Citation Nr: 21027071 Decision Date: 05/04/21 Archive Date: 05/04/21 DOCKET NO. 16-29 070 DATE: May 4, 2021 ORDER 1. Entitlement to a compensable rating for anemia prior to October 29, 2018, is denied. 2. Entitlement to a 10 percent rating, but no higher, for anemia from October 29, 2018, is granted. 3. Entitlement to a rating in excess of 30 percent for migraine headaches is denied. 4. Entitlement to service connection for major hair loss and balding, diagnosed as alopecia areata, is denied. 5. Entitlement to service connection for nerve damage of the right hand is denied. 6. Entitlement to service connection for nerve damage of the left hand is denied. 7. Entitlement to service connection for posttraumatic stress disorder (PTSD) is denied. REMANDED 8. Entitlement to service connection for rectal bleeding is remanded. FINDINGS OF FACT 1. Prior to October 29, 2018, the preponderance of the evidence is against finding that anemia was productive of hemoglobin of 10gm/100ml or less with findings such as weakness, easy fatigability, or headaches. 2. Anemia has been treated with continuous oral supplementation from October 29, 2018. 3. The preponderance of the evidence is against finding that migraine headaches manifest with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 4. The preponderance of the evidence against finding that major hair loss or balding, diagnosed as alopecia areata, had an onset in service, is otherwise related to service, to include the Veteran's service in Southwest Asia. 5. The preponderance of the evidence is against finding that nerve damage of the right hand had an onset in service, is otherwise related to service, to include the Veteran's service in Southwest Asia. 6. The preponderance of the evidence is against finding that nerve damage of the left hand had an onset in service, is otherwise related to service, to include the Veteran's service in Southwest Asia. 7. The preponderance of the evidence is against a finding that the Veteran has a diagnosis of PTSD in accordance with the DSM-5 during the pendency of his claim. CONCLUSIONS OF LAW 1. The criteria for entitlement to a compensable rating for anemia, prior to October 29, 2018, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.117, Diagnostic Code 7700 (2017) 2. The criteria for entitlement to a 10 percent rating, but not higher, for anemia have been met from October 29, 2018. 38 U.S.C. §§ 1155, 5107 (201); 38 C.F.R. § 4.117, Diagnostic Code 7700 (2017), 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.117, Diagnostic Codes 7716, 772023 (2020). 3. The criteria for entitlement to a rating in excess of 30 percent for migraine headaches have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8100 (2020). 4. The criteria for entitlement to service connection for major hair loss and balding, diagnosed as alopecia areata, have not been met. 38 U.S.C. §§ 1110, 1117, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.317 (2020). 5. The criteria for entitlement to service connection for nerve damage of the right hand have not been met. 38 U.S.C. §§ 1110, 1117, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.317 (2020). 6. The criteria for entitlement to service connection for nerve damage of the left hand have not been met. 38 U.S.C. §§ 1110, 1117, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.317 (2020). 7. The criteria for entitlement to service connection for PTSD have not been met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.304 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1989 to October 1989 and from January 1991 to March 1991, which included service on the USNS Comfort in the Persian Gulf. A videoconference hearing was scheduled in August 2019. The Veteran did not appear at the hearing. Thus, the hearing request is deemed withdrawn. 38 C.F.R. § 20.704(d). Increased Rating Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 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 the disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. The U.S. Court of Appeals for Veterans Claims (Court) has held that, in determining the present level of a disability for an increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. 1. 2. Entitlement to a compensable rating for anemia The Veteran is currently in receipt of a noncompensable rating for anemia under Diagnostic Code 7700. The Board has carefully reviewed the evidence of record and finds a compensable rating is denied. The reasons follow. Diagnostic Code 7700 provides that a 10 percent rating is assigned for anemia with a hemoglobin level of 10gm/100ml or less with findings such as weakness, easy fatigability, or headaches. A 30 percent rating is assigned for a hemoglobin level of 8gm/100ml or less, with findings such as weakness, easy fatigability, headaches, lightheadedness, or shortness of breath. A 70 percent rating is assigned for a hemoglobin level of 7gm/100ml or less, with findings such as dyspnea on mild exertion, cardiomegaly, tachycardia (100 to 120 beats per minute), or syncope (three episodes in the last six months). A 100 percent rating is assigned for anemia with a hemoglobin level of 5gm/100ml or less, with findings such as high output congestive heart failure or dyspnea at rest. A note to Diagnostic Code 7700 provides that complications of pernicious anemia, such as dementia or peripheral neuropathy, should be evaluated separately. 38 C.F.R. § 4.117, Diagnostic Code 7700 (2017). On October 29, 2018, VA issued a final rule revising 38 C.F.R. § 4.117, the portion of the VA Schedule for Rating Disabilities that addresses the hemic and lymphatic systems. The final rule updated medical terminology, added certain hematologic diseases, and provided detailed and updated criteria for evaluating conditions pertaining to the hematologic and lymphatic systems. The rule removed Diagnostic Code 7700 (anemia, hypochromic-microcytic and megaloblastic, such as iron-deficiency and pernicious anemia) and added separate diagnostic codes (Diagnostic Codes 77207723) for the four major types of anemia that are neither hereditary nor secondary (addressed under the diagnostic code for the causative condition). Because the rating criteria were changed during the appeal period, the old regulations are applicable both before and after the date of the change in regulations, and the new regulations are applicable only on or after their effective date. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003); VAOPGCPREC 7-2003. Under Diagnostic Code 7716, anemia requiring transfusion of platelets or red cells, on average, at least once per 12-month period; or infections recurring, on average, at least once per 12-month period, warrants a 30 percent rating. Anemia requiring transfusion of platelets or red cells, on average, at least once every three months per 12-month period; or infections recurring, on average, at least once every three months per 12-month period; or using continuous therapy with immunosuppressive agent or newer platelet stimulating factors warrants a 60 percent rating. Anemia requiring peripheral blood or bone marrow stem cell transplant; or requiring transfusion of platelets or red cells, on average, at least once every six weeks per 12-month period; or infections recurring, on average, at least once every six weeks per 12-month period, warrants a 100 percent rating. 38 C.F.R. § 4.117, Diagnostic Code 7716 (2019). Under Diagnostic Code 7720, iron deficiency anemia requiring intravenous iron infusions 4 or more times per 12-month period warrants a maximum 30 percent rating. 38 C.F.R. § 4.117, Diagnostic Code 7720. Under Diagnostic Code 7721, a folic acid deficiency requiring continuous treatment with high-dose oral supplementation warrants a maximum 10 percent rating. 38 C.F.R. § 4.117, Diagnostic Code 7721. Under Diagnostic Code 7722, for pernicious anemia and Vitamin B12 deficiency anemia, continuous treatment with Vitamin B12 injections, Vitamin B12 sublingual or high-dose oral tablets, or Vitamin B12 nasal spray or gel warrants a 10 percent rating; and an initial diagnosis requiring transfusion due to severe anemia, or if there are signs or symptoms related to central nervous system impairment, such as encephalopathy, myelopathy, or severe peripheral neuropathy, requiring parenteral B12 therapy, warrants a 100 percent rating. 38 C.F.R. § 4.117, Diagnostic Code 7722. Finally, under Diagnostic Code 7723, acquired hemolytic anemia requiring at least 2 but less than 4 courses of immunosuppressive therapy per 12-month period warrants a 30 percent rating. Acquired hemolytic anemia requiring immunosuppressive medication 4 or more times per 12-month period warrants a 60 percent rating. Acquired hemolytic anemia requiring a bone marrow transplant or continuous intravenous or immunosuppressive therapy warrants a 100 percent rating. 38 C.F.R. § 4.117, Diagnostic Code 7723. Under Diagnostic Code 7720, the Board finds the evidence supports a finding that the Veteran's anemia meets the requirements for a 10 percent rating from October 29, 2018, as the evidence supports a finding that the Veteran requires continuous treatment with oral supplementation for her iron deficiency anemia. Throughout the period on appeal, VA treatment records document that the Veteran takes a medication for iron replacement. VA examinations from March 2011 and April 2019 note that the Veteran takes iron supplements. In a February 2017 statement, the Veteran reported that she takes iron supplements four times per day. Thus, the Board finds the Veteran's anemia meets the criteria for a 10 percent rating under Diagnostic Code 7720 from October 29, 2018, the earliest date available for a rating under this diagnostic code. The Board has found that the Veteran meets the criteria for a 10 percent rating under Diagnostic Code 7720 from October 29, 2018, the date at which a rating under Diagnostic Code 7720 became available. However, the Board will still assess whether the Veteran's disability meets the criteria for a compensable rating prior to that date under Diagnostic Code 7700 or whether a rating in excess of 10 percent is warranted under Diagnostic Codes 7721, 7722, 7723 from October 29, 2018. Under the old rating criteria, Diagnostic Code 7700, the Board finds the preponderance of the evidence is against finding that the anemia has been productive of hemoglobin level of 10gm/100ml or less with findings such as weakness, easy fatigability, or headaches prior to October 29, 2018 or 8gm/100ml or less from October 29, 2018. February 2011 and April 2011 testing showed hemoglobin of 11.6gm/100ml. At a March 2011 VA examination, hemoglobin normal low value was documented as 12gm/100ml. In December 2011, August 2012, August 2013, May 2015, September 2016, December 2016, February 2017, May 2017, March 2018, July 2018, December 2018 hemoglobin was documented as 11.4 gm/100ml, 11.5gm/100ml, 12.2gm/100ml, 11gm/100ml, 11.9gm/100ml, 12.3gm/100ml, 11.6gm/100ml, 11.6gm/100ml, 10.4 to 12.8gm/100ml, 12.1gm/100ml, 11.1gm/100ml, respectively. Finally, at an April 2019 VA examination, hemoglobin was documented to be 12gm/100ml. While the record supports that the Veteran experiences symptoms of headaches, weakness, and easy fatigability, absent notations of a hemoglobin level of 10gm/100ml, these additional symptoms, on their own, are not sufficient to warrant a compensable rating. Thus, a compensable rating under Diagnostic Code 7700 is denied prior to October 29, 2018. 38 C.F.R. § 4.117, Diagnostic Code 7700 (2017). Additionally, the Veteran's 40 percent rating for fibromyalgia contemplates headaches as does the 30 percent rating for migraine headaches, which disability was granted as being associated with the anemia. Under Diagnostic Code 7716 and 7722, the Board finds that the preponderance of the evidence is against finding that the Veteran had transfusions of platelets or red blood cells at any point during the period on appeal. Additionally, the preponderance of the evidence is against a finding that the Veteran had severe anemia or had signs or symptoms related to the central nervous system impairment, such as encephalopathy, myelopathy, or severe peripheral neuropathy, requiring parenteral B12 therapy, Thus, a rating in excess of 10 percent under Diagnostic Code 7716 and 7722 is denied from October 29, 2018. Under Diagnostic Code 7721, the Board finds that a rating in excess of 10 percent is unavailable. Under Diagnostic Code 7723, the Board finds that the preponderance of the evidence is against finding that the Veteran required immunosuppressive therapy or medication at any point during the period on appeal. Thus, a rating in excess of 10 percent under Diagnostic Code 7723 is denied from October 29, 2018. Given the aforementioned analysis, the Board finds that a 10 percent rating, but no higher, is granted for anemia under Diagnostic Code 7720 from October 29, 2018. However, prior to October 29, 2018, a compensable rating for anemia is denied. 3. Entitlement to a rating in excess of 30 percent for migraine headaches The Veteran is currently in receipt of a 30 percent rating for migraine headaches under Diagnostic Code 8100. The Board has carefully reviewed the evidence of record and finds that a rating in excess of 30 percent for migraine headaches is not warranted. The reasons follow. At a March 2011 VA examination, the Veteran reported that she has headaches every day that lasted for four to seven hours. She reported that when she experiences a headache, she has to sit in a bed or dark room. In a November 2011 statement, the Veteran reported constant pain from migraines, describing it as 7 to 8 out of 10 on a daily basis. She reported that she has to isolate herself and hope the pain does not last all day, noting that this causes her to miss out on family time due to the pain. VA records from February 2013 document that she has typical migraines with minimal nausea, emesis, or fever, and in her August 2014 Notice of Disagreement, the Veteran reported experiencing migraines three times per week with symptoms of light and sound sensitivity, nausea, and blurred vision. In October 2015 VA treatment records, the Veteran reported experiencing migraines up to five days per week. A VA examination was conducted in April 2019. The Veteran was diagnosed with migraine headaches, and she reported that she was experiencing migraines three to five times per week that were triggered by bright lights, loud noises, and/or sudden stressors. The Veteran reported she treated her symptoms by lying down in a cool, dark place with a cold rag as well as with medication. She reported having gone to urgent care over the past two years due to migraine symptoms, but she denied going to the emergency room. The examiner documented pain, which the Veteran described as throbbing and constant pain that became sharp when she coughed or sneezed, alternated sides, and did not occur in a specific location. The examiner also documented that the Veteran reported symptoms of nausea, vomiting, sensitivity to light and sounds, and blurred vision. The symptoms were documented to last for less than a day. Ultimately, the examiner documented that migraines caused prostrating attacks once per month but were not very prostrating or prolonged attacks productive of severe economic inadaptability. Under Diagnostic Code 8100, a 10 percent rating is appropriate with characteristic prostrating attacks occurring on an average of one in two months over the last several months. A 30 percent rating is appropriate with characteristic prostrating attacks occurring on an average once a month over the last several months. 38 C.F.R. § 4.124a, Diagnostic Code 8100. A 50 percent rating is appropriate with very frequent, completely prostrating, and prolonged attacks productive of severe economic inadaptability. A noncompensable rating is warranted when attacks are less frequent than as required for a 10 percent rating. Id. Initially, the Board notes that while it is not bound by the VA examiners documentation that migraine headaches were not very prostrating or prolonged attacks productive of severe economic inadaptability, the Board finds the examiner's characterization to be highly probative evidence that the Veteran's headache symptoms do not rise to the level necessary for a 50 percent rating. Additionally, the Board notes that symptoms, though severe, are adequately compensated by the 30 percent rating as the Veteran experiences three to five headaches per week on average rather than more severe daily severe headaches. Furthermore, though the Veteran experiences prostrating attacks, a medical professional found that the prostrating attacks occurred once a month rather than more frequently. The most probative evidence of record shows that the Veteran's other headaches, which occur three to five days per week, are less severe as they last for less than a day and are not prostrating. Additionally, the Veteran's 40 percent rating for fibromyalgia contemplates headaches. Thus, at the present time, she has two, separate ratings that contemplate headaches, and the level of severity of her headaches are being compensated. As the preponderance of the evidence is against a finding that the Veteran experiences headaches that are very prostrating and prolonged attacks productive of severe economic inadaptability over the entirety of the period on appeal, the Board finds a rating in excess of 30 percent for migraine headaches is denied. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, 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. Service connection may 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). In addition, the Board notes that the Veteran served in the Southwest Asia theater of operations in support of Operation Desert Storm/Desert Shield. 38 C.F.R. § 3.317(e). Under those provisions, service connection may be established for objective indications of a chronic disability resulting from an undiagnosed illness or illnesses, provided that such disability (1) became manifest in service on active duty in the Armed Forces in the Southwest Asia theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2021; and (2) by history, physical examination, and laboratory tests cannot be attributed to a known clinical diagnosis. To fulfill the requirement of chronicity, the illness must have persisted for six months. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. 4. Entitlement to service connection for major hair loss and balding, diagnosed as alopecia areata The Veteran believes that she has major hair loss as a result of her service in Desert Storm. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claim for service connection for major hair loss and balding. The reasons follow. As to evidence of a current disability, a February 2004 VA examination report shows that the Veteran was diagnosed with alopecia areata. Therefore, the facts establish that the first element of a service-connection claim is met. The Board notes that the Veteran has a diagnosis of alopecia areata related to her hair loss. As the Veteran has a diagnosis for her hair loss symptoms, service connection based on 38 C.F.R. § 3.117 and the Veteran's service in Southwest Asia is not warranted. However, the Board will still analyze whether service connection can be granted for major hair loss and balding on another basis. As to evidence of a disease or injury in service, the service treatment records (STRs) do not show a disease or injury related to hair loss or alopecia areata during service. While the Board acknowledges that there does not appear to be records from the Veteran's period of service on the USNS Comfort, the Board notes that the evidence does not show that the hair loss began during or immediately after her return from service in Desert Storm. The earliest documentation in the claims file related to hair loss is within October 1994 treatment records in which it is noted that the Veteran had a previous instance of alopecia that had resolved. She did not have active alopecia at that time. Since the initial report in October 1994, the records continue to show that the Veteran has intermittent flare-ups of alopecia. It is not until March 2006 that treatment records document that the Veteran first reports that she has had symptoms of alopecia and hair loss since her service in Desert Storm, which the Board finds less credible given that in the numerous documentations of alopecia documented in contemporaneous medical records prior to March 2006, the Veteran did not assert that she had experienced symptoms since that time. Furthermore, when being seen for subsequent flare-ups of alopecia and hair loss in June 2014 the Veteran reported an onset in 1999 or 2000, which is many years after her discharge from her service in Desert Storm in 1991. Thus, the Board finds that the preponderance of the evidence of record is against finding that the Veteran had an onset of alopecia areata during her active service or in the months immediately following her discharge, and the facts do not establish that the second element of a service-connection claim is met. VA has not provided the Veteran with an examination or medical opinion in connection with the claim for service connection for alopecia areata. VA must provide a medical examination when there is (1) evidence of a current disability or persistent or recurrent symptoms of a disability (2) evidence establishing that an event, injury, or disease occurred in service, or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). As discussed above, the Board finds that the evidence does not show an event, injury, or disease occurred in service or that the disability may be associated with the Veteran's service. For a VA examination and/or medical opinion to be warranted, all the McLendon criteria have to be met, and at least one of the criteria is not met. Therefore, entitlement to a VA examination and/or medical opinion is not warranted for this service-connection claim. In reaching the above conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, that doctrine is not applicable where, as here, there is not an approximate balance of positive and negative evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Thus, the claim for service connection for major hair loss and balding, diagnosed as alopecia areata, is denied. 5. - 6. Entitlement to service connection for bilateral hand nerve damage The Veteran believes that she has numbness and tingling in her hands and fingers that had an onset following her service in Desert Storm. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claim for service connection for bilateral hand nerve damage. The reasons follow. As to evidence of a current disability, VA treatment records from March 2008 document a diagnosis of bilateral carpal tunnel syndrome, VA treatment records from August 2012 document a diagnosis of tendinitis of the bilateral hands. Therefore, the facts establish that the first element of a service-connection claim is met. The Board notes that the Veteran has a diagnosis related to her reported symptoms of tingling, numbness, and nerve damage in her bilateral hands. As the Veteran has a diagnosis for these symptoms, service connection based on 38 C.F.R. § 3.117 and the Veteran's service in Southwest Asia is not warranted. However, the Board will still analyze whether service connection can be granted for the bilateral hand nerve damage on direct and presumptive bases. As to evidence of a disease or injury in service, the STRs do not show a disease or injury related to the Veteran's bilateral hands during service. While the Board acknowledges that there does not appear to be records from the Veteran's period of service on the USNS Comfort, the Board notes that the preponderance of the evidence does not document that the Veteran's symptoms of numbness or tingling began during or immediately after her return from service in Desert Storm. The earliest documentation in the claims file related to symptoms in the hands is September 2005 VA treatment records that document that the Veteran reported experiencing numbness in both hands. The Board notes that this report is made approximately 14 years after the Veteran's discharge from active service. Furthermore, the claims file does not document that the Veteran reports an onset of symptoms during or immediately following active service, nor does she report an onset prior to September 2005. Thus, the Board finds that the preponderance of the most probative evidence of record is against finding that the Veteran had an onset of symptoms related to carpal tunnel syndrome or bilateral hand tendinitis during her active service or within one year following service discharge. Thus, the facts do not establish that the second element of a service-connection claim, a disease or injury in service, is met. Further, as the diagnosis of carpal tunnel syndrome was diagnosed more than one year following service discharge, service connection on a presumptive basis for a chronic disease is not warranted. VA has not provided the Veteran with an examination or medical opinion in connection with the claims for service connection for a bilateral hand disability. VA must provide a medical examination when there is (1) evidence of a current disability or persistent or recurrent symptoms of a disability (2) evidence establishing that an event, injury, or disease occurred in service, or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). As discussed above, the Board finds that the evidence does not show an event, injury, or disease occurred in service or that the disabilities may be associated with the Veteran's service. For a VA examination and/or medical opinion to be warranted, all the McLendon criteria have to be met, and at least one of the criteria is not met for these claims. Therefore, entitlement to a VA examination and/or medical opinion is not warranted for these service-connection claims. In reaching the above conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, that doctrine is not applicable where, as here, there is not an approximate balance of positive and negative evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Thus, the claim for service connection for bilateral hand nerve damage is denied. 7. Entitlement to service connection for PTSD The Veteran is service connected for major depressive disorder. However, the Veteran also asserts that she has a diagnosis of PTSD that such diagnosis should be added to her service-connected major depressive disorder. Service connection for PTSD specifically requires the presence of three particular elements: (1) a current medical diagnosis of PTSD; (2) medical evidence of a causal nexus between current symptomatology and a claimed in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor actually occurred. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claim for service connection for PTSD. Specifically, at the present time, the evidence does not support that the Veteran has a diagnosis of PTSD. The Veteran has been reporting experiencing a military sexual trauma since at least 2007. Even with her reporting such stressor, examiners did not diagnose PTSD during the appeal period or in close proximity to the appeal period. When she was examined in October 2017 for the service-connected major depressive disorder, the Veteran reported the in-service stressor to the examiner, which she described as a sexual assault while in the Navy. The examiner documented this fact in the examination report. However, when asked what psychiatric diagnosis was warranted, the examiner diagnosed major depressive disorder with anxious distress. When asked if the Veteran had more than one mental disorder diagnosed, the examiner responded, "No." Thus, even knowing that the Veteran reported an in-service sexual assault, the examiner did not diagnose PTSD. Thus, the Board finds that the Veteran's allegation of a military sexual trauma is already part of the service-connected major depressive disorder, as the October 2017 VA examiner diagnosed one psychiatric disorder for all the Veteran's psychiatric symptoms, which includes psychiatric symptoms related to the in-service stressor. Additionally, there are hundreds of pages of VA treatment records in the file, which show an "active problem" list of over 20 diagnoses, which does not include a diagnosis of PTSD, which is further evidence against a finding that the Veteran has PTSD in accordance with the DSM-5. For all these reasons, the Board finds the preponderance of the evidence is against a finding that the Veteran has a diagnosis of PTSD in accordance with the DSM-5 during the pendency of the claim, to include in close proximity to the claim. VA has not provided the Veteran with an examination or medical opinion in connection with this claim. VA must provide a medical examination when there is (1) evidence of a current disability or persistent or recurrent symptoms of a disability (2) evidence establishing that an event, injury, or disease occurred in service, or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). As discussed above, the Board finds that the evidence does not show a current disability outside of the service-connected major depressive disorder. For a VA examination and/or medical opinion to be warranted, all the McLendon criteria have to be met, and at least one element is not met. Therefore, entitlement to a VA examination and/or medical opinion is not warranted for this service-connection claim. In reaching the above conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, that doctrine is not applicable where, as here, there is not an approximate balance of positive and negative evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Thus, the claim for service connection for PTSD is denied. REASONS FOR REMAND 8. Entitlement to service connection for rectal bleeding A review of the file reveals that the Veteran has reported recurrent rectal bleeding since November 1992. In 1992, the bleeding was documented to be associated with hemorrhoids. However, since that time, the records document the Veteran no longer has hemorrhoids, yet, the rectal bleeding continues. To this point, no specific cause or diagnosis has been provided, but treatment providers on occasion have linked rectal bleeding to her diagnosed anemia. The Veteran has not been provided a VA examination as to this claim. However, as the record documents a possible link between the recurrent rectal bleeding and the service-connected anemia, a VA examination is necessary to assess whether the Veteran's rectal bleeding is related to her service in Southwest Asia or part of her diagnosis of anemia for which she is already service connected, or whether the rectal bleeding is a separate disability that is caused or aggravated by the service-connected anemia. The matter is REMANDED for the following action: Schedule the Veteran for an examination to determine the nature and etiology of her recurrent rectal bleeding. The examiner must review the entire claims file. The examiner is informed that the Veteran served in Southwest Asia from January 1991 to March 1991 and is currently service connected for anemia. The examiner is asked to provide responses to the following questions: (a) Is the recurrent rectal bleeding part of the anemia rather than a separate diagnosis or disability? Please state upon what facts and medical principles you base the opinion. (b) If the answer to (a) is negative, is the etiology of the recurrent rectal bleeding (1) inconclusive, (2) partially understood, or (3) fully understood? Please state upon what facts and medical principles you base the opinion. This determination must be based on the Veteran's specific case and cannot be based on the etiology of the disease or disability population as a whole. (c) Is the pathophysiology of the recurrent rectal bleeding (1) inconclusive, (2) partially understood, or (3) fully understood? Please state upon what facts and medical principles you base the opinion. This determination must be based on the Veteran's specific case and cannot be based on the pathophysiology of the disease or disability population as a whole. (d) If both the etiology and pathophysiology are partially understood or fully understood, then is it at least as likely as not (a 50 percent or greater probability) that the recurrent rectal bleeding was incurred in, or is otherwise related to, her active service in Southwest Asia, which was from January 1991 to March 1991? Please state upon what facts and medical principles you base the opinion. (e) If the answers to (a) (d) are negative, is the recurrent rectal bleeding at least as likely as not (50 percent probability or greater) caused by the service-connected anemia? Please state upon what facts and medical principles you base the opinion. (f) If the answer to (e) is negative, is it at least as likely as not (50 percent probability or greater) that the recurrent rectal bleeding is aggravated by the service-connected anemia? Aggravation is different from causation in that it did not cause the disability but rather caused an increase in severity that is not due to the natural progress of the disability. Please state upon what facts and medical principles you base the opinion. (g) If the examiner finds that the anemia aggravates the recurrent rectal bleeding, the examiner is asked to state whether there is medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for the recurrent rectal bleeding prior to aggravation. If the examiner is unable to establish a baseline for the recurrent rectal bleeding prior to the aggravation, he or she should state such and explain why a baseline cannot be determined. The examiner is asked to provide a rationale for each opinion given, including providing the medical principles and evidence relied upon for each opinion. If the examiner is unable to provide an opinion without resorting to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. A. P. SIMPSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Keninger, 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.