Citation Nr: 1334485 Decision Date: 10/30/13 Archive Date: 11/06/13 DOCKET NO. 08-23 191A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California THE ISSUES 1. Entitlement to an increased disability rating for anxiety with depression, currently evaluated as 50 percent disabling. 3. Entitlement to an increased disability rating for inverse psoriasis, currently evaluated as 10 percent disabling. 4. Entitlement to an initial disability rating in excess of 10 percent for abdominal scar residuals. 5. Entitlement to a higher initial disability rating for residuals of incisional hernia repair, currently evaluated as 20 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Mary C. Suffoletta, Counsel INTRODUCTION The Veteran served on active duty from July 1994 to July 1998. These matters come to the Board of Veterans' Appeals (Board) on appeal from a January 2005 decision of the RO that, in pertinent part, granted an increased rating of 30 percent for service-connected anxiety with depression; continued a noncompensable rating for service-connected inverse psoriasis; granted service connection for abdominal scar residuals evaluated as 10 percent disabling; and granted service connection for residuals of incisional hernia repair evaluated as follows: 20 percent disabling effective May 1, 2004; 100 percent disabling effective July 7, 2004, under the provisions of 38 C.F.R. § 4.30 based on surgery and convalescence for this condition; and 0 percent (noncompensable) disabling, effective October 1, 2004. The Veteran timely appealed for higher disability ratings. In August 2008, the RO increased the disability evaluation to 20 percent for residuals of incisional hernia repair, effective from November 2004. In December 2010, the RO increased the disability evaluation to 50 percent for anxiety with depression, effective June 18, 2004; and increased the disability evaluation to 10 percent for inverse psoriasis, effective June 18, 2004. Because higher evaluations remain available for each disability, and the Veteran has specifically indicated that he seeks the maximum available benefit for his disabilities, the claims remain on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The Court has recently held that a request for a TDIU, whether expressly raised by the Veteran or reasonably raised by the record, is not a separate "claim" for benefits, but rather, can be part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). The Board notes that the Veteran already has been awarded a TDIU. Hence, it is unnecessary to remand the matter for further action. Lastly, in addition to reviewing the Veteran's paper claims file, the Board has surveyed the contents of his Virtual VA file. The issues of an increased disability rating for anxiety with depression and an increased disability rating for inverse psoriasis are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. The revised criteria applicable to scars are more favorable to the Veteran. 2. For the rating period prior to October 23, 2008, abdominal scar residuals have been tender and painful; loss of function of the body part affected has not been demonstrated. 3. For the period since October 23, 2008, abdominal scar residuals have been manifested by five or more scars that are painful; loss of function of the body part affected has not been demonstrated. 4. Throughout the rating period (excluding periods when a total disability rating was in effect), the Veteran's residuals of incisional hernia repair have been manifested by post-operative wounds with weakening of abdominal wall, and by pain and functional limitation in lifting, carrying, and reaching. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating in excess of 10 percent, for the rating period prior to October 23, 2008, for abdominal scar residuals are not met or nearly approximated. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.7, 4.20, 4.118, Diagnostic Code 7804 (2007). 2. The criteria for a 30 percent disability rating, for the period from October 23, 2008, for abdominal scar residuals are met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.7, 4.20, 4.118, Diagnostic Code 7804 (2013). 3. The criteria for an initial disability rating in excess of 20 percent for residuals of incisional hernia repair (excluding periods when a total disability rating was in effect) are not met or nearly approximated. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.7, 4.20, 4.114, Diagnostic Code 7339 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The Veteran's claims arise from his disagreement with the initial evaluations assigned following the grant of service connection. Courts have held that once service connection is granted, the claim is substantiated; additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The Board concludes that VA's duty to assist has been satisfied. All available records identified by the Veteran as relating to his claims for higher initial disability ratings for abdominal scar residual of exploratory laparotomy, and for incisional hernia have been obtained, to the extent possible. The RO provided the Veteran with appropriate VA examinations, and there is no evidence indicating that there has been a material change in the severity of the Veteran's disabilities since he was last examined. The Board finds the examination reports to be thorough and adequate upon which to base a decision with regard to these claims. Given these facts, it appears that all available records have been obtained. There is no further assistance that would be reasonably likely to assist the Veteran in substantiating the claims. 38 U.S.C.A. § 5103A(a)(2). II. Analysis Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making disability evaluations. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 4.1. Where the question for consideration is propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999). In this case, the Veteran is competent to testify on factual matters of which he has first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362 (2005). He is also competent to report symptoms of scar pain and abdominal weakness. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). The Veteran is competent to describe his symptoms and their effects on employment or daily activities. The Board will consider not only the criteria of the currently assigned diagnostic code, but also the criteria of other potentially applicable diagnostic codes. A. Abdominal Scar Residuals Service connection has been established for abdominal scar residuals, effective May 2004. The RO has evaluated the Veteran's disability under 38 C.F.R. § 4.118, Diagnostic Code 7804, pertaining to scars. A deep scar is one that is associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7801, Note (2). A scar at a location other than the head, face, or neck that is deep or that causes limitation of motion would have to have an area exceeding 6 square inches (39 square centimeters) to warrant a 10 percent rating, 12 square inches (77 square centimeters) to warrant a 20 percent rating, 72 square inches (465 square centimeters) to warrant a 30 percent rating, or 144 square inches (929 square centimeters) to warrant a 40 percent rating. 38 C.F.R. § 4.118, Diagnostic Code 7801. A superficial scar is one that is not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7802, Note (2). A scar at a location other than the head, face, or neck that is superficial and that does not cause limitation of motion would have to have an area exceeding 144 square inches (929 square centimeters) to warrant a 10 percent rating. 38 C.F.R. § 4.118, Diagnostic Code 7802. A 10 percent evaluation is provided for superficial scars that are poorly nourished with repeated ulcerations under 38 C.F.R. § 4.118, Diagnostic Code 7803; or for superficial scars that are tender or painful on objective demonstration under 38 C.F.R. § 4.118, Diagnostic Code 7804 (2007). Disabling effects are to be rated either as scars or as impairment of function, whichever results in the higher rating. 38 C.F.R. § 4.118, Diagnostic Code 7805 (2007). Although, no more than one of these ratings may be assigned without violating the rule against the pyramiding of disabilities. 38 C.F.R. § 4.14. During the course of this appeal, VA revised the criteria for evaluation of scars, effective on October 23, 2008. 73 Fed. Reg. 54708 (September 23, 2008) (codified at 38 C.F.R. § 4.118 (2009)). Initially, the revised criteria were applicable only to claims received by VA on or after October 23, 2008; and, hence, were inapplicable in this case. Since then, VA published a correcting amendment to allow Veterans whose scars were rated by VA under the former criteria (versions in effect prior to October 23, 2008) to request evaluation review under the revised criteria. See 77 Fed. Reg. 2909 (January 20, 2012). The correction amendment specifically encompasses claims that have received an initial rating, and are still pending in the appeals process. Id. The correction is effective January 20, 2012. Accordingly, the Board accepts the Veteran's August 2013 correspondence (Appellant's Brief) as a request for review under the revised criteria. As the RO or AMC also considered both the former and revised criteria in the December 2010 and January 2011 supplemental statements of the case, the Veteran is not prejudiced by the Board's proceeding in this manner. That said, a rating under the revised criteria may not be established prior to the effective date of that criteria, because they did not exist prior to that date. The revised criteria for Diagnostic Code 7804 provide that one or two scars that are unstable or painful warrant a 10 percent rating; three or four scars that are unstable or painful warrant a 20 percent rating; and five or more scars that are unstable or painful warrant a 30 percent rating. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. See 38 C.F.R. § 4.118, Diagnostic Code 7804, Note (1) (October 23, 2008). Alternatively, the revised criteria provide that disabling effects not considered in a rating provided under Diagnostic Codes 7801, 7802, and 7804 are to be rated as impairment of function. 38 C.F.R. § 4.118, Diagnostic Code 7805 (October 23, 2008). As a preliminary matter, the Board notes that the service-connected residuals of incisional hernia repair have been separately evaluated; and that rating the same disability under various diagnoses is to be avoided, as it would constitute pyramiding. See 38 C.F.R. § 4.14. Historically, the Veteran underwent an emergency exploratory laparotomy with partial small intestinal resection in September 2001. A November 2002 VA examination report reflects a midline scar of the abdomen. The Veteran later developed an enlarging upper abdominal incisional hernia to the right of the previous midline laparotomy incision. The report of the November 2004 VA examination reflects that the surgical scars to the abdomen measured 17 centimeters by 2 centimeters (vertical); and 8 centimeters by 1 centimeter (horizontal). Both scars were mildly tender to palpation, mildly adherent, mildly depressed, and mildly-to-moderately disfiguring, with approximately 2 percent of body surface area covered with surgical scars and psoriasis plaques (based on rule of nines). Examination revealed that the abdomen was soft, non-distended, and mildly tender to surgical scars; and was symmetric with no apparent masses. The report of the August 2008 VA examination reflects that the Veteran had a mesh placed in February 2008 for repair of seven hernias in the abdomen, and currently reported two more hernias around the mesh. The examiner noted a series of at least 25 scars from staples, ranging in size 1 centimeter by 1 centimeter, to 1 centimeter by .5 centimeters. Examination revealed tenderness to palpation, but no adherence to underlying tissue; the midline scar was deep and depressed, and the skin in the area of the midline scar was inflexible. Some of the scars were superficial, and all of the scars were pink in color. There was no inflammation, edema, or keloid formation; nor was there limitation of motion, or limitation of function caused by a scar. The examiner opined that the scars caused disfigurement of the abdomen. Examination of the abdominal scar residuals in December 2009 revealed no skin breakdown over the scars, and revealed reports of pain. The examiner noted that the disabling effects of scars were residuals of incisional hernia repair. No other disabling effects were noted. Nor was there inflammation, edema, or keloid formation. For the Period Prior to October 23, 2008 Here, the objective evidence does not support an initial disability rating in excess of 10 percent on the basis of scars during the applicable period under the former criteria. The objective evidence reflects that the Veteran's service-connected abdominal scar residuals have been manifested primarily by superficial scars that are tender or painful to objective demonstration. The one deep scar neither approaches nor exceeds 12 square inches (77 square centimeters) to warrant a 20 percent rating. No examiner has indicated that any scar was poorly nourished with repeated ulcerations or was otherwise unstable. Solely on the basis of abdominal scar residuals, the evidence does not meet the criteria for an initial disability rating in excess of 10 percent during the applicable period under any diagnostic code. 38 C.F.R. § 4.7. With regard to disfigurement, compensable disability ratings are warranted only for disfiguring scars of the head, face, or neck; and, hence, are inapplicable in this case. Nor is there evidence of any functional impairment from abdominal scar residuals during the rating period. Here, the objective clinical findings outweigh the Veteran's lay assertions regarding severity specific to the scars themselves. For the foregoing reasons, a preponderance of the evidence is against an initial disability rating in excess of 10 percent for abdominal scar residuals during the applicable period. 38 C.F.R. § 4.118, Diagnostic Code 7804 (2007). For the Period since October 23, 2008 In this case, the objective evidence supports an increased disability rating on the basis of scars under the revised criteria, which became effective on October 23, 2008. As stated above, the Board is prohibited from applying a regulation prior to its effective date. These criteria are more favorable to the Veteran. Here, five or more abdominal scars that are painful have been demonstrated to warrant the maximum 30 percent disability rating based on scars under the revised criteria currently in effect. 38 C.F.R. § 4.118, Diagnostic Code 7804 (2013). The Veteran's August 2008 examination confirms the presence of more than five scars, and that these scars are painful. Loss of function of the body part affected has not been demonstrated, as pertaining to abdominal scar residuals; no other diagnostic codes are applicable. Given these findings, the Veteran's complaints of painful scars, and resolving reasonable doubt in the Veteran's favor, the Board finds that the evidence meets the revised criteria for a 30 percent disability rating under revised Diagnostic Code 7804. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). B. Residuals of Incisional Hernia Repair Service connection has been established for residuals of incisional hernia repair, effective May 2004. The RO has evaluated the Veteran's disability as 20 percent disabling under 38 C.F.R. § 4.114, Diagnostic Code 7339, pertaining to post-operative ventral hernia. Parenthetically, the Board notes that this decision in no way affects the three periods of convalescence for which a total, 100 percent rating has already been established. Pursuant to Diagnostic Code 7339, a noncompensable rating is warranted for healed postoperative wounds when there is no related disability, and a belt is not indicated. A 20 percent evaluation requires a small postoperative ventral hernia which is not well supported by a belt under ordinary conditions, or a healed ventral hernia or postoperative wound with weakening of the abdominal wall and indications for a supporting belt. A 40 percent evaluation is warranted when the hernia is large, and not well supported by a belt under ordinary conditions. A maximum 100 percent evaluation is warranted for massive, persistent, severe diastasis of recti muscles, or extensive diffuse destruction or weakening of muscular and fascial support of abdominal wall so as to be inoperable. 38 C.F.R. § 4.114, Diagnostic Code 7339. VA records show that the Veteran underwent an incisional hernia repair, primarily without mesh, in July 2004. He then developed cellulitis at the surgical site, and was treated on an emergency basis due to severe infection. Records show that, in August 2006, the Veteran complained of periumbilical pain with lifting, and noticed at least three reducible tender bulges around incision. In February 2008, he underwent another incisional hernia repair with mesh. Records show that the abdomen was well healed without signs of infection or seroma in March 2008. During an August 2008 VA examination, the Veteran reported his prior surgeries; and reported two more hernias have shown up around mesh. Examination of the abdomen at that time revealed a hernia measuring 2 centimeters by 3 centimeters to the right of the midline scar. VA examination in October 2008 reveals that residuals of incisional hernia repair were not supported by a truss or belt, and that the Veteran had weakened abdominal walls. The examiner also noted that, given the prior surgeries, the Veteran had extensive diffuse weakened recti muscles and fascia causing possible more hernias to occur. In December 2009, a VA examiner noted disabling effects of the incisional hernia repairs. Specifically, the examiner found that the mesh limits the Veteran's abdominal flexibility, which reduces his ability to lift and to carry and to reach. The examiner also found that the deep incisional repair limits the Veteran's trunkal motion and shoulder elevation. VA records show that the Veteran underwent another incisional hernia repair with mesh in December 2009, without complication. Follow-up examination in May 2010 reveals no signs of recurrent hernias. In January 2011, the Veteran stated that the incisional hernia repairs covered his entire stomach area. In this case, throughout the rating period and excluding all periods when a total rating was in effect, the evidence shows that the Veteran's residuals of incisional hernia repair have been manifested by postoperative wounds with weakening of the abdominal wall. There is no indication at any time for a supporting belt. While incisional repairs on two occasions have required placement of a mesh, there is no evidence that any of the Veteran's multiple hernias were large. In fact, the hernias were described as reducible; and the last incisional hernia, which was repaired with placement of a mesh in December 2009, measured 2 centimeters by 3 centimeters. None of the photographs of record reflects large hernias. Moreover, while a VA examiner in October 2008 had found that the Veteran had extensive diffuse weakened recti muscles and fascia related to each surgery, there is no finding of record that any of the Veteran's incisional hernias were inoperable. In fact, subsequent surgery in December 2009 was without complication and follow up revealed no hernias. Further there is no evidence of diastasis recti, where there is significant separation between the right and left abdominal muscles. The Veteran's disability, thus, does not meet the criteria for a disability rating in excess of 20 percent under Diagnostic Code 7339 at any time during the appeal period. Lastly, the Board has considered the Court's holding in Deluca. There is evidence that the Veteran's abdominal flexibility is limited, and his ability to lift and to carry and to reach is limited as well. However, there is no showing of significant functional loss of the affected part that warrants any separate disability rating. The Veteran's subjective complaints of pain have been attributed to his abdominal scar residuals. Here, the objective findings outweigh the Veteran's lay assertions regarding severity. For these reasons, the Board concludes that an initial disability rating in excess of 20 percent-excluding periods when a total rating is in effect-is not warranted based on functional loss due to pain and other symptoms as contemplated by Deluca. For the foregoing reasons, a preponderance of the evidence is against a higher initial disability rating for residuals of incisional hernia repair (excluding periods when a total disability rating was in effect). C. Extraschedular Consideration An extraschedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. Floyd v. Brown, 9 Vet. App. 88, 94 (1996). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. The Board finds that the schedular evaluations assigned for the Veteran's service-connected abdominal scar residuals and residuals of incisional hernia repair are adequate in this case. The Veteran's abdominal scar residuals, and the severity of his residuals of incisional hernia repair, which are manifested primarily by symptoms of pain and post-operative wounds with weakening of abdominal wall, are specifically contemplated by the schedular criteria. Therefore, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER An initial disability evaluation in excess of 10 percent for abdominal scar residuals, for the period prior to October 23, 2008, is denied. A 30 percent disability rating for abdominal scar residuals, for the period since October 23, 2008, is granted, subject to the regulations governing the award of monetary benefits. An initial disability evaluation in excess of 20 percent for residuals of incisional hernia repair (excluding periods when a total disability rating was in effect) is denied. REMAND Anxiety with Depression The Veteran contends that his service-connected anxiety with depression is more severe than currently rated, and warrants an increased disability rating. Records show that the Veteran was last afforded a VA examination to evaluate the severity of his service-connected anxiety with depression in December 2009. At that time, there was evidence that the Veteran's mood was "anxious, angry, and depressed;" and that he had suicidal ideation at the time. The examiner opined that the Veteran's depression seemed to have worsened in the last year, and that the Veteran had difficulty relating to other people. Since then, the Veteran has described a worsening of the disability. VA treatment records show that the Veteran's medications were increased in March 2010 with minimal benefit. In June 2010, the Veteran called to report being more depressed, and that he "didn't even get out of bed" that day. Records also show that the Veteran's grooming was noted as fair, and that he denied having suicidal or homicidal thoughts. Under these circumstances, VA cannot rate the service-connected anxiety with depression without further medical clarification. Hence, the Veteran is entitled to a new VA examination. See, e.g., Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); VAOPGCPREC 11-95 (1995). Inverse Psoriasis In evaluating the Veteran's request for an increased disability rating, the Board has reviewed the medical evidence of record. The report of a November 2004 VA examination reflects chronic inverse psoriasis. Examination of the skin at that time revealed well demarcated erythmatous plaque to inguinal folds and right axilla, mild redness which was hardly visible to chin, and no significant plaque to hands. The report of a December 2009 VA examination reflects findings of inverse psoriasis in the right upper eyelid, both axillae, both inguinals, intertriginous area, scrotom, and anus. The course of the Veteran's skin condition was noted as progressive; and, at the time, the examiner opined that greater than 5 percent, but less than 20 percent, of total body area was affected. The examiner also opined that less than 5 percent of exposed areas (head, face, neck, and hands) were affected. In January 2011, the Veteran reported that his skin condition was not "broken out" at the time of the December 2009 VA examination; and that, during a "full breakout," the inverse psoriasis covers over 60 square inches of his armpit, leg, groin, eyes, and hair. The Veteran is competent to describe his symptoms. The Board notes that photographs of the Veteran's skin disability have already been submitted. Under these circumstances, VA cannot rate the service-connected inverse psoriasis without further medical clarification. Moreover, if more than one skin disability is diagnosed, the examiner should, to the extent possible, distinguish symptoms attributable to the service-connected inverse psoriasis, from those attributable to any nonservice-connected skin disability. Hence, the Veteran is entitled to a new VA examination. See, e.g., Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); VAOPGCPREC 11-95 (1995). Accordingly, the case is REMANDED for the following action: 1. Obtain recent VA treatment records for anxiety with depression and for inverse psoriasis-dated from October 2010 to the present date; and associate them with the Veteran's claims file (physical or electronic). 2. Accord the Veteran an appropriate VA examination for evaluation of the service-connected anxiety with depression. All appropriate tests should be conducted. The entire claims file, to include a complete copy of this REMAND, must be made available to the examiner, and the examination report should note review of the file. All pertinent findings shown on evaluation should be noted in the examination report. In addition, the examiner should render a multi-axial diagnosis, including assignment of a Global Assessment of Functioning (GAF) score representing the level of impairment due to the Veteran's anxiety with depression, and an explanation of the meaning of the score. In providing the above-noted findings, the examiner should, to the extent possible, distinguish the symptoms attributable to service-connected anxiety with depression from those of other psychiatric conditions. However, if it is not medically possible to do so, the examiner should clearly so state, and indicate that the findings are with respect to the Veteran's overall psychiatric impairment. The examiner should set forth a rationale for the conclusions reached. These specific findings are needed to rate the Veteran's disability in accordance with the rating schedule. It is therefore important that the examiner furnish the requested information. 3. Afford the Veteran an appropriate VA examination, for evaluation of the service-connected inverse psoriasis, if possible, during a "full breakout." The entire claims file, to include a complete copy of this REMAND, must be made available to the examiner, and the examination report should note review of the file. Any testing deemed necessary should be performed. The examiner should render specific findings as to the extent to which the skin disability on the Veteran's head, face, or neck is disfiguring (i.e., listing characteristics of disfigurement presented). The examiner should report the percentage of the whole body, and the percentage of exposed areas affected by the service-connected inverse psoriasis. The examiner should indicate whether the skin disability has required constant or near-constant systemic therapy during the past 12-month period. In providing the above-noted findings, the examiner should, to the extent possible, distinguish the symptoms attributable to service-connected inverse psoriasis from those of other skin conditions. 4. Thereafter, readjudicate the claims remaining on appeal. If the benefits sought are not fully granted, furnish the Veteran and his representative a supplemental statement of the case (SSOC), and allow the appropriate response time before the claims file is returned to the Board, if otherwise in order. No action is required of the Veteran and his representative until they are notified by VA; however, the Veteran is advised that failure to report for any scheduled examinations may result in the denial of his claims. 38 C.F.R. § 3.655 (2012). The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims 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). ______________________________________________ BETHANY L. BUCK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs