Citation Nr: 1604618 Decision Date: 02/08/16 Archive Date: 02/18/16 DOCKET NO. 09-12 724 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to a disability rating in excess of 20 percent for left ring finger ulcer scar with left palm scar. 2. Entitlement to a compensable disability rating for post-operative umbilical hernia. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran, his spouse, and his friend ATTORNEY FOR THE BOARD M.W. Kreindler, Counsel INTRODUCTION The Veteran served on active duty from July 1965 to July 1970. These matters came to the Board of Veterans' Appeals (Board) from a December 2007 decision of a Department of Veterans Affairs (VA) Regional Office (RO) which, in pertinent part, denied compensable ratings for left ring finger ulcer scar and post-operative umbilical hernia. In February 2014, the Veteran testified at a videoconference hearing before the Board. Unfortunately, due to apparent technical difficulties, a transcript of the hearing is unavailable. Thus, in June 2014, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge; the transcript is of record. These matters were remanded in August 2014. In a December 2014 rating decision, the Appeals Management Center (AMC) assigned a 20 percent rating to left ring finger ulcer scar with left palm scar, effective December 12, 2006. Although an increased rating has been granted, the issue remains in appellate status, as the maximum schedular rating has not been assigned. AB v. Brown, 6 Vet. App. 35 (1993). FINDINGS OF FACT 1. The Veteran's left ring finger ulcer scar with left palm scar is not manifested by five or more scars that are unstable or painful. 2. The Veteran's post-operative umbilical hernia is manifested by no active hernia and does not require the need of a supportive belt or involve weakening of abdominal wall and is not manifested by nerve entrapment. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 20 percent for left ring finger ulcer scar with left palm scar have not been met. 38 U.S.C.A. §§ 1155 , 5107 (West 2014); 38 C.F.R. §§ 4.118, Diagnostic Codes 7800-7805 (2008, 2015). 2. The criteria for a compensable evaluation for post-operative umbilical hernia have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.2, 4.7, 4.10, 4.21, 4.114, Diagnostic Code (DC) 7339 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Proper notice from VA must inform the claimant of any information and medical or lay 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 C.F.R. § 3.159(b)(1). VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, the Veteran was sent a letters in June 2007 and August 2007 that provided information as to what evidence was required to substantiate the claims and of the division of responsibilities between VA and a claimant in developing an appeal. The letter also explained what type of information and evidence was needed to establish a disability rating and an effective date. Accordingly, no further development is required with respect to the duty to notify. A decision from the Court that provided additional guidance on the content of the notice that is required under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) in claims involving increase compensation benefits. See Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). The Board points out that the U.S. Court of Appeals for the Federal Circuit reversed the Court's holding in Vazquez, to the extent the Court imposed a requirement that VA notify a Veteran of alternative diagnostic codes or potential "daily life" evidence. See Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Vazquez notice was issued to the Veteran in December 2008. Next, VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. All necessary development has been accomplished, to include substantial compliance with the Board Remand. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); see Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's VA treatment records and lay statements and testimony from the Veteran. The Board has perused the medical and lay records and testimony for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims. He underwent VA examinations in July 2007 and November 2014 which will be discussed below. The Court has held that the provisions of 38 C.F.R. § 3.103(c)(2) impose two distinct duties on VA employees, including Board personnel, in conducting hearings: the duty to explain fully the issues and the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010) (per curiam). At the Veteran's June 2014 hearing, the undersigned identified the increased rating issues on appeal and asked the Veteran about the treatment received for his service-connected hernia to ensure that all relevant treatment records were obtained. Also, the Veteran provided testimony as to the symptoms and history of his conditions. Moreover, as a result of his testimony, the issues were remanded to assess the severity of his conditions. The Veteran has demonstrated actual knowledge of the ability to identify and submit additional relevant evidence. The duties imposed by Bryant were thereby met. For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Increased ratings Disability ratings are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1 , 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Left ring finger ulcer scar Service connection is in effect for left ring finger ulcer scar, rated 20 percent disabling per 38 C.F.R. § 4.118, Diagnostic Code 7804. During the pendency of this appeal, the criteria for evaluating disabilities of the skin were revised, effective October 23, 2008. The revised rating criteria for evaluation of scars are applicable only to claims received by VA on or after October 23, 2008, absent specific request for consideration under the revised code. See 73 Fed. Reg. 54708 (September 23, 2008). The date of claim here was in December 2006. It appears that both the "old" and "new" criteria have been considered and that the AMC assigned the 20 percent rating under the "new" Diagnostic Code 7804. As a result, the Board will consider both sets of criteria. The relevant rating criteria, the pre-amended Diagnostic Code 7800, provides a minimum 10 percent evaluation when there is disfigurement of the head, face, or neck with one characteristic of disfigurement. A 30 percent rating is warranted when there is disfigurement with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips); or with two or three characteristics of disfigurement. A 50 percent rating is warranted when there is disfigurement with 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 maximum 80 percent rating is warranted when there is disfigurement 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. 38 C.F.R. § 4.118, Diagnostic Code 7800 (2008). The eight characteristics of disfigurement, for purposes of evaluation under § 4.118, are: (1) scar 5 or more inches (13 or more centimeters (cm.)) in length; (2) scar at least one-quarter inch (0.6 cm.) wide at widest part; (3) surface contour of scar elevated or depressed on palpation; (4) scar adherent to underlying tissue; (5) skin hypo- or hyper-pigmented in an area exceeding 6 square inches (39 sq. cm.); (6) skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding 6 square inches (39 sq. cm.); (7) underlying soft tissue missing in an area exceeding 6 square inches (39 sq. cm.); and (8) skin indurated and inflexible in an area exceeding 6 square inches (39 sq. cm.). Id. at Note (1). DC 7801 provides ratings for scars, other than the head, face, or neck, which are deep or cause limited motion. Scars that are deep or that cause limited motion in an area or areas exceeding 6 square inches (39 square centimeters) are rated 10 percent disabling. Scars in an area or areas exceeding 12 square inches (77 square centimeters) are rated 20 percent disabling. Scars in an area or areas exceeding 72 square inches (465 square centimeters) are rated 30 percent disabling. Scars in an area or areas exceeding 144 square inches (929 square centimeters) are rated 40 percent disabling. Note (1) to DC 7802 provides that scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with 38 C.F.R. § 4.25. Note (2) provides that a deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7801 (2008). DC 7802 provides ratings for scars, other than the head, face, or neck, which are superficial or that do not cause limited motion. Superficial scars that do not cause limited motion, in an area or areas of 144 square inches (929 square centimeters) or greater, are rated 10 percent disabling. Note (1) to DC 7802 provides that scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with 38 C.F.R. § 4.25. Note (2) provides that a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7802 (2008). Also of relevance, Diagnostic Code 7803 provides that a scar, superficial, unstable, warrants a 10 percent rating. Note 1 states that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note 2 states that a superficial scar is one not associated with underlying soft tissue damage. Id. Diagnostic Code 7804 provides that a scar, superficial, painful on examination, warrants a 10 percent rating. Note 1 states that a superficial scar is one not associated with underlying soft tissue damage. Id. Diagnostic Code 7805 provides that other scars are to be rated on limitation of function of affected part. Id. Per the "new" criteria, Diagnostic Code 7800 pertains to scars of the head, face and neck and is not applicable in this case. 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.) warrants a 10 percent rating. A 20 percent rating requires an area or areas of at least 12 square inches (77 sq. cm.) but less than 72 square inches (465 sq. cm.). A 30 percent rating requires an area or areas of at least 72 square inches (465 sq. cm.) but less than 144 square inches (929 sq. cm.). A 40 percent rating requires an area or areas of 144 square inches (929 sq. cm.) or greater. A qualifying scar is one that is nonlinear and deep, and is not located on the head, face, or neck. Note (1) to Diagnostic Code 7801 provides that a deep scar is one associated with underlying tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7801 (2015). Diagnostic Code 7802 provides that a 10 percent rating is assignable for burn scars or scars due to other causes, not of the head, face or neck, that are superficial and nonlinear and have an area or areas of 144 square inches (929 sq. cm.) or greater. 38 C.F.R. § 4.118, Diagnostic Code 7801 (2015). According to Diagnostic Code 7804, a 10 percent rating is assignable for one or two scars that are unstable or painful. A 20 percent rating is assignable for three or four scars that are unstable or painful. A 30 percent rating is assignable for five or more scars that are unstable and painful. Note (1) provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) 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) provides that scars evaluated under diagnostic codes 7800, 7801, 7802 or 7805 may also receive an evaluation under this diagnostic code, when applicable. The revised version of Diagnostic Code 7805 pertains to other scars (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 7800-7804 are to be evaluated under an appropriate diagnostic code. Specifically, with regard to his left ring finger ulcer scar, the Veteran testified that his scar cracks open and he experiences loss of tissue and loss of mobility. 06/24/2014 Virtual VA entry, Hearing Transcript at 3. He also attested that he experiences weakness and numbness. Id. at 7-8. The Veteran reported to the July 2007 QTC examiner that the scar breaks open at times and bleeds and he cannot wear a wedding ring. On examination, there was a level scar present at the left ring finger, ulnar aspect measuring about 3 cm by 1 cm with disfigurement, tissue loss of less than six square inches, hypopigmentation of less than six square inches and abnormal texture of less than six square inches. There was no tenderness, ulceration, adherence, instability, inflammation, edema, keloid formation or hyperpigmentation. Range of motion of the finger joints were essentially normal and not limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. In August 2014 correspondence, J.W.H., P.A., noted that the Veteran was under his medical care and had chronic scar tissue and numbness in his left ring finger related to a surgical procedure completed while in the service. In November 2014, the Veteran underwent a VA examination. The examiner reconfirmed with the Veteran his left ring finger (LRF) assertions that he made at the June 2014 Board hearing. The examiner noted confusion as to the current frequency of LRF ulcerations (LRFUs) from the June 2014 hearing as they ranged from: "constant breaking open," "quite often," "quite a bit," "twice a week," "broke open about two months ago," to "takes about a week or so to heal when it breaks open." On detailed questioning, the Veteran confirmed he has ulnar periungual LRF ulceration (LRFU) breakdowns once every two months and they take about a week to heal. He asserts that with an active LRFU the LRF is painful, tender, has decreased range of motion due to pain, and it impairs his left hand function (with difficulty opening jars, opening doors, tying shoes, buttoning a shirt, etc...). When non-ulcerated he has no significant LRF pain or tenderness and has full left hand function. He always chooses to preferentially use his dominant right hand to avoid risk of LRF injury when non-ulcerated and to avoid LRF pain when ulcerated. The examiner noted that the only two operations on the LRF were the active duty December 1967 LRF graft to the left thumb and the VA December 1976 LRF ulcer surgery. The VA's September 1981 surgery was on the left thumb (bone graft lengthening) and did not involve the LRF. In terms of the LRF, the STRs demonstrated that after the December 1967 LRF surgery he recovered uneventfully and was returned to full active duty (as a cook) where he had no problems with the LRF through discharge. In fact, the Veteran had no problems with the LRF until 1973 (as the Veteran confirmed today and as noted in the December 1976 VA Hand notes). In 1973, the Veteran (the Veteran confirmed today the following history of the LRF) took on a cement truck driver occupation and due to the work requirements involving heavy physical labor (lift, grip, pull, push, etc... of heavy rough metal and cement objects) he developed recurrent scar breakdown at the right angle of his left palm scar and along the ulnar periungal area of his LRF scar (both of these scars came from the December 1967 surgery). He presented to the VA hand service in 1976 where they operated on the LRF but without benefit as the Veteran continued his cement truck driver work and suffered from recurrent LRF/palm scar breakdowns ("ulcers") until he terminated his cement truck driver work in 1991 (due to a low back injury). The Veteran received a Worker's Compensation settlement for the low back and attempted computer-based training (vocational rehabilitation) but was unable to perform adequately on the computer due to his left thumb and LRF deformities. He then applied for Social Security Disability for the back and left hand which was awarded in 1992 and the Veteran has been unemployed since. Currently, preferential use of the right hand, to avoid potential ulcer inducing injuries of the left hand/LRF, was noted. However, the left hand (and LRF) were essentially asymptomatic when there is no LRFU. The Veteran goes years between any left palm ulcers. He states once every two months he will damage the LRF and develop an ulnar periungal LRFU that causes loss of function with chores that require both hands (e.g., can't open jars, tie his shoelaces, or button a shirt) due to LRF pain. The Veteran has no actual loss of range of motion (ROM) of LRF when ulcerated but he voluntarily does not move it due to pain with motion. The LRF has full ROM when a LRFU is present and he could make it move through the full ROM but doesn't due to pain. The examiner agreed with the August 2014 statement of P.A. J.W.H. that the Veteran does have LRF scar tissue and numbness. The examiner responded 'No' to all of the following 7 LRF scar factors: (1) scar five or more inches in length; (2) scar at least one-quarter inch wide at widest part; (3) surface contour of scar elevated or depressed on palpation; (4) skin hypo-or hyper- pigmented in an area exceeding six square inches (39 sq. cm.); (5) skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); (6) underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.); or (7) skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.). The examiner noted that the combined scar areas of the left palm and LRF are less than 2 square inches. The LRF has adherence to underlying tissue, abnormal skin texture (atrophic and shiny), and underlying soft tissue loss along the ulnar side of the LRF. However, there is no induration of inflexibility of the less than 2 square inches of the left palm and LRF scars. The left palmar scar has no adherence to underlying tissue, no hypo or hyperpigmentation, no abnormal texture, and no underlying tissue loss. The LRF scar is not hyper or hypopigmented either. The examiner opined that the Veteran's LRF and left palm scars and residuals would not impair sedentary employment that did not involve computer use or require heavy labor use of the left hand. It was noted that the Veteran was clearly able to perform cement truck driving duties through 1991 and his LRF condition has not changed since 1991 (except to improve with less frequent LRFU and very infrequent left palm ulcers). The Veteran could readily function by monitoring a security video or performing phone call services. Whether such LRF appropriate jobs are available to a prospective employee who is already disabled due to a low back condition is a matter beyond the scope of the examiner. The examiner opined that the Veteran's LRF 1967 and 1976 surgical residuals do not impair sedentary employment. On examination, the Veteran had no left palm or LRF ulcerations or breakdowns. He had 5/5 symmetric hand and LRF strength with grip and normal finger range of motion (ROM): abduction, adduction, extension, flexion. He was able to oppose (no gaps) the LRF tip to the left thumb tip and was able to oppose the LRF (and all of the left fingers) to the palm and proximal palmar crease. There was no pain on LRF ROM testing and no decrease of ROM upon repeat ROM testing due to pain, fatigue, weakness, lack of endurance, or incoordination with repetitive use. The examiner opined that if a LRFU was present (a "flare") the LRF ROM would remain normal and unchanged from his non-ulcerated state. There is no ankyloses of the LRF. LRF DIP ROM is 0 - 70 degrees of flexion. LRF PIP ROM is 0 - 100 degrees of flexion. LRF MCP joint ROM is 0 - 90 degrees of flexion with 0 - 30 degrees of extension (basically the same as recorded at the July 2007 QTC exam. The left palmar and LRF scars were tender with firm/deep palpation. The entire length of the LRF scar was numb with loss of sensation except pain with firm palpation. There was no numbness or loss of sensation with the palmar scar. The left palm and LRF scars were clearly unstable as they periodically breakdown (ulcerate) as described previously. The examiner stated that it is well-known clinically that often scars lose sensation as a normal residual. The LRF scar loss of sensation is a routine scar residual and does not entail any defined nerve damage. As detailed above, the AMC assigned a 20 percent rating pursuant to the revised Diagnostic Code 7804. Based on a review of the December 2014 rating decision, the AMC explained that a 20 percent evaluation was assigned to his left ring finger ulcer scar based on one painful and unstable scar. Diagnostic Code 7804 provides for a 10 percent rating for one or two scars that are unstable or painful and a 20 percent rating for three or four scars that are unstable or painful. It appears that only a 10 percent rating should have been assigned based on the rating criteria and manifestations reflected in the examination reports; however, the instant decision does not disturb the 20 percent rating assigned, especially in light of the fact that the Veteran's LRF scar is manifested by numbness, adherence to underlying tissue, abnormal skin texture, and underlying soft tissue loss along the ulnar side of the LRF. Such rating also compensates him for his symptomatology associated with any ulcers of the LRF/palm scar which the Veteran reported occurred every two months. The examiner, however, indicated that even if a LRFU was present, LRF ROM would remain normal and unchanged. In contemplation of the rating criteria, a 30 percent rating is not warranted per Diagnostic Code 7804 as there are not five or more scars that are unstable or painful. A 30 percent rating is not warranted per Diagnostic Code 7801 as the scar does not affect an area of at least 72 square inches. There are no further diagnostic criteria that could provide a rating in excess of 20 percent. Post-operative umbilical hernia The Veteran's umbilical (ventral) hernia is rated under Diagnostic Code 7339. A 20 percent rating is warranted for small ventral hernias that are not well-supported by belt under ordinary conditions, healed ventral hernias, or post-operative wounds with weakening of abdominal wall and indication for a supporting belt. A 40 percent rating is warranted for large ventral hernias that are not well-supported by a belt under ordinary conditions. A maximum 100 percent rating is warranted for massive, persistent, and severe diastasis of recti muscles; or, extensive diffuse destruction or weakening of muscular and fascial support of the abdominal wall so as to be unoperable. 38 C.F.R. § 4.114, Diagnostic Code 7339. With regard to his post-operative umbilical hernia, he testified that he experiences a burning sensation and that he feels pain when he twists his body. 06/24/2014 Virtual VA entry, Hearing Transcript at 10-11. He asserts that his hernia causes problems, not the scar. Id. at 14. The July 2007 QTC examination reflects that the Veteran had an umbilical hernia repaired in service and that the condition has existed since 1968. It was not due to injury or trauma and did not affect general health or body weight. He did not have any gastrointestinal symptoms such as nausea and vomiting, chronic constipation or diarrhea. He reports no abdominal pain. He was not receiving any treatment for the condition and had not been hospitalized or had surgery. There was no functional impairment. Examination of the abdomen revealed diastasis recti. There were no findings of liver enlargement, superficial distension of the veins, striae on the abdominal wall, tenderness to palpation, an ostomy, ascites, splenomegaly or aortic aneurysm. No intestinal fistula was noted on examination. In August 2014 correspondence, J.W.H., P.A., noted that the Veteran was under his medical care and had been referred for a hernia belt due a large ventral hernia. 08/22/2014 VBMS entry, Third Party Correspondence. In November 2014, the Veteran underwent a VA examination. At the examination, the examiner confirmed with the Veteran his "umbilical hernia" assertions that he made at the June 2014 Board hearing. The examiner noted that the Veteran asserts that his 1968 active duty epigastric hernia (EH) scar causes him no problems (completely asymptomatic). His problem is with the "active hernia" diastasis recti (DR) condition that physically is a huge abdominal bulge arising longitudinally in the midline between the rectus muscle sheaths (and pushing the sheaths to the sides). The Veteran asserts the DR is a residual of his EH condition or active duty EH surgical repair. He asserts the DR condition causes local pain with movement (getting out of a chair, turning over in bed, exercise, etc...). He asserts the DR condition is associated with gastrointestinal (GI) complaints of epigastric pyrosis (burning) which requires peptic medications (such as antacids and/or Nexium). The examiner noted that the only active duty abdominal surgery the Veteran had (and the only supra umbilical surgery the Veteran has ever had) was the February 1968 epigastric hernia repair. Addressing the abdominal hernia issue, the examiner explained that it is well-known clinically that umbilical hernia (UH), epigastric hernia (EH), and diastasis recti (DR) conditions are separate and distinct diagnoses involving different etiologies, different anatomy, and different surgical requirements. They simply are not related at all except in that all three arise from the same general umbilical/supraumbilical area. The Veteran has never had an UH. The STRs, specifically referencing the March 1968 narrative summary, clearly documented that the Veteran was serendipitously found to have a small EH during his December 1967 - March 1968 LRF to thumb graft admission. The supraumbilical EH was February 1968 routinely repaired using an 8 cm transverse skin incision. The Veteran recovered uneventfully from his February 1968 EH repair with no subsequent active duty or post-service EH complaints or reoccurrence in the medical treating records that were reviewed through August 2012. The VA examiner noted that the July 2007 QTC exam was in error only in attributing the 8cm x 0.5 cm supraumbilical scar to an UH condition when in actuality it was an EH surgery. Otherwise that examination was accurate. The EH scar was, and is, asymptomatic (confirmed by the Veteran today) and has not changed whatsoever in character or dimension since July 2007. The examiner opined 'No' to all of the inquiries re the eight EH scar disfigurement factors. The examiner noted that the VA medical treating records documented progressive post-service obesity (weight of 192 pounds at the June 1970 discharge exam with post-service weights approaching 300 pounds). It is well-known clinically that the most common etiology for the development of a DR is obesity. The examiner opined that the Veteran's DR condition, which is what he is clearly complaining about at the June 2014 Board hearing is due to obesity and is not due to, or aggravated by, or related in any way to the Veteran's EH repair or scar. Of note, the examiner opined that the Veteran's pyrosis (epigastric burning) complaints are not due to, aggravated by, or in any way related to the EH repair or scar, or to the DR condition either for that matter. Of note, the examiner continued, DR is not a hernia. DR anatomically represents a thinning of the midline linea alba due to progressive intra-abdominal obesity. The supraumbilical midline bulge associated with a DR is akin to squeezing a balloon and seeing it bulge out due to the pressure you put on it with your squeezing hands. The peritoneum is like a big balloon too. When you "squeeze" the peritoneum (getting out of a chair or a Valsalva maneuver requires tightening the abdominal muscles and diaphragm) that increases the intra-abdominal pressure causing the peritoneum to bulge out where resistance is the least (i.e., it pushes out the thinned out linea alba). The examiner wanted to make clear that the Veteran has no "active hernia" condition as the EH is resolved and the DR is not a hernia. It was further pointed out that the August 2014 statement of P.A. J.W.H. is inaccurate per the Veteran today. The Veteran has not been referred for a hernia belt and the Veteran does not use one. And the large ventral hernia diagnosis of P.A. H.W.H. is in error. The examiner explained that the diagnosis at the July 2007 QTC examination and at the present examination is DR, not ventral hernia. The EH is resolved without reoccurrence or symptoms so there is nothing to reduce, it does not require a truss or belt, it has no nerve entrapment, and it has already been definitively cured with surgery (1968). There are no functional or employment limitations from the resolved EH or the EH scar whatsoever. The examiner did not fill out a hernia DBQ as the Veteran has no hernia. The examiner did not fill out a scar DBQ for the supraumbilical EH scar as the EH scar has not changed since the July 2007 QTC exam (how it was rated then is still current). Based on the evidence above, the Board finds that the Veteran is not entitled to a compensable rating for umbilical hernia at any point during the period under appeal. As detailed by the November 2014 VA examiner, the in-service hernia resolved without reoccurrence or symptoms and does not require a truss or belt, and has no nerve entrapment. As indicated by the VA examiner, the assertions of the August 2014 P.A. are not supported by the record and are not supported by the treatment records on file. Therefore, the Board finds that a compensable rating for umbilical hernia disability is not warranted at any point during the period under appeal. 38 C.F.R. §4.114, Diagnostic Code 7339. Additional considerations At the Board hearing, the Veteran asserted that his disabilities warrant compensable ratings, to include on an extraschedular basis per 38 C.F.R. § 3.321(b)(1). The Board must determine whether the schedular evaluations are inadequate, thus requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1). An extra-schedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture. An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment or frequent periods of hospitalization. Id. at 115-116. When either of those elements has been satisfied, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. In this case, the schedular evaluations are adequate. Evaluations in excess of those assigned are provided for certain manifestations of the service-connected disabilities, but the medical evidence reflects that those manifestations are not present with regard to issues addressed above. Additionally, the diagnostic criteria discussed hereinabove adequately describes the severity and symptomatology of the various aspects of the Veteran's disorders. The current ratings discussed hereinabove are adequate to fully compensate the Veteran for his symptoms. There is no specific assertion from the Veteran or his representative that the evaluations are inadequate for distinct symptomatology nor have they stated that such symptomatology is additionally exceptional in some way or manifests itself in an otherwise unusual disability picture. The Board finds that the diagnostic criteria is adequate for these service-connected disabilities. Indeed, there is no indication that the Veteran experiences symptoms that are outside the range of that contemplated by the relevant diagnostic codes. Accordingly, referral for extraschedular consideration is not for application here. Finally, the Board notes that under Johnson v. McDonald, 2013-7104, 2014 WL 3562218 (Fed. Cir. Aug. 6, 2014), a veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. In this case, however, after applying the benefit of the doubt under of Mittleider v. West, 11 Vet. App. 181 (1998), there are no additional service-connected disabilities that have not been attributed to a specific service-connected condition. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. A total disability rating based on individual unemployability (TDIU) is part of an increased disability rating claim when such claim is raised by the record. The November 2014 VA examiner opined that the Veteran's LRF and left palm scars and residuals would not impair sedentary employment that did not involve computer use or require heavy labor use of the left hand. The examiner noted that the Veteran was clearly able to perform cement truck driving duties through 1991 and his LRF condition has not changed since 1991 (except to improve with less frequent LRFU and very infrequent left palm ulcers). The Veteran could readily function by monitoring a security video or performing phone call services. With regard to the hernia, as explained by the Veteran, no residuals are present. The Veteran's disabilities do not meet the schedular criteria per § 4.16(a) and based on the findings of the examiner there is no basis for referral to the Director, Compensation Service, for extraschedular consideration. 38 C.F.R. § 4.16(b). ORDER Entitlement to a disability rating in excess of 20 percent for left ring finger ulcer scar with left palm scar is denied. Entitlement to a compensable disability rating for post-operative umbilical hernia is denied. ____________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs