Citation Nr: 18153303 Decision Date: 11/27/18 Archive Date: 11/27/18 DOCKET NO. 15-43 386 DATE: November 27, 2018 ORDER Service connection for a bilateral foot condition, to include pes planus and plantar fascitis, is denied. Service connection for a digestive condition, to include irritable bowel syndrome and gastroesophageal reflux disease, is denied. Service connection for a traumatic brain injury is denied. A compensable disability rating for scars of the right upper forehead, right eyebrow, and below the right eyebrow is denied. A compensable disability rating for a residual surgical scar of the left knee is denied. A disability rating higher than10 percent for a residual, tender scar over the left hip with surrounding numbness due to a left femur fracture surgery is denied. REMANDED A total disability rating based upon individual unemployability due to service-connected disabilities (TDIU) is remanded. An increased disability rating higher than 70 percent for posttraumatic stress disorder (PTSD) is remanded. A compensable disability rating for a left femur fracture surgically treated with residual left leg pain and left hip pain with left hip bursitis (impairment of the thigh with adduction and abduction limitation) is remanded. An increased disability rating higher than 10 percent for a lumbar strain associated with a left femur fracture is remanded. An increased disability rating higher than 10 percent for a left femur fracture surgically treated with residual left leg pain and left hip pain with hip bursitis (extension) is remanded. A compensable disability rating for left femur fracture surgically treated with residual left leg pain and left hip pain with left hip bursitis (flexion) is remanded. An increased disability rating higher than 10 percent for a left knee strain with limitation of flexion is remanded. An increased disability rating higher than 10 percent for a right knee strain with limitation of flexion is remanded. A compensable disability rating for a left knee strain with limitation of extension is remanded. An increased disability rating higher than 10 percent for residuals of a left foot injury is remanded. FINDINGS OF FACT 1. At the time he entered service, the Veteran was diagnosed with asymptomatic bilateral pes planus. 2. The Veteran’s pre-existing bilateral pes planus was not aggravated during service. 3. The preponderance of the evidence is against finding that the Veteran’s plantar fascitis manifested in service or is otherwise etiologically related to service. 4. The preponderance of the evidence is against finding that the Veteran’s irritable bowel syndrome and/or gastroesophageal reflux disease manifested in service or are otherwise etiologically related to service. 5. The preponderance of the evidence is against finding that the Veteran has, or ever has had, a confirmed diagnosis of a traumatic brain injury. 6. The Veteran’s service-connected face and forehead scars do not reflect any characteristics of disfigurement to warrant the assignment of a compensable disability rating. 7. The Veteran’s service-connected residual surgical scar of the left knee is deep and nonlinear, but does not cover an area of at least 6 square inches (39 sq. cm) but not less than 12 square inches (77 sq. cm). 8. The Veteran’s service-connected left hip scar with surrounding numbness is tender and painful. CONCLUSIONS OF LAW 1. The criteria for service connection for a bilateral foot condition, to include pes planus and plantar fascitis, have not been met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306. 2. The criteria for service connection for a digestive condition, to include irritable bowel syndrome and gastroesophageal reflux disease, have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for a traumatic brain injury have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for a compensable disability rating for scars of the right upper forehead, right eyebrow and below the right eyebrow have not 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 7800. 5. The criteria for a compensable disability rating for a residual surgical scar of the left knee have not 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 7801. 6. The criteria for a disability rating higher than 10 percent for a residual tender scar over the left hip with surrounding numbness due to femur surgery have not 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 April 1994 to June 1998. He currently has a combined disability rating of 90 percent. Service Connection Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Generally, to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a nexus, or link, between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection for certain chronic diseases will be presumed if the diseases manifest to a compensable degree within one year following active military service. This presumption, however, is rebuttable by probative evidence to the contrary. 38 U.S.C. §§ 1110, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Regulations provide that service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). When considering evidence supporting a service connection claim, the Board must consider, on a case-by-case basis, the competence and sufficiency of lay evidence offered to support a finding of service connection. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In determining whether service connection is warranted for a disability, VA is also responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Service connection for a bilateral foot condition, to include pes planus and plantar fascitis. Prior to a discussion of the Veteran’s claims for pes planus and plantar fascitis, the Board observes for the record that the Veteran has already been service-connected and assigned a 10 percent disability rating for residuals of a left foot injury that involved a May 1994 incident in which he “jammed” his small toe. (a) Service connection for pes planus. A review of the Veteran’s service records reveals that he had mild, asymptomatic, bilateral pes planus prior to/upon his entrance into service. See February 1994 service entrance examination report. Evidence that the Veteran’s pes planus was asymptomatic at that time includes a January 1994 service prescreening form on which the Veteran reported that he did not have trouble with his feet; and a February 1994 clinical medical examination report that reflects the Veteran’s feet were normal. A Veteran is presumed to be in sound condition upon entrance into service, except for defects, infirmities or disorders noted when examined, accepted, and enrolled for service, or where clear and unmistakable evidence establishes that an injury or disease existed prior to service and was not aggravated by service. 38 U.S.C. § 1111. The presumption of soundness attaches only where there has been an induction examination during which the disability about which the Veteran later complains was not detected. See Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). VA regulations provide expressly that the term “noted” denotes “[o]nly such conditions as are recorded in examination reports,” 38 C.F.R. § 3.304(b), and that a “[h]istory of pre-service existence of conditions recorded at the time of examination does not constitute a notation of such conditions.” Id. at (b)(1). Because the Veteran’s pes planus was clearly documented on his service entrance examination, the presumption of soundness did not attach and the only issue to be resolved is whether his pre-existing pes planus was aggravated during service. In terms of potential aggravation, a review of the Veteran’s service records reveals that he was seen once in May 1994 in relation to complaints that he “jammed” the small toe of his left foot (as mentioned above). At that time, the Veteran was diagnosed with a contusion of the left foot and mild callous of the 4th digit. The Veteran’s remaining service medical records are silent as to complaints, treatment or any diagnoses of any other foot-related problems. A May 1998 clinical medical examination report prepared as part of the Veteran’s service discharge reflects the Veteran’s feet were once again noted to be normal; and in his corresponding May 1998 report of medical history, the Veteran denied having foot problems. At no time did the Veteran ever mention any active symptomatology that can be, currently or in the past, associated with his pes planus. For the Veteran to be granted service connection for pes planus in this case, there must be objective evidence of worsening of his pre-existing bilateral pes planus. A review of the claims file reveals no such evidence. Rather, all medical evidence during service reflects that the Veteran’s pes planus remained asymptomatic. Post-service medical evidence supports this finding, as does a June 2014 VA medical opinion provided by a medical doctor who interviewed the Veteran and reviewed the evidence in the claims file. In his medical opinion, it was less likely as not that the Veteran’s pes planus was permanently aggravated by service since there was insufficient evidence in the Veteran’s service records to support a claim of aggravation by specific events that occurred while in service (i.e., the Veteran either consistently reported that his feet were fine or he was found upon clinical examination to have normal feet). The Veteran is not competent to report that his preexisting pes planus was aggravated beyond its natural progression in service. Thus, the most probative evidence is the June 2014 VA opinion finding no aggravation during service. Given the complete lack of evidence of the Veteran having any negative foot symptomatology in service other than a jammed toe, and the sole medical opinion pertaining to this issue is unfavorable to the Veteran’s claim, the Board has no basis upon which to grant service connection in this case. Therefore, service connection for bilateral pes planus is denied. (b) Service connection for plantar fascitis. The Veteran has a current diagnosis of plantar fascitis. According to a June 2014 General Medical Examination report, the Veteran was not diagnosed with plantar fascitis until 2013 - almost 15 years after he separated from service. The Veteran’s bilateral plantar fascitis in 2013 was noted to be moderate in severity. As mentioned previously, a review of the Veteran’s service medical records reveals that he was seen only once in May 1994 for complaints of small toe pain resulting from “jamming” his left foot while playing volleyball. Again, he is already service-connected for the residuals of this injury. He had a radiologic examination at that time to determine if he had a chip fracture of the left foot. The examination was reported as normal; and the Veteran was subsequently diagnosed with a left foot contusion and mild callous of the 4th digit. The Veteran’s remaining service medical records are silent as to complaints, treatment, or any diagnoses of any foot-related problems other than asymptomatic bilateral pes planus. In fact, there are no statements, currently or in the past, from the Veteran indicating that he experienced any foot problems in service other than the previously referenced May 1994 left foot small toe injury. See April 2014 VA Miscellaneous Foot examination report. Other evidence not supportive of the Veteran’s claim includes a May 1998 medical examination report prepared in anticipation of discharge from service that notes the Veteran’s feet were clinically normal; and in his corresponding May 1998 report of medical history, the Veteran denied having foot problems. Given the complete lack of evidence of the Veteran having any foot symptomatology in service other than his left foot jammed toe; and what appears to be the onset of plantar fascitis in 2013; the Board finds that the preponderance of the evidence is against the Veteran’s plantar fascitis claim. For the record, the Board notes an error in the April 2014 VA Miscellaneous Foot examination report referenced above. A review of the report reveals two diagnoses related to the Veteran’s feet, the first being a diagnosis of residuals of a left foot injury (i.e., May 1994) with plantar fascitis in 1994. This 1994 citation was clearly an error on the VA examiner’s part because he states in the latter part of his report that the Veteran was diagnosed with bilateral plantar fascitis in 2012. A June 2014 General Medical Examination report notes that the Veteran was not diagnosed with plantar fascitis until 2013. Lastly, a review of the Veteran’s actual service medical records of his foot injury reveals only that he was assessed as having a contusion of the left foot and mild callous of the 4th digit. Symptomatology that could be related to a diagnosis plantar fascitis was neither raised, discussed or diagnosed in those records. Given the foregoing, it is obvious that the 1994 citation reported in the April 2014 examination report was incorrect. Service connection remains denied as there is no in-service event, injury, or disease related to the plantar fascia of either foot. 2. Service connection for a digestive condition, to include irritable bowel syndrome (IBS) and gastroesophageal reflux disease (GERD). Post service medical records in the Veteran’s claims file reflect that he has been diagnosed with GERD. The records reflect that he has also been diagnosed as having “[s]elf-described IBS with constipation alternating loose stools,” and as having a “past medical history” of IBS with diarrhea. A review of the Veteran’s service medical records fails to reveal any symptomatology, complaints, treatment for and/or diagnoses of either IBS or GERD. A single, undated service medical record reflects that the Veteran was seen with complaints of diarrhea that began 6 hours before. He was noted as not having symptoms of headaches or elevated temperature. No signs of blood stools were reported. No diagnosis, assessment or treatment was documented. Thereafter, on the Veteran’s May 1998 Separation Report of Medical Examination, a clinical examination of the Veteran’s gastrointestinal system was reported as being normal. On his corresponding report of medical history, the Veteran also denied having frequent indigestion; and denied having stomach, liver, or intestinal problems. The Veteran is not competent to opine that his IBS and GERD symptoms are due to service - to include any exposures. He is not shown to have the requisite medical expertise to link the symptoms he can competently report and his military service. Finally, the evidence in the file fails to show the Veteran experienced any event, disease or injury in service related to the digestive symptom that can be service-connected. To the extent that the Veteran has asserted that he has developed GERD or IBS due to exposure to toxic chemicals in service, VA sought a medical opinion to provide guidance on the issue. In response, a medical doctor opined in June 2014 that there was no link between the Veteran’s digestive conditions and service. He stated that acid reflux and irritable bowel syndrome were less likely than not caused by or a result of in-service exposure to toxic chemicals. His rationale was that the Veteran’s service treatment records were negative for care visits for acid reflux or IBS. Additional, he found it persuasive that there was no evidence in the claims file that the Veteran was diagnosed with acid reflux or IBS within one year following his discharge from active duty in 1998. Viewing the lack of evidence in the claims file supportive of the Veteran’s digestive condition claim, in conjunction with the sole medical opinion of record opining against the Veteran’s claim, the Board finds that service connection for a digestive condition, to include GERD and IBS, must be denied directly and based on exposure to toxic chemicals. 3. Service connection for a traumatic brain injury (TBI). The Veteran was involved in a very serious motor vehicle accident while in service. He contends that he suffered a traumatic brain injury as a result of the accident. A review of the evidence reveals the primary question regarding this claim that the Board must determine is whether the Veteran has a current disability of a traumatic brain injury that began during service or is at least as likely as not related to his accident in service. For reasons set forth below, the Board concludes that the preponderance of the evidence is against finding that the Veteran has ever been diagnosed with a traumatic brain injury. Therefore, service connection must be denied. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). Medical records in the claims file include a copy of a January 1998 CT scan that was undertaken to rule out central lesion due to complaints by the Veteran of left extremity weakness and decreased sedation of the right face, arm, and leg. At that time, the impression of the CT scan was normal with and without contrast. According to an April 2014 mental health examination report that documents the Veteran being diagnosed with chronic depression and PTSD, the Veteran denied being diagnosed with a concussion because of his in-service 1995 automobile accident; and reported that he did not lose consciousness during the accident. His medical examiner noted in the mental health examination report that the Veteran did not have a diagnosis of TBI. Most recently, in April 2014, the Veteran was afforded an examination specifically for traumatic brain injuries. The neurologist who examined the Veteran stated that the evidence did not support the finding of a diagnosis of TBI; nor did it reflect a brain disorder that was somehow related to service. He cited to the Veteran’s service and post-service medical records; and pointed out that in those records, the Veteran was not diagnosed with a concussion and did not experience a loss of consciousness (as the Veteran stated himself); and that the January 1998 CT of the Veteran’s head was normal with and without contrast. He stated that the Veteran’s own history provided on the day of his examination also reflected that he did not lose consciousness the day of the accident, have post-traumatic amnesia, or have an alteration of consciousness at the time of the event, which did not support a claimed brain injury related to the remote motor vehicle accident. The Veteran had a neurological examination that was negative for deficits related to a TBI. He noted that the Veteran had an antalgic baseline gait that was not related to a TBI; in addition to a history of migraine headaches over the previous 6-12 months. The neurologist opined that the Veteran’s headaches were associated with photophobia, phonophobia, and dizziness but no visual aura; and that they were remote in onset from and unrelated to the injury in 1995. The Veteran reported having had 2-3 episodes of “passing out” over the last year, a history that was suggestive of syncope and unrelated to a TBI. Regarding the Veteran’s cognitive complaints, the neurologist opined that they were not attributed to a TBI, but might be due to a separately evaluated mental health condition such as his PTSD. Although the Veteran may believe that he has a current TBI diagnosis, he is not competent to provide a TBI diagnosis. The issue of a diagnosis is medically complex, as it requires specialized medical education and knowledge of the interaction between various brain functioning and its manifestations in terms of the development of complex medical conditions. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the opinion of the neurologist. In the absence of competent medical evidence showing that the Veteran presently suffers from a TBI, there is no basis for the granting of service connection under any theory. Thus, the Board finds that the preponderance of the evidence is against the Veteran’s claim; and the appeal as to this issue must be denied. Increased Ratings In a September 2010 rating decision, the Veteran was granted service connection for (1) scars of the right upper forehead, right eyebrow and below the right eyebrow, (2) a scar of the left knee; and (3) a scar over the left hip. In May 2013, he requested higher disability ratings for his service-connected scars. The RO denied increased ratings in a June 2014 rating decision. The Veteran appealed, seeking (1) a compensable disability rating for his head scars, currently evaluated under 38 C.F.R. § 4.118, Diagnostic Code (DC) 7800; (2) a compensable disability rating for his left knee scar, currently evaluated under 38 C.F.R. § 4.118, Diagnostic Code (DC) 7801; and (3) an increased disability rating higher than 10 percent for his left hip scar, currently evaluated under 38 C.F.R. § 4.118, Diagnostic Code (DC) 7804. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. 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 evaluation 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. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Diagnostic Criteria for Disorders of the Skin The diagnostic criteria for disorders of the skin are found at 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805. During the pendency of this appeal, the applicable rating criteria for scars were amended in August 2018. VA’s General Counsel has held that where a law or regulation changes during the pendency of a claim for a higher rating, the Board must first determine whether the revised version is more favorable to the veteran. In so doing, it may be necessary for the Board to apply both the old and new versions of the regulation. If the revised version of the regulation is more favorable, the retroactive reach of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. The Board must apply both the former and the revised versions of the regulation for the period prior and subsequent to the regulatory change, but an effective date based on the revised criteria may be no earlier than the date of the change. The Veteran filed his request for increased ratings in May 2013; and those claims were denied in June 2014. VA thus must consider the claim pursuant to the former and revised regulations during the course of this appeal. See VAOPGCPREC 3-2000, 65 Fed. Reg. 33,422 (2000); DeSousa v. Gober, 10 Vet. App. 461, 467 (1997). Former Diagnostic Criteria (2008) Previously, VA amended its criteria for evaluating scars on September 23, 2008. See 73 Fed. Reg. 54,708 (Sept. 23, 2008). Those amendments became effective for claims filed on or after October 23, 2008, such as the Veteran’s claims on appeal. Pursuant to the former regulations, DC 7800 provides the rating criteria for scars for the head, face, and neck or other disfigurement of the head. 38 C.F.R. § 4.118, DC 7800. For the assignment of a 10 percent disability rating, the evidence must show at least once character of disfigurement. The criteria for the eight different characteristics of disfigurement are set forth in NOTE 1 of DC 7800. DC 7801 provides for the assignment of a 10 percent disability rating for scars that are 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. cm) but less than 12 square inches (77 sq. cm). For the record, a deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7801. DC 7802 provides that scars that are 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 warrant the assignment of a 10 percent rating. For the record, a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7802. Under DC 7804, one or two scars that are either unstable or painful warrant the assignment of a 10 percent rating. Three or four scars that are unstable or painful warrant the assignment of a 20 percent rating. Five or more scars that are unstable or painful warrant a 30 percent evaluation. For the record, an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Also, if one or more scars are both unstable and painful, 10 percent should be added to the evaluation that is based on the total number of unstable or painful scars. Lastly, VA regulations provides that scars evaluated under DC 7800, 7801, 7802, or 7805 may also receive an evaluation under Code 7804, when applicable. 38 C.F.R. § 4.118, DC 7804. Finally, DC 7805 provides that other scars (including linear scars) and other effects of scars evaluated under Diagnostic Codes 7800, 7801, 7802, and 7804 require the evaluation of any disabling effect(s) not considered in a rating provided under DCs 7800-7804 to be evaluated under an appropriate diagnostic code. 38 C.F.R. § 4.118, DC 7805. Revised Diagnostic Criteria (2018) In July 2018, 38 C.F.R. § 4.118 was amended effective August 13, 2018. See 83 Fed. Reg. 32, 592 (July 13, 2018). Initially, the Board observes that the August 13, 2018, amendments did not affect or modify the criteria set forth in 38 C.F.R. § 4.118, DCs 7800 and 7804. Additionally, the Board observes that new notes for the amended DCs 7801 and 7802 define various zones of the body and indicate that separate evaluations may be assigned for each affected zone. The amended DC 7801 now discusses burn scars or scars due to other causes, not of the head, face, or neck, that are associated with underlying soft tissue damage. To be assigned a 10 percent disability rating, the scar in question must cover an area or areas of at least 6 square inches (39 sq. cm) but not less than 12 square inches (77 sq. cm). 38 C.F.R. § 4.118, DC 7801. The amended DC 7802 is for burn scars or scars due to other causes, not of the head face or neck, that are not associated with underlying soft tissue damage. A 10 percent disability rating is warranted if the scar covers an area or areas of 144 square inches (929 sq. cm) or greater. 38 C.F.R. § 4.118, DC 7802. A 10 percent disability rating is the only rating available under the amended DC 7802. Lastly, the amended DC 7805 is for scars, other; and other effects of scars evaluated under DCs 7800, 7801, 7802, or 7804. It provides that any disabling scar effects not considered under DCs 7800-7804 should be evaluated under an appropriate diagnostic code. 38 C.F.R. § 4.118, DC 7805.   4. Increased ratings for service-connected scars. (a) Request for a compensable disability rating for scars of the right upper forehead, right eyebrow and below the right eyebrow. According to VA examination reports in the claims file, the Veteran has a scar of the right upper forehead that has a maximum width of 0.3 cm (.118 inch) and a maximum length of 3.5 cm (1.378 inches). The scar was noted not to be painful; was superficial without signs of skin breakdown; had no inflammation, edema, keloid formation, no abnormal texture; and was not indurated or inflexible. The Veteran’s scar was also noted not to be adherent to underlying tissue and was also found not to have any other disabling effects. The surrounding skin was reported as having an abnormal pigmentation area of 6 square inches or less. The Veteran has also been service-connected for a scar of his right eyebrow. This scar has a maximum width of 0.2 cm (.0787 inch) and maximum length of 2.0 cm (.787 inch). The scar was noted to be non-painful and non-tender. According to an April 2014 VA examination report, there was no elevation, depression, adherence to underlying tissue or soft tissue missing. There was also no abnormal pigmentation and no limitation of function. Lastly, the service-connected scar under the Veteran’s right eyebrow has a maximum width of 0.1 cm (.0394 inch) and maximum length of 0.5 cm (.197 inch). The scar was found not to be painful. It was superficial, without inflammation, edema, keloid formation or abnormal texture. It was neither hyperpigmented nor hypopigmented. The evidence shows the scar was smooth on palpation, with no adherence to underlying tissue. It was also noted to be soft and flexible; and there was no evidence of disabling effects. The Veteran’s face and forehead scars have appropriately been rated pursuant to the criteria set forth in DC 7800 (not amended). Utilizing that code, the Veteran’s scars do not meet the criteria for the assignment of a compensable rating as they do not reflect any of the characteristics of disfigurement set forth in NOTE 1 of the diagnostic code. See 38 C.F.R. § 4.118, DC 7800, Note (1). Viewing the above-referenced scars characteristics in conjunction with the other skin-related diagnostic criteria, the scars do not meet the former rating criteria set forth in DCs 7801, 7802, 7804 or 7805. The Board finds that the revised version of the regulation is no more or less favorable than the version in effect prior to August 13, 2018, in the instant matter because the evidence does not indicate that any of the Veteran’s head scars have underlying soft tissue damage; cover an area or areas of 144 square inches (929 sq. cm) or greater; or result in disabling effects. Therefore, a noncompensable disability rating for the Veteran’s scars of the face and forehead has appropriately been assigned. (b) Request for a compensable disability rating for a residual surgical scar of the left knee. According to an April 2014 VA examination report, the Veteran has two scars of the left leg, a surgical scar at hip level and a surgical scar just above the left knee. The first scar noted in the report appears to be the Veteran’s left hip scar (referenced below). In this examination report, the scar was reported as being on the Veteran’s left lower extremity, measuring 14.0 cm in width and 0.5 cm in length. The examiner indicated that the scar was deep and painful, but neither nonlinear, nor unstable. The second scar noted on the Veteran’s left lower extremity appears to be the residual surgical scar of the left knee, measuring 7.0 cm in width and 0.5 cm in length according to the April 2014 VA examination report. This scar was also noted as being deep and nonlinear; painful, but not unstable. The two deep, nonlinear scars of the left lower extremity were reported as covering an approximate area of 10.5 cm². For the record, the Board observes that an August 2010 VA examination report in the claims file reflects that the Veteran’s residual scar of the left knee had a maximum width of .5 cm and a maximum length of 1.0 cm. The examiner indicated that the Veteran’s scar was not painful, had no signs of skin breakdown, was superficial, had no inflammation, no keloid formation, and no other disabling effects. The RO assigned a noncompensable disability rating pursuant to DC 7801 on the basis that the Veteran’s left knee scar was deep and nonlinear but did not cover an area of at least 6 square inches (39 sq. cm) but not less than 12 square inches (77 sq. cm). The Board finds that in doing so, the RO appropriately resolved doubt in the Veteran’s favor as to whether his left knee scar was deep rather than superficial. A review of DCs 7800 to 7805 reflects that the Veteran’s left knee scar characteristics are not significant enough to meet any of the criteria set forth therein. As such, the RO appropriately assigned the Veteran a noncompensable disability rating pursuant to the former DC 7801. A review of the record reveals that the revised version of 38 C.F.R. § 4.118 is no more or less favorable than the version in effect prior to August 13, 2018, in the instant matter because even though the left knee scar is assumed to have underlying soft tissue damage (a deep scar is one associated with underlying soft tissue damage), it does not cover the required area of at least 6 square inches (39 sq. cm) but not less than 12 square inches (77 sq. cm); or result in disabling effects. c) Request for a disability rating higher than 10 percent for a residual tender scar with surrounding numbness over the left hip due to femur surgery. Lastly, the Veteran’s service-connected scar over his left hip has been noted to be 0.1 cm (.0394 inch) in width with a maximum length of 14.0 cm (5.5 inches) in an August 2010 VA examination report. See also April 2014 VA examination report referenced above. The examiner described the scar to be painful; however, it was found to be superficial, without any signs of skin breakdown. The scar had no inflammation, no edema, no keloid formation and no other disabling effects. A review of the VA examination reports of record appears to reveal that the Veteran has one or two additional scars of the left lower extremity that are noted as being superficial, stable and not painful, with no disabling effects. The RO correctly assigned the Veteran a 10 percent disability rating pursuant to DC 7804 since he has 2 or 3 scars, only 1 of which is painful. To qualify for a 20 percent disability rating, the evidence would need to show 3 or 4 scars that are unstable or painful. A review of DCs 7800 to 7805 reflects that the Veteran’s left hip scar’s characteristics are not significant enough to meet any of the criteria set forth therein. In terms of the amended version of 38 C.F.R. § 4.118, the Board finds that it is no more or less favorable than the version in effect prior to August 13, 2018, in the instant matter because the evidence does not indicate that there is any underlying soft tissue damage; cover an area or areas of 144 square inches (929 sq. cm) or greater; or result in disabling effects. In conclusion, based upon the foregoing, the Board finds that increased ratings for the Veteran’s service-connected scars are not warranted. REASONS FOR REMAND 1. A request for a total rating based upon individual unemployability (TDIU) due to service-connected disabilities is remanded. The Veteran’s representative asserted for the first time in his May 2016 90-day response brief that the Veteran should receive individual unemployability due to a combination of his service-connected impairments. To date, the Veteran never completed or submitted a formal claim for a TDIU via VA Form 21-8940. This form must be provided to the Veteran with a request that he return the completed application to the RO, to specifically include his best approximation at to the date that he became unemployed, for VA to consider the Veteran’s TDIU request.   2. A request for a disability rating higher than 70 percent for PTSD is remanded. According to an April 2014 mental health examination, the Veteran was diagnosed with chronic depression and PTSD. In terms of occupational and social impairment, the psychologist who examined the Veteran stated that he experienced occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. In a September 2014 rating decision, the RO found the Veteran to be incompetent to handle disbursement of his VA monetary payments (i.e., not capable of directing the management of benefits in his own interests). A fiduciary was appointed to assist the Veteran. Subsequently, the Veteran underwent a private medical examination in November 2015 that reflects the examiner’s opinion that the Veteran suffers from occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood, but not complete impairment. In terms of employability, the examiner opined in an “Employability Review” section of the report that the Veteran cannot sustain the stress from a competitive work environment or be expected to engage in gainful activity due to his PTSD. Notably, however, she did not opine that the Veteran suffers from total occupational and social impairment. Lastly, the claims file contains an April 2016 Vocational Opinion with supporting medical articles submitted by the Veteran’s representative as evidence that the Veteran should receive individual unemployability due to a combination of his service-connected disabilities. The Veteran’s status of being found incompetent in 2014 raises the question as to the present state of his mental health condition; and how that condition may be a factor in determining whether he should be granted a TDIU. As such, the Board finds that the issue of entitlement to a higher rating for PTSD should be remanded and considered with the Veteran’s TDIU claim. 3. A request for increased disability ratings for service-connected disabilities of the left femur, the lumbar spine, the left knee, the right knee and the left foot (see list of separate orthopedic disabilities above). In addition to the foregoing, given the Veteran’s claim for a TDIU based upon a combination of his service-connected disabilities, the Board finds that the Veteran should be afforded updated VA examinations as to his orthopedic service-connected disabilities that have been rated based upon limitation of motion. Thus, the matters are REMANDED for the following actions: 1. A review of the record on appeal reveals VA medical records dated through March 2016. On remand, the RO should obtain any outstanding VA medical records from March 2016 to the present. 2. The RO should contact the Veteran and request authorizations for any private medical records pertaining to symptomatology associated with his service-connected disabilities, to specifically include any records related to treatment from/evaluation by H. H-G, Ph.D. and her November 2015 PTSD disabilities questionnaire and vocational consultant S.B. and her April 2016 vocational opinion. 3. The Veteran should be afforded a new PTSD VA examination to determine the current nature and severity of his service-connected mental health condition. The examiner should specifically comment on the Veteran’s competency status, in relation to his ability to manage his funds versus his ability to independently function daily. Additionally, the examiner must comment on the functional impact the Veteran’s PTSD has had on him socially and occupationally. 4. The Veteran should be afforded a new VA orthopedic examination to ascertain the current nature and severity of his service-connected orthopedic conditions (cited above). The examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. To the extent possible, the examiner should identify any symptoms and functional impairments due to the Veteran’s service-connected orthopedic disabilities and discuss the functional impact of these disabilities. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 5. The Veteran and his representative should be provided the proper statutory and regulatory notice regarding what is necessary to substantiate a claim for entitlement to a TDIU. The RO should provide the Veteran with VA form 21-8940 with an explanation and instructions to the Veteran to complete the form. H.M. WALKER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Talpins, Patricia