Citation Nr: 1618839 Decision Date: 05/10/16 Archive Date: 05/19/16 DOCKET NO. 08-39 459 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an initial disability rating in excess of 10 percent for diverticulosis and residuals of temporary colostomy, ventral hernia repair with residuals, and gastroesophageal reflux disorder (GERD) prior to December 31, 2012, and in excess of 30 percent on and after December 31, 2012. 2. Entitlement to an initial rating in excess of 10 percent for abdominal scars, residuals of ventral hernia repair and temporary colostomy. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD A. N. Nolley, Associate Counsel INTRODUCTION The Veteran served on active duty from March 1996 to May 2007. These matters come from the Board of Veterans' Appeals (Board) on appeal from a September 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Veteran testified at a hearing before a Decision Review Office (DRO) in March 2009. A transcript of the proceeding has been associated with the claims file. In the September 2007 rating decision, the RO granted service connection for GERD, to which a noncompensable disability rating was assigned; for diverticulosis and residuals of temporary colostomy, to which a 10 percent disability rating was assigned; and for residuals of ventral hernia repairs, to which a noncompensable rating was assigned. In a September 2009 rating decision, the RO found that there was clear and unmistakable error in the September 2007 rating decision which assigned separate disability ratings for each gastrointestinal disorder. Therefore, the RO combined the gastrointestinal disorders into one disability rating. The RO also granted service connection for an abdominal scar, residuals of ventral hernia repair, to which a noncompensable rating was assigned. In an October 2009 rating decision, the RO assigned an initial 10 percent disability rating for the Veteran's abdominal scar, residuals of ventral hernia repair. Accordingly, the issues have been recharacterized as shown on the title page. In an April 2013 rating decision, the RO increased the assigned disability rating for the Veteran's gastrointestinal disorder from 10 percent to 30 percent on and after December 31, 2012. However, because the increased disability rating assigned is not the maximum rating available throughout the period on appeal, the claim remains in appellate status. See AB v. Brown, 6 Vet. App. 35 (1993); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The issue of entitlement to an initial rating in excess of 10 percent for abdominal scars, residuals of ventral hernia repair and temporary colostomy is addressed in the REMAND portion of the decision below and is remanded to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Prior to December 31, 2012, the most probative evidence reflects that the Veteran's diverticulosis and residuals of temporary colostomy, ventral hernia repair with residuals, and GERD was productive of severe impairment with alternating diarrhea and constipation, with more or less constant abdominal distress. 2. Beginning on December 31, 2012, the most probative evidence of record reflects that the Veteran's diverticulosis and residuals of temporary colostomy, ventral hernia repair with residuals, and GERD was not productive of severe ulcerative colitis with numerous attacks a year and malnutrition, or severe peritoneum adhesions with a definite partial obstruction. CONCLUSIONS OF LAW 1. Prior to December 31, 2012, the criteria for a 30 percent rating, but not greater, for diverticulosis and residuals of temporary colostomy, ventral hernia repair with residuals, and GERD have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.113, 4.114, Diagnostic Codes 7301, 7319, 7323, 7327, 7339, 7346 (2015). 2. Beginning on December 31, 2012, the criteria for a rating in excess of 30 percent for diverticulosis and residuals of temporary colostomy, ventral hernia repair with residuals, and GERD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.113, 4.114, Diagnostic Codes 7301, 7319, 7323, 7327, 7339, 7346 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION VA has met all statutory and regulatory notice and duty to assist provisions with respect to the issue decided herein. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2015). The Veteran is appealing the initial rating assignment. Once service connection has been granted, the context in which the claim initially arose, the claim has been substantiated; therefore, additional VCAA notice under § 5103(a) is not required because the initial intended purpose of the notice has been fulfilled, so any defect in the notice is not prejudicial. Goodwin v. Peake, 22 Vet. App. 128 (2008); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Additionally, the Board notes that the Veteran was provided with the pertinent rating criteria in the November 2008 Statement of the Case. Therefore, no further notice as to this claim is needed. With respect to the duty to assist, the Veteran's service treatment records, private treatment records, VA treatment records, VA examination reports, and lay evidence are associated with the record. The Veteran also underwent VA examinations in connection with his claim in June 2007, May 2009, and December 2012. The VA examiners reviewed the medical evidence and lay statements and performed examinations. Further, taken together, the examination reports provide sufficient information to rate the service-connected disabilities on appeal. 38 C.F.R. § 3.159(c)(4); Barr v Nicholson, 21 Vet. App. 303 (2007). As such, the Board finds the examinations to be sufficient and adequate for rating purposes. Furthermore, the Board finds the RO substantially complied with the February 2012 remand directives with respect to the issue on appeal. See Stegall v. West, 11 Vet. App. 268 (1998). There is no indication in the record that any additional evidence relevant to the issue decided is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 483 (2006); Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). The Board has thoroughly reviewed all of the evidence in the Veteran's claims file. Although an obligation to provide sufficient reasons and bases in support of an appellate decision exists, there is no need to discuss, in detail, all of the evidence submitted by the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the entire record must be reviewed, but each piece of evidence does not have to be discussed). The analysis in this decision focuses on the most salient and relevant evidence and on what the evidence shows or fails to show with respect to the matter decided herein. The Veteran should not assume that pieces of evidence, not explicitly discussed herein, have been overlooked. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2015). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule but findings sufficient to identify the disease and the resulting disability, and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). The primary concern for an increased rating for a service-connected disability is the present level of disability. Although the overall history of the disability is to be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability following an initial award of service connection for that disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. In all claims for an increased disability rating, VA has a duty to consider the possibility of assigning staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Initially, the Board notes that the Veteran is in receipt of a 10 percent rating for a muscle injury associated with his gastrointestinal disorder. He has not challenged this rating and the medical evidence does not reflect his muscle injury has increased in severity. As such, the Board will not address the related service-connected muscle injury at this time. Generally, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is prohibited. 38 C.F.R. § 4.14 (2015). A claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding contrary to the provisions of 38 C.F.R. § 4.14. However, when a veteran has separate and distinct manifestations attributable to the same injury, he should be compensated under different diagnostic codes. Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225 (1993). There are diseases of the digestive system, particularly within the abdomen, which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia and disturbances in nutrition. Consequently, certain coexisting diseases in this area do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in 38 C.F.R. § 4.14. See 38 C.F.R. § 4.113 (2015) Moreover, disabilities of the digestive system are rated in accordance with 38 C.F.R. § 4.114, Diagnostic Codes 7200 to 7348. Section 4.114 provides that ratings under Diagnostic Codes 7301 to 7329, inclusive of, 7331, 7342, and 7345 to 7348, will not be combined with each other. A single rating will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. In this case, the RO determined that the Veteran's symptoms of diverticulosis represented the Veteran's predominant disability picture. Accordingly, the Veteran's gastrointestinal disorder was rated under Diagnostic Code 7327 for diverticulitis under the provisions of 38 C.F.R. § 4.114. Under Diagnostic Code 7327, diverticulitis is ratable as peritoneal adhesions, irritable colon syndrome, or ulcerative colitis, pursuant to Diagnostic Codes 7301, 7319, and 7323 respectively, depending on the predominant disability picture. 38 C.F.R. § 4.114. It appears that the RO has granted the Veteran a 10 percent disability rating under Diagnostic Code 7301 for peritoneal adhesions prior to December 31, 2012 and under Diagnostic Code 7319 for irritable colon syndrome beginning on December 31, 2012. Under Diagnostic Code 7301 for peritoneal adhesions, a 10 percent rating is assigned for moderate adhesions of the peritoneum with pulling pain on attempting work or aggravated by movements of the body, or occasional episodes of colic pain, nausea, constipation (perhaps alternating with diarrhea) or abdominal distension. A 30 percent rating is assigned for moderately severe adhesions of the peritoneum with partial obstruction manifested by delayed motility of barium meal and less frequent and less prolonged episodes of pain. A 50 percent disability rating is assigned for severe adhesions of the peritoneum with definite partial obstruction shown by X-ray, with frequent and prolonged episodes of severe colic distension, nausea or vomiting, following severe peritonitis, ruptured appendix, perforated ulcer, or operation with drainage. Under Diagnostic Code 7319 for irritable colon syndrome, a 10 percent rating is assigned for moderate impairment manifested by frequent episodes of bowel disturbance with abdominal distress. A maximum 30 percent rating is assigned for severe impairment manifested by diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. Under Diagnostic Code 7323 for ulcerative colitis, a 10 percent rating is assigned for moderate impairment manifested by infrequent exacerbations. A 30 percent rating is assigned for moderately severe impairment manifested by frequent exacerbations. A 60 percent rating is assigned for severe impairment manifested by numerous attacks in a year and malnutrition, with the health only fair during remissions. A maximum 100 percent rating is assigned for pronounced impairment resulting in marked malnutrition, anemia, and general debility, or with serious complications as liver abscess. With respect to the GERD component of the Veteran's gastrointestinal disorder, under Diagnostic Code 7346 a 10 percent rating is assigned for two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent rating is assigned for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A maximum 60 percent rating is assigned for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. With respect to the residuals of ventral hernia repair component of the Veteran's gastrointestinal disorder, under Diagnostic Code 7339, a noncompensable rating is assigned for wounds, postoperative, healed, no disability, belt not indicated. A 20 percent rating is assigned for small ventral hernias, not well supported by belt under ordinary conditions, or healed ventral hernia or postoperative wounds with weakening of abdominal wall and indication for a supporting belt. A 40 percent rating is assigned for large ventral hernias, not well supported by belt under ordinary conditions. A maximum 100 percent rating is assigned for massive hernias, with persistent, severe diastasis of rectimuscles or extensive diffuse destruction or weakening of muscular and fascial support of abdominal wall so as to be inoperable. I. Prior to December 31, 2012 Prior to December 31, 2012, the Veteran's gastrointestinal disorder was rated as 10 percent disabling based on alteration of bowel habits and pulling pain with activities. Service treatment records showed that the Veteran underwent eight abdominal surgeries during service. Service treatment records also noted a history of diverticulitis, recurrent ventral hernias, and GERD. The Veteran complained of chronic abdominal pain which limited his ability to work and exercise. His abdominal pain was associated with weekly diarrhea. The Veteran underwent a VA examination in June 2007. The examiner noted the Veteran's history of GERD, diverticulosis, diverticulitis, and ventral hernia repairs. It was noted that the Veteran's ventral hernia had not recurred since his last hernia repair. The Veteran continued to report severe constant pulling pain worsened with certain movement such as running or situps. The Veteran reported acid coming up all the way to his throat, occasional abdominal cramping, and diarrhea. His reflux symptoms were controlled by medication. The Veteran denied dysphagia, hematemesis, regurgitation, nausea or vomiting. He reported alternating bowel movements which were constant, and explained that he would go a few days without a bowel movement, and then when he went, he had one to two loose stools. The Veteran denied malnutrition or anemia. The examiner noted that the Veteran tried many different treatment options to alleviate the pain, but none of them worked. It was also noted that the Veteran's abdominal pain impacted his daily activities. The Veteran's wife submitted a statement in December 2008, stating that the Veteran experienced extreme abdominal pain which made it difficult to perform activities of daily living. She further stated that the Veteran was always in the bathroom with diarrhea or constipation. In a December 2008 statement, the Veteran reported recurring episodes of constipation and diarrhea. A February 2009 VA treatment record noted the Veteran's abdominal pain, diarrhea, and constipation. The Veteran rated his pain as constantly a five to seven. A March 2009 statement from a nurse practitioner noted the Veteran's chronic unremitting pain. At the March 2009 DRO hearing, the Veteran testified that he experienced constant pain. The pain was consistently a five, but several times a day the pain would increase in intensity. The Veteran testified that he was unable to lift or bend due to the pain. The Veteran stated that his bowel movements had been abnormal since his surgeries. He explained that he either had massive constipation or massive diarrhea. He also reported rectal bleeding. The Veteran underwent a VA examination in May 2009. The Veteran continued to report abdominal pain described as a pulling sensation, with occasional sharp stabbing pain occurring every two to three days. The Veteran also continued to report constipation and diarrhea. A CT scan of the abdomen did not show any evidence of bowel obstruction. The examiner noted that a barium enema in 2004 also showed no evidence of obstruction. The examiner noted that the Veteran's weight was stable with no malnutrition, nausea, or vomiting. The examiner also noted that the Veteran's abdominal pain limited his activities with lifting heavy objects or increased physical activity. An April 2010 private treatment record showed that the Veteran complained of abdominal pain, constipation, and diarrhea. A CT scan did not show evidence of a recurrent hernia. An October 2010 VA treatment record showed that the Veteran continued to experience abdominal pain, but tried an abdominal binder for the pain with some success. A January 2010 private treatment record showed that the Veteran had abdominal pain with more diarrhea than usual. Upon review, the Board finds that a 30 percent disability rating is warranted prior to December 31, 2012 under the criteria for irritable colon syndrome. 38 C.F.R. § 4.114, Diagnostic Code 7319. The Board recognizes the Veteran's competent lay statements describing his symptoms and their effects. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Treatment records, examination reports, and lay statements show that the Veteran experienced constant abdominal distress, with exacerbations occurring several times throughout the day or week. The Veteran also reported alternating diarrhea and constipation. Therefore, the Board finds the evidence shows that the Veteran experienced symptomatology equivalent to severe impairment manifested by diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. A 30 percent rating is the maximum schedular rating possible under Diagnostic Code 7319. Even so, the Veteran is not entitled to a higher disability rating under Diagnostic Codes 7323 for ulcerative colitis, or 7301 for peritoneal adhesions because the Veteran's symptoms do not include malnutrition, anemia, general debility, serious complication as liver abscess, or partial bowel obstruction as indicated under Diagnostic Codes 7301 or 7323. Moreover, the Veteran's gastrointestinal disorders include GERD and residuals of ventral hernia repair under Diagnostic Codes 7346 and 7339, respectively. However, the Board notes that a disability rating in excess of 30 percent under Diagnostic Code 7346 is not warranted for the Veteran's GERD because the weight of the evidence does not demonstrate pain, vomiting, material weight loss and hematemesis, or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. Furthermore, the evidence does not demonstrate that the Veteran had a ventral hernia during this period, for a rating under Diagnostic Code 7339. II. Beginning on December 31, 2012 The Veteran underwent a VA examination in December 2012. The examiner noted the prior diagnoses of diverticulosis and GERD. The Veteran reported constant abdominal cramping or stress in addition to pain in the left quadrant. He stated that he had alternating diarrhea and constipation. The Veteran also reported that his reflux symptoms were treated with medication, although he had some pyrosis and regurgitation without medication, and a little with medication. The examiner noted that there was no dysphagia or substernal, arm, or shoulder pain. The examiner also noted that there was no current evidence indicating partial bowel obstruction. The examiner also found that the Veteran had occasional bowel disturbance with abdominal distress. There was no weight loss or malnutrition. The Veteran's gastrointestinal disorder impacted the Veteran's ability to do strenuous labor involving repeated trunk motion. The examiner noted that there was no hernia detected, but there was a healed postoperative ventral hernia repair, and no indication for a supporting belt. Upon review, the Board finds that a rating in excess of 30 percent for the Veteran's gastrointestinal disorder is not warranted for the period beginning on December 31, 2012. The Board notes that a 30 percent rating is the maximum schedular rating allowed under Diagnostic Code 7319. However, a 50 percent rating is not warranted under Diagnostic Code 7301 for peritoneal adhesions, because the medical evidence shows that the Veteran does not have a partial bowel obstruction. Furthermore, the Veteran does not have malnutrition as required for a rating in excess of 30 percent under Diagnostic Code 7323 for ulcerative colitis. Additionally, the Veteran's gastrointestinal disorders include GERD and residuals of ventral hernia repair under Diagnostic Codes 7346 and 7339, respectively. The Board finds that a rating in excess of 30 percent under Diagnostic Code 7339 is not warranted because the evidence does not demonstrate that the Veteran currently has a ventral hernia. The evidence demonstrates that the Veteran's GERD symptoms included regurgitation and pyrosis. However, ratings under Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 will not be combined with each other, and a single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such evaluation. 38 C.F.R. § 4.114. As noted above, the predominant disability picture is alternating diarrhea and constipation with constant abdominal distress, symptoms contemplated under Diagnostic Code 7319. Moreover, the criteria for a rating in excess of 30 percent under Diagnostic Code 7346 for GERD include symptoms of pain, vomiting, material weight loss, and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. While the Veteran experienced pain, he did not display the other symptoms to warrant a higher rating under Diagnostic Code 7346. Accordingly, a rating higher than 30 percent for the Veteran's gastrointestinal disorder is not warranted. III. Additional Considerations The Board has also considered whether an extraschedular rating is warranted, noting that if an exceptional case arises where the rating schedule is found to be inadequate, consideration of an extraschedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities will be made. 38 C.F.R. § 3.321(b)(1) (2015). The Court has held that the determination of whether a claimant is entitled to an extraschedular rating under § 3.321(b) is a three-step inquiry, the responsibility for which may be shared among the RO, the Board, and the Under Secretary for Benefits or the Director, Compensation and Pension Service. Thun v. Peake, 22 Vet. App. 111 (2008). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. This means that initially 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. 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 adequate, and no referral is required. If the criteria do not reasonably describe the claimant's disability level and symptomatology, a determination must be made whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). See id. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the service-connected disabilities are inadequate. A comparison between the level of severity and symptomatology of the Veteran's disabilities with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. Abdominal pain, and alternating bowel movements are symptoms contemplated by the applicable rating codes. As the first prong of Thun is not satisfied, the Board finds that the evidence does not demonstrate an exceptional or unusual clinical picture beyond that contemplated by the rating criteria and no further analysis is required. Finally, the Board notes that under Johnson v. McDonald, 762 F.3d 1362 ( Fed. Cir. 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. However, in this case, 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. ORDER Entitlement to an initial disability rating of 30 percent, but no higher, prior to December 31, 2012, for diverticulosis and residuals of temporary colostomy, ventral hernia repair with residuals, and GERD is granted. Entitlement to a disability rating in excess of 30 percent from December 31, 2012 for diverticulosis and residuals of temporary colostomy, ventral hernia repair with residuals, and GERD is denied. (CONTINUED ON NEXT PAGE) REMAND The Veteran has underwent multiple VA examinations to assess the nature and severity of his abdominal scars. The June 2007 VA examiner found that the Veteran had multiple abdominal scars. The first scar was a vertical scar in the epigastric area to the suprapubic area, which was measured as 28 centimeters in length and 2 centimeters in width. The scar was not painful or unstable. The scar was superficial. The second scar was on the left side of the abdomen and measured 8 centimeters in length and 1 centimeter in width. There was mild tenderness and the scar was not adherent to the underlying tissue. The scar was stable and superficial. The Veteran had multiple other smaller scars from laparoscopy portal sites that were not painful or unstable. The Veteran's abdominal scars were examined in May 2009. The first scar was a well-healed midline scar, and measured 26 centimeters in length and 2 centimeters in width. The scar was nontender with varying degrees of numbness. The second scar was in the left lower quadrant, and measured 9 centimeters in length and 1 centimeter in width. There was tenderness to palpation. Both scars were found to be superficial without underlying soft tissue damage. The December 2012 VA examiner noted that the Veteran's scars were not painful and/or unstable. The Veteran underwent a VA examination in June 2013 specifically for his abdominal scars. The examiner noted two deep non-linear scars. The first deep non-linear scar measured 31 centimeters in length and 5 centimeters in width. The second measured 9 centimeters in length and 0.8 centimeter in width. The examiner determined that the total area of the deep non-linear scars was approximately 115 square centimeters. The examiner indicated that there was one painful scar in the left lower quadrant on the abdomen, but overall the scars were stable. The examiner also identified 8 linear scars, with four scars measured 1 centimeter in length, two scars measured 2.5 centimeters in length, and two scars measured 0.5 centimeter in length. There appears to be conflicting medical evidence as to the measurements and total area of the Veteran's deep non-linear abdominal scars. The June 2007 and May 2009 examiners found that the Veteran's longest scar was two centimeters in width and between 26 and 28 centimeters in length. However, the June 2013 examiner found that the Veteran's longest scar was 31 centimeters in length and 5 centimeters in width. The June 2007, May 2009, and June 2013 examiners gave similar measurements for the Veteran's second longest scar. The June 2013 examiner stated that the approximate total area of the deep non-linear scars was 115 square centimeters. Based on the measurements provided by the June 2007 and May 2009 examiners, the Veteran's abdominal scars would warrant a 10 percent disability rating under Diagnostic Code 7801. However, based on the measurements and the approximate total area provided by the June 2013 examiner, the Veteran's abdominal scars would warrant a 20 percent rating under Diagnostic Code 7801. Accordingly, another VA examination is necessary to clarify the measurements and total area of the Veteran's deep non-linear scars. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the nature and severity of his abdominal scars. The claims file and a copy of this Remand must be made available to the examiner in conjunction with the examination. All necessary testing should be conducted. The examiner is asked to determine the current level of impairment of his service-connected abdominal scars. For each scar, the examiner must measure the size of the scar and indicate whether such scar is painful, unstable, deep or superficial, or linear or non-linear. The examiner must also determine the total area of the Veteran's deep and non-linear abdominal scars and the total area of the Veteran's superficial and non-linear abdominal scars. The examiner should reconcile the conflicted findings regarding the measurements of the scars to the extent possible. A complete rationale for any opinion offered should be provided. 2. After completing the above development, and any other development deemed necessary, readjudicate the issue on appeal. If any benefit sought remains denied, provide a supplemental statement of the case to the Veteran and her representative, and return the appeal to the Board for appellate review, after the Veteran has had an adequate opportunity to respond. The Veteran has the right to submit additional evidence and argument on the matter 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. J. Alibrando Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs