Citation Nr: 1322875 Decision Date: 07/17/13 Archive Date: 07/24/13 DOCKET NO. 12-16 001 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUE Entitlement to a disability rating in excess of 60 percent for post-operative verruca acuminata intra-urethral (hereinafter referred to as 'genitourinary (GU) disability'). REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD A. Lindio, Counsel INTRODUCTION The Veteran served on active duty from February 1953 to July 1956. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO), in Hartford, Connecticut. In October 2010, the Veteran initially claimed entitlement to an increased (in excess of 60 percent) rating for his service-connected GU disability. The RO denied his claim in a December 2010 rating decision. In April and May 2011 letters, the Veteran requested reconsideration of that rating action. Within one year of the December 2010 rating action, VA associated new and relevant medical evidence with the claims file. In March 2012, the RO issued another rating decision denying a disability rating in excess of 60 percent. The Veteran timely appealed the March 2012 denial. As noted in the prior Board decision, although the Veteran did not appeal the December 2010 rating decision, new, relevant medical evidence was added to the claims file within one (1) year of that rating decision. Pursuant to 38 C.F.R. § 3.156(b) (2012), new and material evidence received prior to the expiration of the appeal period will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. Therefore, the Board finds that the period under consideration extends from October 19, 2010, the date his original increased rating claim was received by VA. The Veteran testified at a hearing before a Decision Review Officer (DRO) at the RO in May 2012 and a hearing before the undersigned Veterans Law Judge (VLJ) sitting at the RO in November 2012. Transcripts of both hearings are on file. The Board remanded this case in January 2013, and noted that a claim for individual unemployability due to service-connected disabilities (TDIU) was part of the increased rating claim. See Rice v. Shinseki, 22 Vet. App. 447 (2009). At that time, the Board also noted that a March 2010 Board decision had listed the TDIU issue on the title page, but had not addressed that claim. Thus, the issue of TDIU had remained pending, though it had not been certified for appellate consideration. Id.; 38 C.F.R. §§ 3.155(a),19.35. The Board further found that remanding the TDIU claim for further development and consideration did not result in any prejudice and was harmless. Bernard v. Brown, 4 Vet. App. 384, 393-394 (1993). Subsequently, a March 2013 Supplemental Statement of the Case (SSOC) addressed both the issue for a higher rating for the GU disability and for TDIU. In an April 2013 decision, the Board granted the claim for TDIU. The RO implemented that grant of TDIU in an April 2013 rating decision and assigned an effective date of October 19, 2010, the date VA received his claim for an increased rating for his GU disability. As such, that matter is no longer before the Board. In April 2013, the Board also remanded the increased rating claim for the GU disability further development. Such matter now returns to the Board for further appellate review. A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal other than VA treatment records dated from July 2010 to March 2013. Those records were previously considered by the agency of original jurisdiction (AOJ), as noted in the March 2013 SSOC. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. For the entire appeal period, the Veteran's GU disability is manifested predominately by voiding dysfunction resulting in urine leakage necessitating the use of an appliance and the wearing of absorbent materials that must be changed approximately four times daily. 2. The Veteran's renal dysfunction with resulting generalized weakness, fatigue, lack of endurance, and difficulty with ambulation is related to nonservice-connected disabilities. CONCLUSION OF LAW For the entire appeal period, the criteria for a rating in excess of 60 percent for the Veteran's GU disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.321, 4.3, 4.7, 4.115a, 4.115b, Diagnostic Code 7529 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice 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 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. In the instant case, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, a November 2010 letter advised the Veteran of the evidence and information necessary to substantiate his increased rating claim, as well as his and VA's respective responsibilities in obtaining such evidence and information. Such letter also included notice of the evidence and information necessary to establish an effective date in accordance with Dingess/Hartman, supra. Relevant to the duty to assist, the Veteran's service treatment records as well as post-service VA treatment records have been obtained and considered. The Veteran has not identified any additional, outstanding records that have not been requested or obtained. Also of record and considered in connection with the appeal is the transcript of the November 2012 Board hearing, along with various statements by the Veteran. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the 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. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Here, the undersigned Veterans Law Judge (VLJ) identified the issue on appeal and solicited the identification of evidence relevant to the claim, to include the frequency and severity of the Veteran's symptoms associated with his GU disability as well as the impact such have on his employability and daily life. The Veteran reported treatment from the VA Medical Center and such records were subsequently associated with the claims file as a result of the Board's remand. Under these circumstances, nothing gives rise to the possibility that any additional evidence has been overlooked with regard to the Veteran's claim decided herein. 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 claim based on the current record. As indicated previously, the Veteran was also afforded the opportunity to testify before a DRO in May 2012. 38 C.F.R. 3.103(c)(2) requires that the DRO who chairs a hearing fulfill two duties to comply with (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 hearing, the DRO elicited testimony necessary to determine the nature of the Veteran's claim. In addition, the DRO sought to identify any pertinent evidence not currently associated with the claims file that might have been overlooked or was outstanding that might substantiate the claim. Moreover, neither the Veteran nor his representative asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2) nor identified any prejudice in the conduct of the DRO hearing. By contrast, the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim for benefits. As such, the Board finds that, the DRO complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board can adjudicate the claim based on the current record. The Veteran also underwent a VA examination in December 2010. Pursuant to the January 2013 Board remand instructions, the AOJ provided another VA examination in March 2013. Additionally, pursuant to the March 2013 Board remand instructions, the AOJ also obtained an additional medical opinion in May 2013, to more specifically address the severity of the Veteran's disability. Neither the Veteran nor his representative has alleged that such are inadequate for rating purposes. Moreover, the Board finds that the examinations are adequate in order to evaluate the Veteran's service-connected GU disability as they include an interview with the Veteran, a review of the record, and a full physical examination, addressing the relevant rating criteria. Therefore, the Board finds that the examination report of record is adequate to adjudicate the Veteran's increased rating claim and no further examination is necessary. As indicated previously, this claim was remanded by the Board in January 2013 and April 2013. Pursuant to the Board's directives, the AOJ obtained the Veteran's updated VA medical records, provided the Veteran with an opportunity to identify any private treatment records, to include from VNA, in a February 2013 letter, afforded him a VA examination in March 2013 with an addendum opinion in May 2013, and readjudicated his claim in March 2013 and June 2013 SSOCs. Therefore, the Board finds that the AOJ has substantially complied with the January 2013 and April 2013 remand directives such that no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case; at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, he will not be prejudiced as a result of the Board proceeding to the merits of his claim. II. Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian 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. All benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. The Court has held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. Diseases of the genitourinary system result in disabilities related to renal or voiding dysfunctions, infections, or a combination of these. When diagnostic codes refer to these specific areas of dysfunction, only the predominant area of dysfunction shall be considered for rating purposes. The Veteran's service-connected post-operative verruca acuminata intra-urethral has been rated as 60 percent disabling by analogy to Diagnostic Code 7529 for benign neoplasms of the genitourinary system. Under Diagnostic Code 7529, that disability should be rated as voiding dysfunction or renal dysfunction, whichever is predominant. See 38 C.F.R. § 4.115b. The maximum schedular rating for voiding dysfunction is 60 percent based on urine leakage, 40 percent based on urinary frequency, and 30 percent based on obstructive symptomatology. 38 C.F.R. § 4.115a. In this regard, as the Veteran's predominant area of dysfunction is urine leakage, he has been awarded a 60 percent rating based on urine leakage requiring the use of an appliance or the wearing of absorbent materials which must be changed more than four times per day. 38 C.F.R. § 4.115a. The only possible higher schedular rating available requires that the Veteran's GU disability result in a predominant disability of renal dysfunction. In this regard, renal dysfunction is evaluated as 60 percent where there is constant albuminuria with some edema, or a definite decrease in kidney function, or hypertension at least 40 percent disabling under Diagnostic Code 7101. An 80 percent evaluation for renal dysfunction is warranted where there is persistent edema and albuminuria with BUN 40 to 80 mg.%, or creatinine is four to eight mg.%, or where there is generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. A 100 percent evaluation, the maximum evaluation available for renal dysfunction, is warranted where dialysis is regularly required, or where more than sedentary activity is precluded, or where there is markedly decreased kidney or other organ system function. 38 C.F.R. § 4.115a. As will be discussed below, the Board finds that a rating in excess of 60 percent for the Veteran's GU disability is not warranted. In this regard, for the entire appeal period, such disability is manifested predominately by voiding dysfunction resulting in urine leakage necessitating the use of an appliance and the wearing of absorbent materials that must be changed approximately four times daily. Moreover, the Veteran's renal dysfunction with resulting generalized weakness, fatigue, lack of endurance, and difficulty with ambulation is related to nonservice-connected disabilities. VA medical records generally document a long history of genitourinary treatment. In this regard, an August 2011 VA medical record documented a history of monthly changes of a suprapubic catheter and a catheter-related infection. An October 2011 VA medical record documented a history of extensive long segment urethral stricture and pain in the urethra. The VA medical records, however, generally do not address which of the Veteran's symptoms or treatments are related to his service-connected GU disability currently on appeal and which are attributable to nonservice-connected disabilities. In December 2010, the Veteran underwent a VA examination, which included a review of the VA medical records. The examiner noted a history of urethral stricture disease and bladder carcinoma in situ (CIS). The Board notes that it previously denied service connection for bladder cancer in a May 2006 decision. The December 2010 VA examiner noted that that the Veteran had no lethargy, weakness, anorexia, or weight loss or gain. He reported cathetering himself, and having urinary hesitancy, dysuria, and a weak stream with occasional dribbling. The Veteran also reported incontinence and having to change his adult pads up to four times a day. The December 2010 VA examiner noted that the Veteran's treatments included intermittent catheterization five times a day, dilations (twice in the past year), drainage procedures (with catheters five times a day), diet therapy, medications and invasive and noninvasive procedures. The examiner noted, however, that the Veteran was not on dialysis. The December 2010 VA examiner diagnosed the Veteran with urethral stricture that required cystoscopy with urethrotomy, twice in the past year, which was complicated with a urinary tract infection. The examiner further found that the Veteran had incontinence that required the use of pads four times a day. The examiner noted that the Veteran was waiting for a suprapubic tube place. The examiner found moderate functional impairment based on subjective complaints and that the Veteran remained able to perform activities of daily living. In May 2012, the Veteran provided testimony at a hearing before a DRO. At that time, he reported having leakage problems three to four times a day and the need for absorbent pads at all times. He further reported that he sometimes lost his appetite, felt weak and had lethargy. In November 2012, the Veteran also provided testimony before the undersigned Veterans Law Judge. The Veteran again reported that he constantly used absorbent pads. He also reported urinary hesitancy, a weak stream, the use of catheterization tubes, urinary tract infections and bladder pain. The Veteran further reported lethargy, weakness and lack of appetite with weight loss. In March 2013, the Veteran underwent another VA examination, which included a claims file review. The examiner diagnosed the Veteran with urethral stricture secondary to verruca acuminata that required suprapubic tube placement. During the March 2013 VA examination, the Veteran reported that he required straight, intermittent catheterization, had some residual incontinence, and required the use of absorbent pads. The Veteran eventually had a suprapubic tube placed due to difficulty with straight cathetering, but still had daily leakage and needed to change his pads at least three times a day. He also reported some abdominal discomfort if the tube was not draining properly and needed to be readjusted. The Veteran also indicated that he had generalized weakness, fatigue, lack of endurance and difficulty with ambulation. However, he claimed that his appetite and weight were stable. He otherwise remained able to perform activities of daily living. The March 2013 VA examiner found voiding dysfunction that caused urine leakage and required the use of absorbent materials that must be changed two to four times per day. The voiding dysfunction also required the use of an appliance in the form of a suprapubic tube. The voiding dysfunction further caused signs or symptoms of obstructed voiding, including: stricture disease requiring dilation (with a suprapubic tube placement), recurrent urinary tract infections secondary to obstruction, and the need for a suprapubic tube placement after not being able to straight catheter anymore. In contrast, the examiner found no increased urinary frequency. The March 2013 also performed diagnostic testing and noted findings of urea nitrogen (BUN) of 29 mg/dL and creatinine serum (creatinine) of 1.85 mg/dL. The March 2013 VA examiner noted functional impact that included the Veteran's reports of generalized weakness, fatigue, lack of endurance and difficulty with ambulation causing moderate functional impairment. The VA examiner found that those symptoms would cause difficulty in performing a physical or sedentary job. The examiner also noted that the Veteran had evidence of chronic kidney disease that is like likely related to diabetes mellitus, type II, and hypertension. The examiner further indicated that, other than relying on others for transportation and shopping, the Veteran remained independent in his activities of daily living. In May 2013, the March 2013 VA examiner provided an addendum medical opinion. The VA examiner clarified that, although the Veteran had evidence of chronic kidney disease, it was likely related to nonservice-connected diabetes mellitus, type II, and hypertension, rather than his service-connected urethral verruca acuminata. The VA examiner further noted that evidence of chronic kidney disease included GFR of 36, albuminuria and lower extremities edema. Finally, the VA examiner found that it was less likely as not that the Veteran's service-connected urethral verruca acuminata (GU disability) was causing the Veteran's generalized weakness, fatigue, lack of endurance or increased difficulty with ambulation. Rather, the examiner found that those symptoms were more likely of a multifactorial nature, with contributing factors of nonservice-connected chronic kidney disease, coronary artery disease, and osteoarthritis. The examiner also noted that she was unable to determine the degree each disorder contributed without resorting to speculation. She further noted that the Veteran denied anorexia and weight loss. As previously noted, under Diagnostic Code 7529, the Veteran's disability is rated under voiding dysfunction or renal dysfunction, whichever is the predominant disability. 38 C.F.R. § 4.115b. The Veteran is already in receipt of the maximum schedular rating, i.e., 60 percent, for voiding dysfunction pursuant to urine leakage. As such, in order to warrant a disability rating in excess of 60 percent, the Veteran's service-connected GU disability would have to result in renal dysfunction. Under the rating criteria for renal dysfunction, an 80 percent disability rating is characterized by persistent edema and albuminuria with BUN 40 to 80 mg.%, or creatinine is four to eight mg.%, or where there is generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. A 100 percent disability rating would require dialysis regularly; preclude more than sedentary activity; or result in markedly decreased kidney or other organ system function. 38 C.F.R. § 4.115a. In this case, for the entire appeal period, the medical evidence of record does not demonstrate that the Veteran's service-connected GU disability resulted in renal dysfunction. The only medical opinion to address whether the Veteran has renal dysfunction due to the service-connected GU disability is the March 2013 VA examiner. The March 2013 VA examiner clarified in both the March 2013 examination report and the May 2013 addendum medical opinion that the Veteran's chronic kidney disease was not caused by his service-connected GU disability. Rather, the examiner specifically found that the chronic kidney disease was related to the nonservice-connected disabilities of diabetes mellitus, type II, and hypertension. For the sake of clarity, the Board notes that "renal" means pertaining to the kidney. See Dorland's Illustrated Medical Dictionary 1611 (30th ed. 2003). As such, the March 2013 VA examiner found that the Veteran's renal (kidney) dysfunction was due to nonservice-connected disorders. Accordingly, a disability rating in excess of 60 percent for the service-connected post-operative verruca acuminata intra-urethral is not warranted for any period of the increased rating claim. See 38 C.F.R. §§ 4.115a, 4.115b, Diagnostic Code 7529. In making its determination in this case, the Board has also carefully considered the Veteran's contentions with respect to the nature of his service-connected GU disability and notes that his lay testimony is competent to describe certain symptoms associated with such disability, to include the frequency and severity of his urinary leakage. The Veteran's history and symptom reports have been considered, including as presented in the medical evidence discussed above, and has been contemplated by the disability rating that has been assigned. Moreover, the competent medical evidence offering detailed specific findings pertinent to the rating criteria is the most probative evidence with regard to evaluating the pertinent symptoms of the service-connected disability at issue. As such, while the Board accepts the Veteran's testimony with regard to the matters he is competent to address, the Board relies upon the competent medical evidence with regard to the specialized evaluation of functional impairment, symptom severity, and details of clinical features of the service-connected condition at issue. In this regard, the Board further finds that the Veteran is not competent to relate his renal dysfunction and chronic kidney disease to his service-connected GU disability. Specifically, the question of causation of such disorders involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is nonprobative evidence. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). The Board has considered whether staged ratings under Hart, supra are appropriate for the Veteran's service-connected disability; however, the Board finds that his symptomatology has been stable throughout the appeal period. Therefore, assigning staged ratings for such disabilities is not warranted. Additionally, the Board has contemplated whether the case should be referred for extra-schedular consideration. An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under § 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected GU disability with the respective established criteria found in the rating schedule. In this regard, the Board finds that the Veteran's symptomatology associated with that specific disability is fully addressed by the rating criteria under which it is rated. Specifically, the rating criteria addresses the Veteran's voiding dysfunction, including obstructed voiding. The criteria specifically includes consideration of problems such as urine leakage, the use of absorbent materials, the need for catheterization, urinary hesitancy and a weak stream. There are no additional symptoms of the service-connected disability that are not addressed by the rating schedule. Although the Veteran contends that he has renal dysfunction with generalized poor health, including lethargy, weakness and limitation on exertion due to the service-connected GU disability, the March 2013 VA examiner specifically found that those symptoms were not due to the GU disability, but rather to various nonservice-connected disorders. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology for his service-connected GU disability. As such, the rating schedule is adequate to evaluate the Veteran's disability picture. Therefore, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). In Rice, supra, the Court held that a claim for TDIU is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. As noted in the Introduction portion of this decision, the Board has already previously granted the Veteran's TDIU claim, effective the date VA received his claim for an increased rating for his GU disability. As the preponderance of the evidence is against the claim, the benefit of the doubt rule does not apply. Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1991). The Veteran's claim for a disability rating in excess of 60 percent for his service-connected GU disability is denied. ORDER A disability rating in excess of 60 percent for post-operative verruca acuminata intra-urethral is denied. ____________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs