Citation Nr: 1001776 Decision Date: 01/12/10 Archive Date: 01/22/10 DOCKET NO. 02-21 547 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to an initial evaluation in excess of 10 percent for endometriosis with uterine fibroids prior to January 8, 1997, and to an initial evaluation in excess of 30 percent since then. 2. Entitlement to an evaluation in excess of 10 percent for laparoscopy scar. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Joseph R. Keselyak, Counsel INTRODUCTION The Veteran served on active duty from February 1981 to January 1987. This matter comes to the Board of Veterans' Appeals (Board) from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas and Cleveland, Ohio. In a May 2002 rating decision, the Waco RO denied the Veteran's claim for an evaluation in excess of 10 percent for laparoscopy scar. In a March 2004 rating decision, the Waco RO granted the Veteran a separate 30 percent evaluation for endometriosis with uterine fibroids effective April 22, 2002. The Veteran disagreed with this evaluation and the effective date, and, ultimately, in an August 2008 rating decision, the Cleveland RO assigned a 10 percent evaluation for endometriosis with uterine fibroids effective January 8, 1997, and a 30 percent evaluation since then. Because the maximum benefit was not granted, the issue of entitlement to a higher evaluation remains on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). Jurisdiction of the Veteran's claims file now lies with the Cleveland RO. In October 1988 and February 2003 the Veteran was provided hearings before a Decision Review Officer (DRO). Transcripts of the testimony offered at these hearings have been associated with the record. The Board also notes that the Veteran had perfected an appeal with respect to the issues of entitlement to service connection for right breast cancer, entitlement to an evaluation in excess of 40 percent for chronic lumbosacral strain and entitlement to an evaluation in excess of 20 percent for strain, thoracic paraspinal muscles. A November 2008 report of contact indicates that she withdrew her appeal with respect to these claims; thus they are not before the Board. The Board notes that the Veteran initially requested a hearing before the Board. In September 2009 she withdrew this request. The issue of entitlement to an evaluation in excess of 10 percent for laparoscopy scar being remanded is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. The Veteran also appears to have raised a claim for a hernia secondary to her endometriosis with uterine fibroids. This claim is REFERRED to the RO for appropriate action. FINDINGS OF FACT 1. Prior to May 22, 1995, the Veteran's endometriosis with uterine fibroids was not manifested by marked displacement of the uterus and frequent or continuous menstrual disturbances. 2. From May 22, 1995, through October 6, 2003, the Veteran's endometriosis with uterine fibroids was not manifested by bowel or bladder symptoms. 3. Since October 7, 2003, the Veteran's endometriosis with uterine fibroids has manifested by lesions involving the bowel, pelvic pain and heavy, irregular bleeding, not controlled by treatment, and bowel symptoms. CONCLUSIONS OF LAW 1. Prior to May 22, 1995, the criteria for an evaluation in excess of 10 percent for endometriosis with uterine fibroids have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.7, 4.20, 4.116a, Diagnostic Code 7622 (effective prior to May 22, 1995). 2. From May 22, 1995, through October 6, 2003, the criteria for a 30 percent evaluation, but no greater, for endometriosis with uterine fibroids have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.7, 4.14, 4.116, Diagnostic Code 7629 (2009). 3. Since October 7, 2003, the criteria for a maximum 50 percent evaluation for endometriosis with uterine fibroids have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.7, 4.14, 4.116, Diagnostic Code 7629 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Notice and Assistance Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. In the notice, VA will inform the claimant which information and evidence, if any, that the claimant is to provide to VA and which information and evidence, if any, that VA will attempt to obtain on behalf of the claimant. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159 (2008); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). With respect to the endometriosis with uterine fibroids claim, where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess v. Nicholson, 19 Vet. App. 473 (2006); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The appellant bears the burden of demonstrating any prejudice from defective notice with respect to the downstream elements. Goodwin v. Peake, 22 Vet. App. 128 (2008). The Veteran has not alleged any prejudice; thus that burden has not been met in this case. The record also shows that VA has obtained the Veteran's service treatment records, VA records, private medical records, and obtained medical examinations as to the severity of her disabilities. The examinations are thorough, and provide the information necessary to evaluate the Veteran's disability under the appropriate rating criteria. All known and available records relevant to the issue on appeal have been obtained and associated with the Veteran's claims file; and the Veteran has not contended otherwise. VA has substantially complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claim at this time. Laws and Regulations Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2009). Separate rating codes identify the various disabilities. See 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3. The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. Notwithstanding the above, VA is required to provide separate evaluations for separate manifestations of the same disability which are not duplicative or overlapping. See Esteban v. Brown, 6 Vet. App. 259, 261 (1994). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, an appeal from the initial assignment of a disability rating, as in this case, requires consideration of the entire time period involved, and contemplates "staged ratings" where warranted. See Fenderson v. West, 12 Vet. App. 119 (1999). When an unlisted condition is encountered, it should be rated under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (2009). The ratings for gynecologic conditions were changed effective May 22, 1995. 60 Fed. Reg. 19851 (Apr. 21, 1995). The Court has held in the past that where the law or regulation changes after the claim has been filed, but before the administrative or judicial process has been concluded, the version most favorable to the Veteran applies unless Congress provided otherwise or permitted the VA Secretary to do otherwise and the Secretary did so. See Karnas v. Derwinski, 1 Vet. App. 308 (1991). The "Karnas" rule has, however, since been limited to some degree by a decision of the United States Court of Appeals for the Federal Circuit as well as legal precedent of VA's General Counsel. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003) and VAOPGCPREC 7- 03. Now, the revised statutory or regulatory provisions may not be applied to any time period before the effective date of the change. See also 38 U.S.C.A. § 5110(g) (West 2002); 38 C.F.R. § 3.114 (2003); VAOPGCPREC. 3-2000. Under the old criteria in effect prior to May 22, 1995, the Veteran's endometriosis was rated by analogy to displacement of the uterus. 38 C.F.R. §§ 4.20, 4.117 Diagnosic Code 7622 (1994). A maximum 30 percent evaluation was provided under the old criteria for displacement of the uterus where the disability was severe and manifested by marked displacement and frequent or continuous menstrual disturbances. Also, contemplated for lesser 10 percent evaluation under this code were adhesions and irregular menstruation. Id. The Board notes the presence of other diagnostic codes appearing in the old rating schedule pertaining to gynecological conditions. As shown below, the Veteran's disability has predominately manifested by adhesions and irregular menstruation, criteria appearing in this diagnostic code. Under these circumstances, no other diagnostic code appearing in the old rating schedule is arguably more applicable. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). The new criteria provide a specific rating for endometriosis. A 10 percent evaluation is warranted for pelvic pain or irregular bleeding requiring continuous treatment for control. A 30 percent rating is warranted for pelvic pain or heavy or irregular bleeding not controlled by treatment. A maximum 50 percent evaluation requires lesions involving bowel or bladder confirmed by laparoscopy, pelvic pain or heavy or irregular bleeding not controlled by treatment, and bowel or bladder symptoms. It should be noted that the regulation requires that the diagnosis of endometriosis must be substantiated by laparoscopy. 38 C.F.R. § 4.117, Diagnostic Code 7629 (2009). Factual Background Of record is a February 1987 report of VA examination. This report documents normal female genitalia and that the Veteran had had 2 operations for removal of endometrial implants. The Veteran reported dysmenorrhea (difficult and painful menstruation). See Stedman's Medical Dictionary 532 (26th ed. 1995). A scar in the lower abdomen was noted. Her skin was regarded as normal. A private gynecological report, documents that the Veteran presented as a new patient. At this time, she complained of pain with intercourse, heavy bleeding, passing blood clots and vaginal discharge. A history of surgery for endometriosis was noted and the Veteran had a well-healed scar related thereto. A private medical record from the Seton Medical Center dated in June 1987 documents a preoperative diagnosis of pelvic pain and abnormal uterine bleeding. A post-operative diagnosis of mild pelvic endometriosis was assessed. Pathology reports associated with this surgery document no malignancy. An October 1987 note from this provider documents that the Veteran under went exploratory laparotomy, multiple myomectomy, resection of endometriosis and resection of adhesions. The associated operative report, dated October 14, 1987, documents a preoperative diagnosis of large posterior uterine fibroid, rule out endometriosis and a postoperative diagnosis of uterine fibroids, endometriosis and pelvic adhesions. Scarring on the left uterosacral ligament was noted with the colon adherent to that area. It was noted in this report that the Veteran had her menstrual cycle every 28 days. In July 1988, the Veteran was once again afforded a VA examination. She did not complain of any symptomatology related to her service-connected laparoscopy scar or endometriosis. In October 1988, the Veteran testified before a Decision Review Officer. At this hearing, she related that her laparoscopy scar caused her a lot of tenderness and pain when she would bump into something. In November 1988, she was again afforded a VA examination. At this time, she complained that the scar from her surgery was painful and tender. A keloid scar of the lower abdomen was noted. A history of pelvic endometriosis was noted, as was a history of laparoscopy in April 1984 and June 1987. A history of laparotomy/myomectomy, with uterine suspension was noted as well. At the Veteran's request, VA obtained medical records from a Dr. A.C. related to treatment for endometriosis and uterine fibroids. These treatment notes document a history of laparoscopy and laparotomy for myomectomy in 1987, as well as a Caesarean section in 1992. It was noted that at that time the Veteran complained of menorrhagia. A history of multiple fibroids in May 1997 was also noted, including after Depo- Lupron therapy. A June 1997 private treatment note documents a complaint of pain with intercourse and 7 to 10 day menses, even when taking oral contraceptive pills. A subsequent note dated in September 1997 documents a complaint of vaginal discharge and a complaint of hair loss with Lupron treatment. An admission report from the Seton Medical Center dated in January 1998 documents an impression of an irregular uterus and an assessment of uterine fibroids, with a plan to proceed with a myomectomy. The Veteran underwent a myomectomy, with a post and pre-operative diagnosis of uterine fibroids. An April 1998 family practice chart note from the Austin Regional Clinic documents a complaint of increased menstrual flow with menses occurring every 18 days. An assessment of irregular menses with history of uterine fibroids was noted. The Veteran was advised to discuss the options of treating her menstrual irregularity with Dr. A.C. prior to having a tubal ligation. The Veteran was scheduled to have a tubal ligation in May 1998 as she desired to quit using birth control. The operative report associated with her tubal ligation notes dense pelvic adhesions, as well as bowel to uterine adhesions. Of record is a July 2001 pelvic ultrasound report from the Austin Radiological Association. This report notes a clinical history of status-post uterine myomectomies and left lower quadrant pain. In November 2001, the Veteran was seen at the Texas Oncology Center for treatment of breast cancer. Although endometriosis was not the subject of this treatment, the records associated with this treatment note no change in bowel habits, hematemisis or melena. They also note no urinary tract symptomatology at this time. A treatment record from the Austin Regional Clinic documents a complaint of prolonged menstrual cycles. Menorrhagia secondary to fibroids was assessed at this time. Of record is a statement from the Veteran, apparently submitted in December 2002. In this statement, she relates that she had had three laparoscopic surgeries due to her endometriosis and fibroids. She related that she experienced heavy bleeding, blood clots, pelvic pain, and bad cramps on a daily basis. She related that she had opted against having a hysterectomy because of her diagnosis of breast cancer. In April 2002 the Veteran was provided a VA gynecological examination. Although no claims file was available for review by the examiner, the Veteran provided a history of her endometriosis treatment and symptoms. She related that after her discharge from service that she began to have problems with heavy bleeding, severe pain with menses and severe pain with intercourse. She reported some relief with laparoscopy in November 1987, but that heavy bleeding reoccurred about a year thereafter. Two subsequent laparoscopies were noted in 1997 and 1999, each for ligation of a fallopian tube. Examination of the abdomen revealed the presence of a large midline incision with keloid formation and sensation of a small hernia at mid-incision. Examination of the pelvis revealed external genitalia and introitus to be normal. Bartholin's urethra and Skene's glands were likewise normal, as was the vagina. The cervix was parous and clean. The uterus, however, was enlarged 10 to 12 weeks, very irregular and deviated to the left with possible fibroids palpated. The examiner assessed multiple surgical procedures for fibroids and endometriosis while in the military and afterwards, as well as an incisional hernia. The Veteran was counseled that she needed surgical consultation for the possibility of an incisional hernia, which she declined. At the February 2003 DRO hearing, the Veteran related that her laparoscopy scar was tender all of the time. She related that she had been informed that she may have a hernia, but complained mainly of tenderness to touch. She also noted her history of endometriosis and fibroids. She complained of severe menstrual cramps, with clotting, heavy menses and "really bad" pelvic pain. She related that Depro-Lupron shots did not help with her treatment, and thus she opted to have surgery. On October 7, 2003, the Veteran was provided a VA gynecological examination by the same examiner that conducted the April 2002 examination. The examiner noted that the claims file had been reviewed and the Veteran's history of surgeries. At the time of the examination, the Veteran stated that her menstrual periods occurred every 24-26 days and lasted 6 to 8 days. She related that on occasion, she had menstrual cycles that were 16 days apart and that during these menstrual cycles she passed large clots and lost lots of blood. She also reported severe cramps during these episodes. She also complained of severe pain with sexual intercourse and bouts of diarrhea and constipation for months, especially while on her menstrual period. She also reported some stress urinary incontinence for which she had to wear protection. In January 2004 the Veteran was provided yet another VA gynecological examination. In opening, the examiner noted that the claims file had been reviewed and noted the prior history of endometriosis, fibroids and related surgeries. The examiner related that at the present time, the Veteran was having active problems with both endometriosis and large uterine fibroids. The examiner felt that there was not much of a question that the Veteran had had this symptomatology since her period of active service. In February 2004, the Veteran submitted a letter explaining the history of her endometriosis with uterine fibroids. In this letter she relates that since her diagnosis of endometriosis in service that drug therapy had failed to control her heavy bleeding and endometriosis. She further informed in this letter that due to the failure of drug therapy she had to have numerous surgical procedures. She expressed her disagreement with the then assigned 10 percent evaluation, feeling that the evidence had been misinterpreted. An October 2004 VA gynecology consult note documents heavy periods lasting for 6-7 days. At this time, the Veteran reported a history of endometriosis and treatment with Lupron and Danazole, which had failed, as well as surgical treatment. She complained of abdominal pain that was mostly crampy, for which she took Motrin with adequate pain control. Also noted was the history of uterine fibroids and myomectomies, with the last occurring in 1998 with secondary anemia. The Veteran reported having occasional heavy periods where she would need to change pads every 30 minutes. She denied metrorrhagia. There was a mid-line scar of the abdomen, which was soft and non-tender. The vuvla and vagina were within normal limits. The possibility of a hysterectomy was noted if her symptoms and anemia continued. A December 2004 VA gynecology clinic note documents a history of a large pelvic mass seen on MRI and on pelvic examination. At this time, the Veteran reported having two periods in the prior month and that her periods continued to be heavy. The right and left ovaries appeared normal on ultrasound, but pelvic examination revealed a mobile, irregular central mass continuous with the uterus and consistent with fibroids. A January 2005 VA gynecology clinic note documents a recent episode of metrorrhagia. On examination the Veteran's uterus was 16 week size, midline and mobile. Her cervix was slightly deviated to the left. At this time, the Veteran was noted as strongly considering a hysterectomy. In April 2005 the Veteran was again provided a VA gynecological examination. The purpose of the examination was to determine the extent of her endometriosis and whether she suffered from lesions of the bowel or bladder. At this time, the Veteran reported continuing heavy vaginal bleeding and cramping abdominal pain. She was the currently being evaluated for a possible hysterectomy. Her abdomen showed a midline vertical scar that was well-healed. It was soft and non-tender. Pelvic examination was remarkable for a 16 week midline mobile uterus with the cervix slightly deviated to the left. Recent studies, including endometrial biopsy, showed secretory phase endometrium and a 12.2 cm. x 6.5 cm. pelvic mass that appeared to be a uterine fibroid. The examiner noted that from the Veteran's prior surgical evaluation that it was clear that she has had endometriosis involvement of her anterior peritoneum or bladder, but it was unclear if she had endometriosis directly involving her colon. In terms of service connection for such adhesions, the examiner felt that due to her minimal symptoms that laparoscopy solely for confirming the presence of these adhesions would not be advised. In October 2006 the Veteran presented for a VA annual women's health evaluation. At this time, the Veteran reported that it had been a while since she had her period. She related that her most recent period had been painful and longer than the others. She denied problems with urination. She acknowledged that she needed a hysterectomy, but was afraid of the need for hormone replacement therapy. In December 2006 the Veteran presented for a pre-operative visit at VA for an abdominal hysterectomy for the indication of large uterine fibroids. The records associated with this consultation document that the Veteran had over a 3 year history of heavy and irregular vaginal bleeding and pelvic pressure from a 16-plus-week-sized uterine fibroids. The Veteran was noted as having her period every 21 to 31 days and bleed from between 6 and 8 days with clots. A history of three prior myomectomies was noted, with a recent unsuccessful attempt at medical management with NSAIDs. Examination showed an 18 week sized irregular mass arising from the pelvis. The cervix was without lesions and leftward deviated. The uterus was enlarged and lobular, consistent with the known history of fibroids. It measured 15.8 cm. x 11.3 cm. It displaced and compressed the adjacent structures. An abdominal hysterectomy was planned for January 2007. Ultimately, in January 2007, the Veteran underwent a total abdominal hysterectomy and left salpingo-oophorectomy. She tolerated the procedure well with notable findings of a 16- size fibroid uterus with dense adhesive disease of the bowel to the uterus. She was scheduled for a follow-up shortly after the surgery for staple removal. In February 2008 the Veteran was admitted to the Mercy Hospital of Fairfield for complaints of abdominal pain and possible bowel obstruction. The Veteran underwent resection of the bowel due to obstruction, apparently secondary to her history of surgeries. Analysis The Board notes that effective May 22, 1995, the rating schedule was amended to include a diagnostic code directly addressing endometriosis. Resolving any doubt in the Veteran's favor, the Board finds that a 30 percent evaluation should be assigned as of this date through October 6, 2003, and a 50 percent evaluation since then. A 30 percent evaluation is assigned, as noted above, for pelvic pain or heavy or irregular bleeding not controlled by treatment. At the time this regulation became effective, the record noted complaints of menstrual symptomatology, particularly occasional heavy and irregular bleeding. See e.g. June 1987 Seton Medical Center note. Moreover, the Veteran has described having had pelvic pain and heavy/irregular bleeding. She is competent to relate this type of symptomatology, which is observable by a layperson. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As for control with treatment, the record shows that various non-surgical therapies were unsuccessful and that the Veteran had a history of surgeries related to this disability, with continuing symptomatology. Accordingly, as the evidence establishes that at the time this regulation became effective that the Veteran had pelvic pain and heavy/irregular bleeding not controlled by treatment, a 30 percent evaluation is granted effective May 22, 1995. In order to substantiate a higher evaluation, the maximum 50 percent, the evidence would have to show lesions involving bowel or bladder, pelvic pain or heavy irregular bleeding, not controlled by treatment and bowel or bladder symptoms. The Board notes that as of the time the new regulations became effective that the evidence noted scarring of the uterosacral ligament with the colon adherent to that area. See October 1987 operative report. Nevertheless, no evidence of any bowel symptoms appears until October 7, 2003, when the Veteran complained of bouts of diarrhea and constipation for months, especially when she had her period. Accordingly, effective October 7, 2003, a maximum 50 percent evaluation is warranted as this date marks the earliest clinical evidence of bowel symptoms associated with endometriosis. Having addressed the new criteria and assigned an effective date earlier than that previously assigned, the Board will now address evaluation under the old criteria prior to May 22, 1995. Under the old criteria, the Veteran has been assigned a 10 percent evaluation. A maximum 30 percent evaluation requires marked displacement of the uterus and frequent or continuous menstrual disturbances. With reference to the history outlined above, prior to May 22, 1995, there appears no evidence of marked displacement of the uterus or frequent or continuous menstrual disturbances. Prior to this time, the Veteran's disability was mainly manifested by pelvic pain and adhesions. Although dysmenorrhea was noted in February 1987 and menorrhagia was noted in 1992, these appear to be isolated instances as there are numerous occasions during that period in which the Veteran underwent evaluation related to her endometriosis in which she did not report any menstruation problems. Accordingly, prior to May 22, 1995, an evaluation in excess of 10 percent is not warranted. As to the period on and after May 22, 1995, the Board notes that a 30 percent was already assigned above under newer criteria of Diagnostic Code 7629. As 30 percent was the maximum rating available under Diagnostic Code 7622, a higher rating is not available under that code. Furthermore, separate disabilities ratings under these codes would constitute pyramiding, in violation of 38 C.F.R. § 4.14 (2009). The Board has also considered whether the Veteran's disability presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of an extra-schedular rating is warranted. See 38 C.F.R. § 3.321(b)(1) (2009); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology; thus, her disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extraschedular consideration is not warranted. (CONTINUED ON NEXT PAGE) ORDER Entitlement to an initial evaluation in excess of 10 percent for endometriosis with uterine fibroids prior to May 22, 1995, is denied. Entitlement to an evaluation of 30 percent, but no greater, for endometriosis with uterine fibroids is granted effective May 22, 1995, through October 6, 2003, subject to the laws and regulations governing the award of monetary benefits. Entitlement to an evaluation of 50 percent, but no greater, for endometriosis with uterine fibroids is granted effective October 7, 2003, subject to the laws and regulations governing the award of monetary benefits. REMAND The Board notes the Veteran's history of several surgeries related to her endometriosis with fibroids. Her last VA gynecological examination was performed in April 2005, which noted a well-healed, soft, non-tender midline vertical scar. In January 2007, the Veteran underwent an abdominal hysterectomy due to her endometriosis with fibroids, which involved further surgery to the abdomen with the placement of surgical staples. Given this history or subsequent surgery, it appears that the Veteran's laparoscopy scar may have increased in severity. When it is indicated that the severity of a service-connected disability has increased since the most recent rating examination, an additional examination is appropriate. VAOPGCPREC 11-95 (April 7, 1995); see also Caffrey v. Brown, 6 Vet. App. 377 (1995); Green v. Derwinski, 1 Vet. App. 121 (1991). Because the record indicates that the severity of the symptomatology associated with the Veteran's laparoscopy scar may have increased in severity, remand for a VA examination is necessary. Moreover, the Board notes that prior VA examinations pertaining to the scars were in adequate. The rating criteria pertaining to scars other than the head, face or neck, provide for evaluation of scars based upon numerous manifestations, including their size, depth, whether they cause limitation of motion or function, as well as instability and pain. See 38 C.F.R. §§ 4.118, Diagnostic Codes 7801-7805. The prior examination reports do not adequately address these criteria, particularly the size of any scaring. Upon remand, all scars associated with the Veteran's endometriosis with uterine fibroids should be evaluated under these criteria. Accordingly, the case is REMANDED for the following action: 1. The Veteran should be scheduled for a VA dermatologic examination to ascertain the extent and severity of her service- connected scars. All required tests should be performed. In accordance with the latest Automated Medical Information Exchange (AMIE) worksheet for dermatological disorders, the examiner is to provide a detailed review of the history, current complaints, and the nature and extent of the Veteran's service-connected scars, particularly the scars associated with her numerous laparoscopies and hysterectomy. All applicable diagnoses must be fully set forth. The claims folder must be available for review by the examiner in conjunction with the examination and this fact should be acknowledged in the report. The examiner is also asked to elicit a complete history directly from the Veteran regarding these scars. 2. After the above development has been completed to the extent possible, as well as any additional development deemed necessary as a result of the development requested in this remand, the claim should be readjudicated. If any benefit sought on appeal remains denied, furnish a supplemental statement of the case (SSOC) to the Veteran and her representative and allow adequate time for a response. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2009). ____________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs