Citation Nr: 1311262 Decision Date: 04/04/13 Archive Date: 04/19/13 DOCKET NO. 06-28 464 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for pseudo-folliculitis barbae (PFB), posterior neck area and scalp, with scars, prior to November 8, 2010, and in excess of 50 percent thereafter. 2. Entitlement to an initial rating in excess of 20 percent for tender and unstable scar of the scalp. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD J. N. Moats, Counsel INTRODUCTION The Veteran had active military service from June 1990 to January 1991 and from June 1992 to September 1992, with additional service in the United States Army National Guard. This matter initially came to the Board of Veterans' Appeals (Board) on appeal from a December 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama, that granted service connection for PFB, and assigned an initial 30 percent disability rating, effective August 9, 2005, the date VA received the Veteran's claim for service connection. In September 2010, the Board remanded the Veteran's case to the agency of original jurisdiction (AOJ) for further evidentiary development. In a December 2011 rating decision, the AOJ granted a 50 percent evaluation for the Veteran's service-connected PFB, effective November 8, 2010. However, where there is no clearly expressed intent to limit the appeal to entitlement to a specified disability rating, the RO and Board are required to consider entitlement to all available ratings for that condition. AB v. Brown, 6 Vet. App. 35, 39 (1993). The issue therefore remains in appellate status. At the time of the December 2011 rating decision, the RO also awarded a separate 20 percent rating for a tender and unstable scar of the scalp, effective November 8, 2010. With respect to the latter issue, the AOJ informed the Veteran that such issue was ancillary to the issue on appeal and was regarded as inextricably intertwined. Additionally, he was notified that no further action was required. In light of the AOJ's actions, the Board finds that the issue of entitlement to an initial rating in excess of 20 percent for tender and unstable scar of the scalp is also properly before the Board and, as such, has been included on the first page of the decision. Subsequently, in March 2012, the Board again remanded the case for additional development. The case has now been returned to the Board for appellate review. A review of the Virtual VA paperless claims processing system reflects that such does not contain any documents relevant to this appeal that are not also contained in the paper claims file. FINDINGS OF FACT 1. When resolving the benefit of the doubt in favor of the Veteran, since VA received his initial claim on August 9, 2005, his service-connected PFB, posterior neck area and scalp, with scars, covers more than 40 percent of exposed areas affected and has required constant use of topical corticosteroids. 2. Prior to November 8, 2010, the Veteran's scar of the scalp was not unstable or painful. 3. From November 8, 2010, the Veteran's scar of the scalp has been unstable and painful, but does not cover at least 72 square inches, have five or more scars that are unstable and painful, or six or more characteristics of disfigurement. CONCLUSIONS OF LAW 1. Effective August 9, 2005, the criteria for entitlement to a disability rating of 60 percent, but no higher, for the Veteran's service-connected PFB, posterior neck area and scalp, with scars, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, including § 4.7, 4.118, Diagnostic Code 7806 (2008), (2012). 2. Prior to November 8, 2010, the criteria for a separate compensable disability rating for scar of the scalp had not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, including § 4.7, 4.118, Diagnostic Code 7804 (2008), (2012). 3. From November 8, 2010, the criteria for entitlement to a disability rating in excess of 20 percent for the Veteran's service-connected tender and unstable scar of the scalp, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, including § 4.7, 4.118, Diagnostic Code 7804 (2008), (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), 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 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim. Accordingly, notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In the instant case, the Veteran's claim arises from an appeal of the initial evaluations following the grant of service connection. Courts have held that 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). Therefore, no further notice is needed under VCAA. Next, VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting him 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. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's post-service reports of private treatment and VA examinations. A review of Virtual VA does not reveal any additional documents pertinent to the present appeal. Moreover, the Veteran's statements in support of the claim are of record. The Board has carefully reviewed such statements and concludes no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims. Additionally, the Veteran was afforded VA examinations in November 2005 and November 2010 to evaluate the severity of his service-connected skin and scar disorders. The Board finds that the VA examinations are adequate because, as discussed below, they were based upon consideration of the Veteran's pertinent medical history, his lay assertions and current complaints, and because they provide detail sufficient to allow the Board to make a fully informed determination. Barr v. Nicholson, 21 Vet. App. 303 (2007) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). Furthermore, the Veteran has not asserted, and the evidence does not show, that his symptoms have materially worsened since the most recent November 2010 evaluation. See 38 C.F.R. §§ 3.326, 3.327 (reexaminations will be requested whenever VA determines there is a need to verify the current severity of a disability, such as when the evidence indicates there has been a material change in a disability or that the current rating may be incorrect.); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). The Board accordingly finds no reason to remand for further examination. For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). Finally, the Board finds that there was substantial compliance with the September 2010 and March 2012 remand directives. A remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand order. Stegall v. West, 11 Vet. App. 268 (1998). Nonetheless, it is only substantial compliance, rather than strict compliance, with the terms of a remand that is required. See D'Aries v. Peake, 22 Vet. App. 97, 104 (2008) (finding substantial compliance where an opinion was provided by a neurologist as opposed to an internal medicine specialist requested by the Board); Dyment v. West, 13 Vet. App. 141 (1999). In particular, the Board in September 2010 directed the AOJ to contact the Veteran to identify all VA and non-VA providers who had treated him for his skin disorder. In particular, the AOJ was to request an authorization to obtain medical records from the Dermatology Clinic from August 2006 to the present. In September 2010, the AOJ sent a letter to the Veteran requesting this information. While the Veteran did not submit any additional authorizations, it appears that he did submit additional private treatment records. Further, the AOJ was also directed to schedule the Veteran for a VA examination. As noted above, the Veteran was afforded a VA examination in November 2010 that is adequate for appellate review. In March 2012, the Board remanded the case to obtain all photographs taken at the November 2010 VA examination, which were subsequently associated with the claims file. Accordingly, the Board finds that there has been substantial compliance with the September 2010 and March 2012 Board remand directives and, therefore, no further remand is necessary. See Stegall, supra; D'Aries, 22 Vet. App. at 104 (2008). Legal Criteria Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 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 order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where, as in the instant case, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). As in the instant case, at the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Id. at 126. The RO has rated the Veteran's PFB, posterior neck area and scalp, with scars under the provisions of Diagnostic Codes 7813-7800. Under 38 C.F.R. § 4.118, Diagnostic Code 7813, dermatophytosis, including tinea barbae of the beard area, is to be rated as disfigurement of the head, face, or neck (under Code 7800); scars (under Codes 7801, 7802, 7803, 7804, or 7805); or dermatitis (under Code 7806) depending upon the predominant disability. 38 C.F.R. § 4.118, Diagnostic Code 7813 (2012). The RO has rated the Veteran's service-connected tender and unstable scar of the scalp as 20 percent disabling under Diagnostic Code 7804 for unstable or painful scars. 38 C.F.R. § 4.118, Diagnostic Code 7804 (2012). During the pendency of the appeal, the Board notes that effective October 23, 2008, VA amended criteria for rating the skin so that it more clearly reflects VA's policies concerning the evaluation of scars. Specifically, these amendments concern 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805 and apply to all applications for benefits received by VA on or after October 23, 2008. See Notice, 73 Fed. Reg. 54,708 (September 23, 2008). A Veteran previously evaluated under the previous criteria may request review under the revised criteria. Id. In the instant case, the AOJ adjudicated the Veteran's claims under both the pre- and post- October 2008 regulations in the December 2011 rating decision and supplemental statement of the case and, therefore, the Board will consider both sets of criteria. Under the previous Diagnostic Code 7800 for disfigurement of the head, face or neck, a 30 percent evaluation is warranted for disfigurement of the head, face or neck with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with 2 or 3 characteristics of disfigurement. A 50 percent is evaluation is warranted with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement; and a 80 percent evaluation is assigned when there is visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement. The eight characteristics of disfigurement for evaluation purposes are: (1) a scar 5 inches or more (13 or more cm.) in length; (2) a scar at least 1/4 inch (0.6 cm.) wide at its widest part; (3) surface contour of scar elevated or depressed on palpation; (4) scar adherent to underlying tissue; (5) skin hypo-or hyper-pigmented in an area exceeding 6 square inches (39 sq. cm.); (6) skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding 6 square inches (39 sq. cm.); (7) underlying soft tissue missing in an area exceeding 6 square inches (39 sq. cm.); and (8) and indurated and inflexible in an area exceeding 6 square inches (39 sq. cm.). Under the previous criteria for Diagnostic Code 7801, a 10 percent rating is assigned for a scar on other than the head, face or neck, that is deep (associated with underlying soft tissue damage) or that causes limited motion with area or areas exceeding 6 square inches (39 sq. cm.). A 20 percent rating is awarded if the area or areas exceeding 12 square inches (77 sq. cm.); a 30 percent rating is warranted for area or areas exceeding 72 square inches (465 sq. cm.); and a 40 percent rating is warranted for area or areas exceeding 144 square inches (929 sq. cm,). Under the previous criteria for the remaining codes, Diagnostic Code 7802, for a scar on other than the head, face or neck, provides a maximum 10 percent rating if scar is affecting an area or areas of 144 square inches (929 sq. cm.) or greater, is superficial (not associated with soft tissue damage) and does not cause limited motion. A superficial and unstable (involving frequent loss of covering of skin over the scar) scar will be assigned a maximum 10 percent rating under Diagnostic Code 7803. Similarly, a scar that is superficial and painful on examination will be assigned a maximum 10 percent rating under Diagnostic Code 7804. Finally, Diagnostic Code 7805 provides that a scar may also be evaluated based on limitation of function of the affected part. Relevant to the rating criteria in effect as of October 2008, the new Diagnostic Code 7800 refers to burn scars of the head, face, or neck; scars of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck. However, the code rates the disability under the same criteria as the old version. Diagnostic Code 7801 pertains to scars not of the head, face, or neck, that are deep and nonlinear. Again, the code essentially rates the disability under the same criteria as the old version. Note (1) under this code provides that a deep scar is one associated with underlying soft tissue damage. Again, under Diagnostic Code 7802, scars not of the head, face, or neck that are superficial and nonlinear in an area or areas of 144 square inches (929 square centimeters) or greater will be evaluated as 10 percent disabling. A note following the Diagnostic Code defines a superficial scar as one not associated with underlying soft tissue damage. Diagnostic Code 7804 provides that one or two scars that are unstable or painful warrant a 10 percent rating. Three or four scars that are unstable or painful warrant a 20 percent rating. Five or more scars that are unstable or painful warrant a 30 percent rating. Note (1) provides that an unstable care is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provides that, if one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Note (3) provides that scars evaluated under Diagnostic Codes 7800, 7801, 7802, or 7805 may also receive an evaluation under this Diagnostic Code when applicable. Diagnostic Code 7805 is relevant to other scars (including linear scars) and other effects of scars evaluated under Diagnostic Codes 7800, 7801, 7802, and 7804. It provides that any disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-04 should be evaluated under an appropriate diagnostic code. For purposes of this analysis, the Board also observes that, under Diagnostic Code 7806 for dermatitis or eczema, a noncompensable evaluation is warranted when there is less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12-month period, and a 10 percent rating is warranted if 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 affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating requires that 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas be affected, or; that systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A maximum rating of 60 percent is warranted when the skin disability covers an area of more than 40 percent of the entire body or when more than 40 percent of exposed areas is affected, or; when constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs were required during the past 12-month period. 38 C.F.R. § 4.118, Diagnostic Codes 7806. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis and demonstrated symptomatology. Any change in a diagnostic code by a VA adjudicator must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Factual Background The Board has thoroughly reviewed all of the evidence of record. To summarize, private treatment records from 1995 showed that the Veteran was seen for acne keloidalis with extenstive scarring. He underwent surgery in August 1995 to excise multiple large keloids from his upper posterior neck. A follow up October 1995 record indicated that a keloid was also removed from the back of the scalp. The records also indicated that the Veteran had undergone steroid shots. In 1998, he again underwent surgery to have a painful, progressing keloid on the occipital area of the scalp removed. The Veteran was afforded a VA examination in November 2005. The claims file was not available for review. The Veteran reported periods of break-outs of bumps with itching, bleeding, and soreness. The skin condition was ongoing and required daily treatment consisting of over-the-counter medicated shampoo. The percentage of the exposed area affected of the scalp and posterior neck was 70 percent and seven percent of the entire body. There was scarring and disfigurement of the scalp and posterior neck. Some of the areas were superficial, while others were deep. There was scarring as well as papules and pustules on the scalp. There was disfigurement on the lower part of the scalp (posterior neck). While there was urticaria, there was no vasculitis, erythema, fever, weight loss or malignancy. Acne and chloracne with papules and pustules were present. The Veteran also had deep scarring with nodules and the involvement of the scalp was four percent. There was alopecia toward the bottom of aspect of the scalp. The examiner also observed scars on the posterior neck and scalp that were to diffuse to measure. There was no pain, adherence to underlying tissue, atrophy or scaling. However, the texture of the skin of the scalp and posterior neck were mildly irregular. The scars were stable and there were no current ulcerations. Areas of elevation and depression of the surface contour of the scars were evidenced upon palpation. There was no loss or damage of underlying soft tissue. There were areas of keloid of the posterior neck, but no inflammation or keloid was observed. The scars were flesh colored and the skin affected was moderately flexible. There were no limitations of motion or other limitation of function caused by the scars. No color photographs were done. The diagnosis was PFB, severe; and scars with no functional limitations. Subsequent private treatment records dated from December 2005 to November 2009 also showed treatment for the Veteran's skin problems. A December 2005 record showed that the Veteran presented with complaints of itching, moles, irritation, oozing and light or dark spots. The examiner observed macules, papules and nodules on the scalp. Follow up records documented treatment for folliculitis keloidalis. In his August 2006 substantive appeal, the Veteran asserted that he was entitled to at least a 50 percent rating for his PFB. He stated that he suffered from deep scarring over more than five inches of his scalp and neck. He reiterated that the examiner had determined that 70 percent of his head was affected. The Veteran was afforded another VA examination on November 8, 2010. The claims file was reviewed. The Veteran reported that he still had breakouts with "bumps" on his face and facial exacerbation occurred at least once a month. He had been given Cipro at one point last year to clear any residual infection. He applied Clobetasol Propionate and Clindamycin Phosphate to the scalp daily. The examiner observed that the treatment was a topical corticosteroid. There were no side effects. Further, the examiner observed a 11 cm by 4 cm area of macular scarring with keloid formation present in the lower occipital region. There was uniform scarring, but no open lesions. The Veteran reported that the scar was from surgery in 1995. He also indicated that there was skin breakdown over the scar two or more times per year, but less than monthly. He also reported pain over the scar if there was any minor trauma. He also experienced bleeding, with the last episode being six months prior. On physical examination, it was observed that the scar was at least 6 square inches, but less than 12 square inches. While painful, there were no signs of skin breakdown, underlying soft tissue loss, or indurated or inflexible skin. However, there was elevated surface contour and adherence to underlying tissue. There were no other disabling affects. In sum, skin had an area of abnormal texture in the occipital region that was hypo or hyper-pigmented with abnormal pigmentation area of 6 square inches or less and discoloration that was darker than normal. The diagnosis was occipital area scarring. With respect to the PFB, the examiner observed that there was involvement of at least 5 percent, but less than 20 percent of the exposed areas affected. There had been no use of intermittent systemic therapy over the past 12 months. There had been the use of topical corticosteroids, which the examiner did not consider systemic therapy. There was disfigurement of the head at the occipital region as observed above. The area of the keloid formation was asymmetric. The examiner found the following five characteristics of disfigurement: scar at least 1/4 inch width, elevated surface contour, hyperpigmentation in an area exceeding six square inches, abnormal skin texture in an area exceeding six square inches and adherent to underlying tissue. The examiner determined that there was no marked interference with employment or associated need for frequent hospitalization. On the face, chronic macular skin with hyperpigmentation over bearded area from cheeks to mid/lower neck area was observed. There were no open lesions or areas of infection. The diagnosis was PFB and keloid scarring at occipital scalp. The examiner indicated that photographs were taken, which were later associated with the claims file. Analysis Pseudo-Folliculitis Barbae (PFB) The Veteran is seeking a higher initial rating for his service-connected PFB. As noted above, the Veteran's service-connected PFB has been rated as 30 percent disabling prior to November 8, 2010, and as 50 percent thereafter. Thus, the Board must determine whether a rating in excess of 30 percent is warranted prior to November 8, 2010, and whether a rating in excess of 50 percent is warranted from November 8, 2010. Based on the evidence of record, the Board finds that, given the nature of the Veteran's PFB in that it is characterized by skin breakouts as opposed to just scarring, the disability is more appropriately rated under Diagnostic Code 7806 for dermatitis or eczema. See Butts, supra. Based on the medical evidence of record and resolving the benefit of the doubt in favor of the Veteran, the Board concludes that a maximum 60 percent rating is warranted for the Veteran's service-connected PFB under this code. In this regard, the November 2005 VA examination report specifically stated that the Veteran's PFB covered 70 percent of exposed areas affected, which is one of the exclusive requirements under the 60 percent rating criteria. Importantly, the examiner also characterized the Veteran's PFB as severe. The Board also finds it significant that the private treatment records document continuous treatment for the Veteran's skin disorder on his face. The Board recognizes that the most recent VA examination indicated that it was less than 20 percent of exposed areas affected. Nevertheless, based on the description of the Veteran's disability in that it essentially affects the majority of his head, face and neck, the Board finds that the November 2005 VA examination assessment appears to more accurately reflect the exposed areas affected. Moreover, although the examiner indicated that the treatment was not systemic, the November 2010 VA examination clearly documented the need for daily topical corticosteroids. Accordingly, when resolving the benefit of the doubt in favor of the Veteran, an initial 60 percent rating is warranted from the date service connection was established, i.e., August 9, 2005. See 38 U.S.C.A. § 5107(b); see also Fenderson. However, the Board finds that an initial rating in excess of 60 percent is not warranted. In this regard, the only code available that allows for a higher rating is Diagnostic Code 7800 for disfigurement of the head, face and neck. However, based on the evidence of record, throughout the course of the appeal, there is simply no evidence that the Veteran has palpable tissue loss with either gross distortion or asymmetry of his features. Moreover, there has been no finding of six or more characteristic of disfigurement. The November 2010 VA examination clearly only documented five characteristic of disfigurement. Further, the Board has carefully reviewed and considered the Veteran's statements regarding the severity of his PFB. The Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severe than the assigned disability rating reflects. Moreover, the Veteran is competent to report observable symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). In this case, however, the competent medical evidence offering detailed, specific, and specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. Moreover, the Board has contemplated the Veteran's statements concerning his symptoms when assigning the current 60 percent rating back to the date of claim. The Board has considered whether staged ratings under Fenderson, supra, are appropriate for the Veteran's service-connected PFB; however, the Board finds that his symptomatology has been stable throughout the appeal period. Therefore, assigning staged ratings for such disability is not warranted. In conclusion, an initial 60 percent rating, but no higher, is warranted for the Veteran's service-connected PFB, effective the date of initial claim, August 9, 2005. The Board, however, finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 60 percent for the appeal period. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. Tender and Unstable Scar of the Scalp The present appeal also includes the issue of entitlement to a higher initial rating for the Veteran's service-connected tender and unstable scar of the scalp. Again, the RO awarded a separate 20 percent rating for this disability, effective November 8, 2010, under the revised Diagnostic Code 7804 in the December 2011 rating decision. Initially, given that the appeal has been ongoing since the date of claim for service connection, the Board must determine whether a separate compensable rating was warranted prior to November 8, 2010. However, although the medical evidence shows that the keloid formation resulting in this scar was removed in 1995 and again in 1998, the November 2005 VA examination clearly showed no pain with palpation or instability on examination. Further, there were no functional limitations of the scar. The remaining private treatment records during the applicable time period also do not specifically address the occipital scar. Thus, the proper effective date for the separate compensable rating was the November 8, 2010 VA examination, which is the first medical evidence documenting that the occipital scar was painful and unstable. Moreover, from November 8, 2010, the Board finds that a rating in excess of 20 percent is not warranted. The Board must determine whether a higher rating is warranted under the old and new criteria. Under the new Diagnostic Code 7804, there has been no showing of five or more painful scars to warrant a 30 percent rating. In turning to the old criteria, a higher rating is not available under the previous Diagnostic Code 7804. Likewise, ratings in excess of 10 percent are also not available under the previous Diagnostic Codes 7802 or 7803. Moreover, a higher rating is also not available under the revised Diagnostic Code 7802. Further, as there is no medical evidence showing that the Veteran's scar is at least 72 square inches, a higher rating is also not warranted under the old and new Diagnostic Code 7801. The November 2010 VA examination determined that the scar was approximately 11 cm by 4 cm, which clearly does not meet the criteria for 72 square inches. Moreover, as no functional impairments have been found, a higher rating is also not warranted based on limitation of function or other disabling effects under the old and new Diagnostic Code 7805. Further, there has been no showing that this scar by itself meets the criteria for two or three characteristics of disfigurement to warrant a higher rating under Diagnostic Code 7800 for disfigurement of the head, face and neck. Although the November 2010 examiner found five characteristic of disfigurement associated with the Veteran's skin disability, this finding also contemplated the Veteran's PFB, which was discussed above. To award a higher evaluation based on these symptoms would be considered pyramiding. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disabilities. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). In this case, the symptomatology would be duplicative. Again, the Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severe than the assigned disability rating reflects. In this case, however, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The lay evidence has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. In conclusion, the Board finds that the criteria for a separate compensable rating prior to November 8, 2010, and a rating in excess of 20 percent evaluation thereafter for tender and unstable scar of the scalp have not been. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. Extraschedular Consideration Additionally, the Board has contemplated whether the case should be referred for extra-schedular consideration. In general, the schedular disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. The application of such schedular criteria was discussed in great detail above. To accord justice in an exceptional case where the schedular standards are found to be inadequate, the RO is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1)). An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. Id. The Court has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet. App. 88 (1996). The Court further held that the Board must address referral under 38 C.F.R. §3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In Thun v. Peake, 22 Vet. App. 111 (2008), the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. Either the RO or the Board must first determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. If the RO or the Board finds that the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the Veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected skin disorders with the established criteria found in the rating schedule. The Board finds that the Veteran's symptomatology is fully addressed by the rating criteria under which such disabilities are rated. In this regard, the Veteran's 60 percent rating for his PFB contemplates the amount of areas exposed affected and the necessity for continuous medication. Further, with respect to his scalp scar, the 20 percent rating contemplates both the scars instability and painfulness. There are no additional symptoms of his skin disorders that are not addressed by the rating schedule. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology of his service-connected disabilities. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability picture. Therefore, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Nevertheless, the Board does observe that the November 2010 VA examiner found that there was no marked interference with employment or frequent periods of hospitalization due to the Veteran's service-connected disorders. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). TDIU The Court has held that a request for a total disability rating based on individual unemployability (TDIU), whether expressly raised by a Veteran or reasonably raised by the record, is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities, either as part of the initial adjudication of a claim or, if the disability upon which entitlement to TDIU is based has already been found to be service-connected, as part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). However, in the instant case, the Veteran has not asserted, nor has the evidence shown, that his service-connected skin disorders rendered him unemployable. The most recent examiner also offered an opinion that the Veteran's skin disorders did not markedly interfere with his employment. Accordingly, there is no need for further analysis with respect to this matter. [CONTINUED ON THE NEXT PAGE] ORDER Effective August 9, 2005, an initial 60 percent disability rating, but no higher, for PFB, posterior neck area and scalp, with scars, is granted, subject to the laws and regulations governing payment of monetary benefits. A separate compensable rating prior to November 8, 2010 and an initial rating in excess of 20 percent thereafter for tender and unstable scar of the scalp is denied. ____________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs