Citation Nr: 22061332 Decision Date: 11/01/22 Archive Date: 11/01/22 DOCKET NO. 16-37 532 DATE: November 1, 2022 ORDER Entitlement to a disability rating of 20 percent for striae distensae, right lower extremity, from steroid therapy is granted. Entitlement to a disability rating of 20 percent for striae distensae, left lower extremity, from steroid therapy is granted. REMANDED Entitlement to service connection for a neck disorder, to include cervical myofascial pain syndrome, is remanded. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran's striae distensae of the right lower extremity has manifested in three to four painful scars. 2. Throughout the appeal period, the Veteran's striae distensae of the left lower extremity has manifested in three to four painful scars. CONCLUSIONS OF LAW 1. The criteria for entitlement to a 20 percent disability rating, but no higher, for striae distensae, right lower extremity, from steroid therapy have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.27, 4.118, Diagnostic Code 7804. 2. The criteria for entitlement to a 20 percent disability rating, but no higher, for striae distensae, left lower extremity, from steroid therapy have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.27, 4.118, Diagnostic Code 7804. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 2003 to August 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In March 2019, March 2020, and May 2021, the Board remanded this matter for further development. That development having been completed, this matter has returned to the Board for further appellate review. Increased Rating Entitlement to a disability rating of 20 percent for striae distensae, right lower extremity, from steroid therapy is granted. Entitlement to a disability rating of 20 percent for striae distensae, left lower extremity, from steroid therapy is granted. VA has adopted a Schedule for Rating Disabilities (Schedule) to evaluate service-connected disabilities. See 38 U.S.C. § 1155; 38 C.F.R., Part IV. Disability evaluations assess the ability of the body as a whole, the psyche, or a body system or organ to function under the ordinary conditions of daily life, to include employment. 38 C.F.R. § 4.10. The percentage ratings in the Schedule represent 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. The percentage ratings are generally adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the disability. Id. The Schedule assigns Diagnostic Codes to individual disabilities. Diagnostic Codes provide rating criteria specific to a particular disability. If two Diagnostic Codes are applicable to the same disability, the Diagnostic Code that allows for the higher disability rating applies. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the claimant. 38 C.F.R. § 4.3. The Schedule recognizes that a single disability may result from more than one distinct injury or disease; however, rating the same disability or its manifestation(s) under different Diagnostic Codes-a practice known as pyramiding-is prohibited. Id.; see 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 they are sufficient to warrant changes in the evaluations assignable under the applicable rating criteria. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). For increased-rating claims, where a claimant seeks a higher evaluation for a previously service-connected disability, it is the present level of disability that is of primary concern, and VA considers the level of disability for the period beginning one year prior to the claim for a higher rating. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994); see also 38 C.F.R. § 3.400(o)(2). 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 (1990); see also Wise v. Shinseki, 26 Vet. App. 517, 532 (2014). If the evidence persuasively weighs against the claim, it must be denied. See id.; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). The Veteran's striae distensae of the bilateral lower extremities have been evaluated as noncompensable under 38 C.F.R. § 4.118, Diagnostic Code 7802, which pertains to superficial and nonlinear scars. Scars are rated under 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805. Initially, as concerning the rating for the Veteran's striae distensae, the Board points out that Diagnostic Code 7800 does not apply, as it pertains to scars of the head, face, and neck, so not the bilateral lower extremities. Diagnostic Code 7801 provides ratings for scars not of the head, face, or neck, that are deep and nonlinear; and Diagnostic Code 7802 provides for a 10 percent (maximum) rating for superficial and nonlinear scars with an area of 144 square inches (929 square cm) or greater, which the Veteran does not have to this required extent. The rating criteria governing scars were revised effective August 13, 2018. Claims, including this claim, which were pending prior to August 13, 2018 must be considered under both the old and new rating criteria, and whichever criteria are more favorable to the Veteran will be applied. However, Diagnostic Codes 7804 and 7805 were not substantively changed by the August 13, 2018 amendments. Diagnostic Code 7804 provides a noncompensable rating for superficial unstable scars. Diagnostic Code 7804 further provides that one or two scars that are unstable or painful are rated as 10 percent disabling. Three or more scars that are unstable or painful are rated as 20 percent disabling. Five or more scars that are unstable or painful are rated as 30 percent disabling. Note (1) to Diagnostic Code 7804 explains that an unstable scar was one where, for any reason, there was frequent loss of covering of skin over the scar. Note (2) explains that 10 percent may be added to the evaluation if one or more scars are both unstable and painful. Under Diagnostic Code 7805, any disabling effect(s) not considered in a rating under Codes 7800-04 are to be rated under an appropriate Code. 38 C.F.R. § 4.118, Diagnostic Code 7805. In May 2012, the Veteran submitted a claim for an increased rating for her striae distensae of the lower extremities. She stated that a previous, September 2010 VA examiner conducted her examination at arms-length, and did not even see the scars on the back of her legs or on her calves. She also stated that she told the examiner that her scars were painful, tender, and frequently itchy. See May 2012 Statement in Support of Claim. A November 2012 VA examination report reflected the Veteran had one painful scar, but did not indicate where or which scar was painful. The examiner noted the Veteran's right and left lower extremities each had one superficial non-linear scar, each measuring 10 cm by 20 cm. See November 2012 Scars/Disfigurement Disability Benefits Questionnaire (DBQ). A June 2022 VA examination report reflects the Veteran had five or more painful scars on the bilateral extremities, none of which were unstable. The examiner noted the Veteran had four scars on the right lower extremity and four scars on the left lower extremity, all of which were painful. The approximate area of the Veteran's right lower extremity scars was recorded as 573.55 cm sq. and of her left lower extremity scars was recorded as 324.06 cm sq. See June 2022 Scars/Disfigurement DBQ. Resolving reasonable doubt in the Veteran's favor, the Board finds that separate 20 percent ratings are warranted for the Veteran's striae distensae of the right lower extremity and striae distensae of the left lower extremity under Diagnostic Code 7804, throughout the period under consideration, because she has four painful scars on each lower extremity. The Board notes that the November 2012 VA examination reports reflected the Veteran's striae distensae manifested in one scar on each lower extremity. However, the Veteran's May 2012 statement reflected her striae distensae had resulted in at least two other scars on each leg. As the Board resolves reasonable doubt in her favor, it finds the Veteran's striae distensae has manifested in at least three to four painful scars during the appeal period. The Veteran's striae distensae scars of the right and left lower extremities have been found to be superficial and non-linear, with an area of less than 929 sq. cm., rendering a compensable disability rating under Diagnostic Code 7802 inapplicable. 38 C.F.R. § 4.118. In sum, the Board finds that the Veteran's striae distensae of the right lower extremity and striae distensae of the left lower extremity each manifest in three to four painful scars during the appeal period. Accordingly, the criteria for entitlement to disability ratings of 20 percent for each lower extremity have been met. However, the evidence persuasively weighs against the assignment of a rating in excess of 20 percent, as the Veteran's disability is not manifested by five or more scars on each lower extremity. REASONS FOR REMAND Entitlement to service connection for a neck disorder, to include cervical myofascial pain syndrome, is remanded. The Board previously remanded this matter to obtain an adequate opinion addressing the nature and etiology of the Veteran's claimed neck disorder on a direct basis. In this regard, a June 2022 VA opinion was obtained which substantially complies with the remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (noting that Stegall requires substantial compliance, rather than absolute compliance, with remand orders). The Veteran's service treatment records reflect she was seen in December 2004 for low back pain, which spread to her upper back/neck. See December 2004 Record of Medical Care. The Board notes that a May 2015 VA opinion provided a negative nexus opinion on a secondary basis. However, the May 2015 examiner's rationale was that the Veteran's cervical pain was myofascial in nature with no other explanation. Accordingly, the Board finds the May 2015 opinion inadequate. See Bailey v. O'Rourke, 30 Vet. App. 54, 60 (2018); Stefl v. Nicholson, 21 Vet. App. 102, 124-25 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Given the evidence that the Veteran's neck pain may be related to her service-connected low back disorder, the Board finds a remand is required to obtain an addendum opinion. Stefl, 21 Vet. App. at 123-124. Finally, as this matter is being remanded, the Veteran's updated VA treatment records should be obtained. The matters are REMANDED for the following action: 1. Make arrangements to obtain the Veteran's updated VA treatment records, from November 2021, forward. 2. Thereafter, arrange for an appropriate medical professional to provide an opinion. The Veteran should not be scheduled for a VA examination (or telehealth interviews, reviews of the record, etc., if an in-person examination is not feasible) to address the nature and etiology of her neck disorder unless deemed necessary by the VA medical opinion provider. After reviewing the file, the examiner must provide the following: Whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's neck disorder, or neck symptoms which manifest in symptoms that cause functional impairment, is either (i) caused by, or (ii) aggravated (i.e., worsened) by the Veteran's service-connected lumbar spine disorder. * In reaching this opinion, the examiner should consider and address the December 2004 STR which documents the Veteran's low back pain spreads to her upper back. In providing the opinion concerning aggravation, the examiner is advised that a "permanent worsening" is not required to establish secondary service connection on the basis of aggravation; rather, aggravation may include temporary worsening, or flare-ups, of a disability. A complete rationale for all opinions reached must be provided. If the examiner is unable to provide any opinion as requested, the examiner should fully explain the reason why such opinion could not be rendered. P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. M. Stedman, Associate 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.