Citation Nr: 18154520 Decision Date: 12/03/18 Archive Date: 11/30/18 DOCKET NO. 15-00 395A DATE: December 3, 2018 ORDER Entitlement to service connection for Crohn’s disease, alternately claimed as ulcerative colitis, inflammatory bowel disease, intestinal disease, and irritable bowel disease, due to exposure to herbicide agents or secondary to follicle center cell lymphoma, is denied. Entitlement to service connection for a bladder disorder, due to exposure to herbicide agents or secondary to follicle center cell lymphoma, is denied. Entitlement to service connection for strokes, due to exposure to herbicide agents or secondary to follicle center cell lymphoma, is denied. Entitlement to a rating higher than 50 percent for follicle center cell lymphoma with residual scarring and hypopigmentation is denied. Entitlement to an initial rating higher than 10 percent for anemia is denied. REFERRED The issues of entitlement to service connection for squamous cell carcinoma and hypothyroidism were raised in April and May 2017 correspondence. In August 2018, the Veteran submitted an application to reopen the claims of entitlement to service connection for an acquired psychiatric disorder, headaches, hypertension, and sleep apnea. These issues are referred to the agency of original jurisdiction. FINDINGS OF FACT 1. The preponderance of the most probative evidence is against finding that Crohn’s disease, ulcerative colitis, inflammatory bowel disease, intestinal disease, or irritable bowel disease, was demonstrated during or is related to the Veteran’s active duty service, including due to herbicide agent exposure, or that any of these disorders were caused or aggravated by service-connected follicle center cell lymphoma. 2. The preponderance of the evidence is against finding that a bladder disorder was demonstrated during or is related to the Veteran’s active duty service, including due to herbicide agent exposure, or that it has been caused or aggravated by service-connected follicle center cell lymphoma. 3. The preponderance of the evidence is against finding that the Veteran’s strokes were related to his active duty service, including due to herbicide agent exposure, or that they were caused or aggravated by service-connected follicle center cell lymphoma. 4. The Veteran’s follicle center cell lymphoma has been in remission for the entire period on appeal. 5. The current residuals of the Veteran’s follicle center cell lymphoma consist of three scars which are no larger than 0.8 centimeters by 0.5 centimeters, 1 centimeter by 0.5 centimeters, and 1 centimeter by 0.7 centimeters. The Veteran has also been found to have one scar that is adherent to the underlying tissue. 6. The Veteran has not been found to have visible or palpable tissue loss; gross distortion or asymmetry of three or more features or paired sets of features; six or more characteristics of disfigurement; any unstable scars; or three or more painful scars at any time during the appeal period. 7. The Veteran’s hemoglobin has not been found to be 8 grams (gm.)/100 milliliters (ml.) or less at any time during the appeal period. CONCLUSIONS OF LAW 1. Crohn’s disease, ulcerative colitis, inflammatory bowel disease, intestinal disease, and irritable bowel disease were not incurred or aggravated in service, they may not be presumed to have been so incurred, and they were not caused or permanently aggravated by a service-connected disability. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.307, 3.309, 3.310. 2. A bladder disorder was not incurred or aggravated in service, it may not be presumed to have been so incurred, and it was not caused or permanently aggravated by a service-connected disability. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.307, 3.309, 3.310. 3. Strokes were not incurred or aggravated in service, they may not be presumed to have been so incurred, and they were not caused or permanently aggravated by a service-connected disability. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.307, 3.309, 3.310. 4. The criteria for a rating higher than 50 percent for follicle center cell lymphoma with residual scarring and hypopigmentation of the skin have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.117, Diagnostic Code 7715, 4.118, Diagnostic Codes 7800, 7804. 5. The criteria for an initial rating higher than 10 percent for anemia have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.117, Diagnostic Code 7700. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1966 to December 1968, including service in the Republic of Vietnam. Service Connection The Veteran contends that he has a gastrointestinal/inflammatory bowel disease, a bladder disorder, and strokes which were either caused by exposure to herbicide agents while serving in the Republic of Vietnam or that have been caused or aggravated by service-connected follicle center cell lymphoma. As the Veteran served in the Republic of Vietnam during the Vietnam War, he is presumed to have been exposed to herbicide agents, including Agent Orange. See 38 C.F.R. § 3.307(a)(6)(iii). There are certain diseases that are presumed service connected in veterans exposed to Agent Orange, but this list of diseases does not include any of the Veteran’s gastrointestinal diagnoses, bladder disorder, or stroke. See 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307, 3.309. However, a claimant is not precluded from establishing service connection with proof of actual direct causation related to exposure to herbicide agents. See Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). To establish entitlement to service-connected compensation benefits, a veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). This permits service connection not only for a disability caused by a service-connected disability, but also for the degree of disability resulting from aggravation of a disability by a service-connected disability. See 38 C.F.R. § 3.310(b); Allen v. Brown, 7 Vet. App. 439, 448 (1995). Crohn’s Disease/Inflammatory Bowel Disease The Veteran contends that he has an inflammatory bowel disease that was caused by either exposure to herbicide agents, such as Agent Orange, or was caused by his service-connected follicle center cell lymphoma. A review of the service treatment records does not reveal any complaints, findings or diagnoses of Crohn’s disease, ulcerative colitis, inflammatory bowel disease, intestinal disease, or irritable bowel disease. At his December 1968 separation examination the Veteran’s abdomen was clinically evaluated as normal. The Veteran’s VA and private treatment records show continuous follow up for gastrointestinal problems throughout the appeal period, with diagnoses of Crohn’s disease, diverticulitis, ulcerative colitis, and irritable bowel syndrome. In February 2008, the Veteran reported having diarrhea for the past two months. A March 2008 colonoscopy with biopsy found that the Veteran had mild to moderately active universal ulcerative colitis and mild diverticulosis. The Veteran was diagnosed with active chronic colitis, and the physician noted that the histologic findings would be consistent with inflammatory bowel disease. On multiple medical visits in 2008-2009, the Veteran reported diarrhea and rectal bleeding, and a colon biopsy found moderately active ulcerative pancolitis. In February 2010, he was treated for diverticulitis and also diagnosed with universal ulcerative colitis. In May 2010, the Veteran presented with intermittent diarrhea and rectal bleeding. He reported that stress seemed to make the condition worse. A September 2010 CT scan of the abdomen found extensive diverticulosis. After reviewing all of the evidence of record, the Board finds that the preponderance of the most probative evidence is against finding that any of the claimed bowel/gastrointestinal disorder is related to service, including due to inservice exposure to herbicide agents, and against finding that such a disorder is caused or aggravated by his service-connected follicle center cell lymphoma The Veteran’s December 1968 separation examination does not indicate any bowel or bladder disorder, and the Veteran has not asserted that any inflammatory bowel disorder or gastrointestinal disorder had occurred in service. The earliest evidence of a diagnosis of ulcerative colitis is from 2008, which is many decades after the Veteran’s separation from service. In March 2012, a VA medical opinion was obtained to address the etiology of the Veteran’s gastrointestinal disorders. The examining nurse practitioner wrote that the Veteran’s colitis and intestinal disease was less likely than not related to treatment for lymphoma because there was no physiological basis on which to assert that it was caused by lymphoma according to a literature search. An August 2013 Disability Benefits Questionnaire from the Veteran’s physician stated that the appellant had Crohn’s disease, diarrhea, and anemia. He wrote that the Veteran had diarrhea and fatigue from Crohn’s disease. He indicated that the Veteran had lymphoma, but that it was “not related to Crohn’s.” The Veteran attended an additional VA examination in February 2017. The examiner stated that the Veteran had been diagnosed with ulcerative colitis and Crohn’s disease, but that his most likely diagnosis was Crohn’s disease. The examiner stated that the Veteran’s service treatment records were silent for a chronic intestinal condition, and that this condition has not been shown to be associated with herbicide exposure. The examiner wrote that the etiology of Crohn’s disease was not well understood, but there was no theoretical basis to suspect Crohn’s disease was caused by the Veteran’s remote history of lymphoma or any treatment thereof or that it was aggravated by Veteran’s lymphoma, anemia, or scars. In June 2018, an expert medical opinion was obtained through the Veterans Health Administration regarding the etiology of the Veteran’s inflammatory bowel disease. The physician expert examiner stated that the etiology of pathogenesis of inflammatory bowel disease, including Crohn’s disease, ulcerative colitis, or indeterminate colitis, was not well understood, but there was insufficient medical evidence to identify any specific causative events, exposures, or agents. He wrote that there was no evidence indicating that herbicide agent exposure increased the risk of developing inflammatory bowel disease, and that in fact service in Vietnam has been associated with a decreased risk of developing inflammatory bowel disease. This physician also wrote that a previous history of cancer, in particular lymphoma, and radiation treatment have not been identified as a risk factor for developing inflammatory bowel disease. The expert reviewer wrote that the factors associated with the development of inflammatory bowel disease were age, ancestry, smoking, diet (in particular, a “Western” style diet), physical activity, infection, antibiotics, isotretinoin, and non-steroid anti-inflammatory drugs. He wrote that unless non-steroid anti-inflammatory drugs were used as part of the treatment for the Veteran’s lymphoma, then lymphoma therapy unlikely affected his bowel disease activity, and that while treatment for lymphoma can cause side effects including diarrhea, this effect would have been independent of actual inflammatory disease activity. The physician discussed a study which found that hormonal therapy for cancer may increase the risk of inflammatory bowel disease reactivation, but stated that the Veteran had not received hormonal therapy, and thus treatment for his lymphoma did not impact his inflammatory bowel disease activity. He also wrote that immunosuppression was not a risk factor for developing inflammatory bowel disease, as inflammatory bowel disease was thought to be an overactive gut immunity, and thus treatment for inflammatory bowel disease actually suppressed the immune system, and some treatments used to treat cancer are also effective in treating inflammatory bowel disease. The Board finds these medical opinions to be highly probative medical evidence against finding that the Veteran’s inflammatory bowel disease/gastrointestinal disorder is related to herbicide exposure in service and against finding that it was caused or aggravated by his service-connected lymphoma. Both the February 2017 VA examiner and the June 2018 expert medical opinion discussed how exposure to herbicide agents have not been found to increase the risk of inflammatory bowel disease. The June 2018 opinion noted that service in Vietnam actually correlated to a decreased risk for inflammatory bowel disease. The June 2018 expert opinion also discussed at length what the different risk factors for inflammatory bowel disease were, and found that radiation treatment for lymphoma was not something that would increase the risk of such a disorder. He wrote that suppression of the immune system due to lymphoma would not cause the development of inflammatory bowel disease, as this was due to overactive gut immunity. While the June 2018 VA examiner did not specifically use the language of whether the Veteran’s inflammatory bowel disease was caused or aggravated by lymphoma, his comprehensive medical opinion clearly explained that he found no relationship between these conditions, and no impact, including aggravation, from lymphoma onto the Veteran’s inflammatory bowel disease. See, e.g., Kittrell v. Shinseki, No. 08-3001, 2010 WL 4671873 (Vet. App. Nov. 10, 2010) (“a physician’s choice of language is not error where, as here, his opinion is unambiguous and sufficient to comply substantially with the purpose for which it was sought.”). The Board finds that the February 2017 VA examiner and the June 2018 reviewing physician provided thorough and adequate rationale for their findings, and that together, these opinions provide very probative medical evidence which strongly weighs against the claim. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000); Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). The Veteran has also submitted letters from physicians stating that there was a nexus between the Veteran’s bowel inflammation and either Agent Orange or lymphoma, but these medical opinions do not provide adequate rationale for their findings. An April 2017 letter from Dr. R.S. stated that the Veteran’s “inflammatory disease is related to exposure to herbicides such as Agent Orange.” The doctor did not provide any explanation or clarify whether the inflammatory disease he was referring to was the Veteran’s chronic bowel inflammation, and this lack of explanation or rationale greatly reduces the probative value of this opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-304 (most of the probative value of a medical opinion comes from its reasoning; a medical opinion that contains only data and conclusions is accorded no weight). An April 2017 letter from Dr. S.B. stated that Agent Orange has been associated with lymphoma, and lymphoma “has an association” with irritable bowel disease and Crohn’s disease. He then stated that if the Veteran’s lymphoma was “felt to be due to Agent Orange exposure, then it is possible to assume that the lymphoma (due to agent orange exposure) increased his risk for [C]rohn’s.” In April 2017, Dr. M.A. wrote that it was “possible that Agent Orange exposure may have been a contributing trigger for his Crohn’s disease.” These letters state only that it is possible that the Veteran’s herbicide agent exposure increased his risk for inflammatory bowel disease/Crohn’s disease, but they do not explain why this exposure would cause the development of such a disease or identify any research which supports this finding. As they only indicate that such increased risk was “possible,” these opinions are highly speculative, and this further negates the legal adequacy of the opinions. See Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) (explaining that medical evidence which merely indicates that an alleged disorder may be related to service is too speculative to establish the presence of any such relationship); Obert v. Brown, 5 Vet. App. 30, 33 (1993) (medical opinions that are speculative, general, or inconclusive in nature cannot support a claim). The Veteran has also written that he was prescribed antibiotics and non-steroid anti-inflammatory drugs for the treatment of his chronic inflammatory disease over a long period of time, and that this treatment aggravated his bowel disorders. While the June 2018 expert examiner wrote that antibiotics and non-steroid anti-inflammatory drugs can aggravate inflammatory bowel disease, these assertions do not support a finding that the Veteran’s lymphoma contributed to inflammatory bowel disease, as these medications were not prescribed in conjunction with any service-connected disability, and the prescription of these medications for a nonservice-connected disorder does not provide any evidence in favor of the Veteran’s claim. The Veteran’s medical records do not indicate that his lymphoma was treated with any of the risk factors identified by the June 2018 expert examiner, including hormones, isotretinoin, or non-steroid anti-inflammatory drugs. Further, the June 2018 reviewing physician specifically stated that the Veteran’s radiation therapy would not have led to inflammatory bowel disease. While the Veteran may believe that his gastrointestinal and inflammatory bowel problems were caused by his exposure to Agent Orange in service or was caused by his follicle center cell lymphoma, his statements on the etiology of his condition are less probative than the findings of qualified, expert medical examiners. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465, 470 (1994). In this case, the Veteran’s assertions are not probative medical evidence towards such a complex question as the etiology of inflammatory bowel disease, and they are outweighed by the most probative medical opinions of the VA and expert medical examiners. The Board therefore finds that the Veteran’s lay statements and the positive nexus statements he has submitted are greatly outweighed by the negative medical evidence of record, especially the February 2017 VA examiner’s opinion and the June 2018 expert medical opinion. In sum, the evidence preponderates against finding entitlement to service connection for Crohn’s disease, ulcerative colitis, inflammatory bowel disease, intestinal disease, or irritable bowel disease. The preponderance of the competent and probative medical evidence shows that the Veteran has been given various diagnoses of gastrointestinal/inflammatory bowel disorders, but no such disorder is related to service, including due to exposure to herbicide agents, and no such disorder is caused or aggravated by his service-connected follicle center cell lymphoma disorder or medication prescribed for the treatment of a service-connected disorder. The preponderance of the probative and competent evidence therefore weighs against the claim. The claim is denied. In reaching this determination, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the appellant’s claim, the doctrine is not for application. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990).   Bladder Disorder The Veteran claims that he has a bladder disability that is related to either Agent Orange exposure or his service-connected lymphoma, and has stated that evidence shows that bladder cancer is caused by Agent Orange. In September 2011, the Veteran wrote that the inflammation in his colon had created connections between his bladder and intestines. The Veteran has also reported that he has urge incontinence and often does not make it to the bathroom in time. The Veteran reported that he had been told by his urologist that the mass in his bladder was likely a benign lesion. Throughout 2009, the Veteran was treated for benign prostatic hyperplasia with intermittent bladder neck obstruction, although he denied any significant urination difficulties. Treatment in 2010 for kidney stones also noted that the Veteran had mild lower urinary tract symptoms and a questionable bladder abnormality. In September 2011, the Veteran reported a history of recurring urinary tract infections. He was found to have a fistula in his bladder, which could be related to his irritable bowel disease. A CAT scan showed thickening of the dome of the bladder with a piece of small intestine adjacent to the inflamed dome of the bladder suspicious for enterovesical fistula. A June 2016 ultrasound found a soft tissue mass in the bladder. While the evidence demonstrates that the Veteran has a current bladder disorder the preponderance of the medical evidence indicates that his disability is not related to service, including due to exposure to herbicide agents, and it is not caused or aggravated by his service-connected follicle center cell lymphoma. A March 2012 VA medical opinion stated that the Veteran’s bladder condition was less likely than not related to treatment for lymphoma because there was no physiological basis on which to assert that it was caused by lymphoma according to a literature search. At a February 2017 VA examination, the Veteran reported having a mass on his bladder, but stated that it had not yet been biopsied, because his urologist informed him biopsy was not urgent and a benign lesion was suspected. The VA examiner wrote that the Veteran’s bladder mass would have to be biopsied to determine the diagnosis, but that if there was malignancy in the bladder, there was no evidence that bladder cancer was associated with Agent Orange exposure unless it was an extension of prostate cancer in the bladder. The February 2017 examiner also stated that the Veteran’s service treatment records were silent for any voiding dysfunction or bladder mass, and that these conditions have not been shown to be associated with herbicide exposure. He concluded that there was no theoretical basis to find that a voiding dysfunction was caused or aggravated by the Veteran’s service-connected disabilities. These medical opinions accurately represent the Veteran’s medical history and diagnoses. They contain an adequate rationale to support their findings. The March 2012 VA examiner found no relationship between the Veteran’s bladder disorder and his lymphoma, and the February 2017 VA examiner found that the Veteran’s bladder disorder was not related to service or exposure to herbicide agents. There are no other contradictory medical opinions of record, and the Veteran has not indicated that he has ever been told by a medical professional that his bladder disorder was caused by exposure to Agent Orange or by his lymphoma. The Board has considered the lay statements of the Veteran, but as a lay person, his assertions that his bladder disorder was caused by exposure to herbicide agents such as Agent Orange or by his service-connected lymphoma, are less probative than the findings of the qualified, expert medical examiners. Jandreau, 492 F.3d at 1377. The Board therefore finds that the Veteran’s lay statements are greatly outweighed by the negative VA examination opinions of record. While the Veteran has stated that medical evidence shows that bladder cancer is caused by Agent Orange, and while the February 2017 examiner noted that prostate cancer that had moved into the bladder could be related to herbicide agent exposure, the Veteran has not, at any time, been found to have prostate cancer. The Veteran has been found to have a fistula and lesion which is likely benign, and in the absence of any diagnosis of bladder cancer or prostate cancer, entitlement to service connection is not warranted. The Veteran has also argued that his bladder disorder is secondary to his inflammatory bowel disorder. As noted above, entitlement to service connection for Crohn’s disease, alternately claimed as ulcerative colitis, inflammatory bowel disease, intestinal disease, and irritable bowel disease, has been denied. Hence, entitlement to secondary service connection for a bladder disorder cannot be granted as a matter of law. See 38 C.F.R. § 3.310; Sabonis v. Brown, 6 Vet. App. In sum, all of the probative medical evidence of record weighs against finding that the Veteran has a bladder disorder which is related to service or exposure to herbicide agents, and the evidence is against finding that a bladder disorder was caused or aggravated by his service-connected follicle center cell lymphoma. Because the preponderance of the probative and competent evidence weighs against the claim, the claim is denied. The Board has again considered the doctrine of reasonable doubt, but the preponderance of the evidence is against the appellant’s claim. See Gilbert, 1 Vet. App. 49. Strokes The Veteran contends that he has had strokes which were the result of exposure to Agent Orange and to developing non-Hodgkin’s lymphoma. He wrote in October 2012 that treatment for lymphoma and for immune system issues, including the use of steroids, were direct inputs to his stroke event in 2011, and that his stroke had no other identifiable trigger. The Board has reviewed all of the evidence of record, but finds that while the Veteran has had a stroke, there is no medical evidence linking his stroke to service or to a service-connected disability. Thus, service connection must be denied. In November 2011, the Veteran suffered left-sided hemiplegia of sudden onset. At a VA follow-up evaluation, he was walking normally and now had normal speech. Arm weakness was improving. At a March 2012 VA examination, the Veteran reported that he was told that he had no reason for his recent cardiovascular accident except for a possible vasculitis caused by his pro-inflammatory conditions. At a February 2017 VA examination, the Veteran reported having a stroke in November 2011 which resulted in left hemiparesis and slurred speech, but which he made a good recovery from afterwards. He stated that he had another stroke in January 2017 and was hospitalized at Piedmont Medical Center and then transferred to Presbyterian Hospital in Charlotte. He complained of generalized weakness and mild left hemiparesis which had improved. The examiner opined that the Veteran’s strokes were less likely than not related to a service-connected condition, stating that there was no theoretical basis to suspect strokes had been caused or aggravated by the Veteran’s remote history of lymphoma or any treatment thereof. The February 2017 VA medical opinion provides highly probative medical evidence which weighs against the Veteran’s claim. The VA examiner’s medical opinion accurately represents the evidence of record and the Veteran’s medical history, and it contains adequate explanation and rationale for its findings. The Veteran has not indicated that he has ever been told by a medical professional that strokes were caused by either exposure to Agent Orange or his lymphoma. There are no medical opinions of record which come to a different conclusion regarding the etiology of the Veteran’s strokes. Further, there is no other evidence indicating that the Veteran’s strokes could be related to service or to a service-connected disability. The Board has considered the lay statements of the Veteran, but as was discussed above, the Veteran is a lay person, and his assertions that his strokes were caused by exposure to herbicide agents such as Agent Orange or by his service-connected lymphoma are less probative than the highly probative findings of the VA examiner. See Jandreau, 492 F.3d at 1377. All of the probative medical evidence of record weighs against finding that the Veteran’s strokes were related to service or exposure to herbicide agents, or that they were caused or aggravated by his service-connected follicle center cell lymphoma. Because the preponderance of the probative and competent evidence weighs against the claim, the claim is denied. The preponderance of the evidence is against the Veteran’s claim, and the doctrine of reasonable doubt is not applicable. See Gilbert, 1 Vet. App. 49. Follicle Center Cell Lymphoma The Veteran contends that his follicle center cell lymphoma with residual scarring and hypopigmentation of the skin warrants a rating higher than 50 percent. The Veteran wrote in September 2011 that the scars on his head feel hot, itch, and were uncomfortable and sometimes painful. In a separate statement, the Veteran wrote that he felt his disease was “active permanent,” because he was required to have regular blood work done, regular CAT scans, and regular doctor’s visits, even though his disorder is in a “watch and wait” status. In February 2012, he reported that his lymphoma had increased and that he now had more lymph nodes. In a February 2009 rating decision, the Veteran was granted entitlement to service connection for status post follicle center cell lymphoma and assigned a noncompensable rating, effective July 29, 2007. In a December 2009 rating decision, the Veteran was assigned a 100 percent rating from July 29, 2007, due to the disease being active, and an evaluation of 50 percent, effective February 1, 2008. On June 3, 2011, the Veteran submitted a claim for an increased rating for status post follicle center cell lymphoma. The Veteran was subsequently assigned a separate 10 percent rating for a painful facial scar associated with follicle center cell lymphoma, effective June 3, 2011. Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. Where there is a question as to which of two evaluations shall be applied, the higher evaluations will be assigned if the disability more closely approximates the criteria required for that rating. 38 C.F.R. § 4.7. The Veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is or primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the question for consideration is the propriety of the initial rating assigned, evaluation of the medical evidence since the effective date of the grant of service connection to consider the appropriateness of a “staged rating” (i.e., assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson v. West, 12 Vet. App. 199, 126 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran’s status post follicle center cell lymphoma is rated under Diagnostic Codes 7715-7800. Diagnostic Code 7715 states that non-Hodgkin’s lymphoma warrants a 100 percent rating with active disease of during a treatment phase. The note accompanying this diagnostic code further instructs that the 100 percent rating shall continue beyond the cessation of any surgical, radiation, antineoplastic chemotherapy or other therapeutic procedures. Six months after discontinuance of such treatment, the appropriate disability rating shall be determined by mandatory VA examination. If there has been no local recurrence or metastasis, the condition should be rated based on residuals. 38 C.F.R. § 4.117, Diagnostic Code 7715. The evidence of record clearly shows that the Veteran’s lymphoma is in remission, and has been throughout the entire period on appeal. In April 2007, the Veteran was diagnosed with follicle center cell lymphoma in the scalp. He underwent successful radiation treatment and removal of the cancerous lesions. The Veteran attended a VA examination in September 2011. The Veteran reported that when lesions had been discovered on his scalp, he had to undergo multiple radiation treatments for lymphoma. The Veteran reported having symptoms of weakness, easy fatigability, needing extra sleep, light-headedness, shortness of breath, dyspnea on mild exertion, intermittent tachycardia, and six syncopal episodes in the prior two years. The examiner indicated that the Veteran’s treatment had completed in 2007, and that he was currently in watchful waiting status. The examiner indicated that continuous medication was not required for treatment of the Veteran’s condition, and the condition was currently in remission. A March 2012 VA medical opinion indicated that the Veteran was taking a multi-vitamin with iron and that his condition was in watchful waiting status. The examiner indicated that the Veteran’s lymphoma treatment had completed, and he was currently in watchful waiting status. The Veteran most recently attended a VA examination in February 2017. The examiner found no current symptoms associated with the Veteran’s lymphoma, which was in remission. His treatment was completed, and he was currently in watchful waiting status. There were no benign or malignant skin neoplasms, and no other manifestations of a skin disorder. The examiner indicated that the Veteran had undergone surgical excision of cutaneous lymphoma and radiation therapy in 2007. The Veteran believes that he should be assigned a 100 percent rating for lymphoma, despite being in remission, because he is still required to have regular check-ups and tests in case his lymphoma returns. The Board acknowledges that the Veteran is not free from the fear that his lymphoma may recur and that that this requires diligence, but the rating criteria under 38 C.F.R. § 4.117, Diagnostic Code 7715 only allow for a 100 percent rating when the disease is active or currently being treated. A higher rating therefore cannot be assigned under Diagnostic Code 7715. The Board therefore can consider only the residuals of the Veteran’s lymphoma, which have been found to be scars from the lesions removed from his head. A December 2009 rating decision assigned the Veteran a 50 percent rating, effective February 1, 2008, due to visible or palpable tissue loss and either gross distortion or asymmetry of two features of the head with four or five characteristics of disfigurement. Under Diagnostic Code 7800, governing scars of the head face or neck, a 10 percent rating is warranted for scars of the head, face, or neck with one characteristic of disfigurement. A 30 percent rating is warranted when there is visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features; or with two or three characteristics of disfigurement. A 50 percent rating is warranted when there is visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features; or with four or five characteristics of disfigurement. An 80 percent rating is warranted when there is visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features; or with six or more characteristics of disfigurement. 38 C.F.R. § 4.118, Diagnostic Code 7800. The eight characteristics of disfigurement are: 1) a scar of 13 or more centimeters in length; 2) a scar at least 0.6 centimeters wide at the widest part; 3) elevated or depressed scar surface contour on palpation; 4) scar adherent to underlying tissue; 5) hyper- or hypopigmentation in an area exceeding 39 square centimeters; 6) abnormal skin texture (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches; 7) missing underlying soft tissue in an area exceeding 39 square centimeters; and 8) indurated and inflexible skin in an area exceeding 39 square centimeters 38 C.F.R. § 4.118, Diagnostic Code 7800, Note 1. Disabling effects other than disfigurement associated with the individual scar of the head, face or neck, such as pain, instability and residuals of associated muscle or nerve injury, are to be rated separately under the appropriate diagnostic code. Id. at Note 4. In this case there is no evidence that a rating higher than 50 percent for follicle center cell lymphoma with residual scarring and hypopigmentation of the skin is warranted. At the September 2011 VA examination, the Veteran was noted to have a painful or unstable scar. The Veteran had a scar on the top of his head to the left of midline which was .8 centimeters by .5 centimeters and two scars on the top of the head to the right of midline which were 1 centimeter by .5 centimeters and 1 centimeter by .7 centimeters. All three scars had hypopigmentation. The third scar was adherent ot the underlying tissue, and the Veteran stated that it felt “throbbing and hot,” especially in hot weather. There was no gross distortion or asymmetry of facial features or visible or palpable tissue loss. The scars did not result in any limitation of function. At the February 2017 VA examination, the Veteran had two hypopigmented scars on the crown of his head which were pruritic at times. The scars were 0.7 by 0.5 centimeters and 0.7 by 0.4 centimeters. The scars were not painful or unstable, and there was no elevation, depression, adherence to underlying tissue, missing underlying soft tissue, or gross distortion or asymmetry of facial features. The scars did not cause any limitation of function. The evidence therefore shows that the Veteran has three scars which are at least 0.6 centimeters wide and which were found by the September 2011 VA examiner to all be hypopigmented. These whose areas did not exceed 39 centimeters. The September 2011 examiner also found one scar adherent to the underlying tissue. This constitutes a finding of four characteristics of disfigurement, and is the basis of the award of a 50 percent rating under Diagnostic Code 7800. For a rating of 80 percent, the Veteran must have visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features, have six or more characteristics of disfigurement. 38 C.F.R. § 4.118, Diagnostic Code 7800. As there is no evidence at any time of any further disfigurements than those found on examination, and no assertions from the Veteran that he has any further disfigurement that was not considered, the assignment of a rating higher than 50 percent under Diagnostic Code 7800 is not warranted. The Board also notes that a separate 10 percent rating was also assigned in September 2012 for a painful scar under 38 C.F.R. § 4.118, Diagnostic Code 7804. Note (3) to Diagnostic Code 7804 states that scars evaluated under Diagnostic Code 7800 can also receive a separate evaluation under this criteria. While the Veteran has not appealed the evaluation assigned under this separate rating, the Board has nonetheless considered whether a higher rating can be assigned under this diagnostic code. The Veteran has reported that one of his scars is sometimes painful. Under Diagnostic Code 7804, a 10 percent rating is warranted when a veteran has one or two scars that are unstable or painful. Id. A 20 percent rating is warranted when there are three or four scars that are unstable or painful. There is no evidence that the Veteran has had more than one painful scar at any time during the period on appeal, or that his scar has been both painful and unstable. There is therefore no indication that any higher rating related to the Veteran’s lymphoma residuals can be assigned under any other diagnostic codes. The Board has considered the Veteran’s lay statements regarding his symptomatology, such as his statements regarding needing to have regular testing and check-ups. In determining the actual degree of disability, however, objective examination is more probative of the degree of the Veteran’s functional impairment, and there is no clinical evidence indicating that the appellant has any further functional impairment due to his residuals of lymphoma. The Veteran has also alleged that he has symptoms of weakness, easy fatigability, headaches, light-headedness, and shortness of breath; however, the majority of his statements indicate that he is alleging that these symptoms are caused by his service-connected anemia. The Veteran’s medical treatment records and VA examinations also do not indicate that these symptoms are caused by status post lymphoma, and he has multiple other diagnoses to which these symptoms have been attributed, including anemia. As the symptoms have already been contemplated in the Veteran’s evaluation for anemia, to assign an additional separate rating would be impermissible pyramiding. See 38 C.F.R. § 4.14. These symptoms are contemplated in the evaluation assigned for anemia, and are discussed further below. The preponderance of the evidence is against entitlement to an evaluation in excess of 50 percent for follicle center cell lymphoma with residual scarring and hypopigmentation of the skin. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 55. Anemia The Veteran contends that his service-connected anemia warrants an initial rating higher than 10 percent. The Veteran has written that his evaluation should be higher than 30 percent because he currently has symptoms of weakness, easy fatigability, headaches, light-headedness, and shortness of breath. The Veteran’s anemia is rated under Diagnostic Code 7700, and it is assigned a 10 percent evaluation. A 10 percent evaluation is assigned when there is hemoglobin of 10 gm./100 ml. or less, with findings such as weakness, easy fatigability, and headaches. 38 C.F.R. § 4.117, Diagnostic Code 7700. For a 30 percent evaluation to be warranted, there must be hemoglobin of 8 gm./100 ml. or less, with findings such as weakness, easy fatigability, headaches, lightheadedness, or shortness of breath. Id. At a VA examination in September 2011, the Veteran was noted to have anemia. He did not have thrombocytopenia or any complications requiring a transfusion of platelets or red blood cells. The Veteran reported symptoms of weakness, easy fatigability, light-headedness, shortness of breath, dyspnea on mild exertion, tachycardia, and syncope. Hemoglobin levels were 11.4 gm/100 ml. The Veteran reported having difficulties remaining awake at work due to his excessive fatigue. At a March 2012 VA examination, the Veteran was noted to require a multivitamin with iron due to anemia. The Veteran reported having fatigue and often falling asleep while working. A September 2012 VA medical opinion also indicated that the Veteran had weakness, easy fatigability, light-headedness, headaches, and syncope, and that he required a multi-vitamin with iron. An August 2013 Disability Benefits Questionnaire indicated that the Veteran had hemoglobin of 11.2 gm./100 ml. at an October 2012 test. The Veteran’s VA treatment records from 2016-2018 show multiple blood test results, but there were no results below 14.0 gm./100 ml. At a February 2017 VA examination, the Veteran reported that he was diagnosed with anemia in 2007 and that he had a recurrence in 2011. The Veteran reported that he continuously took Vitamin D. Laboratory blood testing was scheduled, but the Veteran did not show up for the testing. The examiner noted that the Veteran had a history of anemia, but there was no current evidence of anemia because he had failed to show for the blood testing. The examiner found no current symptoms associated with anemia. After reviewing all of the medical evidence, the Board finds that an initial rating higher than 10 percent is not warranted at any time during the appeal. While the Veteran reports symptoms of weakness, easy fatigability, headaches, lightheadedness, and shortness of breath, he has not at any time been shown to have hemoglobin of 8 gm./100 ml. or less. While the Veteran failed to show for laboratory testing at the February 2017 VA examination, his VA treatment records include recent blood test results from February 2018 with hemoglobin of 14.1 gm./100 ml. The Veteran has also submitted blood test results from April 2016 that show hemoglobin of 14.9 gm./100 ml. The Veteran has not indicated that any other blood test results have been performed during the appeal period which would show results allowing for a rating higher than 10 percent. In the absence of any evidence showing that the Veteran has had hemoglobin of 8 gm. /100 ml. or less, a higher rating cannot be assigned. The Board has taken into consideration the Veteran’s complaints of feeling tired and having shortness of breath and weakness, but these symptoms are contemplated by the 10 percent already assigned. The assignment of a higher rating requires clinical evidence of hemoglobin of 8 gm. /100 ml. or less, and the laboratory tests that have been conducted provide the most probative evidence regarding the severity of the Veteran’s anemia. The medical findings on examination are of greater probative value than the Veteran’s allegations regarding the severity of his anemia. Here, his functional impairment is adequately reflected by those medical findings. The preponderance of the evidence is therefore against entitlement to an evaluation in excess of 10 percent for anemia. The Board has again considered the benefit of the doubt doctrine, but in this case, it is not applicable. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 55. Lastly, the question of entitlement to referral for consideration of an extraschedular rating is neither an issue argued by the claimant nor reasonably raised by the record through evidence of the collective impact of the claimant’s service-connected disabilities. Yancy v. McDonald, 27 Vet. App. 484, 494 (2016). DEREK R. BROWN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Mary E. Rude, Counsel