Citation Nr: 21028532 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 17-10 770A DATE: May 11, 2021 ORDER Service connection for status post hair replacement is denied. Service connection for an eye disability, other than dry eye syndrome, status post photorefractive keratectomy is denied. Service connection for bilateral shin splints is denied. Service connection for posttraumatic stress disorder (PTSD) is granted. A rating higher than 10 percent for bilateral dry eye syndrome is denied. A rating higher than 50 percent for a psychiatric disability, to include adjustment disorder with mixed anxiety and depressed mood is denied. A 30 percent rating for pseudofolliculitis barbae (PFB) and post-inflammatory hyperpigmentation (PIH) or melanoderma (hereinafter referred to collectively as PFB) as of December 17, 2019 is granted. A rating higher than 50 percent for migraines with aura is denied. REMANDED Service connection for a left shoulder condition is remanded. Service connection for a right shoulder condition is remanded. FINDINGS OF FACT 1. The preponderance of the evidence indicates that the Veteran's hair loss was congenital; and that there is no disability related to the elective hair replacement procedure conducted during service. 2. The preponderance of the evidence is against a finding that the Veteran currently has a diagnosed eye disability other than dry eye syndrome. 3. The preponderance of the evidence is against a finding that the Veteran currently has a diagnosed disability related to shin splints. 4. The evidence is in relative equipoise regarding whether the Veteran has a PTSD diagnosis related to service. 5. During the appeal period, the Veteran's dry eye syndrome has not caused decreased visual acuity; symptoms have been no worse than dry eye with blurriness and irritation, comparable to active conjunctivitis. 6. During the appeal period, psychiatric symptoms have resulted in occupational and social impairment with reduced reliability and productivity, but not with deficiencies in most areas or total impairment 7. The preponderance of the evidence is against a finding that during the appeal period, the Veteran's PFB has manifested in a rash or characteristic lesions on at least 20 percent of total or exposed body area; treatment has not consisted of systemic therapy; as of December 17, 2019, the evidence indicates two characteristics of disfigurement. 8. During the appeal period, the Veteran's migraines have been manifested by very frequent completely prostrating and prolonged attacks of headache pain productive of severe economic inadaptability; these symptoms have been contemplated by the applicable rating criteria. CONCLUSIONS OF LAW 1. The criteria for service connection for hair loss and status post hair replacement are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for an eye disability, other than dry eye syndrome, status post photorefractive keratectomy are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for bilateral shin splints are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for PTSD are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for a rating higher than 10 percent for bilateral dry eye syndrome are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.79, Diagnostic Code (DC) 6018. 6. The criteria for a rating higher than 50 percent for a psychiatric disability are not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.130, DC 9440. 7. As of December 17, 2019, the criteria for a 30 percent rating for PFB are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, DC 7899-7806. 8. The criteria for a rating higher than 50 percent for migraines with aura have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.124a, DC 8100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 2002 to February 2013. This matter is before the Board of Veterans' Appeals (Board) on appeal from a July 2014 rating decision. The Board remanded the claim in September 2019 for further development, including to obtain VA examinations for the claims. As the necessary development has been completed, the Board will proceed with adjudication. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. To establish a service connection for a disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). That determination requires a finding of current disability that is related to an injury or disease in service. Watson v. Brown, 4 Vet. App. 309 (1993). Service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury that was incurred or aggravated in service. 38 C.F.R. § 3.303(d). A Veteran need only demonstrate that there is an approximate balance of positive and negative evidence to prevail. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 519 (1996). Status post hair replacement The Veteran claims that hair loss was due to service. Specifically, the Veteran reported that hair loss began in 2005 during service, and he believed it was related to stress. In September 2010, the record indicates that the Veteran underwent elective hair restoration or replacement treatment. At a November 2011 VA examination, the examiner noted that the Veteran described hair loss and a receding hair line consistent with male pattern baldness. The examiner noted that the hairline was no longer receded. There were no other findings related to the hair noted. July 2017 VA medical records noted a long transverse scar along the back of the head, which was an old surgical scar from a hair transplant procedure. At a December 2019 VA skin examination, the examiner noted a diagnosis of status post hair replacement. The examiner noted reduced hair at the frontal scalp. No other findings related to the hair replacement were made. The examiner provided a positive nexus opinion based on the fact that the hair replacement occurred during service. The Board finds that service connection for hair loss, including status post hair replacement surgery, is denied. The evidence indicates that the Veteran began experiencing congenital, male pattern baldness during service. There is no evidence that the hair loss was caused by service or incurred in service for a reason other than a congenital defect. Further, elective/ameliorative procedures without unusual results or additional disability attributed to the procedure are not eligible for service connection. The only residual apparent in the record is a treatment scar from the hair replacement. This is an expected result of the procedure. There is no additional disability that can be attributed to the hair replacement procedure. The Board notes that the December 2019 examiner provided a positive nexus. However, the opinion provided was simply that hair replacement occurred during service, therefore a nexus was established. The Board must make the legal findings related to elective procedures. In this case, the Board finds that the preponderance of the evidence indicates that the Veteran's hair loss was congenital, and that the elective hair replacement procedure did not cause unusual results or additional disability. Therefore, the claim for service connection must be denied. An eye disability, other than dry eye syndrome The Veteran filed a claim for "post photorefractive keratectomy." By way of history, the Veteran underwent photorefractive keratectomy (PRK) during service to correct a congenital refractive error. The evidence indicates that the procedure resulted in the development of dry eye syndrome. The Veteran has already been service connected for dry eye syndrome secondary to PRK. The evidence indicates that the Veteran has dry eye syndrome and meibomian gland dysfunction secondary to PRK. A September 2015 VA medical record also notes a congenital cataract. However, there is no evidence of additional eye diagnosis other than service-connected dry eye syndrome that may be related to service or caused by the in-service PRK. At a December 2019 VA examination, the examiner noted a right eye stye, that was partially drained at the examination. The examiner noted a 2016 acute diagnosis of allergic conjunctivitis. However, there were no clinical signs or symptoms at the examination. Therefore, no additional diagnosis related to the eyes was made. In sum, the Veteran does not have a diagnosed eye disability other than dry eye syndrome, for which he is already service connected. In the absence of a diagnosed eye condition, the claim for service connection must be denied. Bilateral shin splints The Veteran claims shin splints are related to service. At a December 2019 VA examination, the Veteran reported the onset of shin and/or knee pain during service. The Veteran described shooting pains along the shins when standing for long periods of time. There are no medical records documenting complaints or treatment of shin splints. The December 2019 VA examiner found that the Veteran's complaints were subjective only, and that there were no clinical signs or symptoms of shin splints found in the file or on examination. No diagnosis was rendered. The Board finds that the claim for service connection for bilateral shin splints must be denied. Although the Board acknowledges the Veteran's reports of shin and knee pain at the VA examination, the preponderance of the evidence indicates no treatment or complaints related to shin splints. There are no Service Treatment Records (STRs) that show any complaints or treatment related to shin splints. At the VA examination, the Veteran reported shin and knee pain. The Board notes that the Veteran is service-connected for a knee disability. The examiner opined that with no evidence of shin splints in service and no chronicity of care for shin splints in the claims file, no nexus could be established. In the absence of a diagnosis or any evidence indicating the presence of shin splints, the claim for service connection must be denied. PTSD The Veteran contends he has diagnosed PTSD related to service. The Board notes that the Veteran has already been service-connected for adjustment disorder with mixed anxiety and depressed mood. There are particular requirements for establishing entitlement to service connection for PTSD in 38 C.F.R. § 3.304(f) that are in ways similar, but also nonetheless separate, from those for establishing entitlement to service connection generally. Arzio v. Shinseki, 602 F.3d 1343, 1347 (Fed. Cir. 2010). Entitlement to service connection for PTSD requires (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); (2) credible supporting evidence that a claimed in-service stressor occurred; and (3) a link, established by medical evidence, between current symptoms and the in-service stressor. 38 C.F.R. §§ 3.304(f) and 4.125. Where an alleged stressor involves "fear of hostile military or terrorist activity," a Veteran's lay testimony alone may establish the occurrence of the stressor if a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service. 38 C.F.R. § 3.304(f)(3). The Veteran's reported stressor was that he experienced a mortar attack during service in Iraq approximately 100 yards away. The Veteran also reported an incident being frightened as he watched an IED being diffused while in a convoy. The record corroborates the Veteran's service in Iraq, and the Veteran's stressors are consistent with duties during service. A November 2011 VA examiner found that the Veteran met the cut-off scores for PTSD, but that presentation at the examination was not consistent with classic PTSD. The examiner diagnosed adjustment disorder instead. However, the record does include medical records indicating a diagnosis of PTSD, and some relate that diagnosis to combat experience. An April 2014 VA provider noted that the Veteran had psychological stressors "beyond the PTSD from active duty." An April 2019 VA medical record notes PTSD from 2008 in the military. The Board finds that although information regarding the claimed stressors are limited, there is sufficient evidence to support the Veteran's account of fear of hostile military activity. Further, the record includes a diagnosis of PTSD, which VA psychiatrists reviewed and concurred with during ongoing treatment. The Board acknowledges the December 2019 VA examiner's finding that the Veteran does not meet the criteria for PTSD. However, given VA medical records to the contrary, the Board finds that the evidence is in relative equipoise regarding whether the Veteran has a PTSD diagnosis. Therefore, when all doubts are resolved in the Veteran's favor, a VA psychiatrist has diagnosed him with PTSD attributable to hostile military or terrorist activity that is consistent with the circumstances of his service, and service connection for PTSD is warranted. Increased Rating Disability ratings are determined by the application of VA's Schedule for Rating Disabilities. 38 C.F.R. Part 4. The determination of whether an increased rating is warranted is based on review of the entire evidence of record and the application of all pertinent regulations. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 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 entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999). Bilateral dry eye syndrome The Veteran contends that the symptoms of bilateral dry eye syndrome warrants a higher rating. The Veteran's dry eye syndrome has been assigned a 10 percent rating by analogy under DC 6018 for chronic conjunctivitis. Under DC 6018, inactive chronic conjunctivitis is evaluated based on residuals, such as visual impairment and disfigurement. Active chronic conjunctivitis is evaluated under the General Rating Formula for Diseases of the Eye, with a minimum rating of 10 percent. During the pendency of the appeal, VA issued a final rule revising the portion of the VA Schedule for Rating Disabilities that addresses the organs of special sense and schedule of ratings-eye. 89 Fed. Reg. 15316 (Apr. 10, 2018). The final rule went into effect May 13, 2018. Where there is a change in the rating criteria during the appeal period, the Board will consider the claim in light of both the former and revised schedular rating criteria, although an increased evaluation based on the revised criteria cannot predate the effective date of the amendments. Both the former and revised criteria distinguish active and inactive disease processes. Under the former criteria, an active disease process (with objective findings, such as red, thick conjunctivitae, mucous secretion, etc.) is assigned a 10 percent rating. Under the revised criteria, an active disease process is rated pursuant to the General Rating Formula for Diseases of the Eye, with a minimum rating of 10 percent. For an inactive disease process, both the former and revised criteria instruct to evaluate based on residuals, such as visual impairment and disfigurement (DC 7800). With regard to visual impairment, the May 2018 amendments made no substantive changes to how visual acuity is rated. With regard to visual field and muscle function examinations, the use of a Goldmann chart is no longer required. There are otherwise no substantive changes to how those types of visual impairment are rated. The General Rating Formal for Diseases of the Eye instructs to evaluate on the basis of either visual impairment due to a particular condition or on incapacitating episodes, whichever results in a higher evaluation. Where there are documented incapacitating episodes requiring at least 1 but less than 3 treatment visits for an eye condition during the past 12 months, a 10 percent rating is warranted. Where there are documented incapacitating episodes requiring at least 3 but less than 5 treatment visits for an eye condition during the past 12 months, a 20 percent rating is warranted. Where there are documented incapacitating episodes requiring at least 5 but less than 7 treatment visits for an eye condition during the past 12 months, a 40 percent rating is warranted. Where there are documented incapacitating episodes requiring 7 or more treatment visits for an eye condition during the past 12 months, a 60 percent rating is warranted. Both the former and revised criteria provide for consideration of visual impairment. The amendments made no substantive changes to how visual acuity is rated. The evaluation of visual impairment is based on impairment of visual acuity (excluding developmental errors of refraction), visual field, and muscle function. 38 C.F.R. § 4.75(a). To determine the evaluation for visual impairment when both decreased visual acuity and visual field defect are present in one or both eyes and are service connected, visual acuity and visual field defects are evaluated separately, and then combined under the provisions of § 4.25. Evaluation of visual acuity is based on corrected distance vision with central fixation. 38 C.F.R. § 4.76(b)(1). The measurements for each eye are applied to the table for Impairment of Central Visual Acuity. Generally, the table is divided into steps corresponding to different levels of visual acuity for one eye, and each step is further divided into subsections of visual acuity for the other eye, with corresponding ratings. Where a reported visual acuity is between two sequentially listed visual acuities, the visual acuity which permits the higher evaluation will be used. 38 C.F.R. § 4.76(c). A pre-discharge VA examination in March 2012 indicates that the Veteran reported his "eyes just get dry," and that he used artificial tears two times daily. VA and private medical records during the appeal period indicate a history of dry eye syndrome, causing blurriness and treated with artificial tears. The Veteran sometimes rubbed the eyes and blinked for relief. These records show that visual acuity remained 20/20 or better during the appeal period. There is no evidence of visual defect at any time during the appeal period. At a December 2019 VA examination, the Veteran reported mild to moderate dry eyes. On examination, visual acuity was 20/20 or better in both eyes. External examination found a right lower lid external hordeolum, or stye. Internal examination was normal. There was no visual field defect found. The examiner found that there was no decrease in visual acuity or other visual impairment due to the eye condition. There was no scarring or disfigurement, or incapacitating episodes found. Further, the examiner found no functional impact due to the eye condition. The VA examiner noted that there were no corneal or conjunctival symptoms related to the dry eye syndrome, indicating that the artificial tear therapy was working. After review of the record, the Board finds that the preponderance of the evidence is against a finding that a rating higher than 10 percent is warranted for the Veteran's eye condition. The Veteran's symptoms of blurriness and dry eyes is well documented in the record, as is the treatment with artificial tears. However, these symptoms are contemplated by the 10 percent rating currently assigned for the irritation comparable to active conjunctivitis. The evidence indicates that visual acuity has remained 20/20 or better throughout the appeal period. There is no indication of other visual impairment, such as visual field defect, due to the eye condition. Further, no scarring or disfigurement or incapacitating episodes due to the eye condition were found. Neither the Veteran nor his representative has indicated why a higher rating is warranted in this case. Accordingly, the Board finds that the preponderance of the evidence is against a finding that a rating higher than 10 percent is warranted for the Veteran's dry eye syndrome. Therefore, the claim for increased rating is denied. Psychiatric disability The Veteran has been assigned a 50 percent rating for his psychiatric disability. This rating contemplates occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech, panic attacks more than once a week; difficulty understanding complex commands; impairment of short- and long-term memory; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. The higher 70 percent rating is assigned where there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech that is intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. A 100 percent rating is assigned when there is total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, or for the Veteran's own occupation or name. The criteria listed above serve as examples of the type and degree of the symptoms or effects that would justify a rating and are not meant to be an exhaustive list. Mauerhan v. Principi, 16 Vet. App. 436, 442-44 (2002). Social and occupational impairment must be due to the symptoms listed for that rating level, "or others or others of similar severity, frequency, and duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). Neither the Veteran nor his representative have asserted why a higher 100 percent rating is warranted, and they have not cited evidence supporting such a rating. Based on a review of the evidence, the Board finds that a 100 percent rating is not warranted. The Veteran's treatment records and examination reports during the appeal period document moderately severe psychiatric symptoms. For example, at a pre-discharge VA examination, the Veteran reported exaggerated startle response, anger insomnia, decreased motivation, rumination, and conflict in relationships. At the December 2019 VA examination, the Veteran reported depressed mood, anxiety, irritability, racing thoughts and nightmares. The examiner noted that the Veteran's mood was euthymic with broad affect and an overall unremarkable mental status examination. The examiner opined that the Veteran's psychiatric symptoms were not severe enough to interfere with occupational and social functioning. Other evidence of record indicates continued complaints of anxiety, nightmares, racing thoughts, insomnia, and isolative behaviors. However, these symptoms are all contemplated by a 50 percent rating. During the appeal period, the Veteran consistently denied suicidal or homicidal ideation, was not a persistent danger to himself or others, and showed no evidence of hallucinations or delusional thoughts. Mood was often noted as euthymic with congruent affect. Mental status examinations were generally unremarkable. The evidence is otherwise negative for any grossly inappropriate behavior, disorientation to time or place, memory loss for basic concepts such as his own name, or other symptoms which might suggest occupational and social impairment consistent with a 70 percent rating or higher. The Board acknowledges the nature of the Veteran's psychiatric symptoms, however, finds that they are contemplated by a 50 percent rating. Therefore, a rating higher than 50 percent is not warranted. Accordingly, the claim must be denied. PFB The Veteran contends that a rating higher than 10 percent is warranted for PFBB). The Veteran's PFB has been assigned a 10 percent rating by analogy pursuant to DC 7806, for dermatitis or eczema. VA amended the criteria for rating skin disabilities effective from August 13, 2018. These new regulations apply to all applications for benefits received by VA or that are pending before the agency of original jurisdiction on or after August 13, 2018. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. The Board may not apply a current regulation prior to its effective date unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. Prior to August 13, 2018, under DC 7806 a noncompensable rating is assigned for less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and no more than topical therapy required during the past 12 months. A 10 percent rating is assigned for at least 5 percent, but less than 20 percent, of the entire body, or; at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is assigned for 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly during the past 12-month period. A 60 percent rating is assigned for more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or constant or near- constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12- month period. Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, DC 7806. For claims filed prior to August 13, 2018, the Court held that a systematic therapy is one that that affects the entire body in its treatment of the condition at issue, and that the Board must determine (1) whether a topical treatment affects the body as a whole in treating a veteran's skin condition; and (2) whether the given treatment is "like" a corticosteroid or other immunosuppressive drug." Burton v. Wilkie, 30 Vet. App. 286 (2018). Only the second question need be addressed if the treatment is clearly systemic. Effective August 13, 2018, VA regulations explicitly state that systemic therapy is treatment that is administered through any route other than the skin, and topical therapy is treatment that is administered through the skin. 38 C.F.R. § 4.118 (a). Additionally, effective August 13, 2018, a new General Rating Formula for the Skin applies to Diagnostic Codes 7806, 7809, 7813 to 7816, 7820 to 7822, and 7824. 38 C.F.R. § 4.118. Under this formula, a noncompensable rating is assigned for no more than topical therapy required over the past 12-month period and at least one of the following: characteristic lesions involving less than 5 percent of the entire body affected; or characteristic lesions involving less than 5 percent of exposed areas affected. A 10 percent rating is assigned for at least one of the following: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12- month period. A 30 percent rating is assigned at least one of the following: characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent rating is assigned for at least one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required over the past 12-month period. Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, General Rating for the Skin for DCs 7806, 7809, 7813-7816, 7820-7822, and 7824. The Veteran has also been assigned a separate noncompensable rating for scars status post-surgery for PFB under DC 7800, for burn scar(s) of the head, face, or neck; scar(s) of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck. DC 7800 was not changed by the August 13, 2018, amendments. Under DC 7800, one characteristic of disfigurement warrants a 10 percent rating. A scar with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement warrants a 30 percent rating. A scar with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement warrants a 50 percent rating. A scar with visible or palpable tissue loss and either gross distortion of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement warrants an 80 percent rating. 38 C.F.R. § 4.118. Note 1 to DC 7800 list the eight characteristics of disfigurement: a scar 5 or more inches in length; a scar at least one-quarter inch wide at widest part; surface contour of scar elevated or depressed on palpation; scar adherent to underlying tissue; skin hypo- or hyper-pigmented in an area exceeding six square inches; skin texture abnormal in an area exceeding six square inches; underlying soft tissue missing in an area exceeding six square inches; and, skin indurated and inflexible in an area exceeding six square inches. At a March 2012 pre-discharge examination, the examiner found two scars of the face. The first scar on the right anterolateral neck was described as a 1.0 cm by 0.2 cm hypopigmented scar. The second scar on the lateral left chin was described as a 1.3 cm by 0.4 cm hypopigmented rectangular scar. The scars were nontender to palpation, without indentation, attachment to the subcutaneous tissue, keloid, breakdown, or drainage. The scars also did not affect the range of motion of the proximal joints. At a December 2019 VA examination, the examiner noted characteristic lesions due to PFB affected less than 5 percent of total and exposed body area. The examiner described the lesions specifically as hyperpigmentation on the chin and neck. At a contemporaneous scars examination, the examiner found scars at the right anterolateral neck and lateral left chin, secondary to PFB surgery. The scars were not painful or unstable. The examiner found that the surface contour of the scars on the face and neck were elevated on palpation. The contour of the scar on the neck was depressed on palpation. Hyperpigmentation on the face and neck was noted and covered 450 square centimeters. The scars were not tender to palpation. There was no gross distortion due to the scars. Further, the examiner found no limitation or function nor any impact on the Veteran's ability to work, due to the scars. VA and private medical records indicate inflammatory papules on the face and chin, and hyperpigmentation of the skin. These records do not provide additional findings as to size or composition of the scar or hyperpigmentation. The Board finds that as of December 17, 2019, the evidence indicates that a higher 30 percent rating is warranted for the Veteran's PFB scar under DC 7800. The VA examiner found two characteristics of disfigurement: surface contour elevated on palpation; and hyperpigmentation exceed 39 square centimeters. Two characteristics of disfigurement warrant a 30 percent rating under DC 7800. No higher rating is warranted for the scar because the scars are not unpainful or unstable, no other characteristics of disfigurement have been shown, and there is no visible or palpable tissue loss with gross distortion or asymmetry of features. Further, the evidence prior to the December 2019 VA examination does not support the 30 percent rating, as the prior VA examiner did not find the characteristics of disfigurement. Regarding DC 7806, the Board finds that the preponderance of the evidence is against the assignment of a rating higher than 10 percent under the pre-August 13, 2018, regulations at any time during the appeal period because the Veteran's PFB does not more nearly approximate at least 20 percent, but less than 40 percent, of the entire body, or at least 20 percent, but less than 40 percent, of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more , but not constantly, during the past 12-month period. The Board finds that the preponderance of the evidence is against the assignment of a compensable evaluation under the August 13, 2018, regulations at any time during the appeal because the Veteran's PFB does not more nearly approximate (1) characteristic lesions involving at least 20 percent, but less than 40 percent, of the entire body affected; or (2) at least 20 percent, but less than 40 percent, of exposed areas affected; or (3) intermittent systemic therapy required for a total duration of less than 6 weeks over the past 12- month period. The VA examiner found that the total and exposed area of the body affected was less than 5 percent. In order to warrant a rating higher than the current 10 percent, the evidence would need to show that the affected area covered at least 20 percent of exposed or total body area. The evidence also does not indicate that the Veteran undergoes any systemic therapy or other treatment for the PFB. Therefore, a rating higher than 10 percent under DC 7806 is not warranted. Accordingly, the Board finds that as of December 17, 2019, but no higher, a 30 percent rating is warranted for the Veteran's PFB scar under DC 7800. However, the preponderance of the evidence is against a finding that a rating higher than 30 percent is warranted for the PFB under DC 7806 at any time during the appeal period. Migraines The Veteran's migraine headaches are currently rated 50 percent disabling under 38 C.F.R. § 4.124a, DC 8100. Under DC 8100, migraine headaches with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability are rated 50 percent. This is the highest schedular rating available for migraines. The phrase "characteristic prostrating attacks" means migraine attacks that typically produce powerlessness or a lack of vitality. Johnson v. Wilkie, 30 Vet. App. 245 (2018). In other words, the term "prostrating" takes on its plain meaning of "lacking in vitality or will: powerless to rise: laid low." Id. Moreover, lay evidence may be probative of the frequency, prolongation, and severity of headaches. Pierce v. Principi, 18 Vet. App. 440, 445-46 (2004). Regarding "economic inadaptability," the Court has held that under DC 8100, a headache disorder need only be "capable of producing" economic inadaptability, and that this standard is different from the "unemployability" standard applicable in the context of determining entitlement to a total disability rating based on individual unemployability (TDIU). Pierce v. Principi, 18 Vet. App. 440, 445-46 (2004); see also 38 C.F.R. §§ 3.340, 4.16 (setting forth the requirements for establishing entitlement to TDIU). Relevant to this appeal, the criteria for rating migraines are "successive." Johnson, 30 Vet. App. 245. "Successive" criteria exist where the evaluation for each higher disability rating includes the criteria of each lower disability rating, such that if a component is not met at any one level, the Veteran can only be rated at the level that does not require the missing component. Tatum v. Shinseki, 23 Vet. App. 152, 156 (2008). A December 2019 VA examiner opined that the Veteran was unable to complete tasks when experiencing migraines due to light and sound sensitivity, and vomiting. At the examination, the Veteran reported daily headache pain with vision changes and vomiting. The examiner noted that the Veteran experienced characteristic prostrating attacks of headache pain once every month. The examiner further found that the Veteran did not experience very prostrating and prolonged attacks of pain productive of severe economic inadaptability. VA medical records indicate a history of migraine headaches with aura, including vision changes, light, and sound sensitivity, and sometimes causing vomiting. The Veteran consistently reported daily headaches. The Veteran utilizes Botox injection treatment, which alleviates much of the pain although does not eliminate the pain. The Veteran reported that with the injections, he is able to function. The record is clear that the Veteran has consistent, severe symptoms related to migraine headache which are very prostrating and prolonged and productive of severe economic inadaptability. The Veteran is currently receiving the highest schedular rating for migraines, which contemplates this level of severity. Therefore, a higher rating would only be available on an extraschedular basis. The Board notes that neither the Veteran nor his representative has provided evidence or argument as to why a rating higher than the maximum schedular rating is warranted in this case. Accordingly, the Board finds that the maximum 50 percent schedular rating appropriately contemplates the severity of the Veteran's migraine symptoms. Therefore, the claim for increased rating is denied. REASONS FOR REMAND Service connection for bilateral shoulder condition The Veteran contends that a bilateral shoulder disability is related to service. At a December 2019 VA examination, the Veteran reported he began experiencing shoulder pains during service. He reported current symptoms of aches and numbness in the shoulders, making it harder to lift things. The examiner diagnosed bilateral shoulder strain and opined that it was less likely than not that the strain was related to service. The examiner explained that the Veteran was first seen for shoulder pain in September 2015, more than 2 years after service and reported that the pain began 6 months prior. Therefore, the examiner found that the shoulder pain reported was not related to service. The Board finds that the VA examination is inadequate. VA medical records prior to the September 2015 record, including as early as June 2014, indicate complaints of shoulder pain. Further, the examiner indicates in the examination report that service records were unavailable in the Veteran's c-file. Therefore, remand is necessary to obtain an adequate examination and opinion. The matter is REMANDED for the following action: 1. Associate any pertinent VA or private medical records that are not already of record with the claims file. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of any bilateral shoulder disability. The examiner must review the claims file and should note that review in the report. A complete history of onset and symptoms should be elicited from the Veteran. Any tests and studies deemed necessary should be conducted and all findings should be reported in detail. The examiner should opine as to whether it is at least as likely not (50 percent or greater probability) that any bilateral shoulder disability had its onset in service or is otherwise related to service. The examiner should specifically address June 2014 VA medical records indicate shoulder pain, and the Veteran's statements regarding onset of shoulder pain during service. JOHN Z. JONES Veterans Law Judge Board of Veterans' Appeals Attorney for the Board H. Ahmad, 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.