Citation Nr: 1539339 Decision Date: 09/15/15 Archive Date: 09/24/15 DOCKET NO. 10-02 256 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Whether there was clear and unmistakable error in a November 2012 rating decision which granted a separate 40 percent evaluation for a bladder/voiding dysfunction. 2. Entitlement to an initial evaluation in excess of 10 percent for tinnitus. 3. Entitlement to an initial evaluation in excess of 10 percent for residuals of a gunshot or shrapnel wound of the left calf, status post open debridement. 4. Entitlement to a separate, compensable evaluation for a left calf scar with sensory loss. 5. Entitlement to an effective date prior to August 3, 2009, for service connection of prostate cancer. 6. Entitlement to service connection for hemorrhoids. 7. Entitlement to service connection for residuals of malaria. 8. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities prior to August 3, 2009. REPRESENTATION Appellant represented by: North Carolina Division of Veterans Affairs ATTORNEY FOR THE BOARD W. H. Donnelly, Counsel INTRODUCTION The Veteran served on active duty with the United States Army from October 1966 to October 1968. These matters come before the Board of Veterans' Appeals (Board) on appeal from April 2008, September 2011, and May 2013 rating decisions by Department of Veterans Affairs (VA) Regional Offices (ROs). The April 2008 decision denied service connection for hemorrhoids and residuals of malaria; and granted service connection for tinnitus, rated 10 percent disabling, and a left calf disability, rated 10 percent disabling. In the September 2011 decision, service connection for prostate cancer was granted, and a 100 percent rating was assigned from August 3, 2009. Most recently, in May 2013, the RO found CUE in a November 2012 grant of a separate 40 percent evaluation for voiding/bladder dysfunction, as secondary to service-connected prostate cancer; the separate evaluation was ended and the bladder problem rated as part of the cancer. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims (Court) held that a TDIU claim is part of a claim for a higher rating when such claim is raised by the record or asserted by the Veteran. The Court further held that when evidence of unemployability is submitted during the pendency of a claim for an increased evaluation, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. During the pendency of this appeal the Veteran asserted that he was unemployable due at least in part to the tinnitus and left calf disabilities. Accordingly, even though the Veteran did not file a substantive appeal with respect to the May 2011 statement of the case regarding this matter it is nevertheless before the Board as part and parcel of the increased rating claims for the period of time prior to August 3, 2009. From that date, the Veteran is in receipt of special monthly compensation under 38 U.S.C.A. § 1114(s) rendering the TDIU matter moot. To the extent that additional evidence was received following the issuance of a supplemental statement of the case in September 2011, the Board notes that the evidence does not provide information pertinent to the severity of the increased ratings decided herein. Accordingly, neither remand nor a waiver of RO consideration is required. The Veteran had requested a hearing before a Veterans Law Judge, to be held at the Board's Washington, DC, offices. In April 2015 correspondence, however, the Veteran withdrew his request. The Veteran's file has been scanned, and converted from a hybrid paper and electronic file to a purely electronic file. The Board has reviewed the records and documents maintained in Virtual VA and the Veterans Benefits Management System (VBMS) to ensure consideration of the totality of the evidence. The issues of entitlement to an earlier effective date for prostate cancer, service connection for hemorrhoids and residuals of malaria, as well as evaluation of any left calf scar and TDIU, are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The 100 percent evaluation for active service-connected prostate cancer contemplates the direct manifestations and residuals of that disease, to include voiding dysfunction. 2. No disease process or disability manifested as a voiding dysfunction is diagnosed as secondary to service-connected prostate cancer. 3. Tinnitus does not markedly interfere with employment. 4. The injury of the left calf did not involve a through and through or deep penetrating wound, or prolonged infection; there is no loss of deep tissue or consistent showing of cardinal signs and symptoms of muscle disability. CONCLUSIONS OF LAW 1. The grant of a separate 40 percent evaluation for a bladder/voiding dysfunction as secondary to service-connected prostate cancer was CUE. 38 U.S.C.A. §§ 1155, 5109A (West 2014); 38 C.F.R. §§ 3.105, 4.14, 4.115b (2015). 2. The criteria for an initial evaluation in excess of 10 percent for tinnitus are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.87, Diagnostic Code 6260 (2015). 3. The criteria for an initial evaluation in excess of 10 percent for a left calf disability are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.56, 4.73, Diagnostic Code 5311 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION VA's Duties to Notify and Assist 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; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). However, the United States Court of Appeals for Veterans Claims (Court) has specifically held that these duties have no application to allegations of CUE as a matter of law. Livesay v. Principi, 15 Vet. App. 165, 178 (2001). Therefore, no further action is necessary under those duties with regard to the evaluation of a voiding/bladder dysfunction. With regard to the evaluations for tinnitus and a left calf disability, the appeals arise from the Veteran's disagreement with the initial evaluation following the grant of service connection. Once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). No additional discussion of the duty to notify is therefore required. VA also has a duty to assist the Veteran in the development of his claims for increased rating, which are not abrogated by the granting of service connection. This duty includes assisting the Veteran in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran's service treatment records, VA medical treatment records, and private treatment records have been obtained. 38 U.S.C.A. § 5103A, 38 C.F.R. § 3.159. The Veteran has not indicated, and the record does not contain evidence, that he is in receipt of disability benefits from the Social Security Administration. 38 C.F.R. § 3.159(c)(2). VA examinations were conducted in February 2008; the examiners provided all necessary clinical findings to permit application of the evaluation criteria. 38 C.F.R. § 3.159(c) (4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). The Veteran has no alleged these examinations were inadequate, and has not reported worsening of the conditions since the examinations. Updated findings are not necessary, particularly in light of the recent treatment records associated with the claims file. There is no indication in the record that any additional evidence, relevant to the issues decided, is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). CUE Previous determinations on which an action was predicated will be accepted as correct in the absence of clear and unmistakable error. Where evidence establishes such error, the prior decision will be reversed or amended. For the purpose of authorizing benefits, the rating or other adjudicative decision which constitutes a reversal of a prior decision on the grounds of clear and unmistakable error has the same effect as if the corrected decision had been made on the date of the reversed decision. 38 C.F.R. § 3.105(a). Clear and unmistakable error is a very specific and rare kind of error; it is the kind of error of fact or law, that when called to the attention of later reviewers compels the conclusion, to which reasonable minds could not differ, that the result would have been manifestly different but for the error. See, e.g., Damrel v. Brown, 6 Vet. App. 242, 245 (1994); Russell v. Principi, 3 Vet. App. 310, 313-14 (1992). To establish clear and unmistakable error in a prior, final decision, all three of the following criteria must be met: (1) either the correct facts, as they were known at the time, were not before the adjudicator or the statutory or regulatory provisions then in extant at the time were incorrectly applied; and (2) the error must be undebatable; and (3) the error must be of the sort which, had it not been made, would have manifestly changed the outcome at the time it was made. See, e.g., Damrel, 6 Vet. App. at 245;Russell, 3 Vet. App. at 313-14. The determination regarding clear and unmistakable error must be made based on the record and the law that existed at the time the decision was made. Damrel, 6 Vet. App. at 245. Evidence that was not of record at the time of the decision cannot be used to determine if clear and unmistakable error occurred. See Porter v. Brown, 5 Vet. App. 233 (1993). A claim of clear and unmistakable error is a collateral attack on an otherwise final rating decision by a VA regional office. Smith v. Brown, 35 F.3d 1516, 1527 (Fed. Cir. 1994). As such, there is a presumption of validity that attaches to a final decision, and when such a decision is collaterally attacked the presumption becomes even stronger. Fugo, 6 Vet. App. at 43-44. Therefore, a claimant who seeks to obtain retroactive benefits based on clear and unmistakable error has a much heavier burden than that placed on a claimant who seeks to establish prospective entitlement to VA benefits. Akins v. Derwinski, 1 Vet. App. 228, 231 (1991). Service connection for prostate cancer was granted in a September 2011 rating decision, and a 100 percent rating was assigned. The rating schedule provides that a total rating is assigned while the malignancy is active, and for six months following the cessation of any curative therapies. At that point, following examination, the residuals of cancer are rated as either voiding dysfunction or renal dysfunction. 38 C.F.R. § 4.115b, Code 7528. The total disability rating was not considered permanent in light of the watchful waiting course being pursued at that time and the possibility of remission or surgical removal of the cancer. Therefore, a routine future examination was performed in October 2012 to check on the status of the cancer. At that examination, the doctor noted that watchful waiting continued, and a recent biopsy had shown the continued presence of active cancer. Under the rating schedule, a 100 percent rating was therefore continued. The examiner also, in describing the current manifestation and impacts of prostate cancer, noted the presence of a voiding dysfunction, manifested by urine leakage and increased urinary frequency. No bladder disability was diagnosed, however; only prostate cancer and comorbid benign prostatic hypertrophy (BPH) were noted. The etiology of the voiding dysfunction was listed as prostatitic hypertrophy with obstructive uropathy. The voiding dysfunction was not diagnosed as a free-standing and independent disability entity. Nevertheless, in a November 2012 rating decision, the RO both continued the 100 percent evaluation for prostate cancer as an active malignancy and granted a separate 40 percent evaluation for the voiding dysfunction; the rater, and not a doctor, labeled the symptoms a neurogenic bladder condition. In a May 2013 decision, the RO determined that the assignment of those separate evaluations was CUE, and the 40 percent evaluation for voiding/bladder dysfunction was discontinued. That manifestation was listed as part and parcel of the prostate cancer, which remained rated 100 percent disabling. The RO found that the bladder problem was a residual of the cancer, and the rating schedule specifically provided that such were rated separately only after termination of the 100 percent rating for active malignancy. The Board agrees. The evidence of record at the time of the finding of CUE shows no diagnosed bladder condition. Both the VA examination of October 2012, and VA treatment records through May 2013 show that bladder problems were not distinct disabilities. A May 2013 VA ultrasound, for example, showed that the enlarged prostate was obstructing the bladder neck. The bladder itself was not the problem, the prostate was. BPH is not a service-connected disability. The prostate cancer was, and is, rated under Code 7528, at 100 percent for active disease still undergoing therapy. This contemplates all manifestations and impacts of the disease under those circumstances. Rating under other Codes may not, by regulation, take place until the 100 percent rating ends. To allow otherwise would be to permit pyramiding, or compensating the same disability manifestations twice; this is prohibited. 38 C.F.R. § 4.14. In other words, Code 7528 recognizes that during active phases of disease and treatment, there will be symptoms and problems of various natures that taken together are totally disabling. Once the disease is successfully treated, by complete removal or through remission, the actual residuals may be considered. By separately rating the voiding dysfunction, the RO was compensating the Veteran twice for the same disease. Accordingly, the Board finds that assignment of a separate 40 percent evaluation for voiding/bladder dysfunction while simultaneously in receipt of total disability compensation under Code 7528, clearly and unmistakably misapplies the provisions of the rating schedule, to include the prohibition against pyramiding. Termination of that rating was proper. It is noted that the Veteran's compensation was not decreased as a result of the CUE determination and the criteria set forth in 38 C.F.R. § 3.105 are not applicable. Evaluation In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Separate ratings may be assigned for separate periods of time based on the facts found, however. This practice is known as "staged" ratings." Fenderson v. West, 12 Vet. App. 119, 126-127 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). If the evidence for and against a claim is in equipoise, the claim will be granted. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Tinnitus The Schedule provides that a 10 percent rating is assigned for recurrent tinnitus, regardless of whether it is unilateral or bilateral. 38 C.F.R. § 4.87, Code 6260. No higher Schedular evaluation is provided, and hence to establish entitlement to a yet higher rating, the Veteran must show extraschedular evaluation under 38 C.F.R. § 3.321 is warranted. Extraschedular consideration involves a three step analysis. Thun v. Peake, 22 Vet. App. 111 (2008). First, a determination must be made as to whether the schedular criteria reasonably describe a veteran's disability level and symptomatology. Id. At 115. If the schedular rating criteria do reasonably describe a veteran's disability level and symptomatology, referral for extraschedular consideration is not required and the analysis stops. Id. If the schedular rating criteria do not reasonably describe a veteran's level of disability and symptomatology, a determination must be made as to whether an exceptional disability picture includes other related factors, such as marked interference with employment and frequent periods of hospitalization. Id. At 116. If an exceptional disability picture including such factors as marked interference with employment and frequent periods of hospitalization exists, the matter must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. The Veteran alleges that his 10 percent rating is not high enough because the constant ringing is irritating and "it is hard to concentrate and talk to and understand people." The Board finds that the complaint of irritation is contemplated by the Schedular criteria; however, the allegations of impaired communication and concentration due to the severity of tinnitus in this case are not clearly addressed. The first prong of the Thun test is therefore met. However, the Veteran has not described, and the objective evidence fails to show, any exceptional circumstances meeting the second prong. No excessive impacts or functional effects were reported at the February 2008 VA examination; treatment records mention tinnitus only to note its presence as a current diagnosis. The evidence does not show that he has ever been hospitalized or required intensive treatment for tinnitus. The Veteran has also not reported any marked interference with employment from tinnitus. He worked as a conductor on a railway for decades, while this condition was present, and there is no allegation or finding that tinnitus interfered with his duties, even though it appears that job would require communication with the public regularly. He attributes no lost time or his retirement to tinnitus; he in fact cites other disabilities. Therefore, the second prong of Thun is not met, and no referral for extraschedular entitlement is required. Left Calf The Veteran's left calf disability is rated as a muscle injury under Code 5311, for damage to Muscle Group (MG) XI, the muscles of the calf. The functions of this group include propulsion, plantar flexion of the foot, stabilization of the arch, flexion of the toes, and flexion of the knee. The schedule provides that a slight muscle injury is noncompensable, while a 10 percent rating is assigned for a moderate injury. Moderately severe muscle injury is rated 20 percent disabling, and a severe MG XI injury is rated 30 percent disabling. 38 C.F.R. § 4.73, Code 5311. Evaluations of muscle injuries and their residuals are based on assessment of the impact of function of the MGs affected. The categorization of injuries on the severe, moderately severe, moderate, or slight scale is governed by 38 C.F.R. § 4.56, based on the type of injury initially sustained, the history of complaints and treatment, and the residual objective findings. A slight injury results from a simple wound of the muscle that did not require debridement or result in infection. Service records will show a superficial wound that necessitated brief treatment followed immediately by a return to duty. Such wounds heal with good functional results, and show none of the cardinal signs and symptoms of muscle disability. Objectively, there is a minimal scar, without atrophy, impaired tone, or loss of muscle tissue. No retained metal fragments are shown. 38 C.F.R. § 4.56(d)(1). The cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, and uncertainty of movement. 38 C.F.R. § 4.56(c). Moderate muscle disabilities are caused by through and through or deep penetrating wounds by a single bullet or fragment, without explosive effect, residuals of debridement, or prolonged infection. Records must show one of more of the cardinal signs and symptoms of muscle disability; a lower threshold of fatigue (less stamina) is particularly notable in such injuries. Objectively, small linear entrance and/or exit scars show a short missile track through the muscle, and there is some loss of the muscle substance or impaired tone. Strength and stamina may be reduced when compared to the uninjured side. 38 C.F.R. § 4.56(d)(2). A moderately severe muscle disability is typified by a through and through or deep penetrating wound by a small high-velocity or large low-velocity missile, with debridement, prolonged infection, and intermuscular scarring. Prolonged hospitalization for treatment of such wounds is required, as is the presence of consistent complaint regarding the cardinal signs and symptoms of muscle disability. These prevent the Veteran from keeping up with work requirements. Entrance and/or exit scars show a missile track through one or more MGs, with loss of muscle substance or firm resistance shown on palpation. There is positive impairment of strength and endurance when compared to the uninjured side. 38 C.F.R. § 4.56(d)(3). A severe injury is due to a through and through or deep penetrating wound from a high-velocity missile, a large low-velocity missile, or multiple low velocity missiles. There may be a shattering bone fracture or open comminuted fracture. These wounds require extensive debridement, or result in prolonged infection, sloughing of soft parts, or intermuscular binding or scarring. Prolonged hospital treatment is needed, with a record of consistent complaints of the cardinal signs and symptoms of muscle disability, at a greater level than a moderately severe injury and resulting in an inability to keep up with work requirements. Objectively, associated scars are ragged, depressed, and adherent, showing widespread damage to the MGs in the missile track. Loss of muscle tissue is shown on palpation, or the muscles in the wound area are soft and flabby. In contraction, there is abnormal swelling and hardening. Strength, coordination, and endurance are severely impaired when compared to the uninjured side. A severe muscle disability may also be shown by x-ray evidence of scattered retained foreign bodies, scar adhesion to bone, diminished excitability on electrodiagnostic testing, visible or measureable atrophy, adaptive contraction of opposing muscles, atrophy of other muscle groups not in the missile track, or atrophy of an entire muscle following penetration. 38 C.F.R. § 4.56(d)(4). The Veteran has here been assigned a 10 percent rating for a moderate disability under Code 5311. To warrant a higher evaluation, the criteria for a moderately severe or severe injury must be met. They are not, and therefore no higher evaluation is warranted. Service treatment records show that in June 1968 the Veteran was treated for an abrasion which became infected and developed into cellulitis. He did not at the time report any gunshot or shrapnel wound, and did not even associate his injury with time in combat or activities at any forward position. The Board notes that at the February 2008 examination, the Veteran reported he was wounded in combat and required medevac for his injury. Although the examiner reported that the claims folder was not available for review that does not result in the examination report being inadequate as the examiner provided information that is sufficient to rate the disability. The service treatment records reflect that he sought treatment for left leg pain and an activity profile for the time he was already spending in the rear. The records showed that he had an abrasion and cellulitis with no evidence of a through and through or penetrating wound by any missile, bullet, or fragment of any type or speed. There was no fracture of the bones of the lower leg. Further, although the Veteran now reports a need for debridement of his "wound," and prolonged hospitalization for infection, the contemporaneous records instead show that his stay was only about a week, and involved only daily cleaning, drainage, and dressing of the abrasion. He did receive antibiotics for his infection, and was treated as an outpatient for another week. The requirements for moderately severe or severe types of injuries are not met. A through and through or deep penetrating wound in service is not shown as the clinician in service assessed the wound as an abrasion. Moreover, intermuscular scarring is not shown nor is prolonged hospitalization shown as the Veteran was only treated for one week as an inpatient. Historically, the Veteran complains of pain and cramping in the leg; he also states that his "ache" increases with extended use. Therefore, fatigue-pain is shown on a regular basis. He does not report lowered threshold of fatigue, weakness or loss of power, incoordination, or impaired movement on any kind of consistent basis. Further, the Veteran stated he did not retire due to any of his left leg problems, though he now avoids strenuous or long-term walking. The required history and complaints necessary for a yet higher evaluation are not present. Finally, the reported objective findings do not show loss of deep tissue, muscle substance or normal firm resistance of muscles. The examiner found that the motor and sensory examination of the knee was normal and the ankle itself was unremarkable. There was no evidence of muscle herniation there. There were no adhesions, no tendon damage and no obvious damage to the bone, joint or the nerves in that area. Accordingly, while a slight depression in the calf was noted on examination, there was no impairment of muscle strength or joint movements in the area. Required objective findings are not present. Accordingly, as no moderately severe or severe muscle injury is shown, no evaluation in excess of the currently assigned 10 percent is warranted. Although the Schedular criteria fully contemplate the Veteran's reports of pain, cramping, and a lack of endurance, the Veteran also reports that the disability affects his sleep, which is not so contemplated. However, there is no indication that the Veteran has been hospitalized for this disability after service or that it markedly interfered with his employment. The Veteran instead reported that he retired due to problems that were not related to the left leg. 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. Johnson v. McDonald, 762 F.3d 1362 (2014). In this case, the Veteran is also service connected for prostate cancer with neurogenic bladder, posttraumatic stress disorder (PTSD), tinnitus, bilateral hearing loss and erectile dystunction. The Veteran has not alleged that his currently service-connected disabilities combine to result in additional disability or symptomatology that is not already contemplated by the rating criteria for each individual disability. It is noted that the schedular criteria for PTSD contemplate chronic sleep impairment and difficulty concentrating. Further, there is no medical evidence indicating that the Veteran's service-connected disabilities combine or interact with one another in such a way as to result in further disabilities, functional impairment, or additional symptomatology not accounted for by the rating criteria applicable to each disability individually. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to award compensation for a disability that can be attributed only to the combined effect of multiple conditions. Consideration for an evaluation of a left calf scar is addressed separately, in the Remand section below. (CONTINUED ON NEXT PAGE) ORDER Restoration of a separate 40 percent evaluation for voiding/bladder dysfunction on the basis of CUE is denied. An initial evaluation in excess of 10 percent for tinnitus is denied. An initial evaluation in excess of 10 percent for residuals of a gunshot or shrapnel wound of the left calf is denied. REMAND Remand is required with regard to the remaining matters, to ensure compliance with VA's duty to assist the Veteran in substantiating his claims. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. That duty may include provision of a VA medical examination. Hemorrhoids and Malaria In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The threshold for determining a possibility of a nexus to service is a low one. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Hemorrhoids are reflected in a VA medical record dated in September 2008; the Veteran appears to have had surgery in 1979, and has had instances of rectal bleeding since. He alleges that the rough ride atop armored personnel carriers (APCs) in Vietnam caused his condition. Although service records show no complaints of or treatment for hemorrhoids, the Veteran is competent to report symptoms, and his allegation is consistent with the circumstances of his service. The low threshold for a VA examination is met. With regard to malaria, the Veteran has competently alleged general residuals of an infection. Service records do not show a diagnosis of or treatment for malaria, but there are notations of treatment for a period of fever, malaise, and fatigue which could represent an undiagnosed malaria infection while in Vietnam. A medical examination is therefore required. Left Calf The Veteran sustained an injury of the left calf in service, for which he is currently service-connected. At his February 2008 VA examination, he described, and the examiner noted, manifestations which may represent additional, separately compensable disability manifestations. There are skin changes, and allegations of sensory deficits. A Veteran is entitled to compensation for all manifestations of disability. See Esteban v. Brown, 6 Vet. App. 259, 261 (1994), 38 C.F.R. § 4.25. An examination is necessary on remand to clearly establish the presence of these disabilities, and to permit the RO an opportunity to consider them in the first instance. TDIU As this matter is inextricably intertwined with the earlier effective date matter, action will be deferred at this time. Earlier effective date The Veteran asserts that he is entitled to an earlier effective date for service connection for prostate cancer asserting that he had prostate cancer before it was diagnosed. In this regard, the Court of Appeals for Veterans Claims has noted that "entitlement to benefits for a disability or disease does not arise with a medical diagnosis of the condition, but with the manifestation of the condition and the filing of a claim for benefits for the condition." DeLisio v. Shinseki, 25 Vet.App. 45, 56 (citing 38 U.S.C. § 5110(a). Accordingly, a VA medical opinion should be obtained. It is also noted that the urology records indicate that the Veteran was seen at PrimeCare in December 2005 and had PSA testing done. Those records should be obtained on remand, Accordingly, the case is REMANDED for the following action: 1. Request that the Veteran provide or authorize the release of records from PrimeCare concerning his claim for an earlier effective date for prostate cancer. 2. Schedule the Veteran for a VA rectum and anus examination. The claims folder must be reviewed in conjunction with the examination; if the examiner does not have access to the complete electronic record, relevant documents must be printed and supplied for review. The examiner must identify all current manifestations or residuals of hemorrhoids. The examiner must opine as to whether it is at least as likely as not (a probability of 50 percent or greater) that any such are related to service. The Veteran asserts that they resulted from riding atop APCs in service. 3. Schedule the Veteran for a VA infectious diseases examination. The claims folder must be reviewed in conjunction with the examination; if the examiner does not have access to the complete electronic record, relevant documents must be printed and supplied for review. Following review of the service treatment records, the examiner must opine as to whether it is at least as likely as not (a probability of 50 percent or greater) that the Veteran had a malaria infection in service, as reflected in complaints of body aches, fever, and malaise. The examiner must then identify any current residuals of manifestations of such, if any. 4. Schedule the Veteran for a VA skin/scars examination. The claims folder must be reviewed in conjunction with the examination; if the examiner does not have access to the complete electronic record, relevant documents must be printed and supplied for review. The examiner must identify all current skin conditions of the left calf, and must clearly state which are at least as likely as likely as not (probability of 50 percent or greater) a manifestation of the service-connected left calf disability. Any scars and localized sensory changes must be addressed. 5. Forward the Veteran's electronic claims file to an appropriate VA clinician to provide an opinion as to the date of onset of the Veteran's prostate cancer. The examiner is requested to opine whether it is at least likely as not (50 percent or greater probability) that the prostate cancer manifested prior to the diagnosis on August 3, 2009, and, if so, was it manifested on May 4, 2007 (when the Veteran filed his claim for service connection) or on some other date. The opinion should include consideration of the presence of elevated PSA levels and whether such were an initial manifestation of the Veteran's prostate cancer. In this regard, the Court of Appeals for Veterans Claims has noted that "entitlement to benefits for a disability or disease does not arise with a medical diagnosis of the condition, but with the manifestation of the condition and the filing of a claim for benefits for the condition." DeLisio v. Shinseki, 25 Vet.App. 45, 56 (citing 38 U.S.C. § 5110(a). A complete rationale must be provided for the opinions proffered. 6. A full and complete rationale for any opinion expressed is required. If the examiner feels that the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). Jones v. Shinseki, 23 Vet. App. 382 (2010). 7. Review the claims file to ensure that all of the foregoing requested development is completed, and arrange for any additional development indicated. Then readjudicate the claims on appeal. If any of the benefits sought remain denied, issue an appropriate supplemental statement of the case and provide the Veteran and his representative the requisite period of time to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. The appellant has the right to submit additional evidence and argument on the 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 2014). ______________________________________________ S. S. TOTH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs