Citation Nr: 0006993 Decision Date: 03/15/00 Archive Date: 03/23/00 DOCKET NO. 98-11 695 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Newark, New Jersey THE ISSUE The propriety of the initial 10 percent disability rating for the service-connected multiple lipomas. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Joseph W. Spires, Associate Counsel INTRODUCTION The veteran served on active duty from December 1965 to October 1967. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a May 1997 rating decision of the RO. REMAND In a January 1997 statement the veteran explained that, since service, he had developed tumors on his arms, upper thighs, stomach and chest and that he had "had well over 100 [tumors] removed." Indeed, a December 1996 private medical statement indicated that the veteran had 61 benign lipomata removed during three surgeries, between October 1976 and October 1991. A February 1997 VA report of skin (other than scars) examination noted a "1.5 x 1.5 cm subcuticular nodule of the right posterior arm, firm, mobile, and asymptomatic." The report noted that the veteran had reported that he began to develop tumors after chemical exposure in the Republic of Vietnam and that he had had about 50 tumors removed and that "they were called lipomas." The report also noted "[m]ultiple 2 x 0.1 cm surgical scars over the arms, thighs, and back." The report listed a diagnosis of multiple lipomas over the trunk and extremities, without evidence of chloracne. The apparently related February 1997 VA report of scars (skin) examination noted merely "see skin for scars trans." In the veteran's July 1997 Notice of Disagreement, he indicated that he had developed 11 additional lipomas and that some itched and others burned. Also, he stated that, due to disfiguring scars on his arms, chest, stomach and thighs, he would not wear shorts, bathing suits or short sleeved shirts in public. In the veteran's June 1998 Substantive Appeal, he stated that he had developed 5 additional lipomas and experienced constant itching and burning sensations, as well as the continued development of new lipomas. Additionally, he stated that the February 1997 VA report of examination was inaccurate in that the examiner did not ask to see his multiple scars or state whether the lipomas itched or recurred. The veteran also indicated that he had previously had 5 operations to remove multiple lipomas and that he would "require another operation shortly." An August 1998 VA report of skin diseases (other than scars) examination noted "about 10, 1 to 2 x 3 cm subcutaneous nodules over the trunk, arms and thighs, not painful to the touch." The report also noted "[m]ultiple 2 x 0.3 to 5 x 0.3 cm linear scars over the truck, arms, thighs, not painful to touch, secondary to multiple surgeries for lipomas over the years." The report indicated diagnoses of multiple lipomas, with some burning and itching at times, and multiple scars secondary to excisions of the lipomas. VA regulations require that, for the application of the rating schedule, accurate and fully descriptive medical examinations are required, with an emphasis upon the limitation of activity imposed by the disability. 38 C.F.R. § 4.1 (1999). Medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. Id. Where medical reports do not contain sufficient detail, the report must be returned for evaluation purposes. 38 C.F.R. § 4.2 (1999). New growths of benign skin are to be rated as for eczema (Diagnostic Code 7806), dependent upon the location, extent and repugnant or otherwise disabling character of the manifestations. 38 C.F.R. § 4.118 including Diagnostic Code 7819 (1999). Indeed, the record indicates that the veteran's service connected multiple lipomas are rated under Diagnostic Code 7806 (eczema). The Board observes that the rating criteria of new benign skin growths and eczema require the consideration of several factors, including the degree of exfoliation, crusting, or lesions, an evaluation of systemic or nervous manifestations, an indication of whether the disability is exceptionally repugnant or markedly disfiguring, and the otherwise disabling character of any manifestations. 38 C.F.R. § 4.118 including Diagnostic Codes 7806 and 7819. The record does not contain a report of medical examination that considers all of the required evaluation factors. Additionally, the VA medical reports indicate that a complete review of the veteran's records was not conducted as part of the examination process. The veteran indicated in his June 1998 Substantive Appeal that he would "require another operation shortly." Furthermore, the record indicates that, although the veteran claimed that his symptoms included constant itching and burning, the August 1998 VA medical report noted that some of the lipomas were itchy and burned "at times." Finally, the RO must consider whether the symptomatology associated with the residual scars warrant compensable ratings based on being painful and tender. In light of the foregoing, the Board is REMANDING this case for the following actions: 1. The RO should take appropriate steps to contact the veteran and request that he identify the names, addresses, and approximate dates of treatment for all VA and non-VA health care providers who have treated him for the service-connected multiple lipomas since service. After obtaining any necessary authorization from the veteran, the RO should attempt to obtain copies of pertinent treatment records identified by the veteran in response to this request, which have not been previously secured, to specifically include records of any additional operations to excise lipomas. 2. After all relevant treatment records are obtained and associated with the claims folder, the RO should schedule the veteran for a VA examination in order to determine the severity of the service- connected multiple lipomas and residuals thereof. The examiner should determine and report on the current level of any ulceration, exfoliation, crusting, exudation, lesions, scarring and itching. The examiner should also indicate whether any disability could be characterized as exceptionally repugnant or a marked disfigurement. The examiner should also report all other systemic and nervous manifestations associated with this disability, as well as the disabling character of all manifestations. All indicated tests must be conducted. The examiner should state whether any of the residual scarring is painful and tender on objective demonstration or poorly nourished with repeated ulceration or productive of some limitation of function. The claims folder must be made available to and reviewed by the examiner, and the examiner should report whether the claims folder was indeed available and reviewed. A complete rationale for each opinion expressed must be provided. 3. After undertaking any additional development deemed appropriate, the RO should conduct a review of the veteran's claim. Due consideration should be given to all pertinent laws and regulations as well as any additional Diagnostic Code which might be relevant. If the benefit sought on appeal is not granted, the veteran and his representative should be issued a supplemental statement of the case, which should include all pertinent laws and regulations, and be afforded a reasonable opportunity to reply thereto. Thereafter, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration, if appropriate. The veteran need take no further action until he is otherwise notified, but he may furnish additional evidence and argument while the case is in remand status. Quarles v. Derwinski, 3 Vet. App. 129, 141 (1992); Booth v. Brown, 8 Vet. App. 109 (1995); Kutscherousky v. West, 12 Vet. App. 369 (1999). In taking this action, the Board implies no conclusion as to any ultimate outcome warranted. This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals 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. STEPHEN L. WILKINS Member, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 1991 & Supp. 1999), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1999).