Citation Nr: 1536830 Decision Date: 08/28/15 Archive Date: 09/04/15 DOCKET NO. 12-36 064 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for tuberculosis (lung). 2. Entitlement to an initial compensable disability rating for internal hemorrhoids. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Shauna M. Watkins, Counsel INTRODUCTION The Veteran served on active duty from November 1988 to December 1992. The Veteran's claims come before the Board of Veterans' Appeals (Board) on appeal from a March 2010 rating decision of the U.S. Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas, which granted service connection for hemorrhoids. The RO assigned an initial noncompensable (0 percent) disability rating, retroactively effective from September 9, 2009. The rating decision also denied service connection for tuberculosis (lung). The Veteran filed a Notice of Disagreement (NOD) in June 2010, appealing the initial disability rating assigned and the service connection denial. The RO issued a Statement of the Case (SOC) in November 2012. In December 2012, the Veteran filed his Substantive Appeal. Thus, the Veteran perfected a timely appeal of these issues. In July 2015, the Veteran was afforded his requested Board hearing before the undersigned Veterans Law Judge (VLJ) at the local RO (Travel Board hearing). A transcript of the hearing has been associated with the claims file. This appeal was processed using the VBMS paperless claims processing system. Accordingly, any future consideration of this Veteran's case should take into consideration the existence of this electronic record, in addition to the Veteran's Virtual VA paperless claims file. FINDINGS OF FACT 1. The Veteran does not have a current respiratory diagnosis, to include tuberculosis. 2. A positive tuberculin skin test result is not a disorder or disability for which VA compensation benefits can be paid and/or granted. 3. Throughout the appeal, the service-connected hemorrhoids have been mild to moderate, but have not been large, thrombotic, or irreducible, and have not been manifested by excessive redundant tissue, secondary anemia, or fissures. CONCLUSIONS OF LAW 1. Service connection for tuberculosis (lung), to include a positive tuberculin skin test, is not warranted. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. § 3.303 (2015). 2. The criteria for an initial compensable disability rating for internal hemorrhoids are not met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.114, Diagnostic Code (DC) 7336 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the veteran). I. VA's Duties to Notify and Assist Under applicable law, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record: (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and, (3) that the claimant is expected to provide. This notice must be provided prior to an initial unfavorable decision on a claim by the Agency of Original Jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Regarding the tuberculosis claim, the content requirements of a duty-to-assist notice letter have been fully satisfied. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). A letter from the RO dated in October 2009 provided the Veteran with an explanation of the type of evidence necessary to substantiate his claim, as well as an explanation of what evidence was to be provided by him and what evidence the VA would attempt to obtain on his behalf. The letter also provided the Veteran with information concerning the evaluation and effective date that could be assigned should service connection be granted, pursuant to Dingess v. Nicholson, 19 Vet. App. 473 (2006). The letter was provided prior to the initial RO adjudication of his claim. Accordingly, VA has no outstanding duty to inform the Veteran that any additional information or evidence is needed. Regarding the hemorrhoids claim, this appeal arises from the Veteran's disagreement with the initial rating assigned following the grant of service connection for hemorrhoids. As such, pertinent regulation provides that VA has no further obligation to provide notice under 38 U.S.C.A. § 5103 on this downstream element of the claim. See 38 C.F.R. § 3.159(b)(3)(1) (2015). In so providing, the courts have held that once service connection is granted, the claim is substantiated, further notice as to the "downstream" elements concerning the initial rating and effective date is not required, and any defect in the notice is not prejudicial. See Dingess v. Nicholson, 19 Vet. App. 473, 490-491 (2006); see also Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Thus, because the section 5103 notice letter provided in October 2009 before the grant of service connection for hemorrhoids was legally sufficient, VA's duty to notify in this case is satisfied. See also Goodwin v. Peake, 22 Vet. App. 128 (2008); Dunlap v. Nicholson, supra. VA also has a duty to assist the Veteran in the development of the claims. This duty includes assisting the Veteran in the procurement of service treatment records (STRs) and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Here, the Board finds that all relevant facts have been properly developed, and that all evidence necessary for equitable resolution of the issues has been obtained. His STRs and post-service VA treatment records have been obtained. At his July 2015 Board hearing, the Veteran testified that his only medical treatment for the disorders on appeal was at the local VA Medical Center (VAMC). He testified that he was last treated at the VAMC for these disorders two to three years ago, and did not state the date of his last VA treatment. See Board hearing transcript, pages 3-4. The most recent VA treatment records in the claims file are dated from November 2012. The Board finds that all of the Veteran's recent VA treatment records have been obtained. At his Board hearing, the Veteran also testified that he received a chest X-ray at the VAMC about a year ago (i.e., July 2014). See Board hearing transcript, page 11. This contradicts the Veteran's prior statement at his Board hearing that he had not been treated at the VAMC for three years. The Board notes that a May 2011 chest X-ray is of record (contained in the July 2012 VA examination), which reveals normal findings. However, even assuming for arguments sake that there is an outstanding recent VA chest X-ray, the Board finds that the Veteran is not prejudiced by deciding his tuberculosis claim below. Specifically, at his Board hearing and at his recent July 2012 VA examination, the Veteran reported that he did not have any current respiratory symptoms, treatment, or diagnosis. See July 2012 VA examination and Board hearing transcript, pages 11-13. At his Board hearing, the Veteran testified that the recent VA chest X-ray was "clear." See Board hearing transcript, page 11. Thus, even if there is an outstanding VA chest X-ray, this X-ray, as described by the Veteran, would not document a current respiratory disorder diagnosis. The Veteran's service connection claim is being denied because he does not have a current respiratory disorder diagnosis. Thus, the Board finds that an attempt to obtain any outstanding VA treatment records would be futile. The claims file also does not present evidence that the Veteran is currently receiving disability benefits from the Social Security Administration (SSA) for the disorders currently on appeal. Therefore, the Board does not need to make an attempt to obtain these records. The Board does not have notice of any additional relevant evidence that is available but has not been obtained. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on a claim, as defined by law. Regarding the tuberculosis claim, the record indicates that the Veteran participated in a VA examination in July 2012, the results of which have been included in the claims file for review. The examination involved a review of the claims file, a thorough examination of the Veteran, and an opinion that was supported by sufficient rationale. Therefore, the Board finds that the VA examination and medical opinion are adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim). Given the foregoing, the Board finds that the VA has substantially complied with the duty to obtain the requisite medical information necessary to make a decision on the Veteran's claim. Regarding the hemorrhoids claim, the Veteran has been afforded VA examinations, and the reports of those evaluations contain all findings needed to properly evaluate his disability. 38 C.F.R. § 4.2 (2015). The Board also finds no credible lay or medical evidence demonstrating or alleging an increased severity of the disability since the most recent VA examination in July 2012. At his Board hearing, the Veteran testified that his hemorrhoids "worsened but it's less." See Board hearing transcript, page 8. The Veteran continued by stating that he does not really bleed anymore, but he still has pain and itching. Id. Pain and itching were documented at the Veteran's recent July 2012 VA examination. The treatment records dated since the July 2012 VA examination do not suggest a worsening of the Veteran's service-connected hemorrhoids since the examination. Thus, the Board finds that this evidence does not suggest a worsening of the service-connected hemorrhoids since the July 2012 VA examination. There is no duty to provide further medical examination on the claim on appeal. See VAOPGCPREC 11-95 (Apr. 7, 1995). Furthermore, the Veteran was afforded a Board hearing in July 2015. A Board member has two duties at a hearing: (1) a duty to fully explain the issues still outstanding that are relevant and material to substantiating the claim; and, (2) a duty to suggest that a claimant submit evidence on an issue material to substantiating the claim when the record is missing any evidence on that issue or when the testimony at the hearing raises an issue for which there is no evidence in the record. See 38 C.F.R. § 3.103(c)(2) (2015); Procopio v. Shinseki, 26 Vet. App. 76 (2012) (citing Bryant v. Shinseki, 23 Vet. App. 488, 492, 496 (2010)). Here, during the Board hearing, the VLJ specifically noted the issues as stated on the title page of this decision. See Board hearing transcript, page 2. The Veteran was assisted at the hearing by an accredited representative from the Veterans of Foreign Wars of the United States. Id. The VLJ noted the elements of the claims that were lacking to substantiate the claims for benefits. Id. at 3. The VLJ and representative asked the Veteran questions regarding these elements of the claims. The representative and the VLJ then asked questions to ascertain whether the Veteran had submitted evidence in support of these claims. In addition, the VLJ and representative sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claims. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with the hearing requirements, nor identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claims, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claims for benefits. As such, the Board finds that the VLJ complied with the aforementioned hearing duties. For the foregoing reasons, the Board concludes that all reasonable efforts were made by the VA to obtain evidence necessary to substantiate the Veteran's claims. Therefore, no further assistance to the Veteran with the development of evidence is required. II. Tuberculosis Claim The Veteran seeks service connection for tuberculosis (lung). Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 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 the military discharge, when all the evidence, including that pertinent to the period of military service, establishes that the disease was incurred during the active military service. 38 U.S.C.A. § 1113(b) (West 2014); 38 C.F.R. § 3.303(d). Service connection for certain chronic diseases, including active tuberculosis, will be presumed if they manifest to a compensable degree within three years following the active military service. This presumption, however, is rebuttable by probative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2014); 38 C.F.R. §§ 3.307, 3.309 (2015). Presumptive periods are not intended to limit service connection to diseases so diagnosed when the evidence warrants direct service connection. The presumptive provisions of the statute and VA regulations implementing them are intended as liberalizations applicable when the evidence would not warrant service connection without their aid. 38 C.F.R. § 3.303(d). For the showing of a chronic disease in service, there must be a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. If chronicity in service is not established, evidence of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. 38 U.S.C.A. § 7104(a) (West 2014); Baldwin v. West, 13 Vet. App. 1 (1999); see 38 C.F.R. § 3.303(a). When there is an approximate balance of positive and negative evidence regarding a material issue, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); see 38 C.F.R. § 3.102. If the Board determines that the preponderance of the evidence is against the claim, it has necessarily found that the evidence is not in approximate balance, and the benefit of the doubt rule is not applicable. Ortiz, 274 F.3d at 1365. As noted above, the first element of service connection requires medical evidence of a current disorder. Here, a current diagnosis has not been established. The Veteran's STRs document that he had a positive tuberculin skin test in September 1989. However, the Veteran was never diagnosed with tuberculosis during service or since service. At his July 2012 VA examination, the VA examiner determined that the Veteran did not have tuberculosis. At his July 2015 Board hearing, the Veteran testified that he did not have a current respiratory disorder diagnosis, to include tuberculosis, and could not recall ever being diagnosed with tuberculosis. See Board hearing transcript, pages 11-13. Medical evidence pertaining to a current respiratory disorder diagnosis, to include tuberculosis, is not of record. A positive tuberculin skin test in service is not sufficient for a grant of service connection because a positive tuberculin skin test is not considered to be a disability for which compensation benefits can be granted under VA law. The Veteran does not assert that he currently has, or has ever had, tuberculosis, and the claims file does not contain evidence that the Veteran currently has tuberculosis. For these reasons, the Board finds that the Veteran does not meet the first requirement for the establishment of service connection for tuberculosis, to include a positive tuberculin skin test. Where the evidence establishes that a Veteran does not currently have a disorder for which service connection could be granted, service connection for that disorder is not authorized under the statues governing veterans' benefits. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). Further discussion of the remaining requirements for service connection is not warranted and the Veteran's claim must be denied. The Board notes that under the provisions of 38 U.S.C.A. § 5107(b), the benefit of the doubt is to be resolved in the claimant's favor in cases where there is an approximate balance of positive and negative evidence in regard to a material issue. The preponderance of the evidence, however, is against the Veteran's claim and that doctrine is not applicable. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Thus, the Veteran's claim of entitlement to service connection for tuberculosis, to include a positive tuberculin skin test, is not warranted. III. Hemorrhoids Claim Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity in civil occupations. Separate DCs identify the various disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R. § Part 4 (2015). Where a veteran appeals the initial rating assigned for a disability at the time that service connection for that disability is granted, evidence contemporaneous with the claim and with the initial rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous . . . ." Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found. Id. The Veteran is in receipt of a noncompensable (0 percent) disability rating under 38 C.F.R. § 4.114, DC 7336 for his hemorrhoids. He seeks a higher initial disability rating. Under DC 7336, a 0 percent rating is warranted when the hemorrhoids are mild or moderate. A 10 percent rating is warranted when the hemorrhoids are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. A higher 20 percent rating is warranted when there are hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. 38 C.F.R. § 4.114. In applying the above law to the facts of the case, the Board finds that the Veteran is not entitled to a compensable initial disability rating for his hemorrhoids. Here, there is no credible evidence of hemorrhoids that are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences, or hemorrhoids with secondary anemia or with fissures, to warrant a higher disability rating. 38 C.F.R. § 4.114, DC 7336. Specifically, the Veteran was afforded a VA examination in January 2010. The Veteran told the examiner that he uses hydrocortisone cream daily for itching in his rectum. Upon a physical examination of the Veteran and a review of the claims file, the VA examiner determined that the Veteran had anal itching, but did not have diarrhea, difficulty passing stool, pain, tenesmus, or swelling. The Veteran had both internal and external hemorrhoids. The internal hemorrhoids were "barely palpable." His external hemorrhoids were "0.5 x 1.0 cm external skin tag." The hemorrhoids were reducible. There was no evidence of prolapse, thrombosis, bleeding, fissures, excessive redundant tissue, anorectal fistula, anal or rectal stricture, sphincter impairment, or rectal prolapse. The Veteran was afforded another VA examination in July 2012. The examiner stated that the Veteran did not have any external hemorrhoids, just an external skin tag and internal hemorrhoids. The VA examiner determined that the Veteran's hemorrhoids were mild or moderate, but were not large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. The examiner also found that the Veteran's hemorrhoids were not manifested by persistent bleeding, secondary anemia, or fissures. The examiner noted that the Veteran used hydrocortisone cream for the itching of his hemorrhoids. In providing the aforementioned opinion, the VA examiner examined the Veteran, reviewed the Veteran's claims file, and examined the Veteran's September 2011 VAMC CBC and stool tests. At his July 2015 Board hearing, the Veteran testified that his service-connected hemorrhoids were manifested by bleeding, swelling, discharge, pain, and itching. See Board hearing transcript, pages 4, 5, 8, 9. The Veteran stated that he used a cream to treat the itching. Id. at 5. The Veteran initially stated that his bleeding was occurring every two weeks, but then reported that he was not bleeding very often. Id. at 4, 8. The VA treatment records in the claims file document external and internal hemorrhoids with bleeding, pain, and itching, but do not provide any evidence contrary to that obtained above. Based on the evidence of record, the Veteran is not entitled to an initial compensable disability rating under DC 7336 for his hemorrhoids. The Veteran's internal and external hemorrhoids are not large, thrombotic, or irreducible, and are not manifested by excessive redundant tissue, secondary anemia, or fissures. This evidence does not warrant a compensable disability rating for the service-connected hemorrhoids. 38 C.F.R. § 4.114, DC 7336. The Board has considered the application of the remaining DCs under the current version of the regulation in an effort to determine whether a higher rating may be warranted for the Veteran's hemorrhoids, but finds none are raised by the medical evidence. Furthermore, the Veteran's symptoms do not appear to have changed significantly during this initial rating period so as to warrant a staged rating. Fenderson, 12 Vet. App. at 126. The Board notes that in adjudicating a claim, the competence and credibility of the Veteran must be considered. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). The Board acknowledges that the Veteran is competent to give evidence about what he observes or experiences. For example, he is competent to report that he experiences certain symptoms, such as pain and bleeding, and he is credible in this regard. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). The Veteran's competent and credible belief that his disability is worse than the assigned rating, however, is outweighed by the competent and credible medical examinations that evaluated the true extent of impairment based on objective data coupled with the lay complaints. The VA examiners have the training and expertise necessary to administer the appropriate tests for a determination of the type and degree of the impairment associated with the Veteran's complaints. For these reasons, greater evidentiary weight is placed on the physical examination findings. Also, as stated above, the rating criteria are specific in indicating that some of the criteria must be objectively demonstrated. In sum, the preponderance of the evidence is against the assignment of a compensable initial disability rating for the service-connected hemorrhoids at any time during the appeal period. Thus, the claim is denied. IV. Extraschedular and TDIU Consideration The above determination is based on application of provisions of the VA's Schedule for Rating Disabilities. 38 C.F.R. Part 4 (2015). However, the regulations also provide for exceptional cases involving compensation. Pursuant to 38 C.F.R. § 3.321(b)(1) (2015), the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service is authorized to approve an extraschedular evaluation 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 as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1). The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of a veteran's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). If the criteria reasonably describe the claimant's disability level and symptomatology, then a veteran's disability picture is contemplated by the rating schedule. The assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, 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 those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). Here, because the schedular rating for the Veteran's hemorrhoids fully address his symptoms, which include mainly pain, bleeding, swelling, and itching, referral to the VA Under Secretary for Benefits or the Director of Compensation and Pension Service for consideration of an extraschedular evaluation is not warranted. A comparison between the level of severity and symptomatology of the hemorrhoids with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. Specifically, the Veteran reports pain, bleeding, swelling, and itching. All of these symptoms were considered in determining the Veteran had mild to moderate hemorrhoids, which is specifically addressed under the regulations, and were thus considered in assigning him his current disability rating. However, even with consideration of these symptoms, his service-connected hemorrhoids were not severe enough to warrant a compensable disability rating. Thus, the Veteran's symptoms of pain, bleeding, swelling, and itching were considered in the regulations. The symptoms the Veteran complains of are not exceptional or unusual for an individual who suffers from hemorrhoids. There is no credible evidence that the Veteran's service-connected disability causes impairment that is not contemplated by the schedular rating criteria or that renders impractical the application of the regular schedular standards. See Thun, 22 Vet. App. at 111. Accordingly, referral of this case for consideration of an extraschedular rating is not warranted. Id.; see also Bagwell v. Brown, 9 Vet. App. 337 (1996); Floyd v. Brown, 9 Vet. App. 88 (1996). Further, the Board notes that under Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. However, in this case, there are no additional service-connected disabilities that have not been attributed to a specific service-connected condition. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. Finally, pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009), a claim for a total disability rating based in individual unemployability due to service-connected disabilities (TDIU) is considered part and parcel of an increased rating claim when the issue of unemployability is raised by the record. In this case, the issue of unemployability is not raised by the record. At the July 2012 VA examination and at his Board hearing, the Veteran reported that his service-connected hemorrhoids did not impact his employment. There is no allegation in the record that the Veteran's service-connected hemorrhoids have resulted in unemployment. Therefore, consideration of a TDIU is not warranted. ORDER The claim of entitlement to service connection for tuberculosis (lung), to include a positive tuberculin skin test, is denied. The claim of entitlement to an initial compensable disability rating for internal hemorrhoids is denied. ____________________________________________ TANYA SMITH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs