Citation Nr: 1320609 Decision Date: 06/26/13 Archive Date: 07/05/13 DOCKET NO. 08-36 526 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for hypertension. 2. Entitlement to service connection for a low back disorder. 3. Entitlement to service connection for a left eye pterygium. 4. Entitlement to an initial rating higher than 10 percent for a lower lip scar. 5. Entitlement to an initial compensable rating for pseudofolliculitis barbae (PFB). 6. Entitlement to an initial compensable rating for right eye pterygium excision residuals. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD C. Kedem, Counsel INTRODUCTION The Veteran had active duty from March 1968 to December 1969 and from November 1974 to November 1977. In the interim, beginning in March 1970 and after until February 1994, he had additional service in the Army Reserves on active duty for training (ACDUTRA) and inactive duty training (INACDUTRA). He appealed to the Board of Veterans' Appeals (Board/BVA) from a June 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). This case was initially before the Board in September 2010. At that time, the Board erroneously listed two of the issues. The Board indicated the Veteran was seeking an initial compensable rating for his service-connected right lower lip scar and a rating higher than 10 percent for his service-connected right eye pterygium excision residuals. In the earlier June 2007 rating decision, however, the RO had assigned an initial evaluation of 10 percent for the service-connected left lower lip scar and an initial noncompensable (zero percent) evaluation for the service-connected right eye pterygium excision residuals. So the Board mistakenly transposed the initial ratings that had been assigned for these disabilities. This decision corrects that mistake in identifying the claims concerning these disabilities. In that September 2010 decision, the Board remanded these remaining claims to the RO via the Appeals Management Center (AMC), rather than immediately deciding them, because they needed to be further developed. This additional development of these remaining claims since has been accomplished, allowing the Board in turn to now proceed with the adjudication of these remaining claims. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002). The Veteran submitted additional evidence that has not been considered by the RO in the first instance. In April 2013, however, through his representative, he waived his right to have the RO initially consider this additional evidence, preferring instead that the Board do so. 38 C.F.R. § 20.1304(c) (2012). The claims of entitlement to service connection for hypertension, a low back disorder, and a left eye pterygium require still further development before being decided on appeal. So the Board is again remanding these claims to the RO via the AMC in Washington, DC. Whereas the Board, instead, is going ahead and deciding the remaining claims for higher ratings for the lower lip scar, PFB and right eye pterygium excision residuals. FINDINGS OF FACT 1. The lower lip scar has been manifested by no more than a slightly raised area and subjective complaints of pain and discomfort. 2. The PFB has been manifested by no more than mild symptoms. 3. The right eye pterygium has been manifested by no more than a corneal scar and dryness. CONCLUSIONS OF LAW 1. The criteria are not met for a rating higher than 10 percent for the lower lip scar. 38 U.S.C.A. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 4.3, 4.7, 4.118, Diagnostic Code 7803 (effective from August 30, 2002 to August 22, 2008). 2. But the criteria are met for a higher 10 percent rating, though no greater rating, for the PFB. 38 U.S.C.A. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 4.3, 4.7, 4.20, 4.27, 4.118, Diagnostic Codes 7803 and 7899-7806 (effective from August 30, 2002 to August 22, 2008). 3. The criteria also are met as of December 10, 2008, for a higher 10 percent rating for the right eye pterygium excision residuals, though no greater rating. 38 U.S.C.A. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 4.3, 4.7, 4.84a, Diagnostic Code 6034 (effective before December 10, 2008), 4.79, Diagnostic Code 6034 (2012), 4.118, Diagnostic Code 7800 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating claims for VA benefits upon receipt of a complete or substantially complete application. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The claims for higher initial ratings addressed herein arise from disagreement with the initial evaluations assigned following the granting of service connection. The courts have held that once service connection is granted the claim is substantiated, so additional VCAA notice concerning the "downstream" disability rating and effective date elements of the claim is not required because the initial intended purpose of the notice has been served. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice upon receipt of a notice of disagreement (NOD)); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for "downstream" issues following a service connection grant, such as initial rating and effective date claims). According to the holding in Goodwin v. Peake, 22 Vet. App. 128 (2008), and this line of cases and precedent General Counsel opinion, instead of issuing an additional VCAA notice letter in this situation concerning the "downstream" disability rating and effective date elements of the claim, the provisions of 38 U.S.C.A. § 7105(d) require VA to issue a statement of the case (SOC) if the disagreement is not resolved, and this occurred in this particular instance. The RO provided the Veteran this required SOC (also since has provided him a supplemental SOC (SSOC)) citing the applicable statutes and regulations governing the ratings for his now service-connected disabilities and containing discussion of the reasons and bases for not assigning higher initial ratings for these disabilities. He therefore has received all required notice concerning these claims. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim - unless no reasonable possibility exists that such assistance would aid in the substantiation of the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to the claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). To this end, VA has obtained the Veteran's service treatment records (STRs), private medical records, lay statements, including his personal statements, and VA medical examination reports of evaluations conducted regarding each disability at issue in May 2007 and October 2010. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA findings obtained in this case are adequate, as they are predicated on a full reading of the medical records in the Veteran's claims file. The VA examiners considered all of the pertinent evidence of record to include all relevant evidence in the claims file and the statements of the Veteran. Accordingly, the Board finds that VA's duty to assist with respect to obtaining VA examinations or opinions with respect to the issues of higher initial disability ratings for a lower lip scar, PFB, and residuals of a right eye pterygium excision has been met. 38 C.F.R. § 3.159(c)(4). The Board is aware that the complete STRs from the Veteran's first period of service are not on file. However, the Board need not remand the claims decided herein in order that these STRs be secured. These claims being decided are not for service connection; indeed, to the contrary, this already has been granted, at least as concerning these claims. Rather, they concern purported entitlement to higher initial ratings. All of the evidence needed to decide these claims is of record, and a remand for the missing STRs would serve no useful purpose. Soyini v. Derwinski, 1 Vet. App. 540 (1991) (strict adherence to requirements in the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands that would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran should be avoided). Standard of Review After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3 (2012) (reasonable doubt to be resolved in Veteran's favor). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (Court) stated that "a Veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See also Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54 . Increased Ratings Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10 (2012). In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. 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 severity, it is necessary to consider the complete medical history of a Veteran's disability. Schafrath, 1 Vet. App. at 594. Because the appeals are from the initial ratings assigned following the granting of service connection, the possibility of "staged" ratings for separate periods during the appeal period, based on the facts found, must also be considered. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). The provisions of 38 C.F.R. § 4.27 provide that unlisted disabilities requiring rating by analogy will be coded with the first two numbers of the schedule provisions for the most closely related body part and "99." 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 a hyphen. Regulations provide that when a disability not specifically provided for in the rating schedule is encountered, it will be rated under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. The Court held that if the claimant or the record reasonably raises the question of whether the Veteran is unemployable due to the disability for which an increased rating is sought, then part and parcel to that claim for an increased rating is whether a total disability rating based on individual unemployability (TDIU) as a result of that disability is warranted. Rice v. Shinseki, 22 Vet. App. 447 (2009). Lower Lip Scar The Veteran's left lower lip scar has been rated 10 percent disabling under the provisions of Diagnostic Code 7803. 38 C.F.R. § 4.118 (effective August 30, 2002 to October 22, 2008). The applicable rating criteria for skin disorders, found at 38 C.F.R. § 4.118, were amended effective August 30, 2002 and again in October 2008. The October 2008 revisions are applicable to application for benefits received by the VA on or after October 23, 2008. 73 Fed. Reg. 54708 (September 23, 2008). In this case, the Veteran filed his claim in February 2007, and VA has not received a request from him to be rated under the revised criteria effective in 2008. Therefore, only the post-2002 and pre-October 2008 version of the schedular criteria, set out immediately below, is applicable. Under Diagnostic Code 7803, superficial unstable scars are rated 10 percent disabling. That it the maximum rating available under Diagnostic Code 7803. 38 C.F.R. § 4.118, Diagnostic Code 7803 (effective August 30, 2002 to October 22, 2008). On May 2007 VA skin examination, the Veteran reported recurrent irritation of the inner aspect of his lower lip. The irritation was more problematic during the warmer months. He also reported swelling and indicated that the area tended to become red and irritated. These flare-ups lasted several weeks, subsided, and then recurred. On objective examination, the examiner noted that the area was mildly raised and firm. There was some tenderness to palpation. The scar's maximum width was .5 of a centimeter, and its maximum length was .75 of a centimeter. These was no adherence to underlying tissue, no loss of function, no underlying soft tissue damage, no underlying tissue loss, no elevation of the scar, no depression of the scar, no induration, no inflexibility, and no disfigurement of the head, face or neck. The scar was the same color as that of the surrounding skin. Texture of the scar area was normal. The examiner diagnosed scar, residual of shrapnel wound right lower lip. Photos were not included, as the scar was not disfiguring according to the examiner. In the March 2008 notice of disagreement, the Veteran stated that the fragment in the lower lip caused a lifetime of pain in the lower lip region. On October 2010 VA skin examination, the Veteran indicated that the scar was a constant bother and that irritation the lower lip scar caused him to awaken twice a night. As well, the Veteran indicated that three times a year, the scar became swollen. However, it never broke open and never bled. The examiner indicated that there was no skin breakdown due to the scar, no limitations to employment due to the scar, and the scar did not limit daily activities. The examiner indicated that there were no other symptoms associated with the scar. Indeed, the examiner indicated that there was no visible scar per se. Rather, there was a slightly firm area to the right inferior aspect of the transitional zone of the lower lip and right lateral to the right labial frenula area. There were no ulcerations, no excoriations, and no tenderness to palpation. The examiner assessed that the irritation that the Veteran experienced was due to his fixation to the area with his tongue. The scar's maximum width was .5 of a centimeter. Its maximum length was .75 of a centimeter. There was no pain on palpation, instability of the scar, ulceration, breakdown, or limitation of motion or function due to the scar. There was no underlying soft tissue damage. The scar was neither elevated nor depressed. The texture of the scarred area was normal. There was no induration or inflexibility of the scar. The scar did not cause disfigurement or asymmetry of the head, face, or neck. The diagnosis was of a shrapnel scar of the lower lip mucosa. The examiner indicated that the service-connected shrapnel scar of the lower lip mucosa had no impact upon employability. The Veteran is in receipt of the highest evaluation available under Diagnostic Code 7803. 38 C.F.R. § 4.118, Diagnostic Code 7803 (effective from August 30, 2002 to August 22, 2008). Thus, the Board must determine whether he is entitled to a higher evaluation under any other potentially applicable scheduler provision. Schafrath, supra. Diagnostic Code 7800 pertains to disfigurement of the head, face, or neck. 38 C.F.R. § 4.118, Diagnostic Code 7800 (effective from August 30, 2002 to August 22, 2008). Throughout the appeal period, VA examiners have indicated explicitly that there was no disfigurement of the had, face, or neck. As well, the Veteran has not argued that there is any such disfigurement. Thus, Diagnostic Code 7800 is inapplicable herein. Id. Diagnostic Code 7801 concerns scars, other than the head, face, or neck, that are deep or that cause limitation of motion. 38 C.F.R. § 4.118, Diagnostic Code 7801 (effective from August 30, 2002 to August 22, 2008). The Veteran's scar is not deep and does not cause limitation of motion. As such, Diagnostic Code 7801 is not for application. Id. Diagnostic Code 7802 deals with scars, other than the head, face, or neck, that are superficial and that do not cause limitation of motion. 38 C.F.R. § 4.118, Diagnostic Code 7802 (effective from August 30, 2002 to August 22, 2008). The maximum evaluation under this provision is 10 percent for qualifying scars that cover an area of at least 144 square inches (929 square centimeters). The Veteran's scar, which is .5 of a centimeter by .75 of a centimeter, does not cover an area of 929 square centimeters. Thus, Diagnostic Code 7802 does not apply to the Veteran's disability. In any event, he would not fare better with an evaluation under Diagnostic Code 7802, as the maximum evaluation under it is 10 percent, and the Veteran is already in receipt of a 10 percent evaluation under Diagnostic Code 7803. See generally 38 C.F.R. § 4.118 (effective from August 30, 2002 to August 22, 2008). Diagnostic Code 7804 deals with scars that are superficial and painful on examination. 38 C.F.R. § 4.118, Diagnostic Code 7804 (effective from August 30, 2002 to August 22, 2008). This provision is potentially applicable herein because the Veteran has reported pain and discomfort, and there is objective evidence of tenderness to palpation. However, the maximum rating under Diagnostic Code 7804 is 10 percent. Thus, the Veteran would not benefit from a rating under that provision. Id. The last potentially relevant schedular provision is Diagnostic Code 7805. 38 C.F.R. § 4.118, Diagnostic Code 7805 (effective from August 30, 2002 to August 22, 2008). Under this provision, scars, other, are rated on limitation of function of the affected part. The service-connected lower lip scar is not productive of limitation of function. Thus, Diagnostic Code 7805 is inapplicable herein. Id. As apparent from the foregoing discussion, the Veteran's service-connected lower lip scar symptomatology has not risen to the level necessary for an evaluation in excess of 10 percent at any time during the appeal period, and an increased rating cannot be granted. See generally 38 C.F.R. § 4.118 (effective from August 30, 2002 to August 22, 2008); Fenderson, supra. The Board finds that a claim for a TDIU is not raised by the record, either expressly or implicitly. Specifically, the evidence of record fails to show the Veteran is unemployable due to the service-connected lower lip scar, and neither he nor his representative has contended as much. Therefore, the Board finds that no further consideration of a TDIU is warranted. Id. Finally, in making this determination, the Board has considered the provisions of 38 U.S.C.A. § 5107(b), but there is not such a state of approximate balance of the positive evidence with the negative evidence to otherwise warrant a favorable decision. PFB The Veteran's PFB has been rated zero percent disabling by the RO under Diagnostic Code 7899-7806. 38 C.F.R. §§ 4.20, 4.27, 4.118 (effective from August 30, 2002 to August 22, 2008). The applicable rating criteria for skin disorders, found at 38 C.F.R. § 4.118, were amended effective August 30, 2002 and again in October 2008. The October 2008 revisions are applicable to application for benefits received by the VA on or after October 23, 2008. 73 Fed. Reg. 54708 (September 23, 2008). In this case, the Veteran filed his claim in February 2007, and VA has not received a request from the Veteran to be rated under the revised criteria effective in 2008. Therefore, only the post-2002 and pre-October 2008 version of the schedular criteria, set out immediately below, is applicable. Diagnostic Code 7806 pertains to dermatitis and eczema. 4.118, Diagnostic Code 7806 (effective from August 30, 2002 to August 22, 2008). Pursuant to the schedular criteria for Diagnostic Code 7806 (dermatitis or eczema), a noncompensable (zero percent) rating is warranted for 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. A 10 percent rating is warranted for at least 5 but less than 20 percent of the entire body or at least 5 but less than 20 percent of exposed areas affected; or systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than 6 weeks during the past 12- month period. A 30 percent rating is warranted for 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. More than 40 percent of the entire body or more than 40 percent of exposed areas, affected; or constant or near- constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period warrants a 60 percent rating. 38 C.F.R. § 4.118, Diagnostic Code 7806 (effective August 30, 2002 to October 22, 2008). Dermatitis or eczema can be rated as disfigurement of the head, face or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. Id. On VA examination in May 2007, the Veteran indicated that shaving was limited to once a week due to his service-connected PFB. The Veteran reported that the condition was constant and consisted of bumps, a rash, itching, and irritation, especially under the chin. The symptoms were near constant. There were no systemic symptoms. The Veteran used over-the-counter treatment to include over-the-counter alcohol and "magic shaving powder." The Veteran used the foregoing treatments at least every other day; they did not produce any side effects. The Veteran did not use either a corticosteroid or an immunosuppressive form of treatment. On objective examination, the examiner noted that the percent of exposed area afflicted with PFB was less than five percent of exposed areas. The percentage of total body area affected was less than one percent. The examiner observed that the Veteran had a closely cropped beard and a few scattered raised lesions on the cheeks and chin that were two to three millimeters in size. There were no ingrown hairs noted. The examiner diagnosed mild PFB. The examiner indicated that the Veteran's PFB was not productive of scarring or disfigurement. Also, according to the examiner, it caused no functional impairment. In his March 2008 NOD, the Veteran asserted that his PFB caused him to be turned down for certain civilian employment positions, and for that reason, he argued that he was entitled to a compensable evaluation for his service-connected PFB. On October 2010 VA PFB examination, the Veteran stated that he shaved twice a month. He further asserted that a PFB rash bothered him constantly although it was not visible according to the examiner. The Veteran also reported that he could not get a good job due to his lack of shaving although he stated that he was retired from a good job with the county and did not wish to work any longer. The examiner observed that the Veteran's skin symptoms consisted of subjective irritation. There were no systemic symptoms. There had been no skin disease treatment in the previous 12 months. The examiner estimated that the total body area affected was zero percent and that the total exposed area affected was zero percent. The examiner remarked that the Veteran appeared clean and presentable. He further observed there was no excoriation around the face or hair line, no signs of discomfort throughout the interview, no rashes, and no sign of ingrown hair on the face or neck. The diagnosis was of PFB - no objective evidence on today's examination. Under Diagnostic Code 7806, a 10 percent evaluation is not warranted because the evidence does not reflect, and the Veteran does not assert, that at least 5 but less than 20 percent of the entire body or at least 5 but less than 20 percent of exposed areas are affected or that systemic therapy is required. 38 C.F.R. § 4.118, Diagnostic Code 7806 (effective August 30, 2002 to October 22, 2008). The Board finds that a compensable evaluation is not for application under Diagnostic Code 7800, disfigurement of the head, face, or neck, because VA examiners in May 2007 and in October 2010 indicated expressly that there was no disfigurement of the head, face, or neck. The Board emphasizes that PFB was completely asymptomatic in October 2010, and service connection were only mild in May 2007. As such, again, a compensable evaluation under Diagnostic Code 7800 is not warranted. 38 C.F.R. § 4.118, Diagnostic Code 7800 (effective August 30, 2002 to October 22, 2008). Diagnostic Code 7801 pertains to scars other than of the head, face, or neck, that are deep or that cause limited motion. 38 C.F.R. § 4.118, Diagnostic Code 7801 (effective August 30, 2002 to October 22, 2008). Diagnostic Code 7802, which concerns scars other than of the head, face, or neck that are superficial and that do not cause limited motion. 38 C.F.R. § 4.118, Diagnostic Code 7802 (effective August 30, 2002 to October 22, 2008). These provisions do not apply because the Veteran's PFB is presumably of the face and neck. In any event, Diagnostic Code 7801 would be inapplicable because the PFB has not been characterized as deep or as productive of limited motion. A compensable evaluation under Diagnostic Code 7802 would not be warranted because a 10 percent evaluation under this provision requires that area implicated be at least 144 square inches in area (929 square centimeters). The evidence herein does not indicate than an area of this magnitude is implicated. Indeed, at worst, the chin and cheeks are affected, and the chin and cheeks do not comprise of a surface area of that magnitude. Diagnostic Code 7803 pertains to scars that are superficial and unstable. 38 C.F.R. § 4.118, Diagnostic Code 7803 (effective August 30, 2002 to October 22, 2008). An unstable scar is one not where, for any reason, there is frequent loss of covering of skin over the scar. Id., Note (1). A superficial scar is one not associated with underlying soft tissue damage. Id., Note (2). Affording the Veteran the benefit of the doubt, the Veteran's PFB more nearly approximates a superficial scar, as the evidence reflects that for at least part of the appeal period, small raised lesions of the chin and cheeks were apparent. 38 C.F.R. § 4.7. As such, a 10 percent evaluation is warranted under Diagnostic Code 7803. 38 C.F.R. § 4.118, Diagnostic Code 7803 (effective August 30, 2002 to October 22, 2008). The Board finds that the 10 percent evaluation is warranted for the entire appeal period because of the Veteran's regular and diligent efforts to treat his PFB and due to the recurrent nature of the symptoms. Fenderson, supra. Diagnostic Code 7804 pertains to superficial scars that are painful on examination. 38 C.F.R. § 4.118, Diagnostic Code 7804 (effective August 30, 2002 to October 22, 2008). The Board need not consider whether an increased rating is warranted under Diagnostic Code 7804, as 10 percent is the highest rating available under that provision, and the Veteran has already been granted a 10 percent evaluation pursuant to Diagnostic Code 7803. 38 C.F.R. § 4.118 (effective August 30, 2002 to October 22, 2008). Diagnostic Code 7805 involves scars, other, that are rated based on limitation of function of the affected part. 38 C.F.R. § 4.118, Diagnostic Code 7805 (effective August 30, 2002 to October 22, 2008). The Board need not consider Diagnostic Code 7805 because the Veteran's PFB is not productive of limitation of function. The Board notes that the rest of the potentially applicable provisions such as Diagnostic Code 7816 (psoriasis) would require that 20 to 40 percent of exposed areas be implicated or that systemic therapy be required for at least six weeks (but not constantly) in the previous 12 months in order for an evaluation in excess of 10 percent to be granted. See generally 38 C.F.R. § .118 (effective August 30, 2002 to October 22, 2008). The Board finds that a claim for a TDIU is not raised by the record. Specifically, the evidence of record fails to show that the Veteran is unemployable due to the service-connected PFB, and neither he nor his representative has contended as much. Therefore, the Board finds that no further consideration of a TDIU is warranted. Id. The Board realizes that he has indicated that the service-connected PFB has hindered his employment opportunities. But he has never gone so far as to claim he is outright unemployable because of this service-connected disability or even incapable because of it of obtaining and maintaining employment that could be considered substantially gainful versus just marginal in comparison. Furthermore, he has provided no concrete evidence of job opportunities missed due to his PFB. The Board is aware that he might feel self conscious as a result of this condition. Because, however, it has been described as no more than mild, the Board cannot find that there has been any noteworthy or significant impact upon employability. Finally, in making this determination, the Board has considered the provisions of 38 U.S.C.A. § 5107(b), but there is not such a state of approximate balance of the positive evidence with the negative evidence to otherwise warrant an even more favorable decision. Right Eye Pterygium Excision Residuals The service-connected right eye pterygium excision residuals have been rated zero percent disabling under the provisions of Diagnostic Code 6034. 38 C.F.R. §§ 4.84a (effective prior to December 10, 2008), 4.79 (2012). Effective December 10, 2008, during the pendency of this appeal, VA revised the schedular rating criteria for evaluating eye disorders. See 73 Fed. Reg. 66,543-66,554 (Nov. 10, 2008); see also corrections at 74 Fed. Reg. 7,648 (Feb. 19, 2009). The Veteran's service-connected eye disability therefore must be evaluated under both the former and revised standards, although the revised criteria may be applied only prospectively, namely, only as of the effective date of the change to these new criteria. See 38 U.S.C.A. § 5110(g) (West 2002 & Supp. 2012); VAOPGCPREC 3-2000 (Apr. 10, 2000); VAOPGCPREC 7-2003 (Nov. 19, 2003). According to 38 C.F.R. § 4.84a, Diagnostic Code 6034, pterygium is to be rated based on loss of vision, if any. 38 C.F.R. § 4.84a, Diagnostic Code 6034 (effective before December 10, 2008). In effect since December 10, 2008, Diagnostic Code 6013 for pterygium provides that pterygium is to be rated based on visual impairment, disfigurement (Diagnostic Code 7800), conjunctivitis (Diagnostic Code 6018), etc., depending on the particular findings. 38 C.F.R. § 4.79 (2012). Visual impairment is based on the impairment of visual acuity (excluding developmental errors of refraction), visual field, and muscle function. 38 C.F.R. § 4.75(a). These impairments are assigned disability evaluation based on the criteria in Diagnostic Codes 6061-6091. 38 C.F.R. § 4.79. Evaluation of visual acuity is based on corrected distance vision with central fixation, even if central scotoma is present. 38 C.F.R. § 4.76(b). Evaluation of visual fields is determined based on the average concentric contraction of the visual field of each eye by measuring the remaining visual field (in degrees) at each of the eight principal meridians 45 degrees apart, adding them and dividing the sum by eight. 38 C.F.R. § 4.77(b). The normal visual field extent at the eight principal meridians is temporally 85 degrees, down temporally 85 degrees, down 65 degrees, down nasally 50 degrees, nasally 60 degrees, up nasally 55 degrees, up 45 degrees, and up temporally 55 degrees. 38 C.F.R. § 4.76a, Table III. Evaluation of muscle function is based on the degree of diplopia or symblepharon. 38 C.F.R. § 4.79, Diagnostic Codes 6090-6091. Impairment of central visual acuity is evaluated from 0 percent, i.e., noncompensable, to 100 percent based on the degree of the resulting impairment of visual acuity. 38 C.F.R. § 4.84a, Diagnostic Codes 6061 to 6079. A disability rating for visual impairment is based on the best distant vision obtainable after the best correction by glasses. 38 C.F.R. § 4.75. The percentage evaluation will be found from Table V by intersecting the horizontal row appropriate for the Snellen index for one eye and the vertical column appropriate to the Snellen index of the other eye. 38 C.F.R. § 4.83a. A compensable disability rating of 10 percent is warranted for impairment of central visual acuity in the following situations: (1) when vision in one eye is correctable to 20/50 and vision in the other eye is correctable to 20/40; (2) when vision in both eyes is correctable to 20/50; (3) when vision in one eye is correctable to 20/70 and vision in the other eye is correctable to 20/40; or (4) when vision in one eye is correctable to 20/100 and vision in the other eye is correctable to 20/40. 38 C.F.R. § 4.84a, Diagnostic Codes 6078 and 6079. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is not allowed. See 38 C.F.R. § 4.14 (2012) (VA's anti-pyramiding regulation). A claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate him for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993) (interpreting 38 U.S.C.A. § 1155). However, if he has separate and distinct manifestations attributable to the same injury, they should be compensated under different diagnostic codes. See Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225, 230 (1993). On May 2007 VA eye examination, the examiner noted that the Veteran had undergone a right eye pterygium excision. There was no history of trauma to the eye. Right eye symptoms included pain, redness, blurring, and watering. There were no periods of incapacitation due to eye disease. There was no keratoconus. Contact lenses were not required. Right eye corrected distance vision was 20/20-. Corrected near vision was 20/20. There were not more than four diopters of spherical correction between the eyes. Visual acuity was not worse than 5/200. Accommodation was normal. There was no visual field defect. There was no scotoma in the right eye. Right eye pressure was 13. Nystagmus was not present. There was no right eye ptosis. There was no lagophthalmos, symblepharon, or strabismus. Diplopia was not present. The right lacrimal duct functioned normally. The examiner noted bilateral cataracts. The funduscopic examination was abnormal; the right optic nerve was 0.8. The vessels, macula, fundus, media, periphery, and other funduscopic findings were normal. On slit lamp examination, there were abnormalities. As to the sclera/conjunctiva there was mild pterygium excision residual, and there was scarring of the right cornea nasally. The examiner indicated that the Veteran was employed full time as an operator and that he had missed two weeks of work the previous year due to medical appointments. The examiner diagnosed residuals status-post pterygium excision right eye with current corneal scarring/irritation without objective evidence of a current right eye pterygium. As to impact on occupational activities, the examiner noted that it was harder for the Veteran to see and that eye fatigue was present. There was no more than a moderate impact upon daily activities. On VA eye examination in October 2010, the Veteran reported no incapacitating episodes due to the eye. Right eye general symptoms included burning, stinging, and dryness. Visual symptoms consisted of glare, burning, and floaters. There was no right eye diplopia. Funduscopic examination was abnormal. The optic nerve was 0.6/0.6, and vessel was 1/2. The macula was flat. The media and periphery were clear. There was no visual field defect with respect to the right eye. As to central visual acuity, visual acuity was not worse than 5/200. There was no corneal disorder that resulted in sever irregular astigmatism that could be improved more by contact lenses than with glasses. There were not more than three diopters of spherical correction between the eyes. As to distance vision, right eye visual acuity was 20/40 uncorrected and 20/25 corrected. Near right eye vision was 20/60 uncorrected and 20/20 corrected. Right eye slit lamp findings were abnormal. As to the sclera/conjunctiva, there was a temporal pinguecula nasal graft patch in place (this was unrelated to the service-connected right eye pterygium). As to the cornea, there was nasal scarring from the pterygium removal arcus. There was decreased tear film. The lens was intact. There were no findings of abnormal lacrimal duct functioning, abnormal eyelids, chronic conjunctivitis, residuals of an eye injury, lagophthalmos, symblepharon, ptosis, nystagmus, eyelash loss, or eyebrow loss. Accommodation was appropriate for age. The Veteran was retired by reason of age or duration of work. The examiner diagnosed moderate dry eyes and irritation causing significant occupational visual difficulty and moderate impact upon driving. The dry eye was related to the pterygium surgery. There were corneal scars resulting from the pterygium excision surgery. This caused dry eyes, which had a significant occupational impact, as it caused visual difficulty. As to daily activities, it moderately affected driving. Under the criteria effective before December 10, 2008, a compensable evaluation is not warranted because corrected visual acuity was complete or almost complete throughout the appeal period. Indeed, uncorrected right eye distance visual acuity was no worse that 20/40 throughout the appeal period. In sum, when assessing the disability picture under the criteria effective before December 10, 2008, there is no means by which to assign an evaluation in excess of zero percent at any time during the appeal period. 38 C.F.R. § 4.84a, Diagnostic Code 6034 (effective prior to December 10, 2008); see also Fenderson, supra. Under the criteria that became effective December 10, 2008, a compensable evaluation is not warranted for visual impairment, as corrected vision, both near and far, was perfect or near perfect. 38 C.F.R. § 4.79, Diagnostic Code 6034 (effective December 10, 2008). Furthermore, no compensation is warranted for conjunctivitis, as the Veteran does not suffer from this condition. He has had no incapacitating episodes due to the right eye, so the Board need not consider entitlement to a compensable evaluation under the criteria dealing with incapacitating episodes. Furthermore, the evidence does not reveal that the Veteran suffers from any eye disorder listed under Diagnostic Codes 6000-6037 (diseases of the eye) other that the pterygium excision residuals. 38 C.F.R. § 4.79 (effective December 10, 2008). Diagnostic Code 38 C.F.R. § 4.79, Diagnostic Code 6034 (effective December 10, 2008), allows for pterygia to be rated depending of the particular findings, to include disfigurement. Because the current version of Diagnostic Code 6034 became effective December 10, 2008, the Board will consider entitlement to a compensable evaluation under the criteria for potentially applicable disorders of the skin that became effective October 22, 2008. Diagnostic Code 7800 provides ratings for disfigurement of the head, face, or neck. Note (1) to Diagnostic Code 7800 provides that the 8 characteristics of disfigurement, for purposes of rating under 38 C.F.R. § 4.118, are: Scar is 5 or more inches (13 or more cm.) in length. Scar is at least one-quarter inch (0.6 cm.) wide at the widest part. Surface contour of scar is elevated or depressed on palpation. Scar is adherent to underlying tissue. Skin is hypo-or hyper-pigmented in an area exceeding 6 square inches (39 sq. cm.). Skin texture is abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding 6 square inches (39 sq. cm.). Underlying soft tissue is missing in an area exceeding 6 square inches (39 sq. cm.). Skin is indurated and inflexible in an area exceeding 6 square inches (39 sq. cm.). Diagnostic Code 7800 provides that a skin disability with one characteristic of disfigurement of the head, face, or neck is rated 10 percent disabling. A skin disability 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 two or three characteristics of disfigurement, is rated 30 percent disabling. A skin disability of the head, face, or neck 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, is rated 50 percent disabling. A skin disability of the head, face, or neck with 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, is rated 80 percent disabling. The Veteran has a corneal scar, and while the exact size of the scar has not be stated, in order to afford the Veteran the benefit of the doubt and in consideration of the right eye dryness associated with the pterygium excision, the Board finds that the right eye corneal scar more nearly approximates one that is one-quarter of an inch in length. There are no other characteristic disfigurements. With one characteristic disfigurement, a 10 percent evaluation is warranted under Diagnostic Code 7800 effective December 10, 2008. 38 C.F.R. § 4.118, Diagnostic Code 7800 (2012). Potentially applicable are Diagnostic Codes 7804 and 7805. 38 C.F.R. § 4.118 (2012). Diagnostic Code 7804 concerns unstable or painful scars. Because no pain or instability is associated with the residuals corneal scar, the Board need not consider an evaluation in excess of 10 percent under its provisions. Diagnostic Code 7805 provides for scars, other (including linear scars) and other effects of scars. That provision states that these other scars are to be related under Diagnostic Codes 7800, 7801, 7802, 7804 or under an appropriate diagnostic code. Here, the Board has considered all of the potentially applicable scar and disfigurement provisions. Additionally, all of the adverse manifestations of the right eye pterygium residuals have been considered in the assignment of the 10 percent evaluation under Diagnostic Code 7800. Thus, compensation under any other provision would constitute prohibited pyramiding. 38 C.F.R. §§ 4.14; Brady, supra. The Board finds that a claim for a TDIU is not raised by the record. Specifically, the evidence of record fails to show that the Veteran is unemployable due to the service-connected right eye pterygium excision. While the Board is aware that a VA examiner asserted that it would have a significant impact upon employment, he did not argue that the pterygium excision rendered the Veteran unemployable, and neither the Veteran nor his representative has contended as much. Therefore, the Board finds that no further consideration of a TDIU is warranted. Id. Finally, in making this determination, the Board has considered the provisions of 38 U.S.C.A. § 5107(b), but there is not such a state of approximate balance of the positive evidence with the negative evidence to otherwise warrant an even more favorable decision. Extraschedular Consideration In reviewing all of these increased-rating claims, the potential application of the various other provisions of Title 38 of the Code of Federal Regulations also have been considered, including 38 C.F.R. § 3.321(b)(1) (2012), which provides procedures for referral or assignment of an extraschedular evaluation. Schafrath, 1 Vet. App. at 593. The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). The VA Compensation and Pension Service is authorized to approve an extraschedular evaluation 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 as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1). If the evidence raises the question of entitlement to an extraschedular rating, 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. The Board has considered Mittleider, supra. In Mittleider, the Court held that the Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence which does so. Here, the Board has considered all symptomatology potentially related to a service-connected disabilities. Initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Thun v. Peake, 22 Vet. App. 111 (2008). In this case, comparing the Veteran's disability level and symptomatology to the rating schedule, the degree of disability throughout the appeal period under consideration is contemplated by the rating schedule. The Veteran's lower lip scar and PFB have been specifically contemplated by the rating schedule, and no referral is necessary. These disabilities are rated under the applicable scheduler provisions concerning the skin, which provide for ratings based on manifestations such as disfigurement, unstable scars, painful scars, scars causing limitation of function, and the type of treatment required, as well as the percentage of the body, to include exposed areas, implicated. As to the residuals of a right eye pterygium excision, the disability is specifically contemplated by the rating schedule and no referral is necessary. The schedular rating criteria for all periods of time at issue herein provide for ratings for pterygium based on visual impairment, disfigurement, conjunctivitis or any other manifestations. Because the schedular rating criteria are adequate to rate the Veteran's service-connected lower lip scar, PFB, and residuals of a right eye pterygium excision, there is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards to each of the disabilities at issue herein. For these reasons and bases, the Board finds that the criteria for referral for extraschedular rating have not been met with respect to any of the disabilities discussed above. 38 C.F.R. § 3.321(b)(1). ORDER An evaluation higher than 10 percent for the lower lip scar is denied. However, a higher evaluation of 10 percent is granted for the PFB, subject to the statutes and regulations governing the payment of Veterans' benefits. A higher 10 percent rating also is granted for the right eye pterygium excision residuals, effective December 10, 2008, subject to the statutes and regulations governing the payment of Veterans' benefits. REMAND Quite unfortunately, this case must be remanded yet again as concerning the remaining claims, which are all for service connection. In September 2010, the Board remanded these claims so that STRs from the Veteran's first period of service (March 1968 to December 1969) could be obtained. In April 2012, the RO/AMC issued a memorandum titled "Improperly Directed Development" indicating the STRs from the Veteran's first period of service were of record. The Board has located immunization records from the Veteran's first period of service, but no other medical records concerning that initial service. STRs typically include much more than just immunization records. Thus, the RO/AMC must associate with the claims file the complete medical records from the Veteran's first period of service. If they are unavailable, the RO/AMC must document its unfruitful efforts to secure them and appropriately notify the Veteran. 38 C.F.R. § 3.159(c)(2) and (e)(1). Absent this required development, there has not been compliance, even substantial compliance, with this prior remand directive. See Stegall, 11 Vet. App. at 271; D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that substantial compliance with the terms of a Board remand is required). Accordingly, these remaining claims are REMANDED for the following additional development and consideration: 1. Obtain the STRs concerning the Veteran's first period of active duty service from March 1968 to December 1969. If necessary, consider special follow-up by military records specialist and/or referral of the case to the Adjudication Officer or designee for a formal finding on the unavailability of these STRs. In the event these records cannot be obtained, the RO/AMC must document its efforts to obtain them and appropriately notify the Veteran. 38 C.F.R. § 3.159(c)(2) and (e)(1). 2. Then readjudicate the claims for service connection that remain in light of this and any other additional evidence. If these claims are not granted to the Veteran's satisfaction, send him and his representative another SSOC and give them time to submit additional evidence and/or argument in response before returning the file to the Board for further appellate consideration of these remaining claims. The Veteran has the right to submit additional evidence and argument concerning these claims the Board is remanding. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court 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). ______________________________________________ Keith W. Allen Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs