VOIDING DYSFUNCTION

J.P. NORMAN · 2025 · Case ID: A25068826

MIXED

Summary

The veteran, who served in the United States Army from January 1996 to April 1999, appeals three rating decisions concerning her bladder disorder and gynecological conditions. The primary issue was the propriety of a reduction in the rating for her overactive bladder with chronically recurrent urinary tract infections from 60% to 20% effective September 7, 2023. The Board found the reduction improper, restoring the 60% rating effective April 13, 2022, and granting a 40% rating for the period of October 11, 2012, to April 13, 2022, based on urinary frequency. The Board denied a rating in excess of 60% for the bladder disorder thereafter. The veteran also appealed for increased ratings for four abdominal scars from surgery on December 16, 2022, which the Board granted at 20% effective December 16, 2022, finding the scars were painful but not unstable. Finally, service connection for a gynecological condition, secondary to the service-connected bladder disorder, was granted. The claim for increased ratings for the surgical scars was remanded for readjudication after the initial rating and effective date for the gynecological condition are assigned.

Rationale

Reduction from 60% to 20% was improper.; Evidence at least evenly balanced to suggest permanent improvement was not shown.; 40% rating granted for urinary frequency prior to April 13, 2022.; No evidence supports higher ratings for renal dysfunction or more frequent absorbent material changes.

Service Branch

ARMY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

240603-445395

Full Decision Text

Citation Nr: A25068826
Decision Date: 08/14/25 Archive Date: 08/14/25

DOCKET NO. 240603-445395
DATE: August 14, 2025

ORDER

The reduction in the rating of the Veteran's overactive bladder with chronically recurrent urinary tract infections, from 60 percent to 20 percent effective September 7, 2023 was improper; therefore, the petition to restore the 60 percent rating effective April 13, 2022 is granted.

Entitlement to a 40 percent rating from October 11, 2012 until prior to April 13, 2022, but no higher and during no other timeframe, for service-connected overactive bladder with chronically recurrent urinary tract infections is granted.

Entitlement to a rating in excess of 60 percent effective April 13, 2022 for service-connected overactive bladder with chronically recurrent urinary tract infections is denied.

Entitlement to a 20 percent rating effective December 16, 2022, but no higher and no earlier, for service-connected residuals of four (4) surgical scars of the abdomen associated with status post laparoscopic sacro colpopexy, midurethral sling is granted.

Entitlement to service connection for a gynecological condition (initially claimed as hysterectomy, oophorectomy, or sacro hysteropexy) is granted.

REMANDED

Entitlement to increased ratings in excess of 10 percent effective December 16, 2022 for service-connected residuals status post laparoscopic sacro colpopexy, midurethral sling is remanded.

FINDINGS OF FACT

1. The Veteran's 60 percent rating for her bladder disorder was in effect for less than five years (from April 13, 2022 until prior to September 7, 2023), and the reduction for this disability did not reduce the Veteran's overall disability benefits, because she has a total rating of 100 percent and special monthly compensation at the statutory housebound rate, regardless of the outcome of this reduction.

2. Resolving all reasonable doubt in the Veteran's favor, evidence is at least evenly balanced to suggest that the September 7, 2023 VA examination failed to demonstrate that the residuals of her bladder disorder underwent permanent improvement.

3. From October 11, 2012 until prior to April 13, 2022 (in other words, before the staged rating increase to 60 percent), and after resolving all reasonable doubt in the Veteran's favor, evidence is at least evenly balanced to suggest that the Veteran's bladder disorder with chronically recurrent urinary tract infections manifested in daytime voiding interval of less than one hour, which is the maximum available rating for a bladder disorder with urinary frequency as the predominant symptom. Such a 40 percent rating is more advantageous than maximum available ratings for obstructed voiding, or urinary tract infections; however, there is no competent or credible evidence anywhere in the claims file evincing the use of any of the following: urine leakage requiring an appliance at any time prior to April 13, 2022, urine leakage requiring the wearing of absorbent materials which must be changed more than 4 times per day, chronic kidney disease with glomerular filtration rate (GFR) less than 30 mL/min/1.73 m^2 for at least three consecutive months during the past 12 months, chronic kidney disease requiring regular routine dialysis, nor chronic kidney disease rendering her an eligible kidney transplant recipient.

4. Effective April 13, 2022, the Veteran's bladder disorder with chronically recurrent urinary tract infections is afforded a maximum rating as if it manifests predominantly in a voiding dysfunction that requires the use of an appliance or the wearing of absorbent materials which must be changed more than four times per day. This 60 percent rating is more advantageous than maximum available ratings for urinary frequency, obstructed voiding, or urinary tract infections, and there is no competent or credible evidence anywhere in the claims file evincing renal dysfunction of any severity, let alone chronic kidney disease with glomerular filtration rate (GFR) less than 30 mL/min/1.73 m^2 for at least three consecutive months during the past 12 months, requiring regular routine dialysis, or her being an eligible kidney transplant recipient.

5. Resolving all reasonable doubt in the Veteran's favor, evidence is at least evenly balanced to suggest that on December 16, 2022, the Veteran underwent surgery of the abdomen associated with status post laparoscopic sacro colpopexy, midurethral sling, and this surgery has always yielded four painful scars thereafter; however, there is no competent or credible evidence anywhere in the claims file to suggest that (a) the scars were present any earlier than the December 16, 202
filtration rate (GFR) less than 30 mL/min/1.73 m^2 for at least three consecutive months during the past 12 months, requiring regular routine dialysis, or her being an eligible kidney transplant recipient.

5. Resolving all reasonable doubt in the Veteran's favor, evidence is at least evenly balanced to suggest that on December 16, 2022, the Veteran underwent surgery of the abdomen associated with status post laparoscopic sacro colpopexy, midurethral sling, and this surgery has always yielded four painful scars thereafter; however, there is no competent or credible evidence anywhere in the claims file to suggest that (a) the scars were present any earlier than the December 16, 2022 surgery, (b) any of these four scars have ever been unstable in addition to being painful, or (c) there has ever been any more than four scars.

6. Resolving all reasonable doubt in the Veteran's favor, the evidence of record is at least evenly balanced to support a finding that at least one of her gynecological disorders is secondary to her service-connected bladder disorder with recurrent urinary tract infections.

CONCLUSIONS OF LAW

1. The reduction in the rating of the Veteran's overactive bladder with chronically recurrent urinary tract infections, from 60 percent to 20 percent effective September 7, 2023 was improper; therefore, the petition to restore the 60 percent rating effective April 13, 2022 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.105(e)(i); 3.159, 3.344, 4.115(a and b), Diagnostic Code 7542. See also 38 C.F.R. §§ 3.951(b), 3.957.

2. The criteria for entitlement to a 40 percent rating effective October 11, 2012 until prior to April 13, 2022, but no higher and during no other timeframe, for service-connected overactive bladder with chronically recurrent urinary tract infections have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.105, 3.156(d), 4.1-4.14, 4.115a, 4.115b, Diagnostic Code 7542.

3. The criteria for entitlement to a rating in excess of 60 percent for service-connected overactive bladder with chronically recurrent urinary tract infections effective April 13, 2022 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.105, 3.156(d), 4.1-4.14, 4.115a, 4.115b, Diagnostic Code 7542.

4. The criteria for entitlement to a 20 percent rating effective December 16, 2022, but no higher and no earlier, for service-connected residuals of four (4) surgical scars of the abdomen associated with status post laparoscopic sacro colpopexy, midurethral sling have been met. 38?U.S.C. §§?1155, 5107;?38?C.F.R. §§?3.102, 4.1-4.14, 4.40, 4.45, 4.104, Diagnostic Codes 7800-7805.

5. The criteria for entitlement to service connection for a gynecological condition (initially claimed as hysterectomy, oophorectomy, or sacro hysteropexy) have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the United States Army from January 1996 to April 1999. The claims on appeal come before the Board of Veterans' Appeals (Board) on appeal of three separate rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO): dated November 11, 2023 (for the propriety of the reduction for the bladder disorder), dated April 5, 2024 (for claims for increased ratings for the bladder disorder, her four surgical scars, and the laparoscopic sacro colpopexy, midurethral sling), and dated May 20, 2024 (for the claimed service connection for hysterectomy, oophorectomy, and sacro hysteropexy).

If any of these issues were listed in more than one rating decision, then the Board
claims on appeal come before the Board of Veterans' Appeals (Board) on appeal of three separate rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO): dated November 11, 2023 (for the propriety of the reduction for the bladder disorder), dated April 5, 2024 (for claims for increased ratings for the bladder disorder, her four surgical scars, and the laparoscopic sacro colpopexy, midurethral sling), and dated May 20, 2024 (for the claimed service connection for hysterectomy, oophorectomy, and sacro hysteropexy).

If any of these issues were listed in more than one rating decision, then the Board will consider each issue as on appeal from the latest possible rating decision. This maneuver is most helpful to the Veteran, because taking an appeal on a later rating decision allows the Board to permissibly review more evidence in this adjudication. One Notice of Disagreement was received on June 3, 2024, and it is timely and valid with respect to all of the above rating decisions.

In the June 3, 2024 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the respective agency of original jurisdiction (AOJ) decision on appeal, as set forth above. 38 C.F.R. § 20.301. Any evidence submitted after the AOJ decision on appeal cannot be considered by the Board. 38 C.F.R. §§ 20.300, 20.301, 20.801.

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claims, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. Of the claims being adjudicated, the reversal of the reduction and the grant of service connection are each maximum grants of the available benefit, but the claims for higher ratings for the bladder disorder and the scars are still not maximized. Meanwhile, because the Board is remanding the claim for higher ratings for the laparoscopic sacro colpopexy, any evidence the Board could not consider will be considered by the AOJ in the adjudication of that one claim. 38 C.F.R. § 3.103(c)(2)(ii).

As noted, the appellant selected the Direct Review Docket. Pursuant to 38 C.F.R. § 20.202(c)(2), an appellant may modify a NOD to change the Board docket being requested. The time limit for such modification is "within one year from the date that the [AOJ] mails notice of the decision on appeal, or within 60 days of the date that the Board receives the [NOD], whichever is later." See 38 C.F.R. § 20.202(c)(2). "[T]he Board ordinarily may not decide an appeal before this time period is up." See Williams v. McDonough, 37 Vet. App. 305 (2024). As a result of Williams, supra, the Board could normally be precluded from adjudicating this claim until one year after the last rating decision, plus a potential additional 60 days to modify a Notice of Disagreement.

On March 26, 2025, the Board solicited a waiver of any additional time to which the Veteran might have been entitled under Williams, supra, so that the Veteran may receive a faster adjudication. On April 15, 2025, the Board received a signed statement from the Veteran, confirming her waiver of Williams time and her wish to have the Board assert jurisdiction sooner. The Board proceeds accordingly.

Evidence was added to the claims file during a period of time when new evidence was not allowed, including but not limited to an April 18, 2024 VA examination about scars, which is after the April 5, 2024 rating decision about the Veteran's scars. As the Board is deciding the claims of the rating reduction for the bladder disorder, increased ratings for the bladder disorder, increased ratings for the scars, and service connection for the other gynecological disorder separate from what is already service connected, the Board may not consider this evidence in its decision. 38 C.F.R. § 20.300. The Veteran may file a Supplemental Claim and submit or identify this evidence.
The Board proceeds accordingly.

If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. That being said, grants of the claims to reverse a reduction and for service connection are maximum grants of those benefits available on appeal, so there can be no prejudice to the Veteran in making those adjudications. On the other hand, as the Board is remanding the one remaining claim (namely, increased ratings in excess of 10 percent effective December 16, 2022 for service-connected residuals status post laparoscopic sacro colpopexy, midurethral sling) for further development, this additional evidence will be considered by the RO in the adjudication of those claims.

By way of background, the Veteran's overactive bladder with chronically recurrent urinary tract infections (hereinafter "bladder disorder") was first granted service connection in a July 14, 2022 rating decision, which implemented a staged initial rating of 20 percent from October 11, 2012 to prior to April 13, 2022, and then a 60 percent rating thereafter. See Rating Decision (July 14, 2022).

After this initial rating decision, the Veteran made a supplemental claim for higher ratings, and it was received within one year of the previous rating decision. See VA Form 21-526EZ (rec'd Aug. 3, 2022). That subsequent rating decision continued the 60 percent rating, but the AOJ offered no further decision about whether the 20 percent stage was adequate from October 11, 2012 to prior to April 13, 2022. See Rating Decision (Nov. 7, 2022).

The Veteran then filed another supplemental claim for higher ratings, and once again this one was also received within one year of the previous rating decision. See VA Form 21-526EZ (rec'd July 26, 2023). After a VA examination, see C&P Exam (Sept. 7, 2023), the AOJ effectuated a rating reduction backdated to the examination evincing improvement. See Rating Decision (Nov. 11, 2023).

After the reduction, the Veteran filed her most recent supplemental claim for higher ratings, which was received within one year of the previous rating decision. See VA Form 20-0995 (rec'd Nov. 27, 2023). The AOJ issued the last rating decision on April 5, 2024. See Rating Decision (Apr. 5, 2024). This rating decision continues the 20 percent rating for the bladder disorder post-reduction, but it offers no ruling about the 20 percent rating for the bladder disorder from October 11, 2012 until prior to April 13, 2022.

The Veteran submitted her Notice of Disagreement in this appeal, and it was received on June 3, 2024. See VA Form 10182 (rec'd June 3, 2024). This NOD is within one year of all of the following rating decisions: (a) the April 2024 rating decision, which is about the claim for ratings in excess of 20 percent, (b) the November 2023 rating decision, which is about the reduction from 60 percent effective April 13, 2022 until prior to September 7, 2023, to 20 percent thereafter, and (c) the November 2022 rating decision, which is about the claims for ratings in excess of 60 percent. In the context of the
, and it was received on June 3, 2024. See VA Form 10182 (rec'd June 3, 2024). This NOD is within one year of all of the following rating decisions: (a) the April 2024 rating decision, which is about the claim for ratings in excess of 20 percent, (b) the November 2023 rating decision, which is about the reduction from 60 percent effective April 13, 2022 until prior to September 7, 2023, to 20 percent thereafter, and (c) the November 2022 rating decision, which is about the claims for ratings in excess of 60 percent. In the context of the Veteran's appeals, the Board identifies continuous prosecution ever since October 11, 2012, and the Veteran has clearly disagreed with both the AOJ's failure to award any higher ratings, and the AOJ's reducing the award from 60 percent to 20 percent on September 7, 2023.

The Board accordingly asserts jurisdiction over all of those claims. See AB v. Brown, 6 Vet. App. 35, 39 (1993) (citing Hamilton v. Brown, 4 Vet. App. 528, 544 (1993)). Reversing the reduction is a full grant of that claim for the maximum available benefit, so there is no prejudice in making that adjudication. See AB v. Brown, 6 Vet. App. 35, 39 (1993). On the other hand, with respect to the claims for increased ratings, benefits are available up to a 100 percent rating for that disorder, so that claim still must be fully adjudicated.

The Board is in receipt of the Veteran's arguments on her own behalf. See, e.g.: Correspondence (rec'd Nov. 27, 2023). She asserts that "The VA cannot take away my rating that was dated back to 2012," id. at Page 1, Paragraph 3 after salutation," while requesting to "Please give me back my rating it originally [sic] goes back to 2012 which is more than 10 years ago," id. at Page 2, penultimate paragraph," and referring to a conversation "which is I was told after 5 years or no more appointments for that service-connected disability that the VA would not take away my rating," id. at Page 2, last paragraph before closing. The Board wishes to ensure the Veteran that no rating was "taken away," since the bladder disorder has been service-connected since October 11, 2012, which is a period of more than 10 years that continues to the present. See 38 C.F.R. § 3.957.

Meanwhile, prior to this adjudication, and at the very worst, the Veteran's bladder disorder was most recently rated as it was originally rated from October 2012. See 38 C.F.R. §§ 3.105(e), 3.344, 3.951. From October 11, 2012 (when the bladder disorder was rated 20 percent disabling) to immediately prior to this adjudication (when the bladder disorder's rating reverted to 20 percent, after a reduction), there is no reduction between that beginning and that end, see 38 C.F.R. § 3.951, but even so, rating reductions can generally be effectuated until a rating is in effect for 20 years, at which point a rating reduction would only be lawful if the rating was based on fraud.

In other words, if the bladder disorder were ever rated less than 20 percent, then a rating reduction would be measured from October 11, 2012. In this instance, however, the only rating reduction is from April 13, 2022 to September 7, 2023, because during that time, the bladder disorder used to be rated 60 percent disabling, and it was rated 20 percent thereafter. This is a period of less than 2 years, much less 5 years. The Veteran's claim is still valid, and the Board fully understands the crux of her arguments.

The Board will adjudicate the Veteran's claim about the reduction of the bladder rating from 60 percent to 20 percent first, and then the Board will continue to the Veteran's claims about higher ratings for the bladder disorder from October 11, 2012 to the present.

The Veteran's bladder disorder was historically rated 20 percent disabling from October 11, 2012 to prior to April 12, 2022, then 60 percent thereafter until prior to September 7, 2023 (a period of less than two years), and then back to 20 percent thereafter. This disorder has been service-connected for more than 10 years, and it continues to be service-connected, so nothing has been unlawfully "taken away" from her under 38 C.F.R. § 3.957. The Veteran's bladder disorder has never been rated lower than the initial 20 percent rating, so despite all provisions in 38 C.F.R. §§ 3.105(e), 3.344, and 3.951, there is no rating reduction from 2012. The only rating reduction is from 60 percent to 20 percent.

In a November 11, 2023 rating decision, the AOJ invoked a previous VA examination allegedly showing permanent improvement, and retroactively reduced this rating effective September 7, 2023. See Rating Decision (Nov. 11, 2023). A reversal of this reduction is a full grant of that claim with maximum benefits, so there would be no prejudice in making an adjudication that reverses the reduction from 60 percent to 20 percent. See AB v. Brown, 6 Vet. App. 35, 39 (1993).

A veteran's disability rating shall not be reduced unless an improvement in the disability is shown to have occurred. 38 U.S.C. § 1155; Greyzck v. West, 12 Vet. App. 288, 292 (1999). Where a reduction in an evaluation of a service-connected disability is considered warranted and the lower evaluation would result in a reduction or discontinuance of compensation payments currently being made, a rating proposing the reduction or discontinuance must be prepared setting forth all material facts and reasons, and the RO must notify the veteran that they have 60 days to present additional evidence showing that compensation should be continued at the present level. The veteran is also to be informed that they may request a predetermination hearing, provided that the request is received by VA within 30 days from the date of the notice. If no additional evidence is received within the 60-day period and no hearing is requested, final rating action will be taken, and the award will be reduced or discontinued effective the last day of the month in which a 60-day period from the date of notice to the veteran expires. 38 C.F.R. § 3.105(e).

VA's General Counsel has held that the provisions of 38 C.F.R. § 3.105(e) do not apply where there is no reduction in the amount of compensation payable. VAOPGCPREC 71-91 (Nov. 1991); VAOPGCPREC 29- 97 (Aug. 1997). It reasoned that this regulation is only applicable where there is both a reduction in evaluation and a reduction or discontinuance of compensation payable.

During the portion of the appellate period from April 13, 2022 to prior to September 7, 2023, the Veteran was in receipt of a total disability rating of 100 percent, and special monthly compensation at the statutory housebound rate pursuant to 38 U.S.C. § 1114(s) and 38 C.F.R. § 3.350(i)-but only effective August 3, 2022-in light of one disability rated 100 percent disabling by itself (namely PTSD that was increased from 50 percent to 100 percent effective August 3, 2022), and then separate disabilities independently combining as 60 percent disabling or more. See generally Rating Decision (Codesheet) (Nov. 7, 2022). Effective September 7, 2023, and even if the Board were to uphold the reduction as proper, the Veteran would still have her one psychiatric disorder rated 100 percent by itself, separate disabilities independently combining as 60 percent disabling or more (namely a migraine disorder rated 50 percent disabling, the bladder disorder which would never be rated less than 20 percent, her lumbar strain rated 10 percent disabling, left knee disabilities, and residuals of her midurethral sling with scars), and special monthly compensation at the statutory housebound rate pursuant to
2022), and then separate disabilities independently combining as 60 percent disabling or more. See generally Rating Decision (Codesheet) (Nov. 7, 2022). Effective September 7, 2023, and even if the Board were to uphold the reduction as proper, the Veteran would still have her one psychiatric disorder rated 100 percent by itself, separate disabilities independently combining as 60 percent disabling or more (namely a migraine disorder rated 50 percent disabling, the bladder disorder which would never be rated less than 20 percent, her lumbar strain rated 10 percent disabling, left knee disabilities, and residuals of her midurethral sling with scars), and special monthly compensation at the statutory housebound rate pursuant to 38 U.S.C. § 1114(s) and 38 C.F.R. § 3.350(i). See generally Rating Decision (Codesheet) (Nov. 11, 2023).

The Board determines that from 60 percent to 20 percent, the Veteran's bladder disorder was compensated at the higher rating for less than five years, and this reduction affects neither her total disability rating nor her total disability compensation with ancillary benefits. In other words, regardless of whether this reduction is upheld or reversed, neither outcome will affect the Veteran's total disability compensation. Indeed, the Veteran's award of SMC at the statutory housebound rate will remain undisturbed from August 3, 2022, and this will be true whether or not the bladder disorder must suffer a reduction effective September 7, 2023. As such, the Veteran is not entitled to the due process procedures under 38 C.F.R. § 3.105(e).

Rating agencies will handle cases affected by change of medical findings or diagnosis, so as to produce the greatest degree of stability of disability evaluations consistent with the laws and VA regulations governing disability compensation and pension. VA benefits recipients may be afforded greater protections under 38 C.F.R. § 3.344(a) & (b), which sets forth the criteria for reduction of ratings in effect for five years or more, which is not true for this claim on appeal. 38 C.F.R. § 3.344(a) & (b) stipulate that only evidence of sustained material improvement under the ordinary conditions of life, as shown by full and complete examinations, can justify a reduction and prohibit a reduction on the basis of a single examination. Brown v. Brown, 5 Vet. App. 413, 417-18 (1995).

However, with respect to other disabilities that are likely to improve (i.e., those in effect for less than five years), re-examinations disclosing improvement in disabilities will warrant a rating reduction. 38 C.F.R. § 3.344(c). Specifically, it is necessary to ascertain, based upon a review of the entire recorded history of the condition, whether the evidence reflects an actual change in disability and whether examination reports reflecting change are based upon thorough examinations. In addition, it must be determined that an improvement in a disability has actually occurred and that such improvement actually reflects an improvement in the veteran's ability to function under the ordinary conditions of life and work. See Brown, 5 Vet. App. at 420-421; 38 C.F.R. § 3.344(c). Specifically, each disability should be viewed in relation to its history. 38 C.F.R. § 4.1. Also, it is the responsibility of the rating specialist to interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2. Furthermore, 38 C.F.R. § 4.13 provides that when any change in evaluation is to be made, the rating agency should assure itself that there has been an actual change in the conditions, for better or worse, and not merely a difference in thoroughness of the examinations or in use of descriptive terms.

The regulations impose a clear requirement that rating reductions be based upon review of the entire history of the veteran's disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Such review requires VA to ascertain whether the evidence reflects an actual change in the disability and whether the examination reports reflecting such change are based upon thorough examinations. Thus, in any rating reduction case it not only must be determined whether an improvement in disability occurred but whether it actually reflects an improvement in the veteran's ability to function under the ordinary conditions of life and work. Brown, 5 Vet. App. at 420-21; Faust v. West, 13 Vet. App. 342, 350 (
requirement that rating reductions be based upon review of the entire history of the veteran's disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Such review requires VA to ascertain whether the evidence reflects an actual change in the disability and whether the examination reports reflecting such change are based upon thorough examinations. Thus, in any rating reduction case it not only must be determined whether an improvement in disability occurred but whether it actually reflects an improvement in the veteran's ability to function under the ordinary conditions of life and work. Brown, 5 Vet. App. at 420-21; Faust v. West, 13 Vet. App. 342, 350 (2000).

A disability which has been continuously rated at or above any evaluation of disability for 20 or more years for compensation purposes will not be reduced to less than such evaluation (except when based on fraud). 38 C.F.R. § 3.951(b). This is not true in this instance, because the Veteran's bladder disorder has only been service-connected for less than 13 years-at or above 20 percent for all of that time, and at 60 percent for only less than 2 years.

The Board determines that of all procedures that may have to be followed for implementing a reduction, only the ones set forth in 38 C.F.R. §§ 3.105(e) and 3.344(c) apply in this instance, but not 3.344(a or b). The heightened duty to show sustained material improvement as contemplated by 38 C.F.R. § 3.344(a) and (b) is not for application; rather, the provisions of 38 C.F.R. § 3.344(c) concerning disabilities that have not stabilized, are applicable. This regulation provides that reexaminations disclosing improvement will warrant a rating reduction. However, in any rating reduction case, not only must it be determined that an improvement in disability has occurred, but also that that the improvement in disability actually reflects an improvement in the appellant's ability to function under the ordinary conditions of life and work. See Faust v. West, 13 Vet. App. 342, 349 (2000). The burden of proof is on VA to establish that a reduction is warranted by the weight of the evidence. Kitchens v. Brown, 7 Vet. App. 320 (1995).

Having determined that procedural requirements of §§ 3.105(e) and 3.344(c) have been met, the Board turns to the evidence to determine whether actual improvement in the Veteran's bladder disorder, to include improvement in the ability to function under ordinary conditions of life and work, is shown by the evidence such as to warrant the effectuated reduction.

Here, the Board finds that the VA has not met its burden to show improvement in the Veteran's ability to function under the ordinary conditions of life and work based on improvement of her bladder disorder.

The Veteran's bladder disorder was rated 60 percent disabling from April 13, 2022 to prior to September 7, 2023. See 38 C.F.R. §§ 4.115a, 4.115b, Diagnostic Code 7542. The 60 percent rating was awarded for her primary symptom being urine leakage, and for that primary symptom specifically manifesting in either requiring an appliance, or the wearing of absorbent material which must be changed more than 4 times per day. 38 C.F.R. § 4.115a, see also Johnson v. Brown, 7 Vet. App. 95 (1994) (only one disjunctive "or" requirement must be met in order for a higher rating to be assigned). Her 20 percent rating, as effectuated in the November 2023 rating decision and as from her September 2023 VA examination, would be proper if the primary urine leakage symptoms no longer required the use of an appliance, but still requiring the wearing of absorbent materials which must be changed less than 2 times per day; or else, if the primary symptom was instead urinary frequency, manifesting in daytime voiding interval between two and three hours, or awakening to void three to four times per night. Id.; see also Melson v. Derwinski, 1 Vet. App. 334 (1991) (the use of the conjunctive "and" in a statutory provision means that all of the conditions listed in the provision must be met).

Simply stated, the Veteran's history of recurrent, symptomatic bladder or urethral infections is well documented, as this disorder has been service-connected since 2012, and was specifically acknowledged in the August 2022 VA examination. See C&P Exam (Aug. 9,
or else, if the primary symptom was instead urinary frequency, manifesting in daytime voiding interval between two and three hours, or awakening to void three to four times per night. Id.; see also Melson v. Derwinski, 1 Vet. App. 334 (1991) (the use of the conjunctive "and" in a statutory provision means that all of the conditions listed in the provision must be met).

Simply stated, the Veteran's history of recurrent, symptomatic bladder or urethral infections is well documented, as this disorder has been service-connected since 2012, and was specifically acknowledged in the August 2022 VA examination. See C&P Exam (Aug. 9, 2022, rec'd Aug. 11, 2022), at Pages 4-5, Section V, Question No. 5 et seq. As of this examination, the Veteran required use of a transcutaneous electrical nerve stimulation (TENS) unit, which the Board interprets as circumstantial evidence about why the 60 percent rating was awarded. Id. at Page 5, Question No. 5c. Under the Appeals Modernization Act (AMA), the Board is bound by earlier in time findings of fact that are favorable to the appellant, such as these. See 38 U.S.C. § 5104A; 38 C.F.R. § 3.104(c).

When the Veteran submitted to her next VA examination on September 7, 2023, the examiner indicated that she does not have this history of recurrent, symptomatic bladder or urethral infections. See cf. C&P Exam (Sept. 7, 2023), at Page 4, Question No. 5a. The Board has no explanation about why this history was ignored, but the Board now must conclude that upholding this rating reduction would be based upon an inaccurate factual premise. See Reonal v. Brown, 5 Vet. App. 458 (1993) (medical opinion based upon an inaccurate factual premise has no probative value).

Ultimately, the Board must adjudicate whether the September 7, 2023 examiner and the AOJ have adequately discussed whether the Veteran's bladder disorder has demonstrated sustained improvement from 60 percent disabling to 20 percent disabling, and whether this evidence made it reasonably clear that the improvements would be maintained under the ordinary conditions of life, as required by 38 C.F.R. § 3.344. The Board accordingly determines that the AOJ has clearly not adequately performed the above. Meanwhile, the Board is also prohibited from remanding to associate negative evidence against a Veteran's claim with the claims file. See Mariano v. Principi, 17 Vet. App. 305, 312 (2003). Furthermore, when the evidence is at least evenly balanced to grant a claim in full, a remand would cause undue delay in adjudicating the claim. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991).

By granting the claim in full now, the Board can ensure that the Veteran is not so prejudiced. See Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997). The reduction effective September 7, 2023, as carried out by the November 11, 2023 rating decision, is improper, so the former 60 percent rating for the bladder disorder must be RESTORED as undisturbed since April 13, 2022. In other words, the petition to reverse the reduction is hereby GRANTED, and the Board determines that reversing this rating reduction is a full grant of maximum benefits available for this claim on appeal. See Grantham, supra.

2. Entitlement to a 40 percent rating from October 11, 2012 until prior to April 13, 2022, but no higher and during no other timeframe, for service-connected overactive bladder with chronically recurrent urinary tract infections is granted.

3. Entitlement to a rating in excess of 60 percent effective April 13, 2022 for service-connected overactive bladder with chronically recurrent urinary tract infections is denied.

The Board will now shift its attention to the Veteran's claim for increased ratings for the bladder disorder. The Veteran has been continuously prosecuting claims for higher ratings for the bladder disorder ever since it was first awarded service connection, from the initial rating decision dated July 14, 2022, through a first Supplemental Claim received on August 3, 2022, a second rating decision issued on November 7, 2022, a second Supplemental Claim received on July 26, 2023, a third rating decision issued on November 11, 2023, the last Supplemental Claim received on November 27, 2023, the last rating decision issued on April 5, 2024, and finally to the Notice of Disagreement that dockets this appeal. See Rating Decisions (July 14, 2022; Nov. 7, 2022; Nov. 11, 2023; Apr. 5, 2024); VA Forms 21-526EZ (rec'd Aug. 3, 2022; July 26, 2023); VA Form 20-0995 (rec'd Nov. 27, 2023).

The Board is mindful of binding federal jurisprudence, Chisholm v. Collins, 38 Vet. App. 140 (2025), which states that even though claims must be received on a prescribed form, claims are not necessarily limited to any particular or specific prescribed form. The Veteran's filings have all clearly been received on dates never more than one year after any administrative decision, so the Board accepts this claim for increased ratings as continuous from first receipt, which means that the appellate period begins on October 11, 2012. 38 C.F.R. §§ 3.156(d), 3.2501(a)(1), 19.2(a).

Under the Appeals Modernization Act (AMA), the Board is bound by earlier in time findings of fact that are favorable to the appellant. See 38 U.S.C. § 5104A; 38 C.F.R. § 3.104(c). In this Board adjudication, the Board reversed the November 11, 2023 rating decision's rating reduction, as it was improper against the Veteran's bladder disorder. The Board accordingly characterizes this claim on appeal, for increased ratings for the bladder disorder, as follows: in pursuit of a rating in excess of 20 percent for the period from October 11, 2012 until prior to April 13, 2022, and also in pursuit of a rating in excess of 60 percent thereafter. Because there are higher ratings available throughout the appellate period for the Veteran's service-connected bladder disorder, the claim for increased ratings remains on appeal, even after the claim to reverse the reduction was granted in full. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993) (finding that veterans are generally presumed to be seeking the maximum benefit allowed, unless they expressly indicate otherwise); 38 C.F.R. §§ 3.105(e), 4.115a, 4.115b, Diagnostic Code 7528; contra Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997).

In certain circumstances, a claim for an increased rating can give rise to an inferred claim for a total disability rating based on individual unemployability (TDIU), as part and parcel of the claim. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Notwithstanding the award of special monthly compensation at the statutory housebound rate effective August 3, 2022, the competent and credible evidence of record suggests that the Veteran is employed. See, e.g.: VA Medical Record (Apr. 17, 2017, rec'd June 1, 2017), at Page 76; C&P Exam (Jan. 16, 2019), at Page 5, Question No. 10 ("Question: Does the Veteran's condition(s) of the bladder or urethra impact his or her ability to work? Answer: Yes, Veteran must be allowed breaks every hour for bladder control."); C&P Exam (Feb. 12, 2024), at Page 8, Question No. 18 ("Employed"). The Board interprets no error in not applying Rice, nor in not awarding TDIU during substantial and gainful employment. If the Veteran should ever become unemployed and unemployable
17, 2017, rec'd June 1, 2017), at Page 76; C&P Exam (Jan. 16, 2019), at Page 5, Question No. 10 ("Question: Does the Veteran's condition(s) of the bladder or urethra impact his or her ability to work? Answer: Yes, Veteran must be allowed breaks every hour for bladder control."); C&P Exam (Feb. 12, 2024), at Page 8, Question No. 18 ("Employed"). The Board interprets no error in not applying Rice, nor in not awarding TDIU during substantial and gainful employment. If the Veteran should ever become unemployed and unemployable due to service-connected disorders, then she may file a claim for a TDIU at any time, and the claim will be adjudicated when it is received. See generally 38 C.F.R. § 4.16.

Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentage ratings are based on average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1.

If two disability evaluations are potentially applicable, 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. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3.

Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, the Board must also consider staged ratings, which are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods during the appeal. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007).

The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other. Esteban v. Brown, 6 Vet. App. 259, 262 (1994); 38 C.F.R. § 4.14.

The veteran is competent to give evidence of symptoms observable by her senses, and the Board finds her credible as her statements are detailed and consistent. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007).

The Veteran's bladder disorder is rated according to 38 C.F.R. § 4.115b, Diagnostic Code 7542 (neurogenic bladder), which directs the Board to rate the disorder as voiding dysfunction or urinary tract infection, whichever is predominant. The General Rating Formula for dysfunctions of the genitourinary system is located in 38 C.F.R. § 4.115a.

Voiding dysfunction is rated under the three subcategories of urine leakage, urinary frequency, and obstructed voiding. 38 C.F.R. § 4.115a.

Evaluation under urine leakage involves ratings ranging from 20 to 60 percent and contemplates continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence. When these factors require the use of an appliance or the wearing of absorbent materials which must be changed more than four times per day, a 60 percent rating is warranted. When there is leakage requiring the wearing of absorbent materials which must be changed two to four times per day, a 40 percent rating is warranted. A 20 percent rating contemplates leakage requiring the wearing of absorbent materials which must be changed less than two times per day. 38 C.F.R. § 4.115a.

Urinary frequency encompasses ratings ranging from 10 to 40 percent. A 40 percent rating contemplates a daytime voiding interval less than one hour or awakening to void five or more times per night. A 20 percent rating contemplates daytime voiding interval between one and two hours or awakening to void three to four times per night. A 10 percent rating contemplates daytime voiding interval between two and three hours or awakening to void two times per
to four times per day, a 40 percent rating is warranted. A 20 percent rating contemplates leakage requiring the wearing of absorbent materials which must be changed less than two times per day. 38 C.F.R. § 4.115a.

Finally, obstructed voiding entails ratings ranging from noncompensable to 30 percent. A 30 percent rating contemplates urinary retention requiring intermittent or continuous catheterization. A 10 percent rating contemplates marked obstructive symptomatology (hesitancy, slow or weak stream, decreased force of stream) with any one or combination of the following: (1) post-void residuals greater than 150 cubic centimeters (cc's); (2) uroflowmetry; markedly diminished peak flow rate (less than 10 cc's per second); (3) recurrent urinary tract infections secondary to obstruction; (4) stricture disease requiring periodic dilatation every two to three months. A noncompensable rating contemplates obstructive symptomatology with or without stricture disease requiring dilatation one to two times per year. 38 C.F.R. § 4.115a.

Urinary tract infections entail ratings ranging from noncompensable to 30 percent. For poor renal function, UTI's are rated as renal dysfunction, delineated below. Otherwise, a 30 percent rating contemplates a recurrent symptomatic infection requiring drainage by stent or nephrostomy tube; or requiring greater than 2 hospitalizations per year; or requiring continuous intensive management. A 10 percent rating contemplates a recurrent symptomatic infection requiring 1-2 hospitalizations per year or suppressive drug therapy lasting six months or longer. A noncompensable rating contemplates a recurrent symptomatic infection not requiring hospitalization, but requiring suppressive drug therapy for less than 6 months.

Evaluation under renal dysfunction involves ratings ranging from zero to 100 percent and contemplates persistent edema and albuminuria, or else generalized poor health. When a Veteran requires regular dialysis, or when prostate cancer residuals preclude more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80mg%; or, creatinine more than 8mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular, a 100 percent rating is warranted. When there is persistent edema and albuminuria with BUN 40 to 80mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion, an 80 percent rating is warranted. When there is constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension at least 40 percent disabling under diagnostic code 7101, a 60 percent rating is warranted. A 30 percent rating contemplates albumin constant or recurring with hyaline and granular casts or red blood cells; or, transient or slight edema or hypertension at least 10 percent disabling under diagnostic code 7101. A noncompensable rating contemplates albumin and casts with history of acute nephritis; or, hypertension non-compensable under diagnostic code 7101. 38 C.F.R. § 4.115a.

For reference, the Veteran's 60 percent rating effective April 13, 2022 is due to the Veteran's use of a TENS unit, and the Board reversed a reduction because the AOJ did not adequately demonstrate that the reduction is warranted. This 60 percent rating is a maximum rating for urine leakage, and it is also more advantageous than any available rating for urinary frequency, obstructed voiding, or urinary tract infection. The only available ratings listed anywhere in 38 C.F.R. § 4.115a, that would be more advantageous than the current 60 percent rating, would if her bladder disorder's primary symptom was renal dysfunction. Ratings of 80 percent and 100 percent are listed as available for renal dysfunction, but Diagnostic Code 7542 directs the Board to rate the disorder as voiding dysfunction or urinary tract infection, whichever is predominant, but not renal dysfunction. 38 C
the AOJ did not adequately demonstrate that the reduction is warranted. This 60 percent rating is a maximum rating for urine leakage, and it is also more advantageous than any available rating for urinary frequency, obstructed voiding, or urinary tract infection. The only available ratings listed anywhere in 38 C.F.R. § 4.115a, that would be more advantageous than the current 60 percent rating, would if her bladder disorder's primary symptom was renal dysfunction. Ratings of 80 percent and 100 percent are listed as available for renal dysfunction, but Diagnostic Code 7542 directs the Board to rate the disorder as voiding dysfunction or urinary tract infection, whichever is predominant, but not renal dysfunction. 38 C.F.R. § 4.115b. There is no competent or credible evidence of any renal dysfunction, and the Veteran is not making any such argument.

For the portion of the appellate period on appeal from October 11, 2012 to prior to April 13, 2022, the 20 percent rating of record prior to this adjudication appears to be commensurate with either (a) leakage requiring the wearing of absorbent materials which must be changed less than two times per day, if the primary symptom is urine leakage; or else, (b-1) daytime voiding interval between one and two hours or (b-2) awakening to void three to four times per night, if the primary symptom is urinary frequency. Ratings in excess of 20 percent are available by either avenue.

The Board is unable to locate any competent or credible evidence of the bladder disorder ever primarily manifesting in urinary tract infections being the predominant symptom; however, as a matter of principle, the Board acknowledges that its highest rating is 30 percent, which is less advantageous than the 60 percent effective April 13, 2022, and also less advantageous than a maximum rating for urine leakage or urinary frequency (both voiding dysfunctions). Additionally, this maximum 30 percent would be equally advantageous as a maximum rating for obstructed voiding, and still more advantageous than the current 20 percent rating effective from October 11, 2012 to prior to April 13, 2022.

The Board will first address whether any increased rating can be awarded in excess of 20 percent from October 11, 2012 to prior to April 13, 2022.

The Board has seriously considered whether higher ratings can be awarded based upon a sufficiently frequent urinary frequency. Among the competent and credible evidence of record, the Veteran reported daytime urinary frequency as frequently as every 30 minutes. See VA Medical Record (July 3, 2017, rec'd Dec. 19, 2018), at Page 254; see also VA Medical Record (Apr. 14, 2017), at Page 43 (voids every hour); C&P Exam (Jan. 16, 2019), at Page 5, Question No. 10 ("Question: Does the Veteran's condition(s) of the bladder or urethra impact his or her ability to work? Answer: Yes, Veteran must be allowed breaks every hour for bladder control."). Urinating every 30 minutes means only being able to wait less than one hour, so the Board can resolve at least this much reasonable doubt in the Veteran's favor, and determine that the disorder should be rated no less than 40 percent throughout the appellate period.

If there is no other higher rating prior to April 13, 2022, then this 40 percent rating would represent a maximum rating for urinary frequency, and it would also be more advantageous for any available rating for urinary tract infections or obstructed voiding. Higher ratings for her bladder disorder would accordingly still be available, in excess of 40 percent, if the Veteran (a) required the use of an appliance any earlier than April 13, 2022, or the wearing of absorbent materials which must be changed more than four times per day, or (b) suffered renal dysfunction manifesting in constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension at least 40 percent disabling under diagnostic code 7101. The Board will seriously consider all of these alternatives.

The Board has thoroughly reviewed all competent and credible evidence of record, including VA examinations and contemporaneous medical records. There is no dispute that the Veteran required a TENS unit no later than May 26, 2022, but that evidence is of record after April 13, 2022. See C&P Exam (May 26, 2022), at Page 2, Question No. 2A. Prior to April 13, 2022, the Veteran submitted to a VA examination on January 16, 2019. See C&P Exam (Jan
function; or, hypertension at least 40 percent disabling under diagnostic code 7101. The Board will seriously consider all of these alternatives.

The Board has thoroughly reviewed all competent and credible evidence of record, including VA examinations and contemporaneous medical records. There is no dispute that the Veteran required a TENS unit no later than May 26, 2022, but that evidence is of record after April 13, 2022. See C&P Exam (May 26, 2022), at Page 2, Question No. 2A. Prior to April 13, 2022, the Veteran submitted to a VA examination on January 16, 2019. See C&P Exam (Jan. 16, 2019). She denied any requirement of an appliance. Id. at Page 3, Question No. 3c. There is simply no competent or credible evidence establishing her requiring an appliance prior to April 13, 2022.

Meanwhile, with respect to requiring wearing absorbent materials, the Board identifies her needing to change panty liners as frequently as four times daily at the most, but never more frequently than that. See VA Medical Record (July 31, 2017, rec'd Dec. 19, 2018), at Page 158. Other competent and credible evidence suggests that she still required panty liners at other times during this appellate period but replaced less often. See, e.g.: id. at Page 159 (Dec. 11, 2017; about 3 panty liners per day); id. at Page 162 (Oct. 30, 2017; 1 or 2 panty liners per day). Ultimately, the Board will acknowledge that there is some evidence suggesting up to four (but never more than four) changes of absorbent material per day. Even if the July 2017 estimate is too low (in other words, assuming arguendo that the Veteran might have changed absorbent material more than four times daily), she clearly only needed fewer changes after that date, so it would strain Board credulity to conclude that this bladder disorder ever more closely approximated a 60 percent rating prior to April 13, 2022. The competent and credible evidence of record, about her daily frequency of replacing absorbent materials, suggests that a 40 percent rating is never insufficient compensation for voiding dysfunction prior to April 13, 2022. That being said, this 40 percent rating could still alternatively be awarded for urinary frequency more often than hourly, as delineated above.

The only other basis for the Board to award any rating in excess of 40 percent for the Veteran's bladder disorder prior to April 13, 2022, is if her disorder manifested in sufficiently severe renal dysfunction. Simply stated, she does not show any signs or symptoms of renal dysfunction at all, let alone more severe than 30 percent to warrant an increased rating in excess of the 40 percent otherwise available. See contra C&P Exam (Aug. 9, 2022), at Questions No. 4d and 6i; C&P Exam (Sept. 7, 2023), at Questions Nos. 4d and 6i. The Veteran does not allege, and the record does not establish, any of constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension at least 40 percent disabling under diagnostic code 7101.

The Board will now turn its attention to whether any increased rating can be awarded in excess of 60 percent thereafter, i.e.: effective April 13, 2022.

Simply stated, the Veteran does not show any signs or symptoms of renal dysfunction at all, let alone renal dysfunction more severe than 60 percent to warrant an increased rating in excess of the 60 percent already awarded, due to the reversal of a rating reduction on voiding dysfunction, and as if she still requires an appliance. See contra C&P Exam (Aug. 9, 2022), at Questions No. 4d and 6i; C&P Exam (Sept. 7, 2023), at Questions Nos. 4d and 6i. The Veteran does not allege, and the record does not establish, the need for regular dialysis, prostate cancer residuals that preclude more than sedentary activity, persistent edema and albuminuria, BUN more than 80mg%, creatinine more than 8mg% or markedly decreased function of kidney or other organ systems, especially cardiovascular. The Board has reversed an improper rating reduction from 60 percent to 20 percent, and that is binding upon the Board as a favorable finding of fact in the Veteran's favor.

As such, the Board
No. 4d and 6i; C&P Exam (Sept. 7, 2023), at Questions Nos. 4d and 6i. The Veteran does not allege, and the record does not establish, the need for regular dialysis, prostate cancer residuals that preclude more than sedentary activity, persistent edema and albuminuria, BUN more than 80mg%, creatinine more than 8mg% or markedly decreased function of kidney or other organ systems, especially cardiovascular. The Board has reversed an improper rating reduction from 60 percent to 20 percent, and that is binding upon the Board as a favorable finding of fact in the Veteran's favor.

As such, the Board concludes that effective April 13, 2022, the bladder disorder is rated 60 percent disabling, and a rating in excess of 60 percent thereafter is never warranted. With no evidence or allegation of any renal dysfunction, assuming that renal dysfunction might even apply to this disorder, the 60 percent rating currently in effect is equivalent to the Veteran still requiring the use of an appliance, and that is more advantageous than any other alternative method in rating this disorder.

The Board acknowledges the Veteran's statements that her residuals of her bladder disorder are more severe than evaluated. The Veteran is competent to report her symptoms and has presented credible statements in this regard. See, e.g., Layno v. Brown, 6 Vet. App. 465, 470 (1994) and Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). The Board even agrees with the Veteran, because when her disorder was rated 20 percent disabling prior to April 13, 2022, the Board is resolving all reasonable doubt in her favor by concluding that residuals instead more closely approximate a 40 percent rating, but not higher than 40 percent any earlier than April 13, 2022, and never in excess of 60 percent. In excess of those, neither the Veteran's statements nor any other medical evidence demonstrates that the criteria for any such higher ratings than to be awarded have been met. In determining the actual degree of disability, the examination findings are more probative of the degree of impairment, but contemporaneous medical records have been considered. The criteria needed to support higher ratings as the required medical findings that are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-138 (1994). As such, the lay assertions are not considered more persuasive than the objective medical findings which, as indicated above, do not support assignment of any further increased ratings pursuant to any other applicable criteria at any point pertinent to this appeal.

The Board has also considered whether staged ratings under Hart v. Mansfield, supra, are appropriate for the Veteran's service connected bladder disorder. This is exactly what the AOJ awarded, but the Board is awarded an even more favorable staged rating. By awarding a 40 percent rating prior to April 13, 2022, and a 60 percent rating thereafter, the Veteran's 40 percent rating is a maximum rating based upon urinary frequency, but there is no such early evidence of requiring an appliance, absorbent materials changed more frequently than 4 times daily, or any renal dysfunction; meanwhile, the Veteran's 60 percent rating thereafter is a maximum rating based upon needing an appliance then but not earlier, but there is still no evidence of any renal dysfunction. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, with regard to such claim. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record).

The Veteran's claim for higher ratings for her bladder disorder is GRANTED, but only to the extent that a 40 percent rating is warranted from October 11, 2012 to prior to April 13, 2022, but no higher and for no other period of time. The remainder of her claim, including her claim for ratings in excess of 60 percent thereafter, is DENIED. All reasonable doubt has been resolved in the Veteran's favor where evidence of record was at least evenly balanced, but to the extent that the persuasive weight of evidence was against other portions of the claim, the benefit-of-the-doubt rule does not apply there, so those portions of this claim must instead be adjudicated in accordance with the evidence of record. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776
, 2022, but no higher and for no other period of time. The remainder of her claim, including her claim for ratings in excess of 60 percent thereafter, is DENIED. All reasonable doubt has been resolved in the Veteran's favor where evidence of record was at least evenly balanced, but to the extent that the persuasive weight of evidence was against other portions of the claim, the benefit-of-the-doubt rule does not apply there, so those portions of this claim must instead be adjudicated in accordance with the evidence of record. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc).

4. Entitlement to a 20 percent rating effective December 16, 2022, but no higher and no earlier, for service-connected residuals of four (4) surgical scars of the abdomen associated with status post laparoscopic sacro colpopexy, midurethral sling is granted.

Historically, the Veteran's four scars were each initially awarded a noncompensable rating effective December 16, 2022. See Rating Decision (Narrative) (Nov. 11, 2023), at Pages 5-6 of 7, Section No. 5. In a rating decision after the original rating decision, but prior to this one, the AOJ awarded the Veteran a staged rating increase to 20 percent, but only effective January 22, 2024, while maintaining the initial noncompensable rating stage prior to January 22, 2024. See Rating Decision (Narrative) (Apr. 5, 2024), at Pages 3-4 of 6, Section No. 3. Under the Appeals Modernization Act (AMA), the Board is bound by earlier in time findings of fact that are favorable to the appellant. See 38 U.S.C. § 5104A; 38 C.F.R. § 3.104(c).

In short, the Board will resolve reasonable doubt to conclude that the current 20 percent rating should apply effective December 16, 2022, which is the date of the Veteran's surgery. The Board is unable to locate sufficient evidence to specifically identify any date when the Veteran's scars were not painful, so the Board will award backpay and a rating as if the four scars have always been painful. That being said, there is no competent or credible evidence of any of the scars being unstable and painful; meanwhile, there is no dispute that there are exactly four scars, and that the date of the surgery is December 16, 2022.

VA amended the criteria for rating skin disabilities effective from August 13, 2018, and even if the Veteran's underlying bladder disorder claim has been continuously pursued ever since October 11, 2012, this claim for scars (a skin disorder) must be deemed to have come later, because the scars only manifested after surgery dated December 16, 2022. These new regulations apply to all applications for benefits received by VA or that are pending before the AOJ on or after August 13, 2018. The Board may not apply a current regulation prior to its effective date unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). It would strain Board credulity to consider any rating for scars that did not exist prior to December 16, 2022, let alone August 13, 2018.

A claimant may "limit a claim or appeal to the issue of entitlement to a particular disability rating which is less than the maximum disability rating allowed by law" via "clearly expressed intent to limit the appeal to entitlement to a specific disability rating for the service-connected condition." See AB v. Brown, 6 Vet. App. 35, 39 (1993) (citing Hamilton v. Brown, 4 Vet. App. 528, 544 (1993)). There is no competent or credible evidence that DC 7805 should apply for any other residual not otherwise rated, nor is there any such argument. The Veteran's only argument appears to be that the scars have always been painful. The Board will nonetheless fully consider all relevant DC's.

Under the Appeals Modernization Act (AMA), the Board is bound by earlier in time findings of fact that are favorable to the appellant. See 38 U.S.C. § 5104A; 38 C.F.R. § 3.104(c). The Board notes that the Veteran's scars were previously noncompensable from December 16, 2022 until prior to January 22, 2024, and then rated 20 percent thereafter. See, e.g.: Rating Decision (Codesheet) (May 20, 2024). The noncompensable rating is listed under Diagnostic Code 7801, and the 20 percent rating is listed under Diagnostic Code 7804. Id. The Board is bound by the ratings that have already been assigned, because those are intrinsically favorable findings of fact, but if the Board can identify an alternative, but still appropriate, diagnostic code to give the Veteran's scars a more advantageous rating, then the Board can make that adjudication. 38 C.F.R. §§ 4.3, 4.7.

Diagnostic Codes 7800 to 7805 pertain to scars. 38 C.F.R. § 4.118. The Veteran's four scars are located at the abdomen (anterior trunk), which is none of the head, face, or neck. As such, Diagnostic Code 7800 does not apply. Id.

Diagnostic Code 7801 applies to burn scars or scars due to other causes, that are not of the head, face, or neck, and that are associated with underlying soft tissue damage. A 10 percent rating is awarded for area(s) of at least 6 squared inches (39 sq. cm.) but less than 12 sq. in. (77 sq. cm.); a 20 percent rating is awarded for area(s) of at least 12 sq. in. (77 sq. cm.) but less than 72 sq. in. (465 sq. cm.); a 30 percent rating is awarded for area(s) of at least 72 sq. in. (465 sq. cm.) but less than 144 sq. in. (929 sq. cm.); a maximum 40 percent rating is awarded for area(s) of 144 sq. in. (929 sq. cm.) or greater. Id.

Diagnostic Code 7802 applies to burn scars or scars due to other causes, that are not of the head, face, or neck, but that are not associated with underlying soft tissue damage. Under this diagnostic code, a maximum 10 percent rating is awarded for area(s) of 144 sq. in. (929 sq. cm.) or greater of scars that are not associated with underlying soft tissue damage. Id.

Note (1) for each of DC 7801 and 7802 states that for the purposes of DCs 7801 and 7802, the six (6) zones of the body are defined as each extremity, anterior trunk, and posterior trunk. The midaxillary line divides the anterior trunk from the posterior trunk. The Veteran has four scars that are all at her abdomen, which is completely within the anterior trunk. There is no competent or credible evidence of any other scar on any other part of her body, and the Veteran has not made any argument that any other scar is on appeal. Id.

Note (2) for each of DC 7801 and 7802 states that a separate evaluation may be assigned for each affected zone of the body under this diagnostic code if there are multiple scars, or a single scar, affecting multiple zones of the body. If applicable, then the Board should combine the separate evaluations under § 4.25. Alternatively, if a higher evaluation would result from adding the areas affected from multiple zones of the body, a single evaluation may also be assigned under this diagnostic code. This is not true for this Veteran's claim, because the scars are only within the anterior trunk, and no other zones of her body are affected. Id.

Under Diagnostic Code 7804 (unstable or painful scars), a 10 percent rating is awarded where the area presents with one or two scars that are unstable or painful; 20 percent with three or four; and a maximum 30 percent with five or more. Note (1): An unstable scar is one where, for any reason, there is frequent loss of covering of skin over
4.25. Alternatively, if a higher evaluation would result from adding the areas affected from multiple zones of the body, a single evaluation may also be assigned under this diagnostic code. This is not true for this Veteran's claim, because the scars are only within the anterior trunk, and no other zones of her body are affected. Id.

Under Diagnostic Code 7804 (unstable or painful scars), a 10 percent rating is awarded where the area presents with one or two scars that are unstable or painful; 20 percent with three or four; and a maximum 30 percent with five or more. Note (1): An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2): If one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Note (3): Scars evaluated under diagnostic codes 7800, 7801, 7802, or 7805 may also receive an evaluation under this diagnostic code, when applicable. Id. The Veteran has four scars at the abdomen on appeal, and she has not offered any argument that four is the incorrect number of scars.

Under Diagnostic Code 7805 (scars, other), the Board can evaluate any disabling effects not considered in a rating provided under diagnostic codes 7800-04 under an appropriate diagnostic code. Id.

The Veteran submitted to a VA examination for her scars on September 7, 2023. See C&P Exam (Sept. 7, 2023). The examiner correctly identified four scars from the December 2022 surgery, but the examiner characterized all of them as "old healed," not painful, and also not unstable. Id. at Question No. 1 et seq., Pages 1-3 of 10. The examiner confirmed the sizes of each of the four scars (#1, 1 cm long by 0.5 cm wide; #2 [the umbilical scar, as opposed to three abdominal scars], 2 cm long by 0.5 cm wide; #3, 1 cm long by 0.5 cm wide; #4, 1 cm long by 0.5 cm wide; total summed area, 0.4 sq. in. [2.5 sq. cm]), and the examiner also indicated that none of these four scars are tender to palpation, nor are unstable, nor are associated with any underlying soft tissue damage. Id. at Question No. 2E, Page 5.

The Board notes that if all of the above information is correct, then under 38 C.F.R. § 4.118, DC 7800 would not apply (not at the head, face, or neck), the Veteran's scars would not warrant a compensable rating under DC's 7801 or 7802 (no soft tissue damage, but even if there were soft tissue damage, less than 6 sq. in. [39 sq. cm.] in total area of impacted skin), the Veteran's scars would not warrant a compensable rating under DC 7804 either (none of the scars being unstable or painful), and the Board would be unable to interpret any reason to award any higher rating under DC 7805. If there were no other information about the Veteran's scars, then the Board would see no reason to impugn the adequacy of this examination in isolation. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008).

The Veteran next submitted to a VA examination for the scars on February 12, 2024. See C&P Exam (Feb. 12, 2024, rec'd Feb. 13, 2024). This examiner identified the same four scars as originating from the same December 2022 surgery, but in contrast with the previous examination, the scars are now characterized as painful but not unstable, due to keloid formations. Id. at Pages 1-3. The examiner recorded the sizes of each of the four scars, but the reports are not consistent in naming the scars. In this report, Scar #1 is 0.5 cm long by 0.5 cm wide; Scar #2, 1.5 cm long by 1 cm wide; #3, 1 cm long by 0.5 cm wide; #4 [the umbilical scar, as opposed to three abdominal scars, therefore equivalent to Scar #2 in the previous report], 2 cm long by 1 cm wide. Id. at Question No. 2E, Pages 5-6. The umbilical scar [Scar #4 in February 2024,
3. The examiner recorded the sizes of each of the four scars, but the reports are not consistent in naming the scars. In this report, Scar #1 is 0.5 cm long by 0.5 cm wide; Scar #2, 1.5 cm long by 1 cm wide; #3, 1 cm long by 0.5 cm wide; #4 [the umbilical scar, as opposed to three abdominal scars, therefore equivalent to Scar #2 in the previous report], 2 cm long by 1 cm wide. Id. at Question No. 2E, Pages 5-6. The umbilical scar [Scar #4 in February 2024, but Scar #2 in September 2023] grew fatter but did not grow longer, one scar remained the same size of 1 cm long by 0.5 cm wide [Scar #3 in February 2024, which was either Scar #3 or #4 in September 2023], one scar appears to have grown longer and fatter, and one scar appears to have shrunk in length while keeping the same width. See generally C&P Exams, supra. Meanwhile, the February 2024 examiner indicated that all four scars are tender to palpation, and all have underlying soft tissue damage, which is an opposite conclusion from September 2023. Id. Despite these two inconsistencies, the examiners agree that none of the scars are unstable upon inspection. Id.

If these measurements from February 2024 are correct, then the total summed areas of the scars are 0.7 sq. in. (4.3 sq. cm). If all of the other information is correct as well, then under 38 C.F.R. § 4.118, DC 7800 would still not apply (still not at the head, face, or neck), and the Veteran's scars would not still warrant a compensable rating under DC's 7801 or 7802 (assuming that soft tissue damage has always been present, still less than 6 sq. in. [39 sq. cm.] in total area of impacted skin), but the Veteran's four scars would appear to merit the current 20 percent rating under DC 7804, for all four scars being painful, but none of them being unstable and painful. The Board still sees no argument in favor of any higher rating under DC 7805, nor any competent or credible evidence to make such a determination. See generally Scott v. McDonald, 789 F.2d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board to search the record address procedural arguments when the Veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument).

If there were no other information about the Veteran's scars, then the Board would see no reason to impugn the adequacy of this examination in isolation either. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008). Nevertheless, when the above two examination reports are taken together, the Board is unable to reconcile how the same constellation of four abdominal scars (from the same December 2022 surgery) can manifest in soft tissue damage only appearing as of February 2024, but not in September 2023. The Board concludes that if this evidence is at least evenly balanced, then the Board should resolve reasonable doubt in the Veteran's favor by concluding that the scars have at least as likely as not always been associated with underlying soft tissue damage.

Ultimately, in the April 5, 2024 rating decision that granted the 20 percent staged rating increase, the AOJ determined that the Veteran competently complained of a worsening on January 22, 2024. See Rating Decision (Narrative) (Apr. 5, 2024), at Pages 2-5 (Sections "Evidence" and Nos. 3 and 4). The Board has reviewed all of the VA medical evidence that can be permissibly reviewed at this time, i.e.: which was of record as of the April 5, 2024 rating decision. The Board cannot locate the January 22, 2024 notation of factually ascertainable worsening symptoms. See VA Medical Records (rec'd Apr. 5, 2024). On January 22, 2024 (the cited date), the Veteran stated that she needed to cancel future appointments, because she began new employment and would not be able to take enough time off
Apr. 5, 2024), at Pages 2-5 (Sections "Evidence" and Nos. 3 and 4). The Board has reviewed all of the VA medical evidence that can be permissibly reviewed at this time, i.e.: which was of record as of the April 5, 2024 rating decision. The Board cannot locate the January 22, 2024 notation of factually ascertainable worsening symptoms. See VA Medical Records (rec'd Apr. 5, 2024). On January 22, 2024 (the cited date), the Veteran stated that she needed to cancel future appointments, because she began new employment and would not be able to take enough time off. Id. at Page 59 (Jan. 22, 2024). This is not evidence that the scars only became painful on this date. On January 24, 2024, the Veteran stated that her keloids are painful and that the scars are getting bigger, id. at Page 57 (Jan. 24, 2024), but the Board is bound by the AOJ's finding of a worsening two days prior, on the 22nd. Finally, the Veteran sought medical attention on February 2, 2024, complaining of "painful itching at times" at the navel for "months, had abdominal surgery 12/2022," with recent changes being "size." Id. at Page 29 (Feb. 2, 2024). The Board notes that the Veteran stated that this problem began "months" ago, but that January 22, 2024 would be mere weeks ago relative to that date, not "months." Id.

In adjudicating this claim, the Board cannot escape the conclusion that any failure to award a compensable rating prior to January 22, 2024 would be impermissible, as predicated upon an absence of evidence of record. See generally Dalton v. Nicholson, 21 Vet. App. 23 (2007) (an examination was inadequate where the examiner did not comment on a veteran's reports of in-service injury and instead relied on the absence of evidence in a veteran's service treatment records to provide a negative opinion). To the extent that the Veteran has argued that her scars have always been painful ever since her surgery, but may have been intermittently painful, the Board will take her at her word. See, e.g., Layno v. Brown, 6 Vet. App. 465, 470 (1994); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993).

Evidence is at least evenly balanced that the four scars have always been painful but never unstable, so the Board will award a 20 percent rating effective December 16, 2022, but no higher and no earlier. See 38 C.F.R. § 4.118, DC 7804. To this extent only, all reasonable doubt has been resolved in the Veteran's favor, but beyond this extent, there is no competent or credible evidence of a fifth scar or more, any unstable and painful scar, nor scar coverage in excess of 72 sq. in. (465 sq. cm.) with underlying soft tissue damage, so there is simply no basis to award any rating in excess of 20 percent for her scars at any time during the appellate period. The Board determines that after correcting an insufficient noncompensable stage, all other competent and credible evidence of record suggests stability in the Veteran's four abdominal (including umbilical) scars being painful from December 16, 2022 to the present, but never unstable and never having a fifth scar. As such, no further staged rating can be assigned, and the now uniform 20 percent rating is more advantageous than the former staged rating. See Hart v. Mansfield, supra. The Veteran has not raised any other issues, nor has any other issues been reasonably raised by the record, with regard to the increased rating claim adjudicated herein. See Doucette v. Shulkin, 28 Vet. App. 366 (2017).

This claim on appeal is hereby GRANTED IN PART, to the extent that a 20 percent rating is warranted effective December 16, 2022 (no longer merely effective January 22, 2024, with a noncompensable rating prior to that date), but no higher and no earlier, but otherwise DENIED. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc).

5. Entitlement to service connection for a gynecological
ette v. Shulkin, 28 Vet. App. 366 (2017).

5. Entitlement to service connection for a gynecological condition (initially claimed as hysterectomy, oophorectomy, or sacro hysteropexy) is granted.

Under the Appeals Modernization Act (AMA), the Board is bound by earlier in time findings of fact that are favorable to the appellant. See 38 U.S.C. § 5104A; 38 C.F.R. § 3.104(c). The Veteran has a service-connected bladder disorder that also manifests in recurrent urinary tract infections, and the Veteran also underwent a surgical procedure on December 16, 2022, for which a constellation of four scars is service-connected as well.

Service connection may be established on a secondary basis for: (1) a disability that is proximately due to or the result of a service-connected disease or injury; or (2) any increase in the severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease or injury. 38 C.F.R. §§ 3.310(a)-(b); Allen v. Brown, 7 Vet. App. 439, 448 (1995) (explaining 38 C.F.R. § 3.310(b)).

The Veteran submitted to a VA gynecological examination on April 18, 2024. See C&P Exam (Apr. 18, 2024, rec'd Apr. 25, 2024). Relevant diagnoses include a total vaginal hysterectomy with bilateral salpingectomy and a laparoscopic sacro colopexy. Id. at Pages 1-2. The Veteran's bladder disorder has been service-connected throughout the appellate period, and she claims that her December 16, 2022 surgeries were performed to correct an uterovaginal prolapse caused by the bladder disorder. Id. at Pages 2-3, Question Nos. 2 and 4.

The only remaining question is whether the Veteran's current gynecological disorders are attributable to active duty service, namely as secondary to the bladder disorder. The Board notes that the record contains numerous medical opinions which must be considered and weighed. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). See also Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993) (stating that the probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board). When faced with conflicting medical opinions, the Board may favor one medical opinion over the other. See Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995). The Board will consider these opinions below.

In short, the April 2024 etiological opinions conclude that the gynecological disorders were not caused by the bladder disorder, but there is no etiological opinion about whether the gynecological disorders (which might not otherwise be service-connected) underwent an increase in severity that is proximately due to or the result of the service-connected bladder disorder. See C&P Exam (Opinion) (rec'd Apr. 25, 2024); see also cf. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). In other words, the Veteran is entitled to an etiological opinion about whether her hysterectomy or other gynecological disorders were caused
which might not otherwise be service-connected) underwent an increase in severity that is proximately due to or the result of the service-connected bladder disorder. See C&P Exam (Opinion) (rec'd Apr. 25, 2024); see also cf. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). In other words, the Veteran is entitled to an etiological opinion about whether her hysterectomy or other gynecological disorders were caused or accelerated by treatment for the bladder disorder, or whether her gynecological disorders are simply attributable to the natural progression of her life as a woman. The Board interprets this failure as a pre-decisional error in violation of the duty to assist, especially when the opinion also concedes that the Veteran is already service-connected for a laparoscopic sacro colopexy with a midurethral sling.

That being said, instead of remanding and causing unnecessary delay, see Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991), and because the Board is precluded from remanding for the purpose of associating negative evidence against a Veteran's claim with the claims file, see Mariano v. Principi, 17 Vet. App. 305, 312 (2003), the Board will simply grant the claim now, for a gynecological disorder secondarily aggravated by the service-connected bladder disorder. It would strain Board credulity for the Veteran to be service-connected for a constellation of four abdominal scars secondary to treating her service-connected bladder disorder on December 16, 2022, but not the gynecological disorders that are now present and at least as likely as not attributable to the same December 16, 2022 surgeries. By granting the claim in full now, the Board can ensure that the Veteran is not so prejudiced. See Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997). If there is no further symptom to be compensated due to laws against pyramiding, see 38 C.F.R. § 4.14, then the Veteran would be free to file a Notice of Disagreement or a Supplemental Claim about her rating or effective date, which are downstream issues that are simply not on appeal at this time.

Service connection for a gynecological disorder, including but not limited to a total vaginal hysterectomy with bilateral salpingectomy and a laparoscopic sacro colopexy, and as secondarily aggravated by a service-connected overactive bladder disorder with recurrent urinary tract infections, is warranted and must be GRANTED. The evidence of record is at least evenly balanced, so the benefit-of-the-doubt rule applies. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc). This is a full grant of the benefits sought on appeal; therefore, there is no remaining reasonable doubt to resolve.

REASONS FOR REMAND

1. Entitlement to increased ratings in excess of 10 percent effective December 16, 2022 for service-connected residuals status post laparoscopic sacro colpopexy, midurethral sling is remanded.

The Veteran's claim for higher ratings for service-connected residuals status post laparoscopic sacro colpopexy, midurethral sling (currently rated 10 percent disabling effective December 16, 2022) is inextricably intertwined with the granted claim for service connection for the gynecological disorder. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (issues are "inextricably intertwined" when a decision on one issue would have a "significant impact" on a Veteran's claim for the second issue). This claim must be remanded, so that it can be readjudicated after the initial rating and effective date are each assigned.

The matters are REMANDED for the following action:

1. The Veteran's claim for a gynecological disorder, including but not limited to a total vaginal hysterectomy with bilateral salpingectomy and a laparoscopic sacro colopexy, has been granted as secondarily aggravated by a service-connected overactive bladder disorder with recurrent urinary tract infections. Please assign an initial rating and effective date accordingly.

2. After the above is accomplished, readjudicate
inextricably intertwined" when a decision on one issue would have a "significant impact" on a Veteran's claim for the second issue). This claim must be remanded, so that it can be readjudicated after the initial rating and effective date are each assigned.

The matters are REMANDED for the following action:

2. After the above is accomplished, readjudicate the Veteran's claim for increased ratings for service-connected residuals status post laparoscopic sacro colpopexy, midurethral sling. By way of background, this disorder was rated 10 percent disabling effective December 16, 2022, but this claim is dependent upon the outcome of the above granted claim for service connection.

J.P. Norman

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Engle, Michael B.

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.

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