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VA Rating Assistant

DC 7818 · 38 CFR 4.118

Malignant Skin Neoplasms (Other Than Melanoma) C&P Exam Prep

To document the nature, extent, active status, treatment history, and residual effects of malignant skin neoplasms (other than melanoma) for VA disability rating purposes under 38 CFR 4.118, DC 7818. The examiner will determine whether the cancer is active or in remission, what treatments have been used, and how residual effects such as scars or disfigurement should be separately rated.

Format:
Interview + Physical
Typical duration:
15-30 minutes
DBQ form:
Skin_Diseases (Skin_Diseases)
Examiner:
Dermatologist or appropriate clinician

What the examiner evaluates

  • Type, location, and number of malignant skin neoplasms (e.g., basal cell carcinoma, squamous cell carcinoma, Merkel cell carcinoma)
  • Whether each neoplasm is a primary cancer or a metastatic lesion
  • Current active vs. remission status of each neoplasm
  • Whether treatment required systemic chemotherapy, extensive X-ray therapy beyond the skin, or surgery more extensive than wide local excision
  • Date of diagnosis and anatomical location of each neoplasm
  • Complete treatment history including surgery type, radiation therapy, chemotherapy, immunotherapy, and antineoplastic agents
  • Residual scars, disfigurement of the head, face, or neck, or functional impairment resulting from the neoplasm or its treatment
  • Presence of local recurrence or metastasis
  • Functional impairment caused by the condition or treatment
  • Whether the veteran is regularly followed at a clinic
  • Impact of the condition on occupational and daily functioning

Exam typically includes a physical skin examination of all affected areas and a structured interview about diagnosis history, treatment course, and current symptoms. Bring all pathology reports, operative reports, and oncology treatment records. The examiner will physically inspect scars, disfigurement areas, and any active lesions. Each distinct malignant neoplasm may be documented separately on the DBQ.

Measurements and tests

Scar/Disfigurement Documentation

What it measures: Size (length and width in centimeters), location, type (linear, superficial non-linear, painful, unstable), and surface area of scars resulting from excision or treatment of the malignant neoplasm

What to expect: The examiner will physically measure scars using a ruler or measuring tape, note their location relative to anatomical landmarks, and classify them by type. Scars on the head, face, or neck will be evaluated under DC 7800 (disfigurement) or DCs 7801-7805 (scars). The examiner may take photographs.

Critical thresholds

  • Greater than 39 sq cm superficial non-linear scar Higher rating potential under DC 7802; document exact dimensions
  • Painful or unstable scar (any size) Qualifies for rating under DC 7804 regardless of size; be explicit about pain
  • Scar on head, face, or neck causing disfigurement Rated under DC 7800; number and type of disfiguring characteristics directly drive rating percentage
  • Deep, nonlinear scar limiting motion May be rated under DC 7801 or as functional impairment; document range of motion limitation

Tips

  • Show all scars, including those from biopsies, Mohs surgery, excisions, skin grafts, and lymph node removal
  • Point out any scar that is painful to touch, tender, or causes burning sensations
  • Identify scars that are adherent to underlying tissue or restrict movement
  • Do not minimize scar pain - if a scar hurts when pressed or during activity, say so explicitly
  • If a scar on the face or neck causes cosmetic disfigurement, describe how it affects your appearance and daily social interactions

Pain considerations: Scar pain is a separate rating criterion under DC 7804. Describe pain as it occurs on your worst days - burning, shooting, hypersensitivity to clothing contact, or pain with movement. Pain that limits function, causes sleep disruption, or affects employment should be explicitly stated.

Total Body Surface Area (TBSA) and Exposed Surface Area Documentation

What it measures: The percentage of total body surface area and exposed body surface area affected by active skin disease or residual skin changes, required per M21-1 for skin condition DBQs

What to expect: The examiner will document what percentage of the body surface is affected by current skin manifestations or treatment-related skin changes. This is especially relevant if the malignancy has caused widespread skin involvement or treatment has caused diffuse skin effects.

Critical thresholds

  • Any percentage of exposed body surface area affected Required documentation; higher percentages support higher disability ratings for residual skin conditions

Tips

  • If you have multiple sites of excision or radiation damage, help the examiner understand the full scope by identifying each location
  • If your treatment caused skin effects across a broad area, describe the extent accurately
  • Point to all affected areas - do not assume the examiner will find them all without direction

Pain considerations: Not applicable for this measurement type.

Functional Impairment Assessment

What it measures: How the malignant neoplasm, its treatment, or residual effects limit the veteran's physical functioning, including range of motion limitations from scars, lymphedema, nerve damage, or weakness from surgery

What to expect: The examiner may ask about limitations in reaching, gripping, walking, or other functions depending on the location of the neoplasm. If scars restrict joint movement, range of motion testing may be performed.

Critical thresholds

  • Functional limitation from scar tissue or surgical damage Rated as impairment of function under DC 7818; may warrant separate rating for the affected body part

Tips

  • Describe any limitations in movement, grip strength, or activities caused by surgical scars or radiation damage
  • Mention if lymph node removal has caused lymphedema or swelling
  • If peripheral nerve damage occurred from surgery or radiation, describe numbness, tingling, or weakness accurately

Pain considerations: Functional impairment from scars includes pain-limited range of motion. Describe how pain restricts what you can do, not just the anatomical limitation.

Rating criteria by percentage

100%

Active malignant skin neoplasm requiring therapy comparable to that used for systemic malignancies: systemic chemotherapy, X-ray therapy more extensive than to the skin, or surgery more extensive than wide local excision. A 100% evaluation is assigned from the date of onset of such treatment and continues with a mandatory VA examination six months after completion of antineoplastic treatment.

Key symptoms

  • Active malignancy requiring systemic chemotherapy (e.g., IV or oral targeted chemotherapy agents)
  • Radiation therapy extending beyond the skin (e.g., treatment of lymph nodes or internal structures)
  • Surgery more extensive than wide local excision (e.g., radical excision, lymph node dissection, amputation)
  • Immunotherapy or biological agents used for systemic cancer treatment (e.g., checkpoint inhibitors, high-dose interferon)
  • Evidence of active disease or ongoing antineoplastic treatment at time of exam

From 38 CFR: Per 38 CFR 4.118 DC 7818: If a skin malignancy requires therapy comparable to that used for systemic malignancies - systemic chemotherapy, X-ray therapy more extensive than to the skin, or surgery more extensive than wide local excision - a 100% evaluation will be assigned from the date of onset of treatment. Note: If treatment is confined to the skin only, the 100% evaluation provisions do not apply.

0%

After completion of antineoplastic treatment with no local recurrence or metastasis, the evaluation is based entirely on residuals. Residuals are rated under DC 7800 (disfigurement of head, face, or neck), DC 7801 (deep nonlinear scar), DC 7802 (superficial nonlinear scar), DC 7803 (unstable or painful scar), DC 7804 (painful scar), DC 7805 (other scar effects), or as impairment of function. There is no fixed percentage for residuals under DC 7818 - the rating is entirely determined by the applicable residual diagnostic codes. If treatment was confined to the skin only, the 100% evaluation never applies.

Key symptoms

  • No active malignancy, no local recurrence, no metastasis
  • Residual surgical scars from excision or Mohs surgery
  • Residual disfigurement of head, face, or neck
  • Functional limitation from scar tissue, nerve damage, or lymphedema
  • Radiation-related skin changes (fibrosis, telangiectasia, atrophy)
  • Pain or instability at scar site
  • Cosmetic disfigurement affecting daily life or employment

From 38 CFR: Per 38 CFR 4.118 DC 7818: If there has been no local recurrence or metastasis, evaluation will be made on residuals. Rate as disfigurement of head, face, or neck (DC 7800), scars (DCs 7801-7805), or impairment of function. Note: If treatment is confined to the skin, the provisions for a 100% evaluation do not apply - the condition is rated on residuals from the outset.

Describing your symptoms accurately

Active Malignancy and Treatment Intensity

How to describe it: Clearly state the specific type of skin cancer (e.g., squamous cell carcinoma, basal cell carcinoma, Merkel cell carcinoma), all locations, dates of diagnosis, and every treatment modality used. Distinguish between treatments confined to the skin (simple excision, topical treatments, superficial radiation) and treatments that extend beyond the skin (systemic chemotherapy, lymph node dissection, deep radiation fields).

Example: I was diagnosed with squamous cell carcinoma on my left cheek in [year] and underwent a radical neck dissection with removal of 22 lymph nodes, followed by 35 sessions of radiation that included the neck and submandibular nodes, and six cycles of systemic cisplatin chemotherapy. On my worst days during treatment, I could not eat, had severe fatigue, and required hospitalization for dehydration.

Examiner listens for: Whether the treatment modality qualifies for the 100% evaluation under DC 7818 - specifically systemic chemotherapy, radiation beyond skin fields, or surgery beyond wide local excision. The examiner will document each treatment type, dates, and current status.

Avoid: Do not simply say 'I had surgery to remove it.' Specify the extent - wide local excision versus radical excision versus Mohs surgery versus lymph node dissection. Each matters significantly for rating purposes.

Scar Pain and Sensitivity

How to describe it: Describe the quality, frequency, and triggers of scar pain. Use specific language: burning, shooting, stabbing, hypersensitive to touch, pain with clothing contact, weather-related pain, or pain that wakes you at night. Indicate which scars are painful and how pain affects function.

Example: On my worst days, the scar on my neck from the lymph node dissection feels like it is on fire and tightens to the point where I cannot turn my head to check blind spots while driving. Even the collar of my shirt causes significant pain and I have to wear only soft V-neck shirts.

Examiner listens for: Any scar that is painful on direct pressure or with movement, unstable, adherent, or causes functional limitation qualifies for rating under DCs 7804 or 7805. The examiner needs to document this to ensure it is captured in the DBQ.

Avoid: Do not say 'my scar is fine' or 'it doesn't bother me much.' If it hurts at all - even occasionally - describe it accurately and completely. Understating scar pain is the single most common cause of underrating for this condition.

Disfigurement of Head, Face, or Neck

How to describe it: Describe the visual appearance and location of any disfigurement - skin discoloration, tissue loss, asymmetry, contracture, visible scarring, hair loss at the scar site, or changes in skin texture. Explain how the disfigurement affects your self-image, social interactions, and employment.

Example: The scar on my face from the Mohs surgery has left a visible depression and discoloration that causes strangers to stare. I avoid social situations because I am self-conscious. My supervisor commented on my appearance, and I have stopped attending client-facing meetings.

Examiner listens for: The number and severity of disfiguring characteristics under DC 7800 - tissue loss, gross distortion, multiple scars, skin discoloration, or abnormal skin texture on the head, face, or neck. Each characteristic contributes to the rating percentage.

Avoid: Do not minimize the cosmetic impact by saying 'it's not that bad.' Describe the objective appearance accurately and how it has changed your life. The examiner rates what they observe and what you report.

Functional Impairment from Treatment Residuals

How to describe it: Describe any loss of function caused by surgery, radiation, or chemotherapy - including limited range of motion from scar tissue, lymphedema, numbness from nerve damage, weakness in the affected limb or area, difficulty swallowing or speaking if head and neck were treated, or fatigue from ongoing treatment.

Example: After my radical neck dissection, I have persistent shoulder drop and weakness from spinal accessory nerve damage. I cannot raise my right arm above shoulder height, which prevents me from performing overhead work. I also have chronic lymphedema in my right arm that causes significant swelling and tightness every day.

Examiner listens for: Any functional impairment that can be separately rated - shoulder weakness, limited cervical range of motion, lymphedema, neuropathy, or swallowing dysfunction. These may support additional ratings beyond the skin neoplasm itself.

Avoid: Do not fail to mention functional limitations because you think they are 'separate' from the skin cancer. They are direct residuals of treatment and should be described in detail at this exam.

Recurrence, Metastasis, and Ongoing Surveillance

How to describe it: Describe your ongoing monitoring schedule, any history of local recurrence, regional lymph node involvement, or distant metastasis. Include dates of recurrence, retreatment, and current surveillance frequency. If you have been told you are cancer-free, say so - but also describe what monitoring you still undergo.

Example: My squamous cell carcinoma recurred twice - first in [year] and again in [year] - and on the second recurrence it had spread to two cervical lymph nodes, requiring a second neck dissection. I now see my oncologist every three months for surveillance, and each visit brings significant anxiety about recurrence.

Examiner listens for: History of recurrence or metastasis is critical for determining whether the condition should still be rated at 100% or transitioned to a residuals-based evaluation. The examiner must document the current status accurately.

Avoid: Do not omit prior recurrences or metastatic episodes. Each episode of recurrence or spread may restart the 100% evaluation period and affects the overall disability picture.

Common mistakes to avoid

Failing to distinguish treatment extent - saying 'I had surgery' without specifying whether it was a simple excision or a more extensive procedure

Why: The 100% evaluation under DC 7818 applies only when surgery is more extensive than wide local excision. If you do not describe the actual surgical procedure (e.g., radical excision, lymph node dissection, flap reconstruction), the examiner may default to documenting only 'surgery' which could result in a residuals-only rating

Do this instead: Bring operative reports and describe the surgery in specific terms: 'I had a Mohs surgery with three stages,' or 'I had a radical neck dissection with removal of 28 lymph nodes,' or 'I underwent a sentinel lymph node biopsy followed by regional lymphadenectomy'

Impact: 100% vs. residuals

Not reporting scar pain because it feels minor or intermittent

Why: Painful scars qualify for rating under DC 7804 regardless of size. Even mild or intermittent scar pain, if real and accurate, supports a compensable rating. Veterans who underreport scar pain receive 0% for a condition that should be rated

Do this instead: Describe all scar pain accurately - burning, sensitivity to touch, clothing contact pain, cold-weather pain, or pain with movement. Report how often it occurs and what your worst days feel like

Impact: 0% vs. compensable scar rating

Treating each skin cancer as a single condition when multiple primaries exist

Why: Per M21-1, each malignant skin neoplasm is considered a separate primary cancer (e.g., a basal cell carcinoma on the nose and a squamous cell carcinoma on the arm are two separate conditions). Veterans who do not distinguish them may lose separate ratings

Do this instead: Bring a complete list of every skin cancer diagnosis with dates, locations, and pathology reports. Ensure the examiner documents each one separately on the DBQ

Impact: Multiple separate ratings vs. single rating

Assuming a completed treatment means the exam is just a formality with no significant rating

Why: After antineoplastic treatment ends, the VA must conduct a mandatory examination six months post-treatment. The residuals-based rating that follows can still be significant if scars, disfigurement, or functional impairment are properly documented

Do this instead: Come prepared to thoroughly document all residuals - scars, disfigurement, functional limitations, and ongoing symptoms - at the six-month post-treatment examination

Impact: Post-treatment residuals rating

Not mentioning psychological impact or functional limitations from disfigurement

Why: The DBQ specifically asks about the impact of the skin condition on functioning. Disfigurement that causes social withdrawal, employment avoidance, or psychological distress supports both the skin rating and potentially a separate mental health claim

Do this instead: Describe how disfigurement has changed your social behavior, employment activities, and self-confidence. If you have developed anxiety or depression related to your cancer or its appearance, mention this and consider a separate mental health claim

Impact: DC 7800 disfigurement rating and potential separate mental health rating

Failing to bring pathology reports, operative reports, and oncology records to the exam

Why: M21-1 requires that all pathology reports identifying the type of cancer and organ involved be available. Without documentation, the examiner may not be able to confirm diagnosis details, treatment extent, or recurrence history accurately

Do this instead: Bring organized copies of all relevant records: pathology reports for each diagnosis, surgical operative notes, radiation treatment summaries, chemotherapy records, and current oncology follow-up notes

Impact: All rating levels

Prep checklist

  • critical

    Compile all pathology reports for every skin cancer diagnosis

    Gather biopsy and surgical pathology reports identifying each cancer type (basal cell carcinoma, squamous cell carcinoma, Merkel cell carcinoma, etc.), diagnosis date, anatomical location, and staging. Per M21-1, these are required for adjudication. Label each report clearly.

    before exam

  • critical

    Obtain all operative and surgical reports

    Collect surgical notes for every procedure - biopsies, excisions, Mohs surgery, lymph node dissections, reconstructive surgeries, or amputations. The operative report will confirm whether surgery was more extensive than wide local excision, which is critical for the 100% evaluation trigger.

    before exam

  • critical

    Document all treatment records including chemotherapy and radiation

    Obtain radiation oncology treatment summaries (including field size and whether lymph nodes or structures beyond the skin were included), chemotherapy infusion records with drug names and dates, and immunotherapy records. These documents confirm whether systemic-level treatment was received.

    before exam

  • critical

    Create a written timeline of all diagnoses, treatments, and recurrences

    Prepare a chronological one-page summary listing each cancer diagnosis (type, location, date), every treatment received (type, dates, completion date), any recurrences or metastases, and current surveillance schedule. Bring this to hand to the examiner or read from it during the interview.

    before exam

  • recommended

    Photograph all visible scars and disfigurement areas before the exam

    Take clear photographs of all scars - close-up and showing location on body - in good lighting. Include a ruler or common object for scale. Date the photographs. While the examiner may photograph at the exam, having your own documentation ensures nothing is missed if the exam is rushed.

    before exam

  • critical

    Write down all scar symptoms and functional limitations

    List every scar location, its current symptoms (pain, burning, sensitivity, tightness, restriction of motion), and how symptoms affect daily activities and work. Note worst-day examples. Review this list before the exam so you do not forget items under the pressure of the appointment.

    before exam

  • recommended

    Review 38 CFR 4.118 DC 7818 and related scar DCs (7800-7805)

    Understand that DC 7818 ratings ultimately depend on residual ratings under the scar and disfigurement codes. Familiarize yourself with what characteristics are rated under DC 7800 (head, face, neck disfigurement) and DC 7804 (painful scars) so you can accurately communicate relevant symptoms.

    before exam

  • critical

    Identify and document each separate skin cancer as a distinct condition

    Per M21-1, each malignant skin neoplasm is a separate primary cancer. Prepare a list showing: Cancer 1 (type, location, date diagnosed), Cancer 2 (type, location, date diagnosed), etc. This ensures the examiner documents each separately, which can result in multiple separate disability ratings.

    before exam

  • critical

    Wear or bring clothing that allows easy access to all scar sites

    Wear loose, easily removable clothing so the examiner can view all scar and treatment sites. If scars are on the torso, back, or neck, wear clothing that can be opened or removed without difficulty. Do not let inaccessible clothing result in a missed or inadequately documented scar.

    day of

  • recommended

    Do not use heavy makeup or wound coverings over scars before the exam

    The examiner must physically observe the scars and disfigurement to document them accurately. Covering scars with heavy concealer or bandages may obscure findings. Present your condition as it is on a typical day.

    day of

  • recommended

    Arrive early and organize all documents

    Arrive 15 minutes early with all records organized and labeled. Have the written diagnosis and treatment timeline on top. Be prepared to briefly walk the examiner through your cancer history, treatment types, and current status in 2-3 minutes.

    day of

  • critical

    Identify every scar by location and describe symptoms for each one individually

    Do not group scars together. For each scar, state: location on the body, approximate size, whether it is painful (and how), whether it is tender to touch, whether it restricts movement, and whether it is cosmetically disfiguring. Ask the examiner to measure each scar.

    during exam

  • critical

    Explicitly state whether surgery was more than wide local excision

    Tell the examiner the name of the surgical procedure (e.g., 'radical neck dissection with removal of 28 lymph nodes' or 'sentinel lymph node biopsy followed by regional lymphadenectomy'). If you received systemic chemotherapy or radiation beyond the skin, state the names of the drugs or the radiation fields explicitly.

    during exam

  • critical

    Report symptoms as they are on your worst days

    Per M21-1 guidance, the VA is to consider your condition at its worst, not just on the day of the exam. If the exam happens to be a relatively good day, tell the examiner: 'On my worst days, my symptoms are...' and describe the full severity.

    during exam

  • critical

    Describe the functional and occupational impact of your condition and its residuals

    Explain how scars, disfigurement, lymphedema, nerve damage, or treatment effects limit your ability to work, perform daily activities, and participate in social life. The DBQ specifically asks about functional impact and the examiner must document it.

    during exam

  • recommended

    Confirm the examiner has documented each cancer diagnosis separately

    At the end of the exam, politely confirm that each of your skin cancer diagnoses has been documented as a separate condition with its own location, type, and treatment history. Ask if there are any additional questions you can answer to ensure completeness.

    during exam

  • critical

    Request a copy of the completed DBQ

    You have the right to request a copy of your completed Disability Benefits Questionnaire. Review it for accuracy, particularly treatment types (confirming systemic vs. skin-only treatment is correctly noted), scar descriptions, and functional impact documentation.

    after exam

  • critical

    Note any discrepancies and file a statement in support of claim

    If the DBQ inaccurately describes your treatment (e.g., lists 'surgery' without specifying extent, or omits scar pain), submit a written statement on VA Form 21-4138 correcting the record. Reference the specific DBQ field and the accurate information.

    after exam

  • critical

    Ensure you receive the mandatory six-month post-treatment examination

    Per 38 CFR 4.118, a mandatory VA examination must occur six months after completion of antineoplastic treatment. If you have completed treatment and this exam has not been scheduled, contact your VSO or VA claims agent to ensure it is ordered and completed timely.

    after exam

  • recommended

    Consider filing claims for secondary conditions

    After the exam, consider whether you have developed secondary conditions from the malignancy or its treatment: shoulder weakness from spinal accessory nerve injury, lymphedema, depression or anxiety related to cancer diagnosis, radiation-induced hypothyroidism, or peripheral neuropathy from chemotherapy. These may each warrant separate claims.

    after exam

Your rights during a C&P exam

  • You have the right to request that the C&P examination be recorded (audio or video) in most states. Notify the VA in writing before the exam that you intend to record. Check your state's consent laws - most require only one-party consent.
  • You have the right to bring a VSO representative, attorney, or claims agent to the examination as an observer.
  • You have the right to submit a buddy statement or personal statement describing your symptoms before or after the examination.
  • You have the right to request a copy of the completed Disability Benefits Questionnaire (DBQ) after the examination.
  • You have the right to submit additional medical evidence, including private medical opinions, to supplement or rebut the C&P examiner's findings.
  • You have the right to request a new or additional examination if you believe the original examination was inadequate, incomplete, or based on inaccurate information.
  • Under the PACT Act, certain malignant skin cancers may qualify as presumptive conditions for veterans exposed to burn pits, Agent Orange, radiation, or other toxic exposures. Ask your VSO if your cancer may qualify for presumptive service connection.
  • Per M21-1, each malignant skin neoplasm is considered a separate primary cancer entitled to its own separate rating - you have the right to have each diagnosed cancer evaluated individually.
  • A mandatory VA examination must occur six months after completion of antineoplastic treatment. You have the right to ensure this examination is scheduled and completed, as it determines your post-treatment residuals-based rating.
  • Per 38 CFR 3.105(e), any reduction in your disability rating following the six-month post-treatment mandatory examination is subject to specific procedural protections before the reduction becomes effective.
  • You have the right to a clear written notice from the VA explaining any rating decision, including the specific evidence and criteria used to make that decision.

Related conditions

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This C&P exam preparation guide is for educational purposes only and does not constitute legal, medical, or claims advice. Always consult with a qualified Veterans Service Organization (VSO) representative or VA-accredited attorney for guidance specific to your claim. Never exaggerate, minimize, or fabricate symptoms during a C&P examination.