Citation Nr: 21076999
Decision Date: 12/28/21	Archive Date: 12/28/21

DOCKET NO. 18-23 883
DATE: December 28, 2021

REMANDED

A compensable rating for status post left unguus incarnatum is remanded.

REASONS FOR REMAND

The Veteran served on active duty from June 1978 to October 1979, September 1983 to October 1992, and September 2001 to September 2003.  The Board thanks him for his service.  He appeals from a June 2014 agency of original jurisdiction (AOJ) rating decision that granted service connection for the left ingrown toenail disability at issue and assigned it a noncompensable rating pursuant to 38 C.F.R. § 4.118, Diagnostic Code 7819, which is for benign skin neoplasms and advises in part to rate them based on impairment of function.    

In October 2021, the Veteran testified during a virtual hearing before the undersigned Veterans Law Judge. The hearing transcript is not currently associated with the record. However, as the instant decision remands the issue for additional development that will not be affected by the hearing testimony, there is no prejudice to the Veteran by proceeding without the hearing transcript.

During the October 2021 hearing, the Veteran testified about treatment he has received from a VA primary care provider named Dr. Desouza, and from a private provider whose name he could not remember at the time.  These records are not in the claims folder and should be obtained pursuant to VA's duty to assist.  

A May 2014 VA examination report shows that there is evidence of a prior left toenail removal.  Conceptually, it is possible that he is entitled to a compensable rating under Diagnostic Code 7804, on the basis of or by analogy to painful or unstable scarring caused by this disability. 

The Veteran contends that his condition has worsened since the May 2014 VA examination. The Board notes that he submitted poor quality photocopies of foot photographs in September 2018.  

Accordingly, after all additional available relevant medical records are obtained, a VA examination should be scheduled as indicated below, also as part of VA's duty to assist the Veteran.  

The matter is REMANDED for the following action:

1. Obtain any additional relevant VA medical records of treatment which the Veteran has received from VA health care provider Desousa, including all VA medical records of treatment he has received since April 2020.  

2. Ask the Veteran to complete a VA Form 21-4142 for the private health care provider whose treatment the Veteran discussed during his October 2021 hearing. Make two requests for the authorized records, unless it is clear after the first request that a second request would be futile.

3. After the above development is complete, schedule an examination to determine the nature and severity of the Veteran's service-connected status post left unguus incarnatum.  In examining the Veteran, the examiner should elicit the Veteran's subjective complaints, report all clinical findings in detail, including any as to scars or scar symptoms.

Please take color photographs of this condition and include them as part of the examination report. 

Please identify any functional impairment and discuss the effect of this disability on any occupational functioning and activities of daily living.

 

 

Rebecca N. Poulson

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	C. Lawson

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.