Citation Nr: 1814947 Decision Date: 03/09/18 Archive Date: 03/19/18 DOCKET NO. 07-34 547A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for a groin injury. 2. Entitlement to a rating in excess of 20 percent for residuals of a gunshot wound (GSW) to the right hand with peripheral neuropathy. 3. Entitlement to a rating in excess of 30 percent prior to October 22, 2013, and a rating in excess of 50 percent effective from October 22, 2013, for residuals of a gunshot wound to the right lower abdomen, with injury to Muscle Group XIX. 4. Entitlement to a rating in excess of 30 percent for scars of the right flank, right lower abdomen, right mid abdomen, right posterior hip, right third finger, and right mid-palm. 5. Entitlement to a total rating based on individual unemployability due to service-connected disability (TDIU rating), prior to October 21, 2013. REPRESENTATION Appellant represented by: Blinded Veterans Association WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD F. Yankey Counsel INTRODUCTION The Veteran served on active duty from October 1965 to November 1970. The Veteran's service from October 1967 to November 1970 was found to be dishonorable for VA purposes. This matter comes before the Board of Veterans' Appeals (Board) from rating decisions dated in January 2010 and May 2011, of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. In January 2013, the Veteran testified at a hearing held in Washington, D.C. In August 2013, the Board issued a decision finding that new and material evidence had been submitted to reopen the claim for service connection for a groin injury; the Board then remanded the reopened claim for service connection for a groin injury, as well as the other issues set forth above, for further development. By August 2016 rating decision, the RO granted a 50 percent rating for residuals, gunshot wound, right lower abdomen with injury to muscle group XIX, effective from October 22, 2013; the Veteran has continued his appeal for higher ratings prior to, and effective from, October 22, 2013. In August 2017, the Board remanded the case again for further development by the originating agency. The case has been returned to the Board for further appellate action. The issues of entitlement to an increased rating for residuals of a gunshot wound to the right hand with peripheral neuropathy; entitlement to an increased rating for scars of the right flank, right lower abdomen, right mid-abdomen, right posterior hip, right third finger, and right mid-palm; and entitlement to a TDIU, are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if additional action is required on his part. FINDINGS OF FACT 1. The Veteran does not have a groin disability. 2. Prior to October 22, 2013, the Veteran's residuals, gunshot wound, right lower abdomen with injury to Muscle Group XIX, resulted in no more than moderately severe disability from abdominal wall muscle damage. 3. For the period beginning October 22, 2013, the Veteran receives the highest schedular rating available for his residuals, gunshot wound, right lower abdomen with injury to muscle group XIX; there is no evidence of symptomatology warranting consideration under a different diagnostic code or extraschedular evaluation. CONCLUSIONS OF LAW 1. A groin disability was not incurred in or aggravated by the Veteran's active service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (2017). 2. Prior to October 22, 2013, the criteria for a rating in excess of 30 percent for residuals, gunshot wound, right lower abdomen with injury to Muscle Group XIX, have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.118, Diagnostic Codes 7801, 7802, 7803 7804, 7805, § 4.73, Diagnostic Code 5319 (2017). 3. For the period beginning October 22, 2013, the criteria for a rating in excess of 50 percent for residuals, gunshot wound, right lower abdomen with injury to Muscle Group XIX, have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.118, Diagnostic Codes 7801, 7802, 7803 7804, 7805, § 4.73, Diagnostic Code 5319 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist There is no indication in this record of a failure to notify. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Pursuant to the duty to assist, VA must obtain "records of relevant medical treatment or examination" at VA facilities. 38 U.S.C. § 5103A(c)(2). All records pertaining to the conditions at issue are presumptively relevant. See Moore v. Shinseki, 555 F.3d 1369, 1374 (Fed. Cir. 2009); Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). In addition, where the veteran "sufficiently identifies" other VA medical records that he or she desires to be obtained, VA must also seek those records even if they do not appear potentially relevant based upon the available information. Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016) (citing 38 C.F.R. § 3.159(c)(3)). In this case, the Veteran has indicated no such records and all pertinent records have been obtained. The appeal was remanded in August 2013 for further development by the RO, including providing the Veteran with notice related to how to substantiate a claim for TDIU and a secondary service connection claim and the scheduling of VA examinations, and again in July 2017 for the scheduling of a Board hearing. The required notice was provided in October 2013 and the requested examinations were conducted in March 2016. Furthermore, the Veteran was afforded the opportunity to submit additional evidence as well as testify at a Video Conference hearing in August 2017. Neither the information of record nor the contentions of the Veteran suggests that additional pertinent information or evidence can be obtained in this case pertinent to the issues decided herein through further assistance from VA. Service Connection for a Groin Injury Legal Criteria Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza elements is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post- service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. See Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). The theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In relevant part, 38 U.S.C. 1154(a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d at 1337 ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991). Once evidence is determined to be competent, the Board must then determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2017); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Analysis The Veteran contends that he either directly injured his groin in service or that he has residual gunshot wound scars to the groin, and scarring from his subsequent colostomy procedure following his gunshot injury, which are very painful and separate from his already service-connected gunshot wound residuals related to right flank/abdomen/hip scarring and muscle injury, and separate from his already service-connected urethral stricture disease with periurethral abscess and post-operative status, suprapubic cystostomy and internal urethrotomy to include prostatitis. Service treatment records (STR) do not reflect any specific complaints of or direct injuries to the "groin," but they do show ongoing complaints of abdominal and right lower quadrant pain. The Veteran was treated for pain and swelling of the right testis, as well as tender bilateral inguinal lymph nodes, in March 1968. The final diagnosis was right epididymorchitis. STRs also show that the Veteran sustained gunshot wound injuries to the right flank and, specifically the right iliac crest in June 1966; he underwent a post-ilio-transverse colostomy later that same month. VA treatment records show treatment for urethral stricture disease in August 1980. The Veteran complained of groin pain in September 2006, but no diagnosis of a groin disability was made at that time. The Veteran was afforded a VA examination in response to his claim in March 2016. The examiner noted that the Veteran sustained gunshot injuries in service, resulting in pelvic fracture and perforated coecum, with numerous subsequent surgeries and medical follow up for years. He noted further that the Veteran was hospitalized in March 1968 for right epididymorchitis, which was treated with antibiotherapy. The Veteran recovered without any further recurrence of the condition. The examiner also noted that review of the evidence-based medical literature shows that the great majority of epididymitis/orchitis are due to organisms responsible for sexually transmitted infections (STIs), including gonorrhea and chlamydia, and the Veteran's records show that he was treated several times between December 1966 and August 1968 for mainly uncomplicated gonorrhea urethritis. As such, the examiner concluded that the Veteran's in-service epididymo-orchitis was the result of gonorrhea infections and less likely than not a residual of gunshot wounds during service. With regard to a current groin disability, the examiner noted that the Veteran reported an occasional "twinge" in his right testicle, but the testicular examination was entirely normal, without any mass or tenderness, and the examiner did not detect any residual scrotal or inguinal (groin) scar from the incision and drainage the Veteran had for a testicular infection during service in 1968. The examiner did not diagnose a current groin disability. There is no other evidence of record, VA or private, showing a currently diagnosed groin disability, separate from the already service-connected residuals of a gunshot wound and urethral stricture disease, during the current appeal period. Whether service connection is claimed on direct, presumptive, or any other basis, a necessary element for establishing such a claim is the existence of a current disability. See Degmetich v. Brown, 104 F.3d 1328 (1997) (holding that section 1110 of the statute requires the existence of a present disability for VA compensation purposes); see also Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). The presence of a disability at the time of filing of a claim or during its pendency warrants a finding that the current disability requirement has been met, even if the disability resolves prior to the Board's adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). In this case, while the Veteran has reported groin pain, there is no confirmation in the evidence that the Veteran has been diagnosed with a groin disability, separate from his already service-connected gunshot wound residuals and urethral stricture disease noted above, during the pendency of the appeal. In the absence of proof of a current groin disability, there is no valid claim of service connection. In light of the absence of any competent evidence of a groin disability, separate from his already service-connected gunshot wound residuals and urethral stricture disease noted above, during the pendency of this appeal, this claim must be denied. In reaching this decision, the Board has considered the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Increased Rating for Residuals of a Gunshot Wound to the Right Lower Abdomen, with Injury to Muscle Group XIX Legal Criteria Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2017). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2017). Each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2 (2017). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2017). In both initial rating claims and normal increased rating claims, the Board must discuss whether any "staged ratings" are warranted, and if not, why not. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). The severity of muscle disability is determined by the type of injury, the history and complaint, and objective findings. 38 C.F.R. § 4.56(d). For VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement. 38 C.F.R. § 4.56(c). For Diagnostic Codes 5301 through 5323, disabilities resulting from muscle injuries shall be classified as slight, moderate, moderately severe, or severe. 38 C.F.R. § 4.56. Muscle disability is considered to be slight if it was caused by a simple wound without debridement or infection. The history of a slight muscle disability should include service department records of a superficial wound with brief treatment and return to duty, and healing with good functional results. There should be no cardinal signs or symptoms of muscle disability. Objective findings should include a minimal scar; no evidence of fascial defect, atrophy, or impaired tonus; and no impairment of function or metallic fragments retained in muscle tissue. 38 C.F.R. § 4.56. Muscle disability is considered to be moderate if it was caused by a through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without the explosive effect of a high velocity missile, residuals of debridement, or prolonged infection. The history of a moderate muscle disability should include service department records or other evidence of in-service treatment for the wound as well as a record of consistent complaints of one or more of the cardinal signs and symptoms of muscle disability (loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement), particularly, lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. The objective signs of moderate disability include small or linear entrance and (if present) exit scars, indicating a short track of the missile through muscle tissue, some loss of deep fascia or muscle substance, impairment of muscle tonus and loss of power, or a lowered threshold of fatigue when compared to the sound side. Id. Muscle disability is considered to be moderately severe if it results from a through-and-through or deep-penetrating wound by a small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. The history of a moderately severe muscle injury should include service department records or other evidence showing hospitalization for a prolonged period for treatment of the wound, consistent complaints of the cardinal signs and symptoms of muscle disability as noted above and, if present, evidence of inability to keep up with work requirements. The objective evidence of a moderately severe muscle disability includes entrance and (if present) exit scars that indicate a track of the missile through one or more muscle groups, the loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with the sound side, and impairment of strength and endurance in comparison to the sound side. Id. Muscle disability is considered to be severe if it results from a through-and-through or deep-penetrating wound, due to high-velocity missile, or large or multiple low-velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intermuscular binding and scarring. History includes hospitalization for a prolonged period for treatment of the wound; consistent complaint of cardinal signs and symptoms of muscle disability, worse than those shown for moderately severe muscle injuries; and, if present, inability to keep up with work requirements. Objective findings include ragged, depressed and adherent scars, indicating wide damage to muscle groups in the missile track. Palpation shows loss of deep fascia or muscle substance, or soft flabby muscles in the wound area. Muscles swell and harden abnormally in contraction. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side indicate severe impairment of function. If present, the following are also signs of severe muscle disability: X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile; adhesion of a scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle; diminished muscle excitability to pulsed electrical current in electrodiagnostic tests; visible or measurable atrophy; adaptive contraction of an opposing group of muscles; atrophy of muscle groups not in the track of the missile; induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56(d)(4) (2017). The Veteran's service-connected residuals, gunshot wound, right lower abdomen with injury to muscle group XIX is rated under the criteria for evaluating wounds to muscle group XIX, whose function is support and compression of the abdominal wall and lower thorax; flexion and lateral motions of the spine; and synergists in strong downward motion of the arm. Included in this muscle group are the muscles of the abdominal wall, which include the rectus abdominis, external oblique, internal oblique, transversalis and quadratus lumborum. A noncompensable evaluation contemplates disability that is slight. A 10 percent evaluation is warranted for a muscle disability that is moderate, a 30 percent evaluation is warranted for a muscle disability that is moderately severe, while a 50 percent evaluation is in order for a muscle disability that is severe. 38 C.F.R. § 4.73, Diagnostic Code 5319. Period Prior to October 22, 2013 Prior to October 22, 2013, the Veteran's gunshot wound residuals of the lower abdomen is rated as 30 percent disabling. The criteria for a higher rating of 50 percent under Diagnostic Code 5319 are not met during this period. In this regard, on VA examination in November 2009, the Veteran complained of occasional stinging sensation in the area of the abdominal wounds with lifting awkwardly and with bending over. The pain lasted for approximately two days and then resolved. He had three surgeries on his abdomen because of the gunshot wound, causing intestinal damage, with his last occurring in 1984 with a reanastomosis at that time. He no longer had an ileostomy at the time of the examination. He reported normal bowel movements and denied taking any medications for his abdomen. He also reported that his scars had healed well, but they were occasionally tender to touch, and the entry and exit wounds left deep scars. On physical examination, the abdomen was soft, nontender and nondistended, and no organomegaly was noted. There were scars involving the right lower abdomen and right posterior hip, consistent with entry and exit wounds of gunshot with multiple post-surgical scars to the abdomen. Many scars were tender, but none were adherent to underlying tissue and they were all of normal texture, stable, depressed, and superficial. There was no inflammation, edema or keloid formation. Scars were hyperpigmented, with no induration or inflexibility, and no limitation of motion or function. The examiner concluded that the Veteran was able to work in a sedentary position. The Veteran was afforded another VA examination in October 2011, but the examination report did not specifically address the abdominal muscle injury to Muscle Group XIX. The evidence for this period does not show cardinal signs and symptoms of muscle disability, such as loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement for the muscle group affected, or an inability to keep up with work requirements. Furthermore, although there is evidence of numerous gunshot wound scars and post-surgical scars, they were not noted during this period to be ragged, depressed and adherent scars, indicating wide damage to muscle groups in the missile track. Nor was there evidence of palpation showing loss of deep fascia or muscle substance, or soft flabby muscles in the wound area. There was no evidence that muscles of the affected area swelled or hardened abnormally in contraction or that tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side indicated severe impairment of function. There was also no X-ray evidence of a severe muscle injury. The above manifestations are contemplated under the currently assigned 30 percent rating for moderately severe disability of the abdominal region (Muscle Group XIX). 38 C.F.R. §§ 4.56, 4.72. There were also no additional symptoms to indicate severe disability, such as scattered foreign bodies due to explosive effect of a high-velocity missile, or shattering bone or open comminuted fracture. There were also no soft flabby muscles, or muscles that swelled and hardened abnormally in contraction, in the abdominal area. Further, although the Veteran had extensive abdominal scarring, it was post-surgical, and the scars were not extensive, ragged, depressed or situated as to indicate wide damage to muscle groups in the track of the missile. There was also no indication of extensive loss of deep fascia or muscle substance, but only mild atrophy noted at times, and not for muscle groups not in the track of the missile. There was also no diminished muscle excitability compared on electrodiagnostic tests for the abdominal region. Id. Separate, compensable ratings have been assigned for service-connected abdominal wound scarring. Furthermore, to the extent that the Veteran has had marked or moderately severe loss of abdominal muscle strength and endurance, these manifestations are also contemplated under the moderate disability level. There is no indication of severe impairment of strength, endurance, or coordinated movements of the abdomen. Additionally, range of motion was not implicated by the service-connected gunshot wound residuals of the abdominal region. See 38 C.F.R. §§ 4.40, 4.45. Accordingly, an individual disability rating in excess of 30 percent for GSW residuals of the right mid abdomen (MG XIX), is not warranted Period Beginning October 22, 2013 The 50 percent rating for residuals, gunshot wound, right lower abdomen with injury to Muscle Group XIX is the maximum schedular rating assignable for evaluation of Muscle Group XIX injury under Diagnostic Code 5319. Therefore, the Veteran is in receipt of the highest schedular rating available for this disability from October 22, 2013, the effective date of his 50 percent rating. A higher rating is not warranted on a schedular basis. The Board has considered whether there is any other schedular basis for granting a higher rating other than that discussed above, but has found none. In addition, the Board has considered the doctrine of reasonable doubt but has determined that it is not applicable because the preponderance of the evidence is against the claim for a higher schedular rating other than that discussed above. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.7, 4.21. Consideration under 38 C.F.R. § 3.321(b)(1) has not been specifically sought by the Veteran or reasonably raised by the facts found by the Board. As such, there is no basis for extraschedular discussion in this case. See Yancy v. McDonald, 27 Vet. App. 484, 494 (2016). ORDER Service connection for a groin injury is denied. For the period prior to October 22, 2013, a rating in excess of 30 percent for residuals, gunshot wound, right lower abdomen with injury to Muscle Group XIX, is denied. For the period beginning October 22, 2013, a rating in excess of 50 percent for residuals, gunshot wound, right lower abdomen with injury to Muscle Group XIX, is denied. REMAND The law provides that VA shall make reasonable efforts to notify a claimant of the evidence necessary to substantiate a claim and requires VA to assist a claimant in obtaining that evidence. 38 U.S.C. §§ 5103, 5103A (2012); 38 C.F.R. § 3.159 (2017). Such assistance includes providing the claimant a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on a claim. 38 U.S.C. §§ 5103, 5103A (2012); 38 C.F.R. § 3.159 (2017). Increased Rating for Residuals of a GSW to the Right Hand with Peripheral Neuropathy The Veteran is currently in receipt of a 20 percent rating for his service-connected right hand disability. This rating includes both his muscle injury and peripheral neuropathy. He was afforded VA muscle injuries, wrist, peripheral nerves, elbow and forearm and hand and finger examinations in March 2016. During his August 2017 Video Conference hearing, the Veteran testified that he was experiencing burning, numbness and severe weakness in the right hand, resulting in difficulty lifting things heavier than 10 pounds and sometimes things that weigh less than that. The Board finds that the Veteran's testimony suggests that he may be experiencing more than mild incomplete paralysis of his dominant right hand. VA's General Counsel has indicated that when a claimant asserts that the severity of a disability has increased since the most recent rating examination, an additional examination is appropriate. VAOPGCPREC 11-95 (April 7, 1995); see also Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). Given the evidence of increased symptomatology, a new VA examination is warranted to determine the current severity of the Veteran's right hand disability. Increased Rating for Scars of the Right Flank, Right Lower Abdomen, Right Mid Abdomen, Right Posterior Hip, Right Third Finger, and Right Mid-Palm The Veteran was afforded his most recent VA scar examination approximately two years ago, in March 2016. During his August 2017 Video Conference hearing, the Veteran testified that all of his service-connected scars continue to be very painful, and that the scar on his right hip periodically breaks open. He also reported that there is a depression in the right hip, possibly due to the hip scar. Accordingly, as the Veteran has reported that one of his scars is both painful and unstable, and that he has a disabling effect of his right hip scar that has not been considered, the Board finds that a new VA scar examination is warranted. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). In this regard, the Board notes that the Veteran's scars are currently evaluated as 30 percent disabling under Diagnostic Code 7804. However the Veteran could still receive higher ratings for his scars and, specifically, for any disabling effects not considered under Diagnostic Code 7804. See 38 C.F.R. § 4 118, Diagnostic Codes 7804 and 7805. In addition, Note (2) of Diagnostic Code 7804 provides that if one or more scars are both unstable and painful, the rater is to add 10 percent to the evaluation that is based on the total number of unstable or painful scars. 38 C.F.R. § 4 118, Diagnostic Code 7804, Note (2). These provisions should be taken into consideration when evaluating the Veteran's scars upon remand. TDIU The Veteran contends that he has been unemployable since August 1993 due to his service-connected disabilities. The Veteran's combined disability rating effective December 23, 2005 was 80 percent. Therefore, he has met the schedular requirements for a TDIU under 38 C.F.R. § 4.16(a) (2017) since that date. However, the Board notes that because the outcome of the claims for increased ratings for the service-connected gunshot wound to the right hand with peripheral neuropathy and scars of the right flank, right lower abdomen, right mid abdomen, right posterior hip, right third finger, and right mid-palm may have a bearing on the issue of entitlement to TDIU, any Board action on the TDIU matter would be premature. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). This also avoids piecemeal adjudication of claims with common parameters. See Ephraim v. Brown, 82 F.3d 399 (Fed. Cir. 1996). Thus, this issue must also be remanded. The appellant is advised that it is his responsibility to report for the examinations and to cooperate in the development of the case, and that the consequences of failure to report for a VA examination without good cause may include denial of the claim. See 38 C.F.R. §§ 3.158 and 3.655 (2017). Accordingly, the case is REMANDED for the following action: 1. Updated treatment records should be obtained and added to the claims folder/efolder. 2. Following completion of the above, schedule the Veteran for a VA examination to determine the current severity of his service-connected residuals of a gunshot wound to the right hand with peripheral neuropathy. Pertinent documents in the claims file, to include this remand, must be reviewed by the examiner and such review should be noted in the examination report. Any appropriate studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. The examiner should report all signs and symptoms necessary for evaluating the disability under the rating criteria. This shall include, at a minimum, description of any muscle group impairment, any limitation of motion and any nerve involvement of all potentially affected areas (wrist, hand, forearm, etc). Specifically, findings relevant to the criteria in 38 C F R §§ 4. 56, 4.71a, Diagnostic Codes 5213, 5228-30; 4.73, Diagnostic Codes 5307-5309 and Muscle Group IX must be described. Diagnostic Codes 8511-8517 (2017) shall also be considered, if applicable (Note a July 2011 VA examiner confirmed residual ulnar involvement). All results shall be reported and discussed in detail by the examiner. If muscle group impairment or nerve involvement is found, the muscle group(s) or nerve(s) affected and the severity thereof must be specifically discussed. In particular, the examiner should indicate whether the Veteran has mild, moderate, or severe incomplete paralysis or complete paralysis of the right hand. He or she should also discuss any functional impairment resulting from these disabilities. The examiner should provide a rationale for all opinions expressed. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and whether there is additional evidence that would permit the opinion to be provided. The examiner is advised that the Veteran is competent to report symptoms and injuries, as well as diagnoses provided to him by physicians. If the Veteran's reported history is discounted, the examiner should provide a reason for doing so. 3. Arrange for the Veteran to undergo an appropriate VA examination of his service connected gunshot wounds scars of the abdomen, flank, hip and hand. The claims file, to include this remand, must be reviewed by the examiner and such review should be noted in the examination report. Any appropriate studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. The examiner should indicate the location and size of any and all scars on the Veteran's (i) right hand/palm, (ii)abdomen/flank and (iii) right hip, resulting from the gunshot wound incurred in service and resulting ileocolostomy procedure. The examiner should note whether such scars are associated with underlying soft tissue damage, whether there is frequent loss of covering of the skin over the scar (i.e., unstable) or whether the scars are painful on examination. The examiner should also indicate whether there is limitation of function of the Veteran's right hand, right hip, back, trunk, and/or any other area(s) of the lower and/or upper extremities affected by the abdominal and hand scars as a result of any scar and, if so, describe such limitation in detail. The examiner should also indicate whether there are any other disabling effects, per Diagnostic Code 7805. The examiner should provide a rationale for all opinions expressed. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and whether there is additional evidence that would permit the opinion to be provided. The examiner is advised that the Veteran is competent to report symptoms and injuries, as well as diagnoses provided to him by physicians. If the Veteran's reported history is discounted, the examiner should provide a reason for doing so. 4. Finally, readjudicate the remaining claims. If any benefit sought on appeal remains denied, furnish the Veteran and his representative a supplemental statement of the case and provide an appropriate period of time to respond. The case should then be returned to the Board for further appellate review, if in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs