Citation Nr: 1339277 Decision Date: 11/29/13 Archive Date: 12/13/13 DOCKET NO. 12-08 661 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for depression. 2. Entitlement to a compensable rating for a hemorrhoid disorder. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD G. R. Waddington, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1974 to March 1976. This matter comes before the Board of Veteran's Appeals (Board) on appeal from a September 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. The Veteran's October 2002 claim for depression remains open; consequently, the effective date of the current claim for service connection for depression is the date of the open claim (October 11, 2002). The Virtual VA paperless claims processing system contains additional VA treatment records that have been considered by the RO and the Board. FINDINGS OF FACT 1. With resolution of the benefit of the doubt in the Veteran's favor, a current depressive disorder was caused by service. 2. The Veteran has no more than mild to moderate symptoms of hemorrhoids and no large or thrombotic hemorrhoids or persistent bleeding or fissures. CONCLUSIONS OF LAW 1. The criteria for the establishment of service connection for depression are approximated. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2013). 2. The criteria for an increased (compensable) rating for hemorrhoids have not been met at any point during the pendency of this claim. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 4.3, 4.114 Diagnostic Codes 7332, 7336 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In this decision, the Board will discuss the relevant law which it is required to apply. This includes statutes enacted by Congress and published in Title 38, United States Code ("38 U.S.C.A."); regulations promulgated by VA under the law and published in the Title 38 of the Code of Federal Regulations ("38 C.F.R.") and the precedential rulings of the United States Court of Appeals for the Federal Circuit (Federal Circuit) (as noted by citations to "Fed. Cir.") and the United States Court of Appeals for Veterans Claims (Court) (as noted by citations to "Vet. App."). The Board is bound by statute to set forth specifically the issue under appellate consideration and its decision must also include separately stated findings of fact and conclusions of law on all material issues of fact and law presented on the record, and the reasons or bases for those findings and conclusions. 38 U.S.C.A. § 7104(d) (West 2002); see also 38 C.F.R. § 19.7 (2013) (implementing the cited statute); see also Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet. App. 49, 56-57 (1990) (the Board's statement of reasons and bases for its findings and conclusions on all material facts and law presented on the record must be sufficient to enable the claimant to understand the precise basis for the Board's decision, as well as to facilitate review of the decision by courts of competent appellate jurisdiction. The Board must also consider and discuss all applicable statutory and regulatory law, as well as the controlling decisions of the appellate courts). VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000) (codified as amended at 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107), sets forth VA's duties to notify and assist claimants in substantiating claims for VA benefits. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and her representative, if any, of any information and 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). In order to satisfy its duty to notify the claimant under the VCAA, the Court held that 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. Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). All notice under the VCAA should generally be provided prior to an initial decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). However, a delay in timing of the notice is "cured," and therefore harmless, when a fully compliant VCAA notification letter notice is followed by readjudication of the claim (such as through issuing a Statement of the Case (SOC) or Supplemental Statement of the Case (SSOC)) after the claimant has had an opportunity to submit additional evidence. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007). For increased rating claims, VA must notify the claimant that she needs to provide or request VA to obtain medical or lay evidence demonstrating a worsening or increase in severity of the disability at issue. Vazquez-Flores v. Shinseki, 24 Vet. App. 94, 97-103 (2010); Vazquez-Flores v. Peake, 22 Vet. App. 37, 43 (2008), overruled in part sub. nom. Vazquez-Flores/Wilson v. Shinseki, 580 F.3d 1270, 1280-81 (Fed. Cir. 2009). Further, the claimant must be notified that a disability rating will be determined by applying relevant diagnostic codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment. Id. Finally, the notice must provide examples of the types of medical and lay evidence that the claimant may submit (or ask VA to obtain) that are relevant to establishing entitlement to increased compensation. Id. Except when VCAA notice as to how to substantiate an increased-rating claim is not provided at all, the claimant has the burden to show that she was prejudiced by any deficiency in the notice provided. See Vazquez-Flores, 24 Vet. App. at 106-07. Prior to the initial rating decision in this matter, a May 2009 letter notified the Veteran of all five elements of service connection and satisfied the notice requirements for an increased rating claim mentioned in the previous paragraph. The same letter informed the Veteran of her and VA's respective responsibilities for obtaining relevant records and other evidence in support of her claims. Thus, the duty to notify is satisfied with regard to the Veteran's claims. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Dingess/Hartman, 19 Vet. App. at 484; Quartuccio, 16 Vet. App. at 187; see Vazquez-Flores, 24 Vet. App. at 106-07. VA's duty to assist under the VCAA includes helping the claimant to obtain service treatment records and other pertinent records, as well as performing an examination or obtaining a medical opinion when such is necessary to make a decision on the claims. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). The Veteran's service treatment records and VA medical records are in the claims file. She has not identified any other outstanding records or evidence. The duty to obtain relevant records is satisfied. See 38 C.F.R. § 3.159(c). The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. See 38 U.S.C.A. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Unless the claimant challenges the adequacy of the examination or opinion, the Board may assume that the examination report and opinion are adequate, and need not affirmatively establish the adequacy of the examination report or the competence of the examiner. Sickels v. Shinseki, 643 F.3d, 1362, 1365-66 (Fed. Cir. 2011) (holding that although the Board is required to consider issues independently raised by the evidence of record, the Board is still "entitled to assume" the competency of a VA examiner and the adequacy of a VA opinion without "demonstrating why the medical examiners' reports were competent and sufficiently informed"); see also Rizzo v. Shinseki, 580 F.3d 1288, 1290-1291 (Fed. Cir. 2009) (holding that the Board is entitled to assume the competency of a VA examiner unless the competence is challenged). Id. For increased ratings cases, where the evidence of record does not reflect the current state of the claimant's disability, a new VA examination must be conducted. See 38 C.F.R. § 3.327(a); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). With regard to the Veteran's increased rating claim for hemorrhoids, an appropriate and adequate VA examination was performed in June 2009. In her April 2012 substantive appeal (VA Form V9) the Veteran alleged without foundation that the examiner was not competent and the examination was not sufficient. Contrary to the Veteran's statements, the June 2009 examination is adequate to decide her claim for an increased rating for hemorrhoids. The examination was conducted by a medical doctor who considered the Veteran's self-reported medical history, performed a physical examination and diagnostic tests, and described the Veteran's disability in sufficient detail to enable the Board to make a fully informed decision on this claim. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994). Further examination, or an additional opinion, on this issue is not warranted. Although the June 2009 VA examiner did not indicate whether he reviewed the claims file, such a review was not necessary to ensure the adequacy of the examination. When an increased rating is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The examiner's task was to evaluate the Veteran's hemorrhoids as they manifested at the time of the examination. In this respect, the examiner examined the Veteran, recorded all pertinent clinical findings, and considered her relevant medical history. There is no indication that a review of the Veteran's claims file would have altered the examiner's findings regarding how the Veteran's hemorrhoids manifested on the day of the examination, or that lack of such review otherwise impacted its adequacy. See Snuffer v. Gober, 10 Vet. App. 400, 403-04 (1997) (noting that review of claims file not required when such review would not change objective findings made on examination); Mariano v. Principi, 17 Vet. App. 305, 311-312 (2003) (noting that range-of-motion measurements are not conclusions drawn by a VA examiner that would be affected by review of the claims file). Thus, the June 2009 examination is adequate for rating purposes and no prejudice exists. See Shinseki v. Sanders 556 U.S. 396, 407 (2009) (holding that whether prejudicial harm exists is a case-by-case determination). The Veteran has not stated and there is no other evidence indicating that there has been a material change in the severity of her hemorrhoid disorder since she was last examined in June 2009. See 38 C.F.R. § 3.327(a). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11-95 (April 7, 1995). Thus, VA's duty to obtain a VA examination in relation to her increased rating claim has been met. 38 C.F.R. § 3.159(c)(4); Barr, 21 Vet. App. at 312. Accordingly, VA has satisfied its duties to notify and assist and, therefore, the Board may proceed with appellate review. Analyses Depression The Board presently finds the evidence is in approximate balance as to the claim of service connection for depression, and the claim will be granted. The standard of proof to be applied in decisions on claims for veterans' benefits is the benefit-of-the-doubt rule set forth in 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When the evidence is in relative equipoise, the claimant prevails. See Gilbert, 1 Vet. App. at 49. The preponderance of the evidence must weigh against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). The Board must assess the credibility and weight of all evidence, including both lay and medical evidence, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Caluza v. Brown, 7 Vet. App. 498, 506 (1995); see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). This evaluation generally involves a three-step inquiry. First, the Board must determine whether the evidence is competent. See, e.g. Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007). Second, the Board must determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). Third, the Board must assess the probative value and weight of the evidence in light of the entire record. Gonzales, 218 F.3d at 1380-81. With regard to the competency of the evidence, lay statements submitted by or on behalf of a claimant can be competent with respect to both the diagnosis and the etiology or cause of a disability. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Thus, the Board may not "categorically" require medical evidence or disregard lay evidence without first assessing its competence. See id. (holding that it was error in a cause-of-death claim to find "categorically" that a medical opinion was required to prove a nexus between the Veteran's service-connected mental disorder and her drowning death, and likewise to reject categorically the claimant's testimony on this issue as not competent merely because she was a lay person); see also Kahana v. Shinseki, 24 Vet. App. 428, 434 (2011) (holding that the Board erred in categorically rejecting lay evidence without analyzing and weighing it). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. See 38 C.F.R. § 3.159(a)(2); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (holding that lay testimony is not competent to prove that which would require specialized knowledge, training, or medical expertise). Lay evidence is competent if it is provided by a person who has first-hand knowledge of facts or circumstances, or conveys matters that can be observed and described by a lay person. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005) (holding that appellant was competent to testify as to factual matters of which she had first-hand knowledge, such as experiencing pain in her right hip and thigh in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy). Lay evidence may be competent and sufficient to establish a diagnosis of a condition in the following circumstances: (1) when the condition is simple, such as a broken leg, as opposed to when the condition is more complex, such as a form of cancer; (2) when the layperson is reporting a contemporaneous medical diagnosis, or; (3) when lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372, 1377 & n4 (Fed. Cir. 2007). However, lay testimony is not competent with respect to determinations that are "medical in nature" or require medical knowledge due to their complexity. Barr, 21 Vet. App. at 309; see also Jandreau, 492 F. 3d at 1376-77 (observing that a lay person is not competent to identify more complex conditions such as a form of cancer). The Board must discount the probative value of lay evidence if it finds such evidence not to be competent in light of the above guidelines. See King v. Shinseki, 700 F.3d, 1339, 1345 (Fed. Cir. 2012) (noting that lay evidence must "demonstrate some competence") (citing 38 U.S.C.A. § 5107(b) and 38 C.F.R. § 3.307(b)) (internal quotation marks omitted); see also Layno, 6 Vet. App. at 469 (holding that in order for testimony to be probative of any fact, the witness must be competent to testify as to that fact, and that incompetent testimony must be excluded from consideration). Competent medical evidence, as distinguished from lay evidence, is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a)(1); see also Layno, 6 Vet. App. at 469. Competent medical evidence may include statements conveying sound medical principles found in medical treatises. 38 C.F.R. § 3.159(a)(1). It also includes statements contained in authoritative writings such as medical and scientific articles and research reports or analyses. Id. The competency of evidence differs from the weight assigned to the evidence, which varies according to its credibility, probative value, and relationship to other items of evidence. See Layno, 6 Vet. App. at 469 (observing that the credibility and weight of testimony are factual determinations that must be distinguished from the initial assessment of its competency); accord Rucker v. Brown, 10 Vet. App. 67, 74 1997); see also Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board has the "authority to discount the weight and probity of evidence in the light of its own inherent characteristics in its relationship to other items of evidence"); Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (stating that "although interest may affect the credibility of testimony, it does not affect competency to testify."); Washington, 19 Vet. App. at 368 (noting that the witness' credibility affects the weight to be given to her testimony). Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection for depression, there must be competent evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Due consideration shall be given to the places, types, and circumstances of the claimant's service as shown by her service record, the official history of each organization in which the claimant served, the claimant's medical records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a). The Veteran has a current diagnosis for depression and her service treatment records indicate that she appeared depressed in service. She received a positive screen for depression in July 2007 and was diagnosed as having depression by a VA psychiatrist in August 2008 and again by the VA examiner in August 2009. The issue for the Board's resolution is whether there is competent evidence of a connection between the in-service incident and the current diagnosis. In February 1975-during the Veteran's active duty-a psychiatric technician noted that the Veteran appeared depressed and in March 1976 the Veteran reported having depression or excessive worry on separation. The Veteran's separation examination report identifies depression secondary to military environment since March 1975. Thus, the probative evidence establishes a current mental disorder and that the Veteran exhibited symptoms of depression in service. The Veteran is plainly competent to report ongoing symptoms of depression in and since military service. While the STRs document an impression-not a diagnosis-of depression by a psychiatric technician and do not document any psychological stressors or symptoms or symptom severity associated with depression, the Veteran specifically complained of depressive symptoms upon her separation. The evidence of record shows that the Veteran experienced numerous hardships and significant instability after she separated from the Air Force in March 1976. In 1978, she was placed on scholastic probation at her college for failing to attend class and in June 1980 she reported having been under "tremendous strain" for the previous three years (i.e., since approximately 1977 or within one year of separation from active duty). See August 1980 Decision on Waiver of Indebtedness; June 1980 Veteran's Statement. There is also no question that the Veteran has a long history of drug abuse, which may not in and of itself be service connected. However, while substance abuse may not be service connected, the Veteran had depressive symptoms in service, without apparent evidence of drug abuse while on active duty In August 2009, the Veteran underwent a VA examination for mental disorders which essentially could not definitely link the Veteran's in-service symptoms to the current diagnosis, given the Veteran's turbulent personal and occupational history. The VA examiner noted that she could not state whether the Veteran's current depression was at least as likely as not caused by or a result of her active military duty without resorting to speculation. She explained that the lack of "evidence of stressors, symptom presentation, symptom severity, suicidality, or treatment" associated with the psychiatric technician's impression that the Veteran had depression in service prevented her from determining whether the Veteran's reported depression in service "met the clinical diagnosis of depression." She also explained that the Veteran's "years of employment instability and substance abuse further blur how much her mental health functioning is related to active duty depression." In this respect, the examiner found that the evidence of record does not establish a relationship between the Veteran's in-service depression and her current mental disorder. However, the in-service psychiatric consultation was not generated with a view towards diagnosis. What is clear from the record is that the Veteran's in-service depressive symptoms were then noted to be related to military service and she has had continuous and variously manifested symptoms since that time. The law does not require a certainty of connection. The mandate to accord the benefit of the doubt is triggered when the evidence has reached such a stage of balance. In this matter, the Board is of the opinion that this point has been attained. Because a state of relative equipoise has been reached in this case, the benefit of the doubt rule will therefore be applied and service connection will be granted. See Alemany v. Brown, 9 Vet.App. 518 (1996); Brown v. Brown , 5 Vet.App. 413 (1993). Increased Rating - Hemorrhoids VA has adopted a Schedule for Rating Disabilities to evaluate service-connected disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R., Part IV. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10 (2013). The percentage ratings in the Schedule for Rating Disabilities represent, as far as practicably can be determined, the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2013). Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7 (2013). Otherwise, the lower rating will be assigned. Id. Any reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. The schedule recognizes that disability from distinct injuries or diseases may overlap. See 38 C.F.R. § 4.14 (2013). However, the evaluation of the same disability or its manifestation under various diagnoses, which is known as pyramiding, is to be avoided. Id. In increased rating cases, VA must determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim; this practice is known as "staged ratings." See Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Veteran has been assigned a noncompensable rating under Diagnostic Code (DC) 7336, which pertains to hemorrhoids, internal or external. 38 C.F.R. § 4.114, DC 7336 sets forth the following rating criteria: A 0 percent rating is assigned for mild or moderate hemorrhoids. A 10 percent rating is assigned for hemorrhoids that are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. A 20 percent rating is assigned for hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. 38 C.F.R. § 4.114, DC 7336 The June 2009 VA examiner diagnosed the Veteran as having hemorrhoids. The VA examiner found reducible external hemorrhoids, the absence of thrombosis, and frequent recurrence without excessive redundant tissue. Specifically, the examiner noted the presence of one small, non-tender external hemorrhoid with a small amount of redundant tissue. Based on these findings, the Veteran's hemorrhoid disorder does not meet the criteria for a compensable rating under DC 7336. Id. The Board has considered the Veteran's statements regarding her hemorrhoid disorder and associated functional limitations. During her June 2009 VA examination, the Veteran reported having experienced symptoms about five times a month including itching, pain, swelling, and a nagging feeling to empty her bowels. The Veteran also reported that, when her hemorrhoids become exacerbated, she is not able to sit comfortably and has some difficulty with walking. During an October 2010 VA medical consult, the Veteran mentioned that she had periodic hemorrhoids. The Veteran's description of her symptoms suggests that her hemorrhoid disorder is mild to moderate and, therefore, only entitled to a non-compensable rating under DC 7336. Similarly, the medical evidence does not establish that the Veteran's hemorrhoid disorder meets the criteria for a compensable rating under DC 7336. A July 2010 colonoscopy found hemorrhoids and identified a single polyp that was removed during the procedure. A February 2010 endoscopy also found hemorrhoids. Although the Veteran's statements that her 2010 colonoscopy revealed internal hemorrhoids (see June 2010 statement) and that the doctor who performed her colonoscopy commented on her internal and external hemorrhoids (see April 2012 substantive appeal) are competent, the medical evidence does not warrant an increased rating for her hemorrhoid disorder. The Veteran's hemorrhoids may also be rated under DC 7332, which applies to impairment of sphincter control of the rectum or anus. 38 C.F.R. § 4.114. DC 7332 assigns: a noncompensable rating for healed or slight impairment; a 10 percent rating for constant slight or occasional moderate leakage; a 30 percent rating for occasional involuntary bowel movements necessitating the wearing of a pad; a 60 percent rating for extensive leakage and fairly infrequent involuntary bowel movements; and a 100 percent rating for complete loss of sphincter control. Id. The June 2009 VA examination report states that the Veteran does not have diarrhea, perineal discharge, or stool leakage. Moreover, the Veteran does not state, and the medical evidence does not suggest, that her hemorrhoid disorder results in such symptoms. Accordingly, the Veteran's symptoms do not satisfy the criteria for a compensable rating under DC 7332. In summary, the probative evidence of record weighs against assignment of an increased (compensable) rating for hemorrhoids. As shown above, there is no evidence showing that the Veteran is entitled to a compensable rating at any point since her claim for an increased rating for hemorrhoid disorder. Thus, staged ratings are not appropriate for the time frame on appeal. See Hart, 21 Vet. App. at 509-10; Fenderson, 12 Vet. App. at 126. The Veteran has not stated and the evidence of record does not otherwise suggest that her hemorrhoid disorder is incapacitating to prevent her from obtaining or maintaining substantially gainful employment. Thus, the issue of entitlement to TDIU has not been raised. See 38 C.F.R. §§ 3.340, 4.16 (2013); Rice v. Shinseki, 22 Vet. App. 447, 453 (2009) (holding that if a claimant or the record reasonably raises the question of whether he or she is unemployable due to the disability for which an increased rating is sought, part and parcel of that claim for an increased rating is the issue of whether a total rating based on individual unemployability resulting from that disability is warranted). The Board has considered whether the Veteran's claim should be referred for an extraschedular rating. See 38 C.F.R. § 3.321(b) (2013); Thun v. Peake, 22 Vet. App. 111, 114 (2008). Because the ratings provided under the VA Schedule for Rating Disabilities are averages, an assigned rating may be adequate to address the average impairment in earning capacity caused by the disability but not completely account for each individual claimant's circumstances. Thun, 22 Vet. App. at 114. In exceptional situations in which the rating is inadequate, the case may be referred for extraschedular consideration. Id. The governing norm in these exceptional cases is a finding that the disability at issue 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. 38 C.F.R. § 3.321(b)(1). In Thun, 22 Vet. App. at 115, the Court held that the determination of whether a claimant is entitled to an extraschedular rating under 38 C.F.R. § 3.321(b) is a three-step inquiry. First, as a threshold factor, there must be a finding that the evidence of record presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Id. The Board must compare 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. See id. If the rating criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, in which case the assigned schedular evaluation is adequate and no referral is required. Id. Second, if the schedular criteria are inadequate to evaluate the claimant's disability, the Board must determine whether the exceptional disability exhibits other related factors such as marked interference with employment or frequent periods of hospitalization. Id. If so, under the third step of the inquiry the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination of whether the claimant's disability picture requires the assignment of an extraschedular rating. Id. Referral for extraschedular consideration is not warranted. A comparison of the Veteran's hemorrhoid disorder and the rating criteria does not show "such an exceptional or unusual disability picture . . . as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b). The Veteran's hemorrhoid disorder is manifested by symptoms addressed by the rating criteria, including itching, pain, and swelling and no impairment of sphincter control. See 38 C.F.R. § 4.114, DCs 7332, 7336; see also June 2009 VA examination report. Further, she does not have symptoms associated with her hemorrhoid disorder that have been left uncompensated or unaccounted for by the assignment of a schedular rating. See Thun, 22 Vet. App. at 115. The Veteran's reported functional limitations do not appear to be exceptional or unusual for a hemorrhoid disorder and, therefore, fall within the purview of the schedular criteria. See 38 C.F.R. § 4.21 (2013) (providing that "[c]oordination of rating with impairment of function will . . . be expected in all instances"). As noted in Thun, the rating criteria are averages and need not account for each individual circumstance in order to be adequate for evaluation purposes. Because the evidence does not show that the Veteran's hemorrhoid disorder is "exceptional" or "unusual" when compared with the rating criteria, the available schedular evaluations are adequate to rate this disability. Thus, the first step of the inquiry is not satisfied. In the absence of this threshold finding, there is no need to consider the second step of the inquiry, namely whether there are "related factors" such as marked interference with employment or frequent periods of hospitalization. See Thun, 22 Vet. App. at 118-19 (holding that the Board's "threshold" finding that the rating criteria were adequate to evaluate the claimant's disability was a sufficient basis for denying extraschedular consideration without regard as to whether there was marked interference with employment). Moreover, such related factors are not shown. Accordingly, referral for extraschedular consideration is not warranted. Id. Accordingly, the preponderance of the evidence is against the Veteran's claim. Consequently, the benefit-of-the-doubt rule does not apply and entitlement to a compensable rating for hemorrhoid disorder is denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102; 4.3 (2013); Gilbert, 1 Vet. App. at 55. ORDER Entitlement to service connection for depression is granted. Entitlement to a compensable rating for a hemorrhoid disorder is denied. ______________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs