Citation Nr: 20004683 Decision Date: 01/21/20 Archive Date: 01/21/20 DOCKET NO. 17-03 036 DATE: January 21, 2020 ORDER 1. Entitlement to an initial compensable rating for left tonsillar cancer, with positive lymph nodes, status post dissection, is denied. 2. Entitlement to an initial compensable rating for lymph node cancer, status post dissection, secondary to service-connected left tonsillar cancer, status post dissection, is denied. 3. Entitlement to an initial compensable evaluation prior to March 21, 2012, for papilloma of the vocal cords, status post removal, secondary to service-connected left tonsillar cancer with positive lymph nodes, status post dissection, is denied. 4. Entitlement to a 10 percent, but no higher, disability rating from March 21, 2012, for papilloma of the vocal cords, status post removal, secondary to service-connected left tonsillar cancer with positive lymph nodes, status post dissection, is granted. 5. Entitlement to initial compensable rating for xerostomia, secondary to service-connected left tonsillar cancer, status post dissection, is denied. 6. Entitlement to an initial rating in excess of 30 percent for dysphasia, secondary to service-connected left tonsillar cancer with positive lymph nodes, status post dissection, is remanded. 7. Entitlement to initial rating in excess of 30 percent for hypothyroidism, secondary to the service-connected disability of left tonsillar cancer, status post dissection, is denied. 8. Entitlement to an initial rating in excess of 10 percent for left side neck scar, secondary to service-connected left tonsillar cancer with positive lymph nodes, status post dissection, is denied. 9. Entitlement to initial rating in excess of 40 percent for paralysis of the left accessory nerve with atrophy of the left shoulder muscles, secondary to service-connected left tonsillar cancer with positive lymph nodes, status post dissection, is remanded. FINDINGS OF FACT 1. The evidence of record demonstrates that treatment was terminated more than six months prior to August 22, 2006, and there has been no local reoccurrence or metastasis of the Veteran’s left tonsillar cancer and no surgical, X-ray, antineoplastic chemotherapy, or other therapeutic procedure since that date. 2. The evidence of record demonstrates that treatment was terminated more than six months prior to August 22, 2006, and there has been no local reoccurrence or metastasis of the Veteran’s cancer of the lymph nodes and no surgical, radiation, antineoplastic chemotherapy, or other therapeutic procedure since that date. 3. Prior to March 21, 2012, the Veteran’s papilloma of the vocal cords was manifested by occasional or infrequent hoarseness, occurring only with the occurrence of papillomas on his vocal cords and immediately following treatment for those papillomas; it was not manifested by symptoms more closely approximate to hoarseness with inflammation of cords or mucous or symptoms equivalent to hoarseness with thickening or nodules or cords, polyps, submucous infiltration, or pre-malignant changes on biopsy. 4. From March 21, 2012, the Veteran’s papilloma of the vocal cords was manifested by symptoms equivalent to hoarseness with inflammation of cords or mucous but not symptoms equivalent to hoarseness with thickening or nodules or cords, polyps, submucous infiltration, or pre-malignant changes on biopsy. 5. The Veteran’s xerostomia was manifested by a dry mouth, without complete loss of taste. 6. The Veteran’s hypothyroidism was manifested by fatiguability, constipation, and occasional cold intolerance, but without associated weight gain, muscular weakness, mental disturbance, cardiovascular involvement, and bradycardia. 7. For the period on appeal, the Veteran had one left side neck scar, with one characteristic of disfigurement, that was neither painful or unstable, or resulted in limitation of function. CONCLUSIONS OF LAW 1. The criteria for an initial compensable rating for left tonsillar cancer have not been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.97, Diagnostic Code 6819 (2018). 2. The criteria for an initial compensable rating for cancer of the lymph nodes have not been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.117, Diagnostic Code 7715 (2018). 3. Prior to March 21, 2012, the criteria for an initial compensable rating for papilloma of the vocal cords, status post removal, secondary to service-connected left tonsillar cancer with positive lymph nodes, status post dissection, were not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.3, 4.7, 4.97, Diagnostic Code (DC) 6516 (2018). 4. From March 21, 2012, the criteria for a 10 percent disability rating for papilloma of the vocal cords, status post removal, secondary to service-connected left tonsillar cancer with positive lymph nodes, status post dissection, were met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.3, 4.7, 4.97, Diagnostic Code (DC) 6516 (2018) 5. The criteria for a compensable evaluation for xerostomia, secondary to service-connected left tonsillar cancer, status post dissection, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, § 4.114, Diagnostic Code 7200 (2018). 6. The criteria for an initial disability rating in excess of 30 percent for hypothyroidism, secondary to the service-connected disability of left tonsillar cancer, status post dissection, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § § 4.1, 4.3, 4.119, Diagnostic Code 7903. 7. The criteria for an initial rating in excess of 10 percent for left side neck scar, secondary to service-connected left tonsillar cancer with positive lymph nodes, status post dissection have not been satisfied. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.118, Diagnostic Code 7800 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1961 to September 1965. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Des Moines, Iowa, which initially denied the Veteran’s claim for throat cancer. The Veteran filed a timely notice of disagreement (NOD) with the July 2007 rating decision, and in a July 2012 rating decision, the RO again denied the Veteran’s claim. The Veteran again submitted a NOD with the rating decision in November 2012 and December 2012 written correspondences. In January 2014, the RO, finding clear and unmistakable error with the prior rating decisions, granted service connection for left tonsillar cancer with positive lymph nodes, status post dissection, providing a noncompensable evaluation effective August 22, 2006, the date of the Veteran’s initial claim. Additionally, the RO granted service connection, assigning separate ratings, for disabilities associated with Veteran’s left tonsillar cancer. In April 2019, the Veteran appeared with his representative for a videoconference hearing before the undersigned. A transcript of the hearing is of record. Initially, the Board acknowledges that the Veteran contends that, should his combined disabilities not amount to a 100 percent disability rating, he should be awarded a grant of total disability based on individual unemployability due to service-connected disabilities (TDIU). The Board notes that a TDIU was denied in an appealed June 2014 rating decision. Thus, while the Board acknowledges that he raised TDIU as an alternative for his desired ratings, the Veteran did not appeal TDIU and this issue is not currently before the Board. Additionally, at his April 2019 Board hearing, the Veteran, through his representative, indicated that his VA examination was inadequate because the examiner seemingly did not review the Veteran’s medical history; rather, the assessments were made based solely upon examination of the Veteran. However, although the representative did not indicate which examination was inadequate, the Board will assume each of the October 2016 examinations are at issue, as each was conducted by the same VA examiner. The Board notes that the most relevant evidence for increased rating claims is the information concerning the current level of the disability. See Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board finds each of these examinations are adequate. Each examination indicates that the Veteran’s claim folder, VA treatment records, and lay statements were reviewed. Additionally, the examiner was a qualified medical professional. As the Veteran has not pointed to any relevant deficiency in the examination, the Board finds that VA’s duty to assist with respect to obtaining a VA examination or opinion, has been met. 38 C.F.R. § 3.159(C)(4) (2018). Finally, new evidence has been received since the issuance of the supplemental statement of the case (SSOC) in October 2016. The Board observes that that section 501 of the Honoring America’s Veterans and Caring for Camp Lejeune Families Act of 2012, Public Law (PL) 112-154, which amends 38 U.S.C. § 7105 by adding paragraph (e), has addressed new procedures for claims in which new evidence was received after the last supplemental statement of the case (SSOC) without a waiver of AOJ consideration. Under that provision, if new evidence is submitted with or after a Substantive Appeal received on or after February 2, 2013, then it is subject to initial review by the Board unless the Veteran explicitly requests AOJ consideration. Therefore, such claims should not be remanded solely for consideration of such new evidence without a request from the Veteran. In this case, the Veteran’s appeal was perfected after the February 2, 2013 date, and thus, this provision is applicable to the instant case. However, VA has not interpreted the aforementioned amendment to extend to evidence that was not submitted by the Veteran, such as evidence that was suggested by a submission, but gathered separately pursuant to the duty to assist. After a review of the record, it appears that, after the issuance of the last SSOC in October 2016, the RO independently developed evidence that is relevant to the Veteran’s claim by virtue of a July 2019 VA peripheral neuropathy examination. This examination report discusses the current level of severity of the Veteran’s left shoulder injury. Furthermore, additional VA treatment records dated through July 2019 show treatment for the Veteran’s dysphagia and range of motion testing for the Veteran’s left shoulder. As such, the Board finds that the July 2019 VA peripheral neuropathy examination report and VA treatment records dated through July 2019 are pertinent to the Veteran’s claims for increased ratings for his dysphasia and paralysis of the left accessory nerve with atrophy of the left shoulder muscles, and a waiver of AOJ consideration has not been received. Thus, with regard to these issues, a new SSOC must be issued. However, with regard to the remaining issues on appeal, the Board finds that the newly obtained evidence, which was not submitted by the Veteran, is either duplicative or not relevant to the issues on appeal. 38 C.F.R. 20.1304(c). Accordingly, the Board may proceed with the adjudication of the remaining issues as a SSOC is not required. This appeal has been advanced on the Board’s docket pursuant to 38 U.S.C. § 7107 (a)(2) (2012); 38 C.F.R. § 20.900 (c) (2018). 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 ratings 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. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more closely approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When a reasonable doubt arises regarding the degree of disability, that reasonable doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. The regulations preclude the assignment of separate ratings for the same manifestations under different diagnoses. The critical element is that none of the symptomatology for any of the conditions is duplicative of or overlapping with symptomatology of the other conditions. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259 (1995). 1. Left Tonsillar Cancer and Cancer of the Lymph Nodes The Veteran is currently in receipt of a noncompensable rating for left tonsillar cancer, with positive lymph nodes, status post dissection pursuant to Diagnostic Code (DC) 6899-6819. The “99” denotes that his disability is rated by analogy because left tonsillar cancer is an unlisted condition. Diagnostic Code 6819 pertains to malignant neoplasms of the respiratory system. Thus, the Veteran’s left tonsillar cancer has been rated by analogy as malignant neoplasms of the respiratory system. See 38 C.F.R. § 4.114, Diagnostic Code 7346. Additionally, the Veteran’s service-connected cancer of the lymph nodes, status post dissection, associated with his left tonsillar cancer has been rated by analogy as non-Hodgkin’s lymphoma under Diagnostic Code 7715 and has been assigned a noncompensable evaluation. See 38 C.F.R. § 4.117. Pursuant to Diagnostic Code 6819, a 100 percent evaluation shall be assigned for malignant neoplasms of the respiratory system while treatment is ongoing. However, following the cessation of surgical, X-ray, antineoplastic chemotherapy, or other therapeutic procedure, the rating of 100 percent shall continue with a mandatory VA examination at the expiration of six months. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of 38 C.F.R. § 3.105(e). If there has been no local reoccurrence or metastasis, then the Veteran’s cancer is rated based on residuals. 38 C.F.R. § 4.97. Additionally, a 100 percent rating is assigned under DC 7715 for non-Hodgkin’s lymphoma with active disease or during a treatment phase. A Note following DC 7715 provides: the 100 percent rating shall continue beyond the cessation of any surgical, radiation, antineoplastic chemotherapy or other therapeutic procedures. Six months after discontinuance of such treatment, the appropriate disability rating shall be [determined] by mandatory VA examination. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of [38 C.F.R.] § 3.105(e). The Note following DC 7715 finally provides that non-Hodgkin’s lymphoma should be rated on its residuals if there has been no local recurrence or metastasis of the disease. 38 C.F.R. § 4.117. The record reflects that the Veteran was diagnosed with tonsillar cancer in April 2001 and underwent a tonsillectomy, neck dissection for squamous cell carcinoma of the left tonsil and five of 14 lymph nodes. Medical treatment records reflect that he received subsequent radiation therapy for approximately 8 weeks in 2001. The evidence does not reflect, nor does the Veteran contend, that carcinoma has reoccurred. A June 2007 VA examination indicates that the Veteran reported a diagnosis of squamous cell carcinoma, leading to a left neck dissection. The Veteran reported that approximately five of the 15 nodes obtained on the left side of the neck were positive for squamous cell carcinoma. The Veteran indicated that he subsequently underwent seven weeks of radiation therapy, and he had been cancer-free for seven years. An October 2016 VA examination indicates that the Veteran completed treatment for a malignant neoplasm in 2001, which included surgery and radiation of tonsillar squamous cell carcinoma with left neck dissection of positive nodes. Initially, the Board notes that the Veteran filed his claim for service connection for left tonsillar cancer with cancer of the lymph nodes, claimed as throat cancer, on August 22, 2006. See 38 U.S.C. § 5110 (b); 38 C.F.R. § 3.400 (b)(2). There is no dispute regarding the effective date for the grant of service connection for these disabilities. Thus, the Veteran’s treatment was terminated more than six months prior to the date of his initial claim. After a review of the evidence, the Board finds that entitlement to a compensable evaluation for left tonsillar cancer, with positive lymph nodes, status post dissection is not warranted. In this regard, the Board notes that a compensable evaluation under Diagnostic Code 6819 is warranted for malignant neoplasms of the respiratory system while treatment is ongoing. Thus, as the evidence reflects that the Veteran completed treatment for his left tonsillar cancer in 2001, and there has been no local reoccurrence or metastasis noted, a higher evaluation is not warranted under Diagnostic Code 6819. 38 C.F.R. § 4.97. Moreover, a compensable evaluation for cancer of the lymph nodes is not warranted under DC 7715. The evidence reflects that the Veteran had five lymph nodes which were positive for carcinoma; however, after removal of these lymph nodes followed by treatment in 2001, there was no local recurrence or metastasis of the disease. See 38 C.F.R. § 4.117. Therefore, a higher evaluation is not warranted for cancer of the lymph nodes. For the period on appeal, the medical and lay evidence of record reflects that the Veteran’s left tonsillar cancer, which was positive for cancer of the lymph nodes, caused recurrent vocal cord papillomas, xerostomia, a left side neck scar, hypothyroidism, dysphasia, and left shoulder accessory nerve atrophy. As the RO has assigned additional ratings in consideration of these residuals, which will be addressed separately below, the Board finds that the Veteran’s current noncompensable ratings for both his left tonsillar cancer and cancer of the lymph nodes are appropriate. See 38 C.F.R. §§ 4.97, 4.117, DC 6819, 7715. The evidence of record does not indicate any additional residuals of left tonsillar cancer, with positive lymph nodes, during this period for which the Veteran is not already receiving a disability rating; therefore, additional disabilities ratings are not warranted for this period. However, the Board notes that the Veteran has raised additional symptoms associated with the aforementioned residuals, which will be addressed in detail below. 2. Papilloma of the Vocal Cords The Veteran claims that he entitled to an increased evaluation for his service-connected papilloma of the vocal cords. Specifically, at his hearing, the Veteran indicated that his voice has worsened since 2006. The Veteran’s papilloma of vocal cords has been rated by analogy as most equivalent to chronic laryngitis, pursuant to 38 C.F.R. § 4.97, Diagnostic Code 6516, and assigned a noncompensable evaluation, effective August 2006, and a 10 percent disability rating, effective August 2012. Under Diagnostic Code 6516, chronic laryngitis manifested by hoarseness with inflammation of cords or mucous membrane is rated as 10 percent disabling and chronic laryngitis manifested by hoarseness, with thickening or nodules of cords, polyps, submucous infiltration or pre-malignant changes on biopsy is rated as 30 percent disabling. The 30 percent rating is the maximum rating under this Diagnostic Code. 38 C.F.R. § 4.97, Diagnostic Code 6516. Under Diagnostic Code 6519, complete organic aphonia with constant inability to speak above a whisper is rated as 60 percent disabling, and the constant inability to communicate by speech warrants a 100 percent rating. 38 C.F.R. § 4.97, Diagnostic Code 6519. Incomplete aphonia is to be evaluated as laryngitis, chronic, under Diagnostic Code 6516. Initially the Board notes that the Veteran is separately service connected for a deviated septum, pursuant to Diagnostic Code 6502, and an associated facial scar, under Diagnostic Code 7800; as these issues are not currently on appeal, the Board will not address whether increased evaluations are warranted for these disabilities. A June 2007 VA examination indicates that the Veteran reported a diagnosis of squamous cell carcinoma, leading to a left neck dissection and followed by seven weeks of radiation therapy. He indicated that he underwent approximately four surgical corrections for this and subsequently approximately three laser treatments. The last laser treatment was in May 2006. Due to these difficulties, the Veteran reported that he had a somewhat quieter voice but is able to converse comfortably, and the examiner noted that the Veteran was able to talk in a normal volume. Medical treatment records reflect that, following his September 2009 papilloma removal, it took approximately one month for the Veteran to get his voice back; in January 2011, a medical treatment record notes that the Veteran’s voice was good, and it had strength behind it; the Veteran indicated that he was able to yell if needed, which he was unable to do before. A March 21, 2012 treatment record indicates that the Veteran reported issues with hoarseness, and an August 2012 treatment record notes that the Veteran reported chronic, but stable, hoarseness of his voice. A September 2014 medical record notes that the Veteran had mild hoarseness and a raspy voice quality. A January 2015 medical record notes that the Veteran had difficulty with his voice. Following a papilloma removal in September 2015, a January 2016 medical treatment record indicates that the Veteran was healing well, and his voice was coming back slowly. An October 2016 VA examination notes that the Veteran reported that treatment for recurrent papilloma of the vocal cords has recently been with laser treatments; the most recent laser treatment for this condition was on October 22, 2015. The Veteran reported that as the papillomas enlarge, the hoarseness of the voice worsens and the volume of his voice decreases. The Veteran indicated that approximately every year to year and a half, he needs treatment for the vocal cord papillomas. Upon evaluation, the examiner indicated that the Veteran had incomplete organic aphonia, manifested by constant hoarseness, which worsens when papillomas reoccur, and recurrent clearing of throat and coughing. The examination notes that the Veteran underwent the removal of a laryngeal papilloma in October 2015; the Veteran reported that it was a benign, recurrent papilloma. The Veteran reported functional impact in the form of progressive difficulty with speaking to the point that he is unable to speak when the papillomas occur; then after treatment, there is about a three-week time period until he can talk again at a normal volume. Additionally, the Veteran reported that he has to constantly clear his throat and may cough or hack often. After a review of the evidence, the Board finds that the Veteran’s symptoms associated with his service-connected papilloma of the vocal cords more closely approximate a noncompensable rating for the period prior to March 21, 2012 and a 10 percent disability rating thereafter. The evidence prior to March 21, 2012, although noting some hoarseness immediately before and after treatment for his papilloma of the vocal cord in September 2009, shows that his voice was generally unaffected. Indeed, the January 2011 record notes that his voice was strong and he was able to yell if needed. Moreover, the evidence reflects, and the Veteran confirmed, that his voice would worsen when the papillomas would recur and for a few weeks following treatment; however, during this period, the evidence reflects that the Veteran only had one recurrence of a papilloma in 2009. Accordingly, the Board finds that the evidence of record during this period does not demonstrate that the Veteran’s papilloma of the vocal cords more nearly approximated a manifestation of hoarseness with inflammation of cords or mucous membrane. Therefore, the Board finds that a compensable rating is not warranted for the period prior to March 21, 2012. The Board finds that earliest evidence of record of worsening of the Veteran’s voice was March 21, 2012, which indicated a report of hoarseness, and was followed by subsequent ongoing complaints of hoarseness. Therefore, affording the Veteran the benefit of the doubt, the Board finds that a 10 percent disability rating is warranted for the period beginning March 21, 2012. Diagnostic Code 6516, 38 C.F.R. § 4.97. A higher rating under Diagnostic Code 6516 is not warranted. There is no probative evidence of record, nor does the Veteran contend, that his papilloma of the vocal cords was manifested by thickening or nodules of cords, polyps, submucous infiltration or pre-malignant changes on biopsy. Indeed, the evidence of record reflects that the Veteran received treatment only for the recurrence of benign papillomas on his vocal cords, and the medical evidence of record does not otherwise suggest that these benign papillomas amounted to nodules of the cords or polyps. Id. Moreover, the Board finds that a separate rating is not warranted under Diagnostic Code 6519. In this regard, the Board notes that although there were intermittent complaints of hoarseness immediately preceding and following treatment for papillomas on his vocal cords, as previously indicated, the evidence reflects that the Veteran spoke at a normal volume and did not have difficulty conversing. Thus, there is no indication that the Veteran experienced the constant inability to speak above a whisper at any time during the period on appeal. Therefore, a separate rating under Diagnostic Code 6519 is not warranted any time during the period on appeal. 38 C.F.R. § 4.97. The Board acknowledges the Veteran’s contention that he has experienced a worsening of his voice, manifested by hoarseness, since 2006, and his papillomas reoccur every year or two; however, the Board notes that the Veteran’s currently assigned noncompensable rating prior to March 21, 2012 and 10 percent disability rating thereafter reflect such worsening and treatment. 38 C.F.R. § 4.97, Diagnostic Code 6516. While the Board is sympathetic to the Veteran’s claim, taking into consideration all of the relevant evidence of record, including the need for potential ongoing laser treatments for his papillomas of the vocal cords, there is no basis upon which to award higher evaluations under the rating criteria for his papilloma of the vocal cords. 3. Xerostomia The Veteran contends that he is entitled to a compensable evaluation for his dry mouth as a result of potentially associated problems such as problems swallowing, communicating, gum disease, and dental problems. Additionally, at his Board hearing, the Veteran reported problems with constipation and that he lost his ability to taste and smell as a result of his dry mouth. Initially, the Board notes that the Veteran is already receiving a separate disability rating for his difficulty swallowing and, as indicated above, papilloma of the vocal cords with hoarseness, which includes effects on his ability to communicate due to hoarseness and volume. Additionally, as will be addressed below, constipation is considered under the rating criteria for the Veteran’s service-connected hypothyroidism. Therefore, the Board will not address these symptoms as they may relate to the Veteran’s xerostomia. Assigning other ratings based on the same symptoms that are already accounted for would be tantamount to pyramiding. 38 C.F.R. § 4.14. However, the rest of the Veteran’s contentions will be addressed in more detail below. The Veteran is currently in receipt of a noncompensable rating for his xerostomia or dry mouth pursuant to Diagnostic Code 7200, for injuries of the mouth based on impairment in function of mastication. 38 C.F.R. § 4.114. Medical treatment records consistently note that the Veteran suffers from a very dry mouth. However, the evidence throughout the period on appeal does not indicate any difficulty with regards to chewing food; nor does the medical evidence of record provide any indication that the Veteran has any decrease or loss of the sense of taste or smell. An October 2016 VA examination indicates that the Veteran reported that he tried medications to treat his dry mouth, but they did not help; the only thing that helped was to frequently drink water, but then, he had to use the restroom about every hour during the day and more often at night. The Veteran reported having fillings on many teeth due to teeth crumbling due to the xerostomia. The Veteran also attributes the dysphagia to the lack of salivation. The hoarse voice, the cough, and the hacking all worsen with dry mouth and worsen the more he talks. The Veteran reports that he has a hoarse voice all the time. Upon examination, the examiner noted that the Veteran had dryness of mucous membranes in mouth. After a review of the evidence, the Board finds that a compensable rating is not warranted for the Veteran’s dry mouth under Diagnostic Code 7200. In this regard, the Board notes that there is no evidence of record, nor does the Veteran claim, that he has any impairment in his ability to chew his food. 38 C.F.R. § 4.114, Diagnostic Code 7200. The Board has also considered whether separate ratings are warranted for the Veteran’s dry mouth, to include his claimed gum and dental problems and loss of sense of taste and smell. However, the Board finds that there is no probative evidence of record warranting any additional ratings for the claimed symptoms. With regard to his dental treatment, the Board notes that the Veteran’s medical treatment records note that he is indeed missing teeth, and he desired to have his partial modified so that he could wear it more comfortably but was informed that the mandibular teeth have shifted such that there was no longer space for a prostheses on the maxillary arch between the missing teeth. Additionally, the records note that he has slight horizontal bone loss and chronic generalized slight gingivitis. However, there is no indication in the record that any of his dental problems are due to his service-connected xerostomia or other service-connected disability. While the Veteran is competent to report having experienced dental problems, he is not competent to determine that he is currently experiencing any symptoms of a dental disorder that are attributable to a service-connected disability. The issue is medically complex, as a competent opinion as to etiology require medical training and credentials. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Additionally, although the Veteran testified at his Board hearing that he was told that he could not receive certain types of dental care due to receiving prior radiation treatment, the Board notes that this is not in itself a dental disorder for which compensation is payable. See 38 C.F.R. § 4.150, DCs 9900-9916. With regard to the Veteran’s reports that he has lost his ability to taste and smell, the Board finds that a separate rating is not warranted under Diagnostic Code 6276 (taste) or Diagnostic Code 6275 (smell). The probative and competent evidence does not establish the Veteran has a complete loss of sense or taste at any time during the appeal period. Although the Board acknowledges that a treatment record dated in July 2001 indicates that his sense of taste was “off” and a November 2002 record notes a complaint of decreased taste, none of the VA treatment records throughout the period on appeal reflect subjective complaints or clinical findings of a complete loss of taste or smell. The Veteran did not report these symptoms at VA examinations and the VA examiners also did not identify a complete loss of sense of taste or smell during any of the examination reports discussed above. Although the Veteran is competent to report observable symptoms, he is not competent to provide diagnoses. See Jandreau, 492 F.3d at 1377. As such, the Board finds that the medical evidence of record outweighs the Veteran’s assertions and separate ratings are not warranted under Diagnostic Codes 6275 or 6276. Accordingly, the Board finds that an initial compensable evaluation for the Veteran’s xerostomia is not warranted at any time during the period on appeal. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. § 5107. 4. Hypothyroidism The Veteran is currently in receipt of a 30 percent disability rating for his hypothyroidism under Diagnostic Code 7903, effective August 2006. The Veteran’s current evaluation was assigned under the prior version of Diagnostic Code 7903. When the regulation changes during an appeal, the Veteran is entitled to resolution of the claim under the criteria more advantageous. The old criteria can apply to the entire appeal period, but new criteria can only apply as to the effective date of the change. The Board has evaluated the disability under the old criteria both prior to and from December 10, 2017, and under the new criteria as well from December 10, 2017. That prior version of Diagnostic Code 7903 provided a 10 percent rating for hypothyroidism manifested by fatigability, or continuous medication is required for control. A 30 percent rating was warranted for fatigability, constipation, and mental sluggishness. A 60 percent rating was warranted for muscular weakness, mental disturbance, and weight gain. A 100 percent rating was warranted for cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance (dementia, slowing of thought, depression), bradycardia (less than 60 beats per minute), and sleepiness. 38 C.F.R. § 4.119, Diagnostic Code 7903. The current version of the criteria, effective December 10, 2017, provide that a 100 percent rating is assigned for hypothyroidism manifesting as myxedema (cold intolerance, muscular weakness, cardiovascular involvement (including, but not limited to hypotension, bradycardia, and pericardial effusion), and mental disturbance (including, but not limited to dementia, slowing of thought and depression)) for a period of six months after an examiner has determined the condition is stabilized. Thereafter, the residual effects of hypothyroidism are rated under the appropriate diagnostic code(s) within the appropriate body system(s) (e.g., eye, digestive, and mental disorders). For hypothyroidism without myxedema, a 30 percent rating is assigned for six months after initial diagnosis. Thereafter, residuals of disease or medical treatment, to include eye conditions, are rated under the most appropriate diagnostic code(s) under the appropriate body system (e.g., eye, digestive, mental disorders). 38 C.F.R. § 4.119, Code 7903. As the evidence of record does not reflect that the Veteran has myxedema, and as the Veteran was first diagnosed with hypothyroidism in approximately 2004, the Veteran is not entitled to a higher initial disability rating under the new rating criteria; therefore, the remainder of the decision will address whether a higher initial disability rating was warranted under the prior rating criteria. The Court has addressed the specific application of the rating criteria for Diagnostic Code 7903 and found that all the symptoms listed for a particular disability rating were not required to be demonstrated in order to establish entitlement to a higher disability rating. See Tatum v. Shinseki, 23 Vet. App. 152, 155 (2009). The Court noted that symptoms that meet some of the rating criteria should be considered in light of 38 C.F.R. § 4.7 and resolved based on the evidence of record. The Court also stated that the rating criteria for Diagnostic Code 7903 are not successive. Tatum, 23 Vet. App. at 155. A claimant could potentially establish all the criteria required for a 30 percent or 60 percent rating without establishing any of the criteria for a lesser disability rating. Id. at 156. Initially, the Board notes that the Veteran is already receiving a separate disability rating for posttraumatic stress disorder with secondary anxiety and alcohol abuse, which has considered symptoms of depression, and paralysis of the left accessory nerve with atrophy of the left shoulder, which has considered muscle weakness of the left shoulder. Therefore, the Board will not address these symptoms as they may relate to the Veteran’s hypothyroidism. Assigning other ratings based on the same symptoms that are already accounted for would be tantamount to pyramiding. 38 C.F.R. § 4.14. A February 2008 medical treatment record notes that the Veteran denied any constipation or excess fatigue. A January 2010 medical treatment record notes that the Veteran was prescribed medication for treatment of his hypothyroidism; he denied fatigue and cold intolerance. A March 2011 VA environmental registry examination notes that the Veteran’s hypothyroidism was treated with medication, and he experienced symptoms of cold intolerance. No heart or gastrointestinal symptoms or functional impact was noted. An October 2012 medical treatment record notes that the Veteran denied experiencing any cold intolerance or constipation. An October 2016 VA examination for hypothyroidism indicates that the Veteran reported that he felt “run down” if he did not take his medication daily, and he began experiencing constipation following treatment for tonsillar cancer. The examination indicates that the Veteran’s medical treatment records note constipation as early as 2004 and current treatment, as well as current prescribed medication for hypothyroidism. The examiner noted that the Veteran experienced fatigability and constipation due to his hypothyroidism. No other pertinent physical findings, complications, conditions, signs, or symptoms were noted. The examination indicates that the Veteran’s hypothyroidism impacted his ability to work only in that, without his thyroid medication, he felt “run down.” After a careful review of all the evidence, both lay and medical, the Board finds that the symptoms associated with the service-connected hypothyroidism more nearly approximate the criteria for a 30 percent rating under the former DC 7903 for the entire initial period on appeal. In this regard, the Board notes that the evidence reflects that the Veteran experienced, albeit inconsistently, symptoms of constipation and fatigue, and he required the use of continuous medication for treatment. The Board finds that the evidence does not more nearly approximate the 60 percent criteria because symptoms such as muscular weakness and mental disturbance have not been attributable to hypothyroidism, nor has the Veteran experienced weight gain. Further, the Board finds that the evidence does not more nearly approximate the 100 percent criteria because, despite the March 2011 VA environmental registry examination noting cold intolerance, cardiovascular involvement and bradycardia have not been shown at any point during the period on appeal; nor does the evidence indicate that the Veteran has any muscular weakness or mental disturbance separate and distinct from symptoms that have already been considered under other service-connected disabilities. Therefore, the Board finds that a rating in excess of 30 percent for the Veteran’s service-connected hypothyroidism is not warranted for the period on appeal. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. § 5107. 5. Scar on Neck The Veteran is currently in receipt of a 10 percent disability rating for his scar on the left side of his neck associated with his left tonsillar cancer, status post dissection, pursuant to Diagnostic Code 7800, applicable to burn scar(s) of the head, face, or neck; scar(s) of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck. 38 C.F.R. § 4.118. In evaluating skin and scar residuals, the Board notes that during the appeal period, changes were made to certain diagnostic codes under 38 C.F.R. § 4.118. Effective August 13, 2018, VA amended its regulations governing skin disabilities. VA’s intent is that the claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the Veteran will be applied. For applications filed on or after the effective date, only the new criteria will be applied. 83 Fed. Reg. 32592 (July 13, 2018). However, Diagnostic Code 7800 was not revised by the recent regulatory amendments. Under DC 7800, a 10 percent rating is warranted for a scar with one characteristic of disfigurement. A 30 percent rating is warranted for a scar with 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 for a scar with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement. An 80 percent rating is warranted for a scar with visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement. There are eight characteristics of disfigurement, including: a scar 5 or more inches (13 or more cm.) in length, scar at least one-quarter inch (0.6 cm.) wide at its widest part, surface contour of scar elevated or depressed on palpation, scar adherent to underlying tissue, skin hypo-or hyperpigmented in an area exceeding six square inches (39 sq. cm), skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches, underlying soft tissue missing in an area exceeding six square inches, and skin indurated and inflexible in an area exceeding six square inches. See 38 C.F.R. § 4.118, DC 7800, Note (1). The characteristic(s) of disfigurement may be caused by one scar or by multiple scars; the characteristic(s) required to assign a particular evaluation need not be caused by a single scar in order to assign that evaluation. Id., Note (5). A January 2010 medical record notes only that the Veteran had a surgical scar on his neck. A March 2011 treatment record notes that the Veteran had a scar on left anterior neck measuring 14 cm by .2 cm; it was linear, non-tender, and there was no adhesion or ulcerations. An October 2016 VA examination indicates that the Veteran had one scar on the left, anterior neck, measuring 10 cm x 0.2 cm. The examination notes that there was decreased sensation of the left ear lobe and scar of the left side of the neck; specifically, the Veteran indicated that he may nick his left ear when he shaving and not feel it. The examiner noted that the scar was neither painful or unstable, but the scar did have hypopigmentation measuring 2 square centimeters. No functional impact or decreased range of motion was noted as a result of the Veteran’s let side neck scar. In a December 2016 correspondence, the Veteran reported numbness and tightness associated with his neck scar, and he indicated that due to the tightness, his ability to turn his head to the left was impaired. After a review of the evidence of record, the Board finds that a rating in excess of 10 percent for the Veteran’s service-connected left side neck scar is not warranted any time during the period on appeal under Diagnostic Code 7800. Throughout the period on appeal, the evidence reflects that the Veteran had one neck scar, measuring, at most, 14 centimeters long and .2 millimeter wide. Thus, as the Veteran’s scar is five inches or more in length, this is indicative of one characteristic of disfigurement. There is no indication in the record that his neck scar had visible or palpable tissue loss and either gross distortion or asymmetry of one or more feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or more characteristics of disfigurement. In this regard, although the October 2016 VA examination notes that the Veteran’s neck scar had hypopigmentation, it did not measure six square inches. Accordingly, a rating in excess of 10 percent for the Veteran’s neck scar under Diagnostic Code 7800 is not warranted. See 38 C.F.R. § 4.118. The Board has considered whether other ratings are applicable to the Veteran’s left side neck scar. A disability rating under Diagnostic Codes 7801 or 7802 for nonlinear scars is not warranted because the Veteran’s scar was not at least 6 square inches, as noted for a 10 percent rating under DC 7801, or at least 144 square inches, as noted for a 10 percent rating under DC 7802. Additionally, as the Veteran’s scar was neither painful or unstable, a disability rating under DC 7804 is not warranted. The Board acknowledges that the Veteran has indicated that his ability to turn his head to the left has been impaired due to his scar. Although the Board recognizes that the Veteran is competent to report any difficulties with turning his head to the left, the Board does not find that he is competent to render an opinion as to the cause of such impairment, particularly because, in this case, the Veteran is also service-connected for a left shoulder disability affecting his muscles. Therefore, the Board finds that the medical evidence of record, which does not indicate any additional disabling effects of his left neck scar, outweighs the Veteran’s assertions. Accordingly, the Board finds that an increased rating under Diagnostic Code 7805 is also not warranted. See 38 C.F.R. § 4.118, Diagnostic Code 7805. Therefore, the Board finds that a rating in excess of 10 percent for the Veteran’s left side neck scar is not warranted for the period on appeal. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. § 5107. REASONS FOR REMAND As indicated above, after the issuance of the last SSOC in October 2016, the RO independently developed evidence that is relevant to the Veteran’s claim in the form of a July 2019 VA peripheral neuropathy examination and associating additional VA treatment records dated through July 2019 with the Veteran’s claims file, which note treatment for the Veteran’s dysphagia and range of motion testing for the Veteran’s left shoulder. The Board finds that the July 2019 VA peripheral neuropathy examination report and VA treatment records dated through July 2019 are pertinent to the Veteran’s claims for increased ratings for his dysphasia and paralysis of the left accessory nerve with atrophy of the left shoulder muscles. The Veteran did not submit the evidence in question. Rather, this evidence was developed by VA in connection with other claims. The appellate scheme set forth in 38 U.S.C. § 7104(a) contemplates that all evidence will first be reviewed at the RO so as not to deprive the claimant of an opportunity to prevail with his claim at that level. See generally Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). When the agency of original jurisdiction (AOJ) receives evidence relevant to a claim properly before it that is not duplicative of evidence already discussed in the statement of the case (SOC) or a supplemental statement of the case (SSOC), it must prepare a SSOC reviewing that evidence. 38 C.F.R. § 19.31(b)(1). As such, in order to afford the Veteran his full procedural rights, on remand, the AOJ must consider and address all of the evidence of record including the July 2019 VA peripheral neuropathy examination and updated VA treatment records in an appropriate SSOC. See 38 C.F.R. § 19.31. Additionally, with regard to the Veteran’s claim for an increased evaluation for his service-connected dysphagia, the Veteran contends that he has experienced weight loss and is now on a liquid only diet due to his difficulty swallowing. The medical evidence of record reflects fluctuation in the Veteran’s weight over the course of the appeal period but generally demonstrates that the Veteran has indeed lost weight. Moreover, a January 17, 2018 treatment record notes that the Veteran indicated that he desired to gain approximately 10 to 15 pounds, but he was having difficulty gaining weight. A nutrition diagnosis provided that the Veteran had severe malnutrition in the context of chronic disease related to alteration in gastrointestinal function; specifically, achalasia and dysphagia, and previous inadequate protein intake and early satiety. His food intake was noted as including four cans of a liquid meal supplement, a “Mass Gainer” product in his drinks, small dishes of soups, and very soft foods such as mashed potatoes and gravy, mashed up spaghetti or pasta with lots of sauce. In light of this new evidence, a remand is necessary to afford the Veteran new VA examination for his service-connected dysphagia to determine the current level of severity. The matter is REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the current level of severity of his service-connected dysphagia. The electronic claims file must be made available to the examiner for review in conjunction with the examination. The examiner should describe the severity, frequency, and duration of all symptoms associated with the Veteran’s disability. The examiner should also consider all of the evidence of record, including the Veteran’s lay statements, and specifically addressing whether the Veteran’s weight loss is associated with his dysphagia. 2. The Veteran’s claims related to dysphagia and paralysis of the left accessory nerve with atrophy of the left shoulder muscles should be readjudicated in a new SSOC based on the entirety of the evidence, to include the requested examination for dysphagia, the July 2019 VA peripheral neuropathy examination report, and VA treatment records received since the issuance of the October 2016 SSOC. Thomas H. O'Shay Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Hite, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.