Citation Nr: 18159900 Decision Date: 12/20/18 Archive Date: 12/20/18 DOCKET NO. 16-35 511A DATE: December 20, 2018 ORDER New and material evidence has been submitted to reopen the claim for service connection for chronic myelogenous leukemia (CML), to include as due to herbicide agent exposure. Entitlement to service connection for sleep apnea syndrome is denied. Entitlement to service connection for a blood clotting problem is denied. Entitlement to service connection for restless leg syndrome is denied. Entitlement to service connection for right upper extremity peripheral neuropathy is denied. Entitlement to service connection for left upper extremity peripheral neuropathy is denied. Entitlement to a disability rating in excess of 20 percent for service-connected diabetes mellitus type II with erectile dysfunction and mild cortical lens opacities in both eyes is denied. Entitlement to a disability rating in excess of 20 percent for service-connected peripheral neuropathy of the right lower extremity is denied. Entitlement to a disability rating in excess of 20 percent for service-connected peripheral neuropathy of the left lower extremity is denied. Entitlement to a compensable disability rating for service-connected decubitus ulcer is denied. Entitlement to a compensable disability rating for service-connected status post excision lipoma, right buttock is denied. REMANDED Entitlement to service connection for chronic CML, to include as due to herbicide agent exposure, is remanded. Entitlement to service connection for a breathing and throat problem, to include as due to herbicide agent exposure and/or service-connected diabetes mellitus, is remanded. Entitlement to service connection for a depressive disorder, to include as due to service-connected disabilities, is remanded. Entitlement to special monthly compensation based on the need for Aid and Attendance or due to being Housebound is remanded. FINDINGS OF FACT 1. An unappealed February 2007 rating decision denied service connection for CML, to include as due to herbicide agent exposure, based on findings that the evidence of record did not show that the Veteran’s exposure to herbicide agents in service caused his CML. 2. Evidence submitted since the February 2007 final rating decision is not cumulative or redundant of evidence of record at the time of the prior denial; it relates to unestablished facts necessary to substantiate the Veteran’s claim for service connection for CML as due to herbicide agent exposure, and it raises a reasonable possibility of substantiating the claim. 3. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of a sleep apnea syndrome. 4. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of a blood clotting problem. 5. The preponderance of the evidence is against finding that restless leg syndrome began during active service, or is otherwise related to an in-service injury, event, or disease. 6. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of right upper extremity peripheral neuropathy. 7. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of left upper extremity peripheral neuropathy. 8. The Veteran was scheduled for an examination to determine the present nature and severity of his service-connected diabetes mellitus with erectile dysfunction and mild cortical lens opacities in both eyes and peripheral neuropathy in the bilateral extremities; however, he failed to report to the examinations and has not shown good cause for his failures to report. 9. The Veteran’s decubitus ulcer has not involved more than 5 percent of the entire body and/or more than 5 percent of exposed areas affected and has not required systemic therapy. 10. The Veteran has one scar located on his right buttock which is neither painful nor unstable. CONCLUSIONS OF LAW 11. The February 2007 rating decision that denied service connection for CML as due to herbicide agent exposure is final. 38 U.S.C. § 7105; 38 C.F.R. § 3.104, 20.302, 20.1103. 12. Evidence received after the February 2007 rating decision is new and material and serves to reopen the Veteran’s claim of entitlement to service connection for CML as due to herbicide agent exposure. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156. 13. The criteria for service connection for CML to include as due to herbicide agent exposure have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 14. The criteria for service connection for sleep apnea syndrome are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 15. The criteria for service connection for blood clotting problem are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 16. The criteria for service connection for restless leg syndrome are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 17. The criteria for service connection for right upper extremity peripheral neuropathy are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 18. The criteria for service connection for left upper extremity peripheral neuropathy are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 19. The criteria for a disability rating in excess of 20 percent for service-connected diabetes mellitus type II with erectile dysfunction and mild cortical lens opacities in both eyes is denied on the basis of the Veteran’s failure to report for a VA medical examination. 38 C.F.R. § 3.655. 20. The criteria for a disability rating in excess of 20 percent for service-connected peripheral neuropathy of the right lower extremity is denied on the basis of the Veteran’s failure to report for a VA medical examination. 38 C.F.R. § 3.655. 21. The criteria for a disability rating in excess of 20 percent for service-connected peripheral neuropathy of the left lower extremity is denied on the basis of the Veteran’s failure to report for a VA medical examination. 38 C.F.R. § 3.655. 22. The criteria for a compensable disability rating for service-connected decubitus ulcer as not been met. The criteria for an initial compensable disability rating for pseudofolliculitis barbae are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.7, 4.31, 4.118, Diagnostic Code (DC) 7806. 23. The criteria for a compensable disability rating for service-connected status post excision lipoma right buttock has not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.114, Diagnostic Codes (DCs) 7800-7805. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from April 1963 to September 1984. In July 2018, the Veteran filed a notice of disagreement (NOD) for the issues of entitlement to service connection for coronary artery disease, tinnitus, right ear hearing loss as well as entitlement to a compensable disability rating for service-connected left ear hearing loss and entitlement to non-service connected pension. The Regional Office (RO) has acknowledged receipt of the NOD which distinguishes this case from Manlincon v. West, 12 Vet. App. 238 (1999), where a NOD had not been recognized. As the record reflects pending additional action on the NOD, the Board will not address these issues at this time. New and Material Generally, a claim that has been denied in an unappealed RO decision or an unappealed Board decision may not thereafter be reopened and allowed. 38 U.S.C. §§ 7104(b), 7105(c). The exception is that, if new and material evidence is presented or secured with respect to a claim which has been disallowed, VA shall reopen the claim and review the former disposition of the claim. 38 U.S.C. § 5108. New evidence means existing evidence not previously submitted to agency decision-makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). New and material evidence is not required as to each previously unproven element of a claim. There is a low threshold for reopening claims. 38 C.F.R. § 3.156(a); Shade v. Shinseki, 24 Vet. App. 110 (2010). For the purpose of determining whether new and material evidence has been submitted, the credibility of new evidence is presumed. Justus v. Principi, 3 Vet. App. 510 (1992). 1. New and material evidence has been received to reopen the claim for service connection for CML to include as due to herbicide agent exposure. A February 2007 rating decision denied the Veteran’s claim for service connection for CML, to include as due to herbicide agent exposure, on the basis that CML is not a disability that has been positively associated with exposure to herbicides. See decision. The Veteran did not appeal that decision or submit new and material evidence within one year of that decision, and it became final. 38 U.S.C. § 7105; 38 C.F.R. § 3.104, 3.156(b), 20.302, 20.1103. In June 2008, the Veteran filed a claim to reopen. See claim. Evidence added to the record since the February 2007 rating decision includes medical opinions from private physicians, Dr. T.B. and Dr. H.S., which provide opinions regarding the relationship between herbicide agent exposure and CML. In this case, because the Veteran asserts that his CML is due to his herbicide agent exposure, the private medical opinions are considered new and material as they provides additional information relating to an unestablished fact necessary to substantiate this service connection claim. Shade v. Shinseki, 24 Vet. App. 110, 118 (2010). Accordingly, the Board concludes that the claim will be reopened because new and material evidence has been received. Service Connection 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; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (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 or aggravated during service - the so-called “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Secondary service connection is warranted where a disability is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Briefly, the threshold legal requirements for a successful secondary service connection claim are: (1) Evidence of a current disability for which secondary service connection is sought; (2) a disability for which service connection has been established; and (3) competent evidence of a nexus between the two. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 2. Entitlement to service connection for a sleep apnea syndrome, a blood clotting problem, right upper extremity peripheral neuropathy and left upper extremity peripheral neuropathy are denied. The Veteran contends he warrants service connection for a sleep apnea syndrome, a blood clotting problem, and peripheral neuropathy in the bilateral upper extremities. The question for the Board is whether the Veteran has current disabilities that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have a current diagnosis of sleep apnea, a blood clotting problem, or bilateral upper extremity peripheral neuropathy and has not had one at any time during the pendency of the claim or recent to the filing of the claim. 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). The September 2012 VA examination for diabetes mellitus showed the Veteran did not have a diagnosis of either left or right upper extremity peripheral neuropathy. His VA treatment records also do not contain a diagnosis of either condition. Furthermore, the Veteran was scheduled for an examination in October 2017 in conjunction with his increased rating claims but failed to appear for the examination. Therefore, his service connection claim must be decided based on the evidence of record. Additionally, while no VA examination was provided to the Veteran, his VA medical treatment records are silent for any complaints, findings, treatment, or diagnosis related to sleep apnea or a blood clotting problem. While the Veteran believes he has a current diagnosis of sleep apnea, a blood clotting problem and right and left upper extremity peripheral neuropathy, he is not competent to provide a diagnosis in this case. These issues are medically complex, as it requires specialized medical education/knowledge of the interaction between multiple organ systems in the body/the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. 3. Entitlement to service connection for restless leg syndrome is denied. The Veteran contends he suffers from restless leg syndrome as a result of his service. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a diagnosis of restless leg syndrome, the preponderance of the evidence is against finding that it began during active service, or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). The Veteran’s service treatment records are silent for any signs, symptoms or diagnoses of restless leg syndrome while in-service. Moreover, neither the Veteran nor his attorney has offered specific contentions regarding any such signs or symptoms he may have experienced in service that would be attributable to restless leg syndrome. They also have not offered any contentions as to how they believe the Veteran’s current restless leg syndrome is related to his service, and the postservice treatment records of record do not comment on the etiology of that condition. While the Veteran may believe his restless leg syndrome is related to service, the Board reiterates that the preponderance of the evidence weighs against findings that he suffers from restless leg syndrome from service. Increased Rating Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the veteran, as well as the entire history of the veteran’s disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. 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. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as “staging the ratings.” See Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). 4. Entitlement to a disability rating in excess of 20 percent for service-connected diabetes mellitus type II with erectile dysfunction and mild cortical lens opacities in both eyes; entitlement to a disability rating in excess of 20 percent for service-connected peripheral neuropathy of the right lower extremity; and entitlement to a disability rating in excess of 20 percent for service-connected peripheral neuropathy of the left lower extremity are denied. VA regulation 38 C.F.R. § 3.655 provides that when a claimant fails to report for an examination scheduled in conjunction with an original compensation claim, the claim shall be rated based on the evidence of record. When the examination is scheduled in conjunction with any other original claim, a reopened claim for a benefit which was previously disallowed, or a claim for increase, the claim shall be denied. Upon finding that a claimant has not demonstrated good cause for failing to report for a VA exam scheduled in conjunction with a reopened claim or a claim for increase, VA must deny the claim in accordance with § 3.655. See Kyhn v. Shinseki, 24 Vet. App. 228 (2010). Factually, the Veteran was granted service connection for diabetes mellitus type II with erectile dysfunction and mild cortical lens opacities in both eyes as well as peripheral neuropathy of the bilateral lower extremities in a February 2007 rating decision. See decision. In March 2012, the Veteran filed his present increased rating claim for these disabilities. See claim. The Veteran underwent a VA examination in September 2012, which was reviewed and considered in the April 2013 rating decision currently on appeal. Subsequently, as a result of additional claims made by the Veteran (see June 2017, VA Form 21-526EZ), he was scheduled for additional examinations in October 2017 to determine the present nature and severity of his symptomatology for these disabilities. However, the Veteran failed to appear to the examination and no good cause has been provided. In fact, in a November 2017 Report of Contact with the VETFED call center, it was noted that the Veteran had confirmed his appointments, he just did not report for the examinations. See VA Form 21-0820. The Veteran was advised of 38 C.F.R. § 3.655 in the June 2016 Statement of the Case. He was also sent a Supplemental Statement of the Case in December 2017, in which it was noted that he had failed to report for the October 2017 VA examinations, but no response or explanation has been received showing good cause for failure to attend either appointment. The Veteran has been advised that a claimant failing to report for a scheduled examination must show good cause for so doing. See 38 C.F.R. § 3.655. As such, because the law provides that when a claimant fails to report for an examination scheduled in conjunction with a claim for increase, the claim shall be denied under 38 C.F.R. § 3.655, the Board will deny these claims. 5. Entitlement to a compensable disability rating for service-connected decubitus ulcer is denied. The Veteran’s decubitus ulcer is rated under 38 C.F.R. § 4.118, DC 7820-7806. Pursuant to 38 C.F.R. § 4.27, hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. Here, the use of DCs 7820-7806 reflects that the Veteran’s decubitus ulcer is rated as an infection of the skin not listed elsewhere in the diagnostic codes pertaining to the rating of skin disabilities codified at 38 C.F.R. § 4.118 under DC 7820 and that the rating assigned is based on the criteria for rating dermatitis under DC 7806. Under DC 7820, infections of the skin not listed elsewhere (including bacterial, fungal, viral, treponemal and parasitic diseases) are rated as disfigurement of the head, face, or neck (DC 7800), scars (DCs 7801, 7802, 7803, 7804, or 7805), or dermatitis (DC 7806), depending upon the predominant disability. 38 C.F.R. § 4.118, DC 7820. Under the criteria of DC 7806, dermatitis or eczema covering less than 5 percent of the entire body, affecting less than 5 percent of exposed areas; and requiring no more than topical therapy during the past 12-month period warrants a noncompensable rating. Dermatitis or eczema covering at least 5 percent, but less than 20 percent, of the entire body; affecting at least 5 percent, but less than 20 percent, of exposed areas; of requiring intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than six weeks during the past 12- month period warrants a 10 percent rating. Dermatitis or eczema covering 20 to 40 percent of the entire body, affecting 20 to 40 percent of exposed areas, or requiring systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of six weeks or more, but not constantly, during the past 12-month period warrants a 30 percent rating. Dermatitis or eczema warrants a 60 percent rating if it covers more than 40 percent of the entire body, more than 40 percent of exposed areas are affected, or if constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs have been required during the past 12-month period. 38 C.F.R. § 4.118, DC 7806. Additionally, dermatitis can alternatively be rated as disfigurement of the head, face or neck (DC 7800) or scars (DCs 7801-7805) depending upon the predominant disability. 38 C.F.R. § 4.118, DC 7806. Under DC 7800 for burn scars, scars due to other causes, or other disfigurement, of the head, face, or neck, a 10 percent rating is warranted for one characteristic of disfigurement. A 30 percent rating is for application when there is 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 with two or three characteristics of disfigurement. A 50 percent rating is warranted when there is visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips); or with four or five characteristics of disfigurement. A maximum schedular 80 percent rating is warranted when there is visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips); or with six or more characteristics of disfigurement. 38 C.F.R. § 4.118, DC 7800. The eight characteristics of disfigurement, for purposes of evaluation under § 4.118, are: a scar of five or more inches (13 or more centimeters) in length; a scar at least one-quarter inch (.6 centimeters) wide at the widest part; surface contour of the scar elevated or depressed on palpation; a scar adherent to the underlying tissue; skin hypo-, or hyper-, pigmented in an area exceeding six square inches (39 square centimeters); abnormal skin texture (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 square centimeters); underlying soft tissue missing in an area exceeding six square inches (39 square centimeters); indurated and inflexible skin in an area exceeding six square inches (39 square centimeters). 38 C.F.R. § 4.118, Note 1 following DC 7800. Disabling effects other than disfigurement that are associated with an individual scar of the head, face, or neck, such as pain, instability, and residuals of associated muscle or nerve injury are separately evaluated under the appropriate diagnostic code and 38 C.F.R. § 4.25 should be applied to combine the evaluation(s) with the evaluation assigned under this diagnostic code. Id. at Note (4). DCs 7801 and 7802 pertain to burn scars, or scars due to other causes, not of the head, face, or neck. 38 C.F.R. § 4.118, DCs 7801 and 7802. Under DC 7804, one or two scars that are unstable or painful warrant a 10 percent rating. Three or four scars that are unstable or painful warrant a 20 percent rating. Five or more scars that are unstable or painful warrant a 30 percent rating. If one or more scars are both unstable and painful, 10 percent is to be added to the evaluation that is based on the total number of unstable or painful scars. Scars evaluated under DCs 7800, 7801, 7802, or 7805 may also receive an additional evaluation under this diagnostic code, when applicable. 38 C.F.R. § 4.118. Under DC 7805, any disabling effects of other scars (including linear scars), and other effects of scars evaluated under DCs 7800, 7801, 7802, and 7804 not considered in a rating provided under DCs 7800-7804 are to be evaluated under an appropriate diagnostic code. 38 C.F.R. § 4.118. Evidence relevant to the level of severity of the Veteran’s decubitus ulcer includes the November 2014 VA examination report. The Veteran did not have any skin conditions causing scarring or disfigurement of the head, face or neck. He had treated his condition with oral or topical medications in the past 12 months, including antihistamines. No additional treatments or procedures other than systemic or topical medications were used in the past 12 months. Additionally, he did not suffer from any debilitating or non-debilitating episodes in the past year. On physical examination, the Veteran’s dermatitis and decubitus ulcer covered less than 5 percent of his total body area as well as exposed area. See examination. The available VA treatment records do not provide any conflicting medical evidence. After thorough consideration of the limited evidence of record, the Board concludes that a compensable disability rating for the Veteran’s decubitus ulcer is not warranted. Notably, with regard to Diagnostic Code 7806, the evidence does not show that the Veteran’s skin disability covers more than 5 percent of the entire body or more than 5 percent of exposed areas are affected. The evidence also does not show constant or near constant systemic therapy such as corticosteroids or other immunosuppressive drugs have been required during the past 12 months. As noted above, the Veteran was using antihistamines for treatment only. With regard to DC 7800 and 7804, the evidence does not show visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired set of features, or one characteristic of disfigurement. The VA examination showed that there was no disfigurement of the head, face, or neck or painful scarring. As for the lay assertions of record, the Board notes that the Veteran is certainly competent to report his own symptoms, or matters within his personal knowledge. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). In this case, the Veteran has not offered additional complaints or symptoms that would warrant a compensable rating under any applicable diagnostic code. In reaching this decision, the Board considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against a compensable disability rating for decubitus ulcer, the doctrine is not for application. See Gilbert, supra; see also Hart, 21 Vet. App. at 509-10. 6. Entitlement to a compensable disability rating for service-connected status post excision lipoma, right buttock is denied. The Veteran’s scar, status post arthroscopic surgery, right ankle is rated under Diagnostic Codes 7800- 7805. Under Diagnostic Code 7800, a 10 percent rating is warranted for scars that are located on the head, face, or neck when there is one characteristic of disfigurement. 38 C.F.R. § 4.118, Diagnostic Code 7800. A 30 percent rating is warranted when there is 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, or lips), or; with two or three characteristics of disfigurement. Id. A 50 percent rating is warranted when there is visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features, or; with four or five characteristics of disfigurement. Id. An 80 percent rating is warranted when there is visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features, or; with six or more characteristics of disfigurement. Id. For purposes of evaluation of under 38 C.F.R. § 4.118, the eight characteristics of disfigurement are: a scar that is five or more inches, or thirteen centimeters, in length; a scar that is at least one-quarter of an inch, or 0.6 centimeters, wide at the widest part; surface contour of the scar that is elevated or depressed on palpation; a scar that is adherent to underlying tissue; skin that is hypo- or hyper-pigmented in an area exceeding six square inches, or 39 square centimeters; skin texture that is abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches, or 39 square centimeters; underlying soft tissue that is missing in an area exceeding six square inches, or 39 square centimeters; and skin that is indurated and inflexible in an area exceeding six square inches, or 39 square centimeters. 38 C.F.R. § 4.118, Diagnostic Code 7800, Note 1. VA is to consider unretouched color photographs when evaluating under these criteria. Id. at Note 3. Additionally, VA is to separately evaluate disabling effects other than disfigurement that are associated with individual scars of the head, face, or neck, such as pain, instability, and residuals of associated muscle or nerve injury, under the appropriate diagnostic code(s) and apply 38 C.F.R. § 4.25 to combine the evaluation(s) with the evaluation assigned under Diagnostic Code 7800. Id. at Note 4. Finally, the characteristics of disfigurement may be caused by one scar or by multiple scars; the characteristics that are required to assign a particular evaluation need not be caused by a single scar in order to assign that evaluation. Id. at Note 5. Diagnostic Code 7801 applies to burn scars or scars due to other causes, not of the head, face, or neck that are deep and nonlinear. 38 C.F.R. § 4.118, DC 7801. A deep scar is one that is associated with underlying soft tissue damage. Id. at Note 1. Diagnostic Code 7802 pertains to burn scars or scars due to other causes, not of the head, face, or neck that are superficial and nonlinear. 38 C.F.R. § 4.118, DC 7802. A superficial scar is one that is not associated with underlying soft tissue damage. Id. at Note 1. Pursuant to Diagnostic Code 7804, which applies to unstable or painful scars, a 10 percent rating is warranted for one or two scars that are unstable or painful; a 20 percent rating is warranted for three or four scars that are unstable or painful; and a 30 percent rating is warranted for five or more scars that are unstable or painful. 38 C.F.R. § 4.118, DC 7804. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Id. at Note 1. If one or more scars are both unstable and painful, VA is to add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Id. at Note 2. Additionally, scars that are evaluated under Diagnostic Codes 7800, 7801, 7802, or 7805 may also receive an evaluation under Diagnostic Code 7804 when applicable. Id. at Note 3. According to Diagnostic Code 7805, which applies to other scars (including linear scars) and other effects of scars evaluated under Diagnostic Codes 7800, 7801, 7802, and 7804, VA is to evaluate any disabling effect(s) not considered in a rating provided under such Diagnostic Codes under an appropriate diagnostic code. 38 C.F.R. § 4.118, DC 7805. After reviewing the medical evidence of record, the Board finds the Veteran’s service-connected status post excision lipoma, right buttock does not warrant a compensable disability rating under Diagnostic Codes 7800-7805. The November 2014 VA examination found the Veteran’s scar was not painful or unstable and measured less than 39 square centimeters. See examination. The Veteran’s treatment records do not provide medical evidence to the contrary nor has the Veteran contended that his scar has worsened since the November 2014 VA examination. Here, the evidence of record clearly does not reveal scars causing disfigurement of the head, face, or neck (Diagnostic Code 7800); scars other than the head, face, or neck that are deep or cause limited motion in an area exceeding 6 square inches or 39 sq. cm. (Diagnostic Code 7801); scars other than the head, face, or neck that are superficial, do not cause limited motion, and in an area exceeding 144 square inches or 929 cm. or greater (Diagnostic Code 7802); superficial unstable scars with frequent loss of skin covering over the scar (Diagnostic Code 7803); nor was the scar found to be painful or unstable (Diagnostic Code 7804). In reaching this decision, the Board considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against a compensable disability rating for status post excision lipoma, right buttock, the doctrine is not for application. Gilbert, supra; see also Hart, 21 Vet. App. at 509-10. REASONS FOR REMAND 1. Entitlement to service connection for chronic CML to include as due to herbicide agent exposure is granted. The Veteran contends his chronic CML is related to his herbicide agent exposure in service. In support of that claim, he has submitted two private medical opinions. The first opinion from Dr. T.B., dated October 2005, states the Veteran’s exposure to Agent Orange in Vietnam “could have played a role with his development of leukemia,” and that it was therefore “as likely as not that the agent orange did cause his chronic myelogenous leukemia.” However, Dr. T.B. provided no explanation for the rationale of that opinion. A second medical opinion was submitted from Dr. H.S., dated April 2017. He opined that it was “at least as likely as not that the [V]eteran’s chronic myeloid leukemia (CML) [was] caused by his conceded exposure to Agent Orange while serving in Vietnam.” As part of his rationale for that opinion, Dr. H.S. acknowledged that the “exact cause of the [V]eteran’s carcinoma isn’t really known,” but stated that several risks factors had been identified including Agent Orange exposure. In support of that claim, Dr. H.S. cited to a study done on residents of Seveso, Italy after a 1976 industrial accident exposed the surrounding population to chemicals associated with Agent Orange. Dr. H.S. stated that this “long-term study showed an increase in the occurrence of myeloid cancer.” However, the Board has reviewed the article submitted concerning that study, and finds that the impact of the chemical exposure on CML was not specifically discussed. Notably, Dr. H.S. does not cite to any specific portion of that study to support his opinion either. Nevertheless, the Board finds that in light of the private medical opinions submitted in support of this claim, a VA medical opinion is needed to address this issue. 2. Entitlement to service connection for a breathing and throat problem to include as due to herbicide agent exposure and service-connected diabetes mellitus is remanded. The Veteran contends he suffers from a breathing and throat problem, to include as due to herbicide agent exposure in service and/or his service-connected diabetes mellitus. Service treatment records show the Veteran experienced headaches and sinus pain while in-service. See STR. Giving the benefit of the doubt to the Veteran, the Board finds a VA examination is necessary to determine whether the Veteran suffers from a present respiratory condition which may be caused by or related to his active service, to include herbicide agent exposure and/or his service-connected diabetes mellitus. 3. Entitlement to service connection for depressive disorder, to include as due to service-connected disabilities, is remanded. The Veteran submitted a private medical opinion dated September 2016, in which depressive disorder with anxious distress features was diagnosed and it was opined that this disability was aggravated by the Veteran’s service-connected disabilities. See records. While the examiner indicated it was impossible to separate out how much each physical condition was contributing to the Veteran’s overall mental impairment, the examiner did not provide an explanation for the rationale that the psychiatric disability was aggravated by his service-connected disabilities. Because of the lack of supporting evidence for the positive nexus opinion, a VA addendum opinion is necessary before adjudicating the claim. 4. Entitlement to special monthly compensation based on the need for Aid and Attendance or due to being Housebound is remanded. The Veteran contends his service-connected disabilities cause him to be housebound and therefore, he warrants special monthly compensation. A VA examination for housebound status or permanent need for regulation aid and attendance was performed in March 2012. See examination. However, the Board finds that the remand for service-connected disabilities is inextricably intertwined with the issue of special monthly compensation, as any decisions that result from the requested development may impact the decision on special monthly compensation. Therefore, a remand of this issue is also necessary. The matters are REMANDED for the following action: 1. Obtain a medical opinion from an appropriate clinician that addresses the question of whether the Veteran’s CML is at least as likely as not related to an in-service injury, event, or disease, to include his exposure to herbicide agents therein. As part of the medical opinion, the examiner should consider and discuss the private medical opinions and relevant treatise evidence of record. If it is determined that a physical examination of the Veteran is needed in order to provide the requested medical opinion, such should be arranged. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any breathing and throat problem. If a breathing and throat problem (or other respiratory disability) is diagnosed, the examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, to include the Veteran’s herbicide agent exposure therein; and whether it is at least as likely as not (1) proximately due to the Veteran’s service-connected diabetes mellitus, or (2) aggravated beyond its natural progression by service-connected diabetes mellitus. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any depressive disorder with anxious distress features. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, and whether it is at least as likely as not (1) proximately due to the Veteran’s service-connected disabilities, or (2) aggravated beyond its natural progression by his service-connected disabilities. 3. Schedule the Veteran for an examination for Housebound Status or Permanent Need for Regular Aid and Attendance. 4. After the above development, and any additionally indicated development, has been completed, readjudicate the inextricably intertwined issue of special monthly compensation. If the benefit sought is not granted to the Veteran’s satisfaction, send the Veteran and his attorney a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. A. ISHIZAWAR Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Churchwell, Counsel