Citation Nr: 1319812 Decision Date: 06/19/13 Archive Date: 06/27/13 DOCKET NO. 05-35 668 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to an increased, compensable rating for the service-connected residuals of a sternum fracture. 2. Entitlement to an increased rating in excess of 10 percent for the service-connected paresthesia of the right infraorbital branch of the fifth cranial nerve. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD K. Osegueda, Associate Counsel INTRODUCTION The Veteran had active service from February 1961 to February 1965. He had additional service in the Air National Guard. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from rating decisions by the RO. In a March 2005 rating decision, the RO denied the Veteran's claim for an increased evaluation for the service-connected sternum disability. The Veteran appealed this decision. In September 2007, the Board remanded the Veteran's claim for an increase to the RO for additional development. In April 2008, the Veteran testified at a hearing before the Decision Review Officer (DRO) at the RO regarding his claim for an increased evaluation for the service-connected sternum disability. A transcript of the hearing has been associated with the record. In a September 2009 rating decision, the RO denied the claim for an increased evaluation for the service-connected cranial nerve disability. The Veteran appealed this decision. In August 2012, the Veteran testified at a hearing held before the undersigned Veterans Law Judge by means of videoconference technology from the RO. A transcript of the hearing has been associated with the record. In November 2012, the Board remanded the claims to the RO for further development. A review of the Virtual VA paperless claims processing system reveals VA treatment records dated from February 2011 to March 2013 that are not pertinent to the issues on appeal. As previously noted, in September 2011, the Veteran filed a claim seeking special monthly compensation (SMC) based on aid and attendance or at the housebound rate. As this issue still has not been addressed by the RO, the Board does not have jurisdiction and on again must refer the matter to the RO for appropriate action. Additionally, in the November 2012 remand, the Board noted that the Veteran's representative included the issues of increased ratings for the service-connected lumbosacral strain and cervical strain in a brief prepared in July 2012. The Board noted that the issues were previously on appeal and that the Veteran withdrew his appeal in a signed April 2010 statement. However, the Veteran is subsequently shown to have submitted other claims for increased ratings for the service-connected lumbosacral and cervical strain. These matters are referred to the RO for appropriate action. 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). FINDINGS OF FACT 1. The service-connected residuals of a fracture of the sternum is shown to be manifested by complaints of pain and related functional impairment with angulation of one of the fracture fragments and productive of a disability picture that more closely resembles that of removal of one rib. 2. The service-connected right zygomatic fracture residuals with right fifth cranial nerve paresthesia is shown to be manifested by no more than moderate incomplete paralysis of that particular nerve. CONCLUSIONS OF LAW 1. The criteria for the assignment of a 10 percent rating, but no more for the service-connected residuals of the fracture of the sternum have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.71 including Diagnostic Codes 5203, 5297 (2012). 2. The criteria for the assignment of an increased rating higher than 10 percent for the service-connected paresthesia of the right infraorbital branch of the fifth cranial nerve, as a residual of a right zygomatic fracture, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.124 including Diagnostic Code 8045-8205 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim and of the relative duties of the VA and the claimant for procuring that evidence. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The Board concludes that the Veteran has been afforded appropriate notice under VCAA. The RO provided VCAA notice letters to the Veteran in December 2004 and August 2009. The December 2004 letter was provided to the Veteran before initial adjudication of his claim for a compensable evaluation for the service-connected sternum disability. The August 2009 letter was provided to the Veteran after the initial adjudication of his claim and thus represents a "timing error." See Pelegrini v. Principi, 18 Vet.App. 112 (2004). However, the claim was readjudicated in an October 2010 Statement of the Case (SOC) and timing errors can be effectively "cured" by such subsequent readjudication. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet.App. 370, 376 (2006). The letters notified the Veteran of what information and evidence must be submitted to substantiate the claims for increased ratings as well as what information and evidence must be provided by the Veteran and what information and evidence would be obtained by VA. The Veteran was also told to inform VA of any additional information or evidence that VA should have and submit evidence in support of his claims to the RO. The content of the letters complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). The requirements of VCAA also include notice of a disability rating and an effective date for award of benefits if service connection is granted. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Letters dated in March 2006, June 2008, and August 2009 letter provided this notice. The June 2008 letter also advised the Veteran of the specific disability rating criteria pertinent to his increased rating claim for the service-connected sternum disability. See Vazquez-Flores v. Peake, 22 Vet.App. 37 (2008). The Veteran was provided notice of the specific disability rating criteria pertinent to his increased rating claim for the service-connected cranial nerve disability in an October 2010 SOC. However, the Court held in Vazquez-Flores v. Shinseki, 580 F.3d 1270 (2009) that the VCAA notice in a claim for increased rating need not be "veteran specific" or include reference to impact on daily life or rating criteria. Therefore, he has received legally sufficient notice. The Board finds that all relevant, available evidence has been obtained with regard to the Veteran's claims, and the duty to assist requirements have been satisfied. Service treatment and VA treatment records are associated with the claims file. The Board also notes that there is no identified relevant evidence that needs to be obtained in this regard. The Veteran was afforded VA bones examinations in January 2005, June 2009, and January 2013. He was afforded a VA dental and oral examination in July 2009 and a VA cranial nerves examination in February 2013. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. McLendon v. Nicholson, 20 Vet. App. 79 (2006). With respect to the VA examinations that were provided, the Board notes that, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In this case, the Veteran was afforded a VA bones examination in January 2013 and a VA cranial nerves examination in February 2013 in compliance with the November 2012 remand. There has been no allegation that the examinations were inadequate. The most recent VA examinations provided are based on review of the claims file, taking a relevant history from the Veteran, and clinical evaluation of the Veteran. The examination reports are adequate; the information provided by the VA examiners is supported by a thorough history, fully reasoned explanations and clinical findings and, as will be discussed at length below. New examinations are not required as the examiner's opinions are well supported. The need for a more contemporaneous examination occurs only when the evidence indicates that the current rating may be incorrect or when the evidence indicates there has been a material change in the disability. See 38 C.F.R. § 3.327(a); Palczewski v. Nicholson, 21 Vet. App. 174, 182-83. The VA examinations, taken as a whole, are fully sufficient to evaluate the appeal. In addition, no other probative medical or lay evidence demonstrates a worsening of the service-connected disabilities. Therefore, a new VA examination to rate the severity of the bilateral hearing loss is not warranted. Under the circumstances, the Board finds no reasonable possibility that further assistance would aid the Veteran in substantiating the claims. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). Increased Rating Disability ratings are assigned in accordance with the VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1 (2012). Separate diagnostic codes identify the various disabilities. See 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. 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 (2012). The Court has held that an appeal from an initial rating is a separate and distinct claim from a claim for an increased rating. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as "staged ratings." See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. Hart v. Mansfield, 21 Vet. App. 505 (2007). 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 current diagnosis and demonstrated symptomatology. Any change in a Diagnostic Code by VA must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625 (1992). Words such as "moderate," "moderately severe," and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. 4.6 (2012). The use of terminology such as "severe" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2012). It is possible for a Veteran to have separate and distinct manifestations from the same injury that 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); 38 C.F.R. § 4.14 (2012) (precluding the assignment of separate ratings for the same manifestations of a disability under different diagnoses). Sternum The service-connected residuals of the fracture of the sternum have been evaluated as 10 percent disabling by analogy under Diagnostic Codes 5299-5203. The Rating Schedule does not have a specific diagnostic code to account for the residuals of a fractured sternum. However, the RO evaluated these residuals by analogy to impairment of the clavicle or scapula under Diagnostic Code 5203. See 38 C.F.R. § 4.27 (2012) (hyphenated 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; unlisted disabilities requiring rating by analogy will be coded utilizing the numbers of the most closely related body part and "99"). 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 the Veteran's relevant medical history, the current diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). When an unlisted condition is encountered it is permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. Nor will ratings assigned to organic diseases and injuries be assigned by analogy to conditions of functional origin. 38 C.F.R. § 4.20. Under Diagnostic Code 5203, a 10 percent evaluation is warranted for malunion of the clavicle or scapula of the major joint, or nonunion of the clavicle or scapula without loose movement of the major joint. A 20 percent evaluation is warranted for nonunion of the clavicle or scapula with loose movement of the major joint, or dislocation of the clavicle or scapula of the major joint. There is no pertinent Diagnostic Code which addresses disease of the sternum specifically or provides rating criteria based on an injury to the sternum. Therefore, the Board finds that an evaluation under Diagnostic Code 5297 for the removal of ribs is more appropriate in this case. Under Diagnostic Code 5297, a 10 percent disabling rating is warranted for removal of one rib or resection of two or more ribs without regeneration. A 20 percent rating is warranted for removal of two ribs. A 30 percent rating is warranted for three or four ribs; a 40 percent rating is warranted for five or six ribs; and a 50 percent rating is warranted for more than six ribs. Note (1) states that the rating for rib resection or removal is not to be applied with ratings for purulent pleurisy, lobectomy, pneumonectomy or injuries of pleural cavity. Note (2) states that, however, rib resection will be considered as rib removal in thoracoplasty performed for collapse therapy or to accomplish obliteration of space and will be combined with the rating for lung collapse, or with the rating for lobectomy, pneumonectomy or the graduated ratings for pulmonary tuberculosis. The Board is unable to find another Diagnostic Code that would better address to rating of the service-connected residuals of the fracture of the sternum. The Veteran's claim for a compensable rating for the service-connected residuals of the fracture of the sternum was received in November 2004. The main symptomatology associated with the service-connected residuals of a fracture of the sternum consists of intermittent complaints of pain. During a January 2005 VA examination, the Veteran reported having occasional discomfort in the sternum area of his chest approximately four to five times per year. He denied any other symptoms. The examiner noted there were no current infections or constitutional symptoms of bone disease. An examination showed no evidence of deformity, angulation, false motion, shortening or intraarticular movement at the sternomanubrial joint. There was no malunion, nonunion, loose motion or false joint. There was some tenderness at the manubriosternal joint; otherwise, there was no weakness, redness, heat or drainage. Significantly, a January 2005 VA x-ray study showed an old, healed fracture of the distal sternum with anterior angulation of the distal fragment. The interpreter stated that the fracture was a "minor abnormality." During the April 2008 hearing, the Veteran testified that he had not received treatment or any medication for his service-connected sternum disability. He stated that his sternum hurt if he touched the area. During a June 2009 VA examination, the Veteran reported having intermittent chest pain with remissions. He treated the pain with Naproxen, Tramadol, Lidocaine and Gabapentin. He was noted to be right hand dominant. The examiner noted that there was no inflammation, fracture site motion, bone abnormality, or signs of active infection. There was pain and tenderness to palpation on the manubrium and sternum bones. The examiner opined that the Veteran's chest pain had a moderate impact on his usual daily activities, including chores. During the August 2012 videoconference hearing, the Veteran testified about being treated for his service-connected sternum disability. He had pain in the sternum area of his chest. He reported taking "a lot of pain pills," including Tramadol, Gabapentin, and Tinzanidine for his chest pain. During a January 2013 VA examination, the Veteran denied having a history of bone neoplasm, osteomyelitis, inflammation, fracture site motion, or deformity. He reported having severe pain in his anterior chest wall that flared-up weekly for hours at a time. The examiner noted there was no bone abnormality or signs of active infection or bone disease on examination. The Veteran had severe pain upon palpation of the anterior chest wall. He also had pain upon stretching his chest wall. The examiner opined that the Veteran's sternal fracture with chest pain had mild effects on his daily activities, including chores and recreation, but it prevented him from participating in exercise or sports. The examiner noted that the Veteran continued to have "extreme," "severe" pain in his chest wall upon inspiration and stretching of the pectoralis muscles. The examiner also noted that the Veteran had functional limitations in standing and walking. He was able to stand for 15 to 30 minutes and was unable to walk more than a few yards. However, the Board notes that the June 2012 VA aid and attendance or housebound examination showed that the service-connected cervical spine and lumbosacral spine disabilities affected his functional impairment, limiting him to walk without the assistance of another person for up to a few hundred yards. He did not mention that his service-connected sternum disability had an impact on his functional impairment during the examination. Based on a careful review of the record, the Board finds that an increased rating of 10 percent is warranted for the service-connected disability when it is evaluated by analogy to Diagnostic Code 5297. As noted, under Diagnostic Code 5297, a 10 percent disabling rating is warranted for removal of one rib or resection of two or more ribs without regeneration. A 20 percent rating is warranted for removal of two ribs; a 30 percent rating is warranted for three or four ribs; a 40 percent rating is warranted for five or six ribs; and a 50 percent rating is warranted for more than six ribs. The service-connected residuals of the fracture of the sternum in this case is found to be productive of a disability picture that more nearly approximates that of removal of one rib based resulting pain and bony defect. To the extent that the sternal defect is productive of pain and some slight related functional loss, an increased rating of 10 percent is assignable to address the disabling manifestations described by the Veteran. No health care professional has examined the Veteran and determined that the service-connected residuals of a fracture of the sternum is manifested by any symptomatology which could equate with removal of more than one rib. The Board finds that a separate or higher rating cannot be assigned under both Diagnostic Codes 7804 and 5297 for the residuals of the fracture of the sternum. Compensating the Veteran for this pain under both of the above Diagnostic Codes would constitute impermissible pyramiding. Under the anti-pyramiding provision of 38 C.F.R. § 4.14, the evaluation of the "same disability" or the "same manifestation" under various diagnoses is to be avoided. The Court held, in Esteban v. Brown, 6 Vet. App. 259 (1994), that for purposes of determining whether the appellant is entitled to separate ratings for different problems or residuals of an injury, such that separate evaluations do not violate the prohibition against pyramiding, the critical element is that none of the symptomatology for any one of the conditions is duplicative of or overlapping with the symptomatology of the other two conditions. The pain symptomatology is duplicative if applied under both Diagnostic Codes simultaneously. In reaching this decision, the potential application of various provisions of Title 38 Code of Federal Regulations have been considered, whether or not they were raised by the Veteran. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In particular, the Board has considered the provisions of 38 C.F.R. § 3.321(b)(1). However, in this case, the Board finds that the record does not show that the service-connected sternum disability is so exceptional or unusual as to warrant the assignment of a rating higher than 10 percent on an extraschedular basis. See 38 C.F.R. § 3.321(b)(1). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). A comparison between the level of severity and symptomatology of the Veteran's assigned rating with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. The Veteran's chief complaint of pain is fully considered in the assignment of the 10 percent disability rating. Based on the foregoing, the Board finds that referral for an extraschedular evaluation for the service-connected sternum disability under the provisions of 38 C.F.R. § 3.321(b)(1) is not warranted. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995); Thun v. Peake, 22 Vet. App. 111 (2008). Cranial Nerve The service-connected paresthesia of the right infraorbital branch of the fifth cranial nerve is rated as 10 percent disabling under Diagnostic Code 8305, for neuritis of the fifth cranial nerve, which affects sensation in the face and certain motor functions such as biting, chewing, and swallowing. Neuritis is rated by analogy under Diagnostic Code 8205 for paralysis of the fifth cranial nerve. Under that Diagnostic Code, 10, 30 and 50 percent ratings are warranted for moderate incomplete paralysis, severe incomplete paralysis, and complete paralysis, respectively. 38 C.F.R. § 4.124a. During a July 2009 VA examination, the Veteran reported feeling pain and numbness on the right side of his face. He stated that he was unable to open his mouth wide and had some pain after eating. The examiner noted that the Veteran presented some limitation of jaw movements, especially when opening his mouth. He noted that his history of a fractured right zygoma affected the infraorbital branch of the fifth cranial nerve produced paresthesia in that area. During the August 2012 hearing, the Veteran testified that he was not being treated or taking medication for his service-connected cranial nerve disability. He reported having pain and numbness in the right side of his face from his forehead to his cheek. He added that he had headaches when the pain flared-up. When he tried to raise his eyebrow, he reported, the nerve trembled and his face twitched. He also demonstrated that he was able to close his right eye. During a February 2013 VA examination, the Veteran reported having numbness in the right maxillary and mandibular area with associated tenderness to touch or hyperalgesia. He had difficulty shaving due to the sensitivity of the area, and his symptoms worsened on cold days. The examiner noted that the Veteran had paresthesia and/or dyesthesia that was moderate in the mid-face area and mild in the lower-face area. She also noted that the Veteran had numbness which was severe in the mid-face area and moderate in the lower-face area. He reported having mild difficulty chewing and mild decreased salivation. Muscle strength testing and sensory examination of the right fifth cranial nerve were normal. The examiner opined that the right fifth cranial nerve paralysis was incomplete and moderate in severity. She also noted that the Veteran's cranial nerve disability did not impact his ability to work. The VA examiner also noted that the Veteran had a scar related to his service-connected cranial nerve disability. The scar was not painful or unstable, and the total area of the related scars were not greater than 39 square centimeters or 6 square inches. A careful review of the evidence reveals that the service-connected cranial nerve disability results in no more than moderate incomplete paralysis of the fifth cranial nerve at any time during this appeal. At the July 2009 VA examination, the Veteran demonstrated some limitation of motion in opening his jaw. During the August 2012 hearing, he demonstrated an ability to move his right eyebrow and close his right eye. During the February 2013 VA examination, the examiner noted that the Veteran had paresthesia and/or dyesthesia that was moderate in the mid-face area and mild in the lower-face area. She also noted that the Veteran had numbness that was severe in the mid-face area and moderate in the lower-face area; however, muscle strength testing and sensory examination of the right fifth cranial nerve were normal. Moreover, the February 2013 examiner specifically described the neurological findings (loss of sensation) as "incomplete" and "moderate" in severity. As the evidence does not more severe incomplete paralysis and as no examiner has found that sensation was absent in the fifth cranial nerve affected areas, greater than a 10 percent rating is not warranted at any time during the appeal period. While the February 2013 VA examiner noted a scar related to the service-connected cranial nerve disability, the Board finds an increased rating is not warranted when the disability is evaluated under any of the other rating criteria for evaluation of scars. The description of the scar in the medical records does not satisfy any of the criteria for an increased rating based on scars. The Board notes that the schedule for rating disabilities concerning the evaluation of scars was amended effective on October 23, 2008. A veteran, however, may request review under the revised scars criteria irrespective of whether his or her disability has worsened since the last review. However, those revised provisions are applicable only to claims received on or after October 23, 2008. Because the current claim was received prior to that date, those revisions do not apply in this case. 73 Fed. Reg. 54708 (Sept. 23, 2008). Thus, all Diagnostic Codes discussed below are the versions in effect prior to October 23, 2008. Diagnostic Code 7800, which governs disfigurement of the head, face, or neck, a 10 percent evaluation is warranted for one characteristic of disfigurement. A 30 percent disability rating is warranted when there was 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 two or three characteristics of disfigurement. A 50 percent disability rating was warranted when there was visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features, or; with four or five characteristics of disfigurement. An 80 percent disability rating was warranted when there was visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features, or; with six or more characteristics of disfigurement. See 38 C.F.R. § 4.118, Diagnostic Code 7800 (2008). Under Note 1, the eight characteristics of disfigurement are: a scar 5 or more inches (13 or more cm.) in length; a scar at least 1/4 inch (0.6 cm.) wide at widest part; surface contour of scar elevated or depressed on palpation; a scar adherent to underlying tissue; skin hypo- or hyper-pigmented in an area exceeding 6 square inches (39-sq. cm.); skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding 6 square inches (39 sq. cm.); underlying soft tissue missing in an area exceeding 6 square inches (39-sq. cm.); and skin indurated and inflexible in an area exceeding 6 square inches (39- sq. cm.). Id. Diagnostic Code 7801, which governs scars, other than the head, face, or neck, that are deep or cause limited motion, a 10 percent evaluation is assigned when the area or areas exceed six square inches (39 square centimeters). A 20 percent evaluation is assigned when the area or areas exceed 12 square inches (77 square centimeters). Note 2 provided that a deep scar is one associated with underlying soft tissue damage. Diagnostic Code 7802, scars, other than the head, face, or neck, that are superficial, that do not cause limited motion, and that involve area or areas of 144 square inches (929 sq. cm.) or greater are assigned a 10 percent rating. Note 2 under the diagnostic code provided that a superficial scar is one not associated with underlying soft tissue damage. Diagnostic Code 7803, a 10 percent evaluation is assigned for scars that are superficial and unstable. Note 1 under the diagnostic code provided that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note 2 provided that a superficial scar is one not associated with underlying soft tissue damage. Diagnostic Code 7804 assigns a 10 percent rating for scars that are superficial and painful on examination. Note 1 under the diagnostic code provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Diagnostic Code 7805, other types of scars will be rated based on limitation of function of affected part. Diagnostic Code 7819 directs that benign skin neoplasms are to be rated as disfigurement of the head, face, or neck, scars, or impairment of function under the appropriate criteria. In making this decision, the Board has considered evaluating the service-connected disability under other potentially applicable codes. However, a disability rating under Diagnostic Codes 7800, 7801 or 7802 is not for application. The scar has not been found to have visible or palpable tissue loss or with characteristics of disfigurement (Diagnostic Code 7800); the scar is located on the head, face, or neck (Diagnostic Codes 7801, 7802); and the scar is not unstable or painful (Diagnostic Code 7804). The Board notes that the Veteran is competent to describe his current symptoms, such as pain and numbness of the right side of his face. Lay persons are competent to provide testimony as to observable symptoms and manifestations of a disorder. Layno v. Brown, 6 Vet. App. 465, 469 (1994) (noting competent lay evidence requires facts perceived through the use of the five senses); Barr v. Nicholson, 21 Vet. App. 303 (2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Charles v. Principi, 16 Vet. App. 370, 274 (2002) (finding Veteran competent to testify to symptomatology capable of lay observation); Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, the Veteran's reports of pain and numbness are outweighed by the findings of the VA examiners during the period in question. The February 2013 VA examiner reviewed his reported history, performed testing, and concluded that the cranial nerve disability manifested as moderate incomplete paralysis. Thus, the preponderance of the evidence is against a finding of severe incomplete paralysis or complete paralysis. Accordingly, a higher or separate rating is not warranted under Diagnostic Code 8205. In reaching this decision, the potential application of various provisions of Title 38 Code of Federal Regulations have been considered, whether or not they were raised by the Veteran. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In particular, the Board has considered the provisions of 38 C.F.R. § 3.321(b)(1). However, in this case, the Board finds that the record does not show that the service-connected cranial nerve disability picture is so exceptional or unusual as to warrant the assignment of a higher rating on an extraschedular basis. See 38 C.F.R. § 3.321(b)(1). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). The evidence in this case does not show an exceptional disability picture so that the available schedular evaluation for the service-connected disability is rendered inadequate. A comparison between the level of severity and symptomatology of the Veteran's assigned rating with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. The Veteran's chief complaints of pain and numbness are fully considered in the assignment of the 10 percent disability rating. Based on the foregoing, the Board finds that referral for an extraschedular evaluation for the service-connected cranial nerve disability under the provisions of 38 C.F.R. § 3.321(b)(1) is not warranted. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995); Thun v. Peake, 22 Vet. App. 111 (2008). ORDER An increased evaluation of 10 percent for the service-connected sternum disability based on pain, is granted, subject to the regulations governing the payment of VA monetary benefits. An increased evaluation in excess of 10 percent for the service-connected paresthesia of the right infraorbital branch of the fifth cranial nerve is denied. ____________________________________________ STEPHEN L. WILKINS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs