Citation Nr: 21020699 Decision Date: 04/08/21 Archive Date: 04/08/21 DOCKET NO. 16-23 459 DATE: April 8, 2021 ORDER A compensable rating for a scrotal area epidermal inclusion cyst is denied. FINDING OF FACT Throughout the entire period on appeal, the Veteran’s scrotal area epidermal inclusion cyst has manifested as superficial nodules that are stable and non-painful, cover less than five percent of unexposed areas of total body area, and no area of exposed skin, cover an area of less than six square inches, do not require treatment with the use of medication, and do not cause functional limitations. CONCLUSION OF LAW Throughout the entire period on appeal, the criteria for a compensable rating for a scrotal area epidermal inclusion cyst have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.118, Diagnostic Code (DC) 7819. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from October 1990 to October 1995. This matter was previously before the Board of Veterans’ Appeals (Board) in October 2018 when the issue was remanded for further development. Further development having been completed; the matter is once again before the Board. Increased Ratings VA has adopted a Schedule for Rating Disabilities to evaluate service-connected disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 3.321; see generally, 38 C.F.R. § Part IV. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. The percentage ratings in the Schedule for Rating Disabilities represent, as far as practicably can be determined, the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes (“DC”s) identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. All reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3; see also 38 C.F.R. § 3.102. Separate ratings for distinct disabilities resulting from the same injury or disease can be assigned so long as the symptomatology for one condition is not "duplicative or overlapping with the symptomatology" of the other condition. See Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009); Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). However, the evaluation of the same disability or its manifestations under various diagnoses, which is known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Because the level of disability may have varied over the course of the claim, the rating may be "staged" higher or lower for segments of time during the period under review in accordance with such variations, to the extent the evidence shows distinct time periods where the service-connected disability has exhibited signs or symptoms that would warrant different ratings under the rating criteria. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102 (providing, in pertinent part, that reasonable doubt will be resolved in favor of the claimant). When the evidence supports the claim, or is in relative equipoise, the claim will be granted. See Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990); see also Wise v. Shinseki, 26 Vet. App. 517, 532 (2014). If the preponderance of the evidence weighs against the claim, it must be denied. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). A compensable rating for a scrotal area epidermal inclusion cyst is denied. The Veteran contends that his service-connected epidermal inclusion cyst in the scrotal area, which is currently rated under DC 7819, is worse than rated due to pain. The preponderance of the evidence is against the claim and the appeal will be denied. An October 2013 ultrasound report of the testicles noted a clinical history of left side pain. Small epididymal cysts measuring 1mm x 3mm on the right and left epididymal head were noted. No evidence of testicular torsion was noted, and no other indications of pain was noted. The Veteran was afforded a VA examination in February 2014 for a separate male reproductive condition. The examiner noted that an October 2013 ultrasound found epididymal cysts measuring 1mm x 3mm on the right and left epididymal head. The examiner noted that there was no evidence of testicular torsion, and no other indications of pain was noted. In July 2015, the Veteran stated that his scrotal cysts continue to grow in the scrotal area. In May 2016, the Veteran stated that his scrotal cysts are painful. In October 2016 through his representative, the Veteran reported that his condition is painful and causes discomfort and argued the disorder should be rated under DCs 7801-7805 for scars that are unstable or painful. A scrotal ultrasound was performed in October 2017. A clinical history of testicular pain was noted. The presence of small bilateral epididymal cysts, small bilateral hydroceles, and bilateral testicular microlithiasis were noted. The left was noted as the largest with a measurement of .5cm x .4cm. The examiner noted that there was no evidence of testicular torsion, and no other indications of pain was noted. Pursuant to the October 2018 Board remand, the Veteran was afforded a VA examination for skin diseases in November 2018. The examiner noted a diagnosis of epidermal inclusion cyst. Three cysts were noted at the base of the scrotum. The cysts were noted as firm, nodular masses less than 5mm in circumference, which are tender to palpation. Painful ejaculation was noted as due to erectile dysfunction but was noted as unrelated to the epidermal inclusion cysts. The examiner noted that the Veteran has not been treated with medication nor has he had any treatments or procedures other than systemic or topical medications in the past 12 months for his cyst condition. The total body area affected by the cyst condition was noted as less than 5 percent with no exposed area affected. No tumors or neoplasms were noted. The examiner noted that an October 2017 ultrasound showed small bilateral hydroceles, small bilateral epididymal cysts, and bilateral testicular microlithiasis A February 2019 ultrasound showed the presence of benign calcifications in the skin, which were noted as not concerning and noted as posing no health risk. It was noted that removal would be cosmetic only. Bilateral epididymal appendages were noted as measuring up to .7cm. A February 2019 primary care note indicates that the Veteran indicated that he is disturbed about pain that he reported experiencing with the calcifications. Another February 2019 primary care note indicates the presence of six hard “bb” like nodules on the scrotum, which the Veteran reported cause him pain when he ejaculates. However, the examiner noted that the nodules were not painful. A June 2019 ultrasound showed a 3mm epididymal head cyst bilaterally and two areas of shadowing calcification superficially along the posterior scrotum measuring 8mm and 4mm. A July 2019 primary care note referring to a recent ultrasound indicated the presence of testicular scar tissue that is too small to consider removal. No other changes from the previous ultrasound were indicated. Pain and tenderness in the testicular area was noted. A January 2020 primary care outpatient note indicates that the Veteran reported testicular pain, which he believes is due to calcified nodules found on the testicular ultrasound. It was also noted that the Veteran treats his testicular pain with Flomax. In a September 2020 Disability Benefits Questionnaire (DBQ), the examiner noted a noted a diagnosis of epidermal inclusion cyst. Current symptoms of soreness in the testicles was noted, with increased soreness with prolonged sitting. Painful ejaculation was noted as due to erectile dysfunction. Multiple, subcutaneous, mobile, small, non-tender nodules were noted bilaterally along with urethra and base of penis. The presence of benign neoplasms was noted with residual complications of painful ejaculation and erectile dysfunction. No other pertinent findings were noted, and no scars were noted. The examiner referred to the October 2017 testicular ultrasound, which indicated the presence of small bilateral epididymal cysts, small bilateral hydroceles, and bilateral testicular microlithiasis. In particular, the examiner noted that epidermal cysts arise directly from the infundibulum of the hair follicle, whereas hydrocele can develop as a result of injury or inflammation within the scrotum, which might be caused by an infection in the testicle or in the small, coiled tube at the back of each testicle. The examiner stated that the cause of testicular microlithiasis is unknown, but that medical literature theorizes a number of potential origins; none of which were noted to be epididymal cysts. Notably, the examiner stated that the medical literature does not support epidermal inclusion cysts causing other symptoms of the testicles, to include hydroceles or microlithiasis. In terms of functional impact, the examiner noted that the Veteran needs to stop frequently while driving and that sitting for long periods of time is uncomfortable. DC 7819 contemplates benign skin neoplasms and directs that the disability be rated as disfigurement of the head, face, or neck (DC 7800), scars (DCs 7801-7805), or impairment of function. The Veteran contends that his scrotal area epidermal inclusion cyst condition warrants a compensable rating due to pain. Under DC 7804, a 10 percent rating for one or two scars that are unstable or painful, 20 percent for three or four such scars, and 30 percent for five or more such scars. Note (1) provides that an unstable scar is one where, for any reason, there is frequent loss of covering of the skin over the scar. Note (2) provides for adding another 10 percent where one or more scars are both unstable and painful. Note (3) provides that scars evaluated under DCs 7800 to 7802, and 7805, may also receive a separate evaluation under this code when applicable. 38 C.F.R. § 4.118, DC 7804. The evidence indicates that the Veteran has reported painful ejaculation, which has been linked to erectile dysfunction and unrelated to the epidermal inclusion cysts. The record also indicates reported pain, tenderness, and soreness in the testicular area, a condition that the Veteran treats with Flomax medication, which is used to treat benign prostatic hyperplasia. Specifically, as it relates to the Veteran’s cyst condition, he has reported that his cysts are painful. However, the medical evidence of record indicates that the Veteran’s cysts are superficial and tender, but not painful, and the record does not indicate that the Veteran’s cysts are unstable. Thus, the preponderance of the evidence of record does not indicate that the Veteran’s cysts are unstable or painful. Therefore, a compensable rating under DC 7804 is not warranted. A higher rating under DC 7800 is not warranted since the Veteran’s condition is not of the head, face, or neck. 38 C.F.R. § 4.118, DC 7800. A higher rating under DCs 7801 and 7802 is not warranted since there is no evidence that the Veteran's cysts are associated with underlying soft tissue damage and do not cover an area or areas of at least 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.), and because there is no evidence that the Veteran's cysts cover an area or areas of 144 square inches (929 sq. cm.) or greater. 38 C.F.R. § 4.118, DC 7801, 7802. A higher rating under DC 7805 is not warranted since there is no evidence of any disabling effects or functional limitations due to the Veteran’s condition. 38 C.F.R. § 4.118, DC 7805. Lastly, a higher rating under DC 7806 is not warranted since the evidence does not show that the condition involves more than 5 percent of the Veteran's entire body or exposed areas, and there is no evidence of intermittent systemic therapy or other immunosuppressive drugs such as corticosteroids. 38 C.F.R. § 4.118, DC 7806. (Continued on the next page.) The preponderance of the evidence weighs against a finding that the Veteran's scrotal area epidermal inclusion cyst condition warrants a compensable disability rating. The benefit-of-the-doubt rule does not apply, and a compensable disability rating is denied. See 38 U.S.C. §§ 1155, 5107; Gilbert, 1 Vet. App. at 55-57. Vito A. Clementi Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Timothy T. Emmart 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.