Citation Nr: 18148364 Decision Date: 11/07/18 Archive Date: 11/07/18 DOCKET NO. 17-19 751 DATE: November 7, 2018 ORDER Entitlement to an effective date prior to October 8, 2014 for the grant of service connection for coronary artery disease is denied. Entitlement to an initial rating higher than 30 percent for coronary artery disease, status post coronary artery bypass graft (CABG), on a schedular basis, for the period prior to February 28, 2018, is denied. Entitlement to a staged initial rating of 60 percent, but no higher, for coronary artery disease, status post CABG, on a schedular basis, is granted effective February 28, 2018, subject to the law and regulations governing the award of monetary benefits. Entitlement to an initial rating of 10 percent, but no higher, for a residual sternal scar associated with CABG (sternal scar), is granted, subject to the law and regulations governing the award of monetary benefits. Entitlement to an initial rating of 10 percent, but no higher, for two residual scars of the left lower extremity associated with status post saphenous vein graft (left lower extremity scars), is granted, subject to the law and regulations governing the award of monetary benefits. REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for a kidney disability, including kidney stones, is remanded. Entitlement to service connection for a skin disability is remanded. Entitlement to an initial rating higher than 30 percent for posttraumatic stress disorder (PTSD) is remanded. Entitlement to an initial rating higher than 30 percent prior to February 28, 2018, and 60 percent thereafter, on an extraschedular basis, is remanded. Entitlement to a total rating based on individual employability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. On October 8, 2015, VA received a VA Form 21-0966, Intent to File a Claim for Compensation and/or Pension or Survivors Pension and/or DIC, which was followed by an October 18, 2015, claim for entitlement to service connection for ischemic heart disease. There is no unadjudicated claim of service connection for heart disease prior to that date. 2. Prior to February 28, 2018, the most probative evidence indicates that the Veteran’s coronary artery disease did not result in more than one episode of congestive heart failure per year; a workload of 3 metabolic equivalents (METs) but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. 3. Beginning February 28, 2018, the most probative evidence indicates that the Veteran’s coronary artery disease resulted in a workload of 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope. 4. Resolving reasonable doubt in favor of the Veteran, the most probative evidence indicates that his sternal scar is painful, but is not unstable. 5. Resolving reasonable doubt in favor of the Veteran, the most probative evidence indicates that the Veteran’s left lower extremity scars are painful, but are not unstable and do not cause functional impairment. CONCLUSIONS OF LAW 1. The criteria for entitlement to an effective date prior to October 8, 2014, for the grant of service connection for coronary artery disease have not been met. 38 U.S.C. § 5110; 38 C.F.R. §§ 3.114, 3.400, 3.816. 2. For the period prior to February 28, 2018, the schedular criteria for a rating in excess of 30 percent for coronary artery disease, status post CABG, were not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.104, Diagnostic Code 7005. 3. Beginning February 28, 2018, the schedular criteria for a rating of 60 percent, but no higher, for coronary artery disease, status post CABG, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.104, Diagnostic Code 7005. 4. The criteria for a rating of 10 percent, but no higher, for a sternal scar have been met. 38 U.S.C. §§ 1155, 5107, 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.118, Diagnostic Code 7804. 5. The criteria for a rating of 10 percent, but no higher, for left lower extremity scars have been met. 38 U.S.C. §§ 1155, 5107, 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.118, Diagnostic Code 7804. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1963 to May 1968. These matters come before the Board of Veterans’ Appeals (Board) on appeal from January 2016 (higher rating and earlier effective date for coronary artery disease), September 2016 (PTSD, hypertension, skin disability), June 2017 (sternal and left lower extremity scars), and October 2017 (kidney disability) rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). The issue of entitlement to a TDIU was reasonably raised by the record and is part and parcel of the increased rating claims. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). 1. Entitlement to an effective date prior to October 8, 2014 for the grant of service connection for coronary artery disease The Veteran believes that he should be awarded an effective date earlier than October 8, 2014, for the grant of service connection for coronary artery disease. The Board finds that the Veteran does not meet the criteria for an effective date earlier than October 8, 2014. The statutory and regulatory guidelines for the determination of an effective date of an award of disability compensation are set forth in 38 U.S.C. § 5110 (2012) and 38 C.F.R. § 3.400 (2018). The effective date of an evaluation and an award of compensation based on an original claim, a claim reopened after a final disallowance, or a claim for increase will be the date the claim was received or the date entitlement arose, whichever is later. See 38 C.F.R. § 3.400 (2018). The applicable statutory and regulatory provisions require that VA look to all communications from the veteran which may be interpreted as applications or claims-formal and informal-for benefits. In particular, VA is required to identify and act on informal claims for benefits. See 38 U.S.C. § 511(b)(2) (2012); 38 C.F.R. §§ 3.1(p), 3.155(a) (2018); see also Servello v. Derwinski, 3 Vet. App. 196, 198-200 (1992). Retroactive effective dates are allowed, to a certain extent, in cases where an award or increase of compensation is granted pursuant to a liberalizing law. 38 U.S.C. § 5110(g) (2012); 38 C.F.R. § 3.114(a) (2018). To be eligible for a retroactive payment under these provisions, the evidence must show that the claimant met all eligibility criteria for the liberalized benefit on the effective date of the liberalizing law or VA issue and that such eligibility existed continuously from that date to the date of claim or administrative determination of entitlement. Id.; see also McCay v. Brown, 9 Vet. App. 183, 188 (1996), aff’d, 106 F.3d 1577, 1581 (Fed. Cir. 1997). VA has promulgated special rules for the effective dates for the award of presumptive service connection based on exposure to herbicide agents, pursuant to orders of a United States District Court in the class action case of Nehmer v. United States Department of Veterans Affairs. See 38 C.F.R. § 3.816 (2018). A Nehmer class member is defined as a Vietnam veteran who has a “covered herbicide disease.” Id. According to 38 C.F.R. § 3.816(b)(2) (2018), a “covered herbicide disease” includes a disease for which the Secretary of Veterans Affairs has established a presumption of service connection pursuant to the Agent Orange Act of 1991, Public Law 102-4. Certain effective dates apply if a Nehmer class member was denied compensation for such a disorder between September 25, 1985, and May 3, 1989; or if there was a claim for benefits pending before VA between May 3, 1989, and the effective date of the applicable liberalizing law. See 38 C.F.R. § 3.816(c)(1)-(3). In these situations, the effective date of the award will be the later of the date such claim was received by VA or the date the disability arose. 38 C.F.R. § 3.816(c)(1), (c)(2). However, if the requirements of 38 C.F.R. § 3.816(c)(1)-(2) are not met, the effective date shall be assigned according to 38 C.F.R. §§ 3.114 and 3.400. See 38 C.F.R. § 3.816(c)(4) (2018). In this case, the Veteran was granted presumptive service connection for coronary artery disease based on exposure to herbicide agents during service in the Republic of Vietnam. As such, he is a Nehmer class member. However, the Veteran was not denied compensation for coronary artery disease between September 25, 1985 and May 3, 1989. Likewise, he did not submit a claim for service connection for such condition between May 3, 1989, and August 31, 2010, the date on which the liberalizing law that added ischemic heart disease as a disease presumptively due to in-service exposure to herbicides became effective. See Liesegang v. Sec’y of Veterans Affairs, 312 F.3d 1368 (Fed. Cir. 2002); 75 FR 53202. As such, the effective date must be assigned pursuant to 38 C.F.R. §§ 3.114 and 3.400. See 38 C.F.R. § 3.816(c)(4) (2018). As noted above, the effective date is the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110 (2012); 38 C.F.R. § 3.400 (2018). VA received the Veteran’s VA Form 21-0966, Intent to File a Claim for Compensation and/or Pension or Survivors Pension and/or DIC on October 8, 2015, followed by a claim for service connection for ischemic heart disease later that month. The Veteran’s coronary artery disease was service-connected effective October 8, 2014, one year prior to the receipt of the Intent to File a Claim, pursuant to 38 C.F.R. § 3.114(a)(3) (2018). The record does not reflect any communication that can be construed as acclaim for service connection for coronary artery disease prior to October 8, 2015, and the Veteran has not identified any such communication. Accordingly, there are no grounds to assign an earlier effective date because October 8, 2015, is the earliest possible date of claim. Therefore, entitlement to an effective date for the award of service connection for coronary artery disease earlier than October 8, 2014, must be denied. Increased Rating Disability evaluations are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities found in 38 C.F.R. Part 4. Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C. § 1155 (2012). Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. §4.21 (2018); see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). Evaluation of a service-connected disorder requires a review of the veteran’s entire medical history regarding that disorder. 38 C.F.R. §§ 4.1, 4.2 (2018); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When 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 (2018). If there is a question as to which evaluation to apply to the veteran’s disability, 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 (2018). In all claims for an increased disability rating, VA has a duty to consider the possibility of assigning staged ratings. See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings is necessary. 2. Entitlement to a rating higher than 30 percent for coronary artery disease, status post CABG prior to February 28, 2018 The Veteran believes that he should be assigned a rating higher than 30 percent because he has a low energy level, has required multiple stents, and requires treatment with duel antiplatelet therapy. Diagnostic Code 7005 provides ratings for arteriosclerotic heart disease (coronary artery disease). 38 C.F.R. § 4.104a, Diagnostic Code 7005 (2018). Coronary artery disease resulting in workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray, is rated 30 percent disabling. Id. Coronary artery disease resulting in more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent, is rated 60 percent disabling. Id. Coronary artery disease resulting in chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent, is rated 100 percent disabling. Id. Private treatment records from Parkridge Medical Center from April 2015 indicate that the Veteran had an ejection fraction of 55-60 percent and no history of congestive heart failure. A January 2016 VA examination recorded a left ventricle ejection fraction of 78 percent, and based upon an interview-based METs test, found that a METs level of more than 5 to 7 METs would result in fatigue. With regard to functional impact, the Veteran reported feeling tired by the end of the day. On his February 2016 notice of disagreement (NOD), the Veteran reported that his coronary artery disease resulted in chest pain, labored breathing, the need for caution when bending or stooping to avoid falling, dizziness, and loss of balance. A May 2016 statement from the Veteran’s representative noted that the Veteran had required multiple stent placements, and asserted that the Veteran’s coronary artery disease severely impacted his ability to work. The Veteran’s representative went on to discuss the Veteran’s need for duel antiplatelet therapy and how such medication created a “bleeding risk.” He argued that a 60 percent rating was warranted effective November 2015. In May 2017 statements, the Veteran’s wife and daughter reported they had observed a decline in the Veteran’s energy level and stamina, his difficulty in walking even short distances due shortness of breath and fatigue, and his inability to perform tasks around the house due to fatigue and shortness of breath. A June 2017 treatment record from Parkridge Medical Center indicates that the Veteran had an ejection fraction of 55 percent. A September 2017 VA examination report stated that the Veteran was doing “okay,” but experienced chest tightness and shortness of breath when he exerted himself too much. The examiner noted that the Veteran did not have a history of congestive heart failure and had a left ventricular ejection fraction of 78 percent. Based upon an interview-based METs test, the examiner opined that a work load of greater than 5 to 7 METs would cause dyspnea and angina. The examiner opined that coronary artery disease would not impact on the Veteran’s ability to work. Upon review of the evidence, the Board finds that a rating higher than 30 percent is not warranted prior to February 28, 2018, because the Veteran did not experience congestive heart failure, a workload of greater than 3 to 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. The Board recognizes that the statements from the Veteran’s wife and daughter reporting that the Veteran experiences significant fatigue and dizziness with exertion. These symptoms are part of the determination of the Veteran’s METs levels, and two separate interview-based METs tests resulted in a METs level of 5 to 7 METs. While the Board recognizes that the Veteran’s family members are competent to describe their observations of the Veteran’s symptoms, the Board finds that the METs test administered by a medical professional is more exact and therefore more probative than general observations by the Veteran’s family members. Moreover, the record does not contain evidence of congestive heart failure, and the VA examination reports and private treatment records consistently indicate that the Veteran’s left ventricular ejection fraction was greater than 50 percent during this period. As to the Veteran’s representative’s argument regarding antiplatelet therapy, the Board notes that the requirement of continuous medication is contemplated by the rating schedule at the 10 percent level, meaning that such treatment is not an appropriate basis for the assignment of a rating higher than 30 percent. 38 C.F.R. § 4.104a, Diagnostic Code 7005 (2018). For these reasons, the Board finds that the most probative evidence of record is against finding that a rating higher than 30 percent is warranted for the period prior to February 28, 2018. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b) (2012); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). 3. Entitlement to a rating higher than 30 percent for coronary artery disease, status post CABG, from February 28, 2018 The Board finds that a staged rating of 60 percent is appropriate effective February 28, 2018. Although multiple METs tests prior to February 28, 2018 failed to meet the criteria for a higher rating, a February 28, 2018 private treatment from Dr. Lehman indicated that the Veteran had a left ventricular ejection fraction of 60 percent and experienced agnina at a workload of 5 METs. As the Veteran’s workload is limited to 3 to 5 METs, a 60 percent rating, but no higher, is warranted effective February 28, 2018. A rating higher than 60 percent is not warranted because the record does not reflect chronic congestive heart failure, a workload of 3 METs or less, or left ventricular dysfunction with an ejection function of less than 30 percent. On the contrary, a June 2018 private treatment note found left ventricular ejection fraction was estimated to be 55 percent. Therefore, a rating of 60 percent but no higher is granted effective February 28, 2018. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b) (2012); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). 4. Entitlement to a compensable rating for a sternal scar The Veteran’s representative contends that a compensable rating is warranted for the Veteran’s sternal scar on the anterior trunk because it is painful and unstable. The Board finds that a rating of 10 percent, but no higher, is warranted for the Veteran’s sternal scar. The Veteran’s sternal scar is a residual from his CABG surgery. His sternal scar has been rated under Diagnostic Code 7801. The rating criteria governing the scars were revised effective August 13, 2018. Claims, such as this, that were pending prior to August 13, 2018 must be considered under both old and new rating criteria, and whatever criteria is more favorable to the Veteran will be applied. Thus, the Board will discuss both the old and new scar regulations to determine which criteria is more favorable criteria to the Veteran. 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805. Under the criteria in effect prior to August 13, 2018, Diagnostic Code 7801 provides that scars other than those on the face, head, or neck warrant a 10 percent rating for deep, nonlinear scars that cover areas greater than 6 square inches (39 square centimeters) but less than 12 square inches (77 square centimeters). A 20 percent rating is warranted if the area is greater than 12 square inches but less than 72 square inches. A deep scar is one associated with underlying tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7801, Note (1). Under Diagnostic Code 7802, a 10 percent rating is also warranted for a superficial and nonlinear scar if the area is 144 square inches (929 square centimeters) or larger. 38 C.F.R. § 4.118, Diagnostic Code 7802. Diagnostic Code 7804 provides a 10 percent rating for one or two scars that are unstable or painful. 38 C.F.R. § 4.118, Diagnostic Code 7804. Higher ratings are warranted for more than two such scars. Id. An unstable scar is one where, for any reason, there is frequent loss of covering over the skin. Id. at Note (1). If one or more scars are both unstable and painful, 10 percent is to be added to the total evaluation that is based on the total number of unstable or painful scars. Id. at Note (2). Diagnostic Code 7805 directs that any disabling effect(s) not considered in Diagnostic Code 7801 through 7804 should be evaluated under the appropriate diagnostic code. 38 C.F.R. § 4.118, Diagnostic Code 7805. This instruction essentially directs that scars may be rated for the functional impairment caused by the scar. Under the rating criteria effective August 13, 2018, the rating criteria for Diagnostic Code 7801 remained the same, but it now applies to burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7801. The notes accompanying Diagnostic Code 7801 were also revised. Note (1) states that for the purposes of Diagnostic Codes 7801 and 7802, the six (6) zones of the body are defined as each extremity, anterior trunk, and posterior trunk. The midaxillary line divides the anterior trunk from the posterior trunk. Id. at Note (1). Note 2 states that a separate evaluation may be assigned for each affected zone of the body under this diagnostic code if there are multiple scars, or a single scar, affecting multiple zones of the body. Id. at Note (2). Combine the separate evaluations under §4.25. Alternatively, if a higher evaluation would result from adding the areas affected from multiple zones of the body, a single evaluation may also be assigned under this diagnostic code. 38 C.F.R. § 4.118, Diagnostic Code 7801. The rating criteria under Diagnostic Code 7802 also remained the same, but it is now described as applicable to burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are not associated with underlying soft tissue damage. The notes were also changed to mirror the notes accompanying Diagnostic Code 7801. The rating criteria under Diagnostic Code 7804 and 7805 were not amended. In this case, a May 2016 statement from the Veteran’s representative asserted that the Veteran’s scars were unstable and were sometimes painful. The representative argued that the Veteran’s rating should be higher as his scar was both painful and unstable. A January 2016 VA heart conditions examination report noted that the Veteran’s scars from his heart surgery were not painful or unstable. A May 2017 VA scar examination report noted that the Veteran’s sternal scar was a deep and non-linear, but was not painful or unstable. The length and width of the scar was 21 by 0.5 centimeters and it had approximate total area of 10.5 centimeters squared. A September 2017 cardiac examination report noted that the Veteran had a mid-sternal line scar, which was 23 centimeters by.001 centimeters, and was not painful or unstable. As the record reflects that the Veteran’s deep and non-linear sternal scar has an area of less than 77 square centimeters, a compensable rating is not available under 38 C.F.R. § 4.118, Diagnostic 7801, regardless of whether the revised or older rating criteria are considered. The Board will also consider whether a compensable rating is available under Diagnostic Code 7804. The Veteran is competent to report that his scar is painful. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Although the Veteran has not provided a personal statement describing the functional impact of his scars, the Board will accept that the Veteran’s representative was speaking on the Veteran’s behalf to relate his competent observations. Accordingly, as there is conflicting lay and medical evidence regarding whether the Veteran’s scar is painful, the Board will resolve reasonable doubt in the Veteran’s favor and find that his sternal scar is painful, and thus warrants a 10 percent rating under Diagnostic Code 7804. As to the issue of whether the scar is unstable, the medical evidence of record, namely the three VA examination reports, consistently indicated that the Veteran’s scar was stable. While the representative has asserted that the Veteran’s scar is unstable. While the Veteran and his representative are competent to report their own observations, neither has been shown to the medical training or expertise required to provide opinions on medical questions. See Layno, supra; Jandreau v. Nicholson, 492 F.2d 1372, 1377 n. 4 (Fed. Cir. 2007) (a lay person is not competent to diagnose cancer). The determination of whether a scar is stable or unstable is a medical question, meaning that the VA examination reports indicating that the Veteran’s scar is stable is the only competent evidence of record. Therefore, the Board finds that the Veteran’s scar is stable, and an additional 10 percent for a scar that is both unstable and painful is not warranted. 38 C.F.R. § 4.118, Diagnostic Code 7804, Note 2. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b) (2012); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). 5. Entitlement to a compensable rating for left lower extremity scars The Veteran’s representative contends that the Veteran should receive a compensable rating for his left lower extremity scars associated with his status post saphenous vein graft because they are unstable, painful, and receives unwanted attention when the Veteran wears shorts. The criteria for scars has been discussed above. The Board finds that a rating of 10 percent, but no higher, is warranted. In a May 2016 statement, the Veteran’s representative argued that the Veteran’s scar was unstable and sometimes painful. The representative also reported that when the Veteran wears shorts, his left lower extremity scars causes unwanted attention. The representative described the scars as disfiguring. The January 2016, May 2017, and September 2017 VA examination reports all indicated that the Veteran’s scars secondary to his coronary artery disease were not painful or unstable. Additionally, the May 2017 VA examination report indicated that the Veteran’s left lower extremity scars were both linear and were respectively, 65 centimeters and 1 centimeter in length. The Veteran reported functional impact of occasional swelling on the left ankle with prolonged standing, but the record does not contain medical evidence that this swelling is a result of the scar as opposed to some other disability. Moreover, even assuming arguendo, that the swelling could be attributed to the scar, the Veteran did not indicate that the scar or his reported swelling resulted in any functional loss such as limitation of motion. Accordingly, a separate rating under Diagnostic Code 7805 is not warranted. As with the sternal scar, the Board finds that the Veteran is competent to report that the scars on his left lower extremity are painful. The Board finds that the evidence is at least in equipoise, and resolves doubt in favor of the Veteran to find that the Veteran has two painful scars on his left lower extremity. However, as discussed above, the Veteran is not competent to provide a medical finding that his left lower extremity scars are unstable. Therefore, the most probative evidence indicates that the Veteran’s two scars of the left lower extremity are painful but not unstable, meaning that the Veteran is entitled to a rating of 10 percent, but no higher. As to the Veteran’s assertion that the scar is disfiguring because it attracts unwanted attention, the Board notes that the eight characteristics of disfigurement are discussed under Diagnostic Code 7800. Nevertheless, Diagnostic Code 7800 only applies to scars of the head, face, or neck. Accordingly, it is not applicable to the Veteran’s left lower extremity scars. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b) (2012); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). REASONS FOR REMAND 1. Entitlement to service connection for hypertension is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for hypertension because no VA examiner has opined whether the Veteran’s hypertension was caused by his in-service exposure to herbicide agents. The Board notes that the Veteran is presumed to have been exposed to herbicide agents as his personnel record reflects that he served in the Republic of Vietnam from July 1965 to April 1966. Although VA has not conceded a relationship between hypertension and herbicide agents exposure, the Board recognizes that prior to 2006, the National Academy of Science (NAS) placed hypertension in the "Inadequate or Insufficient Evidence" category. However, in its 2006 Update, NAS elevated hypertension to the "Limited or Suggestive Evidence" category. Update 2012 provides the history of NAS changing the categorization of hypertension beginning in its 2006 Update and subsequent Updates. See 79 Fed. Reg. 20,308 (April 11, 2014). Specifically, it notes that NAS has defined this category of limited or suggestive evidence to mean that the "evidence suggests an association between exposure to herbicides and the outcome, but a firm conclusion is limited because chance, bias, and confounding could not be ruled out with confidence." Id. at 20,309. In light of the NAS studies' findings, the Board finds that a medical opinion as to whether the Veteran's current hypertension is related to his in-service exposure to herbicide agents is warranted. 2. Entitlement to service connection for a kidney disability, to include kidney stones, is remanded. In a March 2017 treatment record from Dr. E. B. indicates that the Veteran underwent a kidney surgery in 1979. As such records could be relevant to the pending appeal, a remand is required to allow VA to obtain authorization and request these outstanding relevant records. 3. Entitlement to service connection for a skin disability is remanded. The Veteran was provided a VA skin examination in August 2016. Nevertheless, as the examination report is internally inconsistent another examination is required. Specifically, while the August 2016 examination report initially indicated that the Veteran had a non-specific rash and later noted that he had dermatitis, the corresponding opinion stated that the Veteran did not have a currently diagnosed condition. On remand, another examination is warranted to reconcile the examiner’s contradictory findings. 4. Entitlement to a rating higher than 30 percent for PTSD is remanded. At his September 2016 VA PTSD examination, the Veteran identified relevant outstanding private treatment records. A remand is required to allow VA to obtain authorization and request these records. Additionally, the Veteran’s last VA PTSD examination was in September 2016. On remand, the Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of his PTSD. 5. Entitlement to an initial rating higher than 30 percent prior to February 28, 2018, and 60 percent thereafter, on an extraschedular basis is remanded. As noted above, the Veteran’s representative has argued that the Veteran should be assigned a higher rating due to the placement of multiple stents, the Veteran’s bleeding risk secondary to his duel antiplatelet therapy, and his likely need for more stents to be placed in the future. Because the ratings provided under the VA Schedule for Rating Disabilities are averages, it follows that an assigned rating may not completely account for each individual veteran’s circumstances, but nevertheless would still be adequate to address the average impairment in earning capacity caused by the disability. See 38 C.F.R. § 3.321(b) (2018); Thun v. Peake, 22 Vet. App. 111, 114 (2008). However, in exceptional situations where the rating is inadequate, it may be appropriate to refer the case for extraschedular consideration. Id. The governing norm in these exceptional cases is a finding that the disability at issue presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). The Board cannot assign an extraschedular evaluation in the first instance. See Floyd v. Brown, 9 Vet. App. 88 (1996); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Instead, the Board must refer the Veteran’s claim to the Under Secretary for Benefits or Director of Compensation and Pension Service for this special consideration when the issue is either raised by the claimant or is reasonably raised by the evidence of record. See Thun v. Peake, 22 Vet. App. 111, 115 (2008); Barringer v. Peake, 22 Vet. App. 242 (2008). Only after the Director has determined whether an extraschedular evaluation is warranted does the Board have jurisdiction to decide the merits of the extraschedular aspect of the increased rating claim. Thus, given the Veteran’s claims regarding his stents reasonably raises the possibility that the Veteran’s assigned rating may not completely account for his individual circumstances, the Board refers the Veteran’s claims to the Under Secretary for Benefits or Director of Compensation and Pension Service for an extraschedular evaluation under 38 C.F.R. § 3.321(b), and the claim for extraschedular consideration of coronary artery disease should then be adjudicated. 6. Entitlement to a TDIU is remanded. Finally, because a decision on the remanded issues discussed above could significantly impact a decision on the issue of entitlement to a TDIU, the issues are inextricably intertwined. A remand of the claim of entitlement to a TDIU is required. The matters are REMANDED for the following actions: 1. Ask the Veteran to complete a VA Form 21-4142 for the facility where he received kidney surgery in 1979, as noted in a May 2017 private medical history, and Dr. J., the psychologist who the Veteran reported seeing in the 1970s or 1980s according the September 2016 VA examination. Make two requests for the authorized records from any treatment provider identified by the Veteran unless it is clear after the first request that a second request would be futile. 2. Obtain any VA treatment records dated since April 9, 2018 to the present. 3. Schedule the Veteran for a VA hypertension examination. Following review of the claims file and examination of the Veteran, the examiner should provide an opinion as to whether the Veteran's hypertension at least as likely as not (50 percent probability or greater) arose during service or is otherwise related to service, including the Veteran’s exposure to herbicide agents. A complete rationale for all opinions expressed should be provided. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the nature of any skin disability, including dermatitis, and to obtain an opinion regarding whether any such disability is related to the Veteran’s military service. The examiner must opine whether it is at least as likely as not (50 percent or greater probability) related to an in-service injury, event, or disease, including a rash noted in January 1964 and July 1967. The examiner is asked to reconcile the contradictory information in the August 2016 examination, specifically the finding that the Veteran had no skin condition yet also had dermatitis covering less than 5 percent of the total body area. A complete rationale for all opinions expressed should be provided. 5. Schedule the Veteran for a VA PTSD examination to determine the current severity of his PTSD. The claims file should be reviewed by the examiner. All necessary tests should be performed and the results reported. All symptomatology associated with the Veteran’s PTSD should be reported. 6. Submit the issue of an extraschedular rating for coronary artery disease to the Under Secretary for Benefits or Director of Compensation and Pension Service for an extraschedular evaluation under 38 C.F.R. § 3.321. The response from the Under Secretary for Benefits or the Director of Compensation and Pension Service must be included in the claims file. J. A. Anderson Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Budd, Counsel