Citation Nr: 1804389 Decision Date: 01/22/18 Archive Date: 01/31/18 DOCKET NO. 05-17 206 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to a rating in excess of 10 percent for a fracture of the sternum. 2. Entitlement to an extraschedular rating for degenerative joint disease and dislocations of the right (minor) shoulder, currently rated as 40 percent disabling. 3. Entitlement to an extraschedular rating for scars of the eyebrows, right temple, and left cheek. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Appellant and his wife ATTORNEY FOR THE BOARD A. Purcell, Associate Counsel INTRODUCTION The Veteran had active military service from May 1959 to February 1964. These matters come to the Board of Veterans' Appeals (Board) on appeal from a November 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. In June 2005, the Veteran testified before RO personnel. In March 2006, the Veteran testified before a Veterans Law Judge who has since retired. In a June 2007 decision, the Board denied a number of the Veteran's claims then on appeal, to include as pertinent to the matters now for consideration, claims for a rating in excess of 30 percent for the service connected right shoulder disability and a rating in excess of 10 percent for a fracture of the sternum. Also in June 2007, the Board remanded claims for entitlement to an initial compensable rating for a service connected disability characterized as "scars of the face, forehead, left and right temples, eyebrows, posterior head, left cheek, left wrist, and left knee." The Veteran appealed the Board's June 2007 denials to the United States Court of Appeals for Veterans Claims (Court). In an April 2009 memorandum decision, the Court as pertinent to matters now for consideration reversed the matter of entitlement to an extraschedular rating for the service connected right shoulder disability and directed the Board to refer this issue to the VA Director of the Compensation and Pension service (Director). The Court also set aside and remanded the claim for an increased rating for a fracture of the sternum. In a July 2012 decision, the Board denied a claim for an initial rating for a disability characterized as a compensable initial rating for "scars of the left knee, left wrist, posterior head, left temple, chin (face), and above the right eye (forehead)," and remanded a claim for a disability characterized as an increased initial rating for "scars of the right temple, eyebrows, and left cheek." The Board in July 2012 also remanded the matter of entitlement to an extraschedular rating for the service connected right shoulder disability pursuant to 38 C.F.R. § 3.321(b)-for the purpose of referring this matter to the Director-and remanded the claim for an increased rating for a fracture of the sternum. Thereafter, an August 2013 determination by the Director found that an additional 10 percent rating was warranted for the service connected right shoulder on an extraschedular basis pursuant to 38 C.F.R. § 3.321(b)(1), and an August 2013 rating decision implemented this decision, increasing the rating for this disability to 40 percent effective from August 20, 2013, the date of the Director's opinion. In addition, a September 2013 rating decision increased the Veteran's disability rating for his service-connected multiple scars-characterized as involving the face, forehead, left and right temple, eyebrows, posterior head, left cheek, left wrist, and left knee-from 0 to 80 percent, effective from August 4, 2012. Following the above determinations, a February 2014 Board decision, as pertinent to the matters for consideration herein, denied a compensable initial rating for a scar of the left eyebrow and-in light of the August 2013 determination by the Director-found that further consideration of an extraschedular rating for the service connected right shoulder disability was not permissible and denied a claim for an extraschedular rating for this disability. The Board in February 2014 also again remanded the matter of additional compensation for scarring of the left cheek, right temple, and/or right eyebrow, on an individual basis and aside from the 80 percent rating assigned in September 2013. The Board in February 2014 also remanded the claim for an increased rating for the fracture of the sternum, to include the matter of whether neurologic deficits associated with this disability warranted increased compensation. Development following the February 2014 Board decision resulted in grants by way of a June 2015 rating decision for service connection for a disability characterized as "sternum fracture resulting in neuroma with neuralgia pain" under 38 C.F.R. § 4.124a Diagnostic Code 8519; sternum fracture, Muscle Group XXI, right side under 38 C.F.R. § 4.73, Diagnostic Code 5321; and sternum fracture, Muscle Group XXI, left side (Dominant) also under Diagnostic Code 5321. A 10 percent rating was assigned for the rating assigned under Diagnostic Code 8519, and noncompensable ratings were assigned for the disabilities rated under Diagnostic Code 5321, each effective from January 23, 2004. The Veteran appealed the February 2014 Board decision, to include the denial of an extraschedular rating for a left eyebrow scar and right shoulder disability, and the Court in a June 2015 memorandum decision set aside and remanded the Board's February 2014 determinations with respect to these issues in order for the Board to consider the impact of all of the Veteran's disabilities as a whole on an extraschedular basis. Pursuant to his right to an additional hearing before a Veterans Law Judge given the retirement of the Judge who presided at his March 2006 hearing, the Veteran presented testimony before the undersigned Veterans Law Judge in November 2015. A transcript of this hearing is of record. In February 2016, the Board remanded this matter for further development. In accordance with the February 2016 remand, a VA contract respiratory examination was conducted in January 2017 and the RO referred the question of extraschedular evaluation, to include the collective impact of all of the Veteran's disabilities, to the Director. The Director denied additional extraschedular compensation in an October 2017 decision. There has been substantial compliance with the remand instructions and no further action to ensure compliance with the remand directives is required. See Stegall v. West, 11 Vet. App. 268 (1998). In a May 2017 Decision Review Officer (DRO) decision, the Veteran was awarded service connection for concave deformity of the chest as related to the service-connected sternum fracture, rated noncompensable, effective January 23, 2004. In an October 2017 DRO decision, the Veteran was awarded service connection for Muscle Group V, right upper extremity, and Muscle Group VI, right arm, as related to service-connected right shoulder disability, each rated 20 percent disabling, effective January 23, 2004. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). FINDINGS OF FACT 1. The Veteran's residuals of sternum fracture disability is manifested by pain and inhibited breathing and impaired muscle tonus. 2. For the entire period on appeal, the Veteran's right shoulder disability has resulted in an average impairment in earning capacity warranting a 60 percent rating. 3. The Veteran's scars of the eyebrows, right temple, and left cheek do not result in an exceptional disability picture with related factors such as marked interference with employment. CONCLUSIONS OF LAW 1. The criteria for separate 10 percent ratings for the Veteran's left and right muscles of respiration have been met; the criteria for additional or higher ratings for the Veteran's residuals of sternum fracture have not otherwise been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.71a, 4.73, 4.97, 4.124a, Diagnostic Codes 5297, 5321, 6843, 8519 (2017). 2. The criteria for an extraschedular rating for service-connected right shoulder disability, increased to 60 percent disabling, have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 3.321(b)(1) (2017). 3. The criteria for an extraschedular rating for service-connected scars of the eyebrows, right temple, and left cheek have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 3.321(b)(1) (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Rating in Excess of 10 Percent for Fracture of the Sternum Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the Veteran's favor. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3. Staged ratings are appropriate in adjudicating increased ratings when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 506 (2007). Rating the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The Veteran is service connected for residuals of a fractured sternum, to include a 10 percent rating for a sensation of pain at the fracture site analogous to a rib removal, rated under Diagnostic Code 5299-5297, and a 10 percent rating for neuropathic pain analogous to moderate paralysis of the long thoracic nerve, rated under Diagnostic Code 8519. The Veteran is also service connected for the left and right muscles of respiration under Diagnostic Code 5321, and traumatic chest wall defect under Diagnostic Code 6843, all evaluated as noncompensable. During the November 2015 Board hearing, the Veteran testified that he has nerve pain in his chest. He explained that with certain activities he experiences instant pain which may last 2 to 8 minutes or with more strenuous activities 20 to 30 minutes. He experiences general pain in his chest. See Hearing Tr., pp. 21-26. He also testified that he has painful and inhibited breathing. Hearing Tr., p. 28. His statements throughout the appeal period document these symptoms. See, e.g., June 2005 RO Hearing Tr., p. 7 (reporting nerve pain and pain with activities); December 2009 Veteran's Statement (reporting he experiences pain from a raw nerve healed improperly and pain is exacerbated with upper body movements); July 2012 Veteran's Statement (reporting he experiences pain which is exacerbated with lifting, pushing/pulling, or use of arms, as well as painful breathing at times). The medical evidence also supports such symptoms. See, e.g., May 2004 VA Examination Report (noting tenderness over sternum); February 2006 Private Treatment Letter (noting pain exacerbated with coughing); November 2015 Private Treatment Letter (noting neuralgic pain and pain with lifting, pressure against the chest, and with coughing and sneezing). In a December 2009 VA examination, the Veteran reported sternum pain aggravated by motion along with easily fatigability and shortness of breath. See December 2009 VA Examination Report. Under Diagnostic Code 5297, a 10 percent evaluation is warranted for removal of one rib or resection of two or more ribs without regeneration. A 20 percent evaluation is warranted for removal of two ribs; 30 percent for removal of three or more ribs; 40 percent for removal of five or six ribs; and, a 50 percent evaluation for removal of six or more ribs. See 38 C.F.R. § 4.71a, Diagnostic Code 5297. Here, the Veteran is receiving a 10 percent rating for sensation of pain at the fracture site analogous to a rib removal under Diagnostic Code 5297. There is no basis to award a 20 percent rating under Diagnostic Code 5297, based on the evidence of record. The Veteran has not undergone rib removal, and the 10 percent rating is meant to compensate the Veteran for chest pain. The Veteran's symptoms resulting from his residuals of a fractured sternum do not warrant a higher rating under Diagnostic Code 5297. Under Diagnostic Code 8519, a maximum schedular rating of 30 percent is warranted for complete paralysis of the long thoracic nerve affecting the major extremity. A 20 percent rating is warranted for complete paralysis of the long thoracic nerve affecting the minor extremity. With complete paralysis, there is an inability to raise the arm above shoulder level and a winged scapula deformity. When there is incomplete paralysis, a 20 percent rating is in order for severe disability affecting either the major or minor extremity. Moderately incomplete paralysis affecting either the major or minor extremity warrants a 10 percent evaluation. Mild incomplete paralysis affecting either the major or minor extremity warrants a noncompensable evaluation. 38 C.F.R. § 4.124a, Diagnostic Code 8519. In rating diseases of the peripheral nerves, the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Here, the Veteran is receiving a 10 percent rating for neuropathic pain analogous to moderate paralysis of the long thoracic nerve, rated under Diagnostic Code 8519. The evidence of record does not support a higher rating under Diagnostic Code 8519. The Veteran reported that he has general nerve pain in his chest, and that he experiences instant pain with certain activities which subsides within 30 minutes. See Hearing Tr., pp. 21-26. The May 2015 VA opinion provider noted that the Veteran experiences chronic neuralgic pain. The May 2015 VA opinion provider explained that the thoracic intercostal nerves at T7-T8 dermatomes are affected, that the condition is sensory in nature, and of mild severity. In a November 2015 letter, the Veteran's private physician noted that the Veteran has an area of tenderness around his sternum that is associated with neuralgic pain and consistent with development of a neuroma. The private physician explained that this causes pain exacerbated with lifting, pressure against the chest, and with coughing and sneezing. As noted by the April 2017 VA examiner, who diagnosed peripheral neuropathy but opined that it was unrelated to the Veteran's service-connected condition, the Veteran does not experience any other neurological condition as a residual of the sternum fracture. The evidence of record does not show such severe disability to warrant a higher rating. The VA examiner opined that the Veteran's condition was mild and sensory, the Veteran's private physician described the area as very tender and noted pain with certain activities, and the Veteran has not described symptoms which would show severe disability due to nerve pain. Accordingly, a higher rating is not warranted under Diagnostic Code 8519. The Board has also considered whether a potentially higher evaluation is available under the provisions of 38 C.F.R. § 4.97, Diagnostic Code 6843, for traumatic chest wall defect, or Diagnostic Code 5321, for injuries to Muscle Group XXI. The Veteran is service connected for traumatic chest wall defect and for the left and right muscles of respiration, all rated noncompensable. Under Diagnostic Code 6843, for traumatic chest wall defect, a 10 percent rating is warranted where Forced Expiratory Volume in one second (FEV-1) is 71 to 80 percent predicted; the ratio of FEV-1 to Forced Vital Capacity (FVC) (FEV-1/FVC) is 71 to 80 percent; or where Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) is 66 to 80 percent predicted. A 30 percent rating is warranted for FEV-1 of 56- to 70-percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; DLCO (SB) 56- to 65-percent predicted. A 60 percent rating is warranted for FEV-1 of 40- to 55-percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; DLCO (SB) of 40- to 55-percent predicted, or; maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). A 100 percent rating is warranted for FEV-1 less than 40 percent of predicted value, or; the ratio of FEV-1/FVC less than 40 percent, or; DLCO (SB) less than 40-percent predicted, or; maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation), or; cor pulmonale (right heart failure), or; right ventricular hypertrophy, or; pulmonary hypertension (shown by Echo or cardiac catheterization), or; episode(s) of acute respiratory failure, or; requires outpatient oxygen therapy. When evaluating respiratory conditions based on pulmonary function tests, post-bronchodilator results are to be utilized in applying the evaluation criteria in the Rating Schedule unless the post-bronchodilator results were poorer than the pre-bronchodilator results. In those cases, the pre-bronchodilator values are to be used for rating purposes. 38 C.F.R. § 4.96 (d)(5). Additionally, when there is a disparity between the results of different PFTs so that the level of evaluation would differ depending on which test result is used, the evaluation is to be assigned based on the test result that the examiner states most accurately reflects the level of disability. 38 C.F.R. § 4.96 (d)(6). The evidence of record does not show PFT results sufficient to warrant a 10 percent rating under Diagnostic Code 6843. The Board notes that the Veteran testified that he experiences painful and inhibited breathing. See November 2015 Board Hearing Tr., pp. 28-29. As a result, the Board remanded for VA respiratory examination, to include pulmonary function testing. The January 2017 VA contract examiner reviewed the Veteran's claims file, examined the Veteran, and performed pulmonary function testing. The PFT results showed pre-bronchodilator results of FVC to 53 percent, FEV-1 to 54 percent, and FEV-1/FVC to 102 percent, and post-bronchilator results of FVC to 52 percent, FEV-1 to 57 percent, and FEV-1/FVC to 109 percent. The VA examiner reported that the FEV-1/FVC test result most accurately reflects the Veteran's level of disability. The VA examiner noted that there is some limitation in pulmonary function. While the evidence shows some limitation in pulmonary function, the Veteran's FEV-1/FVC test result which most accurately reflects the Veteran's level of disability does not warrant a compensable rating under the rating criteria. Accordingly, a higher rating for the Veteran's residuals of sternum fracture is not warranted pursuant to Diagnostic Code 6843. Diagnostic Code 5321 is the provision for evaluating injuries to Muscle Group XXI, the thoracic muscle group whose function consists of respiration. Diagnostic Code 5321 provides a noncompensable (zero percent) rating for slight muscle injury, a 10 percent evaluation for a moderate muscle injury, and a 20 percent evaluation for a severe or moderately severe muscle injury. 38 C.F.R. § 4.73, Diagnostic Code 5321. 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). Evaluation of muscle injuries as slight, moderate, moderately severe, or severe, is based on the type of injury, the history and complaints of the injury, and objective findings. 38 C.F.R. § 4.56 (d). A "slight" muscle disability contemplates a simple wound of the muscle without debridement or infection; a service department record of a superficial wound with brief treatment and return to duty; healing with good functional results; and no cardinal signs or symptoms of muscle disability. Objectively, there is a minimal scar; no evidence of fascial defect, atrophy, or impaired tonus; and no impairment of function or metallic fragments retained in muscle tissue. 38 C.F.R. § 4.56 (d)(1). "Moderate" muscle disability contemplates a through and through or deep penetrating wound of short track from a single bullet, small shell, or shrapnel fragment, without the explosive effect of a high velocity missile, residuals of debridement, or prolonged infection; a service department record or other evidence of in-service treatment for the wound; and a record of consistent complaint 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. Objectively, there are entrance and (if present) exit scars that are small or linear, indicating a 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. "Moderately severe" muscle disability contemplates 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 service department record or other evidence showing hospitalization for a prolonged period for the wound; a record of consistent complaint of cardinal signs and symptoms of muscle disability; and, if present, evidence of inability to keep up with work requirements. Objectively, there are entrance and (if present) exit scars indicating track of missile through one or more muscle groups; indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscle compared with the sound side; and tests of strength and endurance compared with the sound side demonstrate positive evidence of impairment. 38 C.F.R. §§ 4.56 (d)(3). After review of the evidence, the Board finds that separate 10 percent ratings are warranted for the Veteran's moderate muscle injury under Diagnostic Code 5321. The February 2015 VA examiner noted non-penetrating muscle injury resulting in some impairment of muscle tonus. The January 2017 VA contract examiner noted the Veteran is easily short of breath. The January 2017 VA contract examiner noted some limitation in pulmonary function. In addition, during a December 2009 VA examination, the Veteran reported shortness of breath and fatigability. Upon review of the evidence as a whole, and reviewing such evidence in the light most favorable to the Veteran, the Board finds that separate 10 percent ratings are appropriate throughout the appeal period for moderate disability of the Veteran's left and right muscles of respiration under Diagnostic Code 5321. The evidence of record does not show a severe or moderately severe muscle injury disability warranting a higher rating. Accordingly, after review of the evidence as a whole, including the lay and medical evidence, the Board finds that separate 10 percent ratings are warranted for the Veteran's left and right muscles of respiration under Diagnostic Code 5321. Additional or higher ratings are not otherwise warranted for the Veteran's residuals of sternum fracture. In rendering this decision, the Board has considered the medical and lay evidence of record, to include the Veteran's reports regarding pain and shortness of breath. The Veteran is competent to report the symptoms that he experiences, such as pain, and their history. Layno v. Brown, 6 Vet. App. 465 (1994). The Board has taken these symptoms into account in its analysis. The type and severity of the Veteran's symptoms relating to his residuals of sternum fracture disability, to include pain and pulmonary limitation, are contemplated by the rating schedule. Accordingly, an extraschedular evaluation is not warranted. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). In addition, the Board notes that although this matter was referred along with the Veteran's extraschedular claims for consideration of the combined effect of the Veteran's service-connected disabilities, an extraschedular rating based on the combined effect of multiple service-connected disabilities is no longer available as a matter of law. See 82 Fed. Reg. 235, 57830 (December 8, 2017). Here, separate 10 percent ratings are warranted for the Veteran's left and right muscles of respiration under Diagnostic Code 5321. Additional or higher ratings are not otherwise warranted. The Board has applied the benefit of the doubt rule in making this determination. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Extraschedular Rating in Excess of 40 Percent for Right Shoulder Disability The Veteran seeks an extraschedular rating in excess of 40 percent for his service-connected right shoulder disability. VA regulations allow for the provision of an extraschedular disability rating for exceptional cases where schedular evaluations are found to be inadequate. 38 C.F.R. § 3.321(b)(1); see also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). There is relatively little guidance as to how to determine whether and at what level to grant an extraschedular rating. In Kuppamala, the Court held that there is a judicially manageable standard limiting the Secretary's discretion for assignment of such a rating, namely that the extraschedular rating is commensurate with the average earning capacity impairment due exclusively to the service-connected disability. 