Citation Nr: 1323889 Decision Date: 07/26/13 Archive Date: 08/06/13 DOCKET NO. 07-17 228A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial disability evaluation in excess of 10 percent for a 12 cm x 0.2 cm surgical scar, status post operative residual subcutaneous mastectomy, right breast. 2. Entitlement to an initial disability evaluation in excess of 10 percent for a 12 cm x 0.2 cm surgical scar, status post operative residual subcutaneous mastectomy, left breast. REPRESENTATION Appellant represented by: New York State Division of Veterans' Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD M. McPhaull, Counsel INTRODUCTION The Veteran had active military service from February 1983 to February 1986. These matters come before the Board of Veterans' Appeals (BVA or Board) on appeal from a June 2005 rating decision of the Department of Veterans Affairs' (VA) Regional Office (RO) in St. Petersburg, Florida, which, in accordance with a May 2005 Board decision, granted service connection for the Veteran's neuropathic breast pain, postoperative residuals, subcutaneous mastectomy, of the bilateral breasts. The RO assigned an initial 10 percent disability evaluation for each breast. In a subsequent April 2006 rating decision, the Veteran's disability evaluations for his neuropathic breast pain, postoperative residuals, subcutaneous mastectomy, of the bilateral breasts were each increased to 20 percent disabling. The Veteran requested a hearing before the Board. The requested Travel Board hearing was conducted in November 2008. In March 2009, the Board remanded the appeal to the RO via the Appeals Management Center (AMC) in Washington, DC, for further development. In a September 2009 rating decision, the RO granted a separate, compensable, 10 percent disability evaluation for a painful scar of the left chest, effective from November 4, 2008 and a 10 percent evaluation for a painful scar of the right chest, effective from November 4, 2008. Subsequently, in March 2010, the Board denied the Veteran's claims for increased ratings for his neuropathic breast pain, postoperative residuals, subcutaneous mastectomy, of the bilateral breasts. The Board then remanded the initial rating scar claims, as well as entitlement to a separate compensable rating for subcutaneous mastectomy due to gynecomastia to the RO via the AMC for further development. In a July 2011 rating decision, the RO granted a separate, compensable, 10 percent disability evaluation for a 3.5 cm x 0.2 cm painful scar of the right chest, effective from January 30, 2001, and a 10 percent evaluation for a 3.0 x 0.2 painful scar of the left chest, effective from January 30, 2001. The rating decision also granted service connection for subcutaneous bilateral mastectomy due to gynecomastia and assigned a 0 percent rating, effective from January 30, 2001. The RO found, based upon the examiner's July 2012 addendum opinion that a compensable rating was not warranted. The Veteran has not disagreed with the ratings or effective dates assigned, and these issues are not before the Board at this time. The evidence shows that the veteran experiences pain in his shoulders upon range of motion (noted in the addendum opinion of July 2012). This matter is referred to the RO for appropriate action as required under Diagnostic Code 7805. The RO continued the initial 10 percent disability ratings for the two scars currently under appeal; however, the July 2012 rating decision assigned an earlier effective date of January 30, 2001 for each scar. FINDING OF FACT The service-connected scars to the left and right breast each measure 12.0 cm x 0.2 cm; are shown to be tender/painful on examination, but do not limit motion or result in loss of function; there is no evidence of skin ulceration or breakdown over the scars and they are not unstable. CONCLUSION OF LAW The criteria for an evaluation in excess of 10 percent each for 12.0 x 0.2 scars of the left and right breast have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.118, Diagnostic Code 7804 (as in effect prior to August 30, 2002; as in effect August 30, 2002; and as in effect October 23, 2008). REASONS AND BASES FOR FINDING AND CONCLUSION VA's Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R§ 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim. Accordingly, notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In the instant case, the Veteran's claim arises from an appeal of the initial evaluations following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed under VCAA. Next, VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's post-service reports of VA treatment and VA examinations. A review of Virtual VA includes additional VA treatment records dated through June 2012. Moreover, the Veteran's statements in support of the claim, including his hearing testimony, are of record. The Board has carefully reviewed such statements and concludes no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims. Additionally, most recently, the Veteran was afforded a VA examination in August 2011 with an addendum opinion obtained in July 2012 to evaluate the severity of his service-connected scars. The Board finds that the VA examination is adequate because, as discussed below, it was based upon consideration of the Veteran's pertinent medical history, his lay assertions and current complaints, and because they provide detail sufficient to allow the Board to make a fully informed determination. Barr v. Nicholson, 21 Vet. App. 303 (2007) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). Furthermore, the Veteran has not asserted, and the evidence does not show, that his symptoms have materially worsened since the most recent August 2011 evaluation. See 38 C.F.R. §§ 3.326, 3.327 (reexaminations will be requested whenever VA determines there is a need to verify the current severity of a disability, such as when the evidence indicates there has been a material change in a disability or that the current rating may be incorrect.); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). The Board accordingly finds no reason to remand for further examination. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. 3.103(c)(2) (2012) requires that any Veterans Law Judge who chairs a hearing fulfill two duties to comply with the VCAA. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant, 23 Vet. App. at 488. Here, during the November 2008 Board hearing, the undersigned Veterans Law Judge adequately explained the claim on appeal and suggested evidence that may support this claim, including evidence that the Veteran might submit that may have been overlooked. The Veteran was also specifically asked questions concerning the severity of this scars. The Board accordingly concludes that the notice requirements under Bryant were effectively satisfied. To the extent any such notice may have been inadequate, this was effectively cured both by actual knowledge as evidence by statements and questions of the Veteran's authorized representative at the hearing, as well as by the Board providing such explanation of issues and suggesting submission of evidence in the subsequent remands the Board issued to develop this claim. For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). Finally, the Board finds that there was substantial compliance with the Board remand directives. A remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand order. Stegall v. West, 11 Vet. App. 268 (1998). Nonetheless, it is only substantial compliance, rather than strict compliance, with the terms of a remand that is required. See D'Aries v. Peake, 22 Vet. App. 97, 104 (2008) (finding substantial compliance where an opinion was provided by a neurologist as opposed to an internal medicine specialist requested by the Board); Dyment v. West, 13 Vet. App. 141 (1999). In particular, in its prior remands, the Board directed the AOJ obtain additional VA treatment records and afford the Veteran an appropriate VA examination. As discussed above, the AOJ obtained VA treatment records and the Veteran was afforded a VA examination in August 2011, with an addendum opinion obtained in July 2012 that is adequate for appellate review because it addresses all the questions raised by the Board, provides a rational basis for opinions offered and was clearly based upon review of the Veteran's record. Accordingly, the Board finds that there has been substantial compliance with the Board remand directives and, therefore, no further remand is necessary. See Stegall, supra; D'Aries, 22 Vet. App. at 104 (2008). Analysis At the outset, as noted in the Introduction, the RO originally granted service connection for a scar to the right breast and a scar to the left breast, each measuring 12 cm x 0.2 cm, effective from November 4, 2008 (the date of the Board hearing). Subsequently, in a July 2011 rating decision, an earlier effective date of January 30, 2001 was assigned (the date of the original claim for service connection for right and left breast postoperative residuals ). The scars are currently rated under Diagnostic Code (Code) 7804. Since the effective date of service connection, the criteria for rating scars have changed twice. The Board finds that given the two separate effective dates, all regulations under 38 C.F.R. § 4.118 prior to August 30, 2002, as in effect August 30, 2002, and since October 23, 2008 are in effect. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 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 for that rating. 38 C.F.R. § 4.7. Where a veteran appeals the initial rating assigned for a disability at the time that service connection for that disability is granted, evidence contemporaneous with the claim and with the initial rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous . . . ." Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found. Id. The Board notes that all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal, has been reviewed. Although there is an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate, and the analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. VA treatment records include a June 2002 treatment record that documents the Veteran's complaints of persistent bilateral chest wall pain radiating out from the area of the scars bilaterally. Physical examination of the scars revealed no masses, no hypertrophic scar growth, and no evidence of hyperesthesia on palpation of the scars. On December 2007 VA examination, physical examination revealed left breast tenderness, retraction of nipple, and horizontal linear 12 cm scar below the nipple that is well healed. Right breast revealed tenderness, retraction of nipple, linear 12 cm scar below the nipple that is well healed. The Veteran was currently employed fulltime as a cemetery arrangement counselor. The examiner noted that the Veteran's status post bilateral mastectomy with associated neuropathic breast pain had an impact on the Veteran's occupational activities in that the Veteran experienced memory loss, decreased concentration, problems with lifting and carrying, difficulty reaching, lack of stamina; weakness, and pain. On December 2007 VA outpatient pain visit, the Veteran continued to describe his pain as 6-7/10, sharp and shooting, radiating from pectoral areas bilaterally to anterior shoulders, worse with activity. Physical examination revealed mild bilateral pain in the pectoral region with dysesthesia, radiation to anterior deltoid region; no trigger points were observed; the Veteran exhibited good range of motion and strength in shoulders bilaterally; biceps and triceps brachioradialis reflexes were intact bilaterally; biceps and triceps finger flexion/extension were intact bilaterally; upper extremity sensation was intact to light touch bilaterally. During the November 2008 Travel Board hearing, the Veteran testified that his scars have been tender and painful since the surgery. On May 2009 VA Joints examination, the Veteran reported that he experiences decreased mobility of both shoulders as a result of post surgical neuropathic pain radiating to both shoulders. He reported that he develops pain upon lifting over 10-15 pounds. He denied any history of arthritis; but claims that he has developed difficulty closing both hands and decreased gripping ability. Physical examination of his shoulders and hands revealed bilateral pain and no deformity, giving way, instability, weakness, stiffness, incoordination, decreased speed of joint motion, dislocation or subluxation, locking episodes, effusions, symptoms of inflammation, or flare-ups. Range of motion was normal with bilateral flexion and abduction to 180 degrees; bilateral internal and external rotation to 90 degrees. There was no additional limitation of motion after three repetitions of range of motion studies; there was no objective evidence of pain following repetitive motion; there was no joint ankylosis bilaterally. X-ray of the shoulders showed no evidence of acute osseous injury or significant degenerative disease; there was mild AC joint space narrowing. X-ray of the hands was normal. The examiner noted that the Veteran's bilateral shoulder and hand pain had no significant effect on his occupation or daily activities. On May 2009 VA scar examination, the Veteran reported his bilateral postmastectomy scars have been very sensitive and painful to touch since the surgery. He indicated that the symptoms have remained unchanged. Physical examination revealed scars 3cm below each nipple; the right scar was 13cm in length and the left scar was 14cm in length; width was 0.2 bilaterally; there was bilateral pain and tenderness; both scars were superficial; there was no adherence to underlying tissue, no skin breakdown, no ulceration, and no limitation of function. The scars were noted to be healed. In a November 2009 statement, the Veteran indicated that his scars were unstable. He submitted photographs with the statement. On June 2010 VA examination, physical examination revealed bilateral breast tenderness and retraction of nipples. Bilateral breast scars were noted as follows: first scar was longitudinal immediately under nipple 2cm below each nipple measuring 12cm long and 0.2cm wide bilaterally- the scars were well-healed, superficial, non-adherent but very tender to light touch. Second scar measured 3cm long and 0.2cm wide non adherent, well-healed, very tender to light touch. The scars were noted to occupy less than 5 percent of the Veteran's surface area of the chest and less than 5 percent of the body. On August 2011 VA examination, physical examination revealed bilateral breast tenderness and retraction of nipples. Bilateral breast scars were noted as follows: first scar was longitudinal immediately under nipple 2cm below each nipple measuring 12cm long and 0.2cm wide bilaterally- the scars were well-healed, superficial, non-adherent but very tender to light touch. Second scar to the left breast measured 3cm long and 0.2cm wide; second scar to the right breast was 3.5cm long and 0.2cm wide. Both scars were non adherent, well-healed, very tender to light touch. The scars were noted to occupy less than 5 percent of the Veteran's surface area of the chest and less than 5 percent of the body. Both of the Veteran's nipples are inverted. There was no skin breakdown over the scars, there was no inflammation, edema, keloid formation; and no other disabling effects. The Veteran was noted to currently be employed fulltime as a cemetery arrangement counselor. Photographs were taken and included with the examination. On July 2012 addendum/clarification opinion, the examiner stated that based upon a review of the Veteran's claims file, to include previous completed VA examinations, the photographs, and the definition of nipple inversion versus retraction; the Veteran had bilateral nipple inversion. He indicated that the significance of nipple inversion, unless associated with other breast findings, was usually not a significant problem. The examiner opined that the breast finding that causes attention to be placed on nipple retraction and inversion is their association with infection and cancer. He stated that the Veteran's bilateral nipple inversion has no significant clinical significance. The examiner indicated that the Veteran's nipple inversion is congenital, and there is no literature to suggest nipple inversion is a common complication of subcutaneous mastectomy for gynecomastia. The examiner also found that the Veteran's scars, based on review of the claims file and photographs, revealed the following: no abnormal skin texture; no induration in association with the scars from breast surgery; surrounding skin was not inflexible; while there was a loss of underlying tissue (due to surgery), there is a normal dermis; the scars were well healed without breakdown, the scars were stable, not unstable; the Veteran does experience a limitation of motion of the affected part, because movement causes pain, the limitation is not in range of motion but in ability to tolerate the pain caused by movement; the photographs show no obvious tissue loss; there was no visible or palpable gross distortion; the scars were not elevated or depressed on palpation; the scars are not hypo-pigmented; they were slightly hyper-pigmented; the examiner noted that the Veteran manifests neuropathic pain, hyperesthesia, associated with scars from his breast surgery that causes disability with occupational activities related to problems with lifting. The Veteran's right and left breast scars are currently rated under 38 C.F.R. § 4.118, Code 7804; scars on the right and left breast are to be rated as scars (Codes 7801, 7802, 7803, and 7804), or as impairment of function (Code 7805). Prior to August 30, 2002 Upon review of the entire evidence of record, the Board finds that initial disability ratings in excess of 10 percent are not warranted for scars, of the right and left breast. The Veteran is currently receiving 10 percent evaluations (the highest percentage available) under Code 7804, effective prior to August 30, 2002), which pertains to superficial scars that are painful on examination. Effective August 30, 2002 and prior to October 23, 2008 Code 7801 directs that scars other than on the head, face, or neck that are deep or cause limited motion are evaluated as 10 percent disabling for areas exceeding 6 square inches, 20 percent disabling for areas exceeding 12 square inches, 30 percent disabling for areas exceeding 72 square inches, and 40 percent disabling for areas exceeding 144 square inches. Notes following the rating criteria explain (1) scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of the extremities or trunk, will be rated separately and combined in accordance with 38 C.F.R. § 4.25, and (2) a deep scar is one associated with underlying soft tissue damage. 38 C.F.R. Part 4. Code 7802 provides that scars other than head, face, or neck scars that are superficial and do not cause limited motion will be rated as 10 percent disabling for areas of 144 square inches or greater. Notes following the rating criteria explain (1) scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of the extremities or trunk, will be rated separately and combined in accordance with 38 C.F.R. § 4.25, and (2) a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. Part 4. Code 7803 notes that unstable superficial scars are evaluated as 10 percent disabling. Note (1) following indicates that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) indicates that a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. Part 4. The next criteria that of Code 7804, provides that superficial scars that are painful on examination are rated as 10 percent disabling. Note (1) following states that a superficial scar is one not associated with underlying soft tissue damage. Note (2) states that in this case, a 10 percent evaluation will be assigned for a scar on the tip of a finger or toe even though amputation of the part would not warrant a compensable evaluation (See 38 C.F.R. § 4.68 of this part on the amputation rule). Finally, Code 7805 directs that other scars shall be rated on the limitation of function of the affected part. 38 C.F.R. Part 4. The evidence shows that, for the entire period of the initial increased rating appeal, the Veteran had superficial scars on his right and left breast that did not cause limitation of motion, and did not cover an area of at least 12 square inches. VA examiners have consistently reported well healed superficial scars measuring about 12-14 cm x 0.2 cm. In this case, the evidence shows two scars, painful on examination, on the Veteran's right and left breasts. A 10 percent rating is the maximum rating under Code 7804 for superficial scars that are painful on examination. 38 C.F.R. § 4.118. The Board then turns to other possibly applicable diagnostic codes relating to the Veteran's scars. The Veteran's scars are on his right and left breast and not on the head, face, or neck, so Code 7800 is not applicable. To receive an increased disability rating in excess of 10 percent for scars on the breasts, under Code 7801, the scars must be deep or cause limitation of motion and cover an area of at least 12 square inches or greater. In this case, the scars seen on each breast covers areas of 12 cm x 0.2cm, which is less than 12 square inches, so a higher rating is not possible under Code 7801. An increased rating in excess of 10 percent is not warranted in this case under Code 7802 because 10 percent is the maximum schedular rating provided under Code 7802 for superficial scars that do not cause limitation of motion. The Veteran's scars have not been shown by the evidence to be unstable, which is a scar that for any reason, where there is frequent loss of covering of skin over the scar, so Code 7803 is not applicable. The Board also finds that the scars themselves do not cause any other disabling effects to warrant a separate rating, as indicated under Code 7805. As such, the Veteran is not entitled to an initial disability rating in excess of 10 percent for scars on the right or left breast under this period. 38 C.F.R. § 4.118. Effective October 23, 2008 Effective October 23, 2008, the criteria for rating painful scars provided a 10 percent disability rating for one or two scars that are unstable or painful; a 20 percent disability rating for three or four scars that are unstable or painful; and, a 30 percent disability rating for five or more scars that are unstable or painful. 38 C.F.R. § 4.118 Code 7804 (2012). The revised criteria also provide that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. 38 C.F.R. § 4.118, Code 7804, Note (1) (2012). As the record indicates that the Veteran has no more than two scars on each breast that are tender, a disability rating in excess of 10 percent is not warranted. The Board has also considered whether another diagnostic code would be more appropriate. Again, as the Veteran's scars are not located on the head, face or neck and are less than 6 square inches, Codes 7800, 7801 and 7802 are not for application. While Code 7805, instructs to rate any disabling effects not considered in a rating provided under Codes 7800-7804 under appropriate diagnostic codes, the Board notes, the Veteran has 20 percent ratings for each breast under Code 7326-5321 which takes into consideration additional disability. Accordingly, an initial disability rating in excess of 10 percent is not warranted during this period for the service-connected right and left breast scars. Other Considerations The Board has considered whether staged ratings are appropriate in this case. The symptoms associated with the Veteran's scars have remained relatively consistent throughout the course of the claim period and, as such, staged ratings are not warranted. The Board has also considered the statements of the Veteran as to the extent of his current symptoms. He is certainly competent to report that his symptoms are worse. Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Board notes however, in evaluating a claim for a higher rating, VA must consider the factors as enumerated in the rating criteria discussed above, which in part involves the examination of clinical data gathered by competent medical professionals. Additionally, the Board has contemplated whether the case should be referred for extra-schedular consideration. In general, the schedular disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. The application of such schedular criteria was discussed in great detail above. To accord justice in an exceptional case where the schedular standards are found to be inadequate, the RO is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1). An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. Id. The Court has held that the Board is precluded by regulation from assigning an extra-schedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet. App. 88 (1996). The Court further held that the Board must address referral under 38 C.F.R. §3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In Thun v. Peake, 22 Vet. App. 111 (2008), the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. Either the RO or the Board must first determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. If the RO or the Board finds that the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the Veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extra-schedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected right and left breast scars with the established criteria found in the rating schedule. The Board finds that the Veteran's symptomatology is fully addressed by the rating criteria under which such disabilities are rated. In this regard, the Veteran's 10 percent ratings for breast scars contemplate the number of scars present as well as both any tenderness or painfulness. There are no additional symptoms of the Veteran's scars that are not addressed by the rating schedule. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology of his service-connected disabilities. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability picture. Therefore, the Board need not proceed to consider the second factor, whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of the issues decided herein for consideration of an extra-schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). Finally, as the Veteran is currently employed full-time, a total disability evaluation based upon individual unemployability due to service-connected disabilities has not been raised by the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). ORDER An initial disability evaluation in excess of 10 percent for a 12 cm x 0.2 cm surgical scar, status post operative residual subcutaneous mastectomy, right breast is denied. An initial disability evaluation in excess of 10 percent for a 12 cm x 0.2 cm surgical scar, status post operative residual subcutaneous mastectomy, left breast is denied. ____________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs