Citation Nr: 1629164 Decision Date: 07/21/16 Archive Date: 08/01/16 DOCKET NO. 07-21 665 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for right shoulder bursitis. 2. Entitlement to an initial rating in excess of 10 percent for cervical spine degenerative disc disease (DDD) prior to July 19, 2013. 3. Entitlement to a rating in excess of 20 percent for cervical spine DDD from November 1, 2013. 4. Entitlement to an initial rating in excess of 10 percent for left upper extremity radiculopathy. 5. Entitlement to an effective date earlier than November 1, 2013 for the grant of service connection for left upper extremity radiculopathy. 6. Entitlement to an initial compensable rating for a scar associated with cervical spine DDD. 7. Entitlement to a rating in excess of 60 percent for eczema. 8. Entitlement to an effective date earlier than December 18, 2014 for the grant of an increased, 60 percent rating for eczema. REPRESENTATION Veteran represented by: Virginia A. Girard-Brady, Attorney at Law WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Mary E. Rude, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1992 to August 2003. These matters initially came before the Board of Veterans' Appeals (Board) from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. The claims file is now entirely in VA's secure electronic processing systems, Virtual VA and the Veterans Benefits Management System. In April 2007, the RO granted entitlement to service connection for right shoulder bursitis and assigned an initial noncompensable rating from the February 9, 2005 date of claim. The Veteran timely appealed the initial rating assigned. In June 2009, the Veteran testified during a hearing at the RO before the undersigned. A transcript of that hearing is of record. In September 2009, the Board denied the Veteran's claim for an initial compensable rating for right shoulder bursitis. In December 2010, United States Court of Appeals for Veterans Claims (Court) granted a joint motion to vacate that portion of the Board's decision and remand this matter to the Board. In May 2012, the Board remanded the claim to the agency of original jurisdiction (AOJ) for additional development. In March 2013, the AOJ increased the rating for the Veteran's right shoulder bursitis to 10 percent, effective January 29, 2013, and in December 2013 the Board remanded the claim for additional development. An August 2015 rating decision extended the effective date for the 10 percent rating to February 9, 2005. Separately, in April 2012, the RO granted entitlement to service connection for cervical spine DDD and assigned an initial rating of 10 percent, effective the August 31, 2010 date of claim. The Veteran timely appealed the initial rating assigned. In December 2013, the Board, noting that the Veteran had undergone surgery to address that service-connected disability, therefore considered the issue of entitlement to a temporary total rating due to convalescence under 38 C.F.R. § 4.30 (2015) as part of the claim for a higher initial rating for cervical spine DDD. The Board remanded the claim to the AOJ for additional development. In January 2014, the AOJ granted a temporary total rating for convalescence due to cervical spine surgery from July 19, 2013 to October 30, 2013. As that decision granted the benefit sought and the Veteran did not appeal, the issue of entitlement to a temporary total rating due to convalescence under 38 C.F.R. § 4.30 is no longer before the Board. The AOJ assigned a 10 percent rating from November 1, 2013. Subsequently, however, in July 2014, the AOJ increased the rating for the Veteran's cervical spine DDD to 20 percent, effective November 1, 2013, thus creating a staged rating as indicated on the title page. In a July 2015 rating decision, the RO reduced the Veteran's current rating to 10 percent; however, this reduction was restored in a May 2016 rating decision. The July 2014 rating decision also granted entitlement to service connection for left upper extremity radiculopathy and assigned a 10 percent rating, effective November 1, 2013, and granted entitlement to service connection for a scar associated with cervical DDD with a noncompensable rating, effective July 19, 2013. In February 2015, the Veteran filed a timely NOD regarding all issues adjudicated in the July 2014 rating decision. In January 2015, the RO granted entitlement to an increased 60 percent rating for eczema, effective the December 18, 2014 date of the increased rating claim. In March 2015, the Veteran filed a timely NOD, including disagreement with the effective date assigned for the increased rating. In May 2015, the Board granted the Veteran an initial rating of 10 percent for right shoulder bursitis and remanded the question of whether a rating higher than 10 percent was warranted. The Board also remanded the remaining issues for further development and so that a statement of the case (SOC) could be issued addressing entitlement to an initial rating in excess of 10 percent for left upper extremity radiculopathy, entitlement to an effective date earlier than November 1, 2013 for the grant of service connection for left upper extremity radiculopathy, entitlement to an initial compensable rating for scar associated with cervical spine DDD, entitlement to a rating in excess of 60 percent for eczema, and entitlement to an effective date earlier than December 18, 2014 for the 60 percent rating for eczema. While the case was under review at the Board, the RO issued an SOC addressing the issues of entitlement to increased ratings for left upper extremity radiculopathy and for a scar related to cervical spine DDD in a May 2015. An SOC addressing entitlement to an earlier effective date for the grant of 60 percent for eczema was issued in June 2015. The Veteran perfected his appeals of these issues in July 2015. The issues of entitlement to an initial rating in excess of 10 percent for cervical spine DDD prior to July 19, 2013 and in excess of 20 percent since November 1, 2013, to an initial rating in excess of 10 percent for left upper extremity radiculopathy, and to an effective date earlier than November 1, 2013 for the grant of service connection for left upper extremity radiculopathy are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. (CONTINUED ON NEXT PAGE) FINDINGS OF FACT 1. The Veteran's right shoulder bursitis has not been shown to have limitation of motion at the shoulder level. 2. The Veteran's scar associated with cervical spine DDD is superficial, is not painful or unstable, has an area of less than 39 square centimeters, and does not manifest of any characteristics of disfigurement. 3. The Veteran is in receipt of the highest possible schedular rating for her eczema under the applicable diagnostic code. 4. The Veteran submitted a claim for an increased rating for eczema on December 18, 2014. The medical evidence of record indicates that the Veteran's service-connected eczema underwent an increase in severity on April 11, 2014. The evidence does not show that an increase in severity occurred between December 18, 2013 and April 11, 2014. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for right shoulder bursitis have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Codes 5003, 5019, 5024, 5201 (2015). 2. The criteria for an initial compensable rating for a scar associated with cervical spine DDD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.118, Diagnostic Codes 7800-7805 (2015). 3. The criteria for a rating in excess of 60 percent for eczema have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.31, 4.118, Diagnostic Code 7806 (2015). 4. Since April 11, 2014, but no earlier, the criteria for a 60 percent rating for eczema have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 5110 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 3.400, 4.118, Diagnostic Code 7806 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Clams Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. The requirements of the statute and regulation have been met with regard to the claims decided herein. VA notified the Veteran of the information and evidence needed to substantiate and complete her claims in correspondence sent in March 2005, May 2008, December 2014, and March 2015. The issues were last readjudicated in May 2015, June 2015, and January 2016. The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran, including service treatment records, VA and private treatment records, written personal statements, and personal hearing testimony. Pursuant to the prior Board remands, all Board instructions pertaining to the issues decided at this time were completed. The records identified in the most recent June 2015 Board remand have been obtained and associated with the claims file. The Board finds that there has been substantial compliance with the prior remand directives pertaining to the issues decided herein, fulfilling the duty to assist. See Stegall v. West, 11 Vet. App. 268 (1998). The Veteran attended VA examinations in March 2007, January 2009, August 2010, April 2011, January 2013, June 2014, January 2015, and July 2015. These examinations were held following review of the Veteran's medical history and in-person examination of the Veteran. The VA examination reports provide adequate information regarding the Veteran's current diagnoses and symptomatology for the Board to evaluate the claims decided herein. Accordingly, the Board finds that VA's duty to assist with respect to obtaining VA examinations has been met. 38 C.F.R. § 3.159(c)(4). Lastly, during the June 2009 Board hearing, which addressed the issue of entitlement to higher ratings for right shoulder bursitis and eczema, the undersigned explained the issues on appeal and suggested the submission of evidence that may have been overlooked. These actions provided an opportunity for the Veteran and his representative to introduce material evidence and pertinent arguments, in compliance with 38 C.F.R. § 3.103(c)(2) (2015) and consistent with the duty to assist. See Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010). The Veteran has not requested a Board hearing addressing the remaining issues on appeal. As there is no indication that any failure on the part of VA to provide any additional notice or assistance reasonably affects the outcome of the issues decided at this time, the Board finds that any such failure is harmless. See Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). The Veteran has had a meaningful opportunity to participate in the adjudication of these claims such that the essential fairness of the adjudication is not affected. II. Right Shoulder Bursitis The Veteran contends that her service-connected right shoulder bursitis warrants an initial rating higher than 10 percent. The Veteran's right shoulder disability was assigned an effective date of February 9, 2005. The Veteran testified in June 2009 that she has constant pain in her shoulder blade and that she cannot reach as high as she can with her left arm. Board Hearing Transcript 13, 15. The Veteran has also submitted written statements describing how her shoulder becomes tired and painful and has spasms. She has indicated that her pain is distracting, reduces her reflexes, and impacts her ability to sleep. The Veteran's VA and private treatment records show frequent complaints of right shoulder pain. In April 2005, the Veteran reported having right shoulder pain and was found to have full range of motion with crepitus. The Veteran was able to "pop" her right scapula. In July 2006, she reported chronic right shoulder pain, and in August 2006, she reported continued right shoulder pain and some paresthesia, but denied loss of range of motion or strength. Physical examination showed full range of motion and strength. The Veteran had full range of motion in September 2006 with no pain and normal strength, and reported right shoulder pain on numerous occasions in 2007 and 2008. A January 2008 MRI of the right shoulder showed Type-II acromion with small subacromial spur, with no evidence of subacromial bursitis, outlet narrowing, or rotator cuff pathology. In April 2010, the Veteran had right shoulder pain with good range of motion. At a March 2007 VA examination, the examiner noted that the Veteran's range of motion was within normal limits and her examination was unremarkable regarding pain and fatigue in the right shoulder. The examiner noted that there were no signs of edema, effusion, weakness, tenderness, redness, heat, abnormal movement, subluxation, or guarding of movement in the right shoulder. Flexion was to 180 degrees, abduction to 180 degrees, external rotation to 90 degrees, and internal rotation to 90 degrees. The examiner noted that joint function in the right shoulder was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. The Veteran also attended a January 2009 VA examination, where she reported pain in her right shoulder that increased with typing, carrying objects, or repetitive motion. She reported that she was employed as a secretary and that the disability's impact on her occupational functioning was that she had to take frequent breaks while typing. She denied any effect on her daily activities. The examiner noted pain in the right shoulder with full range of motion. Flexion was to 180 degrees without pain. Abduction was to 180 degrees without pain. Internal and external rotations were to 90 degrees without pain. The examiner noted no additional limitation of motion with repetitive use. At an April 2011 VA examination, the Veteran reported right shoulder flare ups once a day, with fatigability, lack of endurance, and stiffness. She had no signs of inflammation or history of subluxation. She reported no hospitalizations or surgery and stated that it prevented her from lifting, pushing, or pulling. Physical examination found no joint deformity, deviation, or muscle atrophy. There was mild tenderness. Range of motion was flexion of 0 to 120 degrees with pain, abduction of 0 to 100 degrees with pain, external rotation of 0 to 70 degrees, and internal rotation of 0 to 75 degrees. Repetition of range of motion produced no decrease in function secondary to pain, fatigue, weakness, or lack of endurance. At a January 2013 VA examination, the Veteran reported having dull daily pain with flare ups which resulted in decreased range of motion. The examiner noted that a flare up would result in decreased range of motion and fatigue. Range of motion testing found right shoulder flexion to 180 degrees, with painful motion at 90 degrees, and abduction to 180 degrees, with painful motion at 145 degrees. There was no change in range of motion after repetitive motion. There was localized tenderness and guarding, decreased muscle strength, and no ankylosis. The examiner noted that the Veteran's occupational activities would be limited when they involved reaching above shoulder level or performing repetitive lifting, pushing, or carrying more than 15 pounds. The examiner also noted that the Veteran would be limited at working at a high rate of speed and would need to take rest breaks and use modifications such as headsets for the telephone. The examiner was unable to state the additional loss of range of motion during flare ups because the examiner was not present during a flare up and would have to resort to speculation. The Veteran most recently attended a VA examination for the right shoulder in June 2014. She reported that she was unable to use her arm for long and had to rest often. Right shoulder flexion was to 125 degrees and 115 with pain, and right shoulder abduction was to 110 degrees, including with pain. Repetitive use caused additional limitation of motion to 115 degrees of flexion and 110 degrees of abduction. The Veteran had guarding and localized tenderness. There was normal strength and no ankylosis. The Veteran's ability to work was impacted by limiting her range of motion and ability to reach overhead. The degree of range of motion loss during pain on use or flare ups was approximately 15 degrees of flexion. Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings 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 their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Fenderson v. West, 12 Vet. App. 119, 126 (1999); Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where there is a question as to which of the two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Functional loss may be due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. 38 C.F.R. §§ 4.45; 4.59. A higher rating can be based on "greater limitation of motion due to pain on use." DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Any such functional loss must be "supported by adequate pathology and evidenced by the visible behavior of the claimant." 38 C.F.R. § 4.40. The Veteran's right shoulder bursitis is rated under Diagnostic Codes 5019 and 5024, for bursitis and tenosynovitis. 38 C.F.R. § 4.71a, Diagnostic Codes 5019, 5024. These diagnostic codes require that the disability be rated on limitation of motion of the affected part or as degenerative arthritis. The Veteran's affected part is her right shoulder, which is her major extremity (she is right handed), and limitation of motion of the arm is rated under Diagnostic Code 5201. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Limitation of motion of the major arm at shoulder level (90 degrees) is assigned a 20 percent evaluation. Id.; 38 C.F.R. § 4.71, Plate I. Limitation of motion limited to midway between the side and shoulder level is assigned a 30 percent evaluation. Id. Limitation of motion to 25 degrees from the side is assigned a 40 percent evaluation. Higher ratings may be assigned for ankylosis of the scapulohumeral articulation or impairment of the humerus, clavicle, or scapula. 38 C.F.R. § 4.71a, Diagnostic Codes 5200, 5202, 5203 (2015). Under Diagnostic Code 5003, degenerative arthritis is rated on the basis of limitation of motion under the appropriate diagnostic code for the appropriate joints. 38 C.F.R. § 4.71a, Diagnostic Code 5003. When limitation of motion is noncompensable, Diagnostic Code 5003 allows for the assignment of 10 percent for each major joint or group of minor joints affected by limitation of motion. Id. There is no evidence that any rating higher than 10 percent is warranted for the Veteran's right shoulder bursitis. To be assigned a 20 percent evaluation based on the limitation of motion of the right shoulder, it must be demonstrated that the Veteran has limitation of motion to the shoulder level, either in flexion or abduction. 38 C.F.R. § 4.71a, Diagnostic Code 5201. At none of the Veteran's VA examinations has she been found to be unable to lift her arms 90 degrees or less. At the April 2011 and June 2014 VA examinations, her abduction was limited to 100 and 110 degrees, which is greater than the minimum range of motion allowing for a 20 percent rating under Diagnostic Code 5201. This is consistent with the Veteran's VA and private treatment records, which show complaints of pain, but no significant decrease in range of motion. In fact, the Veteran was noted on several occasions to have "good" range of motion or "full" range of motion. Although the Veteran's limitation of motion is not sufficient to warrant a rating under Diagnostic Code 5201, she has been shown to have some limitation of motion. Because she has restriction in motion which is noncompensable, a 10 percent rating, but not higher, is assigned under Diagnostic Code 5003. 38 C.F.R. § 4.71a, Diagnostic Code 5003. The Board has taken into consideration the Veteran's painful motion, which is noted at several of her VA examinations. At the January 2013 VA examination, the Veteran had painful motion starting at 90 degrees of flexion. While the Board acknowledges this finding of pain at 90 degrees of flexion, this, alone, is not sufficient to warrant an evaluation of 20 percent for limitation of motion, as it did not result in any clinically measurable further limitation of function. See Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011). Although pain may cause functional loss, pain itself does not constitute functional loss. Rather, pain must affect some aspect of "the normal working movements of the body," such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Id. (quoting 38 C.F.R. § 4.40). Hence, while the Veteran has been shown to experience considerable pain when she raises her arm, it does not result in any clinically measurable further limitation of function, even after performing repetitive motion exercises. The Veteran's functional restrictions due to pain are adequately considered and are included within the rating criteria applied. The Board empathizes with the Veteran, but without evidence of further physical restriction or painful motion that restricts functional motion in excess of that found on examination, pain, alone, does not provide an additional basis for a higher evaluation. There is also no evidence that the Veteran has ankylosis of the scapulohumeral articulation or impairment of the humerus, clavicle, or scapula, and thus these Diagnostic Codes are not applicable to the Veteran's left shoulder impairment. 38 C.F.R. § 4.71a, Diagnostic Codes 5200, 5202, 5203. The Board has also considered the Veteran's lay statements regarding the functional impact of her right shoulder disability. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Her statements are credible, and the symptomatology she has testified regarding is consistent with the findings of the VA examinations discussed above and has been taken into consideration in the assignment of the current evaluations. In sum, the Veteran has limitation of motion of the right shoulder of no worse than 100 degrees of abduction. There is no medical evidence indicating that her limitation of motion of the shoulder is any worse than that shown at the examinations discussed above, and the assignment of initial rating higher than 10 percent is not warranted. In reaching this decision the Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable. 38 U.S.C.A. § 5107(b); See, e.g., Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). III. Scar The Veteran also contends that a compensable initial rating is warranted for her scar associated with her post cervical fusion surgery due to DDD of the cervical spine. The Veteran was granted entitlement to service connection for a scar in a July 2014 rating decision, effective July 19, 2013. The June 2014 VA examination noted that the Veteran had a scar associated with her cervical spine disorder, but that it was not painful, unstable, or of a total area greater than 6 square inches. It was recorded as 4.5 centimeters in size. The Veteran also attended a VA examination in June 2015. She was noted to have a scar due to cervical fusion on the frontal neck which was not painful or unstable. The scar was 6 centimeters by 0.4 centimeters. There was no elevation, depression, adherence to underlying tissue, abnormal pigmentation, abnormal texture, or missing underlying soft tissue, and it did not cause any disfigurement. A photograph of the Veteran's scar was attached to the examination report. The Veteran's scar is rated under Diagnostic Code 7800, governing scars of the head face or neck. 38 C.F.R. § 4.118, Diagnostic Code 7800. Under Diagnostic Code 7800, a 10 percent rating is warranted for scars of the head, face or neck with one characteristic of disfigurement. Id. The eight characteristics of disfigurement are: 1) a scar of five or more inches (13 or more centimeters) in length; 2) a scar at least one-quarter inch (0.6 centimeters) wide at the widest part; 3) elevated or depressed scar surface contour on palpation; 4) scar adherent to underlying tissue; 5) hyper- or hypopigmentation in an area exceeding six square inches; 6) abnormal skin texture (irregular, atrophic, shiny, scaly, etc) in an area exceeding six square inches; 7) missing underlying soft tissue in an area exceeding six square inches (39 square centimeters); and 8) indurated and inflexible skin in an area exceeding six square inches. 38 C.F.R. § 4.118, Diagnostic Code 7800, Note 1. When rating scars of the head, face, or neck, unretouched color photographs are to be taken into account when evaluating the disability. Id. at Note 3. Disabling effects other than disfigurement associated with the individual scar of the head, face or neck, such as pain, instability and residuals of associated muscle or nerve injury, are to be rated separately under the appropriate diagnostic code. Id. at Note 4. The Board has applied these rating criteria, and does not find that a compensable rating is warranted. The Veteran's scar was clearly measured by the June 2015 examiner, and at 6 centimeters by 0.4 centimeters, it is of insufficient size to warrant a compensable rating. The VA examiner indicated that the scar is not painful, unstable, hypopigmented, or irregular in any other way, nor has the Veteran alleged such symptoms. The Board also reviewed the photograph of the Veteran's scar, and does not find that it is inconsistent with the findings of the VA examiner. Based on this evidence, the Board finds that the preponderance of the evidence is against a finding that an initial compensable rating is warranted for the Veteran's scar. There is no medical or lay evidence that the Veteran's scars meets any of the criteria for one of the characteristics of disfigurement, nor that it is painful or unstable. There is also no evidence of limitation of motion or function attributable to the scar. No additional higher or alternative ratings under different diagnostic code can be applied in this case, as the Veteran's scar does not meet the criteria for a compensable rating under any of the scar or skin disability diagnostic codes. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is inapplicable, and the claim must be denied. 38 U.S.C.A. § 5107(b); See, e.g., Gilbert, 1 Vet. App. at 55-57. IV. Eczema The Veteran submitted a letter received on December 18, 2014 stating that her service-connected eczema, previously evaluated as 10 percent disabling, had considerably worsened. She wrote that she had chronic eczema over her entire body and that she needed to take oral steroid medication for any relief. She wrote that she has missed work due to eczema and that it interferes with exercise and family activities and causes embarrassment. The Veteran's attorney has submitted an e-mail from the Veteran showing that the Veteran actually submitted this letter to her attorney on August 13, 2014. The Veteran testified in June 2009 that during flare ups, she gets pustules on her hands that itch and break open. Board Hearing Transcript 19. She stated that she also has itching on her scalp, scabs, and loss of hair. Id. at 20-21. She stated that she uses a steroid-based topical cream Id. at 22. The Veteran has submitted written statements describing how her eczema causes extreme dryness in her hands that causes the skin to crack, split, and bleed, which is then painful and itchy. She has also written that she has open sores on her scalp which leak and result in scabbing, flaking skin, and hair loss. The Veteran's VA and private treatment records show frequent complaints related to itchy skin and rashes. In November 2013, she reported no recent rashes and none were noted on examination. On April 11, 2014, the Veteran was treated for an increase in itchiness and rash in her private areas. In May 2014, the Veteran reported having a rash all over and itching. She reported an earlier possible rash reaction from taking antibiotics in February. Physical examination found scattered dermatitis with excoriations and dermatographia. In August 2014, the Veteran reported an increase in symptoms in her genital area, and in September 2015 she was treated for eczema on the upper extremities, found to have raised plaque like lesions on upper inner arm. In December 2014, she reported swelling on her head and was given a medicated ointment. The Veteran's last VA examination held before the one year period prior to the current claim on appeal was in January 2013. The examiner found that the Veteran had intrinsically dry, irritable skin which caused dry, cracked, itchy break-outs on her hands and psoriasiform plaque on her scalp. There was no scarring or disfigurement. The Veteran required treatment from topical corticosteroids and other lotions for 6 weeks or more in the past year. The total body area and total exposed area affected was less than 5 percent. The examiner stated that the impact on the Veteran's ability to work was that she should avoid jobs which required frequent immersion of her hands in water, such as waitressing or hair dressing. The examiner noted in an addendum in March 2013 that the areas involved were less than 2 inches of area on the back of the scalp and less than 5 percent of the total body surface. The Veteran next attended a VA examination in January 2015. She stated that she had eczema on her scalp, arms, legs, genitals, and face. She reported that it had been debilitating constantly for 7 months of the past 12 months and had caused her to miss work and family events. The examiner found no scarring or disfigurement and noted that the Veteran required systemic corticosteroids, antihistamines, topical corticosteroids, and other creams for less than 6 weeks in the past 12 months. Over 40 percent of the total body area was affected, and less than 5 percent of the exposed area. The examiner found that the condition did not impact the Veteran's ability to work. On the basis of this examination, the Veteran's evaluation was raised to 60 percent, due to over 40 percent of the body being affected. The Veteran and her attorney now argue that the Veteran's evaluation should be higher than 60 percent and that she should be assigned an effective date of up to one year prior to December 18, 2014. Eczema is rated under 38 C.F.R. § 4.118, Diagnostic Code 7806. Diagnostic Code 7806 assigns a 60 percent rating when there is more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or there is constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12 months. 38 C.F.R. § 4.118, Diagnostic Code 7806. This is the highest available rating under this Diagnostic Code, and the highest rating available to the Veteran for this disability. The Board has considered whether another diagnostic code can be applied which would allow for a rating higher than 60 percent. While the Board may not assign a rating under another diagnostic code when a veteran's disability diagnosis is specifically listed in the Rating Schedule, Diagnostic Code 7806 does allow for evaluation under the ratings for disfigurement of the head, face, and neck, or other diagnostic code for scars. See Suttman v. Brown, 5. Vet. App. 127, 134 (1993); see also Copeland v. McDonald, 27 Vet. App. 333, 337 (2015). The Veteran has not been shown to have any of the characteristics of disfigurement or scars which would allow for evaluation under these alternate diagnostic codes, nor has she alleged such symptoms. The Board therefore finds that evaluation under 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805 does not apply. Regarding the effective date assigned for the 60 percent rating, the Board finds that an earlier effective date of April 11, 2014 is warranted. Except when otherwise provided, the effective date of an evaluation and award of compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C.A. § 5110; 38 C.F.R. § 3.400. Claims for increased benefits may be awarded at the earliest date in which it is factually ascertainable that an increase in disability had occurred, if the claim is received within 1 year of the date such an increase occurred. Otherwise, the increase is effective the date of receipt of claim. 38 C.F.R. § 3.400(o)(2). The Veteran's attorney has submitted documentation indicating that although the Veteran's claim was only received in December 2014, she had actually informed her attorney that her eczema has considerably worsened in August 2014. The symptoms described in the Veteran's August 2014 correspondence to her attorney sufficiently match the symptoms demonstrated at her January 2015 to indicate that she had already worsened to that degree by August 2014. Furthermore, the Veteran's VA treatment records show that she contacted her VA treatment providers regarding increasingly worsening symptoms in April, May, and August 2014. The Board therefore accepts the first of these complaints, which occurred on April 11, 2014, constitutes the earliest factually ascertainable date that some increase in severity occurred in the Veteran's condition. See Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010) ("... the entire claimed increase need not occur within the one-year period, but at least some part of the increase must occur during that period. If there is some increase during that period, the veteran is entitled to an earlier effective date (up to one year) for the entire increased disability."). The Board acknowledges that the Veteran indicated in her VA treatment records that she had a reaction to antibiotics which caused a rash in February 2104. However, this assertion, by its very nature, indicates that it was a rash unrelated to the Veteran's service-connected eczema and stemmed from a separate etiology. There is no medical record documenting an increase in severity of the Veteran's eczema at that time, nor has the Veteran alleged that this occurred or presented any evidence relating to this. The Board therefore does not find that this indicates that an effective date in February 2014 is warranted. There is therefore no recorded medical evidence or lay assertions of the Veteran indicating that her disability increased in severity any earlier than April 11, 2014 or after December 18, 2013 (the start of the one year period prior to the receipt of the claim), and therefore no earlier effective date than April 2011, 2014 can be assigned. 38 C.F.R. § 3.400(o)(2). The Board has again considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against any further benefit, that doctrine is not applicable. 38 U.S.C.A. § 5107(b); See, e.g., Gilbert, 1 Vet. App. at 55-57. V. Extraschedular Consideration The Board has also considered whether the Veteran's service-connected disabilities warrant referral for extraschedular consideration. In exceptional cases where schedular disability ratings are found to be inadequate, consideration of an extraschedular disability rating is made. 38 C.F.R. § 3.321(b)(1) (2015). There is a three-step analysis for determining whether an extraschedular disability rating is appropriate. See Thun v. Peake, 22 Vet. App. 111 (2008). All steps must be met to justify referral. Under the first step there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability and the established criteria found in the rating schedule to determine whether the Veteran's disability picture is adequately contemplated by the rating schedule. Id. The Board does not find that the evidence presents such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). The Veteran's symptoms for each of the issues discussed above are fully encompassed by their relevant rating criteria. The Veteran's right shoulder disability is primarily manifested by pain and limitation of motion, and these are precisely the factors considered in the rating criteria. Fatigue and weakness are also encompassed by this criteria and have been considered, but as they have not been shown to result in any further limitation of motion, are not sufficient to warrant any higher rating than that now assigned. The Veteran's eczema has been assigned the highest rating available, an acknowledgement of the severity of these symptoms, both in terms of the large amount of her body that they affect and the considerably medical care required to manage them. There is no evidence of any further symptom impairment fully outside of the norm for these disabilities or which would not be contemplated by the rating criteria applied. The Veteran was not hospitalized at any time during the period currently being decided. The Veteran and her attorney have indicated that her employment is impacted by her disabilities, in that they affect her ability to work for long periods of time without breaks, that she often needs breaks, and that she sometimes misses work. VA rating criteria are designed to be "adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. The Veteran's current total evaluation of 90 percent, including 10 and 60 percent for the issues decided herein, are reflective of the serious impact that such disabilities are expected to have on the Veteran's occupational functioning. There is no evidence that the occupational impact of the Veteran's disabilities has been greater than that which is already compensated by the schedular rating. There is also no evidence indicating any additional functional impairment caused by the collective impact of the Veteran's service-connected disabilities, nor has the Veteran alleged any such further impairment. See Yancy v. McDonald, 27 Vet. App. 484, 490 (2016) (Referral for consideration of extraschedular evaluation for disabilities on a collective basis is only necessary when it is reasonably raised by the record.); Johnson v. McDonald, 762 F.3d 1362 (2014). As the Veteran's symptoms are the type of symptoms contemplated by the Rating Schedule, the threshold factor for extraschedular consideration under step one of Thun has not been met, and the assigned schedular ratings are adequate. Therefore, referral for the assignment of extraschedular disability rating is not warranted. ORDER Entitlement to an initial rating in excess of 10 percent for right shoulder bursitis is denied. Entitlement to an initial compensable rating for a scar associated with cervical spine DDD is denied. Entitlement to a rating in excess of 60 percent for eczema is denied. Entitlement to an effective date of April 11, 2014, but no earlier, for the grant of a 60 percent rating for eczema is granted, subject to the laws and regulations governing the payment of monetary benefits. REMAND I. Increased Rating for Radiculopathy The Veteran has been assigned a 10 percent rating for radiculopathy in the left upper extremity associated with cervical spine DDD, effective November 1, 2013. In June 2009, the Veteran testified that she has numbness in her arm that travels all the way to her fingers. Board Hearing Transcript 16. The Veteran's VA and private treatment records do show repeated complaints related to left arm numbness and pain. The Veteran has consistently complained of symptoms in her left hand fingers, and an April 2008 nerve conduction study found results consistent with active C7 radiculopathy, with no evidence of polyneuropathy or myopathic process. However, the Veteran's treatment records also show complaints related to possible radiculopathy in the right arm. In September 2006, the Veteran reported that her right arm goes numb when sleeping. In September 2009, right hand numbness associated with her cervical spine pain, and at a March 2011 physical therapy evaluation, the Veteran reported numbness and tingling in her right arm and hand. A March 2012 letter from the Veteran's treating nurse practitioner stated that the Veteran had right upper extremity radiating pain caused by her cervical spine. When evaluating service-connected spinal disorders, any associated objective neurologic abnormalities must be considered and evaluated separately under an appropriate diagnostic code. See 38 C.F.R. § 4.71a, Note (1). While the Veteran has been granted partial service-connection for such symptoms in the grant of a 10 percent rating for left arm symptoms, it does not appear that the Veteran's right arm symptomatology has been properly evaluated. Furthermore, the Veteran's most recent VA examination, held in June 2015 found no radicular pain or other signs or symptoms related to radiculopathy whatsoever. This appears inconsistent with the many references to radiculopathy in the Veteran's VA and private treatment records and indicates that a more thorough and accurate VA examination is needed to properly address this issue. The Board therefore finds that this issue must be remanded for a new VA examination. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); see also Kowalski v. Nicholson, 19 Vet. App. 171, 179 (2005). II. Earlier Effective Date for Radiculopathy In June 2015, the Board remanded the issue of entitlement to an effective date earlier than November 1, 2013 for the grant of service connection for left upper extremity radiculopathy so that the AOJ could issue an SOC in response to the Veteran's timely NOD. 38 C.F.R. §§ 19.9(c) (2015); Manlincon v. West, 12 Vet. App. 238 (1999). It does not appear that an SOC has been produced for this issue. The Board therefore again remands this issue so that this procedural deficiency can be corrected. See 38 C.F.R. § 19.29 (2015); Stegall, 11 Vet. App. at 271. III. Cervical Spine DDD In the June 2015 Board remand, the Board also ordered the AOJ to request additional records and to then to readjudicate the issues of entitlement to an initial rating higher than 10 percent for cervical spine DDD prior to July 19, 2013 and to a rating higher than 20 percent for cervical spine DDD from November 1, 2013 in a supplemental SOC. It does not appear that any such supplemental SOC was issued by the AOJ since the June 2015 remand, and therefore these issues must again be remanded, and a supplemental SOC issued after all appropriate development has been completed. See 38 C.F.R. § 19.31 (2015); Stegall, 11 Vet. App. at 271. IV. Private and VA Treatment Records Lastly, the record shows that the Veteran has received extensive treatment through private treatment providers. The Veteran should be requested to provide any more recent records, or authorization to obtain such records, which are related to her service-connected disabilities. The record also shows that the Veteran receives medical care at the Oklahoma City VA Health Care System. As additional, more recent records may provide evidence, all relevant treatment records dated since October 2015 must be acquired and associated with the claims file. Accordingly, the case is REMANDED for the following action: 1. Provide the Veteran and her attorney with a statement of the case regarding the issue of entitlement to an effective date earlier than November 1, 2013 for the grant of service connection for left upper extremity radiculopathy, and advise them of the time period in which to perfect the appeal. If the Veteran perfects her appeal of this issue in a timely fashion, the case should then be returned to the Board for further appellate review. 2. Send to the Veteran and her attorney a letter requesting that she provide sufficient information and a signed and dated authorization, via a VA Form 21-4142 (Authorization and Consent to Release Information) to enable VA to obtain all relevant more recent private medical records of treatment related to the cervical spine or upper extremity radiculopathy. 3. Obtain the Veteran's VA treatment records from the Oklahoma City VA Health Care System from October 2015 to the present. 4. The Veteran should be scheduled for an appropriate VA examination to determine the current severity of her cervical spine DDD and all associated right or left upper extremity radiculopathy. The entire claims files (i.e., all medical records contained in Virtual VA and VBMS) must be provided to the examiner, and the examination report should reflect consideration of the Veteran's documented medical history and assertions. All indicated tests should be accomplished, and all clinical findings reported in detail. The examiner should conduct a full examination of the Veteran's cervical spine and all associated neurological symptomatology pursuant to the appropriate VA regulations for those disabilities. The examiner must specifically address whether the Veteran has neurological symptoms, such as radiculopathy, in the right upper extremity. If no current diagnosis is found for either the right or left upper extremity, please address the Veteran's private and VA treatment records which show complaints of pain and numbness in both the right and left arms. The examiner must set forth all examination findings with a complete explanation based on the facts of this case and any relevant medical literature for the comments and opinions expressed. 5. Provide the Veteran with adequate notice of the date and place of any requested examination at her latest address of record. A copy of all notifications must be associated with the claims folder. She is hereby advised that failure to report for any scheduled VA examination without good cause shown may have adverse effects on the claims. 38 C.F.R. § 3.655 (2015). 6. After the above development has been completed, as well as any additionally indicated development, readjudicate the issues. If any benefit sought on appeal remains denied, furnish the Veteran and her representative with a supplemental statement of the case and return the case to the Board. 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). ______________________________________________ K. A. KENNERLY Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs