Citation Nr: 1604488 Decision Date: 02/08/16 Archive Date: 02/18/16 DOCKET NO. 12-09 518 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for subcutaneous cysts of the forehead and right nasal bridge. 2. Entitlement to an increased rating for a scar residual of the removal of a left chest cyst and a tender scar to the right nasal bridge, rated as noncompensably disabling prior to November 13, 2012 and 10 percent thereafter. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Kristy L. Zadora, Counsel INTRODUCTION The Veteran had active duty service from May 1964 to May 1968. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a March 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. In February 2012, the Agency of Original Jurisdiction (AOJ) assigned a 10 percent rating for a subcutaneous cyst of the forehead and right nasal bridge, effective June 11, 2010. However, inasmuch as a higher rating is available for scaring, and the Veteran is presumed to seek the maximum available benefit for a disability, the claim for a higher rating has remained viable on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). In January 2013, the AOJ recharacterized the service-connected scar residual of the removal of a left chest cyst as scar residual of the removal of a left chest cyst and a tender scar to the right nasal bridge. The AOJ also assigned a 10 percent rating for this disability, effective November 13, 2012. However, inasmuch as a higher rating is available for scaring, and the Veteran is presumed to seek the maximum available benefit for a disability, the claim for a higher rating has remained viable on appeal. Id. In November 2015, the Veteran testified at a Board video-conference hearing before the undersigned Veterans Law Judge. A hearing transcript has been associated with the record. At such time, the Veteran waived initial AOJ consideration of evidence received since the February 2013 supplemental statement of the case. 38 C.F.R. § 20.1304(c) (2015). The Board may therefore properly consider such evidence. The Board notes that, in a January 2015 rating decision, the AOJ proposed to reduce the rating for subcutaneous cysts of forehead and right nasal bridge from a 10 percent rating to a noncompensable rating as of June 1, 2015. However, it does not appear that his proposed reduction has been implemented by the AOJ. This appeal was processed using the Veterans Benefits Management System (VBMS) and Virtual VA paperless claims processing systems. FINDINGS OF FACT 1. For the entire appeal period, the Veteran's subcutaneous cysts of the forehead and right nasal bridge manifested as three slightly hyperpigmented scars on the forehead and a scar on the nasal bridge that protruded from the skin, without visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features or two or three characteristics of disfigurement. 2. For the period prior to November 13, 2012, the Veteran's scar residual of a removal cyst on the left chest manifested as a chest scar without pain or instability. 3. For the period beginning on November 13, 2012 the Veteran's scar residual of a removal of a cyst on the left chest and tender scar to the right nasal bridge manifested as an intermittently tender chest scar, but it has not been shown that the Veteran has three or four scars that are unstable and painful, visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features or two or three characteristics of disfigurement. CONCLUSIONS OF LAW 1. An initial rating in excess of 10 percent for subcutaneous cysts of the forehead and right nasal bridge is denied. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.118, Diagnostic Code 7800 (2015). 2. An increased rating for a scar residual of a removal of a left chest cyst and a tender scar to the right nasal bridge, rated as noncompensably disabling prior to November 13, 2012 and 10 percent thereafter, is denied. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.118, Diagnostic Code 7804 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between a Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. With respect to the propriety of the assigned rating for the service-connected subcutaneous cysts of the forehead and right nasal bridge, the Veteran has appealed from the original grant of benefits. VA's General Counsel has held that no VCAA notice is required for such downstream issues. VAOPGCPREC 8-2003, 69 Fed. Reg. 25180 (May 5, 2004). In addition, the Board notes that the Court held that "the statutory scheme contemplates that once a decision awarding service connection, a disability rating, and an effective date has been made, § 5103(a) notice has served its purpose, and its application is no longer required because the claim has already been substantiated." Dingess/Hartman, supra. In this case, the Veteran's claim for service connection was granted and an initial rating was assigned in the March 2011 rating decision on appeal. Therefore, as the Veteran has appealed with respect to the initially assigned rating, no additional 38 U.S.C.A. § 5103(a) notice is required as the purpose that the notice is intended to serve has been fulfilled. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Relevant to the Veteran's claim for an increased rating for a scar residual of the removal of a left chest cyst and a tender scar to the right nasal bridge, an October 2012 letter advised the Veteran of the evidence and information necessary to substantiate his increased rating claim as well as his and VA's respective responsibilities in obtaining such evidence and information. Additionally, such letter advised him of the information and evidence necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. While the October 2012 letter was issued after the initial March 2011 rating decision, the United States Court of Appeals for the Federal Circuit has held that VA could cure such a timing problem by readjudicating the Veteran's claim following a compliant VCAA notification letter. Mayfield v. Nicholson, 444 F. 3d 1328, 1333-34 (Fed. Cir. 2006). The Court clarified that the issuance of a statement of the case could constitute a readjudication of the Veteran's claim. See Prickett v. Nicholson, 20 Vet. App. 370 (2006). In the instant case, after the October 2012 letter was issued, the Veteran's claim was readjudicated in the February 2013 supplemental statement of the case. Therefore, any defect with respect to the timing of the VCAA notice has been cured. Relevant to the duty to assist, the Veteran's service treatment records as well as VA and private treatment records have been obtained and considered. The Veteran has not identified any additional, outstanding records that have not been requested or obtained. The Veteran has been afforded several VA examinations in conjunction with the claims for higher rating decided herein. Such VA examinations include those conducted in January 2011, November 2012, and January 2015 to determine the severity of his subcutaneous cysts of the forehead and right nasal bridge as well as scar residual of a removal of a left chest cyst on and a tender scar to the right nasal bridge. Neither the Veteran nor his representative has alleged that these VA examinations are inadequate for rating purposes. Moreover, the Board finds that the examinations are adequate in order to evaluate the Veteran's service-connected disabilities as they include interviews with the Veteran, a review of the record, and full examinations, addressing the relevant rating criteria. Moreover, neither the Veteran nor his representative has alleged that his subcutaneous cysts of the forehead and right nasal bridge and/or scar residual of a removal of a left chest cyst and a tender scar to the right nasal bridge have worsened in severity since the last VA examination. Rather, with respect to such claims, they argue that the evidence reveals that these disabilities have been more severe than the currently assigned rating for the duration of the appeal period. Palczewski v. Nicholson, 21 Vet. App. 174 (2007) (the passage of time alone, without an allegation of worsening, does not warrant a new examination). Therefore, the Board finds that the examinations of record are adequate to adjudicate the Veteran's claims for higher ratings and no further examination is necessary. Additionally, in November 2015, the Veteran was provided an opportunity to set forth his contentions during the hearing before the undersigned Veterans Law Judge. In Bryant v. Shinseki, the Court held that 38 C.F.R. § 3.103(c)(2) requires that the RO Decision Review Officer or Veterans Law Judge who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Here, during the November 2015 hearing, the undersigned Veterans Law Judge enumerated the issues on appeal, which included higher ratings for subcutaneous cysts of the forehead and right nasal bridge as well as scar residual of a removal of a left chest cyst and tender scar to the right nasal bridge. Additionally, testimony regarding the nature and severity of the Veteran's service-connected cyst and scar disabilities was solicited, to include the type and frequency of the symptoms he experiences as a result of such disabilities, as well as the impact such have on his daily life and employment. Therefore, not only were the issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim," were also fully explained. See Bryant, 23 Vet. App. at 497. While the undersigned elicited testimony regarding treatment for the Veteran's disabilities, the hearing discussion did not reveal any additional, outstanding records referable to such claims as all identified records had previously been associated with the record. Under these circumstances, nothing gives rise to the possibility that evidence had been overlooked with regard to the Veteran's claims decided herein. As such, the Board finds that, consistent with Bryant, the undersigned Veterans Law Judge complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board may proceed to adjudicate the claims based on the current record. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of his claims. II. Analysis Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the 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 rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). While the Veteran's entire history is reviewed when making a disability determination, where service connection has already been established and an increase in the disability rating is at issue, it is a present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The Court has held that, in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. The diagnostic criteria for disorders of the skin are found at 38 C.F.R. § 4.118, Diagnostic Codes 7801-7805. The Board notes that on September 23, 2008, VA amended the criteria for evaluating scars. See 73 Fed. Reg. 54,708 (Sept. 23, 2008). The amendments are only effective for claims filed on or after October 23, 2008. As the Veteran's claims were received in June 2010, only the amended regulations are applicable to these claims. Under Diagnostic Code 7800, burn scars of the head, face, or neck; scars of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck. A 10 percent rating is assigned when one characteristic of disfigurement is present and a 30 percent rating is warranted when there is visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features, or; with two or three characteristics of disfigurement. A 50 percent rating for disfigurement of the head, face, or neck is warranted for visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement. A rating of 80 percent for disfigurement of the head, face or neck with visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement. The eight characteristics of disfigurement for purposes of evaluation under 38 C.F.R. § 4.118 are: Scar five or more inches (13 or more centimeters) in length; Scar at least one-quarter inch (0.6 centimeters) wide at the widest part; Surface contour of scar elevated or depressed on palpation; Scar adherent to underlying tissue; Skin hypo-or hyper-pigmented in an area exceeding six square inches (39 square centimeters); Skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 square centimeters); Underlying soft tissue missing in an area exceeding six square inches (39 square centimeters); Skin indurated and inflexible in an area exceeding six square inches (39 square centimeters). Under Diagnostic Code 7801, burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are deep and nonlinear in an area or areas of at least 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.) warrant a 10 percent rating. Higher ratings are available for scars of greater area. 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 evaluation. Note (2) under that code provides that if multiple qualifying scars are present, assign a separate evaluation for each affected extremity based on the total area of the qualifying scars that affect that extremity. Under Diagnostic Code 7804, one or two scars that are unstable or painful warrant a 10 percent rating. A 20 percent rating is warranted where there are three or four scars that are unstable or painful, and a 30 percent rating is warranted where there are five or more scars that are unstable or painful. Note (2) for that code provides that 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. Note (3) under that provides that scars evaluated under Diagnostic Codes 7800, 7801, 7802, or 7805 may also receive an evaluation under this diagnostic code when applicable. Diagnostic Code 7805 provides that other scars (including linear scars) and other effects of scars evaluated under Diagnostic Code 7800, 7801, 7802, and 7804 require the evaluation of any disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-04 under an appropriate Diagnostic Code. A. Subcutaneous Cysts of Forehead and Right Nasal Bridge The Veteran contends that a higher rating is warranted for his subcutaneous cysts of the forehead and right nasal bridge. During a November 2015 hearing, the Veteran testified that his cysts swelled, that he was self-conscious about his facial scars and that he felt his scars were disfiguring. A January 2011 VA examination report reflects the Veteran's reports of having a lump removed from his right forehead in the 1990s, a mass removed from between his eyes sometime after service, and a mass removed from the right bridge of his nose in December 2009. He reported that the cysts were intermittent, that his only treatment had been the previous surgery, and that there was no treatment in the past 12 months. Physical examination revealed a nontender subcutaneous cyst on the forehead above the nasal bridge that was noted to measure eight mm by 10 mm as well as a nontender subcutaneous cyst on the right nasal bridge adjacent to the surgical scar that was noted to measure three mm by five mm. The examiner found that less than one percent of exposed areas were affected and less than one percent of the entire body were affected by the scar. Examination was negative for acne or chloracne. A November 2012 VA examination report reflects the Veteran's reports that his right nasal bridge scar was tender but not painful. He denied taking any medication. Physical examination revealed a one inch circinate scar on the bridge of the right side of the nose. Examination was negative for a loss of skin, disfigurement, elevation, depression, abnormal pigmentation, distortion of features or limitation of function. A January 2015 VA scars Disability Benefits Questionnaire (DBQ) report reflected diagnoses of a well-healed, asymptomatic scar on the right nasal bridge and three asymptomatic hardly visible small slightly hyperpigmented scars on the forehead. The Veteran reported that he had an eruption of cysts on the forehead and nasal bridge of the right nose, that there was no recurrence of the sebaceous cyst on the face and that he did have a hypertrophic scar on the nasal bridge. The scar was noted to be well-healed without keloids, instability, or pain. Physical examination revealed a U-shaped, well-healed, asymptomatic, nontender scar on the right nasal bridge. The scar was noted to measure two cm by 0.01 cm. A second scar was noted to be located on the forehead, presumably from removal of the cyst, that was described as well-healed, asymptomatic, and nontender. This scar was noted to measure one cm by 0.01 cm. A third scar was noted to be located on the right side of the forehead, presumably from excision of a sebaceous cyst, and was described as small, hardly visible, and mildly hyperpigmented. The scar was noted to measure one cm by 0.01 cm. A fourth scar was noted to be located on the left side of the forehead, presumably from the excision of a sebaceous cyst, and was described as asymptomatic, well-healed, hardly visible, and non-tender. The scar was noted to measure one cm by 0.01 cm. Examination was negative for elevation, depression, adherence to underlying tissue, missing underlying soft tissue, the distortion of facial features, tissue loss for the head, face and neck, asymmetry of facial features, or visible or palpable tissue loss. Based on the evidence of record, the Board must find that a higher rating for subcutaneous cysts of the forehead and right nasal bridge is not warranted during the course of the appeal. In this regard, the Board notes that the January 2011 VA examiner found a nontender cyst on the Veteran's forehead and right nasal bridge. While the January 2015 VA examiner noted that there were three slightly hyperpigmented scars on the Veteran's forehead, the area affected did not exceed six square inches. Moreover, during his November 2015 hearing, the Veteran testified that his right nasal bridge cyst protruded from his skin, suggesting that the surface contour of the scar was elevated or depressed on palpation. A higher rating is not warranted as the record does not establish, and the Veteran does not allege, that his disability manifested as a scar measuring five or more inches, a scar that was at least one-quarter inch wide at the widest part, that the scar was adherent to the underlying tissue, that the scar was hypo- or hyper-pigmented in an area exceeding six square inches, that the underlying soft tissue was missing in an area exceeding six square inches or that the skin indurated and inflexible in an area exceeding six square inches. 38 C.F.R. § 4.118, Diagnostic Code 7800. Therefore, the severity of this subcutaneous cysts are adequately contemplated in the current 10 percent rating. B. Left Chest and Right Nasal Bridge Scars The Veteran generally contends that a higher rating is warranted for his left chest and right nasal bridge scars. During a November 2015 hearing, the Veteran testified that his scars were not tender to the touch. A January 2011 VA examination report indicates that the Veteran had a sebaceous cyst removed from his left areolar region during service and that such removal left a residual scar. He also reported having two or three such cysts removed subsequent to service. Physical examination revealed a two inch by 0.25 inch scar in the inferior region of the left areola and inferior nipple. This incision line was noted to be curvilinear, mildly hypopigmented, and superficial. Examination was negative for obvious edema or keloid formation, pain, skin breakdown or evidence of burns. This scar did not result in limitation of motion or function. A November 13, 2012 VA examination report indicates that there was a scar on the Veteran's left nipple that measured one-half inch by one-half inch and was described as barely visible, tender, and stable. Examination was negative for the loss of underlying tissue or burns. A January 2015 VA DBQ report reflects a diagnosis of a hardly visible hypopigmented scar below the nipple. The Veteran denied that the scar was painful, that the scar was unstable, or that the scars on the trunk were due to burns. Physical examination revealed one well-healed, fading hypopigmented scar below the left nipple as well as a U-shaped, well-healed, asymptomatic nontender scar on the right nasal bridge. The scar was noted to measure two cm by 0.01 cm. Based on the evidence of record, the Board finds that a higher rating for scar residual of a removal cyst left chest is not warranted for any period during the course of the appeal. Prior to November 13, 2012, the Veteran's left chest scar manifested as a superficial and mildly hypopigmented scar. The Veteran has not alleged, and the record does not otherwise suggest, that this scar was unstable or painful. As such, a compensable rating for this appellate period is not warranted. Beginning on November 13, 2012, the Veteran's scar residual of the removal of a left chest cyst and tender scar to the right nasal bridge manifested as barely visible, intermittently tender, and stable on the chest and a hypertrophic scar on the nasal bridge. The Veteran has not alleged, and the record does not otherwise suggest, that such scars were unstable. Similarly, there is no suggestion that there are three or four scars that were unstable or painful. Therefore, the severity of this scar is adequately contemplated in the current 10 percent rating. The Board has also considered whether higher or separate ratings were warranted under alternative diagnostic codes. With regard to the Veteran's right nasal bridge scar, a higher or separate rating under Diagnostic Code 7800 is not warranted as such symptomatology is already considered in the current rating assigned under such Diagnostic Code for his cyst of the right nasal bridge. Furthermore, as discussed in the preceding section, the record does not establish, and the Veteran does not allege, that this scar manifested as a scar measuring five or more inches, a scar that was at least one-quarter inch wide at the widest part, that the scar was adherent to the underlying tissue, that the scar was hypo- or hyper-pigmented in an area exceeding six square inches, that the underlying soft tissue was missing in an area exceeding six square inches or that the skin indurated and inflexible in an area exceeding six square inches. 38 C.F.R. § 4.118, Diagnostic Code 7800. Moreover, the new Diagnostic Codes 7801 and 7802 are not for application as the Veteran's scars were not deep and did not encompass an area 44 square inches or greater. See 38 C.F.R. § 4.118. C. Other Considerations The Board has considered whether further staged ratings under Fenderson, supra, and Hart, supra, are appropriate for the Veteran's service-connected subcutaneous cysts of the forehead and right nasal bridge as well as a scar residual of a removal of a left chest cyst and a tender scar to the right nasal bridge; however, the Board finds that his symptomatology has been stable for each disability in each stage throughout the appeal. Therefore, assigning staged ratings, or further staged ratings, for each such disability is not warranted. In making its determinations in this case, the Board has carefully considered the Veteran's contentions with respect to the nature of his service-connected disabilities at issue and notes that his lay testimony is competent to describe certain symptoms associated with these disabilities. The Veteran's history and symptom reports have been considered, including as presented in the medical evidence discussed above, and have been contemplated by the disability ratings for which the Veteran has already been assigned. Moreover, the competent medical evidence offering detailed specific findings pertinent to the rating criteria is the most probative evidence with regard to evaluating the pertinent symptoms of the service-connected disabilities at issue. As such, while the Board accepts the Veteran's testimony with regard to the matters he is competent to address, the Board relies upon the competent medical evidence with regard to the specialized evaluation of functional impairment, symptom severity, and details of clinical features of the service-connected conditions at issue. Additionally, the Board has contemplated whether the case should be referred for extra-schedular consideration. An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under § 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that there must be 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. Under the approach prescribed by VA, 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. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected subcutaneous cysts of the forehead and right nasal bridge as well as a scar residual of a removal of a left chest cyst and a tender scar to the right nasal bridge with the established criteria found in the rating schedule. The Board finds that the Veteran's symptomatology is fully addressed by the rating criteria under which each such disability is rated. The Veteran's various subjective complaints-including but not limited to intermittent scar tenderness, elevation of the scar, and facial disfigurement-are contemplated by the rating criteria under which each associated disability is rated. Specifically, with regard to the Veteran's subcutaneous cysts of the forehead and right nasal bridge, his complaints of facial disfigurement were specifically contemplated by his assigned rating. See 38 C.F.R. § 4.118 Diagnostic Code 7800. With regard to the scar residual of the removal of a cyst to the left chest and a tender scar to the right nasal bridge, the relevant Diagnostic Code provides a rating based upon scar tenderness or pain. See 38 C.F.R. § 4.118, Diagnostic Code 7804. In sum, the Veteran's symptoms, and their resulting impairment, are contemplated by the rating schedule. The Board notes that, pursuant to Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a Veteran may be awarded an extra-schedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where evaluation of the individual conditions fails to capture all the symptoms associated with service-connected disabilities experienced. However, in this case, even after affording the Veteran the benefit of the doubt under Mittleider v. West, 11 Vet. App. 181 (1998), there is no additional impairment that has not been attributed to a specific, rated disability. Accordingly, this is not an exceptional circumstance in which extra-schedular consideration may be required to compensate the Veteran for disability that can be attributed only to the combined effect of multiple conditions. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology of his service-connected disabilities. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability picture for each disability. Therefore, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. In this case, the record does not reflect, and the Veteran does not allege, that he is unemployable due to his scars. Therefore, the Board finds that a TDIU is not raised by the Veteran or reasonably raised by the record in connection with his initial and increased rating claims decided herein and, consequently, no further consideration of such is necessary at this time. The Board has also considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claims for a higher rating for subcutaneous cysts of the forehead and right nasal bridge as well as a scar residual of the removal of a left chest cysts and a tender scar to the right nasal bridge. Therefore, the benefit of the doubt doctrine is not applicable in the instant appeals and his claims for higher ratings must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. (CONTINUED ON NEXT PAGE) ORDER An initial rating in excess of 10 percent for subcutaneous cysts of the forehead and right nasal bridge is denied. An increased rating for a scar residual of the removal left chest cyst and a tender scar to the right nasal bridge, rated as noncompensably disabling prior to November 13, 2012 and 10 percent thereafter, is denied. ____________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs