Citation Nr: 1333414 Decision Date: 10/24/13 Archive Date: 10/24/13 DOCKET NO. 10-08 575 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for a back disability. 2. Entitlement to service connection for hemorrhoids, claimed as secondary to herbicide exposure. 3. Entitlement to service connection for a rash in the groin area, claimed as secondary to herbicide exposure. 4. Entitlement to a compensable rating for shell fragment wounds of the right arm and index finger. 5. Entitlement to a compensable rating for shell fragment wound scars of the legs. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Andrew Mack, Counsel INTRODUCTION The Veteran served on active duty from August 1966 to April 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to ensure a total review of the evidence. FINDINGS OF FACT 1. The Veteran's back disability, current groin rash, and hemorrhoids did not begin in service or until many years after service, and are not related to in-service herbicide exposure or to service in any other way. 2. During the period pertinent to the Veteran's August 2005 claim for increase, his service-connected scars have consistently been superficial, stable, not painful, less than 929 square centimeters in area, and productive of no disabling effects or functional impairment at this time. CONCLUSIONS OF LAW 1. The criteria for service connection for a back disability have not been met. 38 U.S.C.A. §§ 1110, 1154(b), 5107 (West 2002) 3.303, 3.307, 3.309 (2013). 2. The criteria for service connection for hemorrhoids, claimed as secondary to herbicide exposure, have not been met. 38 U.S.C.A. §§ 1110, 1154(b), 5107 (West 2002) 3.303, 3.307, 3.309 (2013). 3. The criteria for service connection for a rash in the groin area, claimed as secondary to herbicide exposure, have not been met. 38 U.S.C.A. §§ 1110, 1154(b), 5107 (West 2002) 3.303, 3.307, 3.309 (2013). 4. The criteria for a compensable rating for shell fragment wounds of the right arm and index finger have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.31, 4.118, Diagnostic Codes 7801-7805 (2008, 2013); 73 Fed. Reg. 54,708 (Sept. 23, 2008). 5. The criteria for a compensable rating for shell fragment wound scars of the legs have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.31, 4.118, Diagnostic Codes 7801-7805 (2008, 2013); 73 Fed. Reg. 54,708 (Sept. 23, 2008). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, for certain chronic diseases, such as arthritis, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within one year of discharge from service. 38 C.F.R. §§ 3.307, 3.309(a). When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support a claim for such diseases. 38 C.F.R. §§ 3.303(b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Absent affirmative evidence to the contrary, there is a presumption of exposure to herbicides (to include Agent Orange) for all veterans who served in the Republic of Vietnam during the Vietnam Era (the period beginning on January 9, 1962, and ending on May 7, 1975). 38 U.S.C.A. § 1116(f) and 38 C.F.R. § 3.307(a)(6)(iii). If a veteran was exposed to a herbicide agent (to include Agent Orange) during active service, the following diseases shall be service-connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even though there is no record of such disease during service, provided that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied: AL amyloidosis, chloracne or other acneform diseases consistent with chloracne, type II diabetes, Hodgkin's disease, ischemic heart disease, all chronic B-cell leukemias, multiple myeloma, non-Hodgkin's lymphoma, Parkinson's disease, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea) and soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e). The Secretary of Veterans Affairs has determined that there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. VA has issued several notices in which it was determined that a presumption of service connection based upon exposure to herbicides used in Vietnam should not be extended beyond specific disorders, based upon extensive scientific research. See, e.g., 68 Fed. Reg. 27630-27641 (May 20, 2003); 67 Fed. Reg. 42600 (June 24, 2002); 66 Fed. Reg. 2376 (Jan. 11, 2001); 64 Fed. Reg. 59232 (Nov. 2, 1999). Notwithstanding the presumption, service connection for a disability claimed as due to exposure to Agent Orange may be established by showing that a disorder resulting in disability or death was in fact causally linked to such exposure. See Brock v. Brown, 10 Vet. App. 155, 162-64 (1997); Combee v. Brown, 34 F.3d 1039, 1044 (Fed. Cir. 1994), citing 38 U.S.C.A. § 1113(b) and 1116 and 38 C.F.R. § 3.303. With disability compensation claims, VA adjudicators are directed to assess both medical and lay evidence. As a general matter, a layperson is not capable of opining on matters requiring medical knowledge. See 38 C.F.R. § 3.159(a)(2); see also Routen v. Brown, 10 Vet. App. 183, 186 (1997). In certain circumstances, however, lay evidence may be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In addressing lay evidence and determining its probative value, if any, attention is directed to both competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In terms of competency, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (flatfoot). That notwithstanding, a Veteran is not competent to provide evidence as to more complex medical questions and, specifically, is not competent to provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); see also Routen, 10 Vet. App. 183. In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See generally Caluza v. Brown, 7 Vet. App. 498 (1995). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006); but see Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (evidence of a prolonged period without medical complaint after service can be considered along with other factors in the analysis of a service connection claim). In the case of any veteran who engaged in combat with the enemy in active service with a military, naval, or air organization of the United States during a period of war, campaign, or expedition, the Secretary shall accept as sufficient proof of service-connection of any disease or injury alleged to have been incurred in or aggravated by such service satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease, if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the fact that there is no official record of such incurrence or aggravation in such service, and, to that end, shall resolve every reasonable doubt in favor of the veteran. Service-connection of such injury or disease may be rebutted by clear and convincing evidence to the contrary. 38 U.S.C.A. § 1154(b). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. In this case, as reflected in an October 2006 statement, his August 2007 notice of disagreement, and his January 2010 substantive appeal, the Veteran asserts that he currently has hemorrhoids, a groin rash, and a back disability as a result of in-service exposure to herbicide agents, including Agent Orange. He asserts that his groin rash is a form a chloracne, and therefore should be presumed to be related to such in-service exposure, and during a May 2007 VA examination asserted that he developed a groin rash in Vietnam that had continued to the present. Also, during VA treatment in July 2007, the Veteran reported chronic low back pain for 30 years, during May 2007 VA treatment he reported a 40-year history of back pain, and on VA examination in May 2007 he reported that he "probably hurt his back but never reported it" during service, but, during the same examination, stated, "I don't remember hurting my back." In this regard, it is important for the Veteran to understand that the fact that the Veteran cannot recall hurting his back in service provides only factual evidence against this own claim. VA medical records beginning in May 2007 reflect diagnoses of hemorrhoids, tinea cruris, and chronic low back pain with degenerative changes. However, considering the pertinent evidence in light of the governing legal authority, the Veteran's service connection claims must be denied. The record does not reflect, and the Veteran has not contended, that hemorrhoids began in service. Service treatment records do not reflect any findings or complaints related to hemorrhoids, and the Veteran's April 1969 report of examination for separation from service reflects no findings related to hemorrhoids; at that time, he was noted to have had a normal clinical evaluation of the anus and rectum, with no hemorrhoids indicated, providing evidence against these claims. Also, while the Veteran contended during VA treatment in 2007 that he has had back pain for 30 or 40 years, and during a May 2007 VA examination asserted that he developed a groin rash in Vietnam that had continued to the present, such contentions are not supported by the record. The Board notes that the Veteran's service records indicate that he served in combat while in Vietnam from March 1967 to November 1967, and therefore any assertion of back injury or groin rash incurred in such service would be presumed credible notwithstanding the fact that there is no official record of such incurrence in such service. See 38 U.S.C.A. § 1154(b). However, in this case, while the Veteran asserted on VA examination in May 2007 that he "probably hurt his back but never reported it" during service, during the same examination he stated, "I don't remember hurting my back." In this regard, the Veteran has not reported that he incurred a back injury while serving in combat. A May 1968 service treatment record reflects that the Veteran complained of pain in the back for approximately four days, which had started in just the spinal area but had spread to his shoulders. At that time, the Veteran reported no back injury or prior back injury, and service treatment records reflect no follow-up treatment or further treatment for any complaints related to the back. Also, while service treatment records reflect treatment for a rash in the pubic area in February 1968, such rash was diagnosed as venereal warts; there is no diagnosis or findings related to tinea cruris, the Veteran's currently diagnosed groin rash. Further, the Veteran's April 1969 report of examination for separation from service reflects normal evaluation of the skin, spine, and musculoskeletal system, and no groin rash or back problems were noted at the time, providing evidence against the claim that the current problem is this problem. Furthermore, in April 1969, the month of his separation from service, the Veteran filed service connection claims for three different instances of shrapnel wounds, and for gonorrhea. He did not assert service connection for any groin rash or back problem. Clearly, if the Veteran were having such problems, it would appear likely that the Veteran would have filed claims in 1969 along with his other claims. Such facts only provide more evidence against this claim. At the time of an August 1969 VA examination in connection with that claim, he was noted to have had a normal examination of the skin and musculoskeletal system, and no complaints related to groin rash or the back were noted; even on special genitourinary examination in connection with his claim for gonorrhea, no complaints or findings related to groin rash were noted. It is important for the Veteran to understand that this examination, at this time, provides particularly negative evidence against the Veteran's claim. The Board finds that this claim and examination reports are highly probative evidence that the Veteran did not have a groin rash or back pain that began in service and continued after. The Veteran himself has provided more factual evidence against this claim. The earliest complaint or treatment related to the back noted in the record is a June 1993 record indicating that the Veteran complained of chronic pain of the low back, and that X-ray studies showed no osseous or articular abnormality, which was noted by the May 2007 VA examiner. In this regard, the May 2007 VA examiner noted X-rays of the Veteran's lumbar spine taken in April 2007, and stated that they showed "age-related changes, minimal degenerative changes." The earliest indication in the record of the Veteran's currently diagnosed tinea cruris is May 2007. To the extent that the Veteran actually asserts that his back pain dates back to his period of service, the Board finds that such assertion is not accurate. In addition to the above, the Veteran's statements regarding his history of back pain have been vague and inconsistent. In May 2007, he reported a 40-year history of back pain, and in July 2007 he reported a 30-year history. Also, on VA examination in May 2007, he reported that he "probably hurt his back but never reported it" during service, but during the same examination stated, "I don't remember hurting my back." Such statements call into question credibility of the Veteran's recollection and provide probative evidence against his claim. The Board therefore finds that the weight of the evidence demonstrates that the Veteran's back problems, current groin rash, and hemorrhoids did not begin in service or until many years after service. Thus, the provisions for presumptive service connection for chronic disabilities of 38 C.F.R. §§ 3.307 and 3.309(a) are not applicable in this case. Moreover, there is no competent and probative medical or lay evidence that supports the Veteran's contentions that his groin rash is chloracne and that his disabilities are the result of in-service herbicide exposure, or that otherwise supports his service connection claims in any way, and the Veteran has not identified any. While the record reflects that he served in the Republic of Vietnam during the Vietnam War, and is therefore presumed to have been exposed to herbicides including Agent Orange, none of his claimed disabilities are listed under 38 C.F.R. § 3.309(e) as a disease presumed to be the result of in-service herbicide exposure. Thus, none of his disabilities is presumed to be the result of such exposure. While the Veteran has asserted that his groin rash is chloracne, and therefore warrants presumptive service connection, the May 2007 VA examiner specifically diagnosed tinea cruris, and specifically stated that there was no history or evidence of acne or chloracne. There is no competent and probative medical evidence of record establishing the existence of chloracne, or indicating that the Veteran's current hemorrhoids, tinea cruris, or back problems are in any way related to in-service herbicide exposure or to service in any other way, and neither the Veteran nor his representative have identified any such evidence. The Board notes that lay evidence may be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr, 21 Vet. App. at 308-09 (concerning varicose veins). Also, a lay person may speak as to etiology in some limited circumstances in which nexus is obvious merely through lay observation. Jandreau, 492 F.3d 1372. However, while the Veteran might believe that his current disabilities are medically related to in-service herbicide exposure, or to service in any other way, such a determination of causation in this case extends beyond an immediately observable cause-and-effect relationship, where there is no credible assertions of continuing symptoms from time of service. Whether the Veteran has chloracne and whether any of his disabilities are related to herbicide exposure during service approximately 40 years prior are determinations medical in nature, which the Veteran is not competent to make. Accordingly, the claims for service connection for a back disability, hemorrhoids, and a rash in the groin area, including as secondary to herbicide exposure, must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claims, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 53-56. Increased Ratings Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in a veteran's condition. Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. See 38 C.F.R. § 4.1. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Nevertheless, where the veteran is appealing the rating for an already established service-connected condition, his present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board notes 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 Veteran's shell fragment wounds of the right arm and index finger and shell fragment wound scars of the legs are rated under Diagnostic Code (DC) 7805. Scars not of the head, face, or neck are rated under 38 C.F.R. § 4.118, DCs 7801 to 7805. During the pendency of the Veteran's appeal, the criteria for rating the skin was amended, effective October 23, 2008. See 73 Fed. Reg. 54,708 (Sept. 23, 2008) (codified at 38 C.F.R. § 4.118, Diagnostic Codes 7800 to 7805). Where the rating criteria are amended during the course of an appeal for an increased evaluation, the Board considers both the former and current schedular criteria because, should an increased rating be warranted under the revised criteria, that award may not be made effective before the effective date of the change. See 38 U.S.C.A. § 5110(g); 38 C.F.R. § 3.114; VAOPGCPREC 7-2003 (Nov. 19, 2003); VAOPGCPREC 3-2000 (Apr. 10, 2000). However, because the amended regulations with respect to scars are only applicable to claims received on or after October 23, 2008, the Veteran's claim for increased rating was received in August 2005, and the Veteran has not requested review under the amended criteria, the regulations as amended are not applicable. See 73 Fed. Reg. 54,708 (Sept. 23, 2008). Under the applicable criteria, scars that are deep or that cause limited motion are rated 10 percent disabling for area(s) exceeding 6 square inches (39 sq. cm.), and 20 percent for area(s) exceeding 12 square inches (77 sq. cm.) under DC 7801. Scars that are superficial, do not cause limited motion, and cover area or areas of 144 inches (929 sq. cm.) or greater are given a 10 percent rating under DC 7802. Unstable superficial scars are rated 10 percent disabling under DC 7803. An unstable scar is one where, for any reason, there is frequent loss of covering of the skin over the scar. Superficial scars that are painful on examination are rated 10 percent disabling under DC 7804. DC 7805 provides that other scars are rated on limitation of function of the affected part. A deep scar is one associated with underlying soft tissue damage, and a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DCs 7801-7805 (2008). Ratings for widely separated areas, as on two or more extremities or anterior and posterior surfaces of extremities or trunk, are separately rated. 38 C.F.R. § 4.118, DCs 7801, 7802 (2008). Where the schedular criteria does not provide for a noncompensable evaluation, such an evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. The report of a May 2007 VA examination of the Veteran's shell fragment wound scars of the legs reflects that there were no current symptoms of the scars. On physical examination, the location of the scars was in the middle third of the anterior aspect of the left leg, with four scars separated by an inch-and-a-half of normal tissue, and two more small scars located in the lateral aspect of the left ankle. The scars of the middle third of the anterior aspect of the left leg were 1.5 by 1 centimeters (cm) in size, and the scars located in the lateral aspect of the left ankle were 1 by 1 cm and asymptomatic. There was no pain in the scars on examination, and no adherence to underlying tissue. The skin was not irregular, atrophic, shiny, or scaly, and the scars were superficial and not unstable or deep. There was no inflammation, edema, or keloid formation, and the color of the scar was slightly whiter than the surrounding skin. There was no area of induration or inflexibility in the skin in the area of the scars, and no limitation of motion or function due to the scars. The examining physician diagnosed scars secondary to shrapnel wounds of the left leg, asymptomatic, with no scars found on the right leg. The report of a May 2007 VA examination of the Veteran's shell fragment wounds of the right arm and index finger reflects that the Veteran reported that he did not have any symptoms of his right index finger, but had issues with his right middle finger, as in service he incurred a fragment wound to the middle finger, ulna side distribution with decreased sensation. The Veteran stated that there was no specific treatment because there was no pain, providing evidence against his own claim. He reported sensation and feeling changes, and that he had had these problems since service. Physical examination reveled that direct pressure over the Veteran's right arm scar was not painful, there was no adherence of underlying tissue, and the texture of the skin was soft, moisturized, and slightly shiny scar. The scar was stable, superficial, and not deep. There was no inflammation, edema, or keloid formation, and no impact on range of motion. The scar involved the right lateral soft tissues of the arm and was 1 cm. Examination of the right middle finger revealed no significant scars identifiable as a source of discomfort based on direct digital palpation to the area. The examiner diagnosed normal right hand index finger and subjective sensation loss of the right middle finger without objective abnormality. The Veteran was afforded another examination of his scars in July 2010. At that time, he reported a scar of the right upper forearm caused by an explosion in service. He also reported a scar of the index finger of the right hand from gunfire in service, which was not painful, did not experience breakdown, and had no other symptoms or functional impairment. He also reported shell fragment wounds of the legs, but not experiencing any overall functional impairment from the condition. On examination, there was a linear scar located on the anterior aspect of the right shoulder measuring 2 cm by 1 cm, four nonlinear and round scars located on the right lower extremity measuring 1 cm by 1 cm each, and a nonlinear and round scar on the left lower extremity measuring 1 cm by 1 cm. Each scar was not painful on examination, had no skin breakdown, and was superficial with no underlying tissue damage. Inflammation and edema were absent, there was no keloid formation, and no scar was disfiguring. No scar limited the Veteran's motion, and there was noted not to be any limitation of function do to any of the scars. The diagnoses were scar, right arm, shell fragment wound, left leg, and shell fragment wound, right leg. There was also a diagnosis of scar, right index finger, with the condition quiescent, with history of scar but no current objective factors. Considering the pertinent evidence in light of the governing legal authority, the Board finds that the Veteran's claims for increased ratings must be denied. The record reflects that the Veteran's residual scars, both separately and together, do not warrant any compensable rating under any of the pertinent codes for rating scars. The Veteran's service-connected scars have consistently been noted to be superficial rather than deep, stable, and not painful. The area of the scars has been documented as far less than 929 square cm, and there has consistently been noted to be no disabling effects or functional impairment due to such scars. The Board notes the Veteran's assertions on May 2007 VA examination that he did not have any symptoms of his right index finger, but had issues with his right middle finger including sensation and feeling changes. However, examination of the right middle finger at that time revealed no significant scars identifiable as a source of discomfort based on direct digital palpation to the area, and examiner diagnosed normal right hand index finger and subjective sensation loss of the right middle finger without objective abnormality. Moreover, the Veteran did not mention the middle finger at the time of the July 2010 examination, but rather reported a scar of the index finger of the right hand from gunfire in service at that time; no scar of the middle finger was noted on that examination either, and the diagnosis was scar, right index finger, with the condition quiescent, with history of scar but no current objective factors. Thus, while the Board has considered the Veteran's assertions, he has not been shown to have any factors that would warrant any compensable rating involving either the index or middle fingers of the right hand. The Board also notes that the Veteran has complained of residual disability due to his in-service shrapnel wounds, and specifically disability of the right shoulder. However, in an October 2010 rating decision, the RO awarded service connection for degenerative arthritis of the right shoulder, related to his shell fragment wounds, and assigned a separate disability rating of 10 percent. This matter, unlike the noncompensable ratings for the Veteran's scar disabilities, is not on appeal to the Board, and therefore the Board may not consider it. The Board has also considered the applicability of other diagnostic codes for rating the Veteran's scar disabilities, but finds that no other diagnostic code provides a basis for higher rating. The rating codes discussed above specifically pertain to scars not of the head, face, or neck. The Veteran's disability has not been shown to involve any factors that warrant evaluation under any other provision of VA's rating schedule. Also, this case should not be referred to the Director of the VA Compensation and Pension Service for extraschedular consideration under 38 C.F.R. § 3.321(b). 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, which involves 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. 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. Thun v. Peake, 22 Vet. App. 111, 115 (2008). In this case, the record does not reflect that the average industrial impairment from the Veteran's disabilities would be in excess of that contemplated by the assigned rating. The Veteran's scar disabilities have been primarily manifested by small, superficial, stable scars that are not painful and are in no way productive of functional impairment. Such disability is reasonably contemplated by the schedular criteria for a noncompensable rating under 38 C.F.R. § 4.118, DCs 7801-7805 (2008), which contemplate such scar disabilities not of the head, face, or neck of that nature and severity. The record does not reflect that any of the Veteran's scar disabilities has caused impairment in earning capacity above what would be average for such disability. Also, the record does not reflect, and the Veteran has not contended, that the Veteran's scar disabilities have been productive of marked interference with employment, and there is no indication in the record of frequent hospitalizations related to such disability. In sum, the Board has determined that there are no unusual or exceptional factors in this case warranting the referral of the claim for extraschedular consideration. Accordingly, a compensable rating for either shell fragment wounds of the right arm and index finger or shell fragment wound scars of the legs is not warranted, and there is no basis for staged rating of either disability pursuant to Hart. As the preponderance of the evidence is against assignment of any higher rating, the benefit-of-the doubt doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3 (2012); Gilbert, 1 Vet. App. at 53-56. Duties to Notify and Assist Under applicable criteria, VA has certain notice and assistance obligations to claimants. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Notice must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits and must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). Section 5103(a) notice should also advise a claimant of the criteria for establishing a disability rating and effective date of award. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). In the present case, required notice was provided by letter dated in December 2006, which informed the Veteran of all the elements required by Pelegrini II and Dingess/Hartman. As to VA's duty to assist, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). This duty includes assisting the Veteran in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a Veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the Veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the Court of Appeals for Veterans Claims has stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the Veteran's service. The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, a VA medical nexus opinion was not obtained for the service connection claims because the evidence did not surpass the low threshold set by McLendon. Where the evidence does not establish that a disability may be associated with service, there is no need to obtain a medical opinion regarding any such nexus. As discussed above, the evidence does not establish that the Veteran has had any of his current disabilities since service, and there is no medical or other competent evidence suggesting a nexus between the Veteran's disabilities and service or any other such evidence that would warrant obtaining a medical nexus opinion. In this regard, the Federal Circuit has addressed the appropriate standard to be applied in determining whether an examination is warranted. In Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) and Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010), the Federal Circuit held that while there must be "medically competent" evidence of a current disability, "medically competent" evidence is not required to indicate that the current disability may be associated with service. Colantonio, 606 F.3d at 1382; Waters, 601 F.3d at 1277. On the other hand, a conclusory generalized lay statement suggesting a nexus between a current disability and service (as in this case) would not suffice to meet the standards, as this would, contrary to the intent of Congress, result in medical examinations being "routinely and virtually automatically" provided to all veterans claiming service connection. Waters, 601 F.3d at 1278-1279. Here, as the only evidence that any of the Veteran's claimed disabilities is related to military service are the conclusory generalized lay statements of the Veteran, which are unsupported by even speculative medical evidence. Accordingly, the Board finds that referral for a VA medical examination is not warranted. The Veteran's service treatment records and VA medical treatment records have been obtained. Also, the Veteran was provided examinations regarding his increased rating claims in May 2007 and July 2010. These examinations and their associated reports were adequate because, along with the other evidence of record, they provided sufficient information to decide the appeal and a sound basis for a decision on the Veteran's claims. The examination reports were based on thorough examination of the Veteran by examiners with appropriate expertise who provided the appropriate information for rating the Veteran's scar disabilities. 38 C.F.R. § 3.159(c)(4) (2013); Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board notes that in an August 2013 brief, the Veteran's representative noted that the Veteran's most recent VA examination of his scars was in July 2010, and requested that "the claim be remanded for a new VA examination in order to accurately determine the [Veteran's] current level of disability." When a veteran claims that his condition is worse than when originally rated, and the available evidence is too old for an adequate evaluation of the veteran's current condition, VA's duty to assist includes providing a new examination. See Weggenmann v. Brown, 5 Vet. App. 281, 284 (1993). While a new examination is not required simply because of the time that has passed since the last examination, VA's General Counsel has indicated that a new examination is appropriate when there is an assertion of an increase in severity since the last examination or other evidence of worsening. VAOPGCPREC 11-95 (1995). While the Veteran's representative has requested a new examination, there has been no assertion by the Veteran or his representative that any of his scar disabilities have worsened in any way since the July 2010 VA examination, and the record does not indicate any way that it might have. A review of treatment records fails to indicate a problem and the Veteran himself has indicated no problem with any pain associated with the condition. The current level of disability has been found. As there is no specific contention or other indication in the record of worsening of the Veteran's scar symptomatology, remand for a new examination of the Veteran's service-connected scar disabilities is not warranted. If the scar does become worse in some way, the Veteran may reapply. Therefore, VA has satisfied its duties to notify and assist, and additional development efforts would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Because VA's duties to notify and assist have been met, there is no prejudice to the Veteran in adjudicating this appeal. ORDER Service connection for a back disability is denied. Service connection for hemorrhoids, claimed as secondary to herbicide exposure, is denied. Service connection for a rash in the groin area, claimed as secondary to herbicide exposure, is denied. A compensable rating for shell fragment wounds of the right arm and index finger is denied. A compensable rating for shell fragment wound scars of the legs is denied. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs