Citation Nr: 1329801 Decision Date: 09/17/13 Archive Date: 09/25/13 DOCKET NO. 09-06 544 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for a right knee disorder, claimed as secondary to left thoracic spine hemangioma 2. Entitlement to service connection for a psychiatric disorder, to include depression, claimed as secondary to left thoracic spine hemangioma. 3. Entitlement to service connection for right arm pain, numbness, and tingling, claimed as secondary to left thoracic spine hemangioma. 4. Entitlement to service connection for a right hip disorder, claimed as secondary to left thoracic spine hemangioma. 5. Entitlement to service connection for a left hip disorder, claimed as secondary to left thoracic spine hemangioma. 6. Entitlement to service connection for left inguinal hernia post-operative residuals with gastroesophageal reflux disease (GERD), claimed as secondary to left thoracic spine hemangioma. 7. Entitlement to an initial rating in excess of 10 percent for thoracic surgical scar residuals. 8. Entitlement to a rating in excess of 20 percent for post-operative residuals of thoracic spine hemangioma. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL The Veteran and a Nurse Advisor ATTORNEY FOR THE BOARD W.T. Snyder, Counsel INTRODUCTION The Veteran had active service from November 1980 to January 1990. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). These matters come before the Board of Veterans' Appeal (Board) on appeal from a June 2007 rating decision of the Philadelphia, Pennsylvania, Regional Office (RO) of the Department of Veterans Affairs (VA) and March 2009 and February 2010 rating decisions of the Roanoke, Virginia, RO. The June 2007 rating decision awarded an increased rating from 10 to 20 percent for post-operative residuals of the thoracic spine. The March 2009 rating decision denied a petition to reopen a claim of service connection for a right knee disorder and denied entitlement to service connection for depression and for a right arm disorder. The February 2010 rating decision granted service connection for thoracic spine surgical scar residual and assigned an initial 10 percent rating, effective in February 2009. In pertinent part, that decision also denied entitlement to service connection for the bilateral hip disorder, a left inguinal hernia with acid reflux. The Veteran perfected separate appeals of those determinations. See 38 C.F.R. § 20.200 (2012). In March 2011, the Veteran testified during a videoconference hearing before the undersigned, with the Veteran sitting at the RO and the undersigned sitting at the Board's Central Office in Washington, DC. A transcript of that hearing is associated with the claims file and has been reviewed. Although the Veteran was denied service connection only for depression, the Board has recharacterized the issue to comport with the holding in Clemons v. Shinseki, 23 Vet. App. 1 (2009). In a May 2011 decision, the Board reopened the right knee claim and remanded it and other claims to the Appeals Management Center (AMC), in Washington, DC for additional development. The Veteran has a Virtual claims file, which is a highly secured paperless repository, associated with his appeal. The Board has considered the documents in both files while reviewing this appeal. The issues of entitlement to service connection for right knee and bilateral hip disorders, both as secondary to left thoracic spine hemangioma; and, entitlement to a rating in excess of 20 percent for post-operative residuals of thoracic spine hemangioma, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The preponderance of the evidence shows that the Veteran's acquired psychiatric disorder, to include depression, is not due to or aggravated by his post-operative thoracic spine disability. 2. The preponderance of the evidence shows that the Veteran's right arm disorder is not due to or aggravated his post-operative thoracic spine disorder. 3. The preponderance of the evidence shows that the Veteran's post-operative left inguinal hernia residuals with GERD is not due to or aggravated by his post-operative thoracic spine disorder. 4. The Veteran's thoracic spine surgical scar residuals manifest as superficial in nature, with claimed pain on examination of two of the scars. CONCLUSIONS OF LAW 1. The criteria for an award of service connection for an acquired psychiatric disorder, including depression, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002 and Supp. 2012); 38 C.F.R. § 3.310 (2012). 2. The criteria for an award of service connection for a right arm disorder with pain, numbness and tingling have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. §3.310. 3. The criteria for an award of service connection for post-operative left inguinal hernia residuals with GERD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. §3.310. 4. The criteria for an initial evaluation in excess of 10 percent for thoracic spine surgical scar residuals have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.118, Diagnostic Code (DC) 7804. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the 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; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). 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, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this 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. Id. at 486. 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). Prior to issuance of the June 2007 rating decision on appeal, the Veteran was sent a notice letter in December 2006. This communication explained the division of responsibilities between VA and a claimant in developing an appeal. The letter also expressly informed the Veteran how to substantiate a service connection claim and what type of information and evidence was needed to establish a disability rating and effective date in the event service connection is granted. It also informed him why his prior claim was denied and the evidence needed to reopen it. The December 2006 letter did not address service connection on a secondary basis, but RO letters of March 2009 and January 2010 provided comprehensive VCAA notice prior to issuance of the March 2009 and February 2010 rating decisions. The Board finds that the letters, cumulatively, were time- and content-compliant. 38 C.F.R. § 3.159(b). Accordingly, no further development is required with respect to the duty to notify. VA also 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(c). Upon receipt of the Veteran's claim, the RO obtained his service treatment records and VA outpatient records, and arranged examinations of the Veteran. Records related to Social Security benefits were also obtained. Neither the Veteran nor his representative asserts that there is additional evidence to be obtained, or that VA has failed to seek any records identified as relevant. Further regarding the duty to assist, the United States Court of Appeals for Veterans Claims (Court) has held that the provisions of 38 C.F.R. § 3.103(c)(2) impose two distinct duties on VA employees, including Board personnel, in conducting hearings: the duty to explain fully the issues and the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010) (per curiam). The Board notes that, at the March 2011 hearing, the undersigned made certain the Veteran was aware of the issues before the Board and that all relevant records were included in the claims file. The undersigned also suggested actions which would help the Veteran prove his claim and helped the Veteran clearly articulate the basis of his appeal. The Board then remanded the case to obtain additional records and for another examination. In light of these factors, the Board finds the duties imposed by Bryant were met. In light of the above, the Board finds VA has fully assisted the Veteran with his claims, and that the record is sufficiently developed for a decision on the merits of the appeal without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Board has reviewed all the evidence in the Veteran's Virtual and paper claims file. Although there is an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by an appellant or obtained on his behalf be discussed in detail. Rather, the analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Service Connection Claims The Veteran asserts that his diagnosed depression, right arm disorder, and hernia residuals including GERD are caused by his post-operative thoracic spine disorder. Governing Law and Regulations A disability which is proximately due to or the result of a service-connected injury or disease shall be service connected. 38 C.F.R. § 3.310. Further, a disability that is aggravated by a service-connected disorder may be service connected to the degree that the aggravation is shown. Allen v. Brown, 7 Vet. App. 439 (1995). In order to establish entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Analysis As noted earlier, service connection is in effect for the post-operative residuals of a thoracic spine disorder, variously diagnosed as thoracic hemangioma and low back pain. Hence, the question for consideration is whether there are currently diagnosed mental, right arm and gastrointestinal disorders and, if so, whether they are causally connected to or aggravated by the service-connected thoracic spine disorder. See id. Psychiatric Disorder The August 2012 psychiatric examination report reflects that the examiner conducted a review of the claims file as part of the examination. Diagnoses of polysubstance dependence and depressive disorder not otherwise specified were rendered. The examiner noted the Veteran's long history of drug usage and homelessness. The examiner noted the Veteran's treatment for drug dependence. The Veteran reported his addiction had caused many problems in his life, to include divorce. The examiner noted that a notation of depression in response to his physical pain appears to have first been made during treatment at a VA facility in 2006 for his substance dependence. There were times, however, where he endorsed pain during treatment but denied depression. This indicated to the examiner that there was no clear or consistent showing of pain-related depression. The examiner noted the Veteran had been treated with Trazodone, Fluoxetene, Buproprion, and Hydroxyzine. The Veteran's diagnoses included depression, anxiety, history of polysubstance abuse, and Cluster B personality traits. There had been minimal mention of the service-connected back problem being a significant factor in the Veteran's reported low mood and anxiety. In fact, the Veteran's records indicated his addiction was thought to play a role, as indicated by the entry of rule-out substance-induced mood disorder. Notes dated in May 2012 indicated the Veteran had increased depression due to finances, business stress, and his ex-girlfriend not having a job. A May 2012 psychology note indicated the Veteran was relatively pleased with his pain control, which was lower than his acceptable pain limits. The Veteran reported stress with his ex-girlfriend at that time. The examiner noted the Veteran had a history of alcohol, cocaine, and marihuana abuse/dependence, as well as a history of abusing Percocet. The Veteran reported that he still drank beer. A six-pack lasted a week, and a pint of brandy also lasted him a week. He did not report any recent drug use. Urine drug screens of December 2011, January 2012, and May 2012 were negative. Screens were positive for marihuana, opiates and cocaine in 2011. The records reflected alcohol use regularly at age 16. His father and at least two siblings had addiction problems. The examiner opined the Veteran had some depressive symptoms that are likely strongly associated with his addiction and its consequences, e.g., financial, relationship stress, and homelessness. There appeared to be minimal indication in the treatment records that the service-connected back disorder caused or significantly contributed to the Veteran's clinical depression. The examiner noted that, on the day of the examination, the Veteran's affect was broad, and his mood appeared euthymic, and he did not appear to be in any emotional distress. The Veteran did report some periodic low mood which he estimated occurred about two to three days a week. His son helped him to keep his mood positive. The Veteran also reported periodic feelings of anxiety, often having concern over his business and getting his life together. The examiner opined there was less than a 50-percent probability the Veteran's depression was related to his service-connected thoracic spine disorder. The examiner cited the long-standing history of severe addiction and its severe consequences as a more likely a significant cause of the Veteran's depression. The examiner noted that even when the Veteran's pain was reported to be under control in May 2012, treatment reports noted complaints of depression and anxiety, which suggested they are separate issues. The examiner did not address whether the Veteran's post-operative thoracic spine disorder aggravated his depression. Hence, so the RO obtained another examination by a difference examiner. The June 2013 mental examination report reflects the examiner conducted a review of the claims file. Based on the review of the file, the examiner opined there was less than a 50 percent probability the Veteran's depression was caused or aggravated by his service-connected thoracic spine disorder. The examiner noted the Veteran's lifelong history of substance abuse and dependence that started at age 16. The Veteran also reported physical and emotional abuse by his father. The examiner noted that, while the Veteran did not report depression as a child per se, early drinking and drug abuse are markers for underlying depression that would be consistent with a history of abuse. The examiner noted the Veteran presented at VA treatment facility in 2001 with complaints of pains in his back, knee, and stomach. He explicitly denied any symptoms of depression, to include any pain-related depression. For example, in April 2002, the Veteran denied any symptoms of dysthymia or current major depression despite a pain rating of 7. The Veteran's first mention of a perceived connection between his pain and depression was in December 2006, as part of treatment plan was he was in a VA Domiciliary. The examiner noted that during the next several years, the Veteran variously ascribed his depression primarily to ongoing addiction problems and life stressors, and secondarily to his pain. Moreover, the Veteran had numerous periods of time when he reported experiencing pain but not depression, and vice versa. As the reports of pain and depression have been so inconsistent since 2001, and since problems associated with depression, such as substance abuse, predate his time in the military, the examiner could not conclude the Veteran's depression stems from pain that is related to his service-connected problems. The examiner endorsed a similar rationale for opining the Veteran's depression is not aggravated by his service-connected back disorder. The examiner noted that it was difficult to distinguish between depression induced by substance abuse and a free-standing depressive disorder. Further, since the Veteran's substance dependence included abuse of opiates and alcohol, among other drugs, it was reasonable to conclude they impacted his depression. The examiner noted the lifestyle associated with chronic substance dependence, to include social, unemployment, and financial, result in significant stress. The Veteran has endorsed and acknowledged those problems and an increase in his depression associated with them. Hence, the Veteran's pain related to his back disorder did not aggravate his depression. As noted above, the opinions offered by the VA examiners weigh against the claim. As they were based on a thorough evaluation of the Veteran and a review of the pertinent history, they are deemed highly probative. No other competent evidence of record refutes those findings. Moreover, while the Veteran is competent to report his symptoms, he lacks the expertise to opine as to the etiology of his psychiatric diagnoses, as such requires skill beyond the mere observations of a layperson. Accordingly, the preponderance of the evidence is against the claim. Right Arm and Hernia with GERD The Veteran underwent a VA examination in June 2013. He reported that he had never had a diagnosis related to his right arm. He described his problem as numbness that started in 2010. It originated in his neck and radiated through his shoulder to his fingertip. He was unable to complete an EMG, and he also reported a weak grip. He is right hand dominant. The examiner's review of the claims file revealed no permanent residual of the right arm or neurologic findings of the right upper extremity related in cause to the service-connected left thoracic hemangioma condition. Objectively, the examination revealed no gross neurological deficits originating from the thoracic spine. The Veteran reported that he could not feel monofilament sensitivity but then stated that he felt monofilament sensitivity and vibratory sensitivity in the same dermatome. There were no other neurological deficits on examination to support the claimed loss of sensitivity. The examiner noted further that there was no neurological innervation of the right upper extremity affected by a thoracic spine nerve. Further, the examiner noted, the Veteran had significant cervical spine pathological findings contributing to the subjective symptoms reported. The objective findings on clinical examination did not reveal findings of the right upper extremity proximately related to his thoracic spine condition. As a result, the examiner opined the Veteran's right arm pain, numbness, and tingling was not proximately due to or aggravated by the left thoracic spine disorder. The RO had obtained examinations in August 2012, but determined they were incomplete. A section of the reports seems to indicate that an examiner opined there was at least a 50-percent probability that the Veteran's right arm symptoms were causally related to his thoracic spine disorder. The Board notes "seems" because it is unclear whether this is actually an opinion of an examiner or merely an example provided by the RO. In any event, even if the former, no rationale was provided for the opinion, which renders it of less weight than that of the examiner who conducted the 2013 examination. See Nieves v. Rodriguez, 22 Vet. App. 295 (2008). The evidence of record reflects that the Veteran underwent left inguinal hernia surgery in 2009. The June 2013 examination report reflects the examiner noted the review of the claims file and the Veteran's electronic records revealed inguinal hernia or reflux condition etiologically related to the left thoracic spine condition. Further, based on the Veteran's reports and the review of the records, the Veteran used Hydrocodone for pain. The examiner noted Hydrocodone (Vicodin) would not cause GERD, but it could aggravate existing GERD. Nonetheless, the examiner noted, it would not be a permanent chronic aggravation, as it was easily remedied by changing medication. Further, any aggravation would be a flare and the fact the Veteran takes Pantoprazole would control any flare. Therefore, any aggravation of the Veteran's GERD by the Hydrocodone would not be a chronic worsening of the disorder. The Veteran's nurse advisor, L.H., testified at the Board hearing. She testified she had over 30 years of nursing experience, and that she had reviewed the Veteran's medical records. She also implied a treating relationship. L.H. testified that the Veteran has depression associated with his condition. She explained his belief that his entire body is compensating for long-term symptoms associated with his thoracic spine disorder, which in turns causes problems associated with the back and arm. See Hearing Transcript, pp. 4 and 6. L.H. noted essentially the same information in an undated letter. The Board must 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 Veteran. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). In doing so, the Board must weigh the evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others, as long as the reasons for doing so are provided. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999); see also Winsett v. West, 11 Vet. App. 420, 424-25 (1998). Further, the Board is not required to accord more weight to the opinion of a treating medical professional solely on that basis. See Van Slack v. Brown, 5 Vet. App. 499, 502 (1993) (citing Harder v. Brown, 5 Vet. App. 183, 188 (1993)); see Guerrier v. Brown, 7 Vet. App. 467 (1993). The Board finds the conclusions and opinions of the VA examiners far more persuasive than those offered by L. H's. In fact, L.H. only stated conclusions and did not provide a rationale for her opinion. Concerning the depression claim, she gave no indication that she had any specialized mental health training. See Black v. Brown, 10 Vet. App. 279 (1997) (an opinion may be reduced in probative value even where the statement comes from someone with medical training, if the medical issue requires special medical knowledge). Both of the VA examinations were conducted by a clinical psychologist who also reviewed the claims file. Contrary to L.H., the VA examiner who conducted the June 2013 examination provided a full explanation for his opinions. See Nieves v. Rodriguez, 22 Vet. App. 295 (2008). Further, the Board finds his opinions are supported by the evidence of record. To the extent that the Veteran opines his depression, left inguinal hernia with GERD, and right arm disorder are causally related to his left thoracic spine disorder, the Board finds such opinions not probative. Lay persons are deemed capable of identifying certain medical disorders, i.e., varicose veins. Nonetheless, the Board finds the process of diagnosing depression, neurological disorders, or GERD, and the etiology of either disorder, is beyond the training and experience of the average lay person. See 38 C.F.R. § 3.159(a); see also Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Hence, the Veteran's opinion is not probative. In light of all of the above, while the preponderance of the evidence shows the presence of Wallin Elements 1 and 2, it also shows the absence of Wallin Element 3: a causal or aggravating relationship between the service-connected left thoracic spine disability and the depression, right arm pain, tingling, etc., and post-operative left inguinal hernia residuals with GERD. Hence, the Board is constrained to deny the claim. 38 C.F.R. § 3.310. Increased Rating Applicable Law and Regulation Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. VA must also interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability. 38 C.F.R. § 4.2. VA must resolve any reasonable doubt regarding the degree of disability in favor of the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3. Where there is a question as to which of two ratings apply, VA will assign the higher of the two where the disability picture more nearly approximates the criteria for the next higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7, see also 38 C.F.R. § 4.21. The Board will consider entitlement to staged ratings to compensate for times since the effective date for grant of service connection for the skin disability may have been more severe than at other times during the course of the claim on appeal. See Fenderson, 12 Vet. App. 119. Staged ratings are also available for any existing service-connected disability on the same basis. See Hart v. Mansfield, 21 Vet. App. 505 (2007). VA must also evaluate functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity. 38 C.F.R. § 4.10; see Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Analysis Skin Disorder The rating criteria for skin disorders were amended effective October 2008 and are applicable for claims received by VA on and after October 23, 2008. See 38 C.F.R. § 4.118. VA received the Veteran's claim of entitlement to service connection for scar residuals in February 2009. Hence, the current criteria are applicable to his claim. Those criteria provide for a 30 percent rating for five or more scars that are unstable or painful; a 20 percent rating for three or four scars that are unstable or painful; and, a 10 percent rating for one or two scars that are unstable or painful on examination. Id., DC 7804. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Id., Note (1). A superficial scar is one not associated with underlying soft tissue damage. Id., DC 7802, Note (1). A scar that causes disabling affects is evaluated under an appropriate DC. See DC 7805. At the October 2009 skin examination, the Veteran reported a total of four scars due to the two surgeries to remove his spine tumor. He reported that the scars were painful. He also reported numbness on the left side adjacent to one of the scars. Scar 1: the examiner noted that the scar was located at the midline posterior thoracic spine. Physical examination revealed the scar as 0.25 cm x 22 cm. There was no skin breakdown. The scar was superficial and without edema, inflammation, or keloid formation. The scar was painful. The diagnosis was a well-healed midline thoracic surgical scar. Scar 2: the examiner noted the location of the scar was curved on the left side of the posterior thorax. There was no skin breakdown over the scar, and the Veteran reported pain. Physical examination revealed the scar to be 0.25 cm by 26 cm. It was superficial and without edema, inflammation, or keloid formation. The diagnosis was a well-healed curved left posterior thoracic scar. Scar 3: the scar was small and linear, on the left posterior close to the axilla. There was no skin breakdown over the scar, and the Veteran reported no pain. Physical examination revealed the scar to be 0.25 cm by 2.5 cm. It was superficial and without edema, inflammation, or keloid formation. The diagnosis was well-healed linear scar, status post-surgical drain removal. Scar 4: this scar was located on the posterior trunk. There was no skin breakdown over the scar, and the Veteran reported no pain. Physical examination revealed the scar to be 0.25 inch by 2 inch. It was superficial and without edema, inflammation, or keloid formation. The diagnosis was well-healed linear scar, status post-surgical drain removal. The Veteran reported the pain and numbness associated with the two large scars that caused problems when he worked as a barber, as he had difficulty with prolonged standing and movement. The examiner, however, noted that there were no disabling effects from either scar, and the scars had no impact on the Veteran's daily activities. The objective findings on clinical examination show the Veteran's spine surgical scar residual most nearly approximated the assigned 10 percent rating, as of the April 2009 examination. 38 C.F.R. § 4.118, DC 7804. A higher rating is not warranted, as fewer than three of the scars were painful or unstable on examination. A rating in excess of 10 percent requires either disfigurement of the head, face, or neck, or a total affected area exceeding 12 square inches. In this case, the Veteran's scars neither affect his head, face, or neck, nor have a total area exceeding 12 square inches. See DC 7801. Consequently, a rating in excess of 10 percent is not warranted. Id. Further, as there is no demonstration of a skin disorder or any limitation of function due to the scarring, a rating in excess of 10 percent is not warranted under any alternative rating code. Another VA skin examination was conducted in June 2013. The examiner noted that the Veteran did not have any scars or disfigurement of the head, face, or neck. There was a scar residual on the trunk, secondary to left inguinal hernia surgery. In light of the fact the inguinal hernia residuals are not service connected, the Board will not discuss them in this decision. On the posterior trunk, the examiner noted a scar at the mid-thoracic spine measuring 22 cm by 3 cm. The scar was a flesh-colored, smooth surfaced, nontender to palpation, superficial post-surgical scar. A second scar at the left posterior-lateral thorax measured 29 cm by 1 cm. The examiner described the scar as a flesh-colored, smooth surfaced, nontender to palpation, superficial post-surgical scar. The examiner did not note any limitation of function due to the scars. The findings at the June 2013 examination do not support a rating in excess of 10 percent. 38 C.F.R. § 4.118, DC 7804 (2007). The Board also notes that an August 2012 examination report notes that the scars were asymptomatic. The Veteran testified at the hearing that his surgical scar was painful. As set forth above, he is in fact compensated at the applicable rate for a painful scar. There is no basis for a higher evaluation under the applicable criteria. As noted earlier, the Veteran is entitled to a staged rating for any part of the rating period where his scar residual manifested at a more severe rate. See Fenderson, 12 Vet. App. 119. The preponderance of the evidence, as discussed above, however, shows the Veteran's scar residual to have manifested at the same rate throughout the entire rating period on appeal, which is 10 percent. 38 C.F.R. § 4.118, DC 7804. Hence, there is no factual basis for a staged rating. In reaching this decision, the Board considered the doctrine of reasonable doubt. As the preponderance of the evidence is against the Veteran's claims, however, the doctrine is not for application. Schoolman v. West, 12 Vet. App. 307, 311 (1999). ORDER Entitlement to service connection for a psychiatric disorder, to include depression, as secondary to left thoracic spine hemangioma, is denied. Entitlement to service connection for right arm pain, numbness, and tingling as secondary to left thoracic spine hemangioma is denied. Entitlement to service connection for left inguinal hernia post-operative residuals with GERD as secondary to left thoracic spine hemangioma is denied. Entitlement to an initial rating higher than 10 percent for thoracic surgical scar residuals is denied. REMAND The June 2013 examination reports were incomplete with respect to the right knee, bilateral hip, and thoracic spine claims. Specifically, the prior opinion fails to address whether the claimed right knee and bilateral hip disorders were aggravated by the service-connected thoracic spine disability. Regarding the increased rating claim, the examiner did not estimate any additional loss of function during periods of flare-up. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. The AMC/RO will return the claims file to the examiner who conducted the June 2013 examination. Ask the examiner to opine whether there is at least a 50-percent probability that the service-connected thoracic spine disability aggravates, that is, chronically worsens, either the right knee disorder or bilateral hip disorder, or both. If so, the examiner is asked to specify the permanent, measurable increase in severity of the right knee or bilateral hip disorder that is due to the service-connected thoracic spine disability. The examiner is asked to provide a full explanation for all opinions rendered. The examiner's attention should also be directed to the February 2007 VA spine examination report. That report notes the Veteran reported that his flare-ups could last up to two hours, with an intensity of 9/10; and, during flares he had additional functional impairment of 60 to 70 percent. The examiner is asked to estimate any additional functional loss in degrees of ROM during the reported flare-ups. If the examiner cannot do so without resort to speculation, please comment on whether, given the objective evidence on clinical examination, the Veteran's report of a 60-70-percent reduction in function would be realistic. In the event that the examiner who conducted the June 2013 examination is no longer available, refer the claims file to an equally qualified examiner. Should the examiner advise the requested opinion cannot be rendered without an examination of the Veteran, the AMC/RO will arrange the examination. The claims file must be provided for review by the examiner as part of the examination. 2. After completion of all of the above, the AMC/RO should re-adjudicate the claims on appeal. If the decision remains in any way adverse to the Veteran, he and his representative should be provided with a Supplemental statement of the case (SSOC). The case should thereafter be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The Veteran need take no action unless otherwise notified. VA will notify him if further action is required on his part. He has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs