Citation Nr: 20021572 Decision Date: 03/26/20 Archive Date: 03/26/20 DOCKET NO. 19-36 817 DATE: March 26, 2020 ORDER A rating in excess of 10 percent for a scar on the nose/disfigurement is denied. REMANDED The claim for a compensable rating for a heart condition (idiopathic premature ventricular contractions with bradycardia) is remanded. FINDING OF FACT The Veteran’s scar condition on his nose is not shown to have at least two characteristics of disfigurement and did not cause visible or palpable tissue loss or gross distortion or asymmetry of his face. CONCLUSIONS OF LAW The criteria for a rating in excess of 10 percent for a scar on the nose are not meet. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7800. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from November 1977 to March 1998. The scar on the Veteran’s nose is rated under DC 7800, which provides that: a 10 percent rating is assigned for scars with one characteristic of disfigurement; A 30 percent rating is assigned for scars 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 assigned for scars 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; and An 80 percent rating is assigned for scars 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. 38 C.F.R. § 4.118, DC7800. Note 1 to Diagnostic Code 7800 list the eight characteristics of disfigurement: (1) a scar 5 or more inches (13 or more cm) in length; (2) a scar at least one-quarter inch (0.6 cm) wide at widest part; (3) surface contour of scar elevated or depressed on palpation;(4) scar adherent to underlying tissue; (5) skin hypo- or hyper-pigmented in an area exceeding six square inches (39 sq. cm); (6) skin texture abnormal in an area exceeding six square inches (39 sq. cm); (7) underlying soft tissue missing in an area exceeding six square inches (39 sq. cm); and, (8) skin indurated and inflexible in an area exceeding six square inches (39 sq. cm). VA amended criteria for rating skin disabilities effective August 13, 2018 (New Regulation). Relevant to scar evaluation, the New Regulation revises the rating criteria for DC 7801 and Diagnostic Code 7802. However, DC 7800, 7804 and 7805 remain unchanged. See 83 Fed. Reg. 32,592 (July 13, 2018). In October 2018, the Veteran was afforded a VA scar examination, at which the examiner found a scar on the tip of his nose with measurement of 1.5 cm (length) x 1 cm (width at widest part), as well as a slight narrowing of 3 mm on the nares on his left side. While listing the left nares narrowing as a disfigurement, the examiner indicated that there was no gross distortion or assymetry of facial features, or visible or palpable tissue loss. The examiner found no elevation, depression, adherence to underlying tissue, missing underlying soft tissue, abnormal pigmentation or texture. The examiner indicated that the scar was neither painful nor unstable, and that the scar did not result in limitation of function or other symptoms such as muscle or nerve damage. The Board finds that the evidence is against the assignment of a rating in excess of 10 percent under Diagnostic Code 7800, because a scar would be rated at 30 percent or higher if it has at least two characteristics of disfigurement listed in the rating criteria. Here, the Veteran’s scar has only one characteristic of disfigurement, namely, a scar at least one-quarter inch (0.6 cm) wide at the widest part. While the examiner also found slight narrowing of 3 mm on the left nares, this is not a characteristic disfigurement listed in the rating criteria. Alternatively, a scar could also be rated at 30 percent or higher, if a scar has visible or palpable tissue loss and causing gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips). Here, the examiner found no visible or palpable tissue loss, or gross distortion or assymetry of facial features. As such, a rating in excess of 10 percent is not warranted. The Board has also considered the other Diagnostic Codes pertaining to scars. DC 7801 and 7802 (under both New Regulation and the previous regulation) evaluates scars not on the head, face or neck, therefore they are not applicable to the scar on Veteran’s nose. DC 7804 evaluates scars that are unstable or painful, however, the evidence shows the scar on his nose is neither painful nor unstable, this diagnostic code does not apply. Finally, DC 7805 evaluate other disabling effect that are not considered under DC 7800-04, here, the Veteran’s scar on the nose has been considered under DC 7800. DC 7805 is not applicable either. The Veteran stated in his substantive appeal (Form 9) that the rating decision dated November 2018 appeared to assign a 10 percent rating based on telangiectasis of the nose, but his real concern was disfigurement (asymmetry) of the left nostril following a Mohs surgery to remove basal cell skin cancer in 2009. Here, the Veteran’s nose condition was properly evaluated under DC 7800 for scar/disfigurement, not for the underlying cause of the scar. Hence, whether the scar was due to treatment for telangiectasis of the nose or basal cell skin cancer was irrelevant to the evaluation under DC 7800. As the evidence does not show the scar condition on the Veteran’s nose has at least two characteristics of disfigurement or has caused gross distortion or asymmetry of his nostrils with visible or palpable tissue loss, a rating in excess of 10 percent is denied. REASONS FOR REMAND A November 2018 rating decision granted service connection for idiopathic premature ventricular contractions with bradycardia, and assigned a noncompensable rating under diagnostic code 7010, which evaluates supraventricular arrhythmias. A 10 percent rating is assigned for supraventricular arrhythmias manifested by permanent atrial fibrillation (lone atrial fibrillation), or one to four episodes per year of paroxysmal atrial fibrillation, or other supraventricular tachycardia documented by ECG (“electrocardiogram”) or Holter monitor. A 30 percent rating is assigned for paroxysmal atrial fibrillation or other supraventricular tachycardia, with more than 4 episodes/year documented by ECG or Holter monitor. 38 C.F.R. § 4.104, DC 7010. The Veteran was afforded a VA heart examination in October 2018, at which the examiner noted that he was diagnosed with premature ventricular contractions (PVCs) in November 2001. An echocardiogram (echo) was conducted at the examination, and the examiner found that the Veteran had cardiac arrhythmia, specifically, constant sinus bradycardia (slow heartbeat). Echo showed no hypertrophy and the left ventricular ejection fraction (LVEF) was 50-55 percent. However, the examiner did not indicate any atrial fibrillation or supraventricular tachycardia (fast heartbeat) condition which are the rating criteria under DC 7010. The Board noted that there are other diagnostic code evaluates arrhythmias (irregular heartbeat). For example, DC 7011 evaluates sustained ventricular arrhythmias with rating criteria involving factors such as METs and LFEF. DC 7015 evaluates atrioventricular block, which also involving factors such as METs and LVEF, and contains a note regarding pathological bradycardia. As the October 2018 VA examination did not discuss the rating criteria under DC 7010 (such as tachycardia or fast heartbeat), but discussed certain rating criteria under other Diagnostic Codes such as DC 7011 and DC 7015 (such as LVEF and bradycardia), it is not clear which Diagnostic Code(s) best refect the Veteran’s heart condition. Accordingly, the case is REMANDED for the following action: Obtain a clarifying opinion from VA examiner with respect to the Veteran’s service-connected heart disability. If a physical examination is needed to the answer the Board questions, one should be scheduled. The examiner should answer the following questions: (a) Which Diagnostic Code would most appropriately evaluate the Veteran’s current heart disability: Diagnostic Code 7010 (supraventricular arrhythmias), 7011 (ventricular arrhythmias (sustained), 7015 (atrioventricular block), or other diagnostic code? Why? 7010 Supraventricular arrhythmias: Paroxysmal atrial fibrillation or other supraventricular tachycardia, with more than four episodes per year documented by ECG or Holter monitor 30 Permanent atrial fibrillation (lone atrial fibrillation), or; one to four episodes per year of paroxysmal atrial fibrillation or other supraventricular tachycardia documented by ECG or Holter monitor 10 7011 Ventricular arrhythmias (sustained): For indefinite period from date of hospital admission for initial evaluation and medical therapy for a sustained ventricular arrhythmia, or; for indefinite period from date of hospital admission for ventricular aneurysmectomy, or; with an automatic implantable Cardioverter-Defibrillator (AICD) in place 100 Chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent 100 More than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent 60 Workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray 30 Workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required 10 7015 Atrioventricular block: Chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent 100 More than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent 60 Workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray 30 Workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication or a pacemaker required 10 Note: Unusual cases of arrhythmia such as atrioventricular block associated with a supraventricular arrhythmia or pathological bradycardia should be submitted to the Director, Compensation Service. Simple delayed P-R conduction time, in the absence of other evidence of cardiac disease, is not a disability. (b) Does the Veteran’s current heart disability present an unusual case of arrhythmia, such as atrioventricular block associated with a supraventricular arrhythmia or pathological bradycardia (in which case the claim should be submitted to the Director, Compensation Service), as contemplated under Diagnostic Code 7015? Why or why not? MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Q. Wang, 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.