Citation Nr: 0001222 Decision Date: 01/14/00 Archive Date: 01/27/00 DOCKET NO. 92-20 455 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for headaches, claimed as residual to a motor vehicle accident. 2. Entitlement to service connection for blackouts, claimed as residual to a motor vehicle accident. 3. Entitlement to service connection for a right shoulder disorder, claimed as residual to a motor vehicle accident. 4. Entitlement to service connection for a back disorder, claimed as residual to a motor vehicle accident. 5. Entitlement to service connection for optic nerve damage resulting in shaking and blurred vision, claimed as residual to a motor vehicle accident. 6. Entitlement to service connection for a nasal fracture, status post rhinoplasty, claimed as residual to a motor vehicle accident. 7. Entitlement to a compensable evaluation for a scar above the right eyebrow for the period August 8, 1988, through October 16, 1990. 8. Entitlement to an evaluation in excess of 10 percent for a service-connected scar above the right eyebrow. REPRESENTATION Appellant represented by: Georgia Department of Veterans Service WITNESS AT HEARING ON APPEAL The veteran ATTORNEY FOR THE BOARD J. M. Daley, Associate Counsel INTRODUCTION The veteran had active military service from June 1982 to June 1986. These matters come before the Board of Veterans' Appeals (Board) on appeal from rating determinations of the Department of Veterans Affairs (VA), Regional Office (RO), located in Atlanta, Georgia. In connection with his appeal, the veteran presented testimony at a personal hearing in March 1992; a transcript of that hearing is associated with the claims file. The Board notes that during the pendency of this appeal, the RO has assigned a 10 percent evaluation for the veteran's service-connected right eyebrow scar, effective October 17, 1990, and has considered the veteran's appeal as continuous from the date of the initial grant of service connection. See Fenderson v. West, 12 Vet. App. 119 (1999). The award of a 10 percent evaluation represented only a partial grant of benefits, in that VA's Schedule For Rating Disabilities (Schedule) provides for higher evaluations for facial scarring, and also insofar as the veteran initially disagreed with the zero percent evaluation initially assigned to his scar effective August 10, 1988. The veteran has not withdrawn his appeal, continuing to argue that a higher percentage evaluation is warranted for his scar. The issues on the first page of this opinion are phrased to reflect his continued disagreement both with the noncompensable evaluation awarded from August 10, 1988 through October 16, 1990, and with the RO's decision that no more than a 10 percent evaluation is warranted for that scar. See Grantham v. Brown, 114 F.3d 1156 (1997) and AB v. Brown, 6 Vet. App. 35, 38 (1993). The case was remanded by the Board in October 1994 and has been returned for appellate review. The claims of entitlement to service connection for headaches, blackouts, a right shoulder disorder, a back disorder, optic nerve damage resulting in shaking and blurred vision, and a nasal fracture, status post rhinoplasty, all claimed as residual to a motor vehicle accident, are discussed in the remand portion of this decision. FINDINGS OF FACT 1. There is competent evidence of record that plausibly relates existing headaches to the veteran's period of service. 2. There is competent evidence of record that plausibly relates existing blackouts to the veteran's period of service. 3. There is competent medical evidence of record that plausibly relates current right shoulder problems to service. 4. There is competent medical evidence of record that plausibly relates current back problems to service. 5. There is competent medical evidence of record that plausibly relates visual disturbances to the veteran's period of service. 6. There is competent medical evidence of record showing that the veteran had several nasal surgeries during service and that plausibly relates current nasal problems to his period of service. 7. The competent and probative evidence of record reflects that the veteran has a right eyebrow scar, resulting in no more than mild-to-moderate facial disfigurement; the evidentiary record does not reveal that such scarring is severe and/or that is results in a marked and unsightly deformity of the eyelids or marked discoloration/color contrast. CONCLUSIONS OF LAW 1. The claim of entitlement to service connection for headaches is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 2. The claim of entitlement to service connection for blackouts is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 3. The claim of entitlement to service connection for a right shoulder disorder is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 4. The claim of entitlement to service connection for a back disorder is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 5. The claim of entitlement to service connection for optic nerve damage is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 6. The claim of entitlement to service connection for a nasal fracture, status post rhinoplasty, is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 7. The criteria for a 10 percent evaluation for a right eyebrow scar for the period August 8, 1988, through October 16, 1990, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.7, 4.118, Diagnostic Code 7800 (1999). 8. The criteria for an evaluation in excess of 10 percent for a right eyebrow scar have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.118, Diagnostic Code 7800 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Factual Background A history of a nose fracture was noted on the report of physical examination at enlistment, dated in March 1982. Service medical records reflect that in November 1982 the veteran requested nose surgery. He was described as status post broken nose. He was asymptomatic except for headaches, which were noted on history to appear to be tension rather than sinus in origin. Later in November 1982, the veteran again reported that he wanted to have his nose fixed because it gave him headaches. On an ear, nose, and throat consultation in December 1982, it was determined that he had a nasal septum deformity. In February 1983, he underwent septoplasty. The veteran went for a follow-up evaluation in March 1983; and sutures were removed at that point. On observation the septum was straight, though there was some mild anterior widening. His airways were stated to be "good" bilaterally. The assessment was simply status post- septoplasty, with a good result. In April 1983, the veteran reported that he had had facial trauma when he fell and hit his nose on a ladder step. No bony abnormalities were noted. The impression was soft tissue nose trauma. The veteran complained of a stuffy nose in June 1983. Observation at that time did not reveal any abnormality. The veteran was prescribed a decongestant. In February 1984, the veteran was seen for emergency care following a motor vehicle accident. It was reported that he had cut his right eye when his head hit the windshield. There was a three-inch long laceration of the right forehead. X-rays were negative for fracture. There was no loss of consciousness or memory. His visual acuity was 20/20. The laceration was closed with sutures. Radiographic studies appeared within normal limits. He also complained of right shoulder pain with no apparent fracture or dislocation. The diagnoses were laceration supraorbital, right, and closed head trauma. Other records in February 1984 reflect that he was treated with ice to the shoulder and forehead and that no other injuries were noted. In a follow-up examination in February 1984, it was noted that the laceration was healing well with no evidence of infection. There was decreased pinprick sensation in the distribution of the right supraorbital nerve. The sutures were removed one week later. He was seen in April 1984 for itching of the wound site on his head. When the veteran was seen in June 1984, he reported that he had had some glare in his vision on four occasions since his accident earlier that year. There were no neurologic deficits noted. The assessment was status post motor vehicle accident. On an eye examination in June 1984 his vision was 20/20, bilaterally. He reported that he had had intermittent haziness or glaring since an automobile accident three months earlier. When the veteran was seen in November 1984, he reported that he had had headaches off and on since an accident in February 1984. He related that he had been told that the doctors were unable to remove all the glass fragments from his forehead. He described headaches located at the back of his head and above and below the eyes. The assessment was headaches, questionable etiology. When he was seen one day later, it was reported that he had had prior nose surgery and that he then had been struck in the nose after surgery. The diagnosis was deviated nasal septum. The veteran reported that he had struck his head on the windshield and sustained a laceration of the right supraorbital area without loss of consciousness. He complained of intermittent occipital and frontal headaches without blurred vision, decreased vision, or photophobia. The examination of the nose revealed nasal deformity status post septoplasty. The assessment was deviated nasal septum and probable tension headaches. Another record indicates headaches of questionable etiology. In December 1984, the veteran was admitted for an abbreviation septo-rhinoplasty. He complained of decreased airway ability. Due to scheduling of emergency cases, his surgery was deferred until another date. Service records reflect that in April 1985 the veteran was admitted after falling down a ladder while intoxicated. It was stated that he had not had any loss of consciousness but that he had been difficult to arouse. A skull series was normal. Examination revealed an abrasion/contusion to the right lateral back and rib area, and tenderness in the same area. He also complained of nose pain. A nasal series revealed a possible depression fracture of the tip of the nasal bone; however, it was not possible to determine whether this was old or new. In an entry of April 1986, it was noted that the veteran wanted to go to Jacksonville Naval Air Station for treatment of his nasal septum. In May 1986, the veteran underwent a rhinoplasty. Thereafter, he was returned to full duty. There is no separation physical examination report on file. The veteran filed his initial claim in August 1988 for compensation benefits for a broken nose, a blow to the head, headaches, eyes, and scars due to a car accident. He reported no post-service medical treatment. At the time of VA examinations in September 1988, the veteran reported that he had sustained injuries during a motor vehicle collision in service, including a laceration above the right eyebrow and a fracture of the nose and nasal bones. He related that, since the injury, he had had occasional blurred vision and headaches involving the post-occipital area. In connection with neuropsychiatric examination conducted in September 1988, the veteran reported that he was hospitalized and had surgery on his nose following his auto accident. His injuries included fracture of the nose with possible period of unconsciousness. He stated that thereafter he developed headaches which were daily, with bad ones every three or four days. He indicated that his headaches began in the region of the right temple and then radiated to the back of his head and the right side of his head. He stated that the headaches, when severe, would last 1 1/2 hours and that he would often fall asleep. Sometimes the headaches were associated with very slight nausea or very slight vertigo and they were usually relieved by falling asleep. He reported no visual difficulties except that very seldom he would see spots in the outer right side of his eye. There was deformity of his nasal bone, a depressed area. The diagnoses included residuals of injury and fracture of the nose, and residual headaches due to post-concussion syndrome. On the September 1988 special ear, nose, and throat examination, the veteran reported that he had received a head injury during service and had two operations on his nose due to a fracture and nasal obstruction. Examination of the nose revealed external deformity with deviation slightly to the right, with flattening of the left side of the bony nose. The cartilaginous portion of the nose was curved back towards the midline giving the whole nose a rather curved shape with a convexity to the right. There was also some depression or slight saddle nose over the middle third and part of the lower third of the nose. There was still considerable obstruction due to deviation of the septum to the right and there appeared to have been some cartilage removed from the caudal end of the septum. It was noted that the operations were some sort of septal reconstruction and corrective rhinoplasty. The diagnoses were traumatic nasal deformity, deviated nasal septum, traumatic in origin with nasal obstruction, status post operative septal reconstruction, and status postoperative rhinoplasty with continued nasal deformity. The impression was that the headaches could be due to pressure inside the nose due to contact between the structures there. It was also noted that there were two irregular scars on the forehead. One was right over the right eyebrow and one above the left eyebrow about 2.5 centimeters. In the one on the left, there was a little hard area where there could be a foreign body underneath the skin. X-rays of the veteran's nose showed that the nasal bones and anterior nasal spine were intact. In connection with eye examination conducted in September 1988, the veteran reported that he had had blurred vision for two weeks following the accident but that this had cleared. Since that time, he had had episodes of blurred vision every so often. His visual acuity was 20/20, bilaterally. The diagnosis was no ocular abnormalities. The RO, in a rating decision dated in December 1988, established service connection and assigned an initial zero percent disability evaluation to a disfiguring scar on the veteran's right eyebrow, effective August 10, 1988. At that time the RO also denied service connection for an unspecified eye disorder; residuals status post elective septoplasty and rhinoplasty; and headaches. When the veteran was seen by the VA in March 1990, he complained of headaches and back and shoulder pain. He described headaches which began behind the ears. He also reported five episodes of loss of consciousness without warning. His headaches lasted two to three days and occurred once every three or four weeks. His headaches were severe, lasting two to three hours. He also reported seeing bright spots in his peripheral vision. The physical examination revealed paraspinous spasm of the left neck to the vertex which reproduced headaches. The impression was mixed musculoskeletal tension/vascular headaches. In a rating decision dated in June 1990, the RO denied service connection for a lower or mid back disorder, a neck disorder and a right shoulder disorder. VA radiographic studies of October 1990 of the right shoulder were within normal limits. A VA medical certificate dated in October 1990 notes the veteran's complains of neck, shoulder and back pain and includes a diagnosis of chronic low back pain. Studies in January 1991, including a computerized tomography (CT) scan of the right shoulder and a double contrast CT arthrogram of the right shoulder resulted in an impression of multiple filling defects in the subscapularis bursa which were felt to represent loose cartilaginous bodies. In March 1991 the veteran was admitted to a VA facility for arthroscopic examination of his right shoulder. He gave a history of problems since his 1984 accident. Examination revealed impingement syndrome of the right shoulder. In a decision dated in November 1991, the RO denied service connection for blackout spells. At the hearing on appeal in March 1992, the veteran testified that he did not lose consciousness after his in-service accident but may have been in a state of shock. He stated that he did not have a separation examination upon service discharge. He reported that he had been told he had a rip in the rotator cuff of his right shoulder; and that his optic nerve may have been clipped which caused his headaches. He reported that he had had blurred vision and shaking of his eyes since the accident. He further testified that he last had a blackout in 1987 but that he continued to have some episodes of dizziness. He also testified that he underwent shoulder surgery in 1991 at the VA Hospital in Atlanta. The veteran alternatively testified that he had pain whenever his scar was touched and that he did not have a lot of feeling at the scar site. A medical certificate dated in March 1993 notes evaluation for the veteran's complaints of blackout spells, headaches, and back and neck pain, with a recent occurrence of syncopal episodes. The veteran reported that he had had a severe head injury in service and was pronounced dead on arrival. He also complained of having an aura of light and stated that sometimes his entire visual field moves and there is a period of black for a few seconds to a few minutes. The impression was status post motor vehicle accident with head injury and to rule out organic problems. A progress note dated in April 1993 indicated that examination had been completely negative but that a head CT was accomplished to rule out organic problems. That note indicates that the veteran had related periods of irritable behavior during his headaches. Head CT was negative. The impression was "prob. emotional component." In January 1995, the veteran reported for a VA examination. The examiner noted the veteran's history of involvement in an in-service motor vehicle accident, resulting in the veteran being "comatose for somewhere between five and 20 minutes." The examiner noted residuals of such accident, per the veteran's history, of a "major laceration above the right eye, trauma to the right shoulder, to the cervical spine, and to the lower thoracic spine." The examiner further noted that the veteran had had a CT scan due to ongoing headaches, blackout spells, etc. The veteran also reported "periods of mental confusion" and reported that his right shoulder had some calcification and a torn right rotator cuff. Examination revealed the veteran's head and neck to be normal. Examination of the ear, nose and throat was negative. The examiner noted that the veteran's right eyebrow scar was "largely obliterated and yet quite noticeable." Examination of the extremities revealed low back pain on adduction of the left hip with minimal paresthesia in the L5 dermatome on the left. The veteran's gait was normal and simple calisthenics were done without incident or difficulty. Shoulder rotation was reduced by 20 degrees in the right as compared to the left, without tenderness or crepitation and without other motion limitations. The diagnoses were 1) a history of head injury with somewhat vague sequelae; 2) a history of right shoulder rotator cuff injury; and 3) thoracic and cervical spine pain. Also in January 1995, VA neurologic examination was performed. The veteran again reported that he had been unconscious after his motor vehicle accident. He complained of numbness and tingling in his forehead, headaches, dizzy spells, blackouts and periods of indistinct vision, with objects moving or where he would go "completely blind." The veteran advised the neurologist that evaluation at a hospital failed to reveal anything. He stated that the "attacks" began about a month after the accident and occurred three-to-four times a year, with the last episode occurring six months earlier. Examination revealed normal cranial nerve testing, prompt and accurate response to coordination testing, negative Romberg, and only a slight tremor to his extended fingers. The diagnosis was post traumatic organic brain syndrome. The examiner directed attention to prior neurologic testing, the reports of which are attached to the examination report. Those testing reports indicate periods of irritable behavior and refer to negative CT with a "prob. emotional component." The January 1995 neurologic examiner noted that head injuries could produce insidious changes in personality without specific findings. At the time of VA eye examination conducted in September 1997, the veteran demonstrated 20/20 vision bilaterally; the impression was that no ocular pathology was found that would fit the veteran's reported symptoms of blurring or vibrating with headaches. The examiner noted to "consider neuro eval." Service Connection: Pertinent Criteria "[A] person who submits a claim for benefits under a law administered by the Secretary shall have the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded." 38 U.S.C.A. § 5107(a); Carbino v. Gober, 10 Vet. App. 507 (1997); Anderson v. Brown, 9 Vet. App. 542, 545 (1996). A well-grounded claim is "a plausible claim, one which is meritorious on its own or capable of substantiation. Such a claim need not be conclusive but only possible to satisfy the initial burden of [section 5107(a)]." Murphy v. Derwinski, 1 Vet. App. 79, 81 (1990). In Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992), the Court held that a claim must be accompanied by supportive evidence and that such evidence "must 'justify a belief by a fair and impartial individual' that the claim is plausible." In order to establish service connection for a claimed disability the facts must demonstrate that a disease or injury resulting in current disability was incurred in the active military service or, if pre-existing active service, was aggravated therein. 38 U.S.C.A. § 1131 (West 1991); 38 C.F.R. § 3.303 (1999). Where a veteran served for at least 90 days during a period of war or after December 31, 1946, and certain chronic diseases, such as diseases of the organic nervous system, or arthritis, become manifest to a degree of 10 percent within one year from the date of termination of such service, such diseases shall be presumed to have been incurred in service, even though there is no evidence of such diseases during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1999). Where there is a chronic disease shown as such in service or within the presumptive period under 38 C.F.R. § 3.307 so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). This rule does not mean that any manifestation in service will permit service connection. To show chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the disease identity is established, there is no requirement of evidentiary showing of continuity. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). The chronicity provision of 38 C.F.R. § 3.303(b) is applicable where evidence, regardless of its date, shows that a veteran had a chronic condition in service and still has such condition. Such evidence must be medical unless it relates to a condition as to which, under the Court's case law, lay observation is competent. If the chronicity provision is not applicable, a claim may still be well grounded if (1) the condition is observed during service, (2) continuity of symptomatology is demonstrated thereafter and (3) competent evidence relates the present condition to that symptomatology. Savage v. Gober, 10 Vet. App. 489 (1997); see also Grottveit v. Brown, 5 Vet. App. 91, 93 (1993) (where the issue involves questions of medical diagnosis or an opinion as to medical causation, competent medical evidence is required). Service connection may also be granted for a disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Thus, for a claim of entitlement to service connection to be well grounded, there generally must be (1) a medical diagnosis of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between an in-service injury or disease and the current disability. See Anderson, supra; Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (table). In any case, a claim for service-connection for a disability must be accompanied by evidence which establishes that the claimant currently has the claimed disability. Absent proof of a present disability there can be no valid claim. See, e.g., Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) ; Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). Medical evidence is required to prove the existence of a current disability and to fulfill the nexus requirement. Lay or medical evidence, as appropriate, may be used to substantiate service incurrence. See Layno v. Brown, 6 Vet. App. 465, 469 (1994); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). For the purposes of determining whether this claim is well- grounded, the Board must presume the truthfulness of the evidence, "except when the evidentiary assertion is inherently incredible or when the fact asserted is beyond the competence of the person making the assertion." King v. Brown, 5 Vet. App. 19, 21 (1993). If a claim is not well grounded, the application for service connection must fail, and there is no further duty to assist the veteran in the development of his claim. 38 U.S.C.A. § 5107, Murphy v. Derwinski, 1 Vet. App. 78 (1990). Service Connection: Analysis Headaches, Blackouts and Visual Complaints Service medical records document in-service complaints of headaches, blackouts and visual disturbances. Moreover, the veteran has testified that he has had a continuity of such symptomatology since service. His statements are deemed credible for the purposes of determining whether his claims are well grounded. Thus, the in-service prong of the Caluza test has been met for those claims. Furthermore, VA examination in 1988 included a diagnosis of residual headaches due to post-concussion syndrome. Also, subsequent VA evaluation in January 1995 resulted in a diagnosis of post-traumatic organic brain syndrome, noting the veteran's complaints of headaches, dizzy spells, blackouts, and visual disturbance and reviewing prior testing. Such evidence shows current disability and a possible nexus between such and service. Accordingly, the Board finds that the veteran's claims for service connection for headaches, blackouts and visual disturbances, claimed as a result of an in-service accident, are well grounded. Right Shoulder and Back Disorders Service records demonstrate that the veteran complained of right shoulder problems following his February 1984 automobile accident. Service records further show that the veteran fell during service and complained of pain in his back thereafter. There is competent evidence of currently diagnosed right shoulder and back disabilities and the veteran has provided a history of continued right shoulder and back problems since his in-service accidents. His statements are credible for the purpose of well-grounding his claims. See King, supra. The record also contains competent medical diagnoses that suggest the veteran's current back and shoulder disabilities are the result of an accident during service insofar as he has reported symptomatology beginning after such accident and continuing to date. Thus, competent evidence of a current disability and of a possible nexus between that disability and service has been provided to well ground the veteran's shoulder and back claims. Nasal Fracture, Status Post Rhinoplasty Service records clearly demonstrate that the veteran underwent several nasal surgery operations while in service, and that in addition to his pre-service history of septal deviation, he sustained an injury to his nose falling down a ladder during service. At the time of VA examination in 1988, the veteran was diagnosed as having residuals of injury and fracture to the nose. Competent evidence to date continues to show symptomatology post septoplasty/rhinoplasty. Thus, competent evidence of a current nasal disability and of a possible nexus between that disability and service has been provided and the veteran's claim is well grounded. The Board finds that additional development is necessary in order to afford the veteran due process and comply with the duty to assist with respect to his service connection claims, discussed above. This development is addressed in the remand portion of the decision. Rating Evaluation: Pertinent Criteria Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Schedule), 38 C.F.R. Part 4 (1999). The percentage ratings contained in the Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (1999). In determining the disability evaluation, the VA has a duty to acknowledge and consider all regulations which are potentially applicable based upon the assertions and issues raised in the record and to explain the reasons and bases for its conclusion. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Governing regulations include 38 C.F.R. §§ 4.1, 4.2 (1999), which require the evaluation of the complete medical history of the veteran's condition. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event; or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7 (1999). All benefit of the doubt will be resolved in the veteran's favor. 38 C.F.R. § 4.3 (1999). Under 38 C.F.R. § 4.118, Diagnostic Code 7800, a disfiguring scar of the head, face, or neck can be assigned a disability evaluation anywhere from zero percent to 50 percent, depending upon its severity. A zero percent evaluation is given for a scar which is only "slight." For a "moderate" scar, one which is "disfiguring," a 10 percent rating is to be granted. A 30 percent evaluation is appropriate for a "severe" scar, especially if producing a marked and unsightly deformity of the eyelids, lips, or auricles, and a "complete or exceptionally repugnant deformity" of one side of the face or a "marked or repugnant bilateral disfigurement" receives a 50 percent disability rating. Diagnostic Code 7800 also provides that when there is additionally "marked discoloration, color contrast, or the like" of the service-connected scar, a 50 percent rating may be increased to 80 percent, a 30 percent rating raised to 50 percent, and a 10 percent evaluation bumped up to 30 percent. Rating Evaluation: Analysis Initially, the Board notes that the veteran's assertions concerning the severity of his service-connected right eyebrow scar (that are within the competence of a lay party to report (see King v. Brown, 5 Vet. App. 19 (1993)), are sufficient to conclude that his claim for an increased evaluation for that disability is well grounded within the meaning of 38 U.S.C.A. § 5107(a); Murphy v. Derwinski1 Vet. App. 78 (1900). The Board is also satisfied that all relevant facts have been properly developed with respect to this claim; and that no further assistance is required in order to comply with VA's duty to assist as mandated by 38 U.S.C.A. § 5107(a). The veteran is currently in receipt of a zero percent evaluation for his scar for the period August 10, 1988, through October 16, 1990; and a 10 percent evaluation effective October 17, 1990. The Board has carefully reviewed the evidentiary record and notes that in connection with VA examination conducted in September 1988, the veteran's right eyebrow scar was opined to be mildly disfiguring, but nontender and well-healed. Photographs were taken at that time. Another report of VA examination, ear, nose, and throat examination, dated in September 1988, also noted the veteran's scar, without indicating that such was "severe," or productive of "marked discoloration, color contrast, or the like." The January 1995 VA examiner noted that the veteran's scar was quite noticeable although "largely obliterated." The competent medical reports show scarring consistent with schedular criteria for a disfiguring facial scar that is no more than moderate in severity. For a disability rating of 30 percent for the veteran's service-connected scar, there would need be evidence of a "severe" scar, especially one resulting in a marked and unsightly deformity of the eyelids, lips, or auricles; or that there be additionally "marked discoloration, color contrast, or the like" of the service- connected scar. That is not the case here as there is no competent evidence of such factors. The veteran's right eyebrow scar has not been described as severely disfiguring and none of the other criteria have been noted in connection with examination or other medical evaluation. Moreover, the veteran himself has only contended that his service-connected right eyebrow scar is "moderately disfiguring." Thus, the evidence supports a grant of a 10 percent evaluation for the period August 10, 1988, through October 16, 1990, resulting in a 10 percent disability evaluation for the entire appeal period. To that extent, the veteran's claim is granted. However, absent competent evidence of a "severe" scar or the other enumerated factors a disability evaluation in excess of 10 percent is not warranted for any portion of the appeal period. In the unusual case where the schedular evaluations are found to be inadequate, an extraschedular evaluation may be assigned commensurate with impairment in the average earning capacity due exclusively to the service-connected disability or disabilities. 38 C.F.R. § 3.321(b)(1) (1999). With respect to this claim, the Board observes that in light of Floyd v. Brown, 9 Vet. App. 88 (1996), the Board does not have jurisdiction to assign an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance. The Board, however, is still obligated to seek all issues that are reasonably raised from a liberal reading of documents or testimony of record and to identify all potential theories of entitlement to a benefit under the law or regulations. Further, in Bagwell v. Brown, 9 Vet. App. 337 (1996), the Court clarified that it did not read the regulation as precluding the Board from affirming an RO conclusion that a claim does not meet the criteria for submission pursuant to 38 C.F.R. § 3.321(b)(1), or from reaching such conclusion on its own. In the veteran's case at hand, the RO neither provided nor discussed the criteria for assignment of an extraschedular evaluation. In reviewing the case, the Board also must consider whether additional benefits are warranted under any of the provisions of 38 C.F.R. Parts 3 and 4 (1999). As to the disability picture presented in this case, the Board cannot conclude that it is so unusual or exceptional, with such related factors as frequent hospitalization or marked interference with employment, so as to prevent the use of the regular rating criteria for evaluating the veteran's right eyebrow scar. In reaching its decision, the Board has considered the complete history of the disability in question as well as the then-current clinical manifestations and the effect that the disability may have had on the earning capacity of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.16. The nature of the disability has been reviewed, and there has been found no objective medical evidence or competent lay testimony demonstrating a basis for the assignment of a higher rating. The criteria for a disability evaluation greater than 10 percent have not been satisfied at anytime during the course of this appeal. ORDER The veteran has submitted well-grounded claims of entitlement to service connection for headaches, blackouts, a right shoulder disorder, a back disorder, optic nerve damage resulting in shaking and blurred vision, and a nasal fracture, status post rhinoplasty, all claimed as residual to an in-service motor vehicle accident. A compensable evaluation for a scar above the right eyebrow for the period August 8, 1988, to October 16, 1990, is granted, subject to the laws and regulations governing the payment of monetary awards. An evaluation in excess of 10 percent for a service-connected scar above the right eyebrow is denied. REMAND The Board is obligated by law to ensure that the RO complies with its directives, as well as those of the United States Court of Appeals for Veterans Claims (known as the United States Court of Veterans Appeals prior to March 1, 1999) (hereinafter, "the Court"). The Court has stated that compliance by the Board and the RO with remand directives is neither optional nor discretionary. Where the remand orders of the Board or the Court are not complied with, the Board errs as a matter of law when it fails to ensure compliance. Stegall v. West, 11 Vet. App. 268 (1998). These matters were previously before the Board in August 1994. At that time, the Board remanded this matter for additional development, to include obtaining medical records and performing additional VA ear, nose, and throat, and neurologic examinations. The neurologic examiner was requested to provide the following opinions: Were the veteran's headaches etiologically related to his pre-existing nasal problems or any head injury in service? Was there an etiological relationship between the veteran's head injury in service and the development of visual disturbances or blackouts thereafter? The orthopedic examiner was requested to render opinions as to the etiology of any right shoulder or back disorder and whether these disorders were related to the in-service automobile accident. The ear nose, and throat examiner was specifically requested to indicate whether any in-service surgical procedures or nose injuries resulted in an increase in the level of disability relating to the veteran's pre-existing nasal disorder. In accordance with the August 1994 remand, the veteran was afforded a VA general and a VA neurological examination in January 1995. However, those examiners did not provide the required opinions, and, a special ear, nose, and throat examination was not performed at that time. Also, in connection with the September 1997 VA ophthalmologic examination, it was indicated that a neurologic evaluation of the veteran's eye complaints should be considered. In a letter dated in October 1997, a VA Medical Center indicated that the veteran was scheduled for various examinations later in October 1997. It further appears that the veteran may have been scheduled for additional VA examinations in December 1997. A computer generated form dated December 11, 1997, indicates that the veteran failed to report for cranial nerve, joint, spine, and nose and sinus examinations scheduled for that time. There does not appear to be any record of notice to the veteran to report for these examinations. The Board observes that while the veteran has a responsibility to report for VA examinations which have been scheduled, 38 C.F.R. § 3.655 (1999), it is incumbent upon the VA to notify the veteran of the scheduling of an examination, and to explain the potential implications of a failure to report. See Connolly v. Derwinski, 1 Vet. App. 566, 569 (1991) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-193 (1991)). It is unclear from information of record as to whether the veteran was notified in writing by either the RO, or a VA Medical Center, of the scheduling of the aforementioned examinations, and of the potential significance not attending such an examination could have on his claim. Therefore, the Board is of the opinion that another attempt should be made to schedule the veteran for the requested VA examinations, and that he should also be informed of the consequences for not attending such an examination. See Dusek v. Derwinski, 2 Vet. App. 519, 521- 522 (1992) (citing 38 C.F.R. § 3.655). Further examination scheduling is also warranted in light of the fact that previously requested remand action was not adequately accomplished. Stegall, at 271. Accordingly, to ensure that the VA has met its duty to assist the claimant in developing the facts pertinent to the claim and to ensure full compliance with due process requirements, the case is remanded to the RO for the following: 1. The RO should again provide the veteran opportunity to identify the names and addresses of all health care providers who have treated him for any of the claimed disabilities since his separation from service. After obtaining any necessary authorization from the veteran, the RO should obtain and associate with the claims folder legible copies of the veteran's complete treatment records from those facilities identified, which have not already been secured. Regardless of the veteran's response, the RO should obtain all outstanding VA records of treatment. 2. The veteran should be afforded a VA neurological examination to determine whether he has any chronic neurological residuals of a head injury in service. All necessary tests and studies should be performed and all findings should be reported in detail. The claims folder and a copy of this remand MUST be made available to the examiner for review prior to the examination. The examiner should review the record to determine the nature of the veteran's headaches and whether they are etiologically related to his pre-existing nasal problems and/or any in-service head injury. The examiner should also comment on whether there is an etiological relationship between the veteran's head injury in service and the development of visual disturbances or blackouts thereafter. 3. The veteran should also be afforded a VA orthopedic examination to determine the nature and etiology of any right shoulder or low back disorder. All necessary tests and studies should be performed and all findings reported in detail. The claims folder and a copy of this remand MUST be made available to the examiner for review prior to the examination. The examiner is requested to render an opinion as to whether any current back or right shoulder disorder is etiologically related to the in- service motor vehicle accident, or other incident of service. 4. The RO should schedule the veteran for a special VA ear, nose, and throat examination to determine the current status of his nasal disorder. All appropriate tests and studies should be performed and all findings must be reported in detail. The claims folder and a copy of this remand MUST be made available for review. The examiner should specifically address whether the veteran's in-service surgical procedures or any in-service nose injuries resulted in an increase in the level of disability related to his pre-existing nasal disorder. 5. The veteran should be advised of the consequences of the failure to report for the scheduled examinations under the provisions of 38 C.F.R. § 3.655. 6. Thereafter, the RO should review the claims file to ensure that all of the foregoing requested development has been completed. In particular, the RO should review the requested examination reports and required opinions to ensure that they are responsive to and in complete compliance with the directives of this remand. If they are not, the RO should implement corrective procedures. Stegall v. West, 11 Vet. App. 268 (1998). 7. After undertaking any development deemed appropriate in addition to that specified above, the RO should re- adjudicate the issues of service connection for headaches, blackouts, a right shoulder disorder, a back disorder, optic nerve damage resulting in shaking and blurred vision, claimed as a residual of a motor vehicle accident; and for a nasal fracture, status post rhinoplasty. If any benefit requested on appeal remains denied, the RO should issue a supplemental statement of the case and afford the veteran and his representative a reasonable period of time in which to respond. Thereafter, the case should be returned to the Board, if in order. By this remand, the Board intimates no opinion as to any final outcome warranted. No action is required of the veteran until he is notified by the RO. The veteran has the right to submit additional evidence and argument on the matters the Board has remanded to the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44-8.45 and 38.02-38.03. HOLLY E. MOEHLMANN Member, Board of Veterans' Appeals