Citation Nr: 21008635 Decision Date: 02/17/21 Archive Date: 02/17/21 DOCKET NO. 11-11 725A DATE: February 17, 2021 ORDER An initial compensable evaluation for hemorrhoids prior to July 1, 2010, is denied. A 10 percent evaluation, but no higher, for hemorrhoids for the period of July 1, 2010 to April 18, 2019, is granted. An evaluation in excess of 20 percent for hemorrhoids for the period beginning on April 19, 2019, is granted. FINDINGS OF FACT 1. For the period prior to July 1, 2010, the Veteran’s hemorrhoids are shown to be more closely approximate to mild or moderate in severity, with evidence that such were reducible and without evidence of excessive redundant tissue, persistent bleeding, fissures, or secondary anemia. 2. From July 1, 2010 to April 18, 2019, the Veteran’s hemorrhoid symptomatology was more closely approximate to hemorrhoids with excessive redundant tissue, evidencing frequent recurrences, but did not include persistent bleeding with secondary anemia or fissures. CONCLUSIONS OF LAW 1. The criteria for an initial compensable evaluation for hemorrhoids for the period prior to July 1, 2010, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.114, Diagnostic Code 7336. 2. The criteria a 10 percent evaluation for hemorrhoids for the period of July 1, 2010 through April 18, 2019, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.114, Diagnostic Code 7336. 3. The criteria for a 20 percent evaluation for hemorrhoids for the period beginning April 19, 2019, but not before, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.114, Diagnostic Code 7336. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Navy from May 1985 to May 2005. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from an August 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). This rating decision granted entitlement to service connection for hemorrhoids and assigned a noncompensable rating effective December 16, 2008. During the pendency of the appeal, a November 2020 rating decision increased the disability rating to 20 percent effective from October 1, 2020. This matter was previously before the Board in July 2017, November 2018, and May 2020, at which point the claim was remanded for additional development. The most recent VA examination was performed in October 2020 and adequately addresses the directives from the May 2020 Board remand. Accordingly, the Board finds that there has been substantial compliance with the most recent Board remand. See Stegall v. West, 11 Vet. App. 268 (1998). The Board notes that the Veteran requested a hearing in his May 2011 VA Form 9. The Veteran was scheduled for a hearing, which was postponed twice at the request of the Veteran. In June 2016, he withdrew his request for hearing entirely. As such, there are no outstanding Board hearing requests. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C. § 1155. The evaluation of a service-connected disorder requires a review of a veteran’s entire medical history regarding that disorder. 38 U.S.C. § 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When a reasonable doubt arises regarding the degree of disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Evidence to be considered in an appeal from an initial disability rating was not limited to that reflecting the then current severity of the disorder. Fenderson v. West, 12 Vet. App. 119 (1999). In cases where an initially assigned disability evaluation has been disagreed with, it is possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Fenderson, 12 Vet. App. at 126-27; Hart v. Mansfield, 21 Vet. App. 505 (2007). Such separate disability ratings are known as staged ratings. When an unlisted condition is encountered, it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. See 38 C.F.R. § 4.20. The Veteran filed his initial claim for service connection for hemorrhoids on December 16, 2008. In an August 2009 rating decision, the Agency of Original Jurisdiction (AOJ) awarded service connection for the Veteran’s hemorrhoids, and assigned a noncompensable evaluation, effective December 16, 2008—the date of the Veteran’s claim. The Veteran timely appealed that assigned initial rating. During the pendency of the appeal, in a November 2020 rating decision, the AOJ increased the Veteran’s evaluation for his hemorrhoids disability to 20 percent disabling, effective October 1, 2020. Throughout the appeal period, the Veteran’s evaluations were assigned under Diagnostic Code 7336. Under Diagnostic Code 7336, hemorrhoids are assigned a zero percent rating where there is evidence of mild to moderate symptomatology. A 10 percent rating is warranted where there is evidence of large or thrombotic hemorrhoids, which are irreducible, with excessive redundant tissue, evidencing frequent recurrences. Finally, a 20 percent rating, the maximum schedular rating, is warranted where hemorrhoids are present, with persistent bleeding and secondary anemia, or with fissures. See 38 C.F.R. § 4.114, Diagnostic Code 7336. Words such as “mild,” “moderate,” “moderately severe,” and “severe” are not defined in the Rating Schedule or in the regulations. Consequently, the Board must evaluate all of the evidence to ensure that its decisions are “equitable and just.” 38 C.F.R. § 4.6. Turning to the evidence of record, the record reveals that the Veteran was treated for hemorrhoids with chronic bleeding during service in 2003 and again in February 2006. He was not treated again until July 1, 2010. In the interim, the Veteran was evaluated for hemorrhoids by a VA examiner in July 2009. He reported that hemorrhoids are constantly present and external hemorrhoids were observed by the examiner. However, the examiner characterized them as reducible without signs of thrombosis, excessive redundant tissue, or bleeding. The examiner also noted that there were no signs of fissures or significant anemia. In July 2010, the Veteran was seen by a private physician for complaints of possible hemorrhoids. He reported a 25-year history of rectal bleeding and a lump around the anus that he first noticed a week prior. On examination, he exhibited a soft flat anal tag, atypical white skin discoloration changes, and a crack in the middle. The Veteran’s complaints were attributed to the skin tag. His physician expressed concern over the findings, noting that skin changes could not be ignored and that a biopsy would be necessary if steroids did not reduce them. When the Veteran returned for follow up in August 2010, his physician noted that the skin discoloration had reduced but was still present. His physician also noted that the crack/fissure observed in the prior visit had resolved. The Veteran was advised to return in six to eight weeks for continued monitoring of the skin changes. In September 2017, the Veteran was evaluated again for hemorrhoids by a VA examiner, at which time he reported persistent bleeding for 25 years. Small or moderate external hemorrhoids as well as internal hemorrhoids were observed on examination. The examiner characterized them as reducible without signs of thrombosis, active bleeding, or fissures. The Veteran had another VA examination for hemorrhoids in April 2019, at which time he reported a 30-year history of bleeding with every stool. The examiner described the Veteran’s hemorrhoids as mild or moderate. However, the examiner did not perform an examination on the Veteran, noting that the Veteran preferred instead to provide a description. The Veteran disputed the VA examiner’s claim that he deferred an examination, noting in a May 2020 letter that the examining physician had made it clear that he did not desire to do a rectal examination. Finally, the Veteran was afforded another VA examination in October 2020. At this time, the Veteran reported that he started to have rectal bleeding approximately 30 years prior. He reported that he currently experiences intermittent bleeding with loose stools. The Veteran also reported having intermittent blood with loose stools, stinging in the shower and more than half the time when he wipes. A small internal hemorrhoid was observed on examination, which was classified as mild or moderate with persistent bleeding, but without evidence of thrombosis or secondary anemia. There was also no evidence of a fissure on examination. Based on the foregoing evidence, the Board finds that a 10 percent evaluation for the period of July 1, 2010 through April 18, 2019, and that a 20 percent thereafter, is warranted, although higher evaluations for the periods April 19, 2019 are not warranted. For the period prior to July 1, 2010, the evidence demonstrates that the Veteran had treatment for his hemorrhoids in 2006, but that there is a gap in treatment for hemorrhoids between 2006 and 2010. External hemorrhoids were observed during a July 2009 VA examination, but the examiner characterized them as reducible without signs of thrombosis, excessive redundant tissue, or bleeding. In short, the Veteran’s symptomatology prior to July 1, 2010 is more closely approximate to mild or moderate symptoms and hemorrhoids that were reducible without any evidence of redundant tissue or frequent recurrences. However, as noted in the July 1, 2010 private treatment records, the Veteran’s hemorrhoids were noted to have a soft flat anal tag, atypical white skin discoloration changes, and a crack in the middle. The Veteran’s complaints were attributed to the skin tag. In short, beginning in July 1, 2010, it appears that the Veteran’s hemorrhoid symptomatology was manifested by an anal skin tag demonstrable of excessive redundant tissue and frequent recurrences. Moreover, during that treatment and thereafter, the Veteran consistently indicated having continuous hemorrhoids with bleeding. Although it appears that the Veteran complained throughout the period of July 1, 2010 through April 18, 2019, of persistent bleeding, the evidence of record does not demonstrate any fissuring or secondary anemia. A higher evaluation, therefore, is not warranted throughout that period. On April 19, 2019, the Veteran underwent a VA examination, during which he did not receive an anal/rectal examination. The Board reflects that the Veteran’s reports of symptomatology in April 2019 were substantially similar to those reported in the October 2020 VA examination. Based on the examination findings in the October 2020 VA examination, VA has found that the Veteran’s hemorrhoids warranted a 20 percent evaluation due to the severity at that time. As no rectal examination was performed and as the Veteran’s reports were substantially similar in both the April 2019 and October 2020 examination, the Board finds that the evidence of record warrants a finding of 20 percent as of April 19, 2019—the date of the VA examination in which the Veteran stated that he did not decline a rectal examination and that the examiner did not want to provide such an examination. Accordingly, by resolving doubt in the Veteran’s favor, the 20 percent evaluation for the Veteran’s hemorrhoids is warranted as of April 19, 2019, but not prior to that date. See 38 C.F.R. §§ 4.7, 4.114, Diagnostic Code 7336. In so reaching that conclusion, the Board has appropriately applied the benefit of the doubt doctrine in this case. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. MARTIN B. PETERS Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Beech, 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.