27 Vet. App. at 453-55. However, as the Court noted, "average impairment in earning capacity is not a clearly defined standard." Id. The provisions of 38 C.F.R. § 4.1 (2017), declare that the rating schedule is intended to compensate for considerable time lost from work commensurate with the rating. Although a claimant is presumed to be seeking the maximum benefit available by law, he may choose to limit the claim to a lesser benefit. AB v. Brown, 6 Vet. App. 35 (1993). During his November 2015 Board hearing, the Veteran stated that he would be satisfied with a 60 percent rating for right shoulder disability. See November 2015 Board Hearing Tr., p. 38. Upon review of the evidence of record, the Board finds that a 60 percent rating is warranted on an extraschedular basis for the entire appeal period. A July 2013 VA examiner noted that the Veteran's work is impacted by his right shoulder disability in that he can only hold light objects, without lifting heavy objects. In a November 2015 letter, the Veteran's private physician opined that the Veteran experienced severe dysfunction of his right shoulder which made the joint essentially nonfunctional in all but the most gentle of uses. He also noted that the Veteran retired from his work as a machinist due partly to the progression of pain in his shoulder joint. Applying the applicable standards to the evidence as a whole, and resolving all reasonable doubt in favor of the Veteran, the Board finds that a 60 percent rating for right shoulder disability is warranted on an extraschedular basis. The Veteran indicated that he would be satisfied with a 60 percent rating for his right shoulder disability. The Board also notes that extraschedular evaluations based on the combined effect of multiple service-connected disabilities are not available. See 82 Fed. Reg. 235, 57830 (December 8, 2017). Extraschedular Rating for Scars of the Eyebrows, Right Temple, and Left Cheek The Veteran's claim for an extraschedular rating for scars of the eyebrows, right temple, and left cheek was remanded by the Board for consideration of the collective impact of the Veteran's multiple service-connected disabilities pursuant to the Court's June 2015 decision. However, the law changed since the Court's June 2015 decision and the Board's last remand. Extraschedular evaluations based on the combined effect of multiple service-connected disabilities are no longer available as a matter of law. See 82 Fed. Reg. 235, 57830 (December 8, 2017). Here, the evidence does not show that the Veteran is otherwise entitled to consideration of an extraschedular rating for scars of the eyebrows, right temple, and left cheek. The record does not contain information regarding information as to how the current rating code is inadequate to compensate this disability. Because the ratings provided under the VA Schedule for Rating Disabilities are averages, an assigned rating may be adequate to address the average impairment in earning capacity caused by the disability, but not completely account for the Veteran's individual circumstances. See 38 C.F.R. § 3.321 (b) (2017); Thun v. Peake, 22 Vet. App. 111, 114 (2008). Under Thun, the determination of whether a claimant is entitled to an extraschedular rating under 38 C.F.R. § 3.321 (b) is a three-step inquiry. First, there must be a finding that the evidence of record presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, the exceptional disability must exhibit other related factors such as marked interference with employment or frequent periods of hospitalization. Third, the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination of whether the claimant's disability picture requires the assignment of an extraschedular rating. Here, the Veteran's scars of the eyebrows, right temple, and left cheek do not present an exceptional disability picture with other related factors such as marked interference with employment or frequent periods of hospitalization. The evidence in the Veteran's claims file, including both the lay and medical evidence, does not show that the Veteran's scars interfered with employment or required frequent periods of hospitalization or other related factors. The August 2012 VA examiner opined that the Veteran's scars did not impact his ability to work. Applying the legal standards to the evidence as a whole, the requirements of Thun are not met and an extraschedular rating for scars of the eyebrows, right temple, and left cheek is therefore not warranted. As the preponderance of the evidence weighs against the claim, the benefit of the doubt rule is therefore not for application. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). ORDER Entitlement to a rating in excess of 10 percent for fracture of the sternum is denied. Entitlement to a separate 10 percent rating for right Muscle Group XXI is granted. Entitlement to a separate 10 percent rating for left Muscle Group XXI is granted. Entitlement to an extraschedular rating of 60 percent, and no higher, for right shoulder disability is granted. Entitlement to an extraschedular rating for scars of the eyebrows, right temple, and left cheek is denied. ____________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs