Citation Nr: 21065826 Decision Date: 10/27/21 Archive Date: 10/27/21 DOCKET NO. 11-33 134 DATE: October 27, 2021 ORDER Entitlement to service connection for coronary artery disease is denied. Entitlement to compensation under 38 U.S.C. § 1151 for additional disability manifested by hypothyroidism is denied. Entitlement to compensation under 38 U.S.C. § 1151 for additional disability due to failure to remove surgical clip in left lower ankle is denied. Entitlement to compensation under 38 U.S.C. § 1151 for additional disability due to failure to remove staple in lower left leg is denied. Entitlement to a compensable initial rating for Boutonniere deformity of right hand little finger is denied. Entitlement to an initial rating in excess of 10 percent for right hand little finger loss of sensation is denied. Entitlement to a compensable initial rating for right hand little finger scar is denied. REMANDED The issue of entitlement to service connection for basal cell carcinoma is remanded. The issue of entitlement to compensation under 38 U.S.C. § 1151 for valvular heart disease with myocardial infarction is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran's coronary artery disease began during his active service, or was otherwise related to an in-service injury or disease. 2. The preponderance of the evidence is against a finding that the Veteran suffered additional disability manifested by hypothyroidism. 3. The preponderance of the evidence is against a finding that the Veteran suffered additional disability due to VA failure to remove a surgical clip in the left lower ankle. 4. The preponderance of the evidence is against a finding that the Veteran suffered additional disability due to VA failure to remove a staple in the lower left leg. 5. During the relevant rating period, the Veteran's Boutonniere deformity of right hand little finger manifested in subjective loss of strength and range of motion in the right fifth finger. 6. The Veteran's right hand little finger loss of sensation manifested in no more than mild incomplete paralysis of the major extremity. 7. Throughout the relevant rating period, the Veteran's right hand little finger scar was manifested by a scar that was superficial and linear, was not painful or unstable, had an area of less than 929 square centimeters, and had no other disabling effects. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for coronary artery disease have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5107A; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 2. The criteria for entitlement to compensation under 38 U.S.C. § 1151 for additional disability manifested by hypothyroidism have not been met. 38 U.S.C. § 1151; 38 C.F.R. §§ 3.102, 3.361, 17.32. 3. The criteria for entitlement to compensation under 38 U.S.C. § 1151 for additional disability due to VA failure to remove a surgical clip in the left lower ankle have not been met. 38 U.S.C. § 1151; 38 C.F.R. §§ 3.102, 3.361, 17.32. 4. The criteria for entitlement to compensation under 38 U.S.C. § 1151 for additional disability due to VA failure to remove a staple in the lower left leg have not been met. 38 U.S.C. § 1151; 38 C.F.R. §§ 3.102, 3.361, 17.32. 5. The criteria for entitlement to a compensable initial rating for Boutonniere deformity of right hand little finger have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.71a, Diagnostic Code 5230. 6. The criteria for entitlement to a rating in excess of 10 percent for right hand little finger loss of sensation have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.124a, Diagnostic Code 8515. 7. The criteria for entitlement to an initial compensable rating for right hand little finger scar, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.14, 4.21, 4.118, Diagnostic Codes 7801, 7802, 7804, 7805. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1961 to May 1966. The Veteran died in October 2014. The appellant is the Veteran's surviving spouse. These matters come before the Board of Veterans' Appeals (Board) on appeal of May 2011, April 2013, and July 2013 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). In July 2021, the appellant testified during a video conference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the claims file. Neither the appellant nor her representative has raised any issues with regard to the duty to notify or duty to assist as they pertain to the issues decided herein. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). In that regard, the Board notes that the development directed in the Remand section below pertains to the issues remanded herein, and there is no indication that evidence developed as part of those actions may be relevant to the issues decided herein. Service Connection 1. Entitlement to service connection for coronary artery disease is denied. The appellant seeks entitlement to service connection for the Veteran's coronary artery disease. In an August 2011 correspondence, the Veteran reported that his claim for service connection for his heart condition was related to bypass surgery, not for direct service connection. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). The question for the Board is whether the Veteran's coronary artery disease began during service or was at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, although the medical treatment records show that he was diagnosed with coronary artery disease, the preponderance of the evidence is against finding that the Veteran's disability began during active service or was otherwise related to an in-service injury, event, or disease, or that such disability manifested to a compensable degree within one year of the Veteran's separation from active service. The Veteran's service treatment records reflect that he complained of pain or pressure in chest on his April 1966 report of medical history upon separation from active service. The earliest evidence of a diagnosed heart condition is dated February 2005. Accordingly, the record does not show a diagnosis of a heart condition during service or within one year of the Veteran's separation from active service. A November 2010 VA examiner opined that the Veteran's coronary artery disease was less likely than not related to the chest pain he reported during his active service. As rationale, the VA examiner explained that there is no documentation between 1966 and 2005 related to the Veteran's heart or any complaints of chest pain. The VA examiner further explained that there was no documentation that the Veteran was seen during his active service for chest pains. As such, the VA examiner noted that the Veteran's 1966 complaints of chest pain were not the beginnings of coronary artery disease. After reviewing all evidence of record, the Board finds that the uncontradicted opinion from the VA examiner is the most persuasive evidence regarding the etiology of the Veteran's coronary artery disease. The examiner's conclusion followed an extensive examination of the Veteran and a review of his claims file, as well as consideration of reported history; therefore, the November 2010 VA examination is afforded great probative weight. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000) (noting that factors for assessing the probative value of a medical opinion include the medical expert's access to the claims file and the thoroughness and detail of the opinion). In summary, the most probative evidence of record does not support a finding that it is at least as likely as not that there is a causal relationship between the Veteran's coronary artery disease and his active military service. In light of the above, the preponderance of the evidence is against the claim and the benefit-of-the-doubt doctrine is not for application. The claim therefore must be denied. 38 U.S.C. § 5107 (b); see also Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). 2. Entitlement to compensation under 38 U.S.C. § 1151 for additional disability manifested by hypothyroidism is denied. 3. Entitlement to compensation under 38 U.S.C. § 1151 for additional disability due to surgical clip in left lower ankle is denied. 4. Entitlement to compensation under 38 U.S.C. § 1151 for additional disability due staple in lower left leg is denied. The appellant contends that the Veteran was entitled to compensation under 38 U.S.C. § 1151 for: (1) additional disability manifested by hypothyroidism; (2) additional disability due to failure by VA employees to remove a surgical clip in the left lower ankle; and (3) additional disability due to failure by VA employees to remove a staple in the lower left leg. The appellant contends that the Veteran's hypothyroidism was caused by medication prescribed after his February 2005 heart surgery and that the VA physicians failed to remove a surgical clip in the Veteran's left lower ankle and a staple in his lower left leg following the February 2005 surgery. Compensation under 38 U.S.C. § 1151 shall be awarded for a qualifying additional disability in the same manner as if that additional disability was service connected. A qualifying disability is one which is not the result of a Veteran's willful misconduct, and which was caused by hospital care, medical or surgical treatment, or examination furnished under any law administered by VA, and the proximate cause of the disability was (A) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination; or (B) an event not reasonably foreseeable. 38 U.S.C. § 1151 (a). To determine whether a Veteran has an additional disability, VA compares the condition immediately before the beginning of the hospital care, medical or surgical treatment, or examination upon which the claim is based to the condition after such care, treatment, or examination. VA considers each involved body part separately. 38 C.F.R. § 3.361 (b). To establish causation, the evidence must show that the hospital care, medical or surgical treatment, or examination resulted in the additional disability. Merely showing that the Veteran received care, treatment, or examination and that the Veteran has an additional disability does not establish cause. 38 C.F.R. § 3.361 (c) (1). Hospital care, medical or surgical treatment, or examination cannot cause the continuance or natural progress of a disease or injury for which the care, treatment, or examination was furnished unless VA's failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. 38 C.F.R. § 3.361 (c) (2). Additional disability caused by a Veteran's failure to follow properly given medical instructions is not caused by hospital care, medical or surgical treatment, or examination. 38 C.F.R. § 3.361 (c) (3). The proximate cause of disability is the action or event that directly caused the disability, as distinguished from a remote contributing cause. 38 C.F.R. § 3.361 (d). To establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing hospital care, medical or surgical treatment, or examination proximately caused a veteran's additional disability, it must be shown that the hospital care, medical or surgical treatment, or examination caused the additional disability. 38 C.F.R. § 3.361 (c). It must also be shown that VA (i) failed to exercise the degree of care that would be expected of a reasonable health care provider; or (ii) furnished the hospital care, medical or surgical treatment, or examination without the Veteran's or, in appropriate cases, representative's informed consent. 38 C.F.R. § 3.361 (d) (1). Whether the proximate cause of a Veteran's additional disability was an event not reasonably foreseeable is in each claim to be determined based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable, but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures of 38 U.S.C. § 17.32. 38 C.F.R. § 3.361 (d) (2). A review of the Veteran's VA treatment records reveals that the Veteran received 5-vessel coronary artery bypass surgery in February 2005 at a VA medical facility and was then prescribed amiodarone. See February 2005VA treatment record . As to the appellant's claim for entitlement to compensation under 38 U.S.C. § 1151 for hypothyroidism due to medication prescribed after the Veteran's February 2005 surgery, the Veteran was provided a VA examination in December 2012. The VA examiner noted that the Veteran was diagnosed with hypothyroidism in 2006 and opined that the condition was less likely as not due to the carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of Charleston VAMC in furnishing the hospital care, medical or surgical treatment, or examination. As rationale, the VA examiner explained that the medication, amiodarone, has the potential to cause hypothyroidism in long term use. The VA examiner further explained that there is no indication that the medication was utilized for long term and that the use in short term was not out of the standard of care as a lifesaving intervention. Therefore, there is no medical evidence this Veteran's use of the medication in question caused the claimed hypothyroid disease. As to the appellant's claim for entitlement to compensation under 38 U.S.C. § 1151 for additional disability due to failure by VA employees to remove a surgical clip in the left lower ankle and additional disability due to failure by VA employees to remove a staple in the lower left leg, the appellant claims that the Veteran suffered from foot problems and that an x-ray was taken in December 2010 that showed a staple was not removed from the Veteran's leg during his February 2005 heart bypass surgery. See January 2011 correspondence. The Veteran was provided a VA examination related to his left ankle and leg in February 2013. The VA examiner noted the Veteran had a surgical clip in his left lower leg/ankle. The VA examiner further noted that the Veteran had pain in his left ankle and that an x-ray demonstrated a surgical clip. The VA examiner further noted calcaneal spurs of the superior and inferior aspects which is at least as likely as not the source of the Veteran's pain. The VA examiner opined that the Veteran's left ankle/leg condition is less likely than not due to the carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the Charleston VAMC in furnishing the hospital care, medical or surgical treatment or examination. As rationale, the VA examiner explained that evidence of a remaining clip in the ankle where the saphenous vein was harvested for emergent CABG is no indication or sign of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault. The VA examiner further explained that it is often the practice and standard of care to utilize a "clip" for closure of saphenous vein tributaries. The VA examiner noted that residual pain of the ankle area is more likely as not associated with degenerative changes, as evident by radiographic findings. Initially, the Board notes that the questions for consideration involve complex medical issues and whether the VA medical professionals exercised the degree of care that would be expected of a reasonable health care provider. The appellant, as a lay person, is competent to report events such as when the Veteran was provided x-rays and given a diagnosis, as she personally witnessed those events. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, she has not been shown to possess the medical expertise or knowledge required to address the complex medical issues in question in the present case. See Jandreau v. Nicholson, 492 F. 3d 1372, 1377 n. 4 (Fed. Cir. 2007). Therefore, her statements do not constitute competent evidence that the Veteran experienced additional disability due to fault on the part of VA or due to an event not reasonably foreseeable. To determine whether the appellant is entitled to benefits under 38 U.S.C. § 1151, the Board turns to the competent evidence of record. The VA treatment records show that the Veteran had heart surgery in February 2005. The VA treatment records further reveal the Veteran received treatment for his claimed disabilities. The Board finds that the December 2012 and February 2013 examiners' opinions that found no evidence that VA care caused disability and that the proximate cause of the Veteran's left ankle pain is likely from degenerative changes are afforded probative weight. These opinions were based upon examination of the Veteran, a review of the medical records, included a discussion of relevant facts, and provided opinions that were adequately supported by a detailed rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). To the extent the appellant asserts negligence on the part of VA in furnishing the Veteran's care she does not possess the requisite medical expertise to do so. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). After a review of all the evidence, lay and medical, the Board finds that the weight of the evidence is against a finding that VA failed to treat a disease or injury related to the Veteran's claims for entitlement to compensation under 38 U.S.C. § 1151, or that the Veteran experienced additional disability due to fault on the part of VA or due to an event not reasonably foreseeable. Accordingly, the claims for compensation pursuant to 38 U.S.C. § 1151 must be denied. Increased Ratings Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and, above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," in all claims for increased ratings. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999). 5. Entitlement to a compensable initial rating for Boutonniere deformity of right hand little finger is denied. The appellant contends that the Veteran was entitled to a compensable initial rating for his service-connected Boutonniere deformity of right hand little finger. The applicable rating period is from March 29, 2010, the effective date for the award of service connection for Boutonniere deformity of right hand little finger. See 38 C.F.R. § 3.400. The Veteran's service-connected disability of the right fifth metacarpal is currently rated as noncompensably disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5230, which pertains to loss of motion of the little finger. Under Diagnostic Code 5230, a noncompensable rating is assigned for any limitation of motion in the little finger or ring finger. The Veteran underwent a VA hand and finger conditions examination in July 2013. At the examination the Veteran reported his hand gets sore with cramping and he was unable to do some carpentry work. Upon examination, the VA examiner noted painful motion that begins at a gap of less than 1 inch. There was no additional limitation of motion for any fingers post-testing. Additionally, there was no gap between any fingertips and the proximal transverse crease of the palm in attempting to touch the palm with the fingertips post-test. There was no limitation of extension. Upon review of the record, the Board finds that the preponderance of the evidence shows that a compensable initial rating was not warranted for the Veteran's service-connected disability of the right fifth metacarpal. Specifically, under the applicable diagnostic criteria, any limitation of motion of the little finger of either hand is noncompensable. 38 C.F.R. § 4.71a, Diagnostic Code 5230. Additionally, although 38 C.F.R. § 4.59 and Burton v. Shinseki, 25 Vet. App. 1 (2011), provide that actually painful, unstable, or mal-aligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint, there is no compensable rating for limitation of motion of the little finger; thus, a compensable rating cannot be awarded on that basis. As such, a compensable initial rating is not available under Diagnostic Code 5230. The appellant has not raised any other issues with regard to the rating for the service-connected Boutonniere deformity of right hand little finger nor have any other such issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017). The Board therefore finds that the criteria for entitlement to a compensable initial rating for the Veteran's Boutonniere deformity of right hand little finger have not been met at any time during the rating period. Accordingly, there is no basis for staged rating of the disability pursuant to Fenderson, 12 Vet. App. at 126-27. As the preponderance of the evidence is against the assignment of a compensable initial rating, the benefit-of-the-doubt doctrine is not for application, and the appeal must be denied. 38 U.S.C. § 5107 (b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 6. Entitlement to an increased initial rating for right hand little finger loss of sensation is denied. The appellant seeks an increased initial rating in excess of 10 percent for the Veteran's right hand little finger loss of sensation. The applicable rating period is from March 29, 2010, the effective date for the award of service connection for right hand little finger loss of sensation. See 38 C.F.R. § 3.400. The Veteran's right hand little finger loss of sensation is rated under 38 C.F.R. § 4.124a, Diagnostic Code 8515, which pertains to paralysis of the median nerve. Under those criteria, mild incomplete paralysis is rated at 10 percent for the major extremity. Moderate incomplete paralysis is rated at 30 percent for the major extremity. Severe incomplete paralysis is rated at 50 percent for the major extremity. Complete paralysis is rated at 70 percent for the major extremity. When there is complete paralysis of the median nerve, the hand is inclined to the ulnar side, the index and middle fingers are more extended than normally, considerable atrophy of the muscles of the thenar eminence is present, the thumb is in the plane of the hand (ape hand); pronation is incomplete and defective, there is an absence of flexion of index finger and feeble flexion of middle finger, a fist cannot be made, the index and middle fingers remain extended; the distal phalanx of thumb cannot be flexed, there is defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist is weakened; and there is pain with trophic disturbances. 38 C.F.R. § 4.124a. The words "mild," "moderate," and "severe" as used in the various Diagnostic Codes are not defined in the Rating Schedule. According to MERRIAM WEBSTER'S COLLEGIATE DICTIONARY (11th Ed. 2007), "mild" means temperate, not severe, or not being or involving what is extreme. "Moderate" means tending toward the mean or average amount, or not violent, severe, or intense. "Severe" means very painful or harmful or of a great degree. Regulations provide that ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at "Diseases of the Peripheral Nerves." The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). The Veteran was provided a VA hand and finger conditions examination in July 2013. The Veteran reported his hand gets sore with cramping and he was unable to do some carpentry work. The VA examiner remarked that the Veteran had loss of sensation on little finger to MCP joint. Upon examination, the Veteran had 5 out of 5 muscle strength and did not have ankylosis of the right little finger. Based on the evidence of record, the Board finds that the criteria for a rating in excess of 10 percent for right hand little finger loss of sensation have not been met. The medical treatment records show that the Veteran reported soreness and cramping in his right hand. The VA examination showed that the Veteran's symptoms attributable to the service-connected right hand little finger loss of sensation were no more than mild in severity. The Veteran did not have loss of muscle strength or ankylosis. Given the objective findings at the examination, the Board finds that the Veteran's symptoms, as documented in the record, were no worse than mild because they were temperate, not intense, and not involving extremes as to impairment in motor function, trophic changes, and sensory disturbances. The Board concludes that the Veteran's right hand little finger loss of sensation was most appropriately characterized as mild in severity during the entire rating period. Neither the appellant nor her representative has raised any other issues with regard to the rating for right hand little finger loss of sensation, nor have any other such issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017). The Board therefore finds that the criteria for entitlement to a rating in excess of 10 percent for right hand little finger loss of sensation have not been met at any time during the rating period. Accordingly, there is no basis for staged rating of the Veteran's right hand little finger loss of sensation pursuant to Hart, 21 Vet. App. at 519. As the preponderance of the evidence is against the assignment of a higher rating, the doctrine of reasonable doubt is not for application, and the claim must be denied. 38 U.S.C. § 5107 (b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 7. Entitlement to a compensable initial rating for right hand little finger scar is denied. The appellant seeks a compensable initial rating for the Veteran's right hand little finger scar. The applicable rating period is from March 29, 2010, the effective date for the award of service connection for right hand little finger scar. See 38 C.F.R. § 3.400. Scars not of the head, face, or neck that are superficial and linear are rated under 38 C.F.R. § 4.118, Diagnostic Codes 7802, 7804, and 7805. Under Diagnostic Code 7802, a 10 percent rating is warranted for a scar that is superficial, linear, and has an area of 929 square centimeters or greater. Under Diagnostic Code 7804, a 10 percent rating is warranted for one or two scars that are unstable or painful. Higher ratings, up to a maximum 30 percent, are warranted for additional scars that are unstable or painful. If one or more scars are both unstable and painful, 10 percent is to be added to the rating that is based on the total number of unstable or painful scars. 38 C.F.R. § 4.118, Diagnostic Code 7804, Note (2). Diagnostic Code 7805 provides that any disabling effects not considered in a rating provided under diagnostic codes 7800 through 7804 should be rated under an appropriate diagnostic code. The medical treatment records do not show that the Veteran received treatment for his service-connected scar and do not include descriptions of that scar. They do not show that the scar was painful or unstable, had an area of 929 square centimeters or greater, or had any other disabling effects during the relevant rating period. The July 2013 VA examiner noted that the Veteran had a faint scar on the PIP joint of his 5th finger. Upon examination, the scar was 4 cm long on the little finger. The examiner noted that the scar was not painful and/or unstable and the total area of all related scars was not greater than 39 square cm. During the July 2021 VA examination, the appellant testified that the Veteran did not complain of any symptoms related to the scar, including itching, burning, or tingling. Accordingly, throughout the relevant rating period, the Veteran's service-connected scar was superficial and linear, not painful, or unstable, and had an area of less than 929 square centimeters. There also is no indication in the record that the scar had disabling effects not considered under 38 C.F.R. § 4.118, Diagnostic Codes 7801, 7802, or 7804. Therefore, the Board finds that the criteria for entitlement to a compensable initial rating for the service-connected scar under 38 C.F.R. § 4.118, Diagnostic Codes 7801 through 7805 have not been met at any time during the appeal period. The Board therefore finds that the criteria for entitlement to a compensable initial rating for right hand little finger scar have not been met at any time during the relevant rating period. Accordingly, there is no basis for staged rating of the Veteran's service-connected scar. As the preponderance of the evidence is against the assignment of a compensable initial rating, the benefit-of-the-doubt doctrine is not for application, and the claim must be denied. 38 U.S.C. § 5107 (b); see also Gilbert, 1 Vet. App. 49. Neither the appellant nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND 1. Entitlement to service connection for basal cell carcinoma is remanded. The appellant contends that the Veteran had basal cell carcinoma that was directly related to his active service. Specifically, the appellant testified that the Veteran's basal cell carcinoma was related to sun exposure while serving in the United States Coast Guard. As such, there is an indication that the Veteran's basal cell carcinoma was related to his active service such that the threshold for providing an examination/opinion has been met. See 38 U.S.C. § 5103A (d)(2); 38 C.F.R. § 3.159 (c)(4)(i); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). The Board therefore finds that the issue must be remanded so that a medical opinion can be provided related to the Veteran's basal cell carcinoma. Further, in a September 2013 statement the Veteran reported that he received private treatment relating to his skin cancer beginning in 1983 from Dr. H. R. On remand, the appellant must be asked to complete authorization forms concerning any private medical treatment and/or submit copies of any relevant records. 38 U.S.C. § 5103A (c); 38 C.F.R. § 3.159 (c) (1). 2. The issue of entitlement to compensation under 38 U.S.C. § 1151 for valvular heart disease with myocardial infarction is remanded. The appellant seeks entitlement to compensation under 38 U.S.C. § 1151 for the Veteran's valvular heart disease with myocardial infarction. The appellant contends that the Veteran's mitral valve inserted during his surgery leaked and VA medical doctors refused to fix or replace the valve, which led to mitral valve regurgitation. See correspondence, received January 2011. The Veteran was provided a VA examination related to his heart in December 2012 to determine whether the Veteran's heart condition was as likely as not due to carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the Charleston VAMC in furnishing hospital care, medical or surgical treatment. The Board finds the December 2012 VA examination is inadequate for decision-making purposes because it does not contain consideration of relevant evidence of record and is conclusory. Specifically, the VA examiner merely stated that the Veteran's heart conditions were the result of co-morbidities over time. The VA examiner did not address the Veteran's February 2005 heart surgery or his mitral valve leakage. Therefore, the issue must be remanded so that an addendum opinion may be obtained to clarify whether the Veteran's valvular heart condition was at least as likely as not due to carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the Charleston VAMC in furnishing hospital care, medical or surgical treatment. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The matters are REMANDED for the following action: 1. Contact the appellant and request that she complete and submit to VA a signed authorization for disclosure of medical records to VA for each private medical health care provider from whom the Veteran received treatment for the disabilities at issue on appeal. The Board is specifically interested in records from Dr. H. R. After receiving any completed authorization form(s), undertake all appropriate efforts to attempt to obtain the identified records. All development efforts with respect to this directive should be associated with the claims file. The appellant is encouraged to submit directly to VA any outstanding, relevant medical records in her possession. 2. Only after obtaining records from Dr. H. R. or determining such records are not available, then forward the claims file to an examiner for an opinion as to whether it is at least as likely as not the Veteran's basal cell carcinoma was due to sun exposure during his Coast Guard service from 1961 to 1966. 3. Obtain an addendum opinion regarding whether it is at least as likely as not that the Veteran suffered an additional heart disability due to carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA or due to an event not reasonably foreseeable. The opinion should address the Veteran's argument that the surgeons should have done mitral valve repair when they did the bypass surgery and that because they did not, his heart condition worsened. MICHELLE L. KANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. G. LeMoine, 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.