Citation Nr: 1546835 Decision Date: 11/05/15 Archive Date: 11/13/15 DOCKET NO. 11-02 803A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to an evaluation in excess of 20 percent prior to December 21, 2011, and an evaluation in excess of 20 percent since February 1, 2012, for degenerative disc disease (DDD) of the cervical spine, status post cervical discectomy, fusion, and bone graft (hereinafter a "cervical spine disability"). 2. Entitlement to an initial compensable evaluation for left hip residual scar from bone graft associated with service-connected cervical spine disability. 3. Entitlement to an evaluation in excess of 40 percent for right upper extremity (RUE) radiculopathy associated with service-connected cervical spine disability. 4. Entitlement to an evaluation in excess of 30 percent for left upper extremity (LUE) radiculopathy associated with service-connected cervical spine disability. 5. Entitlement to a total disability evaluation based on individual unemployability (TDIU) due to service-connected disabilities. 6. Whether new and material evidence has been received to reopen the claim for service connection for a skin rash or eczema on the face. REPRESENTATION Veteran represented by: Georgia Department of Veterans Services WITNESSES AT HEARING ON APPEAL Veteran and brother ATTORNEY FOR THE BOARD Journet Shaw, Associate Counsel INTRODUCTION The Veteran had service with the U.S. Naval Reserves from 1979 to 1996 with intermittent periods of active duty for training (ACDUTRA) This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions in August 2008, April 2009, and February 2013 by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina and Atlanta, Georgia, respectively. The case has since been returned to the RO in Atlanta, Georgia. In the August 2008 rating decision, the RO denied an evaluation in excess of 20 percent for the Veteran's service-connected cervical spine disability. The Veteran appeals for a higher evaluation. In the April 2009 rating decision, the RO denied the Veteran's petition to reopen the claim for service connection for a skin rash or eczema on the face. The Veteran appeals the decision. In the February 2013 rating decision, the RO granted service connection for a left hip residual scar bone graft and assigned a noncompensable evaluation effective February 14, 2011. The Veteran appeals for an initial compensable evaluation. During the pendency of the appeal, the RO issued a September 2014 rating decision finding clear and unmistakable error with a December 2013 rating decision that denied a temporary total evaluation based on surgery necessitating convalescence for the Veteran's service-connected cervical spine disability. The RO assigned a temporary total evaluation effective December 21, 2011 and, subsequently, evaluated the Veteran's cervical spine disability as 20 percent disabling effective February 1, 2012. The Veteran continues to appeal for a higher evaluation for her cervical spine disability. AB v. Brown, 6 Vet. App. 35 (1993) (holding that a claimant is presumed to be seeking the maximum rating). In January 2012, the Veteran submitted a VA-Form 21-8940 stating that her service-connected cervical spine disability prevented her from securing or obtaining substantially gainful employment. In Rice v. Shinseki, the United States Court of Appeals for Veterans Claims (Court) held that a TDIU rating is part of an increased rating claim when such issue is raised by the record. See Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). Therefore, the issue of a TDIU is raised by the record, is part and parcel of the increased rating claim, and is properly before the Board. Id. Thus, the TDIU claim is reflected on the title page. The Veteran and her brother testified before the undersigned Veterans Law Judge at a July 2015 videoconference hearing. A transcript of this hearing is of record. At the July 2015 Board hearing, the Veteran testified to having worsening symptoms of cervical pain radiating into both arms down into her hands causing problems with her ability to grip her hands. The Veteran is separately service-connected for RUE and LUE radiculopathy associated with service-connected cervical spine disability. The Veteran has not filed an increased rating claim for these service-connected disabilities. Nevertheless, these disabilities are associated with the Veteran's service-connected cervical spine disability, which is already on appeal. The Board finds that increased evaluation claims for the Veteran's service-connected RUE and LUE radiculopathy is part and parcel of the cervical spine disability increased evaluation claim and, therefore, those issues are reflected on the title page. The Board also notes that, in a September 2014 VA Form 9, the Veteran stated that her left hip pain was associated not with her scar, but, rather with the bone graft area. The Veteran had been previously denied service connection for a left hip deformity and left trochanteric bursitis secondary to her service-connected cervical spine disability. The Board finds that the Veteran has asserted a petition to reopen her previously denied claim for service connection for a left hip disability. The issue of whether new and material evidence has been received to reopen the claim for service connection for a left hip disability as secondary to service-connected cervical spine disability has been raised by the record in a September 2014 statement, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2015). Evidence has been added to the claims file since the most recent certification of the appeal to the Board but it is not pertinent to the increased evaluation claims addressed below. See 38 C.F.R. § 20.1304(c). The issues of entitlement to an evaluation in excess of 20 percent since February 1, 2012 for service-connected cervical spine disability; entitlement to an evaluation in excess of 40 percent for RUE radiculopathy; entitlement to an evaluation in excess of 30 percent for LUE radiculopathy; entitlement to a TDIU; and whether new and material evidence has been received to reopen the claim for service connection for a skin rash or eczema of the face are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. From November 27, 2007 to August 8, 2011, the Veteran's cervical spine disability has been manifested by subjective evidence of pain radiating into the left shoulder, fatigue, headaches, and numbness; and objective evidence of tenderness, pain with flexion at no less than 45 degrees with increased pain, weakness, lack of endurance, fatigue, and incoordination with repetitive use. 2. Resolving all reasonable doubt in favor of the Veteran, from August 9, 2011 to December 20, 2011, the evidence demonstrates that the Veteran's cervical spine disability had worsened in regard to various symptoms, including limitation of motion. 3. Resolving all reasonable doubt in favor of the Veteran, the Veteran's left hip residual scar from bone graft is painful to touch. CONCLUSIONS OF LAW 1. From November 27, 2007 to August 8, 2011, the criteria for an evaluation in excess of 20 percent for a cervical spine disability have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242 (2015). 2. From August 9, 2011 to December 20, 2011, the criteria for a 30 percent evaluation have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242 (2015). 3. The criteria for a 10 percent evaluation for a left hip residual scar from bone graft have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.118, Diagnostic Code 7805 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the claims file, and has an obligation to provide an adequate statement of reasons or bases supporting its decision. See 38 U.S.C.A. § 7104 (West 2014); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). While the Board must review the entire record, it need not discuss each piece of evidence. Id. The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. It should not be assumed that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000). The law requires only that the Board address its reasons for rejecting evidence favorable to the claimant. Id. The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Caluza v. Brown, 7 Vet. App. 498, 506 (1995). Equal weight is not accorded to each piece of evidence contained in the record, and every item of evidence does not have the same probative value. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Id. I. Duties to Notify and Assist VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002); Dingess v. Nicholson, 19 Vet. App. 473 (2006). With regard to the Veteran's claim for an initial compensable evaluation for a left hip residual scar from bone graft, the Veteran received sufficient Veterans Claims Assistance Act of 2000 (VCAA) notice prior to the grant of service connection and assignment of an initial evaluation and effective date, thereby satisfying the VA's duty to notify in this case. Dingess, supra. The Board finds that the notice requirements have been satisfied for the increased evaluation claim for her service-connected cervical spine disability by letters in December 2007 and October 2008. See Dingess, supra; Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277-78 (Fed. Cir. 2009). The Board also concludes that the duty to assist has been satisfied as all pertinent post-service treatment records and lay statements are in the claims file. In addition, the Veteran underwent VA examinations in February 2009, December 2011, and February 2014. For the above reasons, the Board finds that VA has fulfilled its duties to notify and assist the Veteran. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of the claims. II. Higher Evaluation Claims Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. The veteran's entire history is to be considered when making disability evaluations. See 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). Cervical Spine Disability The Veteran is seeking a higher evaluation for her service-connected cervical spine disability. The relevant temporal focus for adjudicating the level of disability of an increased rating claim begins one year before the claim was filed. As the instant claim for an increased rating was received on November 27, 2007, the period for consideration will include evidence one year prior to the receipt of claim. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Under 38 C.F.R. § 4.40, functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant on motion. Disability of the musculoskeletal system is the inability to perform normal working movement with normal excursion, strength, speed, coordination, and endurance, and that weakness is as important as limitation of motion, and that a part that becomes disabled on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, through atrophy, for example. 38 C.F.R. § 4.40. The provisions of 38 C.F.R. §§ 4.45 and 4.59 also contemplate inquiry into whether there is limitation of motion, weakness, excess fatigability, incoordination, and impaired ability to execute skilled movements smoothly, and pain on movement, swelling, deformity, or atrophy of disuse. Instability of station, disturbance of locomotion, and interference with sitting, standing, and weight-bearing are also related considerations. The Court has held that diagnostic codes predicated on limitation of motion require consideration of a higher rating based on functional loss due to pain on use or due to flare-ups. 38 C.F.R. §§ 4.40, 4.45, 4.59; Johnson v. Brown, 9 Vet. App. 7 (1997); DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition was not "duplicative of or overlapping with the symptomatology" of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). However, pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a Veteran's service-connected disability. 38 C.F.R. § 4.14 (2015). During the relevant appeal period, the Veteran's cervical spine disability has been currently evaluated as 20 percent disabling, effective February 1, 1999, 100 percent disabling, effective December 21, 2011, and 20 percent disabling, effective February 1, 2012. As previously discussed above, the Veteran's 100 percent evaluation was a temporary total evaluation assigned under 38 C.F.R. § 4.30 for surgery necessitating a period of convalescence. The Veteran is not appealing for an extension of such temporary total evaluation, so it is not appeal. The Veteran's 20 percent evaluations for her cervical spine disability were assigned under 38 C.F.R. §4.71a, Diagnostic Code 5242, which are evaluated under the General Rating Formula For Diseases and Injuries of the Spine as follows: A 20 percent evaluation is warranted where forward flexion of the cervical spine is greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine is not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent evaluation is warranted for forward flexion of the cervical spine of 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent evaluation is provided for unfavorable ankylosis of the entire cervical spine. For VA compensation purposes, normal forward flexion of the cervical spine is 0 to 45 degrees, extension is 0 to 45 degrees, left and right lateral flexion are 0 to 45 degrees, and left and right lateral rotation are 0 to 80 degrees. 38 C.F.R. §4.71a, Plate V. For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision, restricted opening of the mouth and chewing, breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia, atlantoaxial or cervical subluxation or dislocation; or neurological symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. See General Rating Formula for Diseases and Injuries of the Spine, Note (5). Furthermore, under note (1), evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Id. As an initial matter, the discussion of the evidence below has been limited to the appeal period prior to December 21, 2011. Because the record indicates possible worsening cervical spine symptoms during the appeal period since February 1, 2012, the Board will discuss this period in the remand portion below. VA treatment records from April 2007 to April 2008 document the Veteran's complaints of intermittent neck pain which increased with movement. No radiating pain or weakness, morning stiffness, or associated neurological symptoms were reported. See August 2007 VA treatment record. The Veteran did not report using any current methods of treatment for her neck pain. See April 2008 VA treatment record. The Veteran underwent a VA spine examination in February 2009. The examination report includes a recitation of the Veteran's cervical spine complaints. The Veteran reported having flare-ups of pain, rated at 10 out of 10, at least two to three times a month and occurring oftentimes at night. She said that her neck pain made turning her neck quickly difficult and slowed down her ability to perform activities of daily living. Upon objective evaluation, the VA examiner found that the Veteran had a normal gait and curvature of the spine and her cervical spine was tender to percussion. Muscle power grade of the upper limbs was 5. There was no sensory, motor, or autonomic dysfunction in the upper limbs. Deep tendon reflexes were present. No neurological deficit was noted. Range of motion testing of the cervical spine revealed flexion at 45 degrees with pain, extension to 45 degrees with pain, left and right lateral flexion at 45 degrees with pain, and left and right lateral rotation at 80 degrees with pain. Following repetitive use testing, there was no additional limitation in range of motion. The VA examiner found increased pain, weakness, lack of endurance, fatigue, and incoordination throughout her range of motion. Based on the objective findings, including a CT scan of the cervical spine, the VA examiner diagnosed the Veteran with status post cervical spine surgery with degenerative disc disease. The VA examiner found that the Veteran's level of disability due to her cervical spine was mild to moderate. A June 2010 VA treatment record documents that the Veteran reported having worsening neck pain and that she underwent pool physical therapy, but had to stop due to cost. In April 2011, the Veteran continued to complain of axial neck pain. See April 2011 VA treatment record. Private treatment records from August 2011 to November 2011 document that the Veteran had increased neck pain following a motor vehicle accident (MVA) on August 9, 2011. An August 2011 radiology report showed that the Veteran had a mild to moderate anterior spondylosis at the C3-C4 and C4-C5 level, moderate reversal of the cervical curve, and possible evidence that her C5 screws were loosening. There was no evidence of fracture or subluxation. The Veteran reported experiencing neck pain, which was aggravated with rotation. Her neck pain also radiated into both shoulders and down into both arms with pain greater on the left than the right. She also had some weakness in her arm. She also complained of having difficulty sleeping, numbness, and headaches. An objective evaluation showed that the Veteran had a slow gait, decreased range of motion in all directions and slight weakness of the left deltoid and biceps. The Veteran's reflexes were symmetrical and sensory examination results were normal. See September, October and November 2011 private treatment records. The Veteran was afforded a VA spine examination in December 2011. The examination report includes a recitation of the Veteran's cervical spine complaints. The Veteran stated that she was scheduled for additional neck surgery in the next two weeks. No flare-ups were reported. Upon objective evaluation, the VA examiner found that the Veteran had tenderness of the cervical spine, but no guarding or muscle spasm. No muscle atrophy was noted. Muscle strength testing results were 5/5. Sensory examination results were normal. There were hypoactive reflex examination results. The Veteran had moderate bilateral upper extremity pain without any paresthesias or numbness noted. No other neurologic abnormalities were found. The Veteran had intervertebral disc syndrome (IVDS), but no incapacitating episodes due to IVDS in the past 12 months were noted. Range of motion testing of the cervical spine revealed flexion at 20 degrees with pain, extension at 10 degrees with pain, right and left lateral flexion at 20 degrees with pain, right lateral rotation at 50 degrees with pain, and left lateral rotation at 20 degrees with pain. Following repetitive use testing, there was no additional limitation in range of motion. The VA examiner found functional loss of the cervical spine exhibited by less movement than normal, excess fatigability, pain on movement, and interference with sitting, standing and/or weight-bearing. A radiology report documented evidence of degenerative joint disease, mild to moderate chronic degenerative disc disease noted at C2-3, C3-4, and to the greatest extent at C4-5, and periprosthetic lucency around the C5 vertebral body screws, which was concerning for loosening. Based on a careful review of all of the evidence, the Board finds that, from November 27, 2007 to August 8, 2011, the Veteran's cervical spine disability does not warrant a higher 30 percent evaluation. The evidence, during this period, does not show that the Veteran's cervical spine manifests symptoms of flexion 15 degrees or less, or favorable ankylosis of the entire cervical spine. Indeed, the Veteran's cervical spine flexion was no less than 45 degrees (February 2009 VA examination). Although the February 2009 VA examiner found increased pain, weakness, lack of endurance, fatigue and incoordination upon repetitive use testing, no additional functional limitation was found other than difficulty when the Veteran quickly turned her head. Furthermore, the Veteran's activities of daily activities had only been slowed down due to her neck pain. Thus, despite the Veteran's competent and credible statements during this period of flare-ups of pain two to three times a month, the evidence does not demonstrate that the Veteran's cervical spine disability results in a level of diminished functional capacity consistent with the next higher evaluation. However, resolving all reasonable doubt in favor of the Veteran, from August 9, 2011 to December 20, 2011, the Veteran warrants a higher 30 percent evaluation for her cervical spine disability. At the Veteran's December 2011 VA examination, the objective findings showed significant worsening from her February 2009 VA examination, including a significant decrease throughout her range of motion, except for her right lateral rotation, and functional loss exhibited by less movement than normal, excess fatigability, pain on movement and interference with sitting, standing and/or weightbearing. Radiological evidence also showed that the Veteran's screws at level C5 had loosened. Notably, the Veteran's symptoms had progressively worsened such that further surgery was required. Based on the objective findings of the December 2011 VA examination that the Veteran's cervical spine had manifested symptoms of flexion at 20 degrees and functional loss, the Board finds that a higher 30 percent evaluation during this period is warranted. See Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011); Deluca, 8 Vet. App at 204-7. Thus, the Board finds that since August 2011, all of the increased symptomatology combined to roughly equate with limitation of motion to 15 degrees of forward flexion as required for the assignment of the next higher rating of 40 percent. This is based on the evidence of functional loss due to increased pain, weakness, lack of endurance, fatigue, and incoordination upon repetitive use. Indeed, the cervical spine symptoms had worsened at this time to the point where her private treating physician felt that surgery was required. The Board emphasizes that the Veteran's private treatment records document that her worsening neck symptoms began following her August 9, 2011 MVA. As the evidence does not provide objective findings during this period consistent with the requisite rating criteria until her December 2011 VA examination, which found worsening cervical spine symptoms since her February 2009 VA examination, the Board finds that the August 2011 private treatment records denote when those worsening symptoms began. Therefore, the Board finds that the Veteran's cervical spine disability is no more than 30 percent disabling as of August 9, 2011. Finally, the Board notes that the Veteran is already service-connected for her radiculopathy of the RUE and LUE associated with her service-connected cervical spine disability. The discussion of whether the Veteran may be entitled to a higher evaluation for her radiculopathy of her bilateral upper extremities is discussed further in the remand portion below. Left Hip Residual Scar From Bone Graft The Veteran is seeking an initial compensable evaluation for her left hip residual scar from bone graft. At her July 2015 Board hearing, the Veteran testified that her left hip scar was red, long and painful to touch. The Veteran said that she felt pain when her undergarment touched her scar. Scars not of the head, face, or neck are evaluated under 38 C.F.R. § 4.118, Diagnostic Codes 7801 to 7805. The Veteran has been currently evaluated as noncompensable, effective February 14, 2011, under Diagnostic Code 7805. In the alternative, burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are deep and nonlinear, are rated under Diagnostic Code 7801. (Note (1) provides that a deep scar is one associated with underlying soft tissue damage.) Under Diagnostic Code 7802, burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are superficial and nonlinear, in an area or areas of 144 square inches (929 sq. cm.) or greater, warrant a 10 percent rating. A superficial scar is one not associated with underlying soft tissue damage. (Note (1) provides that a superficial scar is one not associated with underlying soft tissue damage). For scar(s) that are unstable or painful: five or more scars that are unstable or painful warrant a 30 percent rating; three or four scars that are unstable or painful warrant a 20 percent rating; one or two scars that are unstable or painful warrant a 10 percent rating. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. If one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Scars evaluated under diagnostic codes 7800, 7801, 7802, or 7805 may also receive an evaluation under this diagnostic code, when applicable. 38 C.F.R. § 4.118, Diagnostic Code 7804. For scars, other (including linear scars) and other effects of scars evaluated under diagnostic codes 7800, 7801, 7802, and 7804, any disabling effect(s) not considered in a rating provided under diagnostic codes 7800-04 are to be evaluated under an appropriate diagnostic code. 38 C.F.R. § 4.118, Diagnostic Code 7805. An April 2011 VA treatment record documents that the Veteran complained of increased left hip pain at the site of her left iliac crest bone graft that she had undergone in 1998 at the time of her anterior cervical discectomy and fusion. A September 2011 VA treatment record reflects that the Veteran reported experiencing left hip or pelvic pain, which kept her awake. Following objective evaluation, the VA treating physician found that the Veteran had post traumatic iliac exostosis possibly status post bone graft harvest from the ilium. A March 2012 VA treatment record documents that the Veteran had worsening left anterior hip pain. An objective evaluation showed that the Veteran had a well-healed surgical scar proximal to the groin which was hypersensitive to palpation. In February 2014, the Veteran underwent a VA examination. Upon objective evaluation, the VA examiner found that the Veteran's scar was located on her left anterior hip, was superficial and non-linear, and measured 5.5 by 0.2 centimeters (cm). The scar was found to be stable, not painful, and had no frequent loss of covering of skin over the scar. No impact to her ability to work due to her scar was reported. Based on a careful review of all of the evidence, and resolving all reasonable doubt in favor of the Veteran, the Board finds that the Veteran's left hip residual scar from bone graft warrants a 10 percent evaluation for having one painful scar. 38 C.F.R. § 4.118, Diagnostic Code 7804. The Board acknowledges that the February 2014 VA examination found that the Veteran's scar was not painful. Nevertheless, the Board finds that the Veteran provided competent and credible testimony at her July 2015 Board hearing and there was objective evidence of hypersensitivity to palpation of the scar (March 2012 VA treatment record), which supports a finding that the Veteran's left hip residual scar has been painful. However, the evidence does not demonstrate that the Veteran's left hip residual scar was deep and nonlinear or had any disabling effects not considered under Diagnostic Codes 7800-7804. Therefore, the Board finds that the Veteran's left hip residual scar from bone graft warrants no more than a 10 percent evaluation. Extraschedular Consideration The Board has considered whether the Veteran's cervical spine disability or left hip residual scar present an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of an extraschedular rating is warranted. See 38 C.F.R. § 3.321(b)(1) (2015); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). The Veteran's service-connected cervical spine disability manifests symptoms of pain, weakness, fatigue, lack of endurance, incoordination, interference with siting, standing and/or weightbearing, headaches, and numbness, which impacted her ability to sleep and caused difficulty when rotating her neck. These symptoms and their resulting effects are fully contemplated by the rating schedule, which provides disability ratings on the basis of musculoskeletal deformity and contemplate a wide variety of manifestations of functional loss. The Veteran's service-connected left hip residual scar manifests symptoms of pain when touched, which caused her discomfort while wearing clothes that touched the area. These symptoms and their resulting effects are fully contemplated by the rating schedule, which takes into account that scars can be painful, unstable and/or disfiguring and provides for higher evaluations for manifestations of more severe symptoms than is currently assigned. The Board concludes that there is nothing exceptional or unusual about the Veteran's disabilities; the rating criteria adequately describe her disability level and symptomatology. Thun v. Peake, 22 Vet. App. 111, 115 (2008). For these reasons, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R. § 3.321(b)(1). Finally, according to Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a veteran may be entitled to "consideration [under 38 C.F.R. § 3.321(b)] for referral for an extra-schedular evaluation based on multiple disabilities, the combined effect of which is exceptional and not captured by schedular evaluations." Referral for an extraschedular rating under 38 C.F.R. § 3.321(b) is to be considered based upon either a single service-connected disability or upon the "combined effect" of multiple service-connected disabilities when the "collective impact" or "compounding negative effects" of the service-connected disabilities, when such presents disability not adequately captured by the schedular ratings for the service-connected disabilities. In this case, the Veteran has not asserted, and the evidence of record has not suggested, any such combined effect or collective impact of multiple service-connected disabilities that create such an exceptional circumstance to render the schedular rating criteria inadequate. In this case, there is neither allegation nor indication that the collective impact or combined effect of more than one service-connected disability presents an exceptional or unusual disability picture to render inadequate the schedular rating criteria. ORDER From November 27, 2007 to August 8, 2011, entitlement to an evaluation in excess of 20 percent for a cervical spine disability is denied. From August 9, 2011 to December 20, 2011, entitlement to a 30 percent evaluation for a cervical spine disability is granted. Entitlement to a 10 percent evaluation for left hip residual scar from bone graft associated with service-connected cervical spine disability is granted. REMAND Unfortunately, a remand is required in this case for the issues remaining on appeal. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claim so that the Veteran is afforded every possible consideration. With regard to the Veteran's increased evaluation claim for her service-connected cervical spine disability since February 1, 2012, the Board finds that the evidence demonstrates that the Veteran's neck symptoms may have worsened. As will be discussed below, the Veteran has asserted an increase in symptoms yet has not had a VA examination since the cervical spine surgery in December 2011. Indeed, following her July 2015 Board hearing, the Veteran submitted a statement in August 2015 indicating she had increased neck pain for which she received increased pain medication and four shoulder injections. She said that her private treating physician believed that she could have nerve damage. She was scheduled for a electromyography (EMG) nerve study and a cervical STASCAN in September 2015. She was also told that she may need further neck surgery. In addition, the Board finds that, at the July 2015 Board hearing, the Veteran testified that she had radiating pain and numbness into her arms and hands causing her difficulty gripping her hands. As previously discussed above, the Veteran did not specifically file for an increased evaluation claim for service-connected RUE radiculopathy and LUE radiculopathy. However, the Veteran's radiculopathy is associated with her service-connected cervical spine disability that is on appeal. Thus, the Board has included the higher evaluation claims for her bilateral upper extremities radiculopathy in this appeal. The Board finds that a new examination is warranted. The Veteran's last VA examination for her service-connected cervical spine disability and her service-connected RUE and LUE radiculopathy was in December 2011, prior to her December 21, 2011 anterior cervical discectomy and fusion. Since her last VA examination, almost four years ago, the Veteran has suggested that her cervical spine disability and bilateral upper extremities radiculopathy have worsened. VA is required to afford the Veteran a contemporaneous VA examination to assess the current nature, extent, and severity of her service-connected disabilities. See Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); see also 38 C.F.R. § 3.326(a) (2015). As the evidence suggests that the Veteran's cervical spine disability and bilateral upper extremities radiculopathy may have worsened since her last VA examination, a remand is required to determine the current severity of her service-connected disabilities. With regard to the Veteran's TDIU claim, the Board finds that, as the issue of whether the Veteran is entitled to a TDIU may be affected by the outcome of her increased evaluation claims for a cervical spine disability and radiculopathy of the bilateral upper extremities, the issues are inextricably intertwined. The Veteran's TDIU claim cannot be decided until her increased evaluation claims have been considered. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Finally, the Veteran is seeking entitlement to service connection for a skin rash or eczema of the face. At present, the issue on appeal is whether new and material evidence has been received to reopen the claim for service connection. The Board notes that if VA receives relevant service records that were not previously associated with the claims file, then VA will reconsider the Veteran's claim for service connection and she would not be required to submit new and material evidence to reopen her claim. See 38 C.F.R. § 3.156(c) (2015). Specifically, the Veteran contends that she developed a skin rash on her face during her U.S. Naval Reserve Service in 1989 or 1990 while she was stationed at the Naval Air Station in Jacksonville, Mississippi. She explained that she was receiving training in Fire Prevention outside in the sun, and then, sometime later, she had a black spot on her face. She said that she received treatment with a cream by a medic on the base. Every summer or when the weather is hot and she is exposed to the sun, the Veteran said that her rash recurs. The Board notes that the record shows that the Veteran did not have any active duty service and only performed active duty for training (ACDUTRA). See December 2007 request for information. In an October 2012 deferred rating, there was a request that the RO identify the dates of the Veteran's ACDUTRA. To date, the record does not include any information that such a search to identify those dates has been performed. The Board finds that a remand is necessary to comply with that October 2012 request. Moreover, the record includes service treatment records (STRs) from February 1994 to December 1995. However, an October 2012 formal finding memorandum was issued, which determined that the Veteran's STRs from May 1979 to July 1996 were unavailable. As there is a discrepancy between the formal finding and the existence of some STRs during that period in the record, the Board finds that additional research into the existence of any other available STRs should be performed. Indeed, as the Veteran has argued that her rash developed while she was in the U.S. Naval Reserves in 1989 or 1990, the AOJ should attempt to find such service records which could help to substantiate her claim. Accordingly, the case is REMANDED for the following action: 1. The AOJ should request identification of the Veteran's periods of ACDUTRA in the U.S. Naval Reserves, to include her service at the Naval Air Station in Jacksonville, Mississippi during 1989 to 1990. All records requests and responses received must be documented in the claims file and all pertinent follow-up should be undertaken. 2. After the above development has been completed, the AOJ should attempt to obtain any missing service treatment records for such identified periods of ACDUTRA in the U.S. Naval Reserves. All records requests and responses received must be documented in the claims file and all pertinent follow-up should be undertaken. 3. The AOJ should obtain and associate with the claims file outstanding clinical records for the Veteran's related to the issues on appeal. In specific regard to the cervical spine and the upper extremity impairments, attempt to obtain copies of the nerve studies identified by the Veteran in the statement submitted in August 2015. 4. After the above development has been completed, the AOJ should schedule the Veteran for a VA examination by an appropriately qualified examiner to determine the current severity of the Veteran's service-connected cervical spine disability and radiculopathy of the right and left upper extremities. The claims file, including a copy of this REMAND, should be made available to the examiner(s). All examination findings along with the complete rationale for all opinions expressed should be discussed in the examination report. 5. Then, the AOJ should readjudicate the increased evaluation claim for a cervical spine disability since February 1, 2012, adjudicate the increased evaluation claims for radiculopathy of the right and left upper extremities, adjudicate the TDIU claim, and readjudicate whether new and material evidence has been received to reopen the claim for service connection claim for a skin rash or eczema of the face. Any additional development deemed necessary to adjudicate claims shall be undertaken. If the benefits sought on appeal remain denied, in whole or in part, the Veteran should be provided with a supplemental statement of the case (SSOC). The Veteran has the right to submit additional evidence and argument on the 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 2014). ______________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs