Citation Nr: 21067948 Decision Date: 11/08/21 Archive Date: 11/08/21 DOCKET NO. 14-21 941 DATE: November 8, 2021 ORDER Entitlement to a compensable rating for hemorrhoids is denied. Entitlement to service connection for residuals of early-onset menopause is granted. REMANDED Entitlement to an increased rating for migraines, rated as noncompensable prior to February 13, 2017 and 30 percent thereafter, is remanded. Entitlement to service connection for a right knee disorder is remanded. Entitlement to service connection for a left knee disorder is remanded. Entitlement to service connection for a right foot disorder is remanded. Entitlement to service connection for a left foot disorder is remanded. FINDINGS OF FACT 1. Throughout the period on appeal, the Veteran's hemorrhoids manifested as mild to moderate internal hemorrhoids without large or thrombotic hemorrhoids with excessive redundant tissue evidencing frequent recurrences, persistent bleeding, secondary anemia, fissures, an anal/perianal fistula, rectal stricture, impairment of rectal sphincter control, rectal prolapse or pruritus ani. 2. The Veteran's residuals of early onset-menopause is the result of her active duty service. CONCLUSIONS OF LAW 1. The criteria for entitlement to a compensable rating for hemorrhoids effective May 20, 2010 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.114, Diagnostic Code 7336. 2. The criteria for entitlement to service connection for residuals of early-onset menopause have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1980 to September 2004. This matter comes before the Board of Veterans' Appeals (Board) on appeal of separate rating decisions issued in May 2011 and August 2011 by Regional Offices (RO) of the Department of Veterans Affairs (VA). The Board previously remanded the instant matters in September 2019 for additional development. An August 2020 rating decision granted the Veteran's claim for service connection for vaginitis, nonpuerperal galactorrhea and anemia and assigned an initial rating for each disability. As this decision represents a full grant of the benefits sought with respect to these claims for service connection, such issues are no longer before the Board for consideration. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1977). 1. Entitlement to a compensable rating for hemorrhoids is denied. Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. 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. Reasonable doubt as to the degree of disability will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. It is permissible to switch diagnostic codes to reflect more accurately a claimant's current symptoms. See Read v. Shinseki, 651 F.3d 1296, 1302 (Fed. Cir. 2011). 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 concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disability. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Separate ratings can be assigned for separate periods based on the facts found - a practice known as "staged" ratings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no obligation to discuss, in detail, the extensive evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as it relates to the Veteran's claims. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran's hemorrhoids has been rated as noncompensable since May 20, 2010, pursuant to criteria listed in 38 C.F.R. § 4.114, Diagnostic Code 7336. Under this rating criteria, a noncompensable rating is awarded for mild or moderate hemorrhoids. Id. A 10 percent rating is awarded when and where the hemorrhoids are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. Id. Finally, a maximum 20 percent rating is awarded with evidence of persistent bleeding and with secondary anemia, or with fissures. Id. By way of background, the Veteran's claim for increased ratings for hemorrhoids was remanded on September 26, 2019 to associate missing treatment records with the claims file. This remand directive was successfully accomplished by the AOJ. See Stegall, supra; Medical Treatment Records (July 8, 2015) (rec'd Oct. 30, 2019 ). As of July 2015 when the Veteran duly sought treatment, she confirmed that despite requiring rectal suppositories one at a time three times daily, and also requiring one scoop of medical powder in water daily, her hemorrhoids presented without mention of any complications. Id. The Board has determined that a compensable rating for hemorrhoids is not warranted. A compensable rating is warranted when there are large or thrombotic irreducible hemorrhoids with excessive redundant tissue, evidencing frequent recurrences. A February 2017 VA examination found that the Veteran had mild to moderate internal hemorrhoids. Such symptomatology is contemplated in the zero percent rating criteria under Diagnostic Code 7336. The clinical evidence is negative for, and the Veteran has not alleged, large or thrombotic hemorrhoids with excessive redundant tissue evidencing frequent recurrences, persistent bleeding, secondary anemia, fissures, an anal/perianal fistula, rectal stricture, impairment of rectal sphincter control, rectal prolapse or pruritus ani. As such, a compensable rating is not warranted. The Board has considered whether a staged rating under Hart, supra, is warranted, however, the Board finds that her symptomatology has been stable throughout the period on appeal. Therefore, assigning a staged rating is not warranted. Further, neither the Veteran nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). The Board acknowledges the Veteran's statements that her hemorrhoid symptoms are more severe than evaluated. The Veteran is competent to report her symptoms and has presented credible statements in this regard. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). The Board finds, however, that neither the Veteran's statements nor medical evidence demonstrate that the criteria for higher ratings have been met. The Board also acknowledges that the Veteran's VA treatment records note complaints of and treatment for her hemorrhoids. However, these records do not address the specific rating criteria necessary to determine severity. In determining the actual degree of disability, the examination findings are more probative of the degree of impairment. Accordingly, the Board finds that the preponderance of the evidence is against a finding that a compensable rating for hemorrhoids is warranted, and the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. 2. Entitlement to service connection for residuals of early-onset menopause is granted. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service, even if the disability was initially diagnosed after service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be granted for any disease diagnosed after discharge, when all evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection is established evidence of (1) a current 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. 38 C.F.R. § 3.304. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Ultimately, the Board will be granting the claims for service connection for early-onset menopause in full on a direct basis; therefore, no discussion is required of other theories of service connection. The Veteran claims that her residuals of menopause first manifested shortly before her 2004 discharge from active duty. See VA Form 21-526 (rec'd May 20, 2010). With respect to early onset, the Veteran was [redacted] years old in 2004. See id. at Section II, Question No. 10. There is no serious dispute of this current disability. Meanwhile, the Veteran's service treatment records are replete with instances of medical care for vaginitis during active duty, see, e.g.: STR (Jan. 7, 1982; Feb. 27, 1989; Jan. 11, 2001; Apr. 14, 2003; June 24, 2003), at least one instance of menorrhagia in July 2001, see id. (July 12, 2001), and at least two instances of galactorrhea prior to discharge, see id. (Dec. 18, 2000; July 5, 2001). To the extent that they may represent in-service occurrence of early-onset menopause, the Board accordingly concedes the above in-service events. The last remaining element is whether there is a nexus between the twoin other words, whether it is at least 50 percent likely that the early-onset menopause occurred due to active duty service. As per a November 28, 2019 VA examination, the examiner concluded that this is at least 50 percent likely due to menopause in the year 2001. See VA Exam (Opinion) ( Nov. 28, 2019 ), at Page 2. The Board further notes in passing that the examination features an incorrect finding, in that despite a "no" answer, the claim was filed on or prior to May 12, 2018. See VA Exam (Nov. 26, 2019), at Page 7, "Historical Questions." To the extent that the Veteran's early-onset menopause might not impact her ability to work, this finding of fact is simply not relevant to service connection. Id. at Page 7, Question No. 18 ("Functional Impact"). See cf. SSOC (Aug. 24, 2020). There is no contrary opinion to contradict a conclusion that the Veteran's early-onset menopause was incurred during service and is entitled to service connection. See Mariano v. Principi, 17 Vet. App. 305 (2003). The claim must be granted, There is no remaining doubt to resolve. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. REASONS FOR REMAND 1. Entitlement to an increased rating for migraines, rated as noncompensable prior to February 13, 2017 and 30 percent thereafter, is remanded. In the September 2019 remand, the agency of original jurisdiction (AOJ) was instructed to obtain outstanding medical treatment records, including from Walter Reed Medical Center postdating April 2010. These records have been associated with the claims file. Some of these records, see, e.g.: Medical Treatment Record (rec'd Oct. 30, 2019), suggest that the Veteran's symptomatology may have become more severe since the most recent VA examination of record in February 2017. See id. at Pages 2 (May 20, 2016) ("migraine without aura, not intractable, without status migrainosus"), 4 (Mar. 12, 2018 (now with aura), 11 (June 2, 2015) (acknowledging headaches as of this date but without indicating prostrating), and 29 (Mar. 12, 2018) (indicating headaches three times per week, sometimes with light flashes, and manifesting in photophobia and nausea). The Board accordingly concludes that adjudication should be deferred, so that the Veteran may be afforded an updated VA examination and so that the Board can more accurately rate the disorder as it currently manifests. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Allday v. Brown, 7 Vet. App. 517 (1995). This claim is remanded. 2. Entitlement to service connection for a right knee disorder is remanded. 3. Entitlement to service connection for a left knee disorder is remanded. 4. Entitlement to service connection for a right foot disorder is remanded. 5. Entitlement to service connection for a left foot disorder is remanded. Examinations of the bilateral knees and feet were conducted in December 2019. Ultimately, the claims for service connection for the bilateral knee and feet disorders were denied as less than 50 percent likely attributable to service because a "[l]ong interval without evaluation, imaging, or treatment bilaterally." The Board concludes that these opinions are inadequate, in that a "[l]ong interval without evaluation, imaging, or treatment bilaterally" a barely conclusory statement that is not otherwise supported by a well-reasoned medical explanation. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2009); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion must support its conclusion with an analysis the Board can consider and weigh against contrary opinion."). The Board therefore concludes that the examinations are inadequate and that a remand is warranted. See Stegall v. West, supra. The matters are REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claims on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and her representative and afford her an opportunity to submit any copies in their possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Following the receipt of outstanding records, forward the Veteran's claims file to a qualified VA examiner to determine the current severity of the Veteran's migraines. The examiner should identify the nature and severity of all current manifestations of the Veteran's service connected migraines. Specifically, he or she should address the frequency and duration of any prostrating attacks, to include whether such result in severe economic inadaptability. He or she should also comment upon the functional impairment resulting from such disability. The examiner is specifically requested to address the relevance or lack thereof of the following evidence as pertaining to increased ratings for migraines: (a.) Medical Treatment Record (rec'd Oct. 30, 2019), at Page 2 (May 20, 2016) ("migraine without aura, not intractable, without status migrainosus"); (b.) Medical Treatment Record (rec'd Oct. 30, 2019), at Page 4 (Mar. 12, 2018 (now with aura), 11 (June 2, 2015) (acknowledging headaches as of this date but without indicating prostrating); (c.) Medical Treatment Record (rec'd Oct. 30, 2019), at Page 29 (Mar. 12, 2018) (indicating headaches three times per week, sometimes with light flashes, and manifesting in photophobia and nausea). A rationale for any opinion offered should be provided. 3. Following the receipt of outstanding records, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any currently present bilateral knee disorder and/or bilateral foot disorder. Any and all indicated evaluations, studies and tests deemed necessary by the examiner should be accomplished. The need for further in-person examination is left to the discretion of the examiner. Thereafter, the examiner is asked to furnish an opinion with respect to the following questions: (a.) Is at least as likely as not (50 percent or greater probability) that the Veteran's bilateral knee disorder had its onset during any period of service, or is otherwise related to such period of service? (b.) Is at least as likely as not (50 percent or greater probability) that the Veteran's bilateral foot disorder had its onset during any period of service, or is otherwise related to such period of service? A rationale should be provided for all opinions offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). (Continued on the next page) The medical opinion must support the conclusions reached with an analysis that is adequate to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Michael B. Engle, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.