Citation Nr: 22045583 Decision Date: 08/11/22 Archive Date: 08/11/22 DOCKET NO. 18-43 458 DATE: August 11, 2022 ORDER Entitlement to an initial 20 percent evaluation for service-connected left shoulder scar is granted. REMANDED Entitlement to an initial evaluation higher than 20 percent for service-connected left shoulder scar is remanded. FINDING OF FACT The left shoulder scar is painful and unstable. CONCLUSION OF LAW The criteria for entitlement to an initial 20 percent evaluation for service-connected left shoulder scar have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code (DC) 7804. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served honorably on active duty in the United States Army from August 1975 to August 1978. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a March 2017 rating decision of a Department of Veterans Affairs (VA) Agency of Original Jurisdiction. The Veteran testified at a Board hearing before the undersigned Veterans Law Judge (VLJ) in April 2022 and a transcript of the proceeding is of record. At the hearing under oath the Veteran waived agency of original jurisdiction consideration of evidence submitted since the July 2018 statement of the case. The Board will proceed to adjudicate the claim. 1. Entitlement to an initial compensable evaluation for service-connected left shoulder scar is granted. The Veteran's scar is rated under DCs 7805. DC 7805 is applicable for other scars, and directs that any disabling effects not considered in a rating provided under DCs 7800-04 should be evaluated under an appropriate diagnostic code. Resolving reasonable doubt in the Veteran's favor, the criteria for a 20 percent rating under DC 7804 are met. VA amended the criteria for rating skin disabilities effective from August 13, 2018. However, Diagnostic Code 7804 was not changed by the August 13, 2018, amendments. Under Diagnostic Code 7804, one or two scars that are unstable or painful scars warrants a 10 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. Id. Note 2 instructs that if one or more scars are both unstable and painful, a 10 percent evaluation is to be added to the evaluation based on the total number of unstable or painful scars. May 2010 VA treatment notes document the Veteran had an operative scar of the left shoulder and was unwilling to do range of motion due to pain. A March 2017 VA examiner documented the Veteran had a scar of the left shoulder that measured 6 cm. by 0.2 cm., and that was not painful or unstable. In his April 2017 notice of disagreement, the Veteran wrote that his left shoulder scar did cause pain and problems, and that the March 2017 examiner did not ask him any questions about his shoulder scar. A January 2020 VA examiner documented a left shoulder scar that measured 17 cm. by 0.7 cm. That examiner documented the scar was not painful or unstable. At the April 2022 hearing, the Veteran and his representative testified that the left shoulder scar was painful, unstable, and unsightly. The Veteran explained he felt self-conscious about the appearance of the scar and he did not like to remove his shirt. He described the scar as painful to the touch and with movement such as lifting the arm. He testified the scar would open up occasionally and leak fluid, and that the area of the scar appeared to be widening. He also explained that his scar stretched from the top of his shoulder to the bottom of the armpit. The lay testimony is sufficient to establish that the Veteran's scar has been painful and unstable throughout the appeal period. Thus, the criteria for a 20 percent evaluation are met under DC 7804. REASONS FOR REMAND 1. Entitlement to an initial evaluation higher than 20 percent for service-connected left shoulder scar is remanded. The Veteran has not yet been afforded a VA scars examination to capture all aspects and residuals of the service-connected left shoulder scar, and he has testified that his scar has widened since his last shoulder examination in January 2020. Thus, remand is necessary to obtain a scars examination that contains all findings necessary to rate the disability. The matters are REMANDED for the following action: 1. Provide the Veteran with an appropriate examination to determine the severity of the service-connected left shoulder scar. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The relevant Disability Benefits Questionnaire must be utilized. LAURA E. COLLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Smith, 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.