Citation Nr: 1322864 Decision Date: 07/17/13 Archive Date: 07/24/13 DOCKET NO. 09-27 758 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for a fungal skin disorder of the left foot. 2. Entitlement to a higher initial rating in excess of zero percent for scars due to basal cell carcinoma. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD C.L. Krasinski, Counsel INTRODUCTION The Veteran, the appellant in this case, had active service with the US Air Force from December 1972 to January 2008, with prior service in the US Air Force Reserves from July 1964 to December 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision by the Houston, Texas, Regional Office (RO) which granted service connection for scars due to basal cell carcinoma and assigned an initial disability rating of zero percent. The RO denied service connection for a scar of the right knee and a fungal disorder of the left foot in addition to several other claimed disabilities. In a February 2013 decision, the Board granted service connection for a scar to the right thigh. The issues of entitlement to a higher initial rating for scars due to basal cell carcinoma and service connection for a fungal skin disorder of the left foot were remanded for additional development. The Board finds that the agency of original jurisdiction substantially complied with the mandates of the February 2013 remand. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (finding that a remand by the Board confers on the appellant the right to compliance with the remand orders). The Veteran was provided a VA examination in May 2013 and the requested medical opinion was obtained. The most recent VA treatment records were associated with the virtual VA file. The Veteran was asked to identify any additional treatment for the skin disorders. The Board concludes that there has been substantial compliance with the remand order. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002). In evaluating this case, the Board has not only reviewed the Veteran's physical claims file, but has also reviewed the file on the "Virtual VA" system to ensure a complete assessment of the evidence. FINDINGS OF FACT 1. The Veteran first experienced recurrent symptoms of a fungal infection of the left foot and toenails in active service. 2. The Veteran experienced recurrent symptoms of a fungal infection of the left foot and toenails since service. 3. The onychomycosis of the left foot and toenails first manifested in active service. 4. For the entire appeal period, the service-connected scars due to basal cell carcinoma are manifested by a right lateral eyebrow scar which is 2 centimeters by .3 centimeters; a right upper forehead scar that is 5 centimeters by .2 centimeters; a left temporal scar which is 4 centimeters by .3 centimeters; a linear scar on the left upper arm which is 3 centimeter long; and a scar on the left upper chest which is 4 centimeters by 2 centimeters. 5. For the entire appeal period, the service-connected scars due to basal cell carcinoma were not manifested by any characteristics of disfigurement; areas of hyperpigmented or hypopigmented skin on the head, face and neck; visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes, ears, cheeks, or lips); elevation or depression; adherence to underlying tissue; missing underlying soft tissue; induration or inflexibility; pain; unstable or loss of covering of the skin on the scar; or a limitation of function of the part affected. 6. For the entire appeal period, the service-connected scars due to basal cell carcinoma affected less than 5 percent of the entire body surface and less than 5 percent of exposed areas and are not shown to have required constant or near-constant systemic therapy, such as with corticosteroids or other immunosuppressive drugs, during a 12-month period. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for a fungal disorder of the left foot and toenails are met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). 2. For the entire appeal period, the criteria for the assignment of an initial compensable rating for the service-connected scars due to basal cell carcinoma have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 4.1-4.7, 4.20, 4.21, 4.118, Diagnostic Codes 7800 to 7806 (in effect prior to October 23, 2008). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and the representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VA must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. The Board finds that the VCAA notice requirements have been satisfied by a letter dated in June 2008. The VCAA letter informed the Veteran of the evidence and information needed to substantiate a claim for service connection and informed the Veteran of which information and evidence he was to provide to VA and which information and evidence VA would attempt to obtain on his behalf. VA informed the Veteran it had to obtain any records held by any federal agency. The letter also informed the Veteran that on his behalf VA would make reasonable efforts to obtain records that were not held by a federal agency, such as records from private doctors and hospitals. Finally, the letter told the Veteran that he could obtain private records himself and submit them to VA. The VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. The Court held that the VCAA notice must include notice that a disability rating and an effective date of the award of benefits will be assigned if service connection was awarded. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In the present appeal, the June 2008 letter explained the type of evidence necessary to establish service connection and the type of evidence necessary to establish a disability rating and effective date for the claims on appeal. The Veteran's appeal for a higher initial rating for the scars due to basal cell carcinoma arises from his disagreement with the initial evaluation following the grant of service connection. VCAA notice regarding the service connection claim was furnished to the Veteran in June 2008. 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); 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); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice upon receipt of a notice of disagreement). Therefore, no further notice is needed under VCAA regarding this issue. VA has a duty to assist a veteran in the development of the claim. This duty includes assisting the veteran 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 Veteran's service treatment records were obtained and are associated with the claims folder. VA treatment records dated from 2008 to 2013 are associated with the virtual file. In March 2013, VA contacted the Veteran and asked him to identify any additional treatment records for the claimed disabilities. The Veteran did not respond to the letter. VA provided an examination in May 2013 to obtain medical evidence as to the nature and likely etiology of the claimed fungal disorder of the left foot and to obtain medical evidence as to the current severity of the scars due to the basal cell carcinoma. The examination is adequate because it was performed by a medical professional based on review of claims file and a solicitation of history and symptomatology from the Veteran, and an examination of the Veteran. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The VA examiner considered the Veteran's reported medical history and lay statements concerning the claimed disorders and provided a medical opinion as to whether the claimed fungal disorder of the left foot was related to active service. The VA examiner described the scars due to basal cell carcinoma, including the size and appearance of the scars. The examination report is accurate and fully descriptive. Neither the Veteran nor his representative has challenged the adequacy of the examination obtained for these issues. Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of his opinion). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4). For these reasons, the Board finds that the duties to notify and assist the Veteran have been met, so that no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claims. 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). The Board finds that no reasonable possibility exists that any other assistance would aid in substantiating the claims and VA met its duty to assist the Veteran. Service Connection for Fungal Infection of the Left Foot Service Connection Laws and Regulations Service connection will be granted for disability resulting from a disease or injury incurred in or aggravated by military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection requires competent evidence showing, (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); see also Caluza v. Brown, 7 Vet. App. 498 (1995). With disability compensation claims, VA adjudicators are directed to assess both medical and lay evidence. As a general matter, a layperson is not capable of opining on matters requiring medical knowledge. See 38 C.F.R. § 3.159(a)(2). In certain circumstances, however, lay evidence may be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In addressing lay evidence and determining its probative value, if any, attention is directed to both competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In terms of competency, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (flatfoot). That notwithstanding, a veteran is not competent to provide evidence as to more complex medical questions and, specifically, is not competent to provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See generally Caluza v. Brown, 7 Vet. App. 498 (1995). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006); but see Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (evidence of a prolonged period without medical complaint after service can be considered along with other factors in the analysis of a service connection claim). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Analysis of Service Connection for Fungal Skin Disorder of Left Foot The Veteran contends that he currently has a fungal skin disorder that affects his left foot. He contends that he incurred the fungal disorder in service and has had this disorder since service. The Veteran reported having the fungus of the left foot in November 2007, when he initially filed his claim for service connection while he was still on active duty. He contends that he treated this fungal infection with over the counter medication while in service. See the June 2009 statement and the November 2007 application for compensation. The Board finds that the evidence is in equipoise on the question of whether the diagnosed onychomycosis of the left foot first manifested in service and is related to active service. The Veteran's lay statements that he has had a fungal infection on the left foot in service and since service weigh in favor of the claim. The Veteran first made these statements and reported the fungal infection in November 2007, when he was still on active duty and applied for VA compensation benefits. The Veteran separated from service in January 2008. He also described the fungal infection of the left foot and toenails in a May 2009 statement. The Board finds that the Veteran is competent to provide lay testimony as to the onset of his observable fungal infection symptoms. The May 2013 VA examination report indicates that the toenail fungus on the left foot is manifested by discoloration and disfigurement of the toenail. The examiner noted that the toenail fungus has been present since onset, although the Veteran reported at that examination that he could not recall the date of onset. The Board finds that the Veteran's statements that he had a fungal infection on the left foot in service and since service generally to be credible and to be reconcilable with the May 2013 history of being unable to recall the date of onset. His statements of in-service onset of symptoms have been consistent with most of his other statements, including the claim for service connection while still in service, though the May 2013 history of being unable to recall the date of onset is slightly inconsistent with other histories specifically recalling date of onset, but still reconcilable. When read compatibly, the Veteran's history of not recalling the date of onset does not preclude that the date of onset otherwise occurred during service. The Board finds the Veteran's statements, when reconciled, are competent and credible evidence that the fungal infection of the left foot and toenails first began in service, has been recurrent since service, and still exists. There is evidence that weighs against the claim for service connection for the fungal infection of the left foot. The May 2008 VA examination report does not document a fungal infection of the left foot and toenails; however, it is not clear from the examination report that the left foot and toes were examined for a fungal infection. The VA examination report focused on other claimed disabilities including the basal cell carcinoma. The May 2013 VA examination report indicates that the Veteran reported that he did not recall when the fungal infection of the left foot began. The examiner stated that it would be speculation to render a medical opinion as to when the onychomycosis began. The Veteran's statements in service and within a year or two since service separation reflect that the fungal infection of the left foot began during active service. The Veteran reported having symptoms of the fungal infection in November 2007, at the end of his period of active duty. The VA examiner who conducted the May 2013 VA examination stated that onychomycosis may exist indefinitely once it becomes established and it has been present since its onset. For these reasons, and resolving reasonable doubt in the Veteran's favor, the Board finds that service connection for onychomycosis of the left foot and toenails is warranted as directly incurred in service. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Initial Rating of Scars due to Basal Cell Carcinoma Skin Rating Criteria Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C.A. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. Where there is a question as to which of two evaluations (ratings) shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative 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(b); 38 C.F.R. §§ 4.3, 4.7. The U.S. Court of Appeals for Veterans Claims (Court) has held that separate ratings may be assigned for separate periods of time based on the facts found, a practice known as "staged" rating. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999) (the Court noted a distinction between claims stemming from an original rating versus increased rating). The Board must analyze the credibility and probative value of the evidence, account for the persuasiveness of the evidence, and provide reasons for rejecting any material evidence favorable to the claimant. Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996). In Fenderson, 12 Vet. App. 119, it was held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. In Fenderson, the Court discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Id. at 126-127. Diagnostic Code 7818 (effective August 30, 2002) indicates that malignant skin neoplasms (other than malignant melanoma) are rated as disfigurement of the head, face, or neck (DC 7800), scars (DC's 7801, 7802, 7803, 7804, or 7805) or impairment of function. 38 C.F.R. § 4.188. Under Diagnostic Code 7800, disfigurement of the head, face, or neck, a 10 percent rating is warranted when a veteran experiences one characteristic of disfigurement. A 30 percent rating is warranted 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 two or three of the aforementioned characteristics of disfigurement. The 8 characteristics of disfigurement for the purposes of evaluation under § 4.118 are: scar of 5 in. or more (13 or more cm) in length; scar at least 1/4 in. (0.6 cm) wide at its widest part; surface contour of scar elevated or depressed on palpation; scar adherent to underlying tissue; skin hypo- or hyper-pigmented in an area exceeding 6 sq. in. (39 sq. cm.); skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding 6 sq. in. (39 sq. cm.); underlying soft tissue missing in an area exceeding 6 sq. in. (39 sq. cm.); and skin indurated and inflexible in an area exceeding 6 sq. in. (39 sq. cm.). 38 C.F.R. § 4.118, Diagnostic Code 7800. Scars which are superficial and painful on examination are rated as 10 percent disabling. Diagnostic Code 7804. A superficial scar is one not associated with underlying soft tissue damage. Diagnostic Code 7804, Note 1. Other scars are rated based upon limitation of function of affected part. Diagnostic Code 7805. Diagnostic Code 7806 (effective August 30, 2002) provides ratings for dermatitis or eczema. A 10 percent rating is assigned when there is evidence of eczema which affects 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, 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 is assigned when there is evidence of eczema which affects 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas, 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. A 50 percent rating is assigned when there is evidence of eczema which affects more than 40 percent of the entire body or more than 40 percent of exposed areas, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. 38 C.F.R. § 4.118. The provisions of Diagnostic Code 7806 indicate that the skin disability may be rated as disfigurement of the head, face, or neck under Diagnostic Code 7800 or as scars under Diagnostic Codes 7801 to 7805, depending on the predominant disability. 38 C.F.R. § 4.118. Analysis of Initial Rating for Scars Initially, the Board notes the criteria for rating scars was revised, effective on October 23, 2008. See 73 Fed. Reg. 54,708 (Sept. 23, 2008) (codified at 38 C.F.R. pt. 4). However, these amendments only apply to claims filed on or after October 23, 2008, although a claimant may also specifically request consideration under the amended criteria. See id. Since the Veteran's claim was pending from November 2007, before the October 2008 changes, and VA has not received a request from the Veteran for consideration under the amended criteria, the 2008 amended criteria will not be addressed at this time. Service treatment records show that the Veteran underwent multiple excisions of basal cell carcinoma lesions in service and the excision required sutures. In a June 2009 statement, the Veteran stated that he currently had scars due to the basal cell carcinoma excisions. The Veteran is competent to report observable symptoms. See also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the assignment of an initial compensable disability evaluation for the service-connected scars due to the basal cell carcinoma for the entire rating appeal period. The service-connected scars due to the basal cell carcinoma are rated under Diagnostic Code 7818 which indicates that the skin disorder is rated as disfigurement of the head, face, or neck (DC 7800), scars (DC's 7801, 7802, 7803, 7804, or 7805) or impairment of function. 38 C.F.R. § 4.118. The competent and credible evidence of record shows that the service-connected scars due to basal cell carcinoma are manifested by five scars. There are three scars on the face or head. There is a right lateral eyebrow scar which is 2 centimeters by .3 centimeters. There is a right upper forehead scar that is 5 centimeters by .2 centimeters. There is also a left temporal scar which is 4 centimeters by .3 centimeters. See the May 2013 VA examination report. The Board finds that the three scars on the face and head do not meet or more nearly approximate the criteria for a 10 percent rating under Diagnostic Code 7800. The competent and credible evidence of record shows that the scars do not meet the criteria for one characteristic of disfigurement. The May 2013 VA examination findings show that each scar is not 13 or more centimeters in length. The scars are not at least 0.6 centimeters wide at its widest part. The scars are not painful, unstable, elevated or depressed. The scars do not have abnormal texture and are not indurated or inflexible. The scars are not hypo- or hyper-pigmented. The scars are not adhered to underlying soft tissue and there is no missing underlying soft tissue. The examiner indicated that there was no gross distortion or asymmetry of the facial features. There was no visible or palpable tissue loss. The examiner noted that the scars were barely visible, did not cause disfigurement, and did not affect the Veteran's occupational or social functioning. See the May 2013 VA examination report. Thus, the Board finds that the preponderance of the evidence establishes that the requirements of one characteristic of disfigurement has not been shown, so a 10 percent rating is not warranted under Diagnostic Code 7800 for the right lateral eyebrow scar, right upper forehead scar, or the left temporal scar due to the basal cell carcinoma at any time during the appeal period. A compensable rating is not warranted for the right lateral eyebrow scar, right upper forehead scar, or the left temporal scar due to the basal cell carcinoma under Diagnostic Codes 7803, 7804 or 7805. The competent and credible evidence shows that the three scars on the face and head are not unstable or painful on examination and the scars do not limit function of the part affected. The May 20013 VA examination findings indicate that the scars did not affect social or occupational functioning, did not limit function, and did not impact work. Thus, the Board finds that the preponderance of the evidence establishes that a 10 percent rating is not warranted under Diagnostic Codes 7803 to 7805 for the right lateral eyebrow scar, right upper forehead scar, or the left temporal scar due to the basal cell carcinoma at any time during the appeal period. The competent and credible evidence of record shows that the service-connected scars due to basal cell carcinoma are also manifested by a scar on the left upper arm and a scar on the left upper chest. The scar on the left upper arm is a 3 centimeter linear scar. The scar on the left upper chest is 4 centimeters by 2 centimeters. The total area affected by the scars is 8 centimeters. See the May 2013 VA examination report. A compensable rating is not warranted for the a scar on the left upper arm and a scar on the left upper chest due to the basal cell carcinoma under Diagnostic Codes 7802, 7803, 7804 or 7805. The competent and credible evidence shows that the total area of the two scars is 8 centimeters. Thus, a compensable rating is not warranted under Diagnostic code 7802. The May 2013 VA examination findings indicate that the scars are not unstable or painful on examination and the scars do not limit function of the part affected. There was no loss of covering of skin over the scar. The May 2013 VA examination findings indicate that the scars did not affect social or occupational functioning, did not limit function, and did not impact work. Thus, the Board finds that the preponderance of the evidence establishes that a 10 percent rating is not warranted under Diagnostic Codes 7802 to 7805 for the scar of the left upper arm and the scar of the left upper chest due to basal cell carcinoma at any time during the appeal period. The Board has also considered whether a compensable rating is warranted under Diagnostic Code 7806. A compensable rating is not warranted under Diagnostic Code 7806 at any time during the appeal period. The medical evidence in this case, specifically the VA examinations, shows that the service-connected scars due to basal cell carcinoma affects less than 5 percent of the entire body and less than 5 percent of the exposed areas. See the May 2013 VA examination report. The May 2008 VA examination report indicates that the scars due to the basal cell carcinoma affected 1 percent of the face, neck, and extremities. The preponderance of the medical evidence establishes that the scars due to the basal cell carcinoma affects less than 5 percent of the entire body or 5 percent of exposed areas. The competent and credible evidence of record shows that the service-connected scars do to basal cell carcinoma do not require constant or near constant systemic therapy such as corticosteroids or other immunosuppressive drugs. The evidence of record shows that the service-connected scars due to basal cell carcinoma requires topical cream as needed, but no systemic therapy. Thus, a compensable rating is not warranted under Diagnostic Code 7806 at any time during the appeal period. For these reasons, the Board finds that the evidence does not establish that a compensable rating is warranted for the service-connected scars due to basal cell carcinoma at any time during the appeal period. The appeal for a higher (compensable) initial rating for the scars due to basal cell carcinoma is denied. 38 C.F.R. § 4.71a, Diagnostic Codes 5235 to 5243. Extraschedular Consideration The Board has considered whether referral for an extraschedular evaluation is warranted for service-connected scars due to basal cell carcinoma. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). 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. Therefore, 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. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, 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. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's scars due to basal cell carcinoma are specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, Diagnostic Codes 7800 to 7805, specifically provide for disability ratings based on size, location, and appearance of the scars. The rating schedule provides specific criteria for scars located on the face and head and disfigurement due to the facial scars is considered. The rating criteria also provide a rating for scars that limit the function of the part affected. In this case, considering the competent and credible evidence, the Veteran's scars due to the basal cell carcinoma cause no disfigurement of the face or head. The scars are not painful or unstable, do not have abnormal texture, do not limit function of the parts affected and do not impact the Veteran's social or occupational functioning. See the May 2013 VA examination report. The evidence shows that the scars due to the basal cell carcinoma are small and are essentially asymptomatic. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In this case, the evidence shows that the service-connected scars do not impact the Veteran's occupational functioning or affect his daily life. In the absence of exceptional factors associated with the Veteran's scars due to basal cell carcinoma, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER Service connection for a fungal disorder of the left foot and toenails to include onychomycosis is granted. A higher (compensable) initial disability rating for scars due to basal cell carcinoma is denied. ____________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs