Citation Nr: 1325312 Decision Date: 08/09/13 Archive Date: 08/13/13 DOCKET NO. 07-20 932 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for residuals of shell fragments wounds (SFW) to the right hand, right index finger, and left lower extremity. 2. Entitlement to an initial compensable disability rating for service-connected residuals of a SFW to the right side of head. 3. Entitlement to an initial compensable disability rating for service-connected residuals of a SFW wound to the left arm. 4. Entitlement to a 10 percent disability rating based on multiple non-compensable service-connected disabilities. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD T. Stephen Eckerman, Counsel INTRODUCTION The Veteran had active service from June 1967 to June 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. In March 2011, the Board remanded the claims for additional development. As an initial matter, review of the RO's July 2006 rating decision, which granted service connection for residuals of shell fragment wounds to the left side of the head, shows that the RO based its decisions solely upon the Veteran's service treatment reports. However, the Veteran has repeatedly stated that his service treatment reports were in error, and that the scar on his head is, in fact, on the right side of his head. As discussed infra, the subsequently-dated medical evidence corroborates his statements. See March 2007 QTC examination report; April 2011 VA examination report; July 2012 VA Disability Benefits Questionnaire. This evidence indicates that the Veteran's service treatment reports were in error, and that the Veteran's residuals of a shell fragment wound to his head are, in fact, on the right side of his head, and not the left. The Board has therefore recharacterized this disability as stated on the cover page of this decision. FINDINGS OF FACT 1. The evidence of record indicates that the Veteran has residuals of shell fragments wounds to the left lower extremity that are due to his service. 2. The evidence of record does not show that the Veteran has residuals of shell fragments wounds to the right hand, or right index finger, that are due to his service. 3. Prior to July 23, 2012, the Veteran's scar, right side of head, is not shown to have been productive of a characteristic of disfigurement, deep scars, scars causing limited motion and covering an area exceeding 6 square inches (39 sq. cm.), superficial scars (without a limitation of motion) with an area or areas of at least 144 square inches (929 sq. cm.), superficial and unstable scars, superficial and painful scars on examination, or a limitation of function. 4. As of July 23, 2012, the Veteran's scar, right side of head, is shown to be superficial and painful, but not productive of disfigurement of the head, face or neck with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features, or, with two or three characteristics of disfigurement, or a limitation of function. 5. The Veteran does not have residuals of shell fragment wound, left arm, that are shown to have been productive of deep scars, scars causing limited motion and covering an area exceeding 6 square inches (39 sq. cm.), superficial scars (without a limitation of motion) with an area or areas of at least 144 square inches (929 sq. cm.), superficial and unstable scars, superficial and painful scars on examination, or a limitation of function. 6. The Veteran is service-connected for several disabilities at a combined total rating of 40 percent. CONCLUSIONS OF LAW 1. Residuals of shell fragments wounds to the left lower extremity are due to the Veteran's active duty service. 38 U.S.C.A. §§ 1110, 1154(b), 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). 2. Residuals of shell fragments wounds to the right hand, and the right index finger, were not incurred in, and are not otherwise due to, the Veteran's active duty service. 38 U.S.C.A. §§ 1110, 1154(b), 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). 3. Prior to July 23, 2012, the criteria for an initial compensable evaluation for service-connected scar, right side of head, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1-4 .16, 4.118, Diagnostic Codes 7800, 7803, 7804, 7805 (2008). 4. As of July 23, 2012, the criteria for a 10 percent evaluation, and no more, for service-connected scar, right side of head, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1-4 .16, 4.118, Diagnostic Codes 7800, 7803, 7804, 7805 (2008). 5. The criteria for a compensable rating for scar, left arm, are not shown to have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.118, Diagnostic Codes 7801, 7802, 7803, 7804, 7805 (2008). 6. The appeal for a 10 percent evaluation for multiple noncompensable service-connected disabilities under the provisions of 38 C.F.R. § 3.324 is dismissed. 38 U.S.C.A. § 7105(d)(5). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service Connection The Veteran asserts that he is entitled to service connection for residuals of shell fragments wounds to the right hand, right index finger, and the left lower extremity. He essentially argues he incurred these residuals during combat in Vietnam in June 1968. He states that he received a field battle dressing to his left arm and leg, and that he received several stitches, with about 15 days of hospitalization in Da Nang. He further states that in December 1968, he received fragment wounds to areas that included his right hand, and small arms fire to his left leg, with stitches in his right index finger, but no broken bones. He states that he was evacuated from the field, and subsequently returned to the Continental United States. See Veteran's letter, dated in December 2005. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection may also be granted on the basis of a post-service initial diagnosis of a disease, when "all of the evidence, including that pertinent to service, establishes that the disease was incurred during service." See 38 C.F.R. § 3.303(d). With chronic disease shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. Id. When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Id. For this purpose, a chronic disease is one listed at 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331, 1338-39 (Fed. Cir. Feb. 21, 2013) (holding that the term "chronic disease in 38 C.F.R. § 3.303(b) is limited to a chronic disease listed at 38 C.F.R. § 3.309(a)). A grant of service connection under 38 C.F.R. § 3.303(b) does not require proof of the nexus element; it is presumed. Id. The Board initially notes that the law provides that, in the case of any veteran who engaged in combat with the enemy in active service, satisfactory lay or other evidence of an injury incurred in service shall be accepted as sufficient proof of service incurrence of the injury if the evidence is consistent with circumstances of service and notwithstanding that there is no official record of service incurrence of the injury. 38 U.S.C.A. § 1154(b) (West 2002 & Supp. 2012); see also VAOPGCPREC 12-99, 65 Fed. Reg. 6256-6258 (2000). The Veteran's service records indicate that his awards include the Combat Action Ribbon, and the Purple Heart. Therefore, participation in combat is established and the Veteran is entitled to the presumptions at 38 U.S.C.A. § 1154(b). The United States Court of Appeals for Veterans Claims (Court) has held that 38 U.S.C.A. § 1154 does not alter the fundamental requirements of a diagnosis, and a medical nexus to service. See Brock v. Brown, 10 Vet. App. 155, 162 (1997); Libertine v. Brown, 9 Vet. App. 521 (1996). The Veteran's service treatment reports indicate that in three separate incidents in 1968, he sustained a fragmentation wounds to the left temporal region, and two separate wounds to the left arm. See service treatment reports, dated in February, June, and December of 1968. The Veteran's separation examination report, dated in June 1971, shows that his upper and lower extremities were clinically evaluated as normal. As for the post-service medical evidence, it consists of VA and non-VA reports, dated between 2001 and 2012. The relevant evidence is summarized as follows: VA progress notes, dated between 2001 and 2009, show that in May 2006, the Veteran reported that he had been shot in the left upper thigh during service. There were no relevant findings or diagnoses. A QTC examination report, dated in March 2007, shows that the Veteran reported a history of scars on his head, and right arm. On examination, there was a scar on the right arm; the location of the right arm scar was not further described. No other scars, or residuals of SFW or gunshot wounds, were noted. An examination of the extremities did not reveal atrophic skin changes, ulceration, or any other relevant findings. Motor function in the extremities was within normal limits. The diagnoses noted that the established diagnosis of scar, SFW, left arm was changed to scar, SFW right arm, and that the Veteran's scar, SFW left side of head, had resolved. VA examination reports for diabetes mellitus, and the peripheral nerves, dated in August 2009, show that the Veteran reported a history of a gunshot wound to the left thigh in 1968 with residual paresthesias. A VA posttraumatic stress disorder examination report, dated in August 2009, shows that the Veteran reported that although his service medical records indicated that he had a history of shrapnel wounds to the left arm, and left temporal region, both of his wounds were actually on the right side. He also reported being shot in the left leg. These examination reports do not contain any relevant findings, or diagnoses. A VA muscle and scar examination report, dated in April 2011, shows that the examiner stated that the Veteran's claims file was not available for review. The Veteran reported that he sustained shrapnel wounds to the scalp and right upper extremity in 1968. He stated that he had "very rare achiness" in these areas, with no significant frequency or duration, or precipitating or alleviating factors, and no additional limitation of motion. He reported receiving treatment at a field hospital, with no other surgeries. The examiner noted that the extensor muscles of the right forearm were involved and that there are no other specific injuries noted of the bony structures, nerves, or vascular structures. The Veteran reported no significant muscle pain activity that would be limited by fatigue or inability to move the joints through portion of his activity. On examination, there was a scar at the right forearm. The diagnosis was shrapnel wounds to the extensor compartment of the right upper extremity within the forearm with residual scar. The examiner also provided findings for a scar on the right side of the scalp, for which the diagnosis was scars of the right frontal scalp and right forearm, secondary to shrapnel wounds sustained while in Vietnam. In an addendum, dated in May 2011, the examiner indicated that he had reviewed the Veteran's claims file. The examiner concluded that there is no evidence for shrapnel wounds or scars associated with the claimed shrapnel wounds of the left lower extremity, right hand, or right index finger. A VA Disability Benefits Questionnaire (DBQ), dated in July 2012, shows that the examiner indicated that the Veteran's claims file had been reviewed. The Veteran reported a history of scars from lacerations, to include shell fragment wounds, during service to the right side of the head, the right arm, the right hand, and the left leg. He reported that his left leg wound was actually from a gunshot wound. He stated that all of his wounds were treated in the field, and that they were all irrigated and treated with dressings and/or sutures, and that the bullet in his left leg was removed. The report notes that for all of the wounds, there was no muscle damage, no muscle repair, and no nerve, bone, or joint damage. The report notes that there were three painful scars: at the right forearm (7 x 1 centimeter (cm.)), at the right dorsal surface of the right middle finger (2.5 x 0.1 cm.), and at the left lower extremity (1.5 x 0.5 cm.). The approximate total area of scarring of the right upper extremity was 7.25 cm. (squared), and of the left lower extremity was 0.75 cm. (squared). With regard to the claim for service connection for shell fragment wounds to the left lower extremity, the Board finds that service connection is warranted. Although there are no corroborating service treatment reports, the Veteran has stated that he sustained a wound to his left lower extremity during participation in combat, and participation in combat has been established. 38 U.S.C.A. § 1154(b). The July 2012 VA DBQ indicates that the Veteran has a scar on his left lower extremity, thus, the existence of a current disability is established. There is no evidence to show an intercurrent cause of this scar. Therefore, affording the Veteran the benefit of all doubt, the Board finds that the evidence is at least in equipoise, and that service connection for a left lower extremity scar is warranted. With regard to the claims for service connection for residuals of shell fragment wounds to the right hand, and the right index finger, the Board finds that the preponderance of the evidence shows that the Veteran does not have these disabilities. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998) (under 38 U.S.C.A. § 1110, an appellant must submit proof of a presently existing disability resulting from service in order to merit an award of compensation). Briefly stated, there is no medical evidence to show that the Veteran has a scar, or shell fragment wound, to the right hand, or the right index finger. See e.g., March 2007 QTC examination report; April 2011 VA examination report; July 2012 VA DBQ. In this regard, the July 2012 DBQ indicates that the Veteran has a scar to another digit of his right hand, i.e., his right middle finger; a scar or shrapnel wound to the right index finger was not found. The April 2011 VA examination report and the July 2012 VA DBQ are considered to be especially probative, as they are shown to have been based on a review of the Veteran's claims file, as well as a physical examination, and as they took the Veteran's subjective history into account. Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). The Board therefore finds that the preponderance of the evidence is against the claims, and that the claims must be denied. With regard to the Veteran's own contentions, a layperson is generally not capable of opining on matters requiring complex medical knowledge. Lay testimony is competent, however, to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). The issues on appeal are based on the contentions that residuals of shell fragment wounds to the right hand, and the right index finger, were caused by service, which ended in 1971. Although the Veteran is competent to report the incurrence of shell fragment wounds, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the Board has determined that the medical evidence, which indicates that the Veteran does not currently have the claimed disabilities, is more probative of the issues. Given the foregoing, the Board finds that the medical evidence outweighs the Veteran's contentions to the effect that he has residuals of shell fragment wounds to the right hand, and the right index finger, were caused by service. The Board therefore finds that the preponderance of the evidence is against the claims for service connection for residuals of shell fragment wounds to the right hand, and the right index finger, and that the claims must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). II. Initial Compensable Evaluations The Veteran asserts that he is entitled to an initial compensable evaluation for his service-connected residuals of a SFW to the right side of head, and residuals of a SFW wound to the left arm. In March 2006, the Veteran filed his claims for service connection. In July 2006, the RO granted service connection for residuals of a SFW to the left side of head, and residuals of a SFW wound to the left arm. In each case, the RO assigned a noncompensable (0 percent) evaluation, and an effective date for service connection of February 6, 2006. The Veteran has appealed the issues of entitlement to initial compensable evaluations. As previously discussed, the Board has determined that the Veteran's residuals of a shell fragment wound to the head are on the right side of his head, and it has therefore recharacterized this disability as stated on the cover page of this decision. See Read v. Shinseki, 651 F.3d 1296 (Fed. Cir. 2011) (a change in determination of situs of Veteran's disability from one muscle group to another, for purposes of determining the correct diagnostic code, did not sever service connection of the disability); see also 38 U.S.C.A. §§ 101(16), 1159 (West 2002 & Supp. 2012); VAOPGCPREC 50-91 (Mar. 29, 1991) (holding that 38 U.S.C. § 359 (the previous codification of 38 U.S.C. § 1159)) does "not prohibit the redesignation of an existing service connected rating to accurately reflect the actual anatomical location of the injury or disease resulting in the Veteran's disability, provided the redesignation does not result in the severance of service connection for the disability in question"). With regard to the claim for an initial compensable evaluation for residuals of shell fragment wound, left arm, a review of the RO's July 2006 rating decision, which granted service connection for residuals of shell fragment wounds to the left arm, and which denied a claim of service connection for a right arm scar, shows that the RO based its decisions solely upon the Veteran's service treatment reports. However, the Veteran has repeatedly stated that his service treatment reports were in error, and that his residuals of shell fragment wounds to his arm are, in fact, to his right arm. See April 2011 VA examination report; July 2012 VA DBQ; cf. Veteran's statement, received in February 2006. As discussed infra, the subsequently-dated medical evidence corroborates his statements about his right arm. See March 2007 QTC examination report; April 2011 VA examination report; July 2012 VA Disability Benefits Questionnaire. This evidence indicates that the Veteran's service treatment reports were in error, and that the Veteran's arm scar is, in fact, on the right side of his body, not the left. In this regard, the Board notes that in May 2012, the Appeals Management Center granted service connection for residuals of shell fragment wounds to the right forearm, evaluated as noncompensable. There are no other medical findings to show residuals of shell fragment wounds to the right arm other than the right forearm. There was no appeal, and this decision became final. See 38 U.S.C.A. § 7105(c) (West 2002 & Supp. 2012). Therefore, although the medical evidence indicates that the Veteran does not have residuals of shell fragment wounds to the left arm (discussed infra), the Board will not disturb the RO's grant of service connection, and will analyze the claim on the merits. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, 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. The Veteran is appealing the original assignments of disability evaluations following awards of service connection. In such a case, it is not the present level of disability which is of primary importance, but rather the entire period is to be considered to ensure that consideration is given to the possibility of staged ratings; that is, separate ratings for separate periods of time based on the facts found. Fenderson v. West, 12 Vet. App. 119, 126 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The Secretary of the VA amended that portion of the Schedule for Rating Disabilities pertaining to scars in 2008. As set forth in the Federal Register, the revised criteria apply to all applications for benefits received by VA on or after the effective date of October 23, 2008. See 73 Fed. Reg. 54,710 (Sept. 23, 2008). Here, the Veteran's claim was received at the RO in March 2006. Thus, the new regulations are not applicable; all cited diagnostic codes are as in effect prior to October 23, 2008. Under DC 7800, disfigurement of the head, face, or neck, with one characteristic of disfigurement, warrants a 10 percent evaluation. Under note (1), the 8 characteristics of disfigurement for purposes of evaluation under § 4.118, are: a scar 5 or more inches (13 or more cm.) in length; scar at least one- quarter inch (0.6 cm.) wide at 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 six square inches (39-sq. cm.); skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); underlying soft tissue missing in an area exceeding six square inches (39-sq. cm.); skin indurated and inflexible in an area exceeding six square inches (39- sq. cm.). Under note (3) the adjudicator is to take into consideration unretouched color photographs when evaluating under these criteria. Under 38 C.F.R. § 4.118, Diagnostic Code (DC) 7801, scars, other than head, face, or neck, that are deep or that cause limited motion: area or areas exceeding 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.), warrant a 10 percent rating. Note (1): Scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with § 4.25 of this part. Note (2): a deep scar is one associated with underlying soft tissue damage. Under 38 C.F.R. § 4.118, Diagnostic Code 7802, a 10 percent rating is warranted for: scars, other than head, face, or neck, that are superficial and that do not cause limited motion: Area or areas of 144 square inches (929 sq. cm.) or greater. Under 38 C.F.R. § 4.118, Diagnostic Code 7803, a 10 percent rating is warranted for superficial and unstable scars. Under 38 C.F.R. § 4.118, Diagnostic Code 7804, a 10 percent rating for scars that are superficial and painful on examination. Under 38 C.F.R. § 4.118, Diagnostic Code 7805, other scars are rated on limitation of function of the affected part. The notes pertaining to these regulations (re-numbered) are shown below: (1) Scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with § 4.25 of this part. (2) A deep scar is one associated with underlying soft tissue damage. (3) A superficial scar is one not associated with underlying soft tissue damage. (4) An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. When the requirements for a compensable rating of a diagnostic code are not shown, a 0 percent rating is assigned. 38 C.F.R. § 4.31 (2012). A. Residuals, Shell Fragment Wounds, Right Side of Head 1. Prior to July 23, 2012 The relevant medical evidence is summarized as follows: a QTC examination report, dated in March 2007, shows that the Veteran provided a history of a scar at the right side of his head, with current symptoms of numbness, and with no functional impairment. In the relevant diagnosis, the examiner stated that the Veteran's shell fragment wound, left side of head, had resolved. A VA examination report, dated in April 2011, shows that the examiner stated that the Veteran's claims file was not available for review. The Veteran reported a history of shrapnel wounds to his scalp, with "very rare achiness," which was mild in severity, with no significant frequency or duration, or precipitating or alleviating factors, and no additional limitation of motion. The Veteran denied any current symptoms, to include pain, breakdown, or other problems. The report notes that there were no limitations of routine of activities of daily living, or employment, due to his scar. The scar measured 12 cm. x 1 millimeter (mm.). It was not painful on examination. There was no skin breakdown. It was mildly deep with no specific underlying soft tissue damage. There was no limitation of motion or limitation of function. There was no evidence of inflammation, edema, or keloid formation. The surfaces were smooth. There was no abnormal texture. There was normal pigmentation. The scar was not indurated or inflexible. There was no evidence of underlying tissue loss. There was no gross distortion or asymmetry of the face as a result of the scalp scar. The diagnosis notes scar of the right frontal scalp secondary to shrapnel wounds sustained while in Vietnam. The Board finds that the claim must be denied. The evidence does not show that the Veteran has functional loss due to the residuals of his scar on the right side of head. Accordingly, a compensable rating is not warranted pursuant to DC 7805. A compensable rating is not warranted under any other potentially applicable code. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Specifically, the evidence does not show that this disability is moderate and disfiguring, poorly nourished with repeated ulceration, or painful and tender on objective demonstration. Accordingly, a compensable rating is not warranted pursuant to Diagnostic Codes 7800, 7803, or 7804. 2. As of July 23, 2012 A VA DBQ, dated in July 2012, states that the examination was performed on July 23, 2012. The examiner stated that the Veteran's claims file had been reviewed. The Veteran reported that during service he had sustained a shrapnel wound to the right side of the head, and his right arm, and that to this extent, his service treatment reports (which indicate that he sustained a shrapnel wound to the left side of the head and his left arm) were erroneous. He indicated that there was no muscle damage, or muscle repair, and no nerve, joint, or bone involvement. The scar of the head was noted to be painful, but not unstable, not productive of frequent loss of covering of skin, and not due to burns. The scar was at the right frontoparietal border, and it measured 3 x 2 cm. There was no elevation, depression, adherence to underlying tissue, or missing underlying tissue. There was abnormal pigmentation (hyperpigmentation). The total area was approximately 6 cm. (squared). There was no gross distortion or asymmetry of facial features, or visible or palpable tissue loss. There was no limitation of function. There was no impact upon the Veteran's ability to work. The Board finds that the criteria for a 10 percent rating for the Veteran's scar, right side of head, have been met. The July 2012 VA DBQ shows that this scar was painful, and under DC 7804, painful and superficial scars warrant a 10 percent evaluation. Therefore, affording the Veteran the benefit of all doubt, the Board finds that as the evidence is at least in equipoise, and that as of July 23, 2012, the criteria for a 10 percent evaluation have been met. To this extent, the claim is granted. An evaluation in excess of 10 percent is not warranted. Under 38 C.F.R. § 4.118, DC 7800, a 30 percent rating is assigned for disfigurement of the head, face or neck with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement. Here, the Veteran is not shown to have these symptoms. In addition, his scar is not shown to have been productive of a limitation of function. DC 7805. Accordingly, an evaluation in excess of 10 percent is not warranted. B. Residuals, Shell Fragment Wounds, Left Arm The relevant medical evidence is summarized as follows: a QTC examination report, dated in March 2007, shows that the Veteran provided a history of a scar at the right arm, with current symptoms of numbness, but no functional impairment. On examination, there were no findings for a left arm scar, or residuals of a shell fragment wound of the left arm. The examiner stated that the diagnosis of shell fragment wound, left arm, was changed to shell fragment wound, right arm, based on subjective reports of numbness and an objectively abnormal physical examination. A VA examination report, dated in April 2011, shows that the Veteran reported having "very rare achiness" in his right upper extremity which was mild in severity, with no significant frequency or duration, or precipitating or alleviating factors, and no additional limitation of motion. On examination, there were no findings for a left arm scar, or residuals of a shell fragment wound of the left arm. The diagnosis noted shrapnel wounds to the extensor compartment of the right upper extremity within the forearm, with residual scar. In a May 2011 addendum, the examiner stated that the Veteran's claims file had been reviewed. A VA scars DBQ, dated in July 2012, shows that the examiner stated that the Veteran's claims file had been reviewed. The Veteran was noted to "clearly state" that he had scars from shrapnel wounds to the right arm, not the left arm. On examination, there were no findings for a left arm scar, or residuals of a shell fragment wound of the left arm. The report indicates that the left upper extremity was not affected. The Board finds that the claim must be denied. As previously discussed, the RO's July 2006 grant of service connection appears to have solely been based on the Veteran's service treatment reports. The post-service medical evidence, as well as the Veteran's reported history, indicates that the service treatment reports were in error, and that his shell fragment wounds were, in fact, to his right arm. Service connection has been granted for a right forearm scar, the evaluation of which is not on appeal. The medical evidence indicates that the Veteran does not have any residuals of shell fragment wounds to his left arm, to include a scar. The Board will not disturb the RO's July 2006 grant of service connection. Therefore, the Board finds that the evidence is insufficient to show that the Veteran has residuals of shell fragment wound, left arm, that are productive of deep scars or scars that cause limited motion, superficial scars that do not cause limited motion with an area or areas of 144 square inches, "superficial and unstable scars," "superficial scars that are painful on examination," or a limitation of function. Accordingly, an initial compensable rating for residual scar, shell fragment wound, left arm, is not warranted pursuant to Diagnostic Codes 7801, 7802, 7803, 7804, or 7805. C. Conclusion The Board has considered the determinations in Fenderson v. West, 12 Vet. App. 119, 126 (1999) and Hart v. Mansfield, 21 Vet. App. 505 (2007), and whether the Veteran is entitled to increased evaluations for separate periods based on the facts found during the appeal period. As noted above, the Board does not find evidence that either of the Veteran's evaluations should be increased for any other separate period based on the facts found during the whole appeal period, other than as noted. The evidence of record supports the conclusion that the Veteran is not entitled to increased compensation during any time within the appeal period, other than as noted. The Board therefore finds that the evidence is insufficient to show that the Veteran had a worsening of the disabilities on appeal such that an increased rating is warranted, other than as noted. The Board has also considered the Veteran's statements that his skin disabilities are worse than currently evaluated. He is clearly competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, the Veteran is not competent to identify a specific level of disability pursuant to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran's skin disorders has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings address the criteria under which the disability is evaluated. The Board finds these records to be more probative than the Veteran's subjective evidence of complaints of increased symptomatology. Further, there is no basis to refer the ratings assigned for the Veteran's scars for extraschedular consideration. In exceptional cases where schedular ratings are found to be inadequate, consideration of an extraschedular rating is made. 38 C.F.R. § 3.321(b)(1) (2012). There is a three-step analysis for determining whether an extraschedular rating is appropriate. Thun v. Peake, 22 Vet. App. 111 (2008). First, there must be a comparison between the level of severity and symptomatology of the Veteran's service- connected disability and the established criteria found in the rating schedule to determine whether the Veteran's disability picture is adequately contemplated by the rating schedule. Id. If not, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as governing norms. Id.; see also 38 C.F.R. § 3.321(b)(1) (governing norms include marked interference with employment and frequent periods of hospitalization). If the factors of step two are present, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. There has been no showing that the disability picture for Veteran's residuals of shell fragment wounds could not be contemplated adequately by the applicable schedular rating criteria discussed above. The criteria provide for higher ratings, but as has been explained thoroughly herein, the currently assigned ratings adequately describe the severity of the Veteran's symptoms for these disabilities during the period of appeal. Given that the applicable schedular rating criteria are adequate, the Board need not consider whether the Veteran's disability picture includes such exceptional factors as periods of hospitalization and interference with employment. Indeed neither hospitalization nor interference with employment has been demonstrated or argued. Referral for consideration of the assignment of a disability rating on an extraschedular basis is not warranted. See Thun, 22 Vet. App. at 111. Finally, although the Veteran has submitted evidence of medical disabilities, and made a claim for the highest rating possible, he has not submitted evidence of unemployability, or claimed to be unemployable. He has never made any allegation that his service-connected residuals of shell fragment wounds have influenced his employment. Therefore, the question of entitlement to a total disability rating based on individual unemployability due to a service-connected disability has not been raised. See Rice v. Shinseki, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). III. Ten Percent Evaluation Under 38 C.F.R. § 3.324 The Veteran asserts that a 10 percent evaluation for multiple noncompensable service-connected disabilities under the provisions of 38 C.F.R. § 3.324 is warranted. Where a veteran is suffering from two or more separate permanent service-connected disabilities of such character as clearly to interfere with normal employability, even though none of the disabilities may be of compensable degree under the rating schedule, a 10 percent evaluation may be assigned, but not in combination with any other rating. 38 C.F.R. § 3.324 (2012). The consideration of the benefits of § 3.324 is predicated on the existence solely of noncompensable service-connected disabilities. The existence of at least one compensable service-connected disability renders this issue moot. Butts v. Brown, 5 Vet. App. 532, 541 (1993). In this case, service connection is in effect for disabilities that include posttraumatic stress disorder, evaluated as 30 percent disabling, and diabetes mellitus, evaluated as 20 percent disabling. Given these two compensable ratings, the claim for a 10 percent rating for multiple noncompensable service-connected disabilities is moot, and the claim is therefore dismissed. IV. Duties to Notify and Assist The Board finds that the duties to notify have been fulfilled by information provided to the Veteran in a letter from the RO dated in March 2006, and July 2007. 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). These letters notified the Veteran of VA's responsibilities in obtaining information to assist the Veteran in completing his claims, and identified the Veteran's duties in obtaining information and evidence to substantiate his claim. 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005); Dingess/Hartman v. Nicholson, 20 Vet. App. 473 (2006); Mayfield v. Nicholson, 20 Vet. App. 537 (2006); Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (Fed. Cir. 2009). With regard to the claims for initial compensable evaluations, in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice was intended to serve has been fulfilled. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 491 (2006). The RO also provided assistance to the appellant as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances in this case. It appears that all known and available service medical reports, and post-service records relevant to the issues on appeal have been obtained and are associated with the Veteran's claims files. The RO has obtained the Veteran's service treatment records, and VA medical records. In this regard, in a memorandum, dated in June 2011, the AMC noted that the Veteran had not responded to a May 2011 duty-to-assist letter, and it determined that any records of inservice hospitalization for June 1968 were not available. See 38 C.F.R. § 3.159(d) (2012). The Veteran has been afforded examinations. With regard to the claims for service connection, he has been found not to have residuals of shell fragment wounds to the right hand, or right index finger, thus etiological opinions are not necessary. Id. In March 2011, the Board remanded this claim. The Board directed that the RO/AMC attempt to obtain any outstanding hospitalization and/or separately-filed clinical records related to the Veteran's reports of treatment at a field hospital or medical unit in Vietnam in June 1968. In June 2011, the AMC determined that these records were not available. The Board also directed that the Veteran be requested to provide any medical records, not already in the claims file, pertaining to recent treatment or evaluation, and to provide the identifying information and any necessary authorization to enable the AMC/RO to obtain such evidence on his behalf. In May 2011, a duty-to-assist letter was sent that was in compliance with the Board's remand, however, there is no record of a response. Finally, the Board directed that the Veteran be afforded VA examinations to determine the current degree of severity of his service-connected left head and left arm shrapnel wound residuals, and to determine the nature, extent, and etiology of any SFW residuals of his right arm, right hand, right index finger, and left lower extremity. In April 2011, and July 2012, this was done. Under the circumstances, the Board finds that there has been substantial compliance with its remand. See Dyment v. West, 13 Vet. App. 141, 146-147 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where Board's remand instructions were substantially complied with); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). The Veteran and his representative have not argued that any error or deficiency in the accomplishment of the duty to notify has prejudiced him in the adjudication of his appeal. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (burden of showing that an error is harmful or prejudicial falls upon the party attacking the agency determination). In view of the above, the Board finds that the notice requirements pertinent to the issues on appeal have been met. In summary, the Board finds that the available medical evidence is sufficient for an adequate determination of the claims on appeal. There has been substantial compliance with all pertinent VA laws and regulations and to move forward with these claims does not cause any prejudice to the Veteran. [Continued on Next Page] ORDER Service connection for residuals of shell fragments wounds of the left lower extremity is granted Service connection for residuals of shell fragments wounds to the right hand, and the right index finger, is denied. Prior to July 23, 2012, an initial compensable evaluation for service-connected residuals of a SFW to the right side of head is denied. As of July 23, 2012, a ten percent rating, and no more, is granted for service-connected residuals of a SFW to the right side of head, subject to the laws and regulations governing the award of monetary benefits. An initial compensable evaluation for service-connected residuals of a SFW wound to the left arm is denied. The claim for a 10 percent rating for multiple noncompensable service-connected disabilities is dismissed as moot. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs