to an increased disability evaluation for hemorrhoids, to include a compensable evaluation prior to November 26, 2012, and a disability evaluation in excess of 10 percent as of November 26, 2012, is denied. ____________________________________________ TANYA A. SMITH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs