Citation Nr: 21000231 Decision Date: 01/04/21 Archive Date: 01/04/21 DOCKET NO. 08-33 369 DATE: January 4, 2021 ORDER A rating in excess of 30 percent for cervical disc herniation at C5-6 status post anterior cervical discectomy and fusion from December 1, 2014, forward is denied. A rating in excess of 20 percent for cervical disc herniation at C5-6 prior to October 7, 2014, is denied. A 10 percent rating beginning March 23, 2007, and then a 30 percent rating from December 1, 2014, for tension headaches is granted. An initial compensable rating for cervical spine surgical scar is denied. REMANDED Entitlement to compensation for total disability based on individual unemployability (TDIU) prior to October 16, 2012, is remanded. FINDINGS OF FACT 1. The weight of the evidence is against finding cervical flexion limited to 15 degrees or less or favorable ankylosis prior to October 7, 2014. 2. The weight of the evidence is against finding unfavorable ankylosis of the cervical spine. 3. The evidence shows no symptom of the neck that has not been considered and compensated by the ratings for the neck, posttraumatic stress disorder (PTSD), and/or headaches. 4. The evidence shows headaches with occasional prostrating attacks prior to the October 7, 2014, surgery and an increase in the severity of headaches including the frequency of prostrating attacks after the surgery. 5. There is insufficient evidence to find prostrating attacks occurred once per month during the period prior to October 7, 2014. 6. The evidence does not show any characteristic of disfigurement, pain, unstable skin, or functional impairment from the cervical spine surgical scar. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent for cervical disc herniation at C5-6 status post anterior cervical discectomy and fusion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code (DC) 5238. 2. The criteria for a rating in excess of 20 percent for cervical disc herniation at C5-6 prior to October 7, 2014, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5238. 3. The criteria for a 10 percent rating from March 23, 2007, and 30 percent rating from December 1, 2014, for tension headaches have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, DC 8100. 4. The criteria for a compensable rating for cervical spine surgical scar have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, DC 7800. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Navy from December 1978 to January 1983. The Board notes that the issues of increased ratings for right upper extremity radiculopathy and in excess of 30 percent for tension headaches were previously remanded by the Board in October 2018. In February 2020, the Veteran submitted a Form 20-0996, Request for Higher-Level Review, timely opting those issues into the system based on the Appeals Modernization Act (AMA) after the December 2019 supplemental statement of the case. Therefore, those issue are no longer before the Board in this legacy appeal. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. In determining the propriety of the initial rating assigned after a grant of service connection, the evidence since the effective date of the grant of service connection must be evaluated and staged ratings must be considered. Fenderson v. Brown, 12 Vet. App. 119, 126-127 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, the Board must also consider staged ratings, which are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods during the appeal. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); see also Fenderson, 12 Vet. App. at 126-127. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other. Esteban v. Brown, 6 Vet. App. 259, 262 (1994); 38 C.F.R. § 4.14. The Veteran and his friends are competent to give evidence of symptoms observable by their senses. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). 1. A rating in excess of 20 percent for cervical disc herniation at C5-6 prior to October 7, 2014 2. A rating in excess of 30 percent for cervical disc herniation at C5-6 status post anterior cervical discectomy and fusion from December 1, 2014, forward The evidence shows the Veteran underwent cervical discectomy and fusion surgery on October 7, 2014. Between October 7, and December 1, 2014, the Veteran received a temporary 100 percent rating for convalescence. The Board’s analysis will focus on the periods before and after that period of convalescence. The Agency of Original Jurisdiction (AOJ) assigned a 20 percent rating prior to the surgery and a 30 percent rating after the surgery. The Veteran’s cervical spine (neck) disability is rated under 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5238. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent rating is warranted for forward flexion of the cervical spine to 15 degrees or less; or favorable ankylosis of the entire cervical spine. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. at Note 5. Unfavorable ankylosis is a condition in which the entire cervical spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Id. Ankylosis is defined as “immobility and consolidation of a joint due to disease, injury, or surgical procedure.” Dorland’s Illustrated Medical Dictionary, 94 (32nd ed. 2012). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). The Board finds that the preponderance of the evidence is against a rating in excess of 20 percent for the neck disability prior to October 7, 2014. Treatment records note neck pain with headaches and radiculopathy. A May 2007 treatment record documents decreased range of motion of the neck but not specific measurements. During the August 2007 examination, the Veteran reported pain and stiffness in the neck with flare-ups once per week lasting two hours. He reported having to duck his head instead of bending his neck when getting into vehicles, experiencing difficulties dressing himself, and difficulty with anything that was pulled over his head, like a t-shirt. The examiner measured flexion with active range of motion to 30 degrees and passive range of motion to 38 degrees. The examiner found no objective evidence of pain, fatigue, weakness, lack of endurance, or incoordination after five flexion and extension movements and stated that an opinion on flare-ups could not be provided without resort to speculation. A March 2009 medical opinion on the spine discusses mild loss of neck motion but does not provide measurements. Private and VA treatment records continue to show neck pain, headache, and radiculopathy. A treating provider on October 1, 2014, noted limited range of motion of the neck, including flexion, but not specific measurements. The evidence does not show the Veteran’s neck flexion was limited to 15 degrees or less or that the neck was fixed in position as to represent unfavorable ankylosis prior to October 7, 2014. The available measurements show flexion to 30 degrees. Similarly, the March 2009 opinion characterizes loss as mild. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to pain and stiffness. However, there is simply no evidence showing flexion limited to 15 degrees or less, and the consistent notation of range of motion suggests the neck was not fixed in one position. Accordingly, the evidence does not support a schedular rating in excess of 20 percent prior to October 7, 2014. For the period after December 1, 2014, a rating in excess of 30 percent requires a showing of unfavorable ankylosis. The November 2014 VA examiner measured neck flexion to 10 degrees after the spinal fusion procedure. The examiner found no evidence of ankylosis. VA treatment records also do not evidence ankylosis of the cervical spine. A notation from March 2020 shows the neck was supple with full range of motion. There is no evidence of symptoms such as difficulty walking because of a limited line of vision, restricted opening of the mouth and chewing, breathing limited to diaphragmatic respiration, gastrointestinal symptoms due to pressure of the costal margin on the abdomen, dyspnea or dysphagia, atlantoaxial or cervical subluxation or dislocation, or neurologic symptoms due to nerve root stretching. Thus, the evidence does not support a schedular rating in excess of 30 percent from December 1, 2014, forward. The Board notes that the Veteran was scheduled for an examination for his neck in October 2019 but failed to appear. Any additional information or clarification could not be obtained to satisfy the holdings of the Court of Appeals for Veterans Claims in Correia v. McDonald, 28 Vet. App. 158, 169-70 (2016) and Sharp v. Shulkin, 29 Vet. App. 26, 34 (2017). Specifically, VA was not able to obtain additional information on functional impairment during flare-ups; obtain range of motion measurements in passive motion, weight-bearing and nonweight-bearing; or obtain opinions on how flare-ups, passive motion, weight-bearing, and nonweight-bearing would have presented on examinations prior to October 2014. The Board must instead rely on the evidence of record. See 38 C.F.R. § 3.655. Consideration has also been given to assigning a rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. However, the evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. The November 2014 VA examiner found the Veteran had IVDS but did not have incapacitating episodes in the prior 12 months. The Veteran has also not presented evidence of being prescribed bed rest by a physician for his neck disability. Regarding neurological impairment, the Veteran has radiculopathy in his left and right upper extremities, which has been rated separately. Those ratings are not currently before the Board on appeal. See February 2020 AMA opt-in, June 2015 statement of the case. The evidence does not show any other neurologic abnormalities related to the Veteran’s cervical spine. The Veteran has alternatively asserted entitlement to an increased rating for his neck on an extra-schedular basis. In Thun v. Peake, 22 Vet. App. 111, 115 (2008), the Court set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a veteran is entitled to an extra-schedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant’s disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extra-schedular disability rating must be in the interest of justice. First, the Board has considered symptoms that may not be considered by the rating criteria. Specifically, in a February 2013 letter, a private provider noted that dizziness, back pain, auditory symptoms, dysphagia, and visual symptoms are known symptoms of cervical spine injury and stenosis and that the Veteran experienced headaches and vertigo after his in-service injury. Although the Veteran may have experienced vertigo and other symptoms at the time of his injury, the evidence does not show that he experienced vertigo, dizziness, or visual or auditory symptoms associated with his neck during the period on appeal. A July 2007 auditory examination revealed normal hearing, middle ear function, and otoscopic examination. The Veteran consistently denied dizziness, vertigo, and vision problems. See VA treatment from November 2008, February 2009, April 2009, December 2009, June 2010, April 2011, May 2012. Indeed, in the February 2013 letter, the private provider described the Veteran’s current symptoms as neck pain, headaches, paresthesias of the upper extremities, and cervical spinal stenosis – all of which have been compensated by the rating criteria. The Board notes that the Veteran experiences tinnitus and that the February 2013 provider noted auditory symptoms could be associated with a neck injury. However, the February 2013 provider did not list tinnitus as a current symptom associated with the neck. The Veteran has previously filed an independent claim for service connection for tinnitus, which has been denied and is not on appeal before the Board currently. There is insufficient evidence for the Board to now find that tinnitus is a symptom of his current neck disability. Instead, the Board finds this disability, which has separate and distinct rating criteria, should be adjudicated independently, should the Veteran choose to bring the claim again. The Board concludes that all of the symptoms and impairment attributed to the neck based on the evidence have been considered by the rating criteria, aside from sleep impairment, which is discussed below. Regarding sleep impairment, the evidence shows the Veteran suffers from sleep impairment. See February 2009, December 2009, August 2014, January 2015, February 2015 treatment; November 2014 mental health examination; July 2016 private treatment. Any clarification as to the effects of sleep impairment that could have been obtained on examination and clinical interview was thwarted when the Veteran failed to report for his October 2019 examination, and the Board must base its finding on the evidence of record. See 38 C.F.R. § 3.655. First, the Board finds sleep impairment is contemplated by the 70 percent rating assigned for the Veteran’s PTSD effective October 16, 2012. See 38 C.F.R. § 4.130; November 2014 examination (showing sleep impairment as a mental health symptom). Accordingly, the Veteran could not receive a duplicate rating for sleep impairment as part of his neck disability from October 16, 2012, forward as this would violate the rule against pyramiding. See 38 C.F.R. § 4.14. To the extent that the Veteran suffered from sleep difficulty prior to the effective date of his PTSD rating, the Board notes that the Court has held that Diagnostic Code 8100 contemplates all symptoms associated with headaches. See Holmes v. Wilkie, 19-2495 (November 25, 2020). As the evidence, including January 2015 treatment, shows the Veteran’s sleep impairment was also associated with his headaches, the Board finds that symptom would be compensated as part of the headache rating assigned prior to October 16, 2012, and therefore, would not be eligible for a duplicate rating based on his neck. See 38 C.F.R. § 4.14. For the sake of completeness, the Board will discuss the second step of the Thun analysis as it relates to headaches. The Board finds the weight of the evidence does not demonstrate that the Veteran’s neck disability presents an exceptional or unusual disability picture with related factors such as marked interference with employment or frequent hospitalization. The Board finds that difficulty finding a comfortable position due to pain appears to be a common presentation of a musculoskeletal disability and would not be considered an exceptional or unusual disability picture. Additionally, there is no evidence of frequent hospitalization associated with sleep impairment, and although daytime sleepiness may have affected the Veteran’s efficiency to work on some occasions, the weight of the evidence does not show that impaired sleep markedly interfered with his employment. Instead, the evidence discussing impairments to employment prior to October 2012 does not mention sleep impairment as a significant factor on his employment. Thus, the Board must conclude that there is insufficient evidence to find the Veteran’s neck disability caused sleep impairment that is exceptional or unusual to that of similar musculoskeletal disabilities rated by the schedular criteria. As the Veteran’s disability picture is not exceptional or unusual, the second Thun step is not satisfied and referral for extraschedular consideration is not necessary. See Chudy v. O’Rourke, 30 Vet. App. 34 (2018). For the foregoing reasons, the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 20 percent prior to October 7, 2014, and in excess of 30 percent from December 1, 2014, for the neck disability. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 3. A 10 percent rating beginning March 23, 2007, and then a 30 percent rating from December 1, 2014, for tension headaches The AOJ assigned zero disability for the Veteran’s headaches from March 23, 2007 to May 14, 2015, and then assigned a 30 percent rating. Headaches, specifically migraines, are rated under Diagnostic Code 8100, which provides for a 10 percent rating for headaches with characteristic prostrating attacks averaging one in 2 months over the last several months. Less frequent prostrating attacks receive a non-compensable rating. A 30 percent rating is warranted for headaches with characteristic prostrating attacks occurring on an average once a month over the last several months and a maximum, 50 percent rating is warranted for very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a, DC 8100. After a review of the record, the Board finds the criteria for a 10 percent rating prior to October 7, 2014, and a 30 percent rating from December 1, 2014, for tension headaches have been met. See 38 C.F.R. § 4.124a, DC 8100. The Board notes that the evidence shows the Veteran’s headaches worsened and increased in frequency after his neck surgery on October 7, 2014. Treatment records from March 2015 note increased frequency of prostrating headaches with symptoms, such as nausea. During April 2015 treatment, the Veteran reported his headaches had been worse since his October 2014 neck surgery. The provider noted severe headaches three times per week and a new prescription for Imitrex, a migraine medicine. Similarly, in May 2015 treatment, the Veteran described severe headaches with nausea and photophobia requiring him to go into a dark room with an ice pack. He reported that his migraine headaches had worsened since his cervical fusion in October 2014 and their frequency changed. The Veteran did not file a separate claim for headaches until September 2014, therefore, there are no headache examinations or claim statements prior to that date, and the evidence is largely treatment records. However, the Board has viewed the evidence in the light most favorable to the Veteran to find that his headaches included prostrating attacks approximately once every two months but not once per month. Prior to October 7, 2014, the Veteran’s headaches were most often described as tension headaches, rather than migraines, and while he had treatment for headaches, he also often denied headaches during treatment workups. The Veteran indicated that he experienced photophobia all his life; therefore, the Board does not find that symptom to necessarily evidence a prostrating attack. See August 2010, October 2013 treatment. During August 2014 treatment, the Veteran described his headaches as occurring twice weekly with only “occasional nausea.” In a June 2016 letter, the Veteran’s friend described watching the Veteran suffer from severe headaches at least two times per week that were bad enough for him to lie down in a bedroom in the dark beginning as far back as a motor vehicle accident in 2008. The Board has considered the Veteran’s friend’s statement of the frequency of headaches requiring bed rest but finds this statement is inconsistent with the other evidence of record, including the Veteran’s own reports. The evidence shows the Veteran had headaches twice per week, but, per the Veteran’s own reports, the severity of his headaches became more frequent after his surgery and previously he only had nausea associated with headaches “occasionally.” Further, treatment records show the Veteran sought treatment for headaches more often and was prescribed migraine medicine to control his headaches after the October 2014 surgery. The Veteran also did not describe his headaches as requiring rest in a dark room during this period. The November 2014 VA examiner indicated that the Veteran’s headaches did not include prostrating attacks. As this examination took place only a month after the neck surgery, the change in the Veteran’s headache condition may not have been fully realized at that time and the examiner’s evaluation would be more consistent with the disability picture prior to October 7, 2014. As such, the Board finds this examination is consistent with the other evidence of record showing less frequent prostrating attacks. Based on the lay evidence, the Board finds the Veteran had prostrating attacks associated with his headaches on a somewhat regular basis but given the lack of evidence of treatment for prostrating attacks, there is insufficient evidence to find prostrating attacks occurred once per month or more frequently prior to October 7, 2014. Thus, when viewed together, the evidence shows headaches with less frequent prostrating attacks prior to the neck surgery and an increase in the frequency of prostrating attacks after the surgery. After resolving doubt in the Veteran’s favor, a 10 percent rating is awarded for the period prior to October 7, 2014. The weight of the evidence is against finding a rating in excess of 10 percent was warranted prior to December 1, 2014, the date at which the Veteran’s temporary, 100 percent convalescent rating ended. As noted above, the issue of entitlement to a rating in excess of 30 percent for headaches from December 1, 2014, forward is not before the Board at this time. 4. A compensable rating for cervical spine surgical scar The Veteran has a scar from his October 2014 neck surgery. The AOJ rated the scar as noncompensable. The Veteran’s scar is rated under Diagnostic Code 7800, for 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. VA amended the criteria for rating skin disabilities effective from August 13, 2018. However, Diagnostic Code 7800 was not changed by the August 13, 2018, amendments. Under Diagnostic Code 7800, one characteristic of disfigurement warrants a 10 percent rating. 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 warrants a 30 percent rating. 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 warrants a 50 percent rating. A scar with visible or palpable tissue loss and either gross distortion 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 warrants an 80 percent rating. 38 C.F.R. § 4.118. Note 1 to Diagnostic Code 7800 list the eight characteristics of disfigurement: a scar 5 or more inches in length; a scar at least one-quarter inch wide at widest part; surface contour of scar elevated or depressed on palpation; scar adherent to underlying tissue; skin hypo- or hyper-pigmented in an area exceeding six square inches; skin texture abnormal 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. Id. The Board finds the preponderance of the evidence is against the assignment of a compensable rating under Diagnostic Code 7800 because the scar is not associated with at least one characteristic of disfigurement. The April 2015 VA examiner identified one superficial scar on the right anterior neck measuring 6.5 centimeters by 0.2 centimeter. The scar does not measure five inches in length, one-quarter inch in width, or six square inches in area to qualify for several of the eight characteristics of disfigurement. Moreover, it is not on the face as to affect facial features. The examiner did not indicate that the scar caused disfigurement, gross distortion, visible or palpable tissue loss, abnormal surface contour, or adherence to underlying tissue. The Board has also considered the other Diagnostic Codes pertaining to scars. However, the Veteran’s scar is not deep and non-linear and is not associated with underlying soft tissue damage. Although it is superficial and not associated with underlying soft tissue damage, it does do not cover an area or areas of 144 square inches or greater. Moreover, the Veteran’s scar is not unstable or painful. The April 2015 examiner specifically found the scar was not painful and did not present with frequent loss of covering of the skin. Therefore, Diagnostic Codes 7801, 7802, and 7804, both prior to and from August 13, 2018, are inapplicable. Finally, the evidence of record shows there are no other disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-04 as contemplated under both pre- and post-August 13, 2018, Diagnostic Code 7805. The Board acknowledges that the Veteran believes the disability on appeal has been more severe than the assigned disability rating reflects. However, he does not assert, and medical records do not show, that the Veteran’s scar is manifest by one characteristic of disfigurement. The Board notes that the Veteran was scheduled for an additional examination for his scar but failed to appear. See October 2019 records. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for a compensable rating for his neck scar. REASONS FOR REMAND 1. Entitlement to compensation for TDIU prior to October 16, 2012, is remanded. The Veteran has been awarded TDIU compensation beginning October 16, 2012. As his neck and headache disability ratings were on appeal for periods prior to October 16, 2012, the issue of entitlement to TDIU prior to that date is also before the Board on appeal. See Harper v. Wilkie, 30 Vet. App. 356 (2018). Although the Veteran’s appeal included this issue, it does not appear that the AOJ considered whether the Veteran was entitled to TDIU prior to October 16, 2012. Indeed, the November 2014 rating decision that granted TDIU shows the effective date was based on the date of receipt of the claim for PTSD and the date the Veteran met the schedular requirement for TDIU. With the Board’s grant of 10 percent for headaches, the Veteran’s combined rating becomes 60 percent, meaning he met the rating requirement for TDIU prior to October 16, 2012. See 38 C.F.R. §§ 4.16, 4.25. The AOJ was not able to consider TDIU in that context and should do so prior to the Board’s decision. Next, the record shows the Veteran had vocational rehabilitation through VA. Those records are not included in the claims file and may be relevant to his claim for TDIU compensation. On remand, the AOJ should obtain any vocational rehabilitation records and associate them with the file and then adjudicate the issue of TDIU prior to October 16, 2012. The matters are REMANDED for the following action: (Continued on the next page)   1. Obtain and associate with the claims file any records from VA Vocational Rehabilitation services. 2. Then, adjudicate the issue of entitlement to TDIU prior to October 16, 2012, and issue a supplemental statement of the case. A. S. CARACCIOLO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A.P. Armstrong 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.