Citation Nr: 1309732 Decision Date: 03/22/13 Archive Date: 04/01/13 DOCKET NO. 10-18 996 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to an initial compensable rating for herpetic whitlow of the left index finger. 2. Entitlement to an initial compensable rating for aphthous stomatitis. REPRESENTATION Veteran represented by: AMVETS WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD E. Woodward Deutsch, Counsel INTRODUCTION The Veteran served on active duty in the United States Navy from July 1982 to June 1988 and from December 1988 to December 2007. These matters comes before the Board of Veterans' Appeals (Board) on appeal from an April 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina, as part of the Benefits Delivery at Discharge (BDD) program. The purpose of the BDD program is to help ensure a smooth transition from military to civilian status by allowing service members to file pre-discharge claims for disability compensation with VA. Procedural history In the above rating decision, the Winston-Salem RO granted service connection and assigned initial noncompensable disability ratings for herpetic whitlow of the left index finger and aphthous stomatitis. Although the Veteran did not contest the effective date of either service-connection award, she disagreed with the assigned ratings and subsequently perfected an appeal with respect to each of the above-captioned issues. In December 2012, the Veteran testified via videoconference from the St. Petersburg, Florida, RO at a hearing before the undersigned, who was designated to conduct that proceeding from the Board's Central Office. See 38 U.S.C.A. § 7101 (c) (West 2002 & Supp. 2012). A transcript of the hearing has been associated with the Veteran's Virtual VA efolder and, thus, is considered part of the record. See Veterans Benefits Administration Fast Letter 11-28 (outlining revised procedures related to electronic records). At the hearing, she submitted additional evidence and waived her right to have it initially considered by the RO. 38 C.F.R. §§ 20.800, 20.1304(c) (2012). As a final introductory matter, the Board notes that this appeal has been processed using the Virtual VA paperless claims processing system. Accordingly, any future consideration of the Veteran's case should take into consideration the existence of this electronic record. The issue of entitlement to an initial compensable rating for aphthous stomatitis is addressed in the REMAND portion of the decision below and is REMANDED to the Department of Veterans Affairs Regional Office. FINDINGS OF FACT 1. Since the effective date of service connection, the Veteran's herpetic whitlow of the left index finger has been manifested by painful scarring, which covers less than five percent of her body and the exposed areas therein, and is not accompanied by underlying tissue damage. Although antiviral medication has been prescribed to treat that service-connected disability, there has been no documented need for intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs. 2. Since the effective date of service connection, the competent evidence of record has not presented an exceptional or unusual disability picture for the Veteran's herpetic whitlow of the left index finger so as to render impractical the application of the regular schedular standards. CONCLUSIONS OF LAW 1. The criteria for an initial 10 percent disability rating, but no higher, for the Veteran's herpetic whitlow of the left index finger have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.118, Diagnostic Codes (DCs) 7804, 7806 (regulations in effect prior to October 23, 2008). 2. The criteria for referral for consideration of an increased rating for herpetic whitlow of the left index finger on an extraschedular basis have not been met. 38 C.F.R. § 3.321(b)(1) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Board has given consideration to the provisions of the Veterans Claims Assistance Act of 2000 (VCAA). The VCAA includes an enhanced duty on the part of VA to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. The VCAA also redefines the obligations of VA with respect to its statutory duty to assist claimants in the development of their claims. As noted in the introduction, the Veteran's claim for an increased initial rating for herpetic whitlow of the left index finger arises from her disagreement with the initial evaluation assigned 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 original notice is not considered prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Accordingly, the Board finds that VA has satisfied its duties to notify the Veteran with respect to her herpetic whitlow claim, the only issue decided herein. Next, with respect to the duty to assist, the Board observes that the Veteran's service and post-service treatment records have been obtained and associated with her Virtual VA efolder. She also has been afforded VA examinations in September 2009 and May 2010. Significantly, the Veteran has not advised the Board of any treatment records that remain outstanding. Nor has she complained of any inadequacies inherent in the above VA examinations. Moreover, the record does not otherwise suggest a need for additional records development or VA examinations with respect to the Veteran's herpetic whitlow claim. In this regard, the Board acknowledges that her last VA examination was conducted more than two years ago. Nevertheless, it is a well-established tenet of VA law that a claim need not be remanded solely because of the passage of time since an otherwise adequate examination was administered. See VAOPGCPREC 11-95; see also Palczewski v. Nicholson, 21 Vet. App. 174 (2007). As a final matter regarding the duty to assist, the Board observes that the Veteran has had the opportunity to testify in support of her herpetic whitlow claim during the aforementioned videoconference hearing. 38 C.F.R. § 20.700(a). The transcript of the proceeding reflects that that the undersigned properly set forth that claim and the other issue on appeal. The VA hearing officer then focused on the elements necessary to substantiate those claims and sought to identify any further development that was required. Significantly, the Veteran has not contended, and the evidence has not otherwise shown, that the undersigned committed prejudicial error, either by failing to fully explain the issue decided herein and or by neglecting to suggest the submission of evidence that may have been overlooked. See Bryant v. Shinseki, 23 Vet. App. 488 (2010). Furthermore, there is no indication that the Veteran was otherwise denied due process during her videoconference hearing. In light of the foregoing, the Board finds that VA's duties to notify and assist have been satisfied with respect to the herpetic whitlow claim and, thus, appellate review of that issue may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). Initial Increased Rating for Herpetic Whitlow of the Left Index Finger The Veteran, in written statements and testimony before the Board, contends that her service-connected herpetic whitlow had its onset in 1991 and has since been manifested by painful breakouts across her left index finger. She further alleges that, while her symptoms only flare up once or twice each year, they require ongoing suppressive treatment. As such, she claims entitlement to a compensable rating under DC 7806. 38 C.F.R. § 4.118, Diagnostic Code 7806. In evaluating the merits of the Veteran's claim, the Board notes, at the outset, that disability ratings are assigned in accordance with the VA Rating Schedule and are intended to represent the average impairment of earning capacity arising from those disabilities for which service connection has been established. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1 (2012). If two schedular ratings are potentially applicable, the higher evaluation will be assigned if the overall disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2012). Consideration will also be given to staged ratings to account for divergent levels of disability that may have manifested since the date of service connection. See Fenderson v. West, 12 Vet. App. 119 (1999). The various diagnostic codes for rating disabilities are set forth in 38 C.F.R. Part 4. The assignment of a particular diagnostic code is dependent on the facts of a particular case. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. In reviewing the claim for a higher rating, the Board must consider which diagnostic code or codes are most appropriate for application in the Veteran's case and provide an explanation for the conclusion. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). In this case, while the Veteran's herpetic whitlow has been rated by analogy to dermatitis or eczema (DC 7806), the Board finds that the criteria governing scars not of the head, face, or neck (DCs 7801-7805) are also for application. 38 C.F.R. § 4.118, Diagnostic Codes 7801, 7802, 7803, 7804, 7805, 7806. Portions of the above rating criteria were revised, effective October 23, 2008. However, the amendments only apply to claims received on or after that date. 73 Fed. Reg. 54, 708 (Sept. 23, 2008). While a claimant can request a review under the new criteria, the Veteran in this case has not done so. Accordingly, the Board finds the revised provisions for rating skin disabilities do not apply to her claim. Even if the foregoing amendments were for application, the Board observes that they did not substantively alter DC 7806, which has remained effectively unchanged throughout the entire appeals period. Under that diagnostic code, a 0 percent rating is warranted where less than 5 percent of the entire body or less than 5 percent of exposed areas are affected, or no more than topical therapy is required during a past 12-month period. A 10 percent rating is assigned where at least 5 percent, but less than 20 percent of the entire body or at least 5 percent, but less than 20 percent of exposed areas are affected or intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of less than six weeks during a 12-month period. A 30 percent rating is assigned where 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas are affected, or; where systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of six weeks or more, but not constantly, during a 12-month period. A 60 percent rating is warranted where more than 40 percent of the entire body or more than 40 percent of the exposed areas are affected; or where there is constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. 38 C.F.R. § 4.118, Diagnostic Code 7806. Turning to the applicable scar codes, the Board observes that the version of DC 7801 in effect prior to October 23, 2008, contemplates a 10 percent rating for scarring that is deep or that limits motion in an area or areas exceeding 6 square inches (39 square centimeters). Higher ratings of 20, 30, and 40 percent are warranted for such scarring that encompasses progressively greater swaths of the body. In this regard, Note (1) to DC 7802 provides that 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 38 C.F.R. § 4.25. Additionally, Note (2) to DC 7802 defines a deep scar as one associated with underlying soft tissue damage. 38 C.F.R. § 4.118. Conversely, a superficial scar is defined as one not associated with such damage. Id. Next, the Board observes that, under the pre-October 23, 2008, version of DC 7802, a maximum 10 percent rating is warranted for superficial scars that do not cause limited motion. Similarly, the concurrent version of DC 7803 provides for a 10 percent rating for superficial, unstable scars. The latter are defined as scars that encompass frequent loss of skin covering but no underlying soft tissue damage. See 38 C.F.R. § 4.118, Note (1) to DC 7803. The Board now comes to the version of DC 7804 in effect prior to October 23, 2008. As will prove relevant below, that diagnostic code provides a 10 percent rating for superficial scars that are painful on examination. Moreover, Note (2) to DC 7804 provides that a 10 percent rating will be assigned for a scar on the tip of a finger or toe even though amputation of the part would not warrant a compensable rating. 38 C.F.R. § 4.118. Diagnostic Code 7804 also directs the rater to consider the amputation rule found at 38 C.F.R. § 4.68. 38 C.F.R. § 4.118. Finally, DC 7805 provides that scars are rated based on the limitation of function of the part affected. 38 C.F.R. § 4.118, Diagnostic Code 7805. While cognizant that each of the above scar codes provides a minimum disability rating of 10 percent, the Board nevertheless observes that, in every instance where the Rating Schedule does not expressly contemplate a 0 percent rating, such a rating shall be assigned when the requirements for a compensable rating are not met. The Board now turns to the relevant facts underlying the Veteran's claim. See Dela Cruz v. Principi, 15 Vet. App. 143 (2001) (a discussion of all evidence by the Board is not required when the Board has supported its decision with thorough reasons and bases regarding the relevant evidence). The Veteran's Virtual VA efolder reflects that, during her September 2009 VA examination, she reported an 18-year history of herpetic lesions on the inner aspect of her left index finger. She indicated that these recurrent symptoms had necessitated VA outpatient treatment in February 1996, April and October 2005, October 2006, September 2007, March 2008, and April and June 2009. The Veteran added that she was currently on a daily prescription regimen of Acyclovir/Valtex to suppress her symptomatic flare-ups, the most recent of which had occurred approximately three months earlier. However, the Veteran did not report any need for intermittent systemic therapy, such as corticosteroids or other immunosuppressive drugs. Nor did she acknowledge any episodes of incapacitation or other significant functional impairment arising from her service-connected disability. To the contrary, the Veteran indicated that she continued to work full-time as a physician's assistant, a job similar to her occupational specialty in the Navy. She added her herpetic whitlow limited her ability to interact with patients, but only during flare-ups. The Veteran did not raise any other specific examples of that service-connected disability's interference with her ability to work or engage in daily living activities. The Veteran reported the same general frequency and severity of herpetic whitlow symptomatology during her follow-up VA examination in May 2010. At that time, she also acknowledged that she had not experienced another herpetic whitlow flare-up since June 2009. Moreover, while she now claimed to have experienced concomitant lymph node inflammation (lymphadenitis), which required antibiotic treatment, she continued to deny any reliance on immunosuppressive drugs. The record thereafter shows that, during the December 2012 videoconference hearing, the Veteran attested to a manifestation of her herpetic whitlow that she had not previously reported. Specifically, she testified that, during an earlier flare-up, this service-connected disability had resulted in scarring on her left index finger. See Board Hearing Tr. at p. 3. The Veteran further testified that, while the scarring had been detected by her prior treating providers, it had not been documented in her treatment records or examination reports and was no longer apparent. Id. Nevertheless, the Veteran continued to complain of episodic pain in the area where the scarring originated. She likewise continued to stress her reliance on anti-viral medication to suppress her herpetic whitlow flare-ups and, presumably, the scarring arising therein. See Board Hearing Tr. at p. 8. Additionally, as she had on her prior VA examination, the Veteran emphasized her limited ability to interact with patients during flare-ups. See Board Hearing Tr. at p. 11-12. She further emphasized the restrictions that such flare-ups placed on her other daily activities, including household chores and dating. Id. In assessing the probative value of the Veteran's testimony, the Board is mindful that her status as a physician's assistant offers her a degree of clinical insight beyond that expected of a lay person. See, e.g., YT v. Brown, 9 Vet. App. 195, 201 (1996). Moreover, even if that were not the case, she would be presumed competent to report a history of episodic flare-ups, marked by painful scarring on her left index finger, as such symptoms are capable of lay observation. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Veteran is likewise competent to report a prior diagnosis of scarring rendered by her treating providers. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Moreover, the mere fact that her assertions are not supported by contemporaneous clinical evidence does not render them inherently incredible. See Buchanan v. Nicholson, 451 F. 3d 1331, 1336-37 (2006) (the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence). Thus, affording the Veteran every reasonable benefit of the doubt, the Board finds that her statements are sufficient to show that her service-connected herpetic whitlow has resulted in painful scarring on her left index finger. 38 C.F.R. § 4.3 (2012). The Board further finds that, while such scarring was not evident during her recent hearing, her testimony suggests that it is liable to recur during a subsequent flare-up. Therefore, given the apparent fluctuating nature of the Veteran's service-connected disability, the Board will confine its analysis to the nature and severity of her underlying symptoms during their most active stage. See, e.g., Ardison v. Brown, 6 Vet. App. 405 (1994); Bowers v. Derwinski, 2 Vet. App. 675 (1992). Accordingly, the Board concludes that, for the purpose of assigning an initial increased rating, it will presume that the Veteran's service-connected disability has consisted of superficial, painful scarring for which a 10 percent rating is warranted under DC 7804. See 38 C.F.R. § 4.118, Diagnostic Code 7804. As noted previously, that is the maximum rating available under that diagnostic code. It is also the highest rating possible under either DC 7803 or DC 7802. Therefore, neither of those codes may serve as a basis for a higher rating in this case, nor may any of the other codes that contemplate scarring. See 38 C.F.R. § 4.118, DC 7801, 7805. Indeed, the Veteran has not alleged, and the record has not otherwise shown, that the scarring associated with her service-connected herpetic whitlow affects an area of skin that exceeds six square inches and is either deep or productive of limitation of motion that would warrant the assignment of a rating higher than 10 percent under Diagnostic Code 7801. With respect to Diagnostic Code 7805 [rated based on limitation of function of the affected part], the Board recognizes the Veteran's recent testimony that she at times has some limitation of motion and cannot make a full fist. See Board Hearing Tr., at 12. Significantly however, she has not suggested that any part of her index finger is ankylosed, and the medical evidence of record similarly does not suggest as much. The Board notes that the maximum assignable rating for limitation of motion of the index finger without ankylosis is 10 percent, which in light of the Board's decision herein, in no way avails the Veteran. See 38 C.F.R. § 4.71a, Diagnostic Code 5229. The Veteran has not contended that her left index finger scarring has been accompanied by any other limitation of function apart from pain, and that particular symptom is expressly contemplated in her 10 percent rating under DC 7804. As such, a higher rating is not warranted under either DC 7801 or DC 7805. Moreover, even assuming, without conceding, that the Veteran's herpetic whitlow comported with the criteria for multiple 10 percent ratings under different scar codes, the assignment of such evaluations would constitute impermissible pyramiding. See Esteban v. Brown, 6 Vet. App. 259, 260 (1994) (holding that separate ratings may only be awarded where none of the symptomatology for one ratable conditions is duplicative or overlapping with another ratable condition); see also Perry v. Nicholson, 23 Vet. App. 502 (2007) (memorandum decision). Similarly, for the Board to assign a separate 10 percent rating under DC 7806 would violate the rule against pyramiding. Id. This code, which served as the basis for the Veteran's initial noncompensable rating, pertains to symptoms other than scarring; however, it also encompasses the criteria in DCs 7801-7805. See 38 C.F.R. § 4.118, Diagnostic Code 7806. Thus, the Board's award of a 10 percent evaluation under DC 7804 is tantamount to the assignment of such an evaluation under DC 7806. Furthermore, the Board has no basis to assign a rating above 10 percent under DC 7806 as none of the requisite diagnostic criteria has been met. To the contrary, while the Veteran has attested to daily use of a prescription anti-viral medication, she has not alleged any use of corticosteroids or other immunosuppressive drugs. Nor has the record otherwise suggested a reliance on such intermittent systemic therapy. The record also has not shown that her service-connected disability affects anything close to 20 percent of her entire body or the exposed areas therein. As such, a rating of 20 percent or higher rating under DC 7806 is not warranted in this case. In arriving at these conclusions, the Board has focused on the schedular rating criteria. Nevertheless, its analysis does not end there as it must also assess whether referral for an extraschedular rating is warranted. Indeed, while the Board is precluded, in the first instance, from assigning such a rating, it has the discretion to refer a claim to the appropriate VA officials for extraschedular consideration. See Floyd v. Brown, 9 Vet. App. 88, 95 (1996); see also VAOPGCPREC 6-96. The specific criteria underlying extraschedular ratings were addressed in Thun v. Peake, 22 Vet App 111 (2008). In that precedential decision, the United States Court of Appeals for Veterans Claims set forth a three-step test for determining whether to refer a claim for extraschedular consideration. First, 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 claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability presents other related factors, such as marked employment interference and frequent hospitalizations, which the regulation identifies 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, the Board should refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. Applying the first prong of Thun to the facts of the instant case, the Board finds that the Veteran's herpetic whitlow does not present such an exceptional disability picture as to render inadequate the available schedular criteria. To the contrary, while she has complained of episodic breakouts on her left index finger that are productive of painful scarring, such symptoms are expressly contemplated by the aforementioned diagnostic codes that are used to rate skin disabilities. See 38 C.F.R. § 4.118; Diagnostic Codes 7801-7806. Moreover, notwithstanding the Veteran's complaints of occupational and social interference posed by her herpetic whitlow, the Board observes that such interference arises from the above symptoms, which are addressed by the Rating Schedule. Furthermore, the Board observes that, under the analytic rubric mandated in Thun, the question of whether there is marked employment impairment, frequent hospitalizations, or related factors of functional loss is only pertinent if the schedular rating criteria are deemed inadequate. Such is not the case here and, thus, the second and third Thun criteria are effectively moot. Accordingly, the Board finds nothing in the record to indicate that the Veteran's service-connected disability causes impairment over and above that which is contemplated by the schedular rating assigned herein. Therefore, there is no need to refer this case for extraschedular consideration pursuant to 38 C.F.R. 3.321(b)(1). In sum, the Board concludes that, over the course of the appeals period, the Veteran's herpetic whitlow of the left index finger has been manifested by painful scarring for which an initial rating of 10 percent, but no higher, is justified. See 38 C.F.R. § 4.118; Diagnostic Code 7804. Consideration has been given to staged ratings; however, such evaluations are not warranted where, as here, the overall disability picture has met the criteria for a single schedular evaluation since the date of servcie connection. Fenderson, supra. Moreover, extraschedular referral is unwarranted in this instance as the schedular rating criteria have not proven adequate to rate the Veteran's claim. See 38 C.F.R. § 3.321. Accordingly, an initial increased rating of 10 percent, but no higher, is granted throughout the entire pendency of the claim. ORDER An initial increased disability rating from 0 to 10 percent for service-connected herpetic whitlow of the left index finger is granted, subject to controlling regulations applicable to the payment of monetary benefits. REMAND The Veteran contends that her aphthous stomatitis is more severe than contemplated by the noncompensable rating she has been assigned since the date of service connection. Throughout the pendency of this appeal, the Veteran's disability has been rated under DC 7899-7819. Such diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. See 38 C.F.R. § 4.27 (2012). When an unlisted disease, injury, or residual condition is encountered, requiring rating by analogy, the diagnostic code number will be assigned as follows: the first two digits will be selected from that part of the schedule most closely identifying the part, or system of the body involved, in this case, the skin, and the last two digits will be 99 for all unlisted conditions. Then, the disability will be rated by analogy under a diagnostic code for a closely related disability that affects the same anatomical functions and has closely analogous symptomatology. 38 C.F.R. §§ 4.20, 4.27 (2012). In this case, the RO has determined that the most appropriate diagnostic code for rating the Veteran's aphthous stomatitis is DC 7819, which pertains to benign neoplasms. 38 C.F.R. § 4.118, Diagnostic Code 7819. According to the version of that code in effect prior to October 28, 2008, such skin disorders are to be rated as disfigurement of the head, face, or neck, scars, or impairment of function. 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805, 7819 (pre-October 28, 2008). The same criteria are encompassed in the pre-October 28, 2008, version of DC 7820, another code that applies to the Veteran's claim as it pertains to infections of the skin not listed elsewhere in the Rating Schedule, with added consideration under the code for dermatitis, depending upon the predominant disability. 38 C.F.R. § 4.118, Diagnostic Codes 7800-7806, 7820 (pre-October 28, 2008). Prior to determining the appropriate rating for the Veteran's aphthous stomatitis under the above codes, further development is warranted. Treatment Records In conjunction with her December 2012 VA hearing testimony, the Veteran submitted medical documentation, which included annual evaluation reports and treatment records generated by the Pensacola Naval Air Technical Training Center Naval Branch Health Clinic. Significantly, the most recent of those records, dated May 5, 2009, noted that the Veteran had recurrent cheek and inner mouth lesions and was scheduled to return for a follow-up evaluation in six months. The Veteran has not submitted any subsequent treatment records from the above health clinic. Nevertheless, the Board is now on notice that such additional records may exist that involve treatment for mouth lesions, which are symptomatic of the disability on appeal. Thus, given that the Veteran's aphthous stomatitis claim already requires additional development for the reasons outlined below, the Board finds that reasonable efforts to obtain the identified missing records should be made on remand. VA examination At the recent videoconference hearing, the Veteran testified that she had last undergone a VA examination in support of her appeal in May 2010. See Hearing Tr. at 10. She further testified that, since that time, her aphthous stomatitis had been productive of painful sores, which existed underneath and on the tip of her tongue, inside her lip, and on her palatine uvula. See Hearing Tr. at 8-9. The Veteran added that these sores were productive of significant functional loss to the extent that they limited her ability to swallow and eat and also affected her speech. See Hearing Tr. at 9-10. In terms of treatment, she professed to have taken a mixture of Kaopectate, Benadryl, and Lidocaine, as well as oral medications. Id. However, the Veteran indicated that these drugs were only temporarily effective in relieving her sores and related symptoms. Id. The Veteran is competent to report the above symptoms, which are capable of lay observation. See Layno, supra. Moreover, the Board has no basis to question the credibility of her assertions as they are uncontroverted by the other evidence of record. See Caluza v. Brown, 7 Vet. App. 498, 511, 512 (1995), aff'd per curiam, 78 F.3d. 604 (Fed. Cir. 1996) (holding that, in determining the weight to be assigned to evidence, credibility can be affected by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor). In this regard, the Board recognizes that the May 2010 VA examination report did not contain any clinical findings of disfigurement, reduced motion, painful or unstable scars, or other limitation of function. Significantly, however, the author of that report conceded that he did not have access to the Veteran's electronic claims file. See the May 2010 VA examiner's report, page 1. As such, that VA examiner does not appear to have considered the Veteran's pertinent medical history. Nor does that examiner appear to have accounted for the Veteran's lay observations, apart from her general complaints of "constitutional symptoms of malaise." See the May 2010 VA examiner's report, page 3. Accordingly, that examiner's omission of the particular symptoms now alleged by the Veteran does not render her assertions inherently incredible. See Buchanan, 451 F. 3d at 1336-37. Furthermore, the Veteran's subsequent complaints of painful mouth sores and related symptoms, in tandem with the documentation she has produced of oral medication prescribed to treat such symptoms, suggests that her overall disability picture may have worsened since the May 2010 examination. The Board is mindful that the mere passage of time is insufficient to trigger VA's duty to assist by providing a new VA examination. Nevertheless, such an examination is warranted where a veteran asserts that a disability is worse than when originally rated, and the available evidence is too old to adequately evaluate the current state of the condition. See Olsen v. Principi, 3 Vet. App. 480, 482 (1992), citing Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992); Palczewski v. Nicholson, 21 Vet. App. 174 (2007). That is the case here. The Board also finds that the aforementioned inadequacies in the May 2010 VA examiner's report serve as further indication that a new examination is needed. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes an examination, even if not required to do so, an adequate one must be produced). Accordingly, on remand, the Veteran should be afforded a follow-up VA examination to assess the current nature and severity of her aphthous stomatitis. In contrast with the May 2010 examiner's report, the new VA examination should take into account all pertinent information of record, including any additional lay and clinical evidence obtained pursuant to this Remand. 38 C.F.R. § 4.1 (2012). The new VA examination should also address the specific diagnostic criteria implicated in this claim, particularly with respect to functional loss. See 38 C.F.R. § 4.118, Diagnostic Code 7099-7819, 7820. According to the version of these codes in effect prior to October 28, 2008, such skin disorders are to be rated as disfigurement of the head, face, or neck, scars, dermatitis, or based on impairment of function. See 38 C.F.R. § 4.118, Diagnostic Code 7800-7806, 7819, 7820 (pre-October 28, 2008). In this regard, the Board again acknowledges that the criteria for rating skin disabilities were revised during the pendency of the appeal. 73 Fed. Reg. 54, 708 (Sept. 23, 2008). However, the amended criteria are not applicable unless the Veteran expressly requests that they be considered in rating her claim. Accordingly, the new VA examination need only include findings responsive to the pre-October 23, 2008, versions of the codes unless the Veteran specifically requests consideration under the revised criteria on remand. Accordingly, the case is REMANDED to the RO/AMC for the following action: 1. Contact the Veteran and request that she identify any additional medical treatment she has received for her service-connected aphthous stomatitis. Attach multiple copies of VA Form 21-4142, Authorization and Consent to Release Information, and ask the Veteran's representative to complete and return these releases, or have the Veteran complete and return these releases, so that VA can obtain any private treatment records on her behalf. Upon return of any required authorization, take appropriate steps to secure copies of any such treatment reports identified by the Veteran which are not in the record on appeal, to include any existing relevant updated VA treatment records, as well as treatment reports from the Pensacola Naval Air Technical Training Center Naval Branch Health Clinic dated since May 5, 2009. In light of recent changes to 38 U.S.C.A. § 5103A(b)(2)(B), should the Veteran specifically request that VA obtain private treatment records on her behalf, two attempts should be made to obtain these treatment records, unless a formal finding can be made that a second request for such records would be futile. See Pub. L. No. 112-154, § 505, 126 Stat. 1165, 1193 (2012). Efforts to obtain these records should be memorialized in the Veteran's VA claims folder. If any records are unavailable, the Veteran must be notified in accordance with 38 C.F.R. § 3.159(e). 2. After completing the above development, schedule the Veteran for an examination at the Pensacola VA Medical Center to assess the current nature, extent, and severity of her service-connected aphthous stomatitis. The entire contents of the Veteran's paper claims file and Virtual VA eFolder should be made available to and be reviewed by the clinician in conjunction with the examination, and it should be confirmed that such records were available for review. A report of the VA examination should be prepared and associated with the Veteran's VA claims file. A complete rationale must be provided for all opinions rendered. If the examiner cannot provide any of the requested opinions without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. The examiner should provide opinions that specifically address the following: a) Identify all pathology related to the Veteran's service-connected aphthous stomatitis. Conduct all necessary tests and elicit clinical findings in response to the applicable diagnostic criteria. 38 C.F.R. § 4.118, Diagnostic Codes 7800, 7801, 7802, 7803, 7804, 7805, 7806, 7819, 7820 (in effect prior to October 23, 2008). b) Specify the location and extent of the disability in terms of a percentage of the body and a percentage of exposed areas, and the frequency that systemic therapy, such as corticosteroids or immunosuppressive drugs, have been required during the past 12-month period, if at all. c) State whether the disability is manifested by exfoliation, exudation, or itching involving an exposed surface or extensive area; constant exudation or constant, extensive lesions, or marked disfigurement; systemic or nervous manifestations and ulceration, extensive exfoliation, or extensive crusting; or whether it is exceptionally repugnant. d) Specifically note whether the disability involves disfigurement of the head, face, or neck, and describe the nature and extent of any disfigurement. Also, take into account any flare-ups the Veteran may have experienced during the year. e) State whether the disability is productive of scarring and specify the size of any scar and whether it causes limitation of motion, or is painful, unstable, or superficial. f) Discuss whether the disability is productive of any additional functional loss or other limitation of the affected part. g) State what impact, if any, the disability has on the Veteran's activities of daily living, including her ability to obtain and maintain employment. 38 C.F.R. § 4.10. 3. Following the completion of the foregoing, and after undertaking any additional development deemed necessary, readjudicate the remaining issue on appeal. If the benefit sought on appeal remains denied, in whole or in part, the Veteran and her representative should be provided with a Supplemental Statement of the Case and be afforded reasonable opportunity to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. The Veteran 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 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). ______________________________________________ VINCENT C. CHIAPPETTA Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs