Citation Nr: 18141854 Decision Date: 10/11/18 Archive Date: 10/11/18 DOCKET NO. 14-25 642 DATE: October 11, 2018 ORDER Service connection for a dental disorder for VA compensation purposes is denied. From January 25, 2011, a disability rating in excess of 10 percent for first and second degree burn scars of the right forearm and hand (rated as analogous to cold injury residuals) is denied. From January 25, 2011, a disability rating in excess of 10 percent for first and second degree burn scars of the left forearm and hand (rated as analogous to cold injury residuals) is denied. From January 25, 2011, a separate disability rating of 10 percent, but no higher, for superficial nonlinear first and second degree burn scars of the right forearm and hand is granted. From January 25, 2011, a separate disability rating of 10 percent, but no higher, for superficial nonlinear first and second degree burn scars of the left forearm and hand is granted. From January 25, 2011, a separate disability rating of 20 percent, but no higher, for unstable and painful first and second degree burn scars of the right forearm and hand is granted. From January 25, 2011, a separate disability rating of 20 percent, but no higher, for unstable and painful first and second degree burn scars of the left forearm and hand is granted. FINDINGS OF FACT 1. The Veteran does not have a current dental disability subject to VA compensation. 2. For the initial rating period from January 25, 2011, first and second degree burn scars of the right forearm and hand have not more nearly approximated cold sensitivity plus tissue loss, nail abnormalities, color changes, locally impaired sensation, hyperhidrosis, or x-ray abnormalities (osteoporosis, subarticular punched out lesions, or osteoarthritis) in the affected parts. 3. For the initial rating period from January 25, 2011, first and second degree burn scars of the left forearm and hand have not more nearly approximated cold sensitivity plus tissue loss, nail abnormalities, color changes, locally impaired sensation, hyperhidrosis, or x-ray abnormalities (osteoporosis, subarticular punched out lesions, or osteoarthritis) in the affected parts. 4. For the initial rating period from January 25, 2011, the first and second degree burn scars of the right forearm and hand have manifested as a superficial and nonlinear burn scar of the right forearm and hand covering an area of at least 144 square (sq.) inches (929 sq. centimeters (cm)). 5. For the initial rating period from January 25, 2011, the first and second degree burn scars of the left forearm and hand have manifested as a superficial and nonlinear burn scar of the right forearm and hand covering an area of at least 144 sq. inches (929 sq. cm.). 6. For the initial rating period from January 25, 2011, the first and second degree burn scars of the right forearm and hand have manifested as a scar that is both unstable and painful. 7. For the initial rating period from January 25, 2011, the first and second degree burn scars of the left forearm and hand have manifested as a scar that is both unstable and painful. CONCLUSIONS OF LAW 1. The criteria for service connection for a dental disorder for VA compensation purposes have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310, 3.381, 4.150. 2. From January 25, 2011, the criteria for a disability rating in excess of 10 percent for first and second degree burn scars of the right forearm and hand (rated as analogous to cold injury residuals) have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.10, 4.104, 4.118, Diagnostic Code 7802-7122. 3. From January 25, 2011, the criteria for a disability rating in excess of 10 percent for first and second degree burn scars of the left forearm and hand (rated as analogous to cold injury residuals) have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.10, 4.104, 4.118, Diagnostic Code 7802-7122. 4. Resolving reasonable doubt in the Veteran’s favor, from January 25, 2011, the criteria for a separate disability rating of 10 percent, but no higher, for superficial nonlinear first and second degree burn scars of the right forearm and hand have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.10, 4.118, Diagnostic Code 7802. 5. Resolving reasonable doubt in the Veteran’s favor, from January 25, 2011, the criteria for a disability rating of 10 percent, but no higher, for superficial nonlinear first and second degree burn scars of the left forearm and hand have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.10, 4.118, Diagnostic Code 7802. 6. Resolving reasonable doubt in the Veteran’s favor, from January 25, 2011, the criteria for a disability rating of 20 percent, but no higher, for unstable first and second degree burn scars of the right forearm and hand have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.10, 4.118, Diagnostic Code 7804. 7. Resolving reasonable doubt in the Veteran’s favor, from January 25, 2011, the criteria for a disability rating of 20 percent, but no higher, for unstable first and second degree burn scars of the left forearm and hand have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.10, 4.118, Diagnostic Code 7804. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the Appellant, served on active duty from July 1963 to January 1970. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from April 2011 and June 2014 rating decision from the Regional Office (RO). The Veteran initially requested a videoconference Board hearing on the July 2014 and July 2015 substantive appeals; however, in written correspondence submitted November 2017, the Veteran, withdrew the hearing request. 38 C.F.R. § 20.704(e). In April 2018, the Board remanded the issues on appeal for additional development, including to obtain outstanding VA treatment records and to obtain VA examinations and a medical opinion. The requested development has been completed; therefore, the Board finds that the Agency of Original Jurisdiction (AOJ) substantially complied with the April 2018 Board Remand directives. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board’s remand instructions were substantially complied with), aff’d, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002). Notably, first and second degree burn scars of the right and left forearm and hand have been rated 10 percent for more than 20 years under DC 7802-7122 (analogous to cold injury residuals), so is a permanent disability that cannot be reduced. 38 C.F.R. § 3.951. In a June 2014 rating decision, the RO awarded a separate, 10 percent disability rating for unstable first and second-degree burn scars of the right and left forearm and hand, respectively, under Diagnostic Code 7804. 38 C.F.R. § 4.118. In an August 2018 rating decision, the RO awarded an increased disability rating of 20 percent for unstable first and second degree burn scars of the right and left forearm and hand that were also painful under Diagnostic Code 7804, and granted a separate 10 percent disability rating for first-and second-degree burn scars that are superficial and nonlinear under Diagnostic Code 7802, effective June 19, 2018. Id. As the Veteran has not expressed satisfaction with the assigned ratings, his claim remains before the Board. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The Board finds that the duties to notify and assist the appellant in this case have been fulfilled. Neither the appellant nor the evidence has raised any specific contentions regarding the duties to notify or assist. 1. Service Connection for a Dental Disorder Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Generally, service connection for a disability requires evidence of: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated by service. Compensation is only available for certain types of dental and oral conditions listed under 38 C.F.R. § 4.150, such as impairment of the mandible, loss of a portion of the ramus, and loss of a portion of the maxilla. Compensation is available for loss of teeth only if such is due to loss of substance of body of maxilla or mandible due to trauma or disease such as osteomyelitis, but not periodontal disease. 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 purpose 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. The Veteran generally contends that service connection is warranted for a dental disorder. Specifically, the Veteran contends that he sustained trauma to the teeth during service when an M-14 malfunctioned causing a live ammunition explosion that partially blew out two of the top front teeth and caused gum damage. The Veteran asserts that the two teeth were capped during service, and that the initial trauma started a problem with all his teeth. See July 2014 and July 2014 VA Form 9. After reviewing all the evidence, both medical and lay, the Board finds that the weight of the evidence is against a finding that the Veteran has a dental disability subject to compensation. 38 C.F.R. § 17.161. That is, there is no diagnosis of record, nor has the Veteran contended there is a diagnosis of 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, for which service-connected compensation could be granted. See 38 C.F.R. § 4.150, Diagnostic Codes 9900-9916. An August 1964 service treatment record reflects that a gun failed to fire properly causing multiple longitudinal pits (gun powder) and pellets to the face, but there was no mention of injury to the teeth or jaw. A June 1967 service treatment note reflects the Veteran’s report that a rifle blew up in his face in 1964 causing him to lose two teeth. Service treatment records are silent as to actual dental treatment due to trauma to the teeth; however, a February 1973 rating decision reflects that crowns were placed on tooth numbers seven and eight in March 1965 and that service connection for dental trauma to tooth number seven and eight was granted for treatment purposes. See February 1973 rating decision. VA treatment records dated August 1972 and January 1973 reflect that between June 1972 and July 1972 the Veteran had four teeth extracted (teeth 7, 8, 30, and 12) due to multiple dental abscesses and caries. A cast for a partial palate replacing tooth number seven, eight, 12, and 13 was made. Between January 1978 and February 1978 tooth two and three were extracted and full upper and lower dentures were provided. See January 1978 and February 1978 VA treatment records. In August 2018, VA provided a VA dental examination. Diagnosis was loss of teeth. The VA examiner did not assess evidence of loss in whole or part of the mandible, maxilla, or any part of the hard palate. The VA examiner opined that the current dental condition was less than likely related to service, to include the rifle explosion during service. The VA examiner assessed that service treatment records do not document a rifle explosion in 1964 that knocked out multiple teeth, and post-service treatment records reflect teeth that were extracted due to abscesses. Although the record suggests that there was some trauma to tooth number seven and eight during service that caused partial loss of the two top teeth, the evidence of record does not show that any claimed teeth and gum disability are due to the loss of substance of the body of maxilla, mandible, or hard palate during service through trauma or disease such as osteomyelitis. The record specifically indicates that tooth seven and eight were treated with crowns during service, and post-service extraction of the teeth (teeth numbers 2, 3, 7, 8, 12, 30) due to dental caries and abscess were replaced by some form of prosthesis. Periodontal disease will be considered service connected solely for the purpose of establishing eligibility for outpatient dental treatment as provided in 38 C.F.R. § 17.161. See 38 C.F.R. § 3.381(a). The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. §§ 1110, 1131; see also Degmetich v. Brown, 104 F. 3d 1328, 1332 (1997) (holding that interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). Evidence must show that the veteran currently has a compensable dental or oral disability for which benefits are being claimed. Because the evidence does not establish that the Veteran has a current compensable dental condition during the pendency of the appeal, the Board finds that the Veteran is not entitled to service connection for a compensable dental disorder under 38 C.F.R. § 4.150. To the extent to which the Veteran seeks service connection solely for outpatient dental treatment, such issue is referred to the RO for appropriate action. As the Veteran has not been diagnosed with, nor asserts he has, a dental disability for which service connection may be granted, the claim for service connection for a dental disorder for compensation purposes must be denied. Rating Criteria Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C. § 1155. 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. Where there is a question as to which of two disability ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where an increase in an existing disability rating based on established entitlement to compensation is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the rating of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran’s service-connected disabilities. 38 C.F.R. § 4.14. It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; however, 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 conditions is duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits compensating a veteran twice for the same symptoms or functional impairment). Burn Scars of the Right and Left Forearm and Hand The Veteran generally contends that a higher disability is warranted for the right and left burn scar disability. The Veteran contends that the affected area of the burn scars is sensitive to cold and heat. The Veteran contends the skin on the right and left (bilateral) forearm and hand is thinner and weaker, which causes the skin to tear easily with simple trauma, such as bumping into something. The Veteran also contends that the bilateral forearm and hand burn scars are also painful due increased susceptibility to tearing and bleeding with trauma. See February 2011 Statement in Support of the Claim, March 2012 Notice of Disagreement, June 2018 VA examination report. 2. Rating Burn Scars as Analogous to Cold Injury Residuals. The Veteran is currently in receipt of a 10 percent rating for the first and second degree burn scars of the right and left forearm and hand under Diagnostic Code 7802-7122 from January 25, 2011 to June 19, 2018. 38 C.F.R. §§ 4.104, 4.118. The hyphenated diagnostic code indicates that the right and left burn scar disability was rated as analogous to cold injury residuals due to symptoms of cold sensitivity. 38 C.F.R. § 4.20. Because the 10 percent rating under Diagnostic Code 7802-7122 has been in effect for at least 20 years continuously, it is a protected rating that cannot be reduced in the absence of fraud. 38 C.F.R. § 3.951(b). Under Diagnostic Code 7122, a 10 percent rating is assigned when cold injury residuals are manifested by arthralgia or other pain, numbness, or cold sensitivity in affected parts. 38 C.F.R. § 4.104. A 20 percent rating requires arthralgia or other pain, numbness, or cold sensitivity plus tissue loss, nail abnormalities, color changes, locally impaired sensation, hyperhidrosis, or x-ray abnormalities (osteoporosis, subarticular punched out lesions, or osteoarthritis) in the affected parts. A maximum 30 percent rating is warranted for arthralgia or other pain, numbness, or cold sensitivity plus two or more of the following in affected parts: tissue loss, nail abnormalities, color changes, locally impaired sensation, hyperhidrosis, or x-ray abnormalities (osteoporosis, subarticular punched out lesions, or osteoarthritis). Id. A note to DC 7122 states that amputations of fingers or toes and complications such as squamous cell carcinoma at the site of a cold injury scar or peripheral neuropathy are to be separately evaluated under other codes. Other disabilities that have been diagnosed as the residual effects of a cold injury, such as Raynaud’s phenomenon, muscle atrophy, etc., also are to be separately evaluated unless they are used to support a disability rating under DC 7122. A second note provides that each affected part is to be evaluated separately. 38 C.F.R. § 4.104. After a review of all the evidence, both lay and medical, the Board finds that, from January 25, 2011, a disability rating in excess of 10 percent for first and second degree burn scars of the bilateral forearm and hand has not been met or more nearly approximated under Diagnostic Code 7802-7122, as the right and left burn scar disability has not manifested as arthralgia or other pain, numbness, or cold sensitivity plus tissue loss, nail abnormalities, color changes, locally impaired sensation, hyperhidrosis, or x-ray abnormalities (osteoporosis, subarticular punched out lesions, or osteoarthritis) in the affected parts. 38 C.F.R. § 4.104. Although lay and medical evidence indicates that the first and second degree burn scars of the left and right forearm and hand have manifested as superficial and thin burn scars susceptible to tearing and pain, the Board will not consider these symptoms in rating the burn scars under hyphenated Diagnostic Code 7802-7122, as these symptoms have already been rated and compensated under Diagnostic Codes 7802 and 7804, discussed below, so compensating the same symptoms under Diagnostic Codes 7802-7122 would constitute impermissible pyramiding. See Esteban, 6 Vet. App. at 261-62; Lyles, 29 Vet. App. 107 (holding that 38 C.F.R. § 4.14 prohibits compensating a veteran twice for the same symptoms or functional impairment). A review of the record reflects that the Veteran has not received any treatment for the bilateral forearm and hand burn scars, as he has managed the skin condition with moisturizing creams and lotions. See February 2011 VA Form 21-4142. The first and second degree burn scars on the bilateral forearm and hand have manifested as sensitivity to extreme hot and cold temperatures without changes in skin texture. The evidence does not reflect that the first and second degree burn scars have manifested as tissue loss, nail abnormalities, color changes, locally impaired sensation, hyperhidrosis, or x-ray abnormalities. See March 2011, March 2013, November 2011, June 2018 VA examination reports. As the preponderance of the evidence is against the appeal for a higher 20 percent rating from January 25, 2011, the appeal for this period must be denied. 38 C.F.R. §§ 4.3, 4.7, 4.104, Diagnostic Code 7802-7122. 3. Rating Superficial and Nonlinear Burn Scars of the Right and Left Forearm and Hand. The Veteran is in receipt of a separate 10 percent rating under Diagnostic Code 7802 for superficial nonlinear first and second degree burn scars of the right and left forearm and hand from June 19, 2018. 38 C.F.R. § 4.118. Under Diagnostic Code 7800, for disfigurement of the head, face, or neck, a 10 percent disability rating is warranted for scarring with one characteristic of disfigurement. A 30 percent disability rating is warranted with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips); or two or three of the characteristics of disfigurement. A 50 percent disability rating is warranted with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips); or four or five characteristics of disfigurement. An 80 percent disability rating is warranted with visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips); or six or more characteristics of disfigurement. 38 C.F.R. § 4.118. The eight characteristics of disfigurement for the purposes of rating under 38 C.F.R. § 4.118 are: scar of 5 in. or more (13 or more centimeters (cm.)) in length; scar at least 1/4 in. (0.6 cm.) wide at its 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 6 sq. in. (39 sq. cm.); skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding 6 sq. in. (39 sq. cm.); underlying soft tissue missing in an area exceeding 6 sq. in. (39 sq. cm.); and skin indurated and inflexible in an area exceeding 6 sq. in. (39 sq. cm.). Id., Note (1). Burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are deep and nonlinear in an area or areas of at least 6 square inches (39 sq. centimeters (cm.)) but less than 12 square inches (77 sq. cm.) will be assigned a 10 percent rating. A scar in an area or areas of at least 12 square inches (77 sq. cm.) but less than 72 square inches (465 sq. cm.) will be assigned a 20 percent rating. A scar in an area or areas of at least 72 square inches (465 sq. cm.) but less than 144 square inches (929 sq. cm.) will be assigned a 30 percent rating. A scar in an area or areas of at least 144 square inches (929 sq. cm.) or greater will be assigned a 40 percent rating. Note (1) indicates that a deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7801. Burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are superficial and nonlinear in an area or areas of 144 square inches (929 sq. cm.) or greater will be assigned a 10 percent rating. Note (1) indicates that a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7802. One or two scars that are unstable or painful will be assigned a 10 percent rating. Three or four scars that are unstable or painful will be assigned a 20 percent rating. Five or more scars that are unstable or painful will be assigned a 30 percent rating. Note (1) indicates that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provides that if one or more scars are both unstable and painful, add 10 percent to the rating that is based on the total number of unstable or painful scars. 38 C.F.R. § 4.118, Diagnostic Code 7804. Any disabling effects of other scars (including linear scars), and other effects of scars rated under Diagnostic Codes 7800, 7801, 7802, and 7804 not considered in a rating provided under Diagnostic Codes 7800 through 7804 are to be rated under an appropriate diagnostic code. 38 C.F.R. § 4.118, Diagnostic Code 7805. After reviewing all the evidence, lay and medical, the Board finds that from January 25, 2011, first and second degree burn scars of the right and left forearm and hand have met or more nearly approximated superficial and nonlinear burn scars covering an area of at least 144 sq. inches (929 sq. cm.). A review of the record reveals that the burn scars of the right and left forearm and hand have manifested as superficial and nonlinear burn scars that affect 1715 cm2 on the right forearm and 1568 cm2 on the left forearm. See November 2013 and June 2018 VA examination reports. Although the November 2013 VA examination report reflects that the superficial nonlinear burn scars affected only 220 cm2 on the right forearm and 240 cm2 on the left forearm, the record indicates that the burn scars have been present since the initial injury in 1968, and there is no indication of any reinjury of the burn scars of the right and left upper extremity (i.e., additional burn injury) to reconcile the vast difference between the areas affected in the November 2013 VA examination report compared to the June 2018 VA examination report. In any case, it is important for VA examiners to provide accurate measurements of the areas affected for the purposes of rating skin and scar disabilities. Because there is no evidence of record that suggests there has been any additional injury to the right and left burn scars to account for the inconsistent reports of the areas affected by superficial nonlinear scars in the November 2013 and June 2018 VA examination reports, the Board has resolved reasonable doubt in the Veteran’s favor in finding that the disability picture of the superficial nonlinear burn scars of the right and left forearm and hand has more nearly approximated an area covering 1,715 cm2 of the right forearm and 1,568 cm2 of the left forearm, that is, at least (929 sq. cm) or greater, throughout the entire rating period on appeal from January 25, 2011. As a 10 percent rating is the maximum rating allowable under Diagnostic Code 7802, the separate 10 percent ratings for superficial nonlinear burn scars of the right and left forearm and hand is deemed a full grant of benefits under Diagnostic Code 7802, and a higher rating is not warranted. 38 C.F.R. § 4.118. Separate or higher ratings are not warranted under Diagnostic Codes 7800, 7801, or 7805. The first and second degree burn scars of the right and left forearm and hand do not affect the head, face, or neck so Diagnostic Code 7800 is not for application. Additionally, the June 2018 VA examination reflects that the superficial nonlinear burn scars have manifested as less than deep partial thickness; therefore, Diagnostic Code 7801, which rates burn scar(s) or scar(s) not of the head, face, or neck that are deep and nonlinear, is not for application. Finally, as the skin disorder does not result in any additional disabling effects, a separate and higher compensable disability rating is not warranted under Diagnostic Code 7805. 38 C.F.R. § 4.118. As the preponderance of the evidence is against the claim for a separate and increased rating under Diagnostic Codes 7800, 7801, and 7805, the claim for an increased rating must be denied. 38 C.F.R. §§ 4.3, 4.7, 4.104, 4.118, Diagnostic Codes 7800-7801, 7805. A discussion of a separate or higher rating under Diagnostic Code 7804 is discussed below. 4. Rating Unstable Burn Scars of the Bilateral Forearm and Hand The Veteran is in receipt of a 10 percent rating from January 25, 2011 to June 19, 2018, and a 20 percent rating from June 19, 2018 under Diagnostic Code 7804 for unstable first and second degree burn scars of the bilateral forearm and hand. 38 C.F.R. § 4.118. After a review of all the evidence, both lay and medical, the Board finds that from January 25, 2011, the criteria for a 20 percent rating, but no higher, have been more nearly approximated, that is, the first and second degree burn scars of the right and left forearm and hand have manifested as burn scars that are unstable and painful. A review of the record reflects that the Veteran has provided lay statements that the burn scars on the right and left forearm have worsened due to thinning and weakness of the skin, which has caused tearing, bleeding, and pain with simple trauma to the burn scars. See January 2011 Claim, March 2012 Notice of Disagreement. The VA examination reports dated from March 2011 to November 2013 reflect that the burn scars on the right and left forearms and hands manifested as very thin, unstable skin, that tears easily upon minimal contact with objects. March 2011, March 2013, November 2013 VA examination reports. The June 2018 VA examination reflects that the burn scars on the right and left forearm and hand were painful and unstable with spontaneous bleeding as the skin tears very easily. Notably, the Veteran presented to the office visit bleeding from several areas to the forearm. See June 2018 VA examination report. The VA examiners observed superficial linear scars or lacerations superimposed on the burn scars ranging from half a centimeter to four centimeters in length, which are likely residuals of healed tears of the skin. See March 2011, November 2013, June 2018 VA examination reports. Given the Veteran’s consistent reports that burn scars on the bilateral forearm and hand have manifested as thin skin that tears easily and causes pain, the Board finds that the first and second degree burn scars on the right and left forearm and hand more nearly approximated one right and left burn scar on the forearm and hand that is both unstable and painful, which warrants a higher 20 percent rating from January 25, 2011. 38 C.F.R. § 4.118, Diagnostic Code 7804 A higher 30 percent rating is not warranted, as the evidence does not reflect that the first and second degree burn scars on the bilateral forearm and hand have manifested as five or more scars that are painful or unstable. Id. 5. Extraschedular Referral Consideration The Board has considered whether the Veteran or the record has raised the question of referral for an extraschedular rating adjudication under 38 C.F.R. § 3.321(b) for any period for the initial rating issue on appeal. See Rice v. Shinseki, 22 Vet. App. 447, 453 (2009); Thun v. Peake, 22 Vet. App. 111 (2008).   After review of the lay and medical evidence of record, the Board finds that the question of an extraschedular rating has not been made by the Veteran or raised by the record as to the issue on appeal. See Doucette v. Shulkin, 28 Vet. App. 366 (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); Yancy v. McDonald, 27 Vet. App. 484, 494 (2016), citing Dingess v. Nicholson, 19 Vet. App. 473, 499 (2006), aff’d, 226 Fed. Appx. 1004 (Fed. Cir. 2007) (holding that when 38 C.F.R. § 3.321(b)(1) is not “specifically sought by the claimant nor reasonably raised by the facts found by the Board, the Board is not required to discuss whether referral is warranted”). J. PARKER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Moore, Associate Counsel