Citation Nr: 19119335
Decision Date: 03/19/19	Archive Date: 03/15/19

DOCKET NO. 17-36 891
 DATE:	March 19, 2019

REMANDED

Entitlement to an initial disability rating in excess of 10 percent for residual painful chest scar, secondary to diabetes and right below the knee amputation associated with diabetes is remanded.

REASONS FOR REMAND

The Veteran served on active duty from September 1968 to May 1972.  This matter came before the Board of Veterans Appeals (Board) on appeal from a January 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO).  

Entitlement to an initial disability rating in excess of 10 percent for residual painful chest scar, secondary to diabetes and right below the knee amputation associated with diabetes is remanded.

Over 5 years has elapsed since the last VA examination in December 2013.  A new examination is therefore required so that the Board can properly assess the current severity of the Veteran’s disability.  In addition, April 2016 VA treatment records note that the Veteran had the keloid scar on his chest removed in April 2016 by private plastic surgeon, Dr Perofsky.  A remand is required to allow VA to obtain authorization and request these records.

In addition, the Board notes that the December 2013 VA examination found that the Veteran’s keloid chest scar was painful but not unstable.  While the examiner noted that the scar was painful to light touch, he did not provide a similar reasoning for the finding that the scar was not unstable.  As the examiner also noted that the scar had grown and had begun having purulent drainage 2 years prior, the basis for finding the Veteran’s chest scar as not unstable is unclear to the Board.  The question of whether the Veteran’s scar has been unstable at any point during the period on appeal should therefore be specifically addressed upon remand.

The matter is REMANDED for the following action:

1. Ask the Veteran to complete a VA Form 21-4142 for Dr. Perofsky, the plastic surgeon who performed the Veteran’s April 2016 keloid scar surgery.  Make two requests for the authorized records from Dr. Perofsky, unless it is clear after the first request that a second request would be futile.

2. Schedule the Veteran for an appropriate VA examination to determine the current level of severity of his chest scar.  The examiner should review the file and provide a complete rationale for all opinions expressed.  The examiner is asked to specifically address:

(a.)  Whether the Veteran’s scar is unstable.  If the scar is found not to be unstable, the examiner should explain why.

(b.) Provide an opinion regarding the December 2013 examination finding that the scar was not unstable.  Please reconcile any opinion with the examination’s findings about the scar’s growth in size and active discharge, as well as the Veteran’s February 2014 and June 2018 lay statements regarding cracks in the scar, losing the scab twice a week while bathing, and bleeding from the scar.  

3. If upon completion of the above action the appeal remains denied, the case should be returned to the Board after compliance with appellate procedures.



 

E. I. VELEZ

Veterans Law Judge

Board of Veterans’ Appeals

ATTORNEY FOR THE BOARD	A. Arnold, Associate Counsel