Citation Nr: 1804327 Decision Date: 01/22/18 Archive Date: 01/31/18 DOCKET NO. 14-12 026 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUES 1. Entitlement to an initial rating in excess of 50 percent for migraines. 2. Entitlement to a rating in excess of 60 percent for gastroesophageal reflux disease (GERD). 3. Entitlement to an extraschedular rating. 4. Entitlement to an initial compensable rating for warts. 5. Entitlement to service connection for alopecia. 6. Entitlement to service connection for a rear head scar. 7. Entitlement to special monthly compensation (SMC) at the rates under 38 U.S.C. § 1114(l), (m), (n), and/or (o). 8. Entitlement to an effective date prior to June 19, 2010, for the grant of SMC at the housebound rate. 9. Entitlement to a total rating based on individual unemployability (TDIU) from December 5, 2008, to June 19, 2010. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD Joshua Castillo, Associate Counsel INTRODUCTION The Veteran had active duty service from May 13, 2003, to July 17, 2003; December 31, 2003, to April 1, 2004; May 13, 2007, to June 30, 2007; July 8, 2007, to August 11, 2007; and from September 4, 2007, to December 4, 2008. These matters come before the Board of Veterans' Appeals (Board) on appeal from May 2013, March 2014, May 2014, June 2015, and December 2015 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). In December 2015, the Board denied entitlement to earlier effectives date for the grant of service connection for several disabilities, to include migraines, and remanded the appeal for further development. In December 2016, the Board denied, the Veteran's motions for revision of prior rating decisions on the basis of clear and unmistakable error, to include revision of the March 2015 rating decision that granted service connection for migraines effective June 13, 2014, and remanded the remaining issues for further development. In March 2017, the Veteran reported that he does not seek an increased rating for migraines, but an earlier effective date for service connection for his service-connected migraines. See Statement (March 1, 2017). As the Board denied the issues of entitlement to an earlier effective date for migraines as well as the Veteran's motion for revision of the rating decision that assigned the current effective date for migraines in December 2015 and December 2016, respectively, the issue of entitlement to an earlier effective date for the grant of service connection for migraines is not currently before the Board. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C.A. § 7107(a)(2) (West 2014). The issues of entitlement to service connection for alopecia and a rear head scar are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran's headaches are very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 2. The Veteran's GERD is characterized by pyrosis, reflux, regurgitation, substernal chest pain, sleep disturbance, nausea, and vomiting. 3. The manifestations of the Veteran's migraines and GERD are contemplated by the ratings schedule under Diagnostic Codes 7346 and 8100. 4. The Veteran's warts effect less than 5 percent of his body. 5. The Veteran's service-connected disabilities do not render him unable to dress, keep clean, feed, or attend to the wants of nature; do not require frequent adjustment of prosthetic which by reason of the disability cannot be done without aid; and do not render him incapable of protecting himself from the hazards or dangers of his daily environment. 6. The Veteran has actual use of his upper and lower extremities without complications that prevent the use of prosthetics, and he does not have service-connected deafness or blindness. 7. Prior to June 19, 2010, the Veteran did not have an additional service-connected disability independently ratable at 60 percent, separate and distinct from a 100 percent service-connected disability; nor was he permanently housebound by reason of service-connected disability or disabilities. 8. From December 5, 2008, to June 19, 2010, the Veteran's service-connected disabilities did not render him unable to secure and follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 50 percent for migraines have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8100 (2017). 2. The criteria for a rating in excess of 60 percent for GERD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.114, Diagnostic Codes 7399-7346 (2017). 3. The criteria for an extraschedular rating have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.114, Diagnostic Codes 7399-7346 (2017). 4. The criteria for an initial compensable rating for warts have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.118, Diagnostic Codes 7820-7806 (2017). 5. The criteria for SMC at the rates under 38 U.S.C. 1114(l), (m), (n), or (o) have not been met. 38 U.S.C.A. §§ 1114, 5107 (West 2014); 38 C.F.R. § 3.350 (2016). 6. The criteria for an effective date earlier than June 19, 2010, for the grant of SMC at the housebound rate are not met. 38 U.S.C.A. §§ 1114(s), 5103, 5103A, 5107, 5110 (West 2014); 38 C.F.R. §§ 3.350, 3.400, 3.401(a) (2017). 7. The criteria for a TDIU from December 5, 2008, to June 19, 2010, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Migraines The Veteran seeks an initial rating in excess of 50 percent for migraines, which has been evaluated under Diagnostic Code 8100. Under Diagnostic Code 8100, a 50 percent rating is assigned for migraine headaches with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. A 30 percent rating is provided for migraine headaches with characteristic prostrating attacks occurring on an average once per month over last several months. A 10 percent rating is provided for migraine headaches with characteristic prostrating attacks averaging one in 2 months over last several months. A noncompensable (zero percent) rating is warranted for less frequent attacks. 38 C.F.R. § 4.124, Diagnostic Code 8100. As the Veteran has been assigned the schedular maximum rating for headaches for the entirety of the appeal period, an increased rating under Diagnostic Code 8100 is not warranted. GERD The Veteran seeks a rating in excess of 60 percent for GERD, which has been evaluated under Diagnostic Code 7346. As GERD is not specifically listed in the rating schedule, it is rated by analogy to a similar disability. Hiatal hernia is closely related to GERD-they effect similar anatomical functions, occur in similar areas, and manifest similar symptoms. Hiatal hernias are rated under Diagnostic Code 7346. A 10 percent rating is warranted for two or more of the following symptoms: epigastric distress; dysphagia; heartburn; regurgitation; or sub-sternal, arm, or shoulder pain. The next higher rating, 30 percent, is warranted when these symptoms produce considerable impairment of health. The maximum rating under this Diagnostic Code, 60 percent, is warranted 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. As the Veteran has been assigned the schedular maximum rating for GERD for the entirety of the appeal period, an increased rating under Diagnostic Code 7346 is not warranted. Extraschedular Consideration The Veteran seeks extraschedular rating for his service-connected GERD and migraines. See Statement (May 26, 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). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under § 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. Id. The Board finds that the first Thun element is not satisfied here for the Veteran's service-connected GERD and/or migraines. The Veteran's service-connected GERD has manifested by signs and symptoms such as pyrosis, reflux, regurgitation, substernal chest pain, sleep disturbance, nausea, and vomiting. These signs and symptoms, and their resulting impairment, are contemplated by the rating schedule under Diagnostic Code 7346, namely the non-inclusive criterion that symptoms produce considerable impairment of health. In short, there is nothing exceptional or unusual about the Veteran's GERD. Moreover, there is no indication that his GERD results in any additional symptomatology for which a separate rating has not been assigned. The Veteran's service-connected migraines have manifested by signs and symptoms such as very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. These signs and symptoms, and their resulting impairment, are contemplated by the rating schedule under Diagnostic Code 8100, namely the non-inclusive criterion that symptoms produce severe economic inadaptability. In short, there is nothing exceptional or unusual about the Veteran's migraines. Moreover, there is no indication that his migraines results in any additional symptomatology for which a separate rating has not been assigned. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology for his service-connected GERD and migraines. Consequently, the rating schedule is adequate to evaluate the Veteran's disability picture. Therefore, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Thun, supra; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). Thus, entitlement to an extraschedular rating for GERD and/or migraines is not warranted. Warts The Veteran seeks an initial compensable rating for residual warts of the right third finger, fourth finger, left hand, back, and genital area associated with psoriatic arthritis of the right knee, hands, wrists, scars of the hands and wrists, which has been rated under Diagnostic Code 7802. The Veteran is in receipt of a 100 percent rating under Diagnostic Code 5009 for psoriatic arthritis of the right knee, hands, and wrists and scars of the hands and wrists. As warts are not specifically listed in the rating schedule, they are rated by analogy to a similar disability. In this case, the Veteran's viral warts are appropriately characterized as infections of the skin not listed elsewhere, which specifically encompasses viral infections, under Diagnostic Code 7820. See, e.g., VA examination (September 2011) (explaining that the Veteran's warts are viral in nature). Infections of the skin not listed elsewhere (Diagnostic Code 7820) are rated as disfigurement of the head, face, or neck (Diagnostic Code 7800), scars (Diagnostic Codes 7801, 7802, 7804, 7805), or dermatitis (Diagnostic Code 7806). As the Veteran's warts do not disfigure the head, fact, or neck, Diagnostic Code 7800 is not applicable. As the Veteran is in receipt of a 100 percent rating, in part for painful scars of the wrists and hands, a separate rating under Diagnostic Code 7804, on the basis of painful scars, would result in impermissible pyramiding, and thus, is not applicable. Accordingly, the Veteran's warts are to be rated under Diagnostic Codes 7801, 7802, or 7806. Under Diagnostic Code 7801, a compensable rating is warranted for scars that cover at least 6 square inches, but less than 12 square inches. Under Diagnostic Code 7802, a compensable rating is warranted for scars that cover at least 144 square inches. Under Diagnostic Code 7806, a compensable rating is warranted for a skin disorder that covers at least 5 percent but less than 20 percent of the entire body or exposed areas of the body; the requires intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a duration of less than six weeks during a 12 month period. Here, the Veteran does not contend and the evidence does not suggest that his service-connected warts cover at least 6 square inches. Accordingly, Diagnostic Code 7801 and 7802 are not applicable. Instead, the Veteran contends that his warts and scars cover 10 percent of his body. See, e.g., Statement (May 26, 2017). Significantly, the in evaluating the Veteran's warts, the Board cannot consider the presence of his service-connected scars as he is already in receipt of a compensable rating for scars. The medical evidence of record indicates that, at best, the Veteran's warts cover less than 5 percent of his body. See VA examination (September 2015); see also VA examination (May 2016) (reporting that warts cover zero percent of the Veteran's body). Significantly, warts were not present during any of the Veteran's VA examinations. See id. While the Board finds that the Veteran is competent to report the presence of warts, it finds that he lacks the relevant, requisite medical expertise to render an opinion regarding the percent of his body they impact. Accordingly, the competent evidence of record pertaining to the percent of the Veteran's body affected by his service-connected warts consists of the VA medical opinions. As the examiners determined that that, at best, the Veteran's warts cover less than 5 percent of his body, an initial compensable rating for warts is not warranted. SMC The Veteran is service-connected for psoriatic arthritis of the right knee, hands and wrists with scars of the hands and wrists, rated 100 percent disabling; GERD, rated 60 percent disabling; migraines, rated 50 percent disabling; nephrolithiasis, rated 30 percent disabling; a left shoulder disability, rated 20 percent disabling; depression, rated 10 percent disabling; and warts, rated zero percent disabling. He is currently in receipt of SMC at the housebound rate. Increased SMC The Veteran seeks entitlement to SMC at the rates described under 38 U.S.C. 1114(l), (m), (n), or (o). The SMC rate payable under 38 U.S.C. 1114(l) is warranted if the veteran, as the result of service-connected disability, has suffered the anatomical loss or loss of use of both feet, or of one hand and one foot, or is blind in both eyes, with 5/200 visual acuity or less, or is permanently bedridden or with such significant disabilities as to be in need of regular aid and attendance. The SMC rate payable under 38 U.S.C.1114(m) is warranted if the veteran, as the result of service-connected disability, has suffered the anatomical loss or loss of use of both hands, or of both legs with factors preventing natural knee action with prostheses in place, or of one arm and one leg with factors preventing natural elbow and knee action with prostheses in place, or has suffered blindness in both eyes having only light perception, or has suffered blindness in both eyes, rendering such veteran so significantly disabled as to be in need of regular aid and attendance. Determinations as to the need for aid and attendance are based on the actual requirements of personal assistance from others. In determining the need for regular aid and attendance, consideration will be given to the inability of the veteran and his or her spouse to dress or undress themselves, or to keep clean; frequent need of adjustment of any prosthetic which by reason of the disability cannot be done without aid; inability of the veteran or his or her spouse to feed themselves; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect themselves from the hazards or dangers of the daily environment. See Turco v. Brown, 9 Vet. App. 222 (1996). The SMC rate payable under 38 U.S.C. 1114(n) is warranted if the veteran, as the result of service-connected disability, has suffered the anatomical loss or loss of use of both arms with factors preventing natural elbow action with prostheses in place, has suffered the anatomical loss of both legs with factors that prevent the use of prosthetic appliances, or has suffered the anatomical loss of one arm and one leg with factors that prevent the use of prosthetic appliances, or has suffered the anatomical loss of both eyes, or has suffered blindness without light perception in both eyes. The SMC rate payable under 38U.S.C. 1114(o) is warranted if the veteran, as the result of service-connected disability, has suffered disability under conditions which would entitle such veteran to two or more of the rates provided in one or more subsections (l) through (n) of this section, no condition being considered twice in the determination, or if the veteran has suffered bilateral deafness (and the hearing impairment in either one or both ears is service connected) rated at 60 percent or more disabling and the veteran has also suffered service-connected total blindness with 20/200 visual acuity or less, or if the veteran has suffered service-connected total deafness in one ear or bilateral deafness (and the hearing impairment in either one or both ears is service connected) rated at 40 percent or more disabling and the veteran has also suffered service-connected blindness having only light perception or less, or if the veteran has suffered the anatomical loss of both arms with factors that prevent the use of prosthetic appliances. The Veteran contends that his disabilities should be rated by analogy at the aforementioned rates. See, e.g., Statement (May 26, 2017). Specifically, he reports that his service-connected arthritis causes pain and limitation of motion, which requires frequent use of arthritic prosthetic gloves for many activities of daily living and that he frequently uses dictation software. He contends that such signs and symptoms, which are currently rated 100 percent disabling, are analogous to loss of use of his hands. He further contends that his GERD symptoms, currently rated 60 percent disabling, should be rated as loss of use of his esophagus. In support of his argument, the Veteran notes that a treatment provider opined that his arthritis results in loss of use of his hands. Initially, the Board notes that entitlement to SMC is not based on analogy, that is, at least one of the enumerated factors within the regulation must be present. See, e.g., Turco v. Brown, 9 Vet. App. 222 (1996). The threshold for SMC at the rates under 38 U.S.C. 1114 (l) and (m) is the need for regular aid and attendance, which is not present in this case. Here, the Veteran does not contend and the evidence does not suggest that his service-connected disabilities do not render him unable to dress, keep clean, feed, or attend to the wants of nature; do not require frequent adjustment of prosthetic which by reason of the disability cannot be done without aid; and do not render him incapable of protecting himself from the hazards or dangers of his daily environment. In fact, throughout the appeal period, the Veteran has been an instructor at a university (2006-2008, 2009-2010, and 2014-present), completed two fellowships (2007-2009 and 2013-2014), obtained two master's degrees (2008 and 2013), worked as a clinical risk manager (2009), served as a health administrative consultant in rebuilding of healthcare infrastructure in Haiti (2010), served as a clinical informatics training instructor (2011), performed a doctoral internship in Japan (2012), became an accredited VA claims agent (2013) and now serves as president/Chief Executive Officer of a company that consults and represents veterans and their families, and obtained his doctorate's (2015). Additionally, treatment records show that the Veteran is able to perform all activities of daily living. While the Board acknowledges the serious nature of the Veteran's service-connected disabilities, his accomplishments affirmatively evince that his disabilities are not so severe as to necessitate regular aid and attendance of another person. Accordingly, SMC is not warranted at the rates under 38 U.S.C. 1114 (l) and (m). Additionally, the lay and medical evidence of record shows that the Veteran retains actual use of his upper and lower extremities without complications preventing use of prosthetics, and that he does not have service-connected deafness or blindness. Accordingly, SMC is not warranted at the rates under 38 U.S.C. 1114(n) or (o). Accordingly, SMC at the rates under 38 U.S.C. 1114 (l), (m), (n), or (o) is not warranted. Earlier Effective Date for SMC at the Housebound Rate The Veteran seeks an effective date prior to June 19, 2010, for the grant of SMC on the basis of housebound status. SMC is payable at the housebound rate where the veteran has a single service-connected disability is rated 100 percent disabling and (1) an 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 (2) is permanently housebound by reason of service-connected disability. 38 U.S.C.A. § 1114(s); 38 C.F.R. § 3.350(i). In this case, the Veteran did not have a single-service-connected disability prior to June 19, 2010. Thus, to prevail, he must establish that he was permanently housebound by reason of service-connected disability prior to June 19, 2010. In this case, the evidence affirmatively shows that he was not housebound at any time during the pendency of the appeal. As discussed above, between separation from service and June 19, 2010, the Veteran worked as an instructor at a university (2006-2008, 2009-2010), completed a fellowship (2007-2009), worked on two master's degrees (2008 and 2013), worked as a clinical risk manager (2009), served as a health administrative consultant in rebuilding of healthcare infrastructure in Haiti (2010). Additionally, treatment records show that the Veteran is able to perform all activities of daily living. While the Board acknowledges the serious nature of the Veteran's service-connected disabilities, his accomplishments affirmatively evince that he was not permanently housebound by reason of service-connected disability. Accordingly, the Board finds that SMC at the housebound rate is not warranted prior to June 19, 2010. TDIU from December 5, 2008, to June 19, 2010 The Veteran seeks a TDIU from December 5, 2008, to June 19, 2010. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that the veteran is precluded, by reason of his service-connected disabilities, from obtaining and maintaining any form of gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. Consideration may be given to a veteran's level of education, special training, and previous work experience, but not to his age or the impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. Unlike the regular disability rating schedule which is based on the average work-related impairment caused by a disability, "entitlement to a TDIU is based on an individual's particular circumstances." Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). The ultimate question of whether a Veteran is capable of substantial gainful employment is an adjudicatory determination, not a medical one. See Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). As the Veteran meets the schedular criteria for a TDIU from December 5, 2008, to June 19, 2010, this case turns on whether he was unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. The Veteran contends that his service-connected disabilities have caused "sub[-] optimized [] capacity for employment." See Statement (May 26, 2017). He explains that, during the period in question, he had to quit one job because of medical-related absenteeism, but that he was only able to work part time with accommodations. He further stated that "I have been and remain able to maintain employment . . . which has been and continues to be inhibited by my service-connected disabilities, only sustained by my spirit and will to remain employed." Id. The Board finds that the Veteran's academic and occupational achievements from December 5, 2008, to June 19, 2010, clearly establish that he was able to secure and follow substantially gainful occupation during that time, despite the serious manifestations of his service-connected disabilities. Significantly, during the period in question, that is, from December 5, 2008, to June 19, 2010, in addition to working on a fellowship (2007-2009) and two masters degrees (completed 2008 and 2013), the Veteran worked part time as a university instructor (2006-2008, 2009-2010) and served as a health administrative consultant in rebuilding of healthcare infrastructure in Haiti (2010). The Board finds that his academic and occupational achievements are the most probative evidence of record pertaining to the Veteran's ability to secure and follow substantially gainful occupation from December 5, 2008, to June 19, 2010, as they demonstrate the ability to obtain, maintain, and even excel at substantially gainful work he continues to perform as a university instructor and healthcare professional. Accordingly, the Board finds that a TDIU from December 5, 2008, to June 19, 2010, is not warranted. ORDER An initial rating in excess of 50 percent for migraines is denied. A rating in excess of 60 percent for GERD is denied. An extraschedular rating is denied. An initial compensable rating for warts is denied. SMC at the rates under 38 U.S.C. § 1114(l), (m), (n), and/or (o) is denied. An effective date prior to June 19, 2010, for the grant of SMC at the housebound rate is denied. A TDIU from December 5, 2008, to June 19, 2010, is denied. REMAND Alopecia & Rear Head Scar The Veteran seeks service connection for alopecia, which he contends began during his period of active duty from December 31, 2003, to April 1, 2004. See statement; see also See Private treatment record (February 3, 2006) (showing that he reported that hair loss began at 19 years old, in 2004). On March 2, 2007, a private physician treated the Veteran's alopecia with elective hair transplant surgery. The surgery left a rear head scar from ear to ear, where donor hair was harvested. Private treatment records dated August 29, 2007; April 4, 2008; and December 5, 2009, show that rear head scar is well-healed and that the surgery yielded "excellent results." In July 2015, the physician who performed the transplant reported that the rear head scar is "neither visible at current hair length nor palpable, and there is no evidence of tissue loss or gross distortion. His head scar is 25cm in length and at least 0.7 cm wide at its widest part. The surface contour of the skin is not elevated or depressed on palpation. The skin texture is normal without induration or inflexibility." Throughout service from May 13, 2007, to June 30, 2007, and from July 8, 2007, to August 11, 2007, and from September 4, 2007, to December 4, 2008, the Veteran did no report a history of alopecia or rear head scar or symptoms of the same, to include on entrance and separation from service. Additionally, clinical evaluation of the Veteran's head, face, neck, and scalp were normal upon entrance and separation examinations. The Veteran contends that wearing headgear during service from May 13, 2008, to December 4, 2008, aggravated his rear head scar. In June 2016, July 2016, and July 2017, VA examiners addressed whether the Veteran's alopecia preexisted service and was aggravated therein. The Board finds, however, that an addendum opinion is needed to address the Veteran's contention that alopecia began during his period of active duty from December 31, 2003, to April 1, 2004. The Veteran's claim for entitlement to service connection for a rear head scar is remanded as it is inextricably intertwined with his claim for alopecia. Accordingly, the case is REMANDED for the following action: 1. Forward the record and a copy of this Remand to an appropriate medical professional. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. Based on review of the claim file, the examiner is to address the likelihood that Veteran's androgenetic alopecia had onset during his period of active duty from December 31, 2003, to April 1, 2004. The examiner is to specifically address the Veteran's reports that his hair loss began in 2004. See Private treatment record (February 3, 2006) (showing that he reported that hair loss began at 19 years old, in 2004); Statement (May 26, 2017). The examiner's report must include a complete rationale for all opinions expressed. 2. Finally, readjudicate the appeal. If the benefits sought remain denied, issue a supplemental statement of the case and return the case to the Board. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). ______________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs