Citation Nr: 1536114 Decision Date: 08/24/15 Archive Date: 08/31/15 DOCKET NO. 12-13 421 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to a rating higher than 10 percent for hemorrhoids. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD D. Jani, Associate Counsel INTRODUCTION The Veteran had honorable active duty service in the Air Force from December 1990 to June 1998. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky. Local jurisdiction of the appeal is currently with the RO in Columbia, South Carolina. A notice of disagreement was received in September 2011, a statement of the case was issued in May 2012 and a VA Form 9 was received in May 2012. In a February 2014 rating decision, the RO in Columbia, South Carolina granted an increased evaluation of 10 percent for hemorrhoids, effective August 27, 2010. Despite the grant of this increased evaluation, the Veteran has not been awarded the highest possible evaluation. As a result, he is presumed to be seeking the maximum possible evaluation. The issue remains on appeal, as the Veteran has not indicated satisfaction with the increased rating. A.B. v. Brown, 6 Vet. App. 35 (1993). In January 2015, the Board remanded this claim for the purpose of scheduling the Veteran for a video conference hearing at the RO before a Veterans Law Judge. Thereafter, a video conference hearing was conducted in May 2015 by the undersigned Veterans Law Judge. A transcript is associated with the claims file. The Board notes that, in addition to the paper claims file, there is a paperless, electronic record associated with the Veteran's claim (including Virtual VA and Veterans Benefits Management System (VBMS)). Any future consideration of this Veteran's case should take into account the existence of this electronic record. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND Increased Rating for Hemorrhoids The Veteran seeks an increased rating for his service-connected hemorrhoids. He asserts his disability is more severe than what the current rating represents. As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to assist a claimant in the development of the claim. This duty includes assisting the Veteran in the procurement of pertinent records and in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A (West 2015); 38 C.F.R. § 3.159 (2015). VA's duty to assist also includes a thorough and comprehensive medical examination. Robinette v. Brown, 8 Vet. App. 69 (1995). The Board finds the duty to assist has not been met and further development is necessary before the Veteran's claim can be decided. The Board notes that during the May 2015 Board hearing, the Veteran mentioned follow-up treatment subsequent to the hearing for his hemorrhoids at the Columbia, South Carolina VA Medical Center (VAMC). See BVA Hearing Transcript at 6-7. Therefore, on remand, all updated treatment records from the Columbia, South Carolina VAMC should be obtained and associated with the claims file. Furthermore, the Board notes that a medical opinion is adequate when it is based upon consideration of prior medical history and examinations, and describes the disability in sufficient detail so that the Board's evaluation will be a fully informed one. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Veteran was afforded a VA examination in January 2014 for his hemorrhoids; however, during the May 2015 Board hearing, the Veteran raised concerns about the adequacy of this examination. The Veteran noted that the January 2014 examiner only examined his external hemorrhoids and failed to inspect his internal hemorrhoids. See BVA Hearing Transcript at 6-9. Therefore, the Veteran contended that this examination is an incomplete evaluation of his condition, as his predominant symptoms of flare ups, severe bleeding, and pain are coming from his internal hemorrhoids. Id. Similarly, the Veteran highlighted that the January 2014 examiner failed to check the internal lining of the anus to determine if the Veteran had developed internal fissures. Id. Hemorrhoids are rated under the criteria of 38 C.F.R. § 4.114 (Schedule of ratings - digestive system), Diagnostic Code 7336 (external or internal hemorrhoids). The rating criteria of Diagnostic Code 7336 are as follows: A noncompensable rating is assigned for mild or moderate hemorrhoids. A rating of 10 percent is assigned for hemorrhoids that are large or thrombotic, irreducible, with excessive redundant tissue and evidencing frequent recurrences. A rating of 20 percent is assigned for hemorrhoids with persistent bleeding and with secondary anemia or with fissures. In essence, the Veteran argued that as the January 2014 examiner failed to inspect for internal fissures, the examination was inadequate to properly evaluate the severity of the Veteran's hemorrhoids under the established rating criteria. See BVA Hearing Transcript at 6-9. The Board agrees with the arguments raised by the Veteran at the May 2015 Board hearing and finds the January 2014 examination inadequate. The Board notes that the January 2014 examiner did not physically examine the Veteran's internal anal cavity to make a determination as to whether the Veteran had developed internal fissures. Similarly, although the examiner noted small or moderate external hemorrhoids, the January 2014 opinion failed to comment on whether the Veteran also had internal hemorrhoids. Furthermore, the January 2014 examination failed to properly comment as to the severity of the Veteran's hemorrhoidal bleeding. The Board observes that the Veteran's treatment records periodically show the Veteran's complaints about his hemorrhoids. See August 2012 Columbia, SC VAMC Records; see also January 2011 Columbia, SC VAMC Records. The Veteran's treatment records also show occasional blood in the Veteran's stool due to his hemorrhoids. See August 2012 Columbia, SC VAMC Records. Additionally, the Board observes that a complete blood count (CBC) was conducted at the January 2014 VA examination. The examination report indicates that the CBC should be completed if anemia was suspected; however, the examiner offers no comments or diagnosis of anemia. Despite this evidence, the January 2014 examiner failed to comment on the severity of the hemorrhoidal bleeding. Therefore, the examination is inadequate to evaluate the Veteran's disability under the rating criteria established within 38 C.F.R. § 4.114, Diagnostic Code 7336. On remand, the Veteran must be afforded a new VA examination and all symptoms and findings must be recorded in detail according to the pertinent rating criteria outlined above. Accordingly, the case is REMANDED for the following action: 1. Associate with the claims file all updated VA medical records pertaining to the Veteran's treatment for hemorrhoids, to include all non-duplicative records, from the Columbia, SC VAMC. 2. Upon completion of the development requested above, as well as the association with the claims file of any additional records obtained, the Veteran should be afforded an in-person VA examination to determine the severity of his service-connected hemorrhoids. An internal and external examination must be conducted. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. The examination report must also include an internal examination of fissures. The Veteran's claims folder must be reviewed by the examiner in conjunction with the examination. The examiner should identify and completely describe all current symptomatology. Based on the evidence of record, the examiner is asked to address the following questions: Does the Veteran suffer from external hemorrhoids? If the answer is "yes," please identify whether such hemorrhoids are: (1) mild or moderate; (2) large or thrombotic, irreducible with excessive redundant tissue evidencing frequent occurrences; or, (3) manifested by persistent bleeding and with secondary anemia or with fissures. Does the Veteran suffer from internal hemorrhoids? If the answer is "yes," please identify whether such hemorrhoids are: (1) mild or moderate; (2) large or thrombotic, irreducible with excessive redundant tissue evidencing frequent occurrences; or, (3) manifested by persistent bleeding and with secondary anemia, or with fissures. 3. The Veteran is hereby notified that it is his responsibility to report for the examination scheduled in connection with this REMAND and to cooperate in the development of his case. 4. After completing the above and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the issue of entitlement to a rating higher than 10 percent for hemorrhoids should be re-adjudicated based on the entirety of the evidence. If the determination remains adverse to the Veteran, he and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. 5. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2015). _________________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2015), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2015).