Citation Nr: 21000397 Decision Date: 01/05/21 Archive Date: 01/05/21 DOCKET NO. 15-14 352A DATE: January 5, 2021 ORDER Entitlement to an initial compensable disability rating prior to May 24, 2019 for temporomandibular disorder (TMD) mandible fracture is denied. Entitlement to a disability rating in excess of 40 percent from May 24, 2019 for TMD mandible fracture is denied. Entitlement to an initial compensable disability rating prior to May 24, 2019 for scar on beard/chin area (formerly two scars, chin) is denied. Entitlement to a disability rating in excess of 10 percent from May 24, 2019 for scar on beard/chin area (formerly two scars, chin) is denied. Entitlement to an initial disability rating in excess of 10 percent for painful scar, beard area/chin associated with TMD, residual of mandible fracture is denied. REMANDED Entitlement to service connection for left eye disability, to include as secondary to end stage glaucoma with no light perception (blindness) of the right eye is remanded. Entitlement to an initial disability rating in excess of 30 percent prior to April 24, 2019 for end stage glaucoma with no light perception (blindness) of the right eye is remanded. Entitlement to a disability rating in excess of 60 percent from April 24, 2019 for end stage glaucoma with no light perception (blindness) of the right eye is remanded. Entitlement to total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Prior to May 24, 2019, the Veteran’s residuals of mandible fracture did not produce a displacement of his mandible nor limitation on range of motion. 2. From May 24, 2019, the Veteran’s TMD mandible fracture did not produce dietary restriction to mechanically altered foods. 3. Prior to May 24, 2019, the Veteran’s chin scars are not manifest by visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features, or; two or three characteristics of disfigurement. 4. From May 24, 2019, the Veteran’s chin scar is not manifest by visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features, or; two or three characteristics of disfigurement. 5. From May 24, 2019, the Veteran has no more than 2 scars that are unstable or painful. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial compensable disability rating prior to May 24, 2019 for mandible fracture have not been met. 38 U.S.C. §§ 1155, 51007; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.150, Diagnostic Code 9905, Diagnostic Code 9999. 2. The criteria for entitlement to a disability rating in excess of 40 percent from May 24, 2019 for TMD mandible fracture have not been met. 38 U.S.C. §§ 1155, 51007; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.150, Diagnostic Code 9904, Diagnostic Code 9905. 3. The criteria for entitlement to an initial compensable disability rating prior to May 24, 2019 for scar on beard/chin area (formerly two scars, chin) have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7800. 4. The criteria for entitlement to a disability rating in excess of 10 percent from May 24, 2019 for scar on beard/chin area (formerly two scars, chin) have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7800. 5. The criteria for entitlement to an initial disability rating in excess of 10 percent for painful scar, beard area/chin associated with temporomandibular disorder (TMD), residual of mandible fracture have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7804. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from his induction in June 1969 until his honorable discharge in June 1971. These matters come before the Board of Veterans’ Appeals (Board) on appeal from the January 2007 and January 2013 rating decisions by the Montgomery, Alabama Regional Office (RO) and the Washington, District of Columbia RO of the United States Department of Veterans Affairs (VA). In June 2018, the Board remanded the case to the RO for further development. Specifically, the Board directed the RO to obtain VA treatment records from Tuskegee VAMC and any other identified VA facility for the period of March 2006 to present; obtain private treatment records from the Veteran’s private ophthalmologist/optometrist; schedule the Veteran for a VA eye examination; and readjudicate the claim for TDIU. The Board finds that there has been substantial compliance with the Board’s previous remand directives regarding the issue(s) on appeal. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board also notes that the Veteran is currently service connected for only his right eye disabilities. However, the evaluation for visual impairment of one eye must not exceed 30 percent unless there is anatomical loss of the eye. 38 C.F.R. § 4.75(d). Although, as noted above, the regulations provide that the maximum schedular rating for visual impairment of one eye must not exceed 30 percent unless there is anatomical loss of the eye, the Veteran has had an increased disability rating granted by the RO of 60 percent since April 24, 2019 without the anatomical loss of an eye. This appears to be a clear and unmistakable error by exceeding the statutory limit of 30 percent for visual impairment of one eye that may resolve itself, depending on the results of the issue of entitlement to service connection for the Veteran’s left eye that is being remanded in this decision. Furthermore, as will be addressed in greater detail below, the Veteran is currently being compensated for two or more skin conditions that involve the same area of the skin (both rated at 10 percent disabling), which should only be compensated by the highest evaluation. The Board notes that it does not have the authority to reduce the Veteran’s disability rating for his service-connected right eye disability nor his scars on his chin, but the Board wishes to ensure that the Veteran is aware that the RO likely will correct these clear and unmistakable errors when they are discovered. As a practical matter though, the Board also notes that if these errors noted in this decision (both his claims for end stage glaucoma and the scars on his chin) are corrected by the RO, the Veteran’s overall disability rating from April 24, 2019 would be reduced to 80 percent disabled. However, the changes and reduction in overall disability to 80 percent disabled would not result in any negative financial implications for the Veteran because he would still be rated at 80 percent disabled with TDIU (which was effective February 14, 2019), resulting in the exact same financial compensation and benefits for the entire period on appeal. Furthermore, as discussed in greater detail below, the remanded issue of entitlement to service connection for his left eye disability associated with his end stage glaucoma with no light perception (blindness) of the right eye may also render the error of the end stage glaucoma with no light perception (blindness) of the right eye moot if the Veteran is granted service connection for his left eye disability. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4. The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran’s medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where an appeal is based on an initial rating for a disability, however, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence “used to decide whether an original rating on appeal was erroneous.” Fenderson v. West, 12 Vet. App. 119, 126 (1999). In either case, if later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Fenderson, 12 Vet. App. at 126; Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). When adjudicating a claim for an increased initial evaluation, the relevant time period is from the date of the claim. Moore v. Nicholson, 21 Vet. App. 211, 215 (2007), rev’d in irrelevant part, Moore v. Shinseki, 555 F.3d 1369 (2009). When adjudicating an increased rating claim, the relevant time period for consideration is the time period one year before the claim was filed. Hart, 21 Vet. App. at 509. Generally, the effective date of compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be on the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400. Under 38 U.S.C. § 5110(a), the effective date for awards in a Veteran’s disability compensation shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor. 38 U.S.C. § 5110(b)(2) provides an exception to this general rule: “The effective date of an award of increased compensation shall be the earliest date as of which it is ascertainable that an increase in disability had occurred, if application is received within one year from such date.” Thus, “the plain language of [section] 5110(b)(2) …only permits an earlier effective date for an increased disability compensation if that disability increased during the one-year period before the filing of the claim.” Thus, three possible dates may be assigned depending on the facts of an increased rating: (1) If an increase in disability occurs after the claim is filed, the date that the increase is shown to have occurred (date entitlement arose) (38 C.F.R. § 3.400 (o)(1)); (2) If an increase in disability precedes the claim by a year or less, the date that the increase is shown to have occurred (factually ascertainable) (38 C.F.R. § 3.400 (o)(2)); or (3) If an increase in disability precedes the claim by more than a year, the date that the claim is received (date of claim) (38 C.F.R. § 3.400(o)(2)). See Gaston v. Shinseki, 605 F.3d 979, 982-84 (Fed. Cir. 2010); Harper v. Brown, 10 Vet. App. 125, 126 (1997). 1. Entitlement to an initial compensable disability rating prior to May 24, 2019 for TMD mandible fracture 2. Entitlement to a disability rating in excess of 40 percent from May 24, 2019 for TMD mandible fracture Due to the similar dispositions for the above claims on appeal, the Board will address them in a common discussion below. During the pendency of the Veteran’s appeal, VA issued a final rule revising the portion of the VA Schedule for Rating Disabilities that address the schedule of ratings for dental and oral conditions. 82 Fed. Reg. 36080, 36083 (August 3, 2017). The final rule went into effect September 10, 2017. Where there is a change in the rating criteria during the appeal period, the Board will consider the claim in light of both the former and revised schedular rating criteria, although an increased evaluation based on the revised criteria cannot predate the effective date of the amendments. Prior to September 10, 2017, under Diagnostic Code 9904, for malunion of the mandible, a noncompensable disability rating is warranted for slight displacement; a 10 percent disability rating is warranted for moderate displacement; and a 20 percent disability rating is warranted for severe displacement. 38 C.F.R. § 4.150. From September 10, 2017, under Diagnostic Code 9904, for malunion of the mandible, a noncompensable disability rating is warranted for displacement not causing anterior or posterior open bite; a 10 percent disability rating is warranted for displacement causing moderate anterior or posterior open bite; and a 20 percent disability rating is warranted for displacement causing severe anterior or posterior open bite. 38 C.F.R. § 4.150. Prior to September 10, 2017, under Diagnostic Code 9905, for temporomandibular articulation, limited motion of range of lateral excursion of 0 to 4mm or limited range of motion of inter-incisal range of 31 to 40 mm warranted a 10 percent disability rating; limited motion of inter-incisal range of 21 to 30 mm warrants a 20 percent disability rating; from 11 to 20 mm warrants a 30 percent disability rating; and from 0 to 10 mm warrants a 40 percent disability rating. 38 C.F.R. § 4.150. Ratings for limited inter-incisal movement shall not be combined with ratings for limited lateral excursion. Id., Note to Diagnostic Code 9905. From September 10, 2017, under Diagnostic Code 9905, for temporomandibular disorder, limited motion of range of lateral excursion of 0 to 4mm or limited range of motion of interincisal range of 30 to 34 mm without dietary restrictions to mechanically altered foods warrant a 10 percent disability rating; limited range of motion of interincisal range of 30 to 34 mm with dietary restrictions to soft and semi-solid foods or limited range of motion of interincisal range of 21 to 29 mm without dietary restrictions to mechanically altered foods warrants a 20 percent disability rating; limited range of motion of interincisal range of 30 to 34 mm with dietary restrictions to full liquid and pureed foods, limited range of motion of interincisal range of 21 to 29 mm with dietary restrictions to soft and semi-solid foods, or limited range of motion of interincisal range of 11 to 20 mm without dietary restriction to mechanically altered foods warrants a 30 percent disability rating; limited range of motion of interincisal range of 21 to 29 mm with dietary restrictions to full liquid and pureed foods, limited range of motion of interincisal range of 11 to 20 mm with dietary restrictions to all mechanically altered foods, or limited range of interincisal range of 0 to 10 mm without dietary restrictions to mechanically altered foods warrants a 40 percent disability rating; and limited range of interincisal range of 0 to 10 mm with dietary restrictions to all mechanically altered foods warrants a 50 percent disability rating. 38 C.F.R. § 4.150. Ratings for limited inter-incisal movement shall not be combined with ratings for limited lateral excursion. Id., Note to Diagnostic Code 9905. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the evaluation assigned; the additional code is shown as a hyphen. 38 C.F.R. § 4.27. Prior to May 24, 2019 Prior to May 24, 2019, the Veteran’s disability is rated under Diagnostic Code 9999-9904. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the evaluation assigned; the additional code is shown as a hyphen. 38 C.F.R. § 4.27. Under Diagnostic Code 9904, for malunion of the mandible, a noncompensable disability rating is warranted for slight displacement; a 10 percent disability rating is warranted for moderate displacement; and a 20 percent disability rating is warranted for severe displacement. 38 C.F.R. § 4.150. VA treatment records reflect that the Veteran reported chronic pain of his gum daily and that he takes Tylenol for his pain and numbness. See June 2006 Tuskegee VAMC treatment records. The Veteran was afforded a VA examination in September 2011. The September 2011 VA examiner noted that the Veteran had endodontic treatment on tooth numbers 24 and 25; and missing teeth supporting a history of trauma. However, the September 2011 VA examiner did not note malunion of the mandible. See September 2011 VA examination. The Board notes that the record does not reflect nor does the Veteran assert that he had any displacement or malunion of the mandible and therefore, a compensable disability rating is not warranted prior to May 24, 2019. Despite no record of malunion of the mandible, the RO granted the Veteran the benefit of the doubt and granted service connection for (residuals of) mandible fracture, effective the date of the Veteran’s initial claim, August 8, 2006. Furthermore, as noted above, if an increase in disability occurs after the claim is filed, the date that the increase is shown to have occurred (date entitlement arose) is the appropriate effective date for the increase. In the present case, the record does not reflect evidence to support an increased disability rating prior to May 24, 2019 under either the pre-September 2017 diagnostic criteria nor post-September 2017 diagnostic criteria. From May 24, 2019 As noted above, from September 10, 2017, the criteria both Diagnostic Codes 9904 and 9905 were updated. The Veteran was afforded a VA examination in May 2019. The Board notes that the May 2019 VA examiner opined that it is not possible to determine the range of motion (during a flare up) without resorting to mere speculation because there is no conceptual or empirical basis for making such a determination without directly observing the function under these conditions. In increased evaluation claims, a VA examination report is not adequate without an explanation for an examiner’s failure to evaluate the functional effects of a flare-up. Sharp v. Shulkin, 29 Vet. App. 26 (2017). The Board may accept a VA examiner’s statement that he or she cannot offer an opinion in that regard without resorting to speculation, but only after determining that this is not based on the absence of procurable information or on a particular examiner’s shortcomings or general aversion to offering an opinion on issues not directly observed. Although not binding on VA examiners, the VA Clinician’s Guide instructs examiners when evaluating certain musculoskeletal conditions to obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves. Sharp, 29 Vet. App. at 34-35, citing VA CLINICIAN’S GUIDE, ch. 11. For example, a VA examination report is not adequate when the VA examiner failed to elicit relevant information as to the veteran’s flares or ask him to describe the additional functional loss, if any, he suffered during flares and then estimate the veteran’s functional loss due to flares based on all the evidence of record- including the veteran’s lay information-or explain why she or he could not do so. Sharp, 29 Vet. App. at 34-35. However, the Board also notes that the Veteran is already at the schedular maximum for his disability if that disability does not result in dietary restrictions limited to only mechanically altered foods and that the inadequate opinion regarding the Veteran’s limitations of range of motion would not have an impact on this decision. Therefore, despite the VA examination being inadequate for the purposes of limitation of range of motion, the Board finds that the VA examination is adequate for purposes of determining whether or not the disability requires dietary restrictions and the Board will not remand this issue. The Board shall therefore evaluate the Veteran’s disability based upon the only factor that could result in an increased disability rating. Specifically, if the Veteran’s disability results in dietary restrictions to all mechanically altered foods, which, if applicable, would result in the Veteran being entitled to an increased disability rating. The May 2019 VA examiner found that the Veteran’s does not require a mechanically altered foods diet. See May 2019 TMDS Disability Benefits Questionnaire. Based on the foregoing evidence, the Board finds that the preponderance of the evidence is against the grant of a disability rating in excess of 40 percent from May 24, 2019 because he does not require a mechanically altered foods diet. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Entitlement to an initial compensable disability rating prior to May 24, 2019 for scar on beard/chin area (formerly two scars, chin) 4. Entitlement to a disability rating in excess of 10 percent from May 24, 2019 for scar on beard/chin area (formerly two scars, chin) Due to the similar dispositions for the above claims on appeal, the Board will address them in a common discussion below. The Veteran asserts that he is entitled to a higher rating because he is unable to shave due to his chin scars. The Veteran’s scar on beard/chin area (formerly two scars, chin) 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. 38 C.F.R. § 4.118(b) provides that two or more skin conditions may be combined in accordance with 38 C.F.R. § 4.25 only if separate areas of skin are involved. If two or more skin conditions involve the same area of skin, then only the highest evaluation shall be used. 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 Veteran was afforded a VA examination in April 2019. The April 2019 VA examiner found that he was unable to measure the Veteran’s scars due to his beard, but noted two scars on his chin and that the Veteran reported numbness, but not pain. See April 2019 VA Scars/Disfigurement Examination, p. 8. The Veteran was afforded a second VA examination in May 2019 in connection with his oral and dental conditions including mouth, lips, and tongue (other than TMJ). The May 2019 VA examiner found that the Veteran had a scar reaching from his neck around the anterior mandible to his chin measuring approximately 5 inches, nothing that the scar is severely Keloided and caused the Veteran discomfort, itching, burns, and prevents him from shaving and that the Veteran reported that he frequently gets a rash on it that is very uncomfortable. The Board finds that the preponderance of the evidence is against the assignment of a rating in excess of 10 percent under Diagnostic Code 7800 because he does not have visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features, or; two or three characteristics of disfigurement. The Board has also considered the other Diagnostic Codes pertaining to scars. However, the Veteran’s scars on his chin are not deep and non-linear and are not associated with underlying soft tissue damage. Although they are superficial and not associated with underlying soft tissue damage, they do not cover an area or areas of 144 square inches or greater. Moreover, the Veteran’s chin scars are not unstable or painful (prior to the May 2019 VA examination). 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 disability rating provided under Diagnostic Codes 7800-04 as contemplated under both pre- and post-August 13, 2018, Diagnostic Code 7805. As noted above, from May 2019, the Veteran reported pain from his scars and was subsequently rated under both Diagnostic Codes 7800 and 7804, each rated at a 10 percent disability despite 38 C.F.R. § 4.118(b) providing that two or more skin conditions may be combined in accordance with 38 C.F.R. § 4.25 only if separate areas of skin are involved and that if two or more skin conditions involve the same area of skin, then only the highest evaluation shall be provided. The Board acknowledges that the Veteran believes that the disability on appeal has been more severe than the assigned disability rating reflects. Moreover, the Veteran is competent to report observable symptoms, to include itching, tingling, and that the scar(s) prevent him from shaving, and his reports are credible. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, he does not assert, and medical records do not show, that the Veteran’s chin scars are manifested by visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features, or; two or three characteristics of disfigurement. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 10 percent for the Veteran’s chin scars. 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. 5. Entitlement to an initial disability rating in excess of 10 percent for painful scar, beard area/chin associated with TMD, residual of mandible fracture The Veteran asserts that he is entitled to a higher rating because he is unable to shave due to the scars. The Veteran’s painful scar is rated under Diagnostic Code 7804 for unstable or painful scar(s). The Board notes that VA amended the criteria for rating skin disabilities effective from August 13, 2018. However, Diagnostic Code 7804 was not changed by the August 13, 2018, amendments. As noted above, 38 C.F.R. § 4.118(b) provides that two or more skin conditions may be combined in accordance with 38 C.F.R. § 4.25 only if separate areas of skin are involved. If two or more skin conditions involve the same area of skin, then only the highest evaluation shall be used. Under Diagnostic Code 7804, one or two scars that are unstable or painful scars warrants a 10 percent rating. Three or four scars that are unstable or painful scars warrants a 20 percent rating. Five or more scars that are unstable or painful warrants a 30 percent rating. 38 C.F.R. § 4.118. Note 1 to Diagnostic Code 7804 instructs that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Id. The Board has also considered the other Diagnostic Codes pertaining to scars, however, the Veteran is already rated under Diagnostic Code 7800 because it is a scar of the head, face, or neck. The Veteran was afforded a VA examination in April 2019. The April 2019 VA examiner found that he was unable to measure the Veteran’s scars due to his beard, but noted two scars on his chin and that the Veteran reported numbness, but not pain. See April 2019 VA Scars/Disfigurement Examination, p. 8. The Veteran was afforded a second VA examination in May 2019 in connection with his oral and dental conditions including mouth, lips, and tongue (other than TMJ). The May 2019 VA examiner found that the Veteran had a scar reaching from his neck around the anterior mandible to his chin measuring approximately 5 inches, nothing that the scar is severely keloided and caused the Veteran discomfort, itching, burns, and prevents him from shaving and that the Veteran reported that he frequently gets a rash on it that is very uncomfortable. The Board finds that the preponderance of the evidence is against the assignment of a rating in excess of 10 percent under Diagnostic Code 7804 because the Veteran’s scar is not manifest by three or four scars that are unstable or painful. Furthermore, the Veteran’s scar is already rated under Diagnostic Code 7800 and since the Veteran’s disability is not rated higher than the 10 percent disability assigned under Diagnostic Code 7800, an increased rating is not warranted. The Board acknowledges that the Veteran believes that the disability on appeal has been more severe than the assigned disability rating reflects. Moreover, the Veteran is competent to report observable symptoms, to include itching and tingles that prevents him from shaving, and his reports are credible. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, he does not assert, and medical records do not show, that the Veteran’s scars on beard/chin area are manifest by three or four scars that are unstable or painful. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for a disability rating in excess of 10 percent for his two scars on the beard/chin area. 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. REASONS FOR REMAND 1. Entitlement to service connection for left eye disability, to include as secondary to end stage glaucoma with no light perception (blindness) of the right eye is remanded. The Veteran asserts that his left eye disability is secondary to his service-connected end stage glaucoma with no light perception (blindness) of the right eye. The Board finds that the April 2019 VA examination is internally inconsistent and inadequate, as it states both that a) the Veteran’s left eye visual impairment is a result of the Veteran’s right eye disability, and b) the Veteran’s left eye ocular hypertension and chronic iridocyclitis of the left eye are separate and unrelated to the Veteran’s right eye disabilities; and the visual impairment of the right eye does not cause the left eye to be weak. Where VA provides the Veteran with an examination, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Therefore, further development is necessary to obtain an addendum opinion from a VA examiner and, if possible, to determine the nature, frequency, and severity of the Veteran’s left eye disability. 2. Entitlement to an initial disability rating in excess of 30 percent prior to April 24, 2019 for end stage glaucoma with no light perception (blindness) of the right eye is remanded. 3. Entitlement to a disability rating in excess of 60 percent from April 24, 2019 for end stage glaucoma with no light perception (blindness) of the right eye is remanded. 4. Entitlement to TDIU is remanded. Due to the similar dispositions for the above claims on appeal, the Board will address them in a common discussion below. Finally, because a decision on the remanded issue of entitlement to service connection for left eye disability, to include as secondary to end stage glaucoma with no light perception (blindness) of the right eye could significantly impact a decision on the issues of entitlement to an initial disability rating in excess of 30 percent prior to April 24, 2019 for end stage glaucoma with no light perception (blindness) of the right eye; entitlement to a disability rating in excess of 60 percent from April 24, 2019 for end stage glaucoma with no light perception (blindness) of the right eye; and entitlement to TDIU are inextricably intertwined. A remand of the claims for entitlement to an initial disability rating in excess of 30 percent prior to April 24, 2019 for end stage glaucoma with no light perception (blindness) of the right eye; entitlement to a disability rating in excess of 60 percent from April 24, 2019 for end stage glaucoma with no light perception (blindness) of the right eye; and entitlement to TDIU is required. As noted above, the evaluation for visual impairment of one eye must not exceed 30 percent unless there is anatomical loss of the eye. 38 C.F.R. § 4.75(d). Combine the evaluation for visual impairment of one eye with evaluation for other disabilities of the same eye that are not based on visual impairment (e.g., disfigurement under diagnostic code 7800). Id. The matters are REMANDED for the following action: 1. After any additional records are associated with the claims file, obtain an addendum opinion regarding the etiology of the left eye disability from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s left eye disability is caused by or aggravated by his service-connected right eye disability of end-stage glaucoma with no light perception. A detailed rationale for all opinions provided must be included, including but not limited to what disabilities in his left eye are caused by or aggravated by his service-connected right eye disability of end-stage glaucoma with no light perception and what impact those disabilities alone have on the Veteran’s left eye impairment(s). 2. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal, including the inextricably intertwined issues of entitlement to an initial disability rating in excess of 30 percent prior to April 24, 2019 for end stage glaucoma with no light perception (blindness) of the right eye; entitlement to a disability rating in excess of 60 percent from April 24, 2019 for end stage glaucoma with no light perception (blindness) of the right eye; and entitlement to TDIU. If the benefit sought is not granted to the Veteran’s satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. M. Tenner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. Deemer, 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.