Citation Nr: 18151865 Decision Date: 11/20/18 Archive Date: 11/20/18 DOCKET NO. 16-33 832 DATE: November 20, 2018 ORDER A rating of 10 percent for hemorrhoids from May 27, 2014 through May 13, 2016 is granted. A rating higher than 0 percent for hemorrhoids from May 14, 2016 is denied. REMANDED Entitlement to service-connection for a left knee condition is remanded. Entitlement to service-connection for right wrist carpal tunnel syndrome is remanded. Entitlement to service-connection for left wrist carpal tunnel syndrome is remanded. REFERRED On her July 2016 VA Form 9, the Veteran indicated she suffers from impairment of sphincter control as secondary to her hemorrhoid surgery. As the issue has not been adjudicated by the RO and appealed to the Board, the issue is referred to the RO for appropriate development.   FINDINGS OF FACT 1. From May 27, 2014 through May 13, 2016, the Veteran’s hemorrhoid condition was manifested by numerous external hemorrhoids that were painful, swollen, and caused occasional bleeding, for which she underwent a hemorrhoidectomy in November 2014. 2. VA examination dated May 14, 2016 showed that she did not have hemorrhoids. CONCLUSIONS OF LAW 1. The criteria for a 10 percent rating for hemorrhoids are satisfied from May 27, 2014 through May 13, 2016. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.114, Diagnostic Code 7336 (2017). 2. The criteria for a rating higher than 0 percent for hemorrhoids are not satisfied. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.114, Diagnostic Code 7336 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from January 2007 to January 2011. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a December 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Newnan, Georgia. Disability ratings are determined by applying the criteria set forth in the VA Schedule of Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating many accurately reflect the elements of disability, 38 C.F.R. § 4.2 (2017); resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3 (2017); where there is a questions as to which of two evaluations apply, assigning a higher of the two where the disability pictures more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person’s ordinary activity, 38 C.F.R. § 4.10 (2017). See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Pursuant to Diagnostic Code 7336, a noncompensable (zero percent) disability rating is warranted where the hemorrhoids are found to be mild or moderate in nature. A 10 percent disability rating is warranted where the hemorrhoids are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. A 20 percent disability rating, the highest rating available pursuant to Diagnostic Code 7336, is warranted for hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. 38 C.F.R. § 4.114. The Veteran is currently in receipt of a noncompensable evaluation for her hemorrhoids from January 29, 2011. She submitted a claim for an increased rating in October 2014. Turning to the medical evidence of record, in September 2013, anemia was not found. The Veteran’s hemoglobin and iron levels were found to be normal in December 2013. The Veteran reported in May 2014 that her hemorrhoids had become more of an issue because she experienced incontinence. In August 2014, a rectal examination found no palpated internal hemorrhoids. It was noted the Veteran had numerous external hemorrhoids. It was also noted in August 2014 the Veteran had developed hemorrhoids from prior constipation and pregnancy. No bleeding was found. The Veteran was positive for swelling and pain. In September 2014, it was noted the Veteran took ibuprofen when experiencing severe hemorrhoidal pain. October 2014 treatment noted complaints of external hemorrhoids. The Veteran reported pain, inflammation, pressure, and some bleeding. The Veteran had a hemorrhoidectomy in November 2014. The Veteran underwent a VA examination in May 2016. No hemorrhoids were found. Anemia was not noted. On her July 2016 VA Form 9, the Veteran indicated she suffered from impairment of sphincter control as secondary to her hemorrhoid surgery. However, that issue is now referred to the RO for appropriate development as the issue has not been adjudicated by the RO and appealed to the Board. The Board finds that from May 27, 2014 to May 13, 2016, the Veteran’s hemorrhoids more nearly approximated the criteria for a 10 percent rating. As the Veteran’s claim was submitted in October 2014, a higher rating may be assigned up to one year prior to the date of claim, depending on when the evidence shows an ascertainable increase in severity of the disability. See Hart, 21 Vet. App. at 509 (noting that “the relevant temporal focus” is on “the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim”); 38 U.S.C. § 5110(b)(2) (2012); 38 C.F.R. § 3.400(o)(2) (2017). The VA treatment record dated May 27, 2014 shows the Veteran reporting that her hemorrhoids had become more of an issue. Indeed, she wound up undergoing a hemorrhoidectomy several months later, and the VA treatment records show that numerous hemorrhoids were found on examination, with the Veteran reporting swelling, inflammation, pain, and some bleeding. She sometimes had severe pain, for which she took Ibuprofen. The criteria for a 10 percent rating are met when hemorrhoids are thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. The VA treatment records do not describe the Veteran’s hemorrhoids, and so the Board cannot determine whether they had this presentation. By the time of the May 2016 VA examination, she had already undergone the hemorrhoidectomy. Nevertheless, given the severity of the Veteran’s symptoms, including pain, swelling, and some bleeding, as well as the fact that she had numerous hemorrhoids that were clearly recurrent and warranted an operation to remove them, the Board finds they more nearly approximated the criteria for a 10 percent rating for this time period. As the Veteran’s hemorrhoids were not manifested by persistent bleeding with secondary anemia, or with fissures, the criteria for a 20 percent rating were not more nearly approximated. The May 14, 2016 VA examination report shows that the Veteran no longer had hemorrhoids. Thus, the preponderance of the evidence shows that a 0 percent rating is warranted as of that date, and weighs against a higher rating. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service-connection for left knee condition is remanded. The Veteran received a VA examination and opinion in October 2014. No left knee diagnosis was found. The Veteran reported left knee pain. Despite the Veteran reporting pain, the examiner did not find any flare-ups. An MRI showed a small joint effusion and medial meniscus without any extension to the surface. The examiner provided a negative opinion based on no finding of a diagnosis. A March 2017 MRI of the left knee shows impressions including medial and lateral meniscus tears, small joint effusion with edema, and chondromalacia patella. The October 2014 VA opinion does not account for this diagnosed pathology. Moreover, the U.S. Court of Appeals for the Federal Circuit recently found that the term “disability” as used in 38 U.S.C. § 1110 “refers to the functional impairment of earning capacity, not the underlying cause of said disability,” and held that “pain alone can serve as a functional impairment and therefore qualify as a disability.” Saunders v. Wilkie, No. 2017-1466, 2018 U.S. App. LEXIS 8467 (Fed. Cir. Apr. 3, 2018). In light of Saunders and the March 2017 MRI, a new examination and opinion are needed. The Board also observes the Veteran’s June 2010 STRs note patellofemoral syndrome of the left knee as part of her problem list. Given this medical evidence from her STRs, a new medical exam and opinion are warranted. 2. Entitlement to service-connection for left and right wrist carpal tunnel syndrome is remanded. On her July 2016 VA Form 9, the Veteran states she experiences bilateral carpel tunnel syndrome due to high-impact exercises involving her forearms and hands and from firing machine guns and other weapons. Her CAPRI records note carpal tunnel syndrome as part of her problem list. March 2016 treatment records reflect a left open carpal tunnel release, and a May 2015 treatment record notes a history of right carpal tunnel surgery. The Veteran has not received an examination to determine the nature and etiology of her bilateral carpel tunnel syndrome. The matters are REMANDED for the following action: 1. Obtain any recent outstanding VA treatment records, and any outstanding private medical records identified by the Veteran as pertinent to her claim. 2. Arrange for an examination and medical nexus opinion for the Veteran’s left knee disability. All pertinent findings must be recorded in the report of examination. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any current left knee condition had its clinical onset during active service or is related to any in-service disease, event, or injury to include the Veteran’s June 2010 STRs noting patellofemoral syndrome of the left knee as part of her problem list. In determining whether the Veteran has a current left knee condition, the examiner is advised that pain resulting in functional impairment can constitute a disability for VA compensation purposes, regardless of whether there is diagnosed underlying pathology. The examiner must also consider the findings in the March 2017 MRI. 3. Obtain an examination and opinion for the Veteran’s bilateral carpal tunnel syndrome. All pertinent findings must be recorded in the report of examination. The examiner is asked to provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any current bilateral carpal tunnel syndrome had its clinical onset during active service or is related to any in service disease, event, or injury, to include the strain from high-impact exercises involving her forearms and hands and from firing machine guns and other weapons. J. Rutkin Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Denton, Buck