Citation Nr: 1331635 Decision Date: 10/01/13 Archive Date: 10/07/13 DOCKET NO. 06-10 847 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for eczema of the hands and feet prior to July 24, 2012. 2. Entitlement to an initial rating in excess of 60 percent from July 24, 2012. 3. Entitlement to a compensable rating for bilateral plantar warts and callosities. 4. Entitlement to an initial rating in excess of 10 percent for tinnitus. 5. Entitlement to an initial compensable rating for bilateral hearing loss. 6. Entitlement to a total disability rating by reason of individual unemployability due to service connected disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. Shawkey, Counsel INTRODUCTION The Veteran served on active duty from September 1960 to June 1964. This matter comes to the Board of Veterans' Appeals (Board) on appeal from rating decisions dated in September 2004, September 2006, and July 2008 of the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California. This case comes to the Board from the RO in Los Angeles, California. The Veteran testified before the undersigned Veterans Law Judge at a hearing held at the RO in March 2012. A transcript of the hearing is of record. This case was previously before the Board in June 2012 at which time the case was remanded for further medical development, namely VA examinations. The examinations were conducted in July and August 2012 and the reports are deemed adequate for rating purposes with respect to the issues being decided herein. Thus, there has been substantial compliance with the Board's June 2012 remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). Consideration has been given to the representative's June 2013 argument that the Board consider affording the Veteran another audiological examination due to a notation by the VA audiological examiner regarding an improper seal in the left ear. More specifically, the examiner reported that left ear contralateral and right ear ipsilateral acoustic reflexes, as well as left reflex decay could not be tested due to difficulty maintaining a hermetic seal. Further, right reflex decay could not be tested at 0.5 kHz due to absent reflex. However, the examiner reported that the audiological test results were valid for rating purposes and use of speech discrimination score was appropriate for the Veteran. The representative has not presented any evidence to the contrary. Thus, the examination report is adequate for rating purposes in terms of assessing his hearing acuity. Barr v. Nicholson, 21 Vet. App. 303 (2007). In February 2013, the Veteran asserted entitlement to an earlier effective date for the 60 percent rating for eczema and was filing a notice of disagreement to the November 2012 rating decision that assigned that rating effective July 24, 2012, as well as a motion for revision of the "Boards decision" based on clear and unmistakable error. The question whether a 60 percent rating is warranted prior to July 24, 2012, is part and parcel of the pending initial increased rating issue discussed below. Thus, it need not be separately addressed. Moreover, the motion for revision of the "Board[']s decision" in regard to this issue is premature since the Board has not previously rendered a decision regarding the rating warranted prior to July 24, 2012. The Veteran included a May 2008 VA outpatient record with his February 2013 request; however, as this record is already on file and was previously considered by the RO , it is not considered additional pertinent evidence under 38 C.F.R. § 20.1304(c) and thus need not be referred to the RO for review in the first instance. The issue of entitlement to a total disability evaluation based on individual unemployability due to service connected disorders is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. For the period prior to July 1, 2007, the Veteran's eczema affected was not manifested by involvement of at least 20 percent of the entire body, or at least 20 percent of exposed areas affected, and there was no use of systemic therapy such as intermittent corticosteroids or other immunospressive drugs required for a total duration of less than six weeks during a 12-month period. 2. For the period from July 1, 2007, the Veteran's eczema affected more than 40 percent of the entire body. 3. For the duration of the appeal, the Veteran's bilateral plantar warts and calluses were not productive of deep or unstable scars, they were not objectively painful on examination, and did not cause limitation of foot function. 4. The Veteran suffers from constant, recurrent bilateral tinnitus for which he is in receipt of a 10 percent evaluation, the maximum evaluation available for that disability. 5. Prior to August 13, 2012, VA audiological findings were no greater than Level I hearing acuity in the right ear and Level V hearing acuity in the left ear. 6. At the August 13, 2012, VA examination, audiological findings were productive of Level II hearing acuity in the right ear and Level X hearing acuity in the left ear. CONCLUSIONS OF LAW 1. The criteria for a rating greater than 10 percent for eczema for the period prior to July 1, 2007, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.118, Diagnostic Code 7806 (2012). 2. The criteria for an increased rating of 60 percent for eczema for the period from July 1, 2007, have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.118, Diagnostic Code 7806. 3. The criteria for a compensable rating for the Veteran's bilateral plantar warts and calluses have not been met at any point during the duration of this appeal. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.118, Diagnostic Codes 7801, 7802, 7803, 7804, 7805, 7819 (as in effect for claims filed prior to October 23, 2008). 4. The law precludes the assignment of a disability rating greater than 10 percent for bilateral tinnitus, including separate compensable evaluations for each ear. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.87, Diagnostic Code 6260 (2012). 5 At no time during the period prior to August 13, 2012, were the criteria for an initial compensable rating for bilateral hearing loss have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.85, 4.86, Diagnostic Code 6100 (2012). 6. The criteria for a compensable rating of 10 percent for the period from August 13, 2012, for bilateral hearing loss have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.85, 4.86, Diagnostic Code 6100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 The requirements of 38 U.S.C.A. §§ 5103 and 5103A have been met. There is no issue as to providing an appropriate application form or completeness of the application. VA notified the Veteran in June 2004, October 2005, May 2006 and February 2007 correspondence of the information and evidence needed to substantiate and complete his claims on appeal, to include notice of what part of that evidence is to be provided by the claimant, what part VA will attempt to obtain, and how VA determines the disability rating and effective date. The claims were most recently readjudicated in a November 2012 supplemental statement of the case. VA has fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate a claim to include pertinent medical records and records from the Social Security Administration. The appellant was provided the opportunity to meaningfully participate in the adjudication of his claim and did in fact participate. See Washington v. Nicholson, 21 Vet. App. 191 (2007). In terms of VA examinations, the Veteran was provided with pertinent VA examinations, to include audiometric examinations. These examination reports contain sufficient findings with which to properly evaluate the appellant's pending claims for increased ratings and are thus deemed adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As far as the audiometric examinations, the examination reports discuss the effect of the hearing loss and tinnitus disorders on occupational functioning and daily activities. See Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007). Also, in March 2012, the Veteran presented hearing testimony in support of his claims. On review, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. 38 C.F.R. § 3.159(c). II. Analysis A. General Rating Provisions Disability ratings are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings shall be applied, the higher rating 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. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). The degree of impairment resulting from a disability is a factual determination and generally the Board's primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994). The United States Court of Appeals for Veterans Claims (Court), however, has 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. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). When all the evidence is assembled, the determination must be made as to whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). B. Eczema and Bilateral Plantar Warts and Callosities Facts Private medical records from Kaiser Permanente in 1997 show treatment and work restrictions due to a back condition and chronic eczema of the hands. In a February 1999 rating decision, the RO granted entitlement to service connection for bilateral plantar warts and callosities and assigned a noncompensable rating, effective in July 1998. Dr. Trinh reported in October 1999 that the Veteran had atopic eczema on his hands. The Veteran was also noted to have eczema on his hands on a January 2000 record from R. Damania, M.D. In December 2003, the Veteran filed a claim for a compensable rating for his skin disability, asserting that his skin disorder had worsened. He enclosed a personnel record (VA Form 50) from the VA healthcare system showing that he was terminated as a housekeeping aid in November 2002 due to medical documentation received after the date of hire in February 1999. On file is an April 2004 medical record from Dr. Trinh showing that the Veteran was restricted from using his hands/fingers from repetitive motion due to chronic eczema in his hands and probable carpal tunnel syndrome. Records from Sunnyside Medical Office show treatment for various ailments from June to November 2004, including eczema of the hands and bilateral carpal tunnel syndrome. An August 2004 VA skin examination did not reveal bilateral plantar warts or callosities. The Veteran was diagnosed as having eczema affecting the hands and feet. There was no evidence of verruca or cutaneous fungal disease. Photographs were taken of the Veteran's bilateral hands and feet at the examination. The Veteran asserted in his October 2004 notice of disagreement that VA had not taken into consideration that his service connected bilateral plantar warts and callosities contributed to his termination from the Fresno VA Medical Center. He also asserted that private medical evidence from Dr. Trinh in April 2004 supported his claim for an increased rating. A March 2005 VA outpatient record shows that it was the Veteran's first visit in over a year. The record notes that he had been seeking treatment with Kaiser, but lost his insurance and was back at VA. His main problems included eczema of the palms and hands. He reported working for the Post Office for 19 years but that he had recently lost his job at VA because of a skin rash. He was noted to have worked at VA for two months as a janitorial worker. He was diagnosed as having chronic eczema. A Social Security Disability Determination and Transmittal form dated in September 2005 shows that the prior determination of August 2004 was revised and the Veteran was being awarded disability benefits effective in April 2004 due to a primary diagnosis of asthma and a secondary diagnosis of degenerative disc disease. In his substantive appeal received in March 2006, the Veteran said that he suffered with pain and limitation due to scarring. At a VA dermatology examination in June 2006, the Veteran reported that he was wrongfully terminated from his employment with VA in November 2002, but was not sure if it had anything to do with his skin disorder. He said his skin disorder had worsened since July 2004. Physical examination revealed no scars or acne. The dorsal surface of each hand was without lesions. The feet revealed no evidence of fungal disease, but intertriginously and interdigitally there was one area of skin breakdown between the fourth and fifth digit. The Veteran was not found to have any plantar warts at that time, and there was no evidence of significant callus formation to warrant any further medical treatment or therapies. The Veteran was diagnosed with eczema of the hands and feet. There was no evidence of verrucae or obvious cutaneous fungal disease. A June 2007 dermatology outpatient record shows that the Veteran reported a one to tow month history of a pruritic rash on his left shin that was not relieved by antifungal creams or Vaseline. Physical examination revealed no pustules or blisters and no prior history. The Veteran was assessed as having psoriasiform/eczematous dermatitis. An October 2007 dermatology outpatient record shows that the Veteran reported a three month history of a pruritic rash on both shins that first began on the left shin and then the right and spread to his belly area and upper extremities. He had no prior history. Physical examination revealed well demarcated, hyperkerotic and mildly scaly plaques on the left anterior shin and two lesions on the right shin. There were lesions on the dorsum of each foot between the first and second digits. A punch biopsy was performed. The assessment was psoriasiform/eczematous dermatitis. At a December 2007 VA outpatient visit the Veteran reported that his rash had increased since his last visit. A later visit that month revealed that the Veteran's skin rash had resolved with the cream provided by dermatology. A February 2008 VA dermatology record shows that traimcinolone cream was being discontinued and the Veteran was being prescribed Taclinex. An April 2008 VA outpatient record shows that the Veteran was being seen for a rash all over his body (neck and extremities). He reported a rash for over two weeks and problems with itching. He complained that his current cream made him drowsy and he was given a new cream. He was also given an antihistamine for the itching. The physician noted that he would try to move up the Veteran's scheduled dermatology appointment. A May 2008 VA dermatology note shows that the Veteran was seen for complaints of a diffusely pruritic rash involving his entire body save for his genitals, palms, and soles. He said he had been using taclinex with some improvement. He was assessed as having psoriasiform /eczematitis. He was given intramuscular celestone and was advised to continue Taclinex. A June 2008 VA dermatology outpatient record noted that since his last visit the Veteran's skin disorder had broken out with a rash over his back and parts of his leg. It now covered over 95 percent of his body. The appellant said he had recently been treated for an ear infection and was told it was due to psoriasiform. The rash was reportedly keeping him up at night. The celestone shot was noted to have "worked completely". Physical examination revealed a diffuse, hyperpigmented non-blanching, scaly rash over the Veteran's entire body except for palms, soles and genitalia. He also had a erythematous rash over the mid back. He was assessed as having psoriasiform/eczematous dermatitis. He was given intramuscular celestone, and advised to continue taking Taclinex until the end of the month. He had also been advised to return to the clinic in three weeks to start Humira. The Veteran returned to the clinic later in June 2008 and was assessed as having extensive psoriasis. He was again given intramuscular celestone at that time and advised to start Humira injections in the clinic. In a June 2008 statement, the Veteran said that as of July 2007 his service-connected skin disability had worsened and presently covered 95 percent of his body. He said that effective in June 2008 he was starting a new in-home treatment of self-injection to control his skin disease. Findings on a November 2009 VA outpatient record show large areas of hyperpigmentation on the torso, arms, legs/post psoriatic flare. A December 2009 VA dermatology consult record shows that the Veteran had a history of biopsy proven psoriasis diagnosed in 2007, with symptoms since 2002. He was noted to have used Humira and Enbrel treatments in the past and admitted at that time to being more pruritc than usual. He was assessed as having wide spread psoriasis sparing his face, hands and feet. He was prescribed clobetasol ointment, calcipotriene cream and hydroxyzine. The Veteran reported at a February 2010 dermatology consult that he was using topical steroids with no resolution. He also reported occasional itching. Findings revealed diffuse hyperpigmented scaly patches and papules on his chest, back, bilateral upper extremities and bilateral lower extremities. A skin biopsy revealed psorasiform dermatitis. Physical findings at a VA outpatient visit in March 2010 revealed hyperpigmented patches with very minimal scale on the back, arms, trunk and lower extremities. It was recommended that the Veteran undergo close monitoring to ensure no clinical progression of the disease. There was no evidence of cutaneous lymphoma at that time. The Veteran was advised to continue topical "DS" oil and calcipotpriol as needed for pruritis. The Veteran testified at a March 2012 Board hearing that he had a recent skin flare up within the prior month and a half, but he did not seek medical treatment every time he had a flare up. He stated that the eczema began on his hands, but spread all over his body. He reported that the eczema got in his ears as well and affects his hearing. He said that since moving to Los Angeles approximately three years ago he had received all of his medical treatment through VA. He also acknowledged that while he was living in Fresno all of his treatment was through VA. In regard to plantar warts, the Veteran testified that he self-treated this disorder rather than seeking VA treatment. He said the over-the-counter medication he takes kills the fungus in four to five days and he has to wear "house shoes" during that time. At a July 2012 VA dermatology examination the Veteran reported that his skin condition was intermittent, but persistent, and that it involved his palms, feet, ears, arms, legs, abdomen, chest and penis. He said he has been prescribed multiple topical medications by VA which he used on a regular basis for maintenance. He said if he did not regularly use the medication, he would experience a flare up. He also said he experienced flare ups approximately two times a month. He reported that he was treated with Humira and Enbrel (immunosuppressants) for five months in 2008 for his skin disorder. He reportedly had also been prescribed oral Prednisone and celstone injections (systemic corticosteroids) in 2006 and Hyydroxysine in 2010. He was noted at that time to be taking topical corticosteroids constantly or near constantly. The Veteran was diagnosed as having dermatitis covering 20 percent to 40 percent of his total body area and 5 percent to less than 20 percent of exposed area; eczema covering 20 percent to 40 percent of total body area and 5 percent to less than 20 percent of exposed area; and psoriasis covering 20 to 40 percent of the total body area and 5 percent to less than 20 percent of exposed area. The examiner explained that dermatitis, eczema, and psoriasis conditions were essentially considered one in the same and there were large areas of hyperpigmented hyperkerototic patches on the Veteran's bilateral lower extremities, hyperpigmented macular patches bilateral thighs, abdomen, bilateral arms and generalized xerosis. The examiner reported that the Veteran's skin condition did not cause scarring or disfigurement of the head, face, or neck. He added that there were no active plantar warts noted on examination. The Veteran also underwent a foot examination in July 2012. The examiner reported reviewing VA medical center records dating back to the 1990s. He diagnosed callosities, relaying that the Veteran reported having foot calluses. The examiner opined that the Veteran's plantar wart and callosities did not functionally impact his level of employability. The examiner went on to state that the appellant's chronic skin disorder, i.e., psoriasis/eczematous dermatitis was expected to remain a chronic disorder and have intermittent bouts of activity which may lead to increased sick days. She also noted that it should not affect his level of function for employment. Pertinent Criteria Under Diagnostic Code 7806 (dermatitis or eczema), a 30 percent rating requires dermatitis or eczema affecting more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A maximum evaluation of 60 percent requires involvement of more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. 38 C.F.R. § 4.118, Diagnostic Code 7806. A disability under Diagnostic Code 7806 may also be rated as disfigurement of the head, face, or neck (Diagnostic Code 7800), or scars (Diagnostic Codes 7801, 7802, 7803, 7804, and 7805) depending on the predominant disability. Id. Disfigurement of the head, face, or neck is assigned a 10 percent evaluation with one characteristic of disfigurement. 38 C.F.R. § 4.118, Diagnostic Code 7800. A 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, or; with two or three characteristics of disfigurement. Id. A 50 percent evaluation is assigned with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features, or; with four or five characteristics of disfigurement. Id. An 80 percent evaluation is assigned with visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes, ears, cheeks, lips), or; with six or more characteristics of disfigurement. Id. The eight characteristics of disfigurement are: a scar, 5 or more inches in length; a scar, at least one-quarter inch wide at widest part; surface contour of a scar that is elevated or depressed on palpation; a scar that is adherent to underlying tissue; hypo-or hyper-pigmented skin in an area exceeding 6 square inches; abnormal skin texture in an area exceeding 6 square inches; underlying soft tissue missing in an area exceeding 6 square inches; and indurated and inflexible skin in an area exceeding 6 square inches. Id. at Note (1). Tissue loss of the auricle and anatomical loss of the eye are rated under Diagnostic Codes 6207, 6061, or 6063 as appropriate. Id. at Note (2). Unretouched color photographs should be considered when evaluating under these criteria. Id. at Note (3). Scars, other than on the head, face, or neck, that are deep or that cause limited motion, are evaluated under Diagnostic Code 7801. 38 C.F.R. § 4.118, 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.). Id. 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. 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). Since the Veteran's applications were received prior to October 23, 2008, and he has not requested review under the clarified criteria, the Board finds that the revisions to the skin regulations that took effect October 23, 2008 are not for application here. Discussion 1. Rating Greater Than 10 Percent for Eczema Prior to July 24, 2012 The Veteran is presently rated 10 percent for eczema under Diagnostic Code 7806 for the period prior to July 24, 2012. As noted, a higher evaluation of 30 percent requires dermatitis or eczema affecting more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A maximum evaluation of 60 percent requires involvement of more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period It is evident from the facts outlined above that the Veteran's service-connected eczema worsened at some point prior to July 24, 2012. This is evident by the Veteran's own report on a June 2008 statement that as of July 2007 his service-connected skin disability has worsened. In support of this statement is an October 2007 VA dermatology record showing that the Veteran had a pruritc rash on both shins for three months (dating back to July 2007) that spread to his belly area and upper extremities. Records prior to this date only document eczema on the hands and feet. Thus, while is it clear from the above that the Veteran's skin disability worsened as of July 2007, it is not clear at what point the condition met the criteria for a higher than 10 percent rating under Diagnostic Code 7806. In terms of the percent of skin disability covered, records prior to this date do not specify the percent of body that the skin disability covered. However, as the October 2007 outpatient record shows, in addition to affecting his hands and feet, the rash had spread to the Veteran's shins, abdomen and upper extremities. Accordingly, it is reasonable to assess this as affecting more than 40 percent of the entire body. There is also an April 2008 VA outpatient record showing that the Veteran was being seen for a rash all over his body (neck and extremities). In addition, a May 2008 VA dermatology note describes a diffusely pruritic rash over the Veteran's entire body save for his genitals, palms, and soles. Shortly thereafter, in June 2008, the Veteran was seen in an outpatient clinic where his skin disability was assessed as covering 95 percent of the entire body. There is also a December 2009 VA dermatology consult record assessing him as having wide spread psoriasis sparing his face, hands and feet. Based on the foregoing evidence and resolving all reasonable doubt in the Veteran's favor, the Board finds that he met the criteria for a 60 percent rating under Code 7806 for eczema effective the approximate date that it worsened, July 1, 2007. 38 C.F.R. §§ 4.3, 4.7, 4.118, Code 7806. That is, that as of July 1, 2007, his service-connected eczema covered more than 40 percent of the entire body. With respect to consideration of a higher than 10 percent rating prior to July 1, 2007, as noted, the evidence shows that the Veteran's eczema affected only his hands and feet. Thus, it did not cover 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected. Moreover, there is no evidence that he was taking systemic therapy for a total duration of six weeks or more during the past 12-month period, for the period prior to July 1, 2007. 38 C.F.R. § 4.118, Code 7806. The Board has also considered the potential applicability of other provisions of the code. Prior to July 1, 2007, the Board finds that separate or higher evaluations are not warranted under the rating schedule based on scars. See 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805. In this regard, although the Veteran reported in his March 2006 substantive appeal that he suffered with painful scarring, there are no scar findings on any of the available, pertinent medical records. Moreover, the VA dermatology examiner in June 2006 specifically found that that Veteran had no scars or acne. The July 2012 VA examiner similarly found that the Veteran's skin condition did not cause scarring or disfigurement of the head, face or neck. Accordingly, the Board finds that the weight of evidence supports the criteria for a 60 percent rating for eczema from July 1, 2007, but does not support a higher than 10 percent rating prior to July l, 2007. 2. Rating Greater than 60 Percent for Eczema from July 1, 2007 As held above, the Veteran is entitled to a 60 percent evaluation for eczema under 38 C.F.R. § 4.118, Diagnostic Code 7806 effective July 1, 2007. From that date, however, the Board finds that an evaluation in excess of 60 percent is not available under this code. This is so since a 60 percent evaluation is the maximum rating available under Code 7806. Accordingly, the Board considered the potential applicability of other provisions of the code. From July 1, 2007, the Board finds that separate or higher evaluations are not warranted under the rating schedule based on scars. See 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805. As noted above, although the Veteran reported on his March 2006 substantive appeal that he suffered from painful scars, this is not borne out by the medical evidence. Rather, there are no scar findings on any of the available, pertinent medical records. Moreover, the VA dermatology examiner in June 2006 specifically found that that Veteran had no scars or acne. Similarly, the July 2012 VA examiner found that the Veteran's skin condition did not cause scarring or disfigurement of the head, face or neck. The Board assigns more weight to the documented medical findings showing no scars than to the Veteran's unsupported assertions of painful scars. Accordingly, the Board finds that from July 21, 2012, an evaluation in excess of 60 percent is not warranted for the Veteran's service-connected dermatitis. 3. Compensable Rating for Bilateral Plantar Warts and Callosities The Veteran is currently assigned a noncompensable rating for bilateral plantar warts and calluses. See 38 C.F.R. § 4.118, Diagnostic Code 7819 (prior to October 2008). Benign skin neoplasms are rated as disfigurement of the head, face, or neck (Diagnostic Code 7800), scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), or other impairment of function. Id. The Veteran's callosities are located on his feet, thus a rating is not warranted under Diagnostic Code 7800 for scars of the head, face, or neck. The weight of probative evidence does not show scarring or a condition analogous to scarring, to include findings characterized as scars that are deep or cause limited motion, superficial scars that do not cause limited motion, or superficial unstable scars to warrant a compensable rating under Diagnostic Codes 7801, 7802, or 7803 (prior to October 2008). In fact, as the facts outlined above show, there is scant evidence of this disability in the evidence to date despite numerous dermatology records on file. In this regard, the June 2006 VA examiner stated that the Veteran clearly did not have any plantar warts at that time and there was no evidence of significant callus formation to warrant any further medical treatment or therapies. Similarly, the July 2012 VA examiner reported that there were no active plantar warts noted on examination. In terms of scarring, the VA dermatology examiner in June 2006 specifically found that that Veteran had no scars or acne. The absence of any medical treatment records for plantar warts and calluses is consistent with his March 2012 hearing testimony wherein he reported that he self-treats this condition rather than seeks VA treatment. He reported that the over-the-counter medication he buys kills the fungus in four to five days, and has to wear "house shoes" during that time. Despite having to wear house shoes, there is no evidence of limitation of foot function. 38 C.F.R. § 4.118, Code 7805 (prior to October 2008). In fact, the VA examiner in July 2012 specifically reported that the Veteran's plantar warts and callosities do not functionally impact his level of employability. Diagnostic Code 7804 (prior to October 2008), has also been considered which allows for a compensable rating for bilateral plantar warts and/or callosities based on objective findings of pain on examination. In this regard, the Board does not dispute the Veteran's March 2012 hearing testimony that his plantar warts are painful to the touch prior to using medication. The rating criteria, however, requires objective findings of pain on examination. There are no objective findings of pain on examination in the medical records. Accordingly, the criteria for a compensable rating under Code 7804 have not been met. 38 C.F.R. § 4.118. Again, the Veteran's contentions regarding the severity of his service-connected disability were considered by the Board. The appellant is competent to report such symptoms because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470. However, the Veteran is not competent to identify the current severity of his bilateral plantar warts and callosities according to the appropriate diagnostic codes. In this case, such competent evidence concerning the nature and extent of his service-connected disability has been provided in the medical evidence of record. As such, the Board finds these records to be the most probative evidence in regard to whether a compensable rating is warranted. C. Tinnitus The Veteran testified at a Board hearing in March 2012 that his tinnitus comes and goes and at times is low. He also said that there is always ringing in his ears. Tinnitus is rated under 38 C.F.R. § 4.87, Diagnostic Code 6260. That Code provides a 10 percent disability rating for recurrent tinnitus. That is the sole and highest disability rating provided for tinnitus under VA schedular regulations and the Veteran is already assigned a 10 percent rating. As there is no other diagnostic code that addresses tinnitus symptoms, the Board finds that Diagnostic Code 6260 is the most appropriate diagnostic code. The Veteran has not contended that another diagnostic code is more appropriate. In sum, the Veteran's tinnitus is assigned the maximum schedular rating available for tinnitus. 38 C.F.R. § 4.87, Diagnostic Code 6260. There is As there is no legal basis upon which to award separate schedular ratings for tinnitus in each ear, or to award any higher rating, the Veteran's appeal must be denied. Sabonis v. Brown, 6 Vet. App. 426 (1994). D. Bilateral Hearing Loss Facts In October 2006, the Veteran filed a claim for service connection for bilateral hearing loss. On the authorized audiological evaluation in July 2007, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 20 25 30 40 LEFT 10 15 50 50 50 Speech audiometry revealed speech recognition ability of 92 percent in the right ear and 84 percent in the left ear. The Veteran reported that he experienced a fullness/plugged sensation in his ears and his hearing condition caused difficulty in class, on the telephone, watching television, at church, when someone whispers and riding in a car. He was assessed as having mild to moderate sensorineural hearing loss in each ear. In September 2007, the Veteran granted service connection for bilateral hearing loss and assigned a noncompensable rating, effective in October 2006. The RO continued this rating in a July 2008 rating decision. A March 2008 audiology consult visit record shows that the Veteran had significant cerumen impaction. It also shows that he was referred to the Ear, Nose and Throat clinic for cerumen removal and would thereafter undergo audiological testing. He was assessed at this time as having impacted cerumen and hearing decrease. An April 2008 record shows that the Veteran had very narrow ear canals and attempts to remove all of the cerumen were unsuccessful. A VA audiology consult record in February 2010 contains an assessment of mild to moderate sensorineural hearing loss from 1500-8K hertz in the right ear and from 2-8K hertz in the left ear. The actual decibel levels are not included. This record also notes that the Veteran was eligible for hearing aids which he was interested in pursuing. On the authorized audiological evaluation in March 2010, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 10 25 45 45 LEFT 15 15 50 50 65 Speech audiometry revealed speech recognition ability of 96 percent in the right ear and of 60 percent in the left ear. The reported effect on the Veteran's usual occupation and daily activity was difficulty hearing and stress from ringing in both ears. The Veteran testified at a Board hearing in March 2012 that since his last examination he had been given hearing aids. He also said that his service-connected eczema gets in his ears and affects his hearing. On the authorized audiological evaluation in August 2012, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 10 30 55 55 LEFT 10 10 55 55 50 Speech audiometry revealed speech recognition ability of 82 percent in the right ear and 16 percent in the left ear. The Veteran reported that his hearing loss affects his occupational functioning and daily activities because he has difficulty communicating with his daughter who tells him he can't hear her. He also said he turns the television volume up. Pertinent Law and Discussion The severity of a hearing loss disability is determined by applying the criteria set forth at 38 C.F.R. § 4.885 (2012). Under these criteria, evaluations of bilateral hearing loss range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests together with the average hearing threshold level as measured by pure tone audiometry tests in the frequencies 1,000, 2,000, 3,000, and 4,000 cycles per second. See 38 C.F.R. § 4.85 (2012). To evaluate the degree of disability from defective hearing, the rating schedule establishes eleven auditory acuity levels from level I for essentially normal acuity through level XI for profound deafness. 38 C.F.R. § 4.85 (2012). To evaluate an individual's level of disability, Table VI is used to assign a Roman numeral designation for hearing impairment based on a combination of the percent of speech discrimination and the pure tone threshold average. 38 C.F.R. § 4.85(b) (2012). Table VII is used to determine the percentage evaluation by combining the Roman numeral designations for hearing impairment for each ear. 38 C.F.R. § 4.85(e) (2012). If the puretone threshold in each of the specified frequencies of 1000, 2000, 3000, and 4000 Hertz is 55 decibels or more, an evaluation can be based either on Table VI or Table VIa, whichever results in a higher evaluation. 38 C.F.R. § 4.86(a) (2012). When the puretone threshold is 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz, the Roman numeral designation for hearing impairment will be chosen from either Table VI or Table VIa, whichever results in the higher numeral, and that numeral will then be elevated to the next higher Roman numeral. 38 C.F.R. § 4.86(b) (2012). The assignment of a disability rating for hearing loss is a "mechanical" process of comparing the audiometric evaluation to the numeric designations in the rating schedule. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1993). VA audiology examination findings in July 2007 revealed that the average pure tone threshold at 1,000, 2,000, 3,000, and 4,000 Hertz was 29 decibels in the right ear and 41 decibels in the left ear. Speech recognition ability was 92 percent in the right ear and 84 percent in the left ear. Under Table VI, the audiological findings correspond to a level I hearing in the right ear and level II hearing in the left ear. 38 C.F.R. § 4.85, Table VI (2012). Under Table VII, these levels yield a 0 percent evaluation. 38 C.F.R. § 4.85, Table VII. VA audiology examination findings in March 2010 revealed that the average pure tone threshold at 1,000, 2,000, 3,000, and 4,000 Hertz was 31 decibels in the right ear and 11 decibels in the left ear. Speech recognition ability was 96 percent in the right ear and 60 percent in the left ear. Under Table VI, the audiological findings correspond to a level I hearing in the right ear and level V hearing in the left ear. 38 C.F.R. § 4.85, Table VI (2012). Under Table VII, these levels yield a 0 percent evaluation. 38 C.F.R. § 4.85, Table VII. Consideration has been given to section 4.86 for exceptional patterns of hearing impairment, but this section is not applicable to the July 2010 or March 2010 examination findings. Pure tone threshold levels were neither 55 decibels or higher at each of the four frequencies, i.e., at 1000, 2000, 3000 and 4000 hertz, nor were they 30 decibels or less at 1,000 hertz and 70 dB or more at 2000 hertz. See 38 C.F.R. § 4.86(a) & (b). VA audiology examination findings in August 2012 revealed that the average pure tone threshold at 1,000, 2,000, 3,000, and 4,000 Hertz was 38 decibels in the right ear and 43 decibels in the left ear. Speech recognition ability was 82 percent in the right ear and 16 percent in the left ear. Under Table VI, the audiological findings correspond to a level II hearing in the right ear and level X hearing in the left ear. 38 C.F.R. § 4.85, Table VI (2012). Under Table VII, these levels yield a 10 percent evaluation. 38 C.F.R. § 4.85, Table VII. Consideration has been given to section 4.86 for exceptional patterns of hearing impairment, but this section is not applicable to the August 2012 VA examination findings. Pure tone threshold levels were neither 55 decibels or higher at each of the four frequencies, i.e., at 1000, 2000, 3000 and 4000 hertz, nor were they 30 decibels or less at 1,000 hertz and 70 dB or more at 2000 hertz. See 38 C.F.R. § 4.86(a) & (b). Based on the foregoing, the evidence clearly shows that the criteria for a compensable rating for the Veteran's bilateral hearing loss disability for the period prior to August 13, 2012, have not been met and that the criteria for a compensable, 10 percent rating, as of the August 13, 2012, VA examination have been met. Interestingly, in continuing the denial of a compensable rating for this disability at any point in the appeal period, the RO, in the November 2012 supplemental statement of the case, appears to have relied on a nexus opinion that the August 2012 VA examiner rendered. However, as the Veteran has already been granted service connection for bilateral hearing loss (see October 2006 rating decision), the issue of service connection is not presently on appeal; rather, the issue perfected for appellate review is the level of impairment of such disability. E. Extraschedular Consideration An extraschedular disability rating is warranted upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2012). An exceptional case includes factors such as marked interference with employment or frequent periods of hospitalization that render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). The Court held in Thun v. Peake, 22 Vet. App, 111 (2008), that the Board must apply a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the level of disability and symptomatology and is found to be inadequate, the Board must then determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto 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 to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. In this case, the Board has been unable to identify an exceptional or unusual disability picture with respect to the Veteran's service-connected skin, bilateral hearing loss or tinnitus disabilities. The record shows that the Veteran is not presently working and has not worked in several years. His complaints of skin symptoms, hearing difficulty and ringing in his ears have been contemplated in the rating schedule. The evidence fails to demonstrate that the symptomatology of these disabilities are of such an extent that application of the ratings schedule would not be appropriate. Since the available schedular evaluation adequately contemplates the Veteran's level of disability and symptomatology, the second and third questions posed by Thun become moot. ORDER Entitlement to a rating in excess of 10 percent for eczema prior to July 1, 2007, is denied. Entitlement to a 60 percent rating for eczema is granted from July 01, 2007, subject to the laws and regulations governing the award of monetary benefits. Entitlement to an initial rating in excess of 10 percent for tinnitus is denied for the duration of the appeal. Entitlement to a compensable rating for bilateral plantar warts and callosities is denied for the duration of the appeal. Entitlement to a compensable rating for bilateral hearing loss is denied prior to August 13, 2012. Entitlement to a 10 percent, rating for bilateral hearing loss is granted from August 13, 2012, subject to the laws and regulations governing the award of monetary benefits. REMAND Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16(a). To qualify for a total rating for compensation purposes, the evidence must show (1) a single disability rated as 100 percent disabling; or (2) that the Veteran is unable to secure or follow a substantially gainful occupation as a result of his service- connected disabilities and there is one disability ratable at 60 percent or more, or, if more than one disability, at least one disability ratable at 40 percent or more and a combined disability rating of at least 70 percent. 38 C.F.R. § 4.16(a). Even if the Veteran does not satisfy these threshold minimum rating requirements of § 4.16(a), it is also possible to receive individual unemployability benefits on an extra-schedular basis under 38 C.F.R. § 4.16(b) if it is determined he is indeed incapable of securing and maintaining substantially gainful employment on account of his service-connected disabilities. Prior to this decision, the Veteran was service connected for eczema of the hands and feet, rated 60 percent disabling; bilateral tinnitus, rated 10 percent disabling; bilateral plantar warts and calluses, rated as noncompensable; and bilateral hearing loss, rated as noncompensable. His combined rating was 60 percent. By way of this decision, the Board has granted an increased rating of 10 percent for the Veteran's bilateral hearing loss. He asserts that he is unable to work due to a combination of his service-connected disabilities, to include eczema. More specifically, he reported on statement dated in October 2007 that he was terminated from his job in housekeeping because of his inability to complete his job duties due to his service-connected skin irritation. He said while working at a VA hospital, his skin condition worsened due to the chemical agents and cleaning solvents he was exposed to. Records on file from the Social Security Administration include a September 2005 decision awarding the Veteran disability benefits as of November 2002 and note that his primary conditions were asthma, eczema and back problems. Further medical development is warranted that addresses the Veteran's ability to secure and follow substantially gainful employment based on all of his service-connected disabilities combined. In this regard, the Board points out that in terms of determining his entitlement to a total disability evaluation based on individual unemployability due to service connected disorders, the Veteran's nonservice-connected disabilities are not considered. Accordingly, the case is REMANDED for the following action: 1. The RO should schedule the appellant for a VA social and industrial survey or, in the alternative, afford the Veteran a new VA examination. The examiner should be provided access to the Veteran claims folder, to include Virtual VA for review. The examiner is to opine whether it is at least as likely as not that the Veteran's service-connected disabilities alone combine to prevent him from securing and following substantially gainful employment. The nature and severity of the service-connected disabilities should be noted and discussed. The examiner should explain the basis for any opinion reached. 2. After undertaking any other development deemed appropriate, consideration should again be given to the claim for a total disability evaluation based on individual unemployability due to service connected disorders based on all of the Veteran's service-connected disabilities. If the benefit sought is not granted, the Veteran and his representative should be furnished a supplemental statement of the case and be afforded an opportunity to respond before the claims file is returned to the Board for further appellate review. The appellant and his representative have 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). ______________________________________________ DEREK R. BROWN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs