Citation Nr: 1307520 Decision Date: 03/05/13 Archive Date: 03/11/13 DOCKET NO. 08-16 623A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to a compensable rating for scar, right arm, excision of basal cell carcinoma. 2. Entitlement to a compensable rating for actinic keratosis, right arm. 3. Entitlement to a compensable rating for recurrent actinic keratosis, left arm. 4. Entitlement to a compensable rating for scar, left shin, excision of basal cell carcinoma. 5. Entitlement to a rating in excess of 10 percent for scar, left cheek, excision of basal cell carcinoma. 6. Entitlement to a compensable rating for scar, right upper lip, excision of basal cell carcinoma. 7. Entitlement to a compensable rating for recurrent actinic keratosis, scalp. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD T. Stephen Eckerman, Counsel INTRODUCTION The Veteran served on active duty from October 1939 to October 1945. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2007 rating decision of the St. Petersburg, Florida, Department of Veterans Affairs (VA) Regional Office (RO). In January 2008, and April 2012, the Board remanded the claims for additional development. In this regard, in April 2012, the Board remanded these claims, which were characterized as "entitlement to a (compensable) rating for excision of basal cell carcinoma of the left cheek, right upper lip, upper extremity, left shin and lower back," and "entitlement to a (compensable) rating for recurrent actinic keratosis." In November 2012, the AMC granted the claim for a compensable rating for scar of the left cheek (excision of basal cell carcinoma), to the extent that it assigned a 10 percent rating. The RO also recharacterized the issues as stated on the cover page of this remand. The record shows that the Veteran has been found to have skin disorders of the right eyebrow and left shoulder. See reports from Dermpath Diagnostics, dated in 2011. Service connection is not currently in effect for these conditions. Under the circumstances, the issues of service connection are raised by the record. These issues have not been adjudicated by the agency of original jurisdiction, and they are referred to the RO for appropriate action. The issues of entitlement to compensable/increased ratings for scars of the left cheek and right upper lip and recurrent actinic keratosis, scalp, are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. Please note 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). FINDING OF FACT The Veteran's scar, right arm, excision of basal cell carcinoma; actinic keratosis, right arm; recurrent actinic keratosis, left arm; and, scar, left shin, excision of basal cell carcinoma, are not shown to have been productive of deep scars, scars causing limited motion and covering an area exceeding 6 square inches (39 sq. cm.), superficial scars (without a limitation of motion) with an area or areas of at least 144 square inches (929 sq. cm.), superficial and unstable scars, superficial and painful scars on examination, or a limitation of function. CONCLUSION OF LAW The criteria for a compensable rating for scar, right arm, excision of basal cell carcinoma; actinic keratosis, right arm; recurrent actinic keratosis, left arm; and, scar, left shin, excision of basal cell carcinoma, are not shown to have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.118, Diagnostic Codes 7801, 7802, 7803, 7804, 7805, 7818, 7819 (2008, 2012). (CONTINUED NEXT PAGE) REASONS AND BASES FOR FINDING AND CONCLUSION I. Increased Ratings The Veteran asserts that he is entitled to compensable ratings for his: 1) scar, right arm, excision of basal cell carcinoma, 2) actinic keratosis, right arm, 3) recurrent actinic keratosis, left arm, and 4) scar, left shin, excision of basal cell carcinoma. In February 2005, the Veteran filed his claim for service connection. In August 2006, the RO granted service connection for "excision of basal cell carcinoma of the left cheek, right upper lip, upper extremity, left shin and lower back," and assigned a noncompensable rating. The RO also granted service connection for recurrent actinic keratosis, and assigned a noncompensable rating. In each case, the effective date for service connection was February 15, 2005. There was no appeal, and the RO's decision became final. See 38 U.S.C.A. § 7105(c) (West 2002). In October 2006, the Veteran filed claims for increased ratings. In April 2007, the RO denied the claims. The Veteran appealed. In January 2008, and April 2012, the Board remanded the claims for additional development. In November 2012, the AMC recharacterized the issues, and in relevant part, assigned noncompensable ratings for: 1) scar, right arm, excision of basal cell carcinoma, 2) actinic keratosis, right arm, 3) recurrent actinic keratosis, left arm, and 4) scar, left shin, excision of basal cell carcinoma. See 38 C.F.R. § 4.118, Diagnostic Code 7805, Note (1). Disability evaluations are determined by comparing the veteran's present symptomatology with the criteria set forth in the VA's Schedule for Ratings Disabilities. 38 U.S.C.A. § 1155; 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. In evaluating skin and scar residuals, the Board notes that changes have recently been made to 38 C.F.R. § 4.118, Diagnostic Code 7800. These changes apply only to applications for benefits received on or after October 23, 2008, which is well after the date of the appellant's February 2005 claim. However, under typical circumstances, a veteran who is rated under DCs 7800 to 7805 before October 23, 2008, may request review under the amended diagnostic codes, irrespective of whether the Veteran's disability has increased since the last review, but in no case will the revised award be effective before October 23, 2008. Here, while there is no indication that he made such a request, the AMC's November 2012 decision clearly noted that the pre-2008 and post-2008 rating criteria had been considered. The Board will therefore address both the pre-2008 rating criteria and post-2008 rating criteria, even though the Veteran cannot receive a revised award under the new criteria until October 23, 2008. With respect to the pre-2008 criteria, the following diagnostic codes are relevant: Under 38 C.F.R. § 4.118, Diagnostic Code (DC) 7801, scars, other than head, face, or neck, that are deep or that cause limited motion: area or areas exceeding 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.), warrant a 10 percent rating. Note (1): Scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with § 4.25 of this part. Note (2): a deep scar is one associated with underlying soft tissue damage. Under Diagnostic Code 7802, a 10 percent rating is warranted for: scars, other than head, face, or neck, that are superficial and that do not cause limited motion: Area or areas of 144 square inches (929 sq. cm.) or greater. Under 38 C.F.R. § 4.118, Diagnostic Code 7803, a 10 percent rating is warranted for superficial and unstable scars. Under 38 C.F.R. § 4.118, Diagnostic Code 7804, a 10 percent rating for scars that are superficial and painful on examination. Under 38 C.F.R. § 4.118, Diagnostic Code 7805, other scars are rated on limitation of function of the affected part. The notes pertaining to these regulations (re-numbered) are shown below: (1) Scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with § 4.25 of this part. (2) A deep scar is one associated with underlying soft tissue damage. (3) A superficial scar is one not associated with underlying soft tissue damage. (4) An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Under the revised DC 7801, scars other than head, face, or neck, that are deep or that cause limited motion warrant the assignment of a 10 percent rating for an area or areas exceeding 6 square inches (39 sq. cm). 38 C.F.R. § 4.118, DC 7801(2012). Under the revised version of DC 7802, burn scars or scars due to other causes not of the head, face or neck, that are superficial and nonlinear warrant a 10 percent evaluation under DC 7802 when they cover an area or areas of 144 square inches (929 sq. cm.) or greater. 38 C.F.R. § 4.118, DC 7802 (2012). The revised DC 7804 allows for compensable evaluation for unstable or painful scars, regardless of the size. Note (1) of DC 7804 defines an unstable scar as one where, for any reason, there is frequent loss of covering of skin over the scar. Note (3) makes clear that a scar rated under DC 7802 may receive an evaluation under DC 7804 when appropriate. For a 10 percent rating under the revised DC 7804, there must be a showing of one or two scars that are unstable or painful. For a 20 percent rating, there must be three or four scars, and for a 30 percent rating, there must be five or six scars. DC 7805 has not changed, providing that scars may be rated on limitation of function of the affected part. DC 7818 provides that malignant skin neoplasms (other than malignant melanoma) are rated as disfigurement of the head, face, or neck (DC 7800), scars (DCs 7801, 7802, 7803, 7804, or 7805), or rated on impairment of function. A Note to DC 7818 provides that, if a skin malignancy requires therapy that is comparable to that used for systemic malignancies, i.e., systemic chemotherapy, X-ray therapy more extensive than to the skin, or surgery more extensive than wide local excision, a 100-percent rating will be assigned from the date of onset of treatment, and will continue, with a mandatory VA examination six months following the completion of such antineoplastic treatment, and any change in rating based upon that or any subsequent examination will be subject to the provisions of 38 C.F.R. § 3.105(e). If there has been no local recurrence or metastasis, rating will then be made on residuals. If treatment is confined to the skin, the provisions for a 100-percent rating do not apply. 38 C.F.R. § 4.118. Under Diagnostic Code 7819, benign skin neoplasms are rated as disfigurement of the head, face, or neck (Diagnostic Code 7800); scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805); or impairment of function. When the requirements for a compensable rating of a diagnostic code are not shown, a 0 percent rating is assigned. 38 C.F.R. § 4.31 (2012). The Veteran's disabilities currently being decided on appeal do not involve scarring or disfigurement of the head, face, or neck. The disabilities in issue are therefore to be rated as scars (under DCs 7801, 7802, 7803, 7804), or rated on impairment of function (DC 7805). DCs 7818, 7819. Reports from B.T.J., M.D., dated in November 2006, March 2008, and April 2012, state the following: the Veteran has a 14-year history of dematological care, with at least half a dozen solar-inducted carcinomas in areas that include the shoulder, back, leg, and hip. Dozens of precancers have been removed due to pain and tenderness, and they will continue to be ongoing throughout the rest of his life. There is no evidence of recurrence of cancers. The Veteran has recurrence of AKs (actinic keratoses) that need LN (liquid nitrogen) and FTT (failure to thrive) treatment. A VA scar examination report, dated in February 2007, shows that the Veteran's history is noted to include scars secondary to several skin cancers that have been removed. The Veteran complained that his scars itched, and that they get irritated from shaving. This report only contains findings for a scar of the left cheek. A VA skin examination report, dated in February 2007, shows that the examiner indicated that the Veteran's claims file had been reviewed. The Veteran reported a history of half a dozen sun-induced skin cancers, as well as precancers that have been treated over the past 14 years. He indicated that his symptoms were intermittent and progressive. The report indicates the following: there was no history of corticosteroid use or use of immunosuppressive drugs, light therapy, or electron beam therapy. There are no side effects of treatment, and no systemic symptoms. There is no history of benign or malignant neoplasms of the skin. There is no disfigurement, or exfoliative dermatitis. This report only contains findings for scars of the face and neck. A VA skin examination report, dated in January 2011, shows that the examiner stated that the Veteran's claims file had not been reviewed, but that his medical records had been reviewed. The report notes the following: the Veteran has a history of many lesions of keratosis removed from different parts of his skin all over his body, some which were keratotic lesions that were benign, and some were basal cell carcinomas. He is checked by a dermatologist every three months, and lesions were removed PRN (as occasion requires). His medical history includes squamous cell carcinoma, dry skin, keratosis, and dermatitis. On examination, he had many keratotic spots all over his body, with no lesion larger than one centimeter (cm.). No lesion was infected or tender. There was no visible scar on the right upper extremity. The left shin had an old surgical scar of 0.5 mm. (millimeters). The relevant aspect of the diagnosis was status post excision basal cell carcinoma, right upper extremity, and left shin. There were no effects on his ADL (activities of daily living), or work, due to his conditions. Reports from Dermpath Diagnostics, dated between 2008 and 2011, show that in October 2008, the Veteran was found to have squamous cell carcinoma, invasive, well-differentiated, from a left forearm sample. In September 2011, the Veteran was found to have inflamed squamous cell carcinoma in situ from a right forearm tissue sample. A VA scar examination report, dated in April 2012, shows that the Veteran's history was noted to include excision of a lesion from the right distal forearm about six months before, that has healed slowly with bleeding. The report indicates that none of the scars of the trunk or extremities were: painful, "unstable, with frequent loss of covering of skin over the scar," both painful and unstable, or due to burns. The right distal forearm had a 2 cm. linear scar that was nontender, with no erythema. The left upper extremity was not affected. The left lower extremity had a scar at the left shin that was superficial and nonlinear, that measured 0.5 x 0.3 cm. The left lower extremity scar had an approximate total area of 1.0 cm (squared). None of the Veteran's scars resulted in limitation of function. There were no other pertinent physical findings, including, but not limited to, muscle or nerve damage. The relevant diagnoses were scar, right forearm, and scar, left shin, residuals of excision of basal cell carcinoma. A VA skin examination report, dated in April 2012, shows that the Veteran's history was noted to include keratinization skin disorders, with diagnoses of actinic keratosis, residual of removal of basal cell cancer, and residual of removal of squamous cell cancer in situ. The Veteran reported that he had skin discomfort like a pinching sensation at the site of his lesions, especially in the back and head when he lies down at night and that his lesions do not heal soon and bleed after excision. He reported a history of small pigmented areas all over his arms and scalp consistent with actinic keratosis, and the report notes that he did not report any symptoms from this condition other than their appearance. The examiner indicated that there were no systemic manifestations due to skin disease, no treatment with oral or topical medications in the past 12 months, no treatments or procedures other than systemic or topical medications in the past 12 months for exfoliative dermatitis or papulosquamous disorder, and no debilitating, or non-debilitating, episodes in the past 12 months due to urticaria, primary cutaneous vasculitis, erthema multiforme, or toxic epidermal necrolysis. The Veteran's history included treatment for benign or malignant neoplasm or metastases, specifically, a six-month history of excision of basal cell carcinoma from the right forearm. There were no residual conditions or complications due to neoplasm or its treatment, other than those documented. The Veteran has small, hyperpigmented 0.3 x 0.2 areas on his arms and sparse areas on his scalp consistent with actinic keratosis. The Veteran's skin conditions do not impact his ability to work. The Veteran's history includes several areas with freezing with liquid nitrogen for areas of actinic keratoses involving areas that include the right arm. The actinic keratosis constitutes less than 20 percent of exposed area and total body area. His basal cell carcinoma constitutes less than 5 percent of exposed area and total body area. His squamous cell carcinoma constitutes less than 5 percent of exposed area and total body area. There is no eczema. This report is accompanied by unretouched color photographs. The Board finds that the claims must be denied under both the old and new rating criteria. The evidence is insufficient to show that the Veteran's scar, right arm, excision of basal cell carcinoma; actinic keratosis, right arm; recurrent actinic keratosis, left arm; and/or scar, left shin, excision of basal cell carcinoma, are productive of: deep scars, scars causing limited motion and covering an area exceeding 6 square inches (39 sq. cm.), superficial scars (without a limitation of motion) with an area or areas of at least 144 square inches (929 sq. cm.), superficial and unstable scars, superficial and painful scars on examination, or a limitation of function. There is no evidence to show that he has required therapy that is comparable to that used for systemic malignancies, or that he has had local recurrence or metastasis. DC 7818. Finally, the Board notes that the April 2012 VA skin examination report indicates that the Veteran does not have eczema or dermatitis, and that the assignment of a higher or separate compensable rating under DC 7806 (dermatitis or eczema), if such would be warranted, is not applicable to this claim. A compensable rating is simply not warranted pursuant to Diagnostic Codes 7801, 7802, 7803, 7804, 7805, 7818, or 7819. Accordingly, the Board finds that the preponderance of the evidence is against the claim, and that the claim must be denied. The Board has considered the determination in Hart v. Mansfield, 21 Vet. App. 505 (2007), and whether the Veteran is entitled to increased evaluations for separate periods based on the facts found during the appeal period. As noted above, the Board does not find evidence that the Veteran's evaluations should be increased for any other separate period based on the facts found during the whole appeal period. The evidence of record supports the conclusion that the Veteran is not entitled to increased compensation during any time within the appeal period. The Board therefore finds that the evidence is insufficient to show that the Veteran had a worsening of the disabilities on appeal such that an increased rating is warranted. The Board has also considered the Veteran's statements that his skin disability is worse than currently evaluated. He is clearly competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, the Veteran is not competent to identify a specific level of disability pursuant to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran's skin disorders has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings address the criteria under which the disability is evaluated. The Board finds these records to be more probative than the Veteran's subjective evidence of complaints of increased symptomatology. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (interest in the outcome of a proceeding may affect the credibility of testimony). Further, there is no basis to refer the ratings assigned for the Veteran's scars for extraschedular consideration. In exceptional cases where schedular ratings are found to be inadequate, consideration of an extraschedular rating is made. 38 C.F.R. § 3.321(b)(1) (2012). There is a three-step analysis for determining whether an extraschedular rating is appropriate. Thun v. Peake, 22 Vet. App. 111 (2008). First, there must be a comparison between the level of severity and symptomatology of the Veteran's service- connected disability and the established criteria found in the rating schedule to determine whether the Veteran's disability picture is adequately contemplated by the rating schedule. Id. If not, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as governing norms. Id.; see also 38 C.F.R. § 3.321(b)(1) (governing norms include marked interference with employment and frequent periods of hospitalization). If the factors of step two are present, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. There has been no showing that the disability picture for Veteran's scars could not be contemplated adequately by the applicable schedular rating criteria discussed above. The criteria provide for higher ratings, but as has been explained thoroughly herein, the currently assigned rating adequately describe the severity of the Veteran's symptoms for these disabilities during the period of appeal. Given that the applicable schedular rating criteria are adequate, the Board need not consider whether the Veteran's disability picture includes such exceptional factors as periods of hospitalization and interference with employment. Indeed neither hospitalization nor interference with employment has been demonstrated or argued. Referral for consideration of the assignment of a disability rating on an extraschedular basis is not warranted. See Thun, 22 Vet. App. at 111. Finally, although the Veteran has submitted evidence of medical disabilities, and made a claim for the highest rating possible, he has not submitted evidence of unemployability, or claimed to be unemployable. He is over 90 years and presumably retired. He has never made any allegation that his service connected scars have influenced his employment. Therefore, the question of entitlement to a total disability rating based on individual unemployability due to a service-connected disability has not been raised. See Rice v. Shinseki, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). II. The Veterans Claims Assistance Act of 2000 The Board is required to ensure that the VA's "duty to notify" and "duty to assist" obligations have been satisfied. See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). The notification obligations in this case were accomplished by way of letters from the RO to the Veteran dated in March 2005 and October 2006. Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F. 3d 1328 (Fed. Cir. 2006); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The RO has provided assistance to the appellant as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances in this case. It appears that all known and available service treatment reports, and post-service records relevant to the issues on appeal have been obtained and are associated with the Veteran's claims file. The RO has obtained the Veteran's VA and non-VA medical records. The Veteran has been afforded examinations. In April 2012, the Board remanded these claims in order to afford the Veteran new examinations, and it was directed that the Veteran be allowed to identify any outstanding treatment records dated after October 2006, and that all treatment reports be obtained from the Tampa VAMC dated since August 2011. That same month, the Veteran was sent a duty-to-assist letter that was in conformance with the Board's directions. An April 2012 statement from Dr. B.T.J. has been associated with the claims file. Additional VA treatment reports have been obtained, dated between August 2011 and February 2012. In April 2012, the Veteran was afforded VA examinations of his scars, and skin. Concerning these examinations, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In this regard, the Board's April 2012 remand noted, in pertinent part, that private records dated in March 2008 showed treatment for eczema, and that private records dated between June 2009 and December 2011 showed that the Veteran had been treated for squamous cell cancer of areas that included the right chest, and right arm. The Board noted that neither his squamous cell carcinoma, nor his eczema, has been attributed to his service-connected basal cell carcinoma and/or actinic keratosis. The Board directed that the examiner should determine if the Veteran's eczema, and/or squamous cell carcinoma, is related to either of his service-connected skin disabilities, and, if so, that they be evaluated in connection with the appropriate skin disability. The April 2012 VA examination reports show that the examiner recorded the Veteran's current complaints, conducted appropriate examinations, and rendered the appropriate findings, which are consistent with the remainder of the evidence of record. Although pathology reports dated in 2008 and 2009 note squamous cell carcinoma of the left arm, and right chest, respectively, it appears that these disorders are essentially asymptomatic and without residual. Specifically, the April 2012 VA scar examination report indicates that the Veteran's trunk and left upper extremity were not affected. Therefore, residuals of squamous cell cancer of the right chest and left arm are not shown. With regard to squamous cell carcinoma of the right arm, an opinion was not provided, however, all right arm skin symptoms have been attributed to the Veteran's service-connected disability, and a remand is therefore not required. To the extent that the examiner did not provide an opinion as to squamous cell carcinoma of the neck, the Board is remanding this issue. Finally, the April 2012 VA skin examination report shows that eczema was not found. Under the circumstances, the Board finds that there has been substantial compliance with its remand. See Dyment v. West, 13 Vet. App. 141, 146-147 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where Board's remand instructions were substantially complied with); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). The Board concludes, therefore, that decisions on the merits at this time do not violate the VCAA, nor prejudice the appellant under Bernard v. Brown, 4 Vet. App. 384 (1993). Based on the foregoing, the Board finds that the Veteran has not been prejudiced by a failure of VA in its duty to assist, and that any violation of the duty to assist could be no more than harmless error. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). ORDER A compensable rating for scar, right arm, excision of basal cell carcinoma, is denied. A compensable rating for actinic keratosis, right arm, is denied. A compensable rating for recurrent actinic keratosis, left arm, is denied. A compensable rating for scar, left shin, excision of basal cell carcinoma, is denied. REMAND The Veteran asserts that his excision of basal cell carcinoma of the left cheek, right upper lip, and low back, are more severe than the current ratings reflect. He claims that the conditions are recurring, and, in relevant part, that they are painful in the area where he shaves. As an initial matter, in April 2012, the Board remanded these claims, which were characterized as "entitlement to a (compensable) rating for excision of basal cell carcinoma of the left cheek, right upper lip, upper extremity, left shin and lower back," and "entitlement to a (compensable) rating for recurrent actinic keratosis." In November 2012, the AMC granted the increased rating claim for the left cheek, to the extent that it assigned a 10 percent rating. As this increase did not constitute a full grant of the benefits sought, the increased rating issue remains in appellate status. AB v. Brown, 6 Vet. App. 35, 39 (1993). The AMC also recharacterized the issues as stated on the cover page of this remand. In the Board's April 2012 remand, it noted, in pertinent part, that private records dated between June 2009 and December 2011 showed that the Veteran had been treated for eczema, and squamous cell cancer of areas that included the right chest, and right arm, and posterior back of the neck. As the April 2012 VA examination reports show that eczema was not found, that the trunk was not affected, and as all findings for the right arm have been attributed to his service-connected disability, the issues of eczema, and squamous cell carcinoma of the right chest and right arm, therefore need not be further discussed. With regard to squamous cell carcinoma of the posterior back of the neck, private treatment reports show that the Veteran was found to have this condition in June 2010. See June 2010 report from Dermpath Diagnostics; see also January 2011 VA examination report. In its remand, the Board essentially noted that the Veteran's squamous cell carcinoma has not been attributed to his service-connected basal cell carcinoma and/or actinic keratosis. The Board stated, in essence, that it must be determined whether the Veteran's squamous carcinoma of the neck is related to either of the Veteran's service-connected skin disorders, and, if so, that it must be appropriately addressed in the Veteran's ratings. Note (5) of the post-2008 rating criteria, which is now deemed necessary to consider, states that the characteristics of disfigurement may be caused by one scar or multiple scars. The characteristics of neck scar (squamous cell carcinoma), if the condition was found to be related to service, could have effect on the overall rating of the Veteran's scars of the head, face, and neck. The Board further determined that this issue is inextricably intertwined with the issues on appeal, and that they must be adjudicated prior to final determination of the claims. Citing Harris v. Derwinski, 1 Vet. App. 180 (1990). Based on the foregoing, the Board directed that the examiner should determine if the Veteran's squamous cell carcinoma of the posterior neck is related to either of his service-connected skin disabilities, and, if so, that it be evaluated in connection with the appropriate skin disability. In reviewing claims where a VA examination has been performed, the Board must make a determination as to whether the examination report is adequate to make a decision on the claim notwithstanding the fact that the Board may not have found the examination necessary in the first place. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Once VA undertakes the effort to provide an examination when developing a service-connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Id. A review of the subsequently obtained VA examination reports, dated in April 2012, shows that the examiner did not provide an opinion as to whether the Veteran's squamous cell carcinoma of the posterior back of the neck is related to either of his service-connected skin disabilities, nor do the reports contain findings sufficient to evaluate the Veteran's squamous cell carcinoma of the neck. See 38 C.F.R. § 4.118, Diagnostic Codes 7800, 7804, 7805, 7818 (2012). A remand is therefore warranted. See Stegall v. West, 11 Vet. App. 268 (1998) (a remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand order). The Veteran is advised that it is his responsibility to report for any examination and to cooperate in the development of his claims. The consequences for failure to report for a VA examination without good cause may include denial of the claims. 38 C.F.R. § 3.655 (2012). Accordingly, the case is REMANDED for the following action: 1. The RO should schedule the Veteran for a VA skin examination. The claims file should be made available for review, and the examination report should reflect that such review occurred. Unretouched color photographs should be performed in connection with this examination. The physician should provide a report indicating whether or not the Veteran has associated skin changes which are analogous to residual scarring associated with his service-connected skin disabilities. If so, the examiner should indicate whether the scarring/changes are deep and nonlinear, or whether they are unstable and painful. A deep scar is one associated with underlying soft tissue damage. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. The examiner should indicate how many scars/skin changes are unstable and painful, if any. Also, the examiner should report the total area of the body, reported in square inches or square centimeters, affected by residual scarring/skin changes. The examiner should also discuss the location of each body part of the scars/skin changes and the dimensions of the area covered by such should be reported. Further, as the Veteran's scars are on his head, face, and neck, the examiner should indicate if those scarring/skin changes show a scar 5 or more inches (13 cm); scar at least one quarter inch (.06 cm) wide at the widest part; if the surface contour of the scar(s) is elevated or depressed on palpation; if the scar(s) is adherent to underlying tissue; if the skin is hyper- or hypo-pigmented in an area exceeding six square inches (39 sq cm); if the skin texture is abnormal (irregular, atrophic, shiny, scaly, etc) in an area exceeding six square inches (39 sq cm); if there is underlying soft tissue missing in an area exceeding six square inches (39 sq cm); or if there is skin indurated and inflexible in an area exceeding six square inches (39 sq cm). The examiner should determine if it is at least as likely as not (a probability of 50 percent or greater) that the Veteran's squamous cell carcinoma of the posterior neck is related to his either of his service-connected skin disabilities (i.e., basal cell carcinoma or actinic keratosis), and, if so, findings should be made for all scars/body areas affected by the squamous cell carcinoma of the posterior neck, and it should be evaluated in connection with appropriate skin disability. Rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 2. After completing the above actions and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraph, the Veteran's increased rating claims should be readjudicated. If any of the decisions is adverse, the Veteran and his representative should then be issued a supplemental statement of the case. An appropriate period of time should be allowed for 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. 2012). _________________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).