Citation Nr: 0631656 Decision Date: 10/11/06 Archive Date: 10/16/06 DOCKET NO. 98-03 280A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUE Entitlement to an initial compensable rating for urticaria, rashes and hypersensitivity, as residuals of inoculations in service. ATTORNEY FOR THE BOARD A. Shawkey, Counsel INTRODUCTION The veteran served on active duty from May 1976 to May 1979, and from September 1979 to July 1986. This matter comes to the Board of Veterans' Appeals on appeal from a March 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon, that granted service connection for urticaria, rashes and hypersensitivity, as residuals of inoculations in service. The veteran disagrees with the noncompensable rating assigned. In the substantive appeal dated in December 2005, the veteran requested a Board hearing. However, he later informed VA in writing in August 2006 that he had made a mistake when he requested the hearing and he did not want a Board hearing. This appeal also initially stemmed from a March 1997 administrative decision of the Department of Veterans Affairs Medical Center (VAMC) that denied entitlement to payment or reimbursement of unauthorized private medical services for atrial fibrillation and Wolff-Parkinson-White syndrome from December 18, 1996, to December 19, 1996. This matter was before the Board in December 2000 at which time it was remanded to the VAMC for readjudication in light of the Board's December 2000 grant of service connection for Wolff-Parkinson-White syndrome. A VA inquiry to the VAMC in April 2006 revealed that the bill for medical services provided December 18, 1996, to December 19, 1996, had been paid thus resolving the December 2000 remand issue. Accordingly, this issue is no longer on appeal. In a June 2006 statement, the veteran said that he suffered a "major manic depression meltdown" after battling his hypersensitivity condition. Thus, he appears to be raising a claim for service connection for a psychiatric disability as secondary to his service-connected urticaria, rashes and hypersensitivity. This matter is referred to the RO for appropriate action. FINDING OF FACT The veteran's service-connected urticaria, rashes and hypersensitivity is manifested by outbreaks that can be pruritic and affect extensive areas of his body; it occurs at least four times per year and is well-controlled with the regular use of antihistamine medication. CONCLUSION OF LAW The criteria for the assignment of an initial 10 percent evaluation for service-connected urticaria, rashes and hypersensitivity have been met since the effective date of the grant of service connection. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, Part 4, including § 4.118, Diagnostic Code 7806 (2002), Diagnostic Code 7825 (2006). REASONS AND BASES FOR FINDING AND CONCLUSION I. Veterans Claims Assistance Act of 2000 On November 9, 2000, the President signed into law the Veterans Claims Assistance Act of 2000 (VCAA). Veterans Claims Assistance Act of 2000, Pub. L. No. 106-475, 114 Stat. 2096 (2000), is codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107 and 5126 (West 2002); see also 38 C.F.R. §§ 3.102, 3.156(a), and 3.326(a) (2005). Under the VCAA, VA has a duty to notify the veteran of any information and evidence needed to substantiate and complete a claim, and of what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain for the claimant. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R §§ 3.159(b)(1) (2005); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The record shows that the claimant has been notified of the applicable laws and regulations, which set forth the criteria for entitlement to the issue on appeal. The discussions in the rating decision, statement of the case, and supplemental statements of the case have informed the claimant of the information and evidence necessary to warrant entitlement to the benefits sought. Moreover, in June 2001 and May 2006 VCAA letters, the veteran was advised of the types of evidence VA would assist him in obtaining as well as his own responsibilities with regard to identifying relevant evidence. See Quartuccio v. Principi, 16 Vet. App. 183 (2002); Charles v. Principi, 16 Vet. App. 370 (2002). Here the issue of an increased rating is a downstream issue of the original service connection claim adjudicated in the March 2004. VA's General Counsel has concluded that, if, in response to notice of its decision on a claim for which VA has already given the § 5103(a) notice, VA receives a notice of disagreement that raises a new issue, § 7105(d) requires VA to take proper action and issue a statement of the case if the disagreement is not resolved, but § 5103(a) does not require VA to provide notice of the information and evidence necessary to substantiate the newly raised issue. VAOPGCPREC 8-2003 (Dec. 22, 2003). This is the situation where we have a VCAA notice to the veteran that relates to establishing service connection, but we do not have a separate § 5103(a) notice following the RO's grant of service connection and the veteran's notice of disagreement raising the downstream issue of an increased rating. However, in the instant case, the RO provided a subsequent notice in May 2006 concerning the veteran's newly raised increased rating claim. The Board also notes that both VCAA letters implicitly notified the appellant of the need to submit any pertinent evidence in the appellant's possession. In this regard, the appellant was repeatedly advised to identify any source of evidence and that VA would assist in requesting such evidence. The Board believes that a reasonable inference from such communication was that the appellant must also furnish any pertinent evidence that the appellant may have and that the requirements of 38 C.F.R. § 3.159(b)(1) have been met. The Board finds that all notices required by VCAA and implementing regulations were furnished to the appellant and that no useful purpose would be served by delaying appellate review to send out additional VCAA notice letters. The United States Court of Appeals for Veterans Claims' decision in Pelegrini v. Principi, 18 Vet. App. 112 (2004) held, in part, that a VCAA notice as required by 38 U.S.C. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim for VA benefits. In this case, the RO provided the initial VCAA notice for service connection to the veteran in June 2001, which was prior to the March 2004 rating decision. Thus, since the current increased rating issue is a downstream issue, the requirements the Court set out in Pelegrini have been satisfied. During the pendency of this appeal, on March 3, 2006, the Court issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) veteran status; 2) existence of a disability; (3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. The Court held that upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Dingess/Hartman, supra. With respect to the present appeal, the RO did send the appellant a letter dated in May 2006 specifically addressing the elements involving a disability rating and effective date. Thus, the Board finds that the veteran is not prejudiced by a decision at this time since adequate notice on all five elements has been given to the appellant. Furthermore, the Board finds that there has been substantial compliance with the assistance provisions set forth in the law and regulations. The record in this case includes service medical records, VA treatment records, private records and VA examinations. The Board finds that the record as it stands includes adequate competent evidence to allow the Board to decide the case and no further action is necessary. See generally 38 C.F.R. § 3.159(c)(4). No additional pertinent evidence has been identified by the claimant. In fact, the veteran stated in writing in April 2006 that he had no additional evidence to present and requested that his claim be decided as soon as possible. Under these circumstances, the Board finds that VA has fulfilled its duty to notify and assist the appellant in the claim under consideration and that adjudication of the claim at this juncture, without directing or accomplishing any additional notification and or development action, poses no risk of prejudice to the appellant. See, e.g., Bernard v. Brown, 4 Vet. App. 384, 394 (1993). The appeal is now ready to be considered on the merits. II. Facts The veteran's service medical records show that he reported to a medical facility in December 1982 complaining of a rash that appeared on his body in different places at night. It had been ongoing for approximately one and a half months and lasted for three to five hours at a time. He reported that it can be non pruritic or very pruritic, and appeared like welts. He was assessed as having probable urticaria. During a February 1983 medical clinic visit, the veteran reported three episodes of urticaria that week, and one that was severe. He said he took Excedrin. He was assessed as having urticaria by history and was noted to be on Benadryl. In April 1998, the veteran filed a claim for service connection for urticaria. He reported typical outbreaks in the evening consisting of "traveling" rashes that lasted two to four hours, and sometimes produced night sweats. He also reported less frequent, more severe outbreaks involving rashes that covered his whole body and produced swelling in his face/jaw, ankles and/or wrists. He said these outbreaks lasted two to five days. He added that he had managed to greatly reduce the frequency of severe outbreaks since becoming a vegetarian and noted that the last severe outbreak had been in October or November of 1997. In August 1998, the RO received pictures of the veteran during what he described was an "urticaria episode." The pictures show the veteran with a large red rash on his back and side. The veteran remarked that the "outbreak" at that time continued until 11:00pm and had traveled to his shoulders/armpits and finally to his upper thigh/groin areas. During a November 1998 VA skin examination, the veteran reported intermittent hives for approximately 11 to 12 years. He also reported taking Benadryl since 1982 on both a regular and intermittent basis with a favorable response. He said the episodes had escalated in the last couple of years in number and were also associated with intense swelling of his face and neck region with associated shortness of breath. Examination findings did not reveal any cutaneous edema or urticaria hives. In May 1999, the veteran reported to a VA urgent care unit complaining of a rash. He reported intermittent rashes and swelling over various parts of his body for 20 years. He related it to certain foods such as MSG and/or peanut oil, and said if he didn't take Benadryl every day he would have a rash all the time. He said his present rash began three to four days earlier and developed over his face, giving him a sunburn appearance. The physician noted the typical urticarial rash and associated dermatographia with no breathing problems, shortness of breath, and said that only on the most recent episode did the veteran have subjective laryngeo edema. However, on examination the veteran had no rash. The examiner gave an impression of chronic urticaria by history. During a VA general outpatient clinic evaluation in March 2000, the veteran said that his biggest concern was ongoing urticaria, and he believed that he had a hypersensitivity to various environmental and food allergens. On examination his skin was warm and dry. The physician noted that the veteran's urticaria was chronic in nature and well controlled with antihistamines. He recommended that the veteran stick with Benadryl and said he would supply the veteran with an insect bite kit containing epinephrine for urticaria episodes in extreme cases as the veteran requested. During a VA outpatient clinic examination in July 2000, the veteran reported having allergies to sulfa and penicillin, and also numerous food allergies. He said that in regard to his hypersensitivity, he found that taking Benadryl at night and also pseudoephedrine in the morning helped alleviate his discomfort. With respect to work, the veteran reported that he had not worked since 1995 and was "overqualified for his age." Findings and diagnoses were identical to the March 2000 VA examination. The veteran underwent a VA outpatient follow up examination in September 2001 at which time he reported having a severe allergic reaction earlier in the week to mayonnaise. He said that he experienced throat swelling and shortness of breath. He said he did not use his anaphylaxis kit, but instead took four Benadryl over a period of time with subsequent resolution. He reported having food problems since the early 90s. He said he was on a limited diet of fruits and vegetables and took Benadryl generally once per day, and otherwise kept his symptoms under good control. The examiner noted that the veteran was "otherwise very comfortable in appearance." He rendered an impression of anaphylaxis secondary to certain foods and noted that the veteran seemed to be controlling this quite well with is present regime. He said the veteran got a good response from Benadryl and he renewed the veteran's anaphylaxis kit. The veteran declined an allergy referral at that time. A February 2002 VA outpatient record notes that the veteran carried EpiPen kits with him in case of anaphylactic shock. During a February 2003 general examination at a VA outpatient facility, the examiner noted that the veteran had an allergy to sulfa and said that he had multiple food allergies that were almost too numerous to note. He also said that it was not clear what was truly an allergy or an intolerance given the veteran's current history. There were no abnormal skin findings noted. The physician diagnosed the veteran as having recurrent urticaria, labeled as a food allergy by the veteran's history. A February 2003 VA outpatient record notes that the veteran had chronic urticaria, marked by a rash and a swollen face. Many foods, food products, and chemicals were noted to start an episode. It was also noted that the veteran carried an epi-pen and Benadryl with him. It was further reported that the veteran had to isolate himself to stay away from things he knew would start a reaction. In March 2003, the veteran