Citation Nr: 1306085 Decision Date: 02/21/13 Archive Date: 02/27/13 DOCKET NO. 11-05 526 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Whether new and material evidence has been received to reopen a previously denied claim of service connection for a chronic headache disability. 2. Entitlement to service connection for a chronic headache disability. 3. Entitlement to an initial compensable disability rating for service-connected pseudofolliculitis barbae (PFB), prior to March 7, 2012. 4. Entitlement to an initial disability rating in excess of 10 percent for service-connected PFB, since March 7, 2012. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD L. B. Cryan, Counsel INTRODUCTION This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The Veteran served on active duty with the United States Marine Corps from November 1974 to February 1976. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2009 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) which granted service connection for PFB, rated 0 percent disabling effective May 4, 2009; declined to reopen the previously denied claims for service connection for a stomach and headache disability; and denied service connection for diabetes mellitus, hypertension, heart disease, peripheral neuropathy of the bilateral upper and lower extremities, and hepatitis C. The case was initially before the Board in January 2012. At that time, the Board issued a decision denying claims of service connection for diabetes mellitus, hypertension, heart disease, and, peripheral neuropathy of upper and lower extremities. Also, the Board denied the Veteran's claim of entitlement to service connection for hepatitis C, to include consideration for compensation under 38 U.S.C.A. § 1151. Finally, the Board denied the Veteran's appeal to reopen a previously denied claim of service connection for a gastrointestinal disability. The issues of entitlement to an initial compensable rating for the service-connected PFB, and the issue of whether new and material evidence had been received to reopen a previously denied claim of service connection for a headache disability were remanded for additional development of the record. On remand, the RO issued a rating decision in September 2012. In that decision, the RO increased the disability rating for service-connected PFB to 10 percent, effective from March 7, 2012. As the award is not a complete grant of benefits, the issue remains in appellate status. See AB v. Brown, 6 Vet. App. 35 (1993) The Board has not only reviewed the Veteran's physical claims file but also the electronic records maintained in the Virtual VA system to insure review of the totality of the evidence. The reopened claim of service connection for a chronic headache disability 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. FINDINGS OF FACT 1. In an unappealed August 1978 rating decision, the RO denied entitlement to service connection for a headache disability based on a finding that no nexus to service was shown. 2. The evidence associated with the claims file since August 1978 relates to an unestablished fact necessary to substantiate the claim, is neither cumulative nor redundant of evidence already of record, and raises a reasonable possibility of substantiating the claim of service connection for a headache disability. 3. Prior to March 7, 2012, PFB has been manifested by hyperpigmentation of an area of the face of six square inches or more; there are no additional characteristics of disfigurement 4. At no time during the appellate period has PFB been manifested by more than one characteristic of disfigurement, visible or palpable tissue loss, gross distortion or asymmetry of one feature or paired set of features, or involvement of greater than 20 percent of the entire body or exposed areas; and, the Veteran has never used systemic therapy such as corticosteroids or other immunosuppressive drugs to treat PFB. CONCLUSIONS OF LAW 1. The August 1978 denial of service connection for a headache disability is final. 38 U.S.C.A. § 7105 (West 2002); 38. C.F.R. §§ 3.104, 20.302, 20.1103 (2012). 2. The criteria for reopening the claim for service connection for a headache disability are met. 38 U.S.C.A. §§ 5108, 7105 (West 2002); 38 C.F.R. §§ 3.102, 3.156 (2012). 3. The criteria for the assignment of an initial 10 percent rating, but no higher, for PFB prior to March 7, 2010, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.21, 4.118, Diagnostic Codes 7800, 7806 (2012). 4. The criteria for the assignment of an initial rating in excess of 10 percent for PFB since March 7, 2010, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.21, 4.118, Diagnostic Codes 7800, 7806 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Assistance VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). With regard to the reopening of the previously denied claim of service connection for a headache disability, the Board is granting in full the benefit sought on appeal. Accordingly, any error committed with respect to either the duty to notify or the duty to assist was harmless and will not be further discussed. With regard to evaluation of PFB, this appeal arises from the Veteran's disagreement with the initial evaluation following the grant of service connection. Once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). No additional discussion of the duty to notify is therefore required. VA also has a duty to assist the Veteran in the development of the claim, which is not abrogated by the granting of service connection. This duty includes assisting the Veteran in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. VA has obtained service treatment records, assisted the Veteran in obtaining evidence, afforded the Veteran physical examinations, obtained medical opinions as to the etiology and severity of disabilities, and afforded the Veteran the opportunity to give testimony before the Board. All known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; and the Veteran has not contended otherwise. The RO complied with the Board's January 2012 remand directives. A review of the claims file reveals that an adequate VA examination of the skin was conducted pursuant to the Board's remand directive. The examiner provided the essential evidence necessary to accurately rate the Veteran's PFB. The Veteran's representative argues that the March 2012 VA examination conducted pursuant to the January 2012 remand directives is inadequate because it did not provide answers to all of the questions posed in the remand. The Board disagrees. The remand directed the VA examiner to identify whether the Veteran's service-connected PFB was manifested by any of the eight characteristics of disfigurement, and if so, the examiner was to identify which characteristics of disfigurement were present. Also, the examiner was to identify whether the PFB resulted in any scarring of the head, neck or chest, and if so, to describe the scars, including whether they were painful or unstable. Finally, the examiner was asked to provide the percentage of the entire body and the percentage of the exposed area affected by the PFB. In response to these inquiries, the March 2012 examiner specifically noted that the Veteran's PFB was productive of one characteristic of disfigurement - hyperpigmentation; and, although the examiner did not specifically indicate whether the area of hyperpigmentation covered at least 6 square inches, the Board, as noted below, has resolved all doubt in the Veteran's favor in concluding that it does. Moreover, in answering the question on the examination report as to whether any of the Veteran's skin conditions cause scarring or disfigurement of the head, face or neck, the examiner checked the "yes" box. Following that question, the examination report followed with, " If yes, indicate skin condition and describe scarring and/or disfigurement:" The examiner indicated that the Veteran had hyperpigmentation. At no time did the examiner indicate that the Veteran had painful or unstable scarring. Moreover, the examiner concluded the examination by answering "no" to the following question, "Does the Veteran have any other pertinent physical findings, complications, conditions, signs, and/or symptoms related to any conditions listed in the diagnosis section above?" Although the examiner did not explicitly state that the Veteran did not have painful or unstable scarring, these symptoms can be ruled out by the way the examiner answered various questions on the March 2012 DBQ examination report. The examiner then specifically described the percentage of the entire body and the percentage of the exposed area affected by the PFB. The examiner satisfactorily answered all the medical questions posed in the remand directives. In addition, VA treatment records from 1999 through 2012 have been associated with the file. For these reasons, the agency of original jurisdiction (AOJ) complied with the January 2012 remand orders and no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 106 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). 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. II. New and Material Evidence In an August 1978 rating decision, the RO denied the Veteran's claim of service connection for a headache disability. The Veteran did not submit a Notice of Disagreement (NOD) or new and material evidence within one year of receiving notice of that determination. Prior unappealed decisions are final. However, a claim will be reopened and the former disposition reviewed if new and material evidence is presented or secured with respect to the claim which has been disallowed. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a). When "new and material evidence" is presented or secured with respect to a previously and finally disallowed claim, VA must reopen the claim. Manio v. Derwinski, 1 Vet. App. 140, 145 (1991). New evidence means evidence not previously submitted to agency decisionmakers. Material evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a) (2012). The Court interpreted the language of 38 C.F.R. § 3.156(a) as creating a low threshold, and viewed the phrase "raises a reasonable possibility of substantiating the claim" as "enabling rather than precluding reopening." The Court emphasized that the regulation is designed to be consistent with 38 C.F.R. § 3.159(c)(4), which, "does not require new and material evidence as to each previously unproven element of a claim." Shade v. Shinseki, 24 Vet. App. 110 (2010). For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence, although not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). Service connection for a headache disorder was denied in the August 1978 rating decision on the grounds that no nexus to service was shown. Evidence consisted of service treatment records showing no diagnosis of or treatment for headaches, and an August 1978 VA examination report diagnosing headaches of unknown etiology, probably due to tension. The Veteran reported headaches since early 1976. Since August 1978, the Veteran has reported that he sustained a head injury in service, when involved in a car accident in May 1975. The Veteran is competent to report an injury in an accident, and his allegation is presumed credible for purposes of reopening. The car accident is referred to in service treatment records, but there was previously no mention of a head injury. The allegation is therefore new. As the occurrence of a head injury as described by the Veteran, involving some loss of consciousness, could result in residual headaches, the allegation is material and, by prompting additional development, raises the reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156; Shade v. Shinseki, 24 Vet. App. 110 (2010). Reopening of the previously denied claim is warranted. Adjudication of the Veteran's claim does not end with the determination that new and material evidence has been received. This matter must now be addressed on a de novo basis. For the reasons detailed in the remand section, additional development is required for a full and fair adjudication of the underlying service connection claim. III. Increased Rating - PFB The Veteran seeks a higher initial disability rating for the service-connected PFB, rated as noncompensable from the effective date of service connection and rated as 10 percent disabling effective from March 7, 2012. Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity resulting from a disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. In a claim for a greater original rating after an initial award of service connection, all of the evidence submitted in support of the Veteran's claim is to be considered. In initial ratings cases, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged ratings." See Fenderson v. West, 12 Vet. App. 119 (1999). 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 for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board has considered staged ratings in this case, but, as will be further discussed below, the evidence shows that the Veteran's service-connected PFB symptoms have remained fairly consistent throughout the appeal period. As such, staged ratings are not for application in this case. Where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. The rating schedule also provides that when an unlisted disability is encountered, it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. §§ 3.102, 4.3. The Veteran filed his initial claim of service connection for PFB in May 2009. At a November 2009 VA examination, the examiner noted the Veteran's medical history with regard to the PFB, and in particular, that the Veteran was given a shaving profile for moderate PFB. The Veteran reported that he has had ongoing problems with his PFB since that time. He now uses a spatula and a chemical magic shaving powder, which was described as a depilatory and spatula to remove his beard hair. With that, the Veteran did not have ingrown hairs; however he had residual hyperpigmentation below his jaw in the region previously affected by the PFB, as well as some itching under his chin. The Veteran also described areas on his upper back and chest that were covered with hyperpigmented irregular plaques, or macules over this area. They were pruritic, and the Veteran believed that this condition was an extension of the facial PFB. The examiner noted that the Veteran took no systemic medication, had no systemic symptoms and had no neoplasms. On examination, there were almost contiguous hyperpigmented bumps from previous PFB and scarring. He did not have ice-pick scars of his jaw or his neck. On his upper chest, and more significantly, on his back, he had scattered hyperpigmented, macules with a tinea appearance, which were distinct from and not a part of his PFB. He had no disfiguring scars. They were superficial. The hyperpigmentation on his neck was not visually apparent as one looked at him. Moreover, there was less than 1 percent of exposed areas affected and less than 1 percent of the entire body affected. The diagnoses were PFB requiring the use of magic shaving creams or depilatory; and, tinea corporis not related to PFB. The Veteran had another VA skin examination in March 2012. The examiner noted a diagnosis of PFB, and that of acne. The Veteran reported that he continues to have outbreaks of the lesions on his face and chin after shaving. The Veteran continued to use Selenium Sulfide 2.5% lotion, ML. On examination, the Veteran's face was unshaven with an immense amount of hair to the face and chin area. Some healing lesions to the neck area with a hyperpigmented base under the facial hairs were noted. With regard to disfigurement of the head, face and/or neck, the examiner noted hyperpigmentation. There were no neoplasms or systemic manifestations due to any skin diseases. The Veteran did not use systemic corticosteroids or other immunosuppressive medications for the PFB. With regard to the exposed body area (face, neck and hands), the examiner described the Veteran's PFB (rated by analogy to eczema) as covering at least 5 percent but less than 20 percent of total body area, and covering at least 5 percent and less than 20 percent of exposed areas. Finally, the examiner noted that the Veteran's skin condition did not impact his ability to work. The claims file contains several black and white photocopies of the back of the Veteran's head and upper back, as well as his chin and beard, to support his claim. It is not clear where the photographs originated, although there is a handwritten note attached to the photos indicating that they are from the Veteran. These photographs are not legible for the purposes of identifying the severity of the Veteran's PFB. The Veteran's service-connected disability of PFB consists of an infection of the skin that is not specifically identified in the rating criteria. Under 38 C.F.R. § 4.118, Diagnostic Code 7820, infections of the skin not listed elsewhere in the rating criteria (including bacterial, fungal, viral, treponemal and parasitic diseases) are rated as disfigurement of the head, face, or neck (Diagnostic Code 7800); scars (Diagnostic Code 7801, 7802, 7804, or 7805); or dermatitis (Diagnostic Code 7806), depending on the predominant disability. In this case, Diagnostic Codes 7800 and 7806 are the only diagnostic codes applicable. Diagnostic Codes 7801 and 7802 apply to scars other than those of the head, face or neck, and as there is no evidence to suggest that the Veteran's PFB covers any area other than the head, face or neck, application of Diagnostic Code 7801 and 7802 are not at issue here. Further, as there is no evidence showing that the Veteran's PFB is manifested by painful or unstable scars, Diagnostic Code 7804 is not applicable in this case. Diagnostic Code 7805 covers other scars, including linear scars, and other effects of scars evaluated under Diagnostic Codes 7800, 7801, 7802, and 7804. Under this code, any disabling effects not considered in a rating provided under Diagnostic Codes 7800-7804 should be considered under an appropriate diagnostic code. Because there are no disabling affects that are not already considered under Diagnostic Codes 7800 and/or 7806, (as explained in greater detail below) application of Diagnostic 7805 is not at issue in this case. See 38 C.F.R. § 4.118, Diagnostic Codes 7801-7805. Moreover, as noted in the Introduction section above, there is no evidence of painful or unstable scarring associated with the PFB. Diagnostic Code 7806 provides ratings for eczema. Under Diagnostic Code 7806, a 60 percent rating is assigned when more than 40 percent of the entire body or more than 40 percent of exposed areas is affected, or when constant or near-constant systemic therapy, such as corticosteroids or other immunosuppressive drugs, was required during the past 12-month period. A 30 percent rating is assigned when 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas is affected, or when systemic therapy, such as corticosteroids or other immunosuppressive drugs ,was required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 10 percent rating is assigned when at least five percent, but less than 20 percent of the entire body, or at least five percent, but less than 20 percent, of exposed areas is affected, or; intermittent systemic therapy was required for a total duration of less than six weeks during the past 12-month period. A noncompensable rating is assigned when less than five percent of the entire body or less than five percent of exposed areas are affected, and; no more than topical therapy was required during the past 12-month period. Or, in the alternative, Code 7806 allows for a rating based on disfigurement of the head, face or neck (Diagnostic Code 7800); or scars (Diagnostic Codes 7801-7805) depending on the prominent disability. Diagnostic Code 7800 is used to rate burn scars of the head face or neck, scars due to other causes on the head face or neck; and, disfigurement of the head, face, or neck. Under Diagnostic Code 7800, a 10 percent evaluation is assigned for one characteristic of disfigurement. A 30 percent evaluation is assigned for visible or palpable tissue loss and either gross distortion or asymmetry of one feature or a paired set of features, (features include nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, and lips); or, with two or three characteristics of disfigurement. A 50 percent evaluation is assigned for visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features, or; with four or five characteristics of disfigurement. An 80 percent evaluation is assigned for visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features, or; with six or more characteristics of disfigurement. The eight characteristics of disfigurement are: a scar, five or more inches in length; a scar, at least one-quarter inch wide at widest part; surface contour of a scar that is elevated or depressed on palpation; a scar that is adherent to underlying tissue; hypo-or hyper-pigmented skin in an area exceeding six square inches; abnormal skin texture in an area exceeding six square inches; underlying soft tissue missing in an area exceeding six square inches; and indurated and inflexible skin in an area exceeding six square inches. When applying the criteria to the evidence in this case, under Diagnostic Code 7806, a compensable rating is not warranted prior to March 7, 2012 because the affected areas are not of sufficient size and the Veteran has not required more than topical therapy. However, the evidence of record, since the effective date of service connection, has always shown that the Veteran has residual hyperpigmentation on his face from the service-connected PFB. Hyperpigmented skin on the head, face or neck is considered one of the eight characteristics of disfigurement if it is in an area that is at least 6 square inches. Although the examination report from November 2009 does not specifically state whether the PFB hyperpigmentation covers an area of at least 6 square inches, it is described as "almost contiguous hyperpigmented bumps from the previous PFB and scarring." Because this residual hyperpigmentation has been described as having occurred on the beard area and neck, it is reasonable to assume that the total area under consideration more nearly approximates 6 square inches. In addition, since there are no photographs provided by the examiner, the Board will afford the Veteran all reasonable doubt that the area involving the pigment changes has been at least 6 square inches throughout the appeal period. The Veteran's examination reports do not describe any of the other eight characteristics of disfigurement. In applying this code, the criteria have been met for the assignment of a 10 percent rating for the entire period covered by this appeal pursuant to Diagnostic Code 7800. The criteria have not been met for the assignment of a disability rating in excess of 10 percent for the service-connected PFB at any time during the period covered by this appeal. The evidence of record does not indicate that the Veteran's PFB is manifested by a scar, five or more inches in length; a scar, at least one-quarter inch wide at widest part; surface contour of a scar that is elevated or depressed on palpation; a scar that is adherent to underlying tissue; abnormal skin texture in an area exceeding six square inches; underlying soft tissue missing in an area exceeding six square inches; or, indurated and inflexible skin in an area exceeding six square inches. Because no more than one characteristic of disfigurement is shown, a rating in excess of 10 percent under Diagnostic Code 7800 is not for application in this case. Similarly, in considering the Veteran's PFB pursuant to the criteria at Diagnostic Code 7806, the criteria for the assignment of a rating in excess of 10 percent are also not met. At the March 2012 VA examination, the examiner indicated that the service-connected PFB affected at least 5 percent but less than 20 percent of exposed areas and of body area. This range of affected body area and/or exposed body area corresponds with the assignment of a 10 percent rating under Diagnostic Code 7806. In order to warrant a rating in excess of 10 percent under Diagnostic Code 7806, the evidence would have to show that the PFB covered at least 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas, or the Veteran would have to show that he required the use of systemic therapy, such as corticosteroids or other immunosuppressive drugs, for a total duration of six weeks or more, but not constantly, during the past 12-month period. The evidence of record in this case shows that the Veteran uses a topical cream for the PFB, but has never used a corticosteroid or immunosuppressive drug for the PFB. Further, the PFB and its residuals have never been shown to cover at least 20 percent of the Veteran's entire body or 20 percent of the exposed areas affected. Based on these criteria at Diagnostic Codes 7800 and 7806, a rating in excess of 10 percent is not warranted at any time covered by this appeal. Although the Veteran believes that his "rash" described as pruritic papules on the upper chest and back is part of the PFB, the examiner in 2009 specifically addressed this contention and explained that the PFB residuals were limited to the Veteran's head, face and neck, and that the disability on the upper chest and back was best described as acne or tinea. As such, the area covered with the acne and/or tinea is not considered part of the service-connected PFB. Moreover, as noted in the Introduction section above, the examiner in March 2012 noted hyperpigmentation as the only disfiguring characteristic on the face/neck, and specifically indicated that there were no other signs or symptoms relative to the PFB that were not discussed on examination. From these findings, it is reasonable to assume that the Veteran does not have painful or unstable scarring as a result of the PFB. For all the foregoing reasons, the criteria for the assignment of a 10 percent rating, but no higher, have been met since the effective date of service connection. In considering the claim for a higher rating, the Board also has considered whether the Veteran is entitled to a greater level of compensation on an extra-schedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). In a recent case, the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). First, the RO or the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the C&P Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. The symptoms associated with the Veteran's PFB are not shown to cause any impairment that is not already contemplated by the relevant diagnostic codes, as cited above. The Veteran's residuals of his PFB are described as hyperpigmented, which is a specific characteristic of disfigurement of the head, face or neck. Further, the body area and exposed areas of PFB have been measured and the Veteran's disability rating is also based on these measurements. No other functional impairment has been described upon which to rate the PFB. The March 2012 VA examination specifically noted that the service-connected PFB had no affect on the Veteran's employment. Thus, the rating criteria reasonably describe his disabilities. Therefore, referral for consideration of an extraschedular rating is not warranted. ORDER Reopening of the previously denied claim of service connection for a headache disability is granted. An initial 10 percent rating, but no higher, for PFB prior to March 7, 2010, is granted. An initial rating in excess of 10 percent for PFB since March 7, 2010, is denied. REMAND Having reopened the Veteran's claim of service connection for a chronic headache disability, the Board has jurisdiction to review the issue de novo, based on the whole record. Further evidentiary development is necessary. The Veteran has alleged a head injury in service during the May 1975 car accident in which a back injury is reflected in service treatment records. He argues that headaches have either been present since that time, or developed soon after service and are related to the reported head injury. Treatment records document that headache complaints and care for such began in early 1976, within the first post service year, and the Veteran has periodically appeared for treatment of headaches or has registered complaints of such when seeking treatment for other conditions. He and his wife have indicated that headaches have been present since service. Current records show headache complaints. In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A(d) and 38 C.F.R. § 3.159(c)(4). The threshold for determining the possibility of a nexus is a low one. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Examination and a nexus opinion are therefore required here. The evidence indicates a possible injury in service, and the onset of headaches in close proximity to service. Current symptoms are reported. Both the potential application of presumptive service connection for a neurological disease and the possibility of direct service connection satisfy the need to potential nexus. Because the claims file is being returned it should be updated to include any recent VA treatment records that are not of record, and, in particular those records dated as of August 1, 2012. See 38 C.F.R. § 3.159(c)(2); see also Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, the case is REMANDED for the following action: (This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is required.) 1. Contact the Veteran and request that he identify any and all non-VA sources of treatment for his headaches since discharge from service that have not already been associated with the claims file. In particular, the Veteran should provide, or authorize VA to obtain, any pertinent private records which are not already of record. 2. Associate with the claims file relevant VA medical treatment records pertaining to the Veteran not already of record, and in particular, those from August 1, 2012. 3. Thereafter, schedule the Veteran for an appropriate neurological examination regarding his claim of service connection for a chronic headache disability. The entire claims file (i.e. the paper claims file and any medical records contained in Virtual VA, CAPRI, and AMIE) must be reviewed by the examiner in conjunction with the examination. If the examiner does not have access to Virtual VA, any relevant treatment records contained in Virtual VA file that are not available on CAPRI or AMIE must be printed and associated with the paper claims file so they can be available to the examiner for review. The examiner is specifically requested to set forth the diagnosis for any current headache disability found, and opine as to whether any diagnosed condition at least as likely as not caused or aggravated by active service. In other words, are the Veteran's current headaches, if found, the same, or similar to, the headaches from which he suffered in service or shortly after service? In that regard, the examiner's attention is directed to service treatment records which do not show complaints of findings of a chronic headache disability; however, the examiner is also directed to the report of a car accident in service, medical records from 1976 (within the first post-service year) and 1978 which show treatment for headaches, as well as the Veteran's statement that he has had headache pain that began in service and has continued ever since. 4. Review the claims file to ensure that all of the foregoing requested development is completed, and arrange for any additional development indicated. Then readjudicate the claims on appeal. If the benefit sought remains denied, issue an appropriate supplemental statement of the case and provide the Veteran and his representative the requisite period of time to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter 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. 2012). ______________________________________________ WILLIAM H. DONNELLY Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs