Citation Nr: 1752740 Decision Date: 11/16/17 Archive Date: 11/22/17 DOCKET NO. 12-33 416 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to compensation for a dental disorder, to include as secondary to radiation treatment for service-connected squamous cell carcinoma of the right tonsil and neck. 2. Entitlement to an initial compensable evaluation for squamous cell carcinoma of the right tonsil and neck prior to January 28, 2014. 3. Entitlement to an initial evaluation in excess of 30 percent for loss of tongue and speech impediment associated with squamous cell carcinoma of the right tonsil and neck prior to July 28, 2015, and in excess of 60 percent thereafter. 4. Entitlement to an initial evaluation in excess of 40 percent for arthrosis effecting muscle groups XXI, XXII, and XXIII of the right shoulder associated with squamous cell carcinoma of the right tonsil and neck. 5. Entitlement to an initial evaluation in excess of 10 percent for residual facial and neck scars associated with squamous cell carcinoma of the right tonsil and neck prior to July 28, 2015, and in excess of 30 percent thereafter. 6. Entitlement to an initial evaluation in excess of 10 percent for residuals scars of the chest, right shoulder and right lateral thigh associated with squamous cell carcinoma of the right tonsil and neck. 7. Entitlement to an initial evaluation in excess of 50 percent for absent soft palate associated with squamous cell carcinoma of the right tonsil and neck. 8. Entitlement to an initial evaluation in excess of 10 percent for loss of taste and dry mouth associated with squamous cell carcinoma of the right tonsil and neck. 9. Entitlement to special monthly compensation (SMC) at the statutory housebound rate. REPRESENTATION Veteran represented by: Virginia A. Girard-Brady, Attorney at Law ATTORNEY FOR THE BOARD M. Peters, Counsel INTRODUCTION The Veteran had active duty service from May 1966 to May 1968, with service in the Republic of Vietnam from July 1967 to May 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from October 2009 and April 2010 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO), which awarded service connection and assigned initial evaluations for the above disabilities, and denied service connection for a dental disorder, respectively. This case was initially before the Board in December 2015, at which time the Board awarded a 100 percent evaluation for the Veteran's squamous cell carcinoma of the right tonsil and neck, effective January 28, 2014. The Board additionally remanded the issue of increased evaluation prior to January 28, 2014, for the Veteran's squamous cell carcinoma of the right tonsil and neck, as well as the other issues on appeal. The case has been returned to the Board at this time for further appellate review. FINDINGS OF FACT 1. The Veteran's loss of teeth is not the result of any in-service trauma or due to the loss of substance of the maxilla or mandible, but rather the result of radiation-induced xerostomia (dry mouth). 2. Prior to January 28, 2014, there was no recurrence or metastasis of the Veteran's service-connected squamous cell carcinoma of the right tonsil and neck. 3. The Veteran's loss of tongue and speech impediment more closely approximates an inability to communicate by speech throughout the appeal period. 4. The Veteran's muscle group II and arthrosis of the right shoulder disability more closely approximates intermediate ankylosis of the right shoulder; the Veteran is not shown to have unfavorable ankylosis of the right shoulder or limitation of abduction to 25 degrees or less throughout the appeal period. 5. The Veteran's muscle injuries of groups XXI, XXII, and XXIII are moderately severe disabilities under the criteria of 38 C.F.R. § 4.56. 6. The Veteran has two characteristics of disfigurement, but no more, respecting his residual facial and neck scars; he does not have visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features due to his two residual facial and neck scars throughout the appeal period. 7. Throughout the appeal period, the Veteran's right chest scar more closely approximates to a single painful but not unstable scar. 8. Throughout the appeal period, the Veteran's residual right thigh, right posterior trunk and three right shoulder scars are not shown to be painful or unstable, although the combined area of those scars is shown to be 77.3 sq cm. 9. The Veteran has been assigned the highest possible scheduler evaluation for his absent soft palate and complete loss of taste and dry mouth throughout the appeal period. 10. Beginning February 20, 2002, the Veteran's loss of tongue with speech impediment is rated at 100 percent disabling, and the combined evaluations of his other service-connected disabilities is 60 percent or more disabling. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to compensation for a dental disorder have not been met. 38 U.S.C. §§ 1110, 1712, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.381, 4.150 (2017). 2. The criteria for establishing a compensable evaluation for squamous cell carcinoma of the right tonsil and neck prior to January 28, 2014, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.97, Diagnostic Code 6819 (2017). 3. The criteria for establishing a 100 percent evaluation for loss of tongue with speech impediment have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.114, Diagnostic Code 7202 (2017). 4. The criteria for establishing an initial evaluation in excess of 40 percent evaluation for residual muscle group II injury with arthrosis of the right shoulder have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.55, 4.56, 4.73, Diagnostic Codes 5200, 5202, 5302, 5203 (2017). 5. The criteria for establishing an initial separate combined 50 percent evaluation residual muscle injuries of groups XXI, XXII, and XXIII have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.55, 4.56, 4.73, Diagnostic Codes 5221-5223 (2017). 6. The criteria for establishing a 30 percent evaluation, but no more, throughout the appeal period for residual facial and neck scars have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.118, Diagnostic Code 7800 (2008 & 2017). 7. The criteria for establishing an initial separate 10 percent evaluation for residual right chest scar have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.118, Diagnostic Code 7804 (2008 & 2017). 8. The criteria for establishing an initial 20 percent evaluation, but no higher, for residual right thigh, right posterior trunk, and three right shoulder scars have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.118, Diagnostic Codes 7801, 7804 (2008 & 2017). 9. The criteria for establishing an evaluation in excess of 50 percent for absent soft palate have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.97, Diagnostic Code 6521 (2017). 10. The criteria for establishing an evaluation in excess of 10 percent for loss of taste and dry mouth have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.87a, Diagnostic Code 6276 (2017). 11. The criteria for establishing entitlement to SMC for statutory housebound benefits beginning February 20, 2002, have been met. 38 U.S.C. § 1114 (2012); 38 C.F.R. § 3.351(d) (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has a duty to notify and assist claimants in substantiating claims for VA benefits. See e.g., 38 U.S.C. §§ 5103, 5103A (2012) and 38 C.F.R. § 3.159 (2017). This duty includes assisting the claimant in the procurement of relevant treatment records and providing an examination when necessary. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. With respect to the claims herein decided, VA has met all statutory and regulatory notice and duty to assist provisions. See generally, 38 U.S.C. §§ 5103, 5103A (2012); 38 C.F.R. § 3.159, 3.326 (2017); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Compensation for Dental Disorder Under current VA regulations, compensation is only available for certain types of dental and oral conditions listed under 38 C.F.R. § 4.150, including conditions of the mandible, maxilla, ramus, condyloid process, coronoid process, hard palate, and loss of teeth due to loss of substance of the body of the maxilla or mandible. See 38 C.F.R. § 4.150, Diagnostic Codes 9900-9916. These conditions include loss of whole or part of the mandible, nonunion or malunion of the mandible, loss of whole or part of the ramus, loss of whole or part of the maxilla, nonunion or malunion of the maxilla, loss of the condyloid or coronoid process, or loss of any part of the hard palate. Compensation is also available for loss of teeth only if such is due to loss of substance of body of maxilla or mandible; bone loss through trauma or disease, such as osteomyelitis, must be shown for compensable purposes. The loss of the alveolar process as a result of periodontal disease is not considered disabling. See 38 C.F.R. § 4.150, Diagnostic Code 9913. In addition, to be compensable, the lost masticatory surface for any tooth cannot be restorable by suitable prosthesis. Treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease will be considered service connected solely for the purpose of establishing eligibility for outpatient dental treatment and cannot be considered for compensation purposes. 38 U.S.C. § 1712; 38 C.F.R. §§ 3.381, 4.150. Otherwise, a veteran may be entitled to service connection for dental conditions including treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease, for the sole purposes of receiving VA outpatient dental services and treatment, if certain criteria are met. 38 U.S.C. § 1712; 38 C.F.R. §§ 3.381, 17.161. Rating activity should consider each defective or missing tooth and each disease of the teeth and periodontal tissues separately to determine whether the condition was incurred or aggravated in line of duty during active service and, when applicable, to determine whether the condition is due to combat or other in-service trauma, or whether the veteran was interned as a prisoner of war. 38 C.F.R. § 3.381(b). The Board has reviewed the Veteran's dental treatment records from throughout the appeal period. Those records document that the Veteran has lost several teeth and that the teeth he has remaining have caries of the root surface or into the pulp; Dr. M.T.B. indicated in March 2013 record that the Veteran's remaining teeth were "grossly decayed/non-restorable secondary to radiation-induced xerostomia." Several other dental records associated with the claims file demonstrate that, following removal of his squamous cell carcinoma of his right tonsil and neck, the Veteran began radiation therapy; that radiation therapy resulted in reduced salivation and eventually xerostomia (dry mouth), causing the loss of or gross decay of the Veteran's teeth. The Veteran underwent a VA dental examination in July 2015. During that examination, the Veteran was noted to have missing teeth. The examiner, however, concluded that the loss of teeth was not due to the loss of substance of the body of the maxilla or mandible, but rather due to caries and periodontitis. The examiner additionally concluded that the masticatory surfaces of his teeth could be restored by suitable prosthesis. The Board reflects that the Veteran and his representative have not claimed that the Veteran has any compensable conditions of his mandible, maxilla, ramus, condyloid process, coronoid process, or hard palate throughout the appeal period; specifically, there is no indication of any loss of whole or part of the mandible, nonunion or malunion of the mandible, loss of whole or part of the ramus, loss of whole or part of the maxilla, nonunion or malunion of the maxilla, loss of the condyloid or coronoid process, or loss of any part of the hard palate. Rather, the sole argument advanced throughout the appeal period is that the Veteran has loss of or grossly decayed teeth as a result of his service-connected squamous cell carcinoma of the right tonsil and neck, specifically the use of radiation therapy to treat that disability and the resultant service-connected dry mouth. The Board, however, finds that compensation for the Veteran's loss of teeth in this case is not warranted, as the evidence does not demonstrate that the loss of teeth or the gross decay of the teeth is the result of in-service trauma or the loss of substance of the body of the maxilla or mandible. In fact, the evidence in this case is clear that the Veteran's dental condition is the result of xerostomia (dry mouth) induced by his radiation therapy; there is no evidence of any osteomyelitis of the maxilla or mandible in this case. In short, the Veteran does not have a dental disability in this case on which a claim of compensation may be predicated. Although, the Veteran is shown to have a loss of teeth, such is not shown by the evidence of record to be the result of in-service trauma, or due to the loss of substance of the body of the maxilla or mandible, but rather is due to radiation-induced xerostomia. The Board therefore denies the Veteran's claim for compensation for a dental disorder at this time. See 38 U.S.C. § 1712; 38 C.F.R. §§ 3.381, 4.150. Finally, insofar as the Veteran's claim for a dental disorder encompasses a claim for treatment purposes, the Board does not address that claim at this time as it does not appear by any evidence of record that the Veteran has been denied treatment for his dental disorder at any time throughout the appeal period. In fact, there is no assertion of a denial of treatment by the Veteran or his representative at any time throughout the appeal period. Moreover, in the Board's previous February 2015 remand, the dental claim for treatment purposes was referred for additional appropriate action with the Agency of Original Jurisdiction (AOJ); if the Veteran wishes to pursue a claim for dental treatment, such claim may be pursued with the AOJ consistent with the Board's previous referral of that issue. Accordingly, the Board will not discuss the treatment issue further, as such issue does not appear to have been explicitly raised either by the Veteran, his representative or by the record. Increased Evaluation Claims Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staging the ratings." See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). Squamous Cell Carcinoma of the Right Tonsil and Neck Prior to January 28, 2014 The Veteran filed his claim for service connection for squamous cell carcinoma of his right tonsil and neck on February 20, 2002, and the AOJ has awarded the Veteran a noncompensable evaluation for that disability from February 20, 2002 through January 27, 2014; the Board awarded a 100 percent evaluation for that disability, effective January 28, 2014, in its December 2015 decision. The Veteran's noncompensable evaluation prior to January 28, 2014, has been assigned under Diagnostic Code 6819. Under Diagnostic Code 6819, a 100 percent rating continues beyond the cessation of any surgical, x-ray, antineoplastic chemotherapy or other therapeutic procedure. Six months after the discontinuance of such treatment, the appropriate disability rating is determined by mandatory VA examination. If there has been no local recurrence or metastasis, the rating is based on residuals. See 38 C.F.R. § 4.97, Diagnostic Code 6819 (2017). In the December 2015 decision, the Board awarded a 100 percent evaluation under Diagnostic Code 6819 based on a January 28, 2014 private treatment record from a public university health system which demonstrated that the Veteran underwent surgery on that date for recurrence of his squamous cell carcinoma of the right tonsil and neck. The Board has reviewed the evidence of record, particularly the private and VA treatment records from the period of February 20, 2002 through January 27, 2014. The Board reflects that there is no evidence in the records prior to January 28, 2014, of any recurrence of the Veteran's squamous cell carcinoma of the right tonsil and neck. In particular, the Board notes a November 2012 records from Dr. G.T.W. indicate that there was no evidence of any recurrent neoplasms at that time. The Veteran and his representative have argued on appeal that the 100 percent evaluation should be assigned an effective date prior to January 28, 2014, although the Veteran and representative have not pointed to any private or VA medical records dated prior to January 28, 2014, which demonstrates a recurrence or metastasis of the squamous cell carcinoma of his right tonsil and neck. Accordingly, the Board must find that the evidence does not demonstrate any recurrence or metastasis prior to January 28, 2014, and a higher evaluation than the noncompensable evaluation assigned during that period for the squamous cell carcinoma of the right tonsil and neck is denied. See 38 C.F.R. § 4.97, Diagnostic Code 6819. Insofar as the Board is redirected by Diagnostic Code 6819 to rate the residuals of his squamous cell carcinoma of the right tonsil and neck during the period prior to January 28, 2014, the Board reflects that it will address those other issues below. Loss of Tongue with Speech Impediment The Veteran filed his claim for service connection for squamous cell carcinoma of his right tonsil and neck on February 20, 2002, and the AOJ has awarded the Veteran a 30 percent evaluation for loss of his tongue with a speech impediment from February 20, 2002 through July 27, 2015, and 60 percent evaluation beginning on July 28, 2015. Those evaluations have been assigned under Diagnostic Code 7202. Under Diagnostic Code 7202, for loss of the tongue, in whole or in part, a 30 percent rating is warranted for loss of all or part of the tongue that results in a marked speech impairment. A 60 percent evaluation is warranted for loss of one-half or more of the tongue, and a 100 percent evaluation is warranted for inability to communicate by speech. See 38 C.F.R. § 4.114, Diagnostic Code 7202 (2017). The Veteran underwent a VA examination in August 2009, which indicated that the Veteran had lost 30 percent of his tongue. That examiner noted that the Veteran was unable to speak clearly enough to be understood at least half the time, although not all of the time. In a July 28, 2015 VA examination, that VA examiner noted that the extent of the anatomical loss of tissue included the entire right half of his tongue, entire right pharyngeal pillar, right tonsil, and entire soft palate; the examiner noted that the Veteran had the loss of half or more of his tongue on examination. The examiner further noted that the right side of the Veteran's mouth appeared to be paralyzed and did not move during speech; he spoke through the left side of his mouth with uncontrolled lip movements. His words were muffled and difficult to understand; the examiner further noted that the absence of his teeth caused his words to be more muffled and indistinct, although wearing a denture did not significantly improve the quality of speech. The examiner noted that one must listen very closely to make out what the Veteran is saying. Respecting the Veteran's occupational impairment, the examiner indicated that the Veteran had an inability to communicate. The Board notes the evidence of record demonstrates that the Veteran's loss of tongue with a speech impediment make his ability to verbally communication incredibly difficult; the examiners have noted that the Veteran's words are muffled and his speech is difficult to understand. Although the August 2009 examiner indicated that the Veteran's speech was unable to be understood over half the time but not all the time, the July 2015 examiner noted substantially similar difficulties in verbal communication and determined that the Veteran was unable to communicate. Accordingly, by resolving reasonable doubt in his favor, the Board finds that the evidence of record demonstrates that the Veteran's loss of tongue with a speech impediment more closely approximates to an inability to communicate by speech throughout the appeal period. Therefore, a 100 percent evaluation for the Veteran's loss of tongue with a speech impediment is warranted throughout the appeal period. See 38 C.F.R. §§ 4.7, 4.114, Diagnostic Code 7202. Arthrosis Effecting Muscle Groups XXI, XXII, and XXIII of the Right Shoulder The Veteran has been assigned a 40 percent evaluation for his arthrosis effecting muscle groups XXI, XXII, and XXIII since February 20, 2002. That evaluation has been assigned under Diagnostic Code 5200. Handedness for the purpose of a dominant rating will be determined by the evidence of record, or by testing on VA examination. Only one hand shall be considered dominant. The injured hand, or the most severely injured hand, of an ambidextrous individual will be considered the dominant hand for rating purposes. 38 C.F.R. § 4.69 (2017). In this case, the evidence demonstrates that the Veteran's right hand is his dominant hand. Accordingly, the Board finds that the Veteran's right upper extremity, including his right shoulder, is his major extremity for purposes of evaluation. Under Diagnostic Code 5200, which provides that ankylosis of the scapulohumeral articulation (the scapula and humerus move as one piece) of the major upper extremity is rated 30 percent when it is favorable, with abduction to 60 degrees and able to reach mouth and head. A 40 percent is assigned with intermediate ankylosis (between favorable and unfavorable); and it is rated 50 percent when unfavorable, with abduction limited to 25 degrees from side. Minor arm evaluations for each of those criteria are 10 percent less than the major arm evaluations. See 38 C.F.R. § 4.71a, Diagnostic Code 5200 and Note (2017). Ankylosis is stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). Alternatively, Diagnostic Code 5202 provides a 20 percent evaluation for malunion of the major humerus with a moderate deformity and, and a 30 percent evaluation with a marked deformity; malunion of the minor humerus with either a moderate or a marked deformity warrants 20 percent. A 20 percent evaluation is also warranted for recurrent dislocation of the major humerus at the scapulohumeral joint with infrequent episodes and guarding of movement only at the shoulder level, and a 30 percent rating is warranted for frequent episodes and guarding of all arm movements; a minor arm with either of those symptoms is evaluated as 20 percent disabling. Impairment of the major humerus is rated at 50 percent if there is a fibrous union, 60 percent if there is nonunion or false flail joint, and 80 percent if there is loss the head of humerus, with flail shoulder; again, the minor arm with those symptoms is evaluated as 10 percent less than the major arm evaluations. See 38 C.F.R. § 4.71a, Diagnostic Code 5202 (2017). Additionally, the factors to be considered in evaluating disabilities residual to healed wounds involving muscle groups are set forth in 38 C.F.R. §§ 4.55 and 4.56. A through-and-through injury with muscle damage shall be evaluated as no less than a moderate injury for each group of muscles damaged. 38 C.F.R. § 4.56(b). For VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, and uncertainty of movement. 38 C.F.R. § 4.56(c). Under Diagnostic Codes 5301 to 5323, disabilities resulting from muscle injuries shall be classified as slight, moderate, moderately severe, and severe. The type of disability associated with a slight muscle disability is a simple wound of muscle without debridement or infection. A history with regard to this type of injury should include service department record of superficial wound with brief treatment and return to duty, healing with good functional results, and no cardinal signs or symptoms of muscle disability. Objective findings should include minimal scar, no evidence of fascial defect, atrophy, or impaired tonus, no impairment of function or metallic fragments retained in muscle tissue. 38 C.F.R. § 4.56(d)(1). The type of injury associated with a moderate muscle disability is a through-and-through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection. A history with regard to this type of injury should include service department record or other evidence of in-service treatment for the wound and record of consistent complaints of one or more of the cardinal signs and symptoms of muscle disability, particularly lowered threshold of fatigue after average use affecting the particular functions controlled by the injured muscles. Objective findings should include entrance and (if present) exit scars, small or linear, indicating short track of missile through muscle tissue and some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. 38 C.F.R. § 4.56(d)(2). The type of injury associated with a moderately severe muscle disability is a through-and-through or deep penetrating wound by a small high-velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. A history with regard to this type of injury should include service medical record or other evidence showing prolonged hospitalization for treatment of wound, record of consistent complaints of cardinal signs and symptoms of muscle disability, and, if present, evidence of inability to keep up with work requirements. Objective findings should include entrance and (if present) exit scars indicating the track of the missile through one or more muscle groups, and indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with the sound side. Tests of strength and endurance compared with sound side should demonstrate positive evidence of impairment. 38 C.F.R. § 4.56(d)(3). The type of injury associated with a severe disability of muscles is a through-and-through or deep penetrating wound due to high-velocity missile, or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intermuscular binding and scarring. A history consistent with this type of injury would include service department record or other evidence showing hospitalization for a prolonged period for treatment of wound, record of consistent complaint of cardinal signs and symptoms of muscle disability, worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements. Objective findings of a severe disability would include ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track; palpation shows loss of deep fascia or muscle substance, or soft flabby muscles in wound area; muscles swell and harden abnormally in contraction; tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side indicate severe impairment of function. If present, a severe injury would also show x-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile; adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle; diminished muscle excitability to pulsed electrical current in electrodiagnostic tests; visible or measurable atrophy; adaptive contraction of an opposing group of muscles; atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle; or induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56(d)(4). A muscle injury rating will not be combined with a peripheral nerve paralysis ratings of the same body part, unless the injuries affect entirely different functions. 38 C.F.R. § 4.55(a). Diagnostic Code 5302 addresses, impairments of muscle group II, which include the extrinsic muscles of the shoulder girdle: (1) pectoralis major II (costosternal); (2) latissimus dorsi and teres major (teres major, although technically an intrinsic muscle, is included with latissimus dorsi); (3) pectoralis minor; and (4) rhomboid, affect the function of depression of the arm from vertical overload to hanging at the side (1, 2); downward rotation of the scapula (3, 4), and acts with group III in 1 and 2 in the forward and backward swing of the arm. Slight disabilities are noncompensable. A 20 percent evaluation is warranted for moderate disabilities, and a 30 percent is warranted for moderately severe disabilities. Severe disabilities are assigned a 40 percent evaluation. The minor extremity is assigned an evaluation that is 10 percent less for moderately severe and severe disabilities, although is assigned the same evaluation for slight and moderate disabilities. 38 C.F.R. § 4.73, Diagnostic Code 5202 (2017). Diagnostic Code 5321 addresses impairments of muscle group XXI, which include the thoracic muscle group, affect respiration. Slight disabilities are noncompensable. A 10 percent evaluation is warranted for moderate disabilities, and a 20 percent evaluation is warranted for moderately severe and severe disabilities. 38 C.F.R. § 4.73, Diagnostic Code 5221 (2017). Diagnostic Code 5322 addresses impairments of muscle group XXII, which include the muscles of the front of the neck (lateral, supra- and infrahyoid group): (1) Trapezius I (clavicular insertion); (2) sternocleidomastoid; (3) the "hyoid" muscle; (4) sternothyroid; and, (5) digastric, affect rotary and forward movement of the head, respiration and deglutition. Slight disabilities are noncompensable. A 10 percent evaluation is warranted for moderate disabilities, and a 20 percent evaluation is warranted for moderately severe disabilities. A severe disability is assigned a 30 percent evaluation. 38 C.F.R. § 4.73, Diagnostic Code 5222 (2017). Diagnostic Code 5323 addresses impairments of muscle group XXIII, which include the muscles of the side and back of the neck: (1) suboccipital; (2) lateral vertebral; and, (3) anterior vertebral muscles, affect movements of the head and fixation of shoulder movements. Slight disabilities are noncompensable. A 10 percent evaluation is warranted for moderate disabilities, and a 20 percent evaluation is warranted for moderately severe disabilities. A severe disability is assigned a 30 percent evaluation. 38 C.F.R. § 4.73, Diagnostic Code 5223 (2017). The Veteran underwent a VA examination in August 2009, at which time he reported instability, pain, weakness, stiffness, and decreased speed of joint motion of the right shoulder, but denied any deformity, giving way, dislocation or subluxation, effusions, symptoms of inflammation, or other symptoms. The Veteran further reported weekly, moderate flare-ups that lasted 1-2 days; his flare-ups were precipitated by overuse, playing horse shoes, reaching, pushing, and pulling. On examination, there was evidence of crepitus, deformity, instability, weakness, and guarding of movement. He had 135 degrees of flexion, 120 degrees of abduction, 85 degrees of internal rotation and 65 degrees of external rotation. There was objective evidence of pain on repetitive motion, although there was no additional limitation of function due to repetitive motion. The examiner, however, noted decrease mobility, problems with lifting and carrying and difficulty with reaching. He was unable to participate in sports; severely impaired in his ability to feed himself; moderately impaired in his ability to do chores, shop, exercise, participate in recreation, and bathe himself; mildly impaired in his ability to travel and groom himself; and, there was no impact on his ability to bathe, dress or toilet. As to the Veteran's muscle injury, he reported loss of right arm strength. The examiner indicated that the Veteran's right anterior chest pectoralis muscle (group II) was involved. The Veteran reported pain, decreased coordination, increased fatigability, weakness, and uncertainty of movement; he also reported numbness and tingling in his hand and fingers. He reported a weekly, moderate flare-up of pain to 5 out of 10, which lasted 1-2 days and was precipitated by overuse, pulling and pushing. On examination, the examiner noted that groups XXI, XXII, and XXIII were injured, with tissue loss and muscle strength of 4 out of 5. The examiner further noted that the Veteran had decreased strength in his right arm for doing tasks and decreased strength with pushing and pulling. There was no evidence of nerve, tendon or bone damage, or any evidence of muscle herniation. There was loss of deep fascia or muscle substance noted; the examiner noted the Veteran's right pectoralis muscle had less muscle mass compared to the left side. The examiner further noted that the Veteran's right shoulder joint was limited due to his muscle injury. The examiner further concluded that the Veteran's muscle disability resulted in a severe impairment in his ability to participate in sports and recreation; a moderate impairment in his ability to do chores, shop, exercise, feed and dress himself; a mild impairment in traveling and grooming; and, he was not impaired in bathing or toileting. The Veteran additionally underwent a VA examination of his right shoulder and muscle disabilities in July 2015. The Veteran reported pain and weakness of his right shoulder; he denied any resting pain, but had a flare-up of pain when performing physical activity such as racking, hammering, or lifting more than 25 pounds. He reported flare-ups occurring every other day that lasted 30 minutes to an hour, relieved by rest. He was right hand dominant. On examination, he had flexion and abduction to 170 degrees, and internal and external rotation to 90 degrees, respectively. The Veteran had pain during flexion and abduction, and there was pain on weightbearing. The Veteran was not additionally limited by repetitive use over time, as the examiner noted that the examination was consistent with repetitive use over time as well as his functional impairment during flare-ups. He had 4 out of 5 strength during muscle strength testing and there was no evidence of muscle atrophy or ankylosis of the right shoulder. There was no evidence of right shoulder instability, dislocation or subluxation, and rotator cuff testing was negative. The examiner finally noted the Veteran did not have loss of his right humeral head (flail shoulder), nonunion (false flail shoulder) or fibrous union of the right shoulder joint. As to his muscle disabilities, the examiner noted that the Veteran developed muscle weakness due to loss of muscle in the right shoulder girdle following surgery for his right tonsil and neck cancer. The examiner noted that the Veteran's muscle group II was affected, as well as groups XXI, XXII, and XXIII. On examination, the Veteran was noted to have some loss of muscle substance, as well as loss of power, weakness, lowered threshold for fatigue, and fatigue pain in groups III, XXI, XXII, and XXIII. He had decreased muscle strength testing to 4 of 5 in shoulder abduction (group III), although he did not have any muscle atrophy. The Veteran concluded that the Veteran reported it hurt to turn his head to the left and that he had a difficulty using his right shoulder effectively. The Veteran has been assigned a 40 percent evaluation for his muscle injury of group II in this case as analogous to intermediate ankylosis of his shoulder. The Board reflects that the Veteran's abduction is not limited to 25 degrees or less from the side, nor is his right shoulder shown to have actual unfavorable ankylosis in this case. Moreover, there is no evidence of any fibrous union, nonunion or false flail joint of the Veteran's right shoulder, or any loss of the right humeral head in this case. Finally, the Board reflects that the highest evaluation under Diagnostic Code 5302 has already been assigned in this case; an evaluation of 50 percent under Diagnostic Code 5200 as contemplated by 38 C.F.R. § 4.55(c)(2) is not appropriate in this case, as only group II is shown to be affected in this case. The Board further reflects that it appears that the July 2015 examiner's reference to muscle group III is in error, and that muscle group II was meant. However, insofar as any injury to muscle group III was actually noted on examination, a separate compensable evaluation for the Veteran's muscle group III injury cannot be assigned, as the Veteran's right shoulder injury is not actually ankylosed and the combined evaluation for muscle groups of the shoulder must be rated less than 50 percent disabling; thus, any muscle group III injury would be contemplated as combined with the muscle group II injury in this case. See 38 C.F.R. § 4.73(d) (2017). Finally, although the Board acknowledges the Veteran's lay complaints of numbness and tingling in his right hand and fingers during the August 2009 VA examination, the Board notes that no separate neurological disorder has been diagnosed throughout the appeal period. Moreover, even if such were shown to have been diagnosed, a separate neurological evaluation would not be applicable in this case, as any such neurological impairment would necessarily affect the same functioning as contemplated by the muscle injury in this case. See 38 C.F.R. § 4.73(a). Accordingly, an evaluation in excess of that already assigned for the Veteran's muscle injury of group II with arthrosis of the right shoulder disability is not warranted. See 38 C.F.R. §§ 4.7, 4.71a, 4.73, Diagnostic Codes 5200, 5202, 5302. Furthermore, the Board does acknowledge that the Veteran's disabilities of muscle groups XXI, XXII, and XXIII have also been service connected, although the AOJ has evaluated those muscle injuries with the above noted right shoulder disability. However, the Board finds that this combination of disabilities is incorrect in light of the provision in 38 C.F.R. § 4.73(f), that muscle group injuries of a different anatomical region (groups XXI, XXII, and XXIII being of the torso and neck group rather than the shoulder girdle and arm group, see 38 C.F.R. § 4.73(b)) which do not act upon ankylosed joints shall be rated separately and combined under 38 C.F.R. § 4.25. Accordingly, the Board assigns a separate combined 50 percent evaluation for the muscle groups XXI, XXII, and XXIII in this case, as the evidence of record demonstrates loss of muscle substance with positive evidence of impairment in strength and endurance testing compared with the Veteran's left side. Such findings commensurate to moderately severe muscle disabilities for each muscle group, with the corresponding 20 percent evaluations, respectively. Three 20 percent evaluations combine under Table I of 38 C.F.R. § 4.25 to 49 percent, which rounds to 50 percent. The Board reflects that severe muscle disabilities of muscle groups XXII and XXIII are not shown in the record, as there is not any evidence of soft flabby muscles in the wound area, muscle atrophy, or that his muscles swell and harden abnormally in contraction. Moreover, there is no indications of severe impairment as contemplated by 38 C.F.R. § 4.56(d)(4) as to those muscle groups throughout the appeal period. Accordingly, a separate initial 50 percent evaluation for muscle groups XXI, XXII, and XXIII is warranted in this case based on the evidence of record. See 38 C.F.R. §§ 4.55, 4.56, 4.73, Diagnostic Codes 5321-5323. Residual Facial and Neck Scars Associated with Squamous Cell Carcinoma of the Right Tonsil and Neck The Veteran has been assigned a 10 percent evaluation for his residual facial and neck scars from February 20, 2002 through July 27, 2015; beginning July 28, 2015, the AOJ increased the Veteran's evaluation to 30 percent disabling. Those evaluations have been assigned under Diagnostic Code 7800. Diagnostic Code 7800 concerns disfigurement of the head, face or neck due to scarring. That code section provides a 10 percent evaluation where there is one characteristic of disfigurement. A 30 percent evaluation is warranted for visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips); or with two or three characteristics of disfigurement. A 50 percent evaluation is assigned for visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips); or with four or five characteristics of disfigurement. An 80 percent evaluation is assigned when there is 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 (2017). The 8 characteristics of disfigurement, for the purposes of evaluation under § 4.118, are scars 5 or more inches (13 or more cm.) in length; scars at least one-quarter inch (0.6 cm.) wide at widest part; surface contour of scar elevated or depressed on palpation; scar adherent to underlying tissue; skin hypo- or hyper-pigmented in an area exceeding six square inches (39 cm.); skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.); and skin indurate and inflexible in an area exceeding six square inches (39 sq. cm.). Id. at Note (1). The Veteran underwent a VA examination in August 2009, at which time the examiner noted that the Veteran had disfigurement or disfiguring scars of the face in the mouth, lips and tongue template. In the scars template, the examiner noted two scars that measured 9 cm by 0.2 cm and 19 cm by 0.2 cm on the right neck; the examiner noted that one of the scars was linear from behind the right ear to the right anterior clavicle and the other was along side the other into the neck area. The examiner noted there was no breakdown of the scar or reported pain. On the physical examination, however, it appears that only one scar was discussed. The examiner noted that the maximum length was 19 cm and the maximum width was 0.2 cm. The examiner noted that the scar was not painful, did not have skin breakdown, was superficial and did not have any inflammation, edema, keloid formation, abnormal texture, or underlying soft tissue loss. The Veteran's scar was not indurated or inflexible, nor was the contour elevated or depressed; the scar was not adherent to underlying tissue and did not have any other disabling effects. The examiner noted that the skin area that was hypo- or hyperpigmented with an abnormal pigmentation was 6 sq cm (39 sq cm) or less, and the discoloration was red or other. The second scar is not discussed by that examiner. Photographs of the scars were included with the examination report. The Veteran underwent another VA examination of his facial scars on July 28, 2015. The examiner noted two scars of the right neck secondary to the Veteran's cancer surgery, although neither of the scars was painful or unstable. On physical examination, the examiner noted that there was a scar from the right side of the neck from the base of the right ear up to the bottom of the chin that was 10 cm long, as well as a second scar that was 7 cm long that extended from the middle of his lower lip up to the right anterio-lateral aspect of his mandible. The examiner noted "yes" to whether there was elevation, depression, adherence to the underlying tissue, or missing underlying soft tissue of the scars, although which specific aspect was not identified. The examiner additionally noted that there was not abnormal pigmentation or contour of the scars, nor was there gross distortion or asymmetry of facial features or visual or palpable tissue loss. The examiner did note, however, that the Veteran reported tightness over the scars of his neck sometimes. The examiner concluded that photographs were not indicated, as photographs were already sent and that there were no changes since that time such that additional photographs would be helpful or provide any additional information. The Veteran's private and VA treatment records from throughout the appeal period have been reviewed. However, although scars are generally noted, the specific criteria for evaluation of the Veteran's scars are not addressed substantially by those records. Based on the foregoing evidence, the Board finds that a 30 percent evaluation, but no higher, is warranted throughout the appeal period. Based on the totality of the two VA examinations, it appears that the Veteran has two or three characteristics of disfigurement, including a scar that is 19 cm in length and surface contour that is elevated or depressed. The most recent VA examiner opined that the Veteran's scars were unchanged from the previous examination in 2009 until the most recent examination in 2015. Therefore, by resolving reasonable doubt in the Veteran's favor, the Board finds that a 30 percent evaluation is warranted throughout the appeal period. The Veteran's scars are not shown throughout the appeal period to have any more than three characteristics of disfigurement of his two neck scars, including: at least one-quarter inch (0.6 cm.) wide at widest part; adherence to underlying skin; skin hypo- or hyper-pigmented in an area exceeding six square inches (39 cm.); abnormal skin texture in an area exceeding six square inches (39 sq. cm.); missing underlying soft tissue in an area exceeding six square inches (39 sq. cm.); or, indurated or inflexible skin in an area exceeding six square inches (39 sq. cm.). Moreover, neither of the examiners indicated that there was visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features due to his two neck scars. In short, by resolving reasonable doubt in his favor, the Board finds that the Veteran has no more than three characteristics of disfigurement due to his two neck scars throughout the appeal period; his scars are not shown throughout the appeal period to have visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features. Accordingly, a 30 percent evaluation, but no higher, is warranted for the Veteran's residuals facial and neck scars throughout the appeal period. See 38 C.F.R. §§ 4.7, 4.118, Diagnostic Code 7800. Residual Scars of the Chest, Shoulders, and Right Lateral Thigh Associated with Squamous Cell Carcinoma of the Right Tonsil and Neck The Veteran has been assigned a 10 percent evaluation for his residual scars of the chest, right shoulder and right anterior lateral thigh since February 20, 2002. That evaluation has been assigned under Diagnostic Code 7801. During the appeal period, the Board notes that the Rating Schedule respecting evaluation of non-facial scarring was revised effective October 23, 2008. Under Diagnostic Code 7801, a 10 percent disability evaluation is assigned when a scar, of an area other than the head, face, and neck, is deep or causes limited motion, and involves an area or areas of at least 6 square (sq.) inches (39 square cm.), but less 12 sq. inches (77 sq. cm.). A 20 percent disability evaluation is warranted for when it involves an area or areas of at least 12 sq. inches (77 sq. cm.), but is less than 72 sq. inches (465 sq. cm.). A 30 percent disability evaluation is warranted when it involves an area or areas at least 72 sq. inches (465 sq. cm.), but less than 144 sq. inches (929 sq. cm.). A 40 percent evaluation is warranted when it involves an area or areas is at least 144 sq. inches (929 sq. cm.), or greater. See 38 C.F.R. § 4.118, Diagnostic Code 7801 (2017). Note (1) indicates that a deep scar is one associated with underlying soft tissue damage. Alternatively, under Diagnostic Code 7804, a 10 percent evaluation is assigned for 1 or 2 unstable or painful scars; a 20 percent evaluation is assigned for 3 or 4 unstable or painful scars; and, a 30 percent evaluation is assigned for 5 or more unstable or painful scars. See 38 C.F.R. § 4.118, Diagnostic Code 7804 (2017). Note (1) indicates that an unstable scar is one where, for any reason, there is frequent loss of covering over the scar. Additionally, if one or more scars are both unstable and painful, an extra 10 percent will be added to the evaluation that is based on the total number of unstable or painful scars. See Id., Note (2). Diagnostic Code 7802 only provides for a 10 percent evaluation, and therefore, a higher evaluation than already assigned is not applicable in this case. The Board will therefore no longer discuss that Diagnostic Code in this case. See 38 C.F.R. § 4.118, Diagnostic Code 7802 (2017). The Veteran underwent a VA examination of his scars in August 2009. The Veteran was noted to have three scars of the right shoulder area up to the right neck, measuring: (1) 2.5 cm by 2 cm; (2) 2.5 cm by 2 cm; and, 4 cm by 0.2 cm, with an irregular shape noted for each. These scars were noted as deep, but not painful; there were no signs of skin breakdown, inflammation, edema, keloid formation, elevated or depressed contour, or adherence to underlying tissue. The skin was not indurated or inflexible, although the examiner noted that there was an abnormal texture due to pulling around the scars and that the skin was smooth and taunt; his skin was noted as being lighter than normal in an area 39 sq cm or less. The Veteran additionally had a right anterior chest scar near his right arm and axilla, which measured 19.5 cm by 3 cm. That scar was noted as being deep and painful, although there were no signs of skin breakdown, inflammation, edema, keloid formation, elevated or depressed contour, or adherence to underlying tissue. The skin was not indurated or inflexible, although the examiner did note an abnormal texture with an area of 39 sq cm or less, and which was taunt and rope-like into the right axilla with the right arm raised. His skin was also noted to be lighter than normal in an area of 39 sq cm or less. The examiner additionally noted visible or palpable underlying soft tissue loss in an area of 39 sq cm or less; his right chest muscle was noted as smaller than the left with a deformity, noted muscle loss, and resulting in decreased range of motion of the right shoulder. Finally, the examiner noted an 8 cm by 10 cm scar on his right lateral anterior thigh; the examiner noted that the scar was at least 39 sq cm in area, but less than 77 sq cm. The right thigh scar was superficial and not painful; there were no signs of skin breakdown, inflammation, edema, keloid formation, or any other disabling effects. The Veteran underwent another VA examination of his non-facial and neck scars in July 2015. The examiner noted three scars on examination: (1) of the left lower extremity that was superficial and non-linear, measuring 7 cm by 8 cm; (2) of the right anterior chest extending from the axilla to just below the right nipple in a curvilinear path, noted as superficial and non-linear, measuring 16 cm by 1 cm; and, (3) of the left posterior axillary line extending from axilla up to the lower most rib, noted as superficial and non-linear, measuring 21 cm by 0.5 cm. The examiner noted that the total area of those scars was 56 sq cm, 16 sq cm, and 10.5 sq cm, respectively. He did not have any deep non-linear scars, and none of the scars were painful or unstable. The Veteran's private and VA treatment records from throughout the appeal period have been reviewed. However, although scars are generally noted, the specific criteria for evaluation of the Veteran's scars are not addressed substantially by those records. By resolving reasonable doubt in favor of the Veteran, the Board finds that the a separate 10 percent evaluation for the Veteran's right chest scar is warranted throughout the appeal period, and that a 20 percent evaluation for the Veteran's right thigh, right posterior trunk and three right shoulder scars warrant a 20 percent evaluation, but no higher, throughout the appeal period. The Board reflects that the Veteran's single right chest scar is shown to be painful during the August 2009 VA examination; although that scar was not noted as being painful during the July 2015 examination, the Board notes that the right chest scar is shown to be deep and causing limited motion of the right shoulder throughout the appeal period, despite being less than 39 sq cm in area. Consequently, the Board finds that the right chest scar more closely approximates to a single painful scar throughout the appeal period and therefore, a separate 10 percent evaluation for that single right chest scar is warranted throughout the appeal period. See 38 C.F.R. §§ 4.7, 4.118, Diagnostic Code 7804. Turning to the three right shoulder, right posterior trunk and right thigh scars, the Board reflects first that the Veteran has been service-connected for a right thigh scar; the July 2015 examiner noted a left thigh scar that is similar in size and area to that noted in the August 2009 examination. Consequently, the Board finds that the July 2015 noted a left thigh scar in error and that the scar described in that examination was really a right thigh scar. Moreover, insofar as the examiner noted a left posterior trunk scar, the Board notes that the examiner's reference to the left rather than the right is also in error, as the surgery was on the right side. Regarding the combined area of the three right shoulder, right posterior trunk and right thigh scars noted on examination, the combined area of those scars is 77.3 sq cm (56 sq cm for the right thigh, 10.5 sq cm for the posterior trunk, and a combined 10.8 sq cm for the 3 right shoulder scars). None of those five scars are shown to be painful or unstable during the appeal period. Consequently, as the combined area of those scars is greater than 77 sq cm but less than 465 sq cm, the Board finds that a 20 percent evaluation, but no higher, is warranted for the residual scars of the right thigh, right posterior trunk and three right shoulder scars throughout the appeal period. See 38 C.F.R. §§ 4.7, 4.118, Diagnostic Codes 7801, 7804. As a final matter, the Board acknowledges that the Rating Schedule for evaluating scars was revised during the appeal period, effective October 23, 2008. The Board, however, notes that Diagnostic Code 7801 was essentially unchanged. Moreover, although painful and unstable scars were rated separately under the Rating Schedule prior to October 2008, such is of no consequence in this case, as there are no unstable scars. Finally, the Board further finds that although Diagnostic Code 7804 was changed in October 2008 to contemplate the number of painful scars, the evaluation in this case would not be effected, as there was only a single painful scar. Accordingly, the Board has contemplated evaluation under both the old and the revised criteria, and the Board finds that the above evaluations are the most advantageous to the Veteran under either set of rating criteria. Absent Soft Palate, Loss of Taste with Dry Mouth, and Extraschedular Considerations The Veteran filed his claim for service connection for squamous cell carcinoma of his right tonsil and neck on February 20, 2002, and the AOJ has awarded the Veteran a 50 percent evaluation for absent soft palate since that date. The Veteran's disability evaluation for that disability has been assigned under Diagnostic Code 6521. Diagnostic Code 6521, for injuries of the pharynx, provides a 50 percent evaluation for the absence of soft palate due to trauma. Accordingly, the Veteran has been assigned the highest possible evaluation under Diagnostic Code 6521, and therefore, the Board is unable to assign any higher evaluation than has already been assigned for that disability. See 38 C.F.R. § 4.97, Diagnostic Code 6521 (2017). Likewise, since February 20, 2002, the Veteran has been assigned a 10 percent evaluation for his loss of taste with dry mouth disability under Diagnostic Code 6276. Diagnostic Code 6276 provides a 10 percent evaluation for complete loss of taste. Accordingly, the Veteran has been assigned the highest possible evaluation under Diagnostic Code 6276, and therefore, the Board is unable to assign any higher evaluation than has already been assigned for that disability. See 38 C.F.R. § 4.87a, Diagnostic Code 6276 (2017). An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1) (2017). Furthermore, in Johnson v. McDonald, 762 F.3d 1362, 1365-66 (Fed. Cir. 2014), the Federal Circuit held that "[t]he plain language of § 3.321(b)(1) provides for referral for extra-schedular consideration based on the collective impact of multiple disabilities." In this case, the Veteran has not raised the issues of entitlement and/or applicability of extraschedular evaluations under 38 C.F.R. § 3.321 for any of his increased evaluation claims on appeal at this time, nor have these issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record); see also Yancy v. McDonald, 27 Vet. App. 484, 495 (Fed. Cir. 2016) ("the Board is required to address whether referral for extraschedular consideration is warranted for a veteran's disabilities on a collective basis only when that issue is argued by the claimant or reasonably raised by the record through evidence of the collective impact of the claimant's service-connected disabilities"). Therefore, the Board will not further discuss these issues at this time. SMC for Statutory Housebound Under 38 U.S.C. § 1114(s), SMC based on housebound status is payable where a Veteran has a single service-connected disability rated as 100 percent disabling and either additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems or is otherwise "permanently housebound" by reason of such disability or disabilities. Based on the foregoing awards and evidence, the Veteran's loss of tongue with speech impediment has been assigned a 100 percent evaluation since February 20, 2002. Moreover, the Veteran's other service-connected disabilities-absence of soft palate, residual facial and neck scars, residual right chest scar, and residual right thigh, right posterior trunk and three right shoulder scars, loss of taste with dry mouth, and muscle group II with arthrosis of the right shoulder, and residual muscle injuries of groups XXI, XXII, and XXIII-independently combine to an evaluation of 60 percent or more. Accordingly, the Board must also award SMC at the statutory housebound rate beginning February 20, 2002. See 38 U.S.C. § 1114(s); 38 C.F.R. § 3.351(d). In reaching the above conclusions, the Board has appropriately applied the benefit of the doubt doctrine in this case. See 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). ORDER Entitlement to compensation for a dental disorder is denied. An initial compensable evaluation for squamous cell carcinoma of the right tonsil and neck prior to January 28, 2014, is denied. An initial 100 percent evaluation for loss of tongue and speech impediment associated with squamous cell carcinoma of the right tonsil and neck is granted, subject to the regulations governing the disbursement of monetary benefits. An initial evaluation in excess of 40 percent for residual muscle group II injury and arthrosis of the right shoulder is denied. An initial separate combined 50 percent evaluation for residual muscle injury of groups XXI, XXII, and XXIII is granted, subject to the regulations governing the disbursement of monetary benefits. An initial 30 percent evaluation, but no higher, for residual facial and neck scars associated with squamous cell carcinoma of the right tonsil and neck is granted, subject to the regulations governing the disbursement of monetary benefits.. An initial separate 10 percent evaluation for a residual right chest scar associated with squamous cell carcinoma of the right tonsil and neck is granted, subject to the regulations governing the disbursement of monetary benefits.. An initial 20 percent evaluation, but no higher, for residual right thigh, right posterior trunk, and three right shoulder scars associated with squamous cell carcinoma of the right tonsil and neck is granted, subject to the regulations governing the disbursement of monetary benefits.. An initial evaluation in excess of 50 percent for absent soft palate associated with squamous cell carcinoma of the right tonsil and neck is denied. An initial evaluation in excess of 10 percent for loss of taste with dry mouth associated with squamous cell carcinoma of the right tonsil and neck is denied. Entitlement to SMC for statutory housebound benefits beginning February 20, 2002, is granted, subject to the regulations governing the disbursement of monetary benefits. ____________________________________________ JAMES G. REINHART Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs