Citation Nr: 21070286 Decision Date: 11/23/21 Archive Date: 11/23/21 DOCKET NO. 15-05 485 DATE: November 23, 2021 REMANDED Entitlement to an initial rating in excess of 10 percent for a painful scar of palmar aspect on 4th digit, left hand (left hand scar) is remanded. Entitlement to an initial compensable rating for a painful scar, dorsal aspect, left index finger, proximal phalanx, and palm at base (left upper extremity scars) prior to July 13, 2020, in excess of 10 percent prior to September 13, 2020, and in excess of 20 percent thereafter is remanded. Entitlement to a total disability rating, based on individual unemployability, due to service-connected disabilities (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1976 to September 1976. In August 2018, the Veteran testified at a videoconference Board hearing before the undersigned. A transcript of that hearing is of record. In March 2020 and May 2021, the issues were remanded for further development. While the claim was in remand status, in an October 2021 rating decision, the RO increased the Veteran's disability ratings for a left hand scar to 20 percent, effective September 13, 2021. Because the increase in the evaluation of the service-connected left hand scar does not represent the maximum rating available, the initial evaluation claim remains in appellate status. See AB v. Brown, 6 Vet. App. 35 (1993). As such, the Board has framed the issue on appeal as reflected on the title page. See, too, Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). 1. Entitlement to an initial rating in excess of 10 percent for a left hand scar 2. Entitlement to an initial compensable rating for left upper extremity scars prior to July 13, 2020, in excess of 10 percent prior to September 13, 2020, and in excess of 20 percent thereafter, is remanded. As noted in the Board's May 2021 remand, the Veteran was afforded a VA examination in July 2020, which did not adequately discuss the totality of the impairment caused by the Veteran's left hand and left upper extremity scars. As such, and in accordance with the Board's May 2021 remand directives, he was afforded another VA scars examination in September 2021. However, the Board finds that the September 2021 examination also fails to adequately discuss the totality of the impairment caused by the Veteran's scars. Specifically, since the Veteran's first VA examination in February 2011, the Veteran has been noted to have decreased left-hand strength, decreased motion, and decreased sensation in the left hand. The September 2021 examiner noted the Veteran's reports of decreased grip strength and decreased fine motor skills for buttoning and opening medication bottles, and noted that there was no loss of range of motion noted for the left hand on examination. However, there are no specific findings related to range of motion of the digits of the left hand or wrist, motor strength, grip strength, or neurological impairment. The Board notes that disabling effects not considered under diagnostic code 7804 should be considered under other appropriate diagnostic codes. See 38 C.F.R. §4.118, Diagnostic Code 7805. As such, the Board finds that the Veteran should be afforded a complete examination of the hand. It should be determined whether the Veteran's 4th digit scar or left upper extremity scars effect sensation, strength, and movement of the left hand, and those findings must be documented in detail. 3. Entitlement to a total disability rating, based on individual unemployability, due to service-connected disabilities (TDIU) is remanded. The Veteran is currently service-connected for painful scar, dorsal aspect, left index, proximal phalanx, and palm at base (20% disabling); painful scar of palmar aspect on 4th digit, left hand (10% disabling); scar, left lower extremity, donor site for hand graft (10% disabling); and history of cellulitis, left hand (0% disabling). He has a combined disability rating of 40 percent since September 13, 2021. Thus, he does not currently meet the percentage requirements for TDIU under 38 C.F.R. § 4.16 (a). A TDIU can be awarded on an extraschedular basis under 38 C.F.R. § 4.16 (b), but the Board cannot consider such entitlement in the first instance. Instead, the claim must be remanded so that it can be referred to VA's Director of Compensation Service for initial consideration. Bowling v. Principi, 15 Vet. App. 1 (2001). The Veteran reported in a January 2013 statement in support of claim that decreased motion in the left hand, as a result of his left hand and left upper extremity scars caused problems with working. His reports are supported by the findings on the July 2020 and September 2021 VA examinations that decreased grip strength and pain, as a result of his scars impacted his ability to work in that they made it difficult to grasp certain objects and button and open bottles and made it difficult for him to use his walker. The Board notes that it does not have a sufficient amount of information regarding the Veteran's employment history to make a determination regarding entitlement to TDIU. In this regard, the RO has not requested and thus, the Veteran has not submitted, a VA Form 21-8940 providing an education and employment history, which would greatly assist the Board in making a determination on the issue of TDIU. The Board also notes that because a decision on the remanded increased rating issues could significantly impact a decision on the TDIU issue, the issue is inextricably intertwined. The matters are REMANDED for the following action: 1. Updated treatment records should be obtained and added to the claims folder/efolder. 2. Send the Veteran a letter advising him of the information and evidence needed to award a TDIU. This letter should also request that he complete a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, in order to provide the information needed to substantiate the claim of TDIU. 3. Following completion of the above, schedule the Veteran for an examination by an appropriate clinician(s) to determine the current severity of his service-connected left hand and left upper extremity scars. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. The electronic entire claims folder should be made available to the examiner for review prior to the examination and the examiner should acknowledge such review in the examination report or in an addendum. The examiner is asked to comment upon any and all limitations related to his service-connected scars, and to describe with specificity all symptomatology and functional impairment due to the left hand scar and left upper extremity scars, including any loss of use, motion, sensation, and/or strength. The ranges of motion of the fingers of the left hand shall be reported in degrees. The examiner shall also specifically answer the following question with respect to all appropriate ranges of finger motions: What is the extent of any additional limitation of finger motion (in degrees) due to weakened movement, excess fatigability, incoordination, pain, and/or flare-ups? In this regard, some speculation/conjecture on the examiner's part may be necessary. The examiner shall also report the size of any gap between the thumb pad and the fingers or between the tip of the index or long finger and the proximal transverse crease of the palm. The examiner shall also report whether there is ankylosis of any finger of the left hand. If ankylosis is present, the examiner shall specifically identify which joints are involved and whether the ankylosis is favorable or unfavorable. The examiner shall also indicate whether it is at least as likely as not (50 percent probability or more) that any functional impairment from the Veteran's service-connected left hand and left upper extremity scars results in loss of use of the left hand (i.e., the Veteran would be equally well served by amputation with prostheses at the site of election). In addition to performing a complete orthopedic examination, the examiner shall determine the existence and extent of any neurologic manifestations related to the Veteran's service-connected left hand and left upper extremity scars, including any found during any nerve conduction and/or electromyography studies conducted. The examiner must specifically state whether any neurologic manifestations found to be related to the Veteran's service-connected left hand scar or left upper extremity scars results in complete or incomplete paralysis of any nerve. The specific nerves involved must be identified. If incomplete paralysis is found, the examiner must state whether the incomplete paralysis is best characterized as mild, moderate, or severe; with the provision that wholly sensory involvement should be characterized as mild, or at most, moderate. The examiner should also address any functional impairment caused by the neurological abnormalities. 4. When the development requested has been completed, the case should be reviewed by the RO on the basis of additional evidence. If the benefit sought on appeal is not granted, the AOJ should issue a supplemental statement of the case, before returning the case to the Board, if otherwise in order. KELLI A. KORDICH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board F. Yankey, 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.