Citation Nr: 1328751 Decision Date: 09/09/13 Archive Date: 09/17/13 DOCKET NO. 06-34 508 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to an increased disability rating (evaluation) in excess of 10 percent for scars of the back of the neck, right and left shoulder areas, and mid back, status post excision of basal cell carcinoma. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Christine C. Kung, Counsel INTRODUCTION The Veteran, who is the appellant in this case, served on active duty from October 1968 to July 1996. This matter comes on appeal before the Board of Veterans' Appeals (Board) from a May 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. In a subsequent November 2007 rating decision, the RO granted an increased 10 percent rating for scars of the mid back, right and left shoulder areas, and back of the neck, effective January 24, 2006. The Board remanded the case in October 2010 and January 2013. The Board remands directed additional development that included a request to obtain outstanding private treatment records and to obtain updated VA examinations to address the service-connected scars. This was accomplished, and the Board concludes that it may proceed with a decision at this time. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002). While a June 2013 supplemental statement of the case addressed entitlement to an increased evaluation in excess of 10 percent for a lip scar, status post excision of basal cell carcinoma, the Board denied the Veteran's appeal on that issue in January 2013. Therefore, the only remaining issue on appeal is entitlement to an increased evaluation in excess of 10 percent for scars of the back of the neck, right and left shoulder areas, and mid back, status post excision of basal cell carcinoma. FINDINGS OF FACT 1. For the entire rating period, the Veteran has had one superficial scar of the back of the neck, measuring between 0.5 centimeters and 1 centimeter in width, and between 1 centimeter and 2 centimeters in length, and this scar does not result in visible or palpable tissue loss, gross distortion or asymmetry of one feature or paired sets of features, or two or three characteristics of disfigurement. 2. For the entire rating period, the Veteran has had superficial scars of the back of the neck, the right shoulder, the left shoulder, and the mid back that affect areas of less than 144 square inches on each extremity and less than 144 square inches on the posterior surface of the truck; the scars are not unstable or painful on examination and do not cause limited motion or limitation of function of the parts affected by the scars. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, for the entire rating period, the criteria for a separate 10 percent evaluation for a scar on the back of the neck, status post excision of basal cell carcinoma, are met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.118, Diagnostic Codes 7800 to 7805 (prior to October 23, 2008). 2. For the entire rating period, the criteria for an increased evaluation in excess of 10 percent for service-connected scars on the right and left shoulder areas and mid back, status post excision of basal cell carcinoma, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.118, Diagnostic Codes 7801-7805 (prior to October 23, 2008). REASONS AND BASES FOR FINDING AND CONCLUSIONS Duties to Notify and Assist As provided for by 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). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and 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 in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ), in this case the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. In a February 2006 letter, the RO provided preadjudicatory notice to the Veteran regarding what information and evidence is needed to substantiate his claim for an increased rating, as well as what information and evidence must be submitted by the Veteran, and what evidence VA would obtain. In March 2006, the RO provided corrective notice that included information regarding how disability ratings and effective dates are assigned. For these reasons, the Board finds that the Veteran was provided with adequate VCAA notice prior to the initial adjudication of the claim in May 2006. The Veteran was afforded several VA examinations to address his service-connected scars. 38 C.F.R. § 3.159(c)(4) (2012). VA examinations were completed in March 2006, February 2007, October 2007, November 2010 with a supplemental examination in December 2010, and March 2013. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that, cumulatively, the VA examinations obtained are adequate for rating purposes, because they were performed by a medical professional, were based on a thorough examination of the Veteran, and address all service-connected scars currently at issue. The Board finds that the examiners reported findings pertinent to the rating criteria and adequately addressed the functional effects of the Veteran's scars. Nieves-Rodriguez v. Peake, 22 Vet. App 295 (2008); see Barr v. Nicholson, 21 Vet. App. 303 (2007) (holding that VA must provide an examination that is adequate for rating purposes). 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). The Board is also satisfied that VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes VA and private treatment records, VA examinations, and the Veteran's statements. In light of the foregoing, the Board finds that VA has provided the Veteran with every opportunity to submit evidence and arguments in support of his claims, and to respond to VA notices. The Veteran and representative have not identified any outstanding evidence that needs to be obtained. For these reasons, the Board finds that VA has fulfilled the duties to notify and assist the Veteran. Disability Rating Laws and Regulations Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim, a practice known as a "staged rating." See Fenderson v. West, 12 Vet. App 119 (1999). The Court has also held that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Id. The Board finds that disability due to service-connected scars of the back of the neck, right and left shoulder areas, and mid back have not increased in severity during the course of the appeal to warrant a staged rating. In rendering a decision on appeal the Board must also analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). The Schedule for Rating Skin Disabilities was amended in 2008 so that it more clearly reflects VA's policies concerning the evaluation of scars, specifically, 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805; however, these changes only apply to applications received by VA on or after October 23, 2008, or if a veteran was previously evaluated under those codes and requests review under the clarified criteria. See 73 Fed. Reg. 54708 (September 23, 2008). The Veteran has not requested review under the clarified criteria, effective October 23, 2008. Consequently, the Board finds that the revisions to the skin regulations that took effect October 23, 2008 are not for application and the Board has evaluated the Veteran's disability based on the rating criteria in effect prior to October 23, 2008, as delineated below. Diagnostic Code 7800 evaluates disfigurement of the head, face, or neck. A 10 percent evaluation is assigned with one characteristic of disfigurement. A higher 30 percent evaluation is assigned 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. 38 C.F.R. § 4.118, Diagnostic Code 7800. The 8 characteristics of disfigurement, for the purposes of evaluation under § 4.118, are: (1) scar 5 or more inches (13 or more cm) in length; (2) scar at least one-quarter inch (.6 cm) wide at widest part; (3) surface contour of scar elevated or depressed on palpation; (4) skin adherent to underlying tissue; (5) skin hypo- or hyper-pigmented in an area exceeding six square inches (39 sq. cm); (6) skin texture abnormal (irregular, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm); (7) underlying soft tissue missing in an area exceeding six square inches (39 sq. cm); and (8) skin indurated and inflexible in an area exceeding six square inches (39 sq. cm). Id. at Note (1). Scars, other than on the head, face, or neck, that are deep or that cause limited motion, are evaluated under Diagnostic Code 7801. Under Diagnostic Code 7801, a 10 percent evaluation is assigned for scars affecting an area or areas exceeding 6 square inches (39 sq. cm.); a 20 percent evaluation is assigned for scars affecting an area or areas exceeding 12 square inches (77 sq. cm.); a 30 percent evaluation is assigned for scars affecting an area or areas exceeding 72 square inches (465 sq. cm.); and a maximum 40 percent evaluation is assigned for scars affecting an area or areas exceeding 144 square inches (929 sq. cm.). 38 C.F.R. § 4.118, Diagnostic Code 7801. Scars in widely separated areas as on two or more extremities or on anterior or posterior surfaces of extremities or trunk, will be rated separately. Id. at Note (1). A deep scar is one associated with underlying soft tissue damage. Id. at Note (2). For scars, other than those of the head, face, or neck, that are superficial and that do not cause limited motion that comprise an area or areas of 144 square inches (929 sq. cm.) or greater, a maximum 10 percent evaluation is provided. 38 C.F.R. § 4.118, Diagnostic Code 7802. Scars in widely separated areas as on two or more extremities or on anterior or posterior surfaces of extremities or trunk, will be rated separately. Id. at Note (1). A superficial scar is one not associated with underlying soft tissue damage. Id. at Note (2). For scars that are superficial and unstable, a maximum 10 percent evaluation is warranted. 38 C.F.R. § 4.118, Diagnostic Code 7803. The notes to this diagnostic code state that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar and that a superficial scar is one not associated with underlying soft tissue damage. Id. For superficial scars that are painful on examination, a maximum 10 percent evaluation is provided. 38 C.F.R. § 4.118, Diagnostic Code 7804. The notes to this diagnostic code provide that a superficial scar is one not associated with underlying soft tissue damage and that 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. Id. Scars can also be assigned disability ratings based upon limitation of function of the affected part. 38 C.F.R. § 4.118, Diagnostic Code 7805. Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a veteran's service-connected disability. 38 C.F.R. § 4.14 (2012). However, it is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; the critical element in permitting the assignment of several evaluations under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994) (impairments associated with a veteran's service-connected disability may be rated separately unless they constitute the same disability or the same manifestation). 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 veteran. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), it was observed that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Increased Rating Analysis The Veteran is currently in receipt of a 10 percent rating for scars of the back of the neck, right and left shoulder areas, and mid back, status post excision of basal cell carcinoma under Diagnostic Code 7800-7801. The November 2007 rating decision, which granted the increased 10 percent evaluation, specified that the 10 percent evaluation was established as it best represented the Veteran's overall disability picture due to his combination of scars, but found that the scars, "considered separately," did not warrant a compensable evaluation. The Board will not disturb the currently assigned 10 percent evaluation assigned by the RO in this case, but will instead determine if a separate or higher rating is warranted for scars of the back of the neck, right and left shoulder areas, and mid back. After a review of all the evidence, the Board finds that for the entire rating period, a separate 10 percent evaluation is warranted for a scar on the back of the neck under Diagnostic Code 7800. After a review of all the evidence, the Board finds that for the entire rating period, a separate or higher evaluation is not warranted for service-connected scars of the right shoulder, the left shoulder, and the mid back. At the outset, it is noted that the Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate. A March 2006 VA examination identified one scar on the posterior neck, measuring 1 centimeter by 1.3 centimeters; one scar on the right shoulder, measuring 1 centimeter by 1.3 centimeters; and one scar on the left shoulder 3 centimeters by 8 centimeters. The examiner indicated that the scars were hypopigmented and normal texture with no elevation or depression of the scars. There was no pain on examination and no adherence to underlying tissue. The scars were superficial and stable, with no limitation of motion, induration, or inflexibility. There was no disfigurement of the head, face, or neck associated with the scar on the posterior neck. A February 2007 VA examination shows that there was one scar on the back of the neck, located on the posterior aspect of the midline of the neck, measuring 0.5 centimeters by 2 centimeters. The examination report shows that the scar was superficial and of normal color and texture; that it was nontender, nonadherent, not unstable, not elevated or depressed; there was no induration or inflexibility; and it did not cause limitation of motion in the neck. The Veteran also had scars located on the right and left shoulder and on the mid back. He had five scars on the right shoulder, one measuring 1.4 centimeters by 1.5 centimeters, and four measuring 1 centimeter by 1 centimeter. He had three scars of the left shoulder, one on the left scapula measuring 8 centimeters by 2 centimeters, and two additional scars on the left shoulder measuring 1.5 centimeters by 1 centimeter, and 1 centimeter by 1 centimeter. He had three scars located on the mid back, each measuring 1 centimeter by 1 centimeter. All of these scars were superficial, not unstable, nontender, and there was no limitation of motion or function due to these scars. The VA examiner noted that there were no symptoms associated with any of the skin scars, except for the fact that some were a brighter color red due to recent basal cell cancer removal. An October 2007 VA examination shows that the Veteran had one scar on the posterior neck, measuring 0.5 centimeters by 2 centimeters and one scar on the left deltoid, measuring 1 centimeter by 1 centimeter. The examiner found no tenderness on palpation, no adherence to underling tissue, no underlying soft tissue damage, and no skin ulceration or breakdown over the scars. There was no limitation of motion or loss of function due to the scars. The examiner indicated that there was no disfigurement of the head, face, or neck associated with the scar on the posterior neck. A November 2010 VA examiner stated that there were dozens of 1 centimeter by 1 centimeter hyperpigmented round scars over both shoulders, the back of the neck, and the mid-back. He stated that these scars were all nontender, non-adherent, and smooth in texture with no underlying tissue loss. There is no instability and no ulceration. The scars are neither elevated nor depressed. There is no inflammation, edema, or keloid formation. There is no induration, inflexibility, or limitation of motion or function caused by the scars. A December 2010 supplemental examination shows that the Veteran reported that his main complaint in relation to his scars was his appearance, and that there was no pain or limitation of function due to these scars. A March 2013 VA examination shows that the Veteran had one scar located on the posterior cervical spine (back of the neck) measuring 0.5 centimeters by 2 centimeters; one scar on the right triceps measuring 1.5 centimeters by 1.5 centimeters; one scar on the left shoulder measuring 1 centimeter by 1 centimeter; and one scar on the posterior trunk, left upper scapula, measuring 7 centimeters by 1.5 centimeters. The VA examiner provided estimates for the total area affected by these service-connected scars, stated to be 2.25 square centimeters in the right upper extremity, 1 square centimeter in the left upper extremity, and 10.5 square centimeters in the posterior trunk. The examiner stated that the scars were superficial, not painful or unstable, and there was no loss of covering over the skin of the scars. The Veteran's scars did not result in any limitation of function. During examination, the Veteran reported that he missed work due to surgery and healing time for treatment of skin cancer. In December 2010, March 2011, and March 2012 lay statements, the Veteran described ongoing treatment related to basal and squamos cell carcinomas, to include surgical removal of carcinomas, and he reported treatment for ackinic keratosis. He submitted photographs in support of his claim, showing the recent affect of surgical biopsies. Additionally, with respect to his claim for an increased rating, the Veteran indicated that his argument centered on disfiguring factors associated with his scars. Private dermatology treatment records dated from 2006 to 2013 show that the Veteran seen for biopsy, excision, and treatment of basal cell carcinoma found on various parts of the body during the course of the appeal period as well as seborrheic keratosis. While the Veteran has provided lay and medical evidence addressing ongoing treatment related to basal and squamos cell carcinomas, ackinic keratosis, and seborrheic keratosis, the Board finds that this evidence is not relevant to the current appeal for an increased rating. In that regard, the Veteran is not currently service-connected for basal cell carcinoma or other skin disease, and service connection for new scars associated with ongoing basal cell carcinoma was referred to the RO for appropriate action in October 2010 and January 2013 Board remands. Moreover, an April 2013 rating decision, which denied service connection for basal cell carcinoma of the left forearm, left posterior neck, and right forearm is not currently on appeal. Accordingly, the Board's present decision will only focus on evidence related to service-connected scars of the back of the neck, left and right shoulders, and mid back currently on appeal. Insomuch as the record reflects scars resulting from more recent removal of basal cell carcinoma in back of the neck, left and right shoulders, and the mid back, because VA examinations do not separate out scars from these more recent surgeries from the service-connected scars in those same areas, the Board will attribute such signs and symptoms to the service-connected disability. See 38 C.F.R. § 3.102 (2005); Mittleider v. West, 11 Vet. App. 181 (1998) citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996) (the Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence which does so.) The Board finds that for the entire rating period, the Veteran has had evidence of one superficial scar of the back of the neck, measuring between 0.5 centimeters and 1 centimeter in width, and between 1 centimeter and 2 centimeters in length. Under Diagnostic Code 7800, a 10 percent evaluation is warranted for a scar, located on the head, face, or neck, which results in one characteristic of disfigurement. See 38 C.F.R. § 4.118. Note 1 to Diagnostic Code 7800 identifies the 8 characteristics of disfigurement, which, in pertinent part, include that a scar that is at least one-quarter inch (.6 cm) wide at widest part. Id. VA examinations identify the presence of one scar located on the posterior neck, or back of the neck; however, there is conflicting evidence with regard to the dimensions of this scar. While a March 2006 VA examination shows that the scar measures 1 centimeter in width by 1.3 in length, and a November 2010 VA examination noted the presence of dozens of 1 centimeter by 1 centimeter round scars over both shoulders, "the back of the neck," and the mid-back; February 2007, October 2007, and March 2013 VA examinations show that a scar a located on the back of the neck measured 0.5 centimeters by 2 centimeters. Resolving the benefit of the doubt in favor of the Veteran on this question, the Board finds that the Veteran has one service-connected scar located on the back of neck which measures at least one-quarter inch (.6 cm) wide at widest part consistent with one characteristic of disfigurement under Diagnostic Code 7800. For these reasons, and resolving the benefit of the doubt in the Veteran's favor, the Board finds that a separate 10 percent evaluation is warranted for a scar on the back of the neck under Diagnostic Code 7800 for the entire appeal period. The Board finds that an evaluation in excess of 10 percent is not warranted for a scar on the back of the neck under Diagnostic Code 7800 where the scar on the does not result in visible or palpable tissue loss, gross distortion or asymmetry of one feature or paired sets of features, or two or three characteristics of disfigurement. See 38 C.F.R. § 4.118. VA examinations show that Veteran's skin texture was normal, with no underlying soft tissue damage in the area of his scar, and the Veteran's scar did not affect the features of his face. Additionally, the Board finds that the Veteran's scar did not result in more than one characteristic of disfigurement. VA examinations show that the surface contour of the Veteran's scar was not elevated or depressed and there was no adherence to underlying tissue. The scar was not 5 centimeters or more in length, and did not affect an area exceeding six square inches (39 square centimeters). Thus, while the Veteran's scars were noted to be either hypo- or hyperpigmented during some VA examinations, the Board finds that the skin on the back of the neck was not hypo- or hyper-pigmented in an area exceeding 39 square centimeters. Moreover, there was no underlying soft tissue missing, and no induration of inflexibility in the area of the scar, and skin texture was stated to be normal. For these reasons, the Board finds that an evaluation in excess of 10 percent is not warranted for a scar on the back of the neck under Diagnostic Code 7800. For the entire rating period, the Board finds that the Veteran had superficial scars of the back of the neck, the right shoulder, the left shoulder, and the mid back, which do not cause limited motion and affect areas of less than 144 square inches on each extremity and less than 144 square inches on the posterior surface of the truck. Because scars of the back of the neck, the right shoulder, the left shoulder, and the mid back are shown by VA examinations to be superficial, and not deep, and because these scars do not result in limited motion, the Board finds that a separate, compensable rating is not warranted under Diagnostic Code 7801. See 38 C.F.R. § 4.118. A 10 percent evaluation is assigned under Diagnostic Code 7802 for scars that are superficial and that do not cause limited motion that comprise an area or areas of 144 square inches (929 sq. cm.) or greater. 38 C.F.R. § 4.118. In this case, scars are located on each extremity and the posterior trunk (the mid back and back of the neck) are each evaluated separately. See Id. at Note 1. The Board finds that the Veteran's scars affect areas of less than 144 square inches on each extremity and less than 144 square inches on the posterior surface of the truck. A March 2006 VA examination identified one scar on the posterior neck, measuring 1 centimeter by 1.3 centimeters; one scar on the right shoulder, measuring 1 centimeter by 1.3 centimeters; and one scar on the left shoulder 3 centimeters by 8 centimeters. An October 2007 VA examination shows that the Veteran had one scar on the posterior neck, measuring 0.5 centimeters by 2 centimeters and one scar on the left deltoid, measuring 1 centimeter by 1 centimeter. A February 2007 VA examination reflects right shoulder scars, one measuring 1.4 centimeters by 1.5 centimeters and four measuring 1 centimeter by 1 centimeter. Left shoulder scars, include an 8 centimeter by 2 centimeter scar on the scapula, as well as additional scars on the left shoulder measuring 1.5 centimeters by 1 centimeter, and 1 centimeter by 1 centimeter. One scar on the back of the neck, measuring 0.5 centimeter by 2 centimeters and three on the mid back, measuring 1 centimeter by 1 centimeter affect approximately 4 square centimeters. Accordingly, the Board finds that these VA examinations reflect service-connected scars of the back, neck, and shoulders affecting less than 30 square centimeters of total body area. While a November 2010 VA examiner identified dozens of scars, he did not provide specific locations for such scars. An March 2013 VA examiner provided estimates of the area affected by service-connected scars of the right extremity, left extremity, and posterior trunk, and the Board finds that these estimates are consistent with the measurements provided for service-connected scars of the right shoulder, left shoulder, and posterior trunk in the examination report. The Board notes that the scar on the left scapula was found by the VA examiner to be located on the posterior trunk. The scars affected 2.25 square centimeters in the right upper extremity, 1 square centimeter in the left upper extremity, and 10.5 square centimeters in the posterior trunk. Despite minor discrepancies noted in the number or size of the Veteran's scars, the Board finds, considering all of the evidence in a light most favorable to the Veteran, that the area affected by service-connected scars in the right extremity, left extremity, or posterior trunk does not nearly approximate an area of 929 square centimeters or greater in each of those areas to warrant a compensable evaluation under Diagnostic Code 7802. The Board finds that scars of the back of the neck, the right and left shoulder areas, and the mid back are not shown to be unstable, painful on examination, and are not shown to result in limitation of function to warrant ratings under Diagnostic Code 7803, 7804, or 7805. See 38 C.F.R. § 4.118. VA examinations dated in March 2006, February 2007, October 2007, November 2010, and March 2013 show that the Veteran's scars were not unstable and there was no adherence, ulceration, or underlying tissue loss. VA examinations consistently show that the Veteran's scars were not tender or painful on examination, and there was no limitation of motion or function associated with his scars. The Veteran does not contend that his scars are painful, and instead has reported in lay statements and during a supplemental December 2010 VA examination that his concern is focused on his appearance or disfigurement due to his scars. For these reasons, the Board finds that a separate or higher rating is not warranted under Diagnostic Code 7803, 7804, or 7805. See 38 C.F.R. § 4.118. The Veteran has presented lay evidence and argument concerning disfigurement due to his service-connected scars. The Board finds that the Veteran is competent to report the physical effects of his scars, to include his own personal concerns with respect to his appearance or disfigurement, and the Board finds that that his reports are credible. In this case, the Board has assigned a separate 10 percent evaluation based on a disfigurement of the neck under Diagnostic Code 7800. The Board notes that the Veteran is also in receipt of separate ratings based on disfigurement of the head, face, or neck, for scars of the left cheek and left lip, which are not a subject of the present appeal. Additionally, the Veteran has several nonservice-connected scars which are not a subject of the current appeal. The Board finds that the Veteran's 10 percent rating, in this case, adequately addresses disfigurement presented by a scar located on the back of the neck. The applicable rating criteria under the Schedule for Rating Skin Disabilities does not provide evaluations based on disfigurement for scars in areas other than the head, face, or neck; thus, the Board finds that a separate rating is not warranted for disfigurement based on scars located on the right and left shoulders and mid-back where these scars do not affect an area or areas of 144 square inches or greater, are asymptomatic, and do not result in any functional limitations. For these reasons, the Board finds that for the entire rating period the preponderance of the evidence is against finding that scars of the mid back and right and left shoulder areas, status post excision of basal cell carcinoma, warrant a higher rating evaluation. In making this determination, the Board has considered the provisions of 38 U.S.C.A. § 5107(b) regarding benefit of the doubt. Extraschedular Consideration The Board has considered whether referral for an extraschedular evaluation is warranted. 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 is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, including Diagnostic Codes 7800-7805 specifically provide for disability ratings based on scars; disfigurement of the head, face, or neck due to scars; and associated symptoms caused by scarring, to include the extent and nature of such scarring, the presence of any painful scars, and functional limitations due to scars. In this case, considering the lay and medical evidence, the Veteran's scars are superficial and have been manifested by one characteristic of disfigurement of the neck, affect areas of less than 144 square inches on each extremity and less than 144 square inches on the posterior surface of the truck, are not unstable, not painful on examination, and do not result in limitation of function. Such symptoms and impairment are part of or similar to symptoms listed under the schedular rating criteria. See 38 C.F.R. § 4.20 (schedular rating criteria provides for rating by analogy based on similar functions, anatomical location, and symptomatology). For these reasons, the Board finds that the schedular rating criteria is adequate to rate the Veteran's scars, and referral for consideration of an extraschedular evaluation is not warranted. 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 problems reported by the Veteran are specifically contemplated by the criteria discussed above. The Veteran's scars are not shown to result in functional limitations or limitations on his occupation and daily life, and the Board finds that the assigned 10 percent evaluation addressing his overall impairment and the separate 10 percent rating the Board is granting based on a disfigurement of the neck adequately addresses his current disability picture. While the Veteran has reported that he missed work due to surgery and healing time for treatment of skin cancer, the Veteran's current evaluation is for his already service-connected scars. In the absence of exceptional factors associated with the Veteran's disability, 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 Resolving reasonable doubt in the Veteran's favor, for the entire rating period, a separate 10 percent evaluation is granted for a scar on the back of the neck, status post excision of basal cell carcinoma. For the entire rating period, an increased evaluation in excess of 10 percent for scars of the mid back and right and left shoulder areas, status post excision of basal cell carcinoma, is denied. ____________________________________________ C. L. KRASINSKI Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs