Citation Nr: 21016119 Decision Date: 03/19/21 Archive Date: 03/19/21 DOCKET NO. 14-27 530 DATE: March 19, 2021 ORDER Entitlement to an initial rating in excess of 10 percent for left knee arthritis with meniscal tear is denied. Entitlement to an initial rating of 10 percent for instability associated with left knee arthritis with meniscal tear is granted from December 1, 2011. Entitlement to a compensable initial rating for anterior and posterior chest acne scars prior to April 18, 2014, is denied. Entitlement to an initial rating of 40 percent for anterior and posterior chest acne scars is granted from April 18, 2014. REMANDED Entitlement to service connection for a low back disability is remanded. FINDINGS OF FACT 1. The Veteran’s left knee arthritis with meniscal tear has been manifested by painful, limited motion that is not compensable under the relevant criteria for rating based on limited motion; it has not been manifested by frequent episodes of effusion into the joint. 2. The Veteran had slight instability of the left knee throughout the relevant period. 3. Prior to April 18, 2014, the Veteran’s anterior and posterior chest acne scars were not associated with underlying soft tissue damage, had a combined area of less than 929 square centimeters, were not unstable or painful, and did not result in other effects. 4. From April 18, 2014, the Veteran’s anterior and posterior chest acne scars were manifested in more than five scars that were both painful and unstable. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial rating in excess of 10 percent for left knee arthritis with meniscal tear 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 Codes 5010-5261 and 5258. 2. The criteria for entitlement to an initial rating of 10 percent for instability associated with left knee arthritis with meniscal tear have been met from December 1, 2011. 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 5257. 3. The criteria for entitlement to a compensable initial rating for anterior and posterior chest acne scars prior to April 18, 2014, 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, 4.118, Diagnostic Codes 7801, 7802, 7804, 7805. 4. The criteria for entitlement to an initial rating of 40 percent for anterior and posterior chest acne scars have been met from April 18, 2014. 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 7804. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from March 1987 to December 2011. In August 2017, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. The Board remanded this case in April 2018. Relevant to the issues decided herein, the April 2018 remand directed the Agency of Original Jurisdiction (AOJ) to afford the Veteran the opportunity to identify all outstanding, relevant treatment records from VA and non-VA health care providers, to include Quick Care and a surgeon in Barksdale who the Veteran referenced in his testimony at the August 2017 Board hearing; schedule the Veteran for an examination to determine the current nature and severity of his service-connected left knee disability; and schedule the Veteran for an examination to determine the current nature and severity of his service-connected anterior and posterior chest acne scars. Pursuant to the April 2018 remand, the AOJ obtained the Veteran’s outstanding VA treatment records; sent the Veteran a letter in May 2019 asking him to identify all outstanding private treatment records, including those specifically identified in the April 2018 remand; and afforded the Veteran VA examinations in October 2019 to determine the current nature and severity of the service-connected left knee disability and anterior and posterior chest acne scars. The October 2019 VA examinations provide the information required to render a decision on the appeals for higher initial ratings for the service-connected left knee disability and chest acne scars. Accordingly, the Board finds that VA at least substantially complied with the April 2018 remand. See 38 U.S.C. § 5103A(b); Stegall v. West, 11 Vet. App. 268, 271 (1998); D’Aries v. Peake, 22 Vet. App. 97, 105 (2008). The Board notes that in correspondence received in December 2019, the Veteran states that he returned a VA Form 21-4142 and a VA Form 21-4142a in response to the May 2019 letter, but that VA did not attempt to obtain the records identified on those forms. He also indicated that he was submitting copies of records from the medical sources listed on the forms. The record does not show that VA received the VA Form 21-4142 and VA Form 21-4142a the Veteran submitted in response to the May 2019 letter. However, in view of the Veteran’s submission of the outstanding records listed on the submitted forms, the Board finds that there are no properly identified but outstanding medical treatment records, and that a remand for further development in that regard is not required. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (holding that remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the claimant are to be avoided). The Board acknowledges the Veteran’s statement in the correspondence received in December 2019 that he “asked to be seen by a VA knee specialist, which was not provided for appeal purposes.” The Veteran has not provided any argument as to why examination by a knee specialist was required in this case or why the VA examination provided in October 2019 as to his left knee was inadequate for decision-making purposes. The Board finds that that examination was adequate for decision-making purposes because it provides the information required to render a decision as to the appeal for a higher initial rating for the service-connected left knee disability and because it was conducted by a competent medical source. Neither the Veteran nor his representative has otherwise 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). The analysis in this decision focuses on the most relevant evidence and on what the evidence shows or does not show with respect to the issues decided herein. The Veteran should not assume that evidence that is not explicitly discussed in the decision has been overlooked. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). 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). 1. Entitlement to an initial rating in excess of 10 percent for left knee arthritis with meniscal tear The Veteran seeks a higher initial rating for left knee arthritis with meniscal tear. The applicable rating period is from December 1, 2011, the effective date for the award of service connection for that disability, through the present. See 38 C.F.R. § 3.400. The Veteran has contended that he is entitled to a 20 percent rating under 38 C.F.R. § 4.71a, Diagnostic Code 5258, based on the meniscal tear aspect of the service-connected left knee disability. The Veteran’s left knee arthritis with meniscal tear is currently rated at 10 percent under 38 C.F.R. § 4.71a, Diagnostic Code 5010-5261. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating assigned. 38 C.F.R. § 4.27. The additional diagnostic code is shown after the hyphen. In this case, rating the Veteran’s service-connected left knee disability under Diagnostic Code 5010, which pertains to traumatic arthritis, requires the use of Diagnostic Code 5261, which pertains to limited extension of the leg. During the pendency of the appeal, the criteria for rating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes “to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities.” Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. Therefore, the Board will consider the Veteran’s appeal under the old criteria prior to February 7, 2021, and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. The regulatory changes reworded Diagnostic Code 5010 from “Arthritis, due to trauma, substantiated by X-ray findings” to “Post-traumatic arthritis”. Prior to the regulatory change, Diagnostic Code 5010 directed that the disability be rated as degenerative arthritis under Diagnostic Code 5003. Diagnostic Code 5003 directs that a rating shall be awarded on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. If noncompensable limitation of motion is demonstrated, a 10 percent rating is assigned for each major joint or group of minor joints affected. As of February 7, 2021, under the amended criteria, Diagnostic Code 5010 directs that the disability be rated as limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with 38 C.F.R. § 4.25. Further criteria for rating disabilities of the knees applicable in this case are found in 38 C.F.R. § 4.71a, Diagnostic Codes 5257, 5260, and 5261. Prior to the regulatory changes, under Diagnostic Code 5257, a 10 percent rating is warranted for slight recurrent subluxation or lateral instability; a 20 percent rating is warranted for moderate recurrent subluxation or lateral instability; and a 30 percent rating is warranted for severe recurrent subluxation or lateral instability. According to MERRIAM WEBSTER’S COLLEGIATE DICTIONARY 999 (11th Ed. 2007), “slight” means small in amount. “Moderate” means limited in scope or effect. “Severe” means very painful or harmful or of a great degree. Objective medical evidence is not required to establish lateral knee instability under Diagnostic Code 5257 as in effect prior to February 7, 2021. Therefore, objective medical evidence cannot be categorically found more probative than lay evidence with respect to that diagnostic code. See English v. Wilkie, 30 Vet. App. 347, 352-53 (2018). As of February 7, 2021, under Diagnostic Code 5257, a 10 percent rating is warranted when there is a sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation; or where there is a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. A 20 percent rating is warranted when there is a sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation; an unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation; or a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: A brace, cane, or walker. A 30 percent rating is warranted when there is an unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation; or there is a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. The regulatory changes did not affect Diagnostic Codes 5260 and 5261. Under Diagnostic Code 5260, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, a noncompensable rating is warranted for extension limited to 5 degrees. A 10 percent rating is warranted for extension limited to 10 degrees. A 20 percent rating is warranted for extension limited to 15 degrees. A 30 percent rating is warranted for extension limited to 20 degrees. A 40 percent rating is warranted for extension limited to 30 degrees. A 50 percent rating is warranted for extension limited to 45 degrees or greater. 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 an initial rating in excess of 10 percent based on limited motion under Diagnostic Codes 5010, 5260, and 5261 was not warranted during the relevant period. The Veteran’s service treatment records show that he had left knee extension to 5 degrees and flexion to 135 degrees in May 2011. An MRI of the left knee obtained in August 2011 showed changes in the cartilage due to repetitive trauma with small tears, but no gross tear that should require surgical intervention. At a VA examination conducted in October 2011 prior to the Veteran’s separation from active service, the Veteran reported that his left knee symptoms flare and that during such flare-ups his knee “hurts a lot worse but I can still move my knees”. On examination, the Veteran had left knee flexion to 125 degrees with objective evidence of pain at 125 degrees, both on initial testing and on repetitive-use testing; he did not have limitation of extension in the left knee. At an April 2014 VA examination, the Veteran stated that his knee will pop and buckle, and that it will dislocate when he squats, but will relocate with movement. His average left pain is at a 5 out of 10 and the pain is worse than a 10 out of 10 when the knee dislocates. He denied swelling in the knees, that he has a problem with using stairs due to the left knee, and that he has flare-ups in his left knee symptoms. On examination, he had had left knee flexion to 125 degrees without objective evidence of pain both on initial testing and on repetitive-use testing; he did not have limitation of extension in the left knee. At the October 2019 VA examination, the Veteran reported that his current left knee symptoms included constant, sharp, stabbing pain that worsens with sitting, walking, standing, squatting, and lifting over 30 pounds. He also reported bruising on the knee and swelling. He indicated that his left knee symptoms flare up. On examination, the Veteran had left knee flexion to 110 degrees and extension to 0 degrees both on initial testing and on repetitive use testing. The examiner opined that the Veteran’s flexion would decrease to 105 degrees on repetitive use over time due to pain and would decrease to 100 degrees during flare-ups due to pain. Thus, the record shows that the Veteran had painful motion of the left knee throughout the relevant period, but that he did not have left knee extension limited to 10 degrees or more or flexion limited to 45 degrees or less such that a compensable rating was warranted under Diagnostic Code 5260 or 5261 during the relevant period. As such, he was not entitled to a rating in excess of 10 percent at any time during the relevant period under Diagnostic Codes 5010, 5260, and 5261. The Board further finds that a separate rating of 10 percent for the service-connected left knee disability was warranted throughout the relevant rating period based on slight instability of the left knee. Specifically, in March 2011, the Veteran had no medial or lateral instability on testing. However, during the course of physical therapy in May 2011, he reported a feeling of giving way, instability, or dislocation in the knee. In August 2011, he reported a sensation of knee shifting or dislocating. On examination, his left knee was stable but he had guarding and was unable to shift the knee. The Veteran had normal stability testing at the October 2011, April 2014, and October 2019 VA examinations. However, he told the April 2014 VA examiner that his left knee pops and buckles, particularly when he squats. The examiner opined that the Veteran would have instability of station after repetitive use of the left knee. The October 2019 VA examiner indicated that on a squat examination, the Veteran had obvious pain and audible popping and that the Veteran had weakness and locking of the joint after several squats. Thus, in summary, the Veteran reported left knee instability during his active service just months prior to the relevant period. Although later instability testing was negative, he continued to report symptoms consistent left knee instability. The April 2014 VA examiner indicated that the service-connected left knee disability causes instability of station following repetitive use. Objective medical evidence is not required to establish lateral knee instability under Diagnostic Code 5257 as in effect prior to February 7, 2021. See English, 30 Vet. App. at 352-53. The Veteran’s left knee instability is considered slight in severity because objective testing has been negative and, more importantly, there is no indication in the record that the instability caused falls, caused other injuries, or was otherwise moderate or severe in terms of the pain or harm it caused. As such, the left knee instability warrants a 10 percent rating, and no higher, under Diagnostic Code 5257 as in effect prior to February 7, 2021, throughout the relevant rating period. The record does not show that the Veteran was entitled to a rating in excess of 10 percent for the service-connected left knee disability under Diagnostic Code 5257 as in effect beginning February 7, 2021. Specifically, the record does not show that the Veteran has been prescribed an assistive device for ambulation due to the service-connected left knee disability. The Board acknowledges the Veteran’s argument that he is also entitled to a rating of 20 percent under 38 C.F.R. § 4.71a, Diagnostic Code 5258, because his service-connected left knee disability involves a meniscal tear that causes locking, popping, and pain. Under Diagnostic Code 5258, a 20 percent rating is warranted for dislocation of semilunar cartilage with frequent episodes of “locking”, pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. The regulatory changes in effect beginning February 7, 2021, did not affect Diagnostic Code 5258. In this case, the record shows that the service-connected left knee disability causes frequent episodes of pain. The Veteran has also stated that he has episodes of locking, particularly when he squats. However, the record does not show that the disability causes frequent episodes of effusion into the joint, as is required for a compensable rating under Diagnostic Code 5258. Specifically, a May 2014 MRI showed a small effusion in the left knee. The record is otherwise absent for probative evidence showing that the Veteran has had frequent episodes of effusion in the left knee due to the service-connected left knee disability. In March and August 2011, the Veteran was found to have no effusion in the left knee. The October 2011, April 2014, and October 2019 VA examiners each indicated that the Veteran does not have frequent episodes of joint effusion. In that regard, the Board observes that the Veteran has reported swelling and bruising in the left knee, particularly after he squats. However, the October 2019 VA examiner considered those manifestations and nevertheless determined that the Veteran does not have frequent episodes of joint effusions. As the only competent evidence of effusion into the left knee is the single occurrence documented in the May 2014 MRI, the Board concludes that the Veteran’s service-connected left knee disability has not manifested in frequent episodes of effusion into the joint and that a compensable rating under Diagnostic Code 5258 is therefore not warranted. The Board notes that the October 2019 VA examination report does not include passive range-of-motion measurements and does not specify range of motion with and without weight-bearing. See Correia v. McDonald, 28 Vet. App. 158 (2016). The fundamental issue in view of Correia is that VA examinations must include adequate joint testing for pain. Generally, active range-of-motion testing produces more restrictive results than passive range-of-motion testing because passive range-of-motion testing requires the physician to force the joint through its motions, which results in measurements beyond what the Veteran could achieve through active motion. There is also no indication that range-of-motion testing was performed at the October 2019 VA examination other than on weight bearing. In addition, the October 2019 VA examiner provided opinions indicating that the Veteran would have additional functional loss on repetitive use over time and during flare-ups. The Veteran’s range of motion would likely be even more reduced in such instances compared to on passive motion and nonweight-bearing motion. Therefore, there is no prejudice to the Veteran in relying on a VA examination that involved active range-of-motion testing on weight-bearing and includes appropriate opinions as to additional functional loss on repetitive use over time and during flare-ups because such results tend to produce the most severe scenarios for impairment and thus would tend to support the highest possible rating. The Board has also considered the other diagnostic codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). However, in this case, the record does not show that the Veteran’s service-connected left knee disability has resulted in ankylosis of the knee or removal of the semilunar cartilage. Therefore, higher or additional ratings under Diagnostic Codes 5256 and 5259 are not warranted. Neither the Veteran nor his representative has raised any other issues with regard to the initial ratings for the service-connected left knee arthritis with meniscal tear, 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). In summary, the Board finds that, for the service-connected left knee disability, the criteria for an initial rating in excess of 10 percent under Diagnostic Codes 5010, 5260, and 5261 were not met, and that the criteria for a compensable initial rating under Diagnostic Code 5258 were not met. However, the criteria for entitlement to an initial rating of 10 percent under Diagnostic Code 5257 were met throughout the relevant period. To the extend the Veteran seeks initial ratings higher than or in addition to those previously assigned and those assigned herein, the preponderance of the evidence is against the appeal, the doctrine of reasonable doubt is not for application, and the appeal must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to a compensable initial rating prior to October 10, 2019, and in excess of 20 percent from that date for anterior and posterior chest acne scars The Veteran seeks a higher initial rating for anterior and posterior chest acne scars. The applicable rating period is from December 1, 2011, the effective date for the award of service connection for that disability, through the present. See 38 C.F.R. § 3.400. The Veteran contends that a 40 percent rating is warranted under 38 C.F.R. § 4.118, Diagnostic Code 7804, based on more than five scars that are both painful and unstable. The Veteran’s anterior and posterior chest acne scars are currently rated as noncompensable under 38 C.F.R. § 4.118, Diagnostic Code 7802, which pertains to scars not of the head, face, or neck that are not associated with underlying soft tissue damage; and at 20 percent from October 10, 2019, under Diagnostic Code 7804, which pertains to painful or unstable scars. VA amended the criteria for rating skin disabilities effective from August 13, 2018. Diagnostic Codes 7804 and 7805 were not changed by those amendments. Prior to August 13, 2018, Diagnostic Code 7802, was for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that were superficial and nonlinear. Under those criteria, a scar with an area or areas of 144 square inches (929 sq. cm.) or greater warrants a 10 percent rating. 38 C.F.R. § 4.118. Note 1 to Diagnostic Code 7802 instructed that a superficial scar was one not associated with underlying soft tissue damage. Id. Since August 13, 2018, Diagnostic Code 7802 is for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are not associated with underlying soft tissue damage. 38 C.F.R. § 4.118. The rating criteria under Diagnostic Code 7802 did not change. 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. Note 2 to Diagnostic Code 7804 instructs that if one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Diagnostic Code 7805 instructs that any disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-04 under an appropriate diagnostic code. The Board finds that the preponderance of the evidence is against the assignment of a compensable rating prior to April 18, 2014. However, from April 18, 2014, a rating of 40 percent was warranted under Diagnostic Code 7804. At an October 2011 VA examination, the Veteran reported that he had treatment of mild acne of the face, neck, chest, and back in 1978 and that he had extensive scarring of the chest and back due to the acne. On examination, he had approximately 30 hypopigmented acne scars on the chest having a total measurement of 8 centimeters by 3 centimeters and approximately 25 hypopigmented acne scars on the posterior trunk having a total are of 10 centimeters by 5 centimeters. The combined area of the scars on the chest and posterior trunk was 74 square centimeters. The scars were neither painful nor unstable and did not cause functional impairment. The findings at the October 2011 VA examination do not establish that a compensable rating was warranted under Diagnostic Codes 7802, 7804, or 7805 because the acne scars of the anterior and posterior chest did not have an area of 929 square centimeters, were not painful or unstable, and did not cause other effects not considered under Diagnostic Codes 7802 and 7804. At an April 2014 VA examination, the Veteran reported that his scars are prone to sunburn and that they itch when he wears rough textured clothing, but there is no oozing or draining from any of the scars. The scars were neither painful nor unstable on examination. The examiner indicated that the scars on the chest and posterior trunk are “too numerous to count”, hypopigmented, slightly raised or superficially pitting, not tender to palpation, and have a combined area of 100 square centimeters. On his June 2014 VA Form 9, the Veteran clarified that the chest acne scars are painful in that contact with clothing causes “uncontrollable itching” and they are unstable in that when he itches them they break open and bleed. Those reports were confirmed by the October 2019 VA examiner, who noted that the Veteran has five or more scars on the trunk that are painful and unstable. The Board concludes that the Veteran’s statement on the June 2014 establishes that, as of April 18, 2014, the date of the VA examination where he reported that the anterior and posterior chest acne scars become are irritated by clothing, become itchy, and break open when itched, the criteria for an initial rating of 40 percent were met under Diagnostic Code 7804 because the scars numbered greater than five and were both painful and unstable. The Board further finds that the criteria for an initial rating in addition to or in excess of 40 percent for the anterior and posterior chest acne scars were not met during the period from April 18, 2014. 40 percent is the highest schedular rating warranted under Diagnostic Code 7804. The April 2014 and October 2019 VA examinations do not indicate that the scars had an area of 929 square centimeters or greater or caused other effects not considered under Diagnostic Codes 7802 and 7804 such that a separate compensable rating was warranted under Diagnostic Code 7802 or 7805. The Board has also considered the other Diagnostic Codes pertaining to scars. However, the Veteran’s anterior and posterior chest acne scars are not of the head, face, or neck, are not deep and nonlinear, 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 929 square centimeters or greater. Therefore, Diagnostic Codes 7800 and 7801, both prior to and from August 13, 2018, are inapplicable. The Board acknowledges the Veteran’s reports that his service-connected anterior and posterior chest acne scars make him feel anxious and self-conscious. The rating schedule provides ratings for psychiatric disabilities under 38 C.F.R. § 4.130. However, the record does not show that the Veteran’s reported feelings of self-consciousness and anxiousness have been associated with a diagnosed psychiatric disability such that those feelings would be compensable in the first instance. Therefore, those manifestations do not warrant a referral for extraschedular consideration. See Long v. Wilkie, 2020 U. S. App. Vet. Claims Lexis 2371, 13 (2020). Neither the Veteran nor his representative has raised any other issues with regard to the ratings for the service-connected anterior and posterior chest acne scars, 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). In conclusion, the Board finds that the criteria for entitlement to an initial rating of 40 percent, and no higher, have been met for the service-connected anterior and posterior chest acne scars from April 18, 2014, under Diagnostic Code 7804. To the extent the Veteran seeks initial ratings higher than or in addition to those assigned previously and assigned herein, the preponderance of the evidence is against the appeal, the doctrine of reasonable doubt is not for application, and the appeal must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND Entitlement to service connection for a low back disability is remanded. The Veteran contends that he first had back pain in 2009 while he was stationed in Alaska and that the pain has continued through the present. He has submitted medical evidence showing that in October 2016 was treated for lumbar strain and muscle spasm. He was provided VA examinations as to his claim for entitlement to service connection for a low back disability in October 2011 and April 2014. However, neither of those VA examiners provided an opinion as to whether the current low back disability may be related to the in-service low back issues. The issue must be remanded so that such an opinion may be obtained. The matter is REMANDED for the following action: Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s low back disability is at least as likely as not (50 percent probability or greater) related to related to an in-service event, injury, or disease. The examiner must consider the Veteran’s assertions that he had an incapacitating episode of low back pain in 2009 while he was stationed in Alaska and has had back pain since then. In considering those assertions, the examiner must note that a lack of contemporaneous medical evidence does not, in and of itself, render lay evidence not credible, but may be considered in conjunction with other factors in determining the credibility of lay evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). The examiner must also consider the October 2016 private treatment records showing that the Veteran was treated for lumbar strain and muscle spasm at that time. MICHAEL MARTIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. J. Anthony, 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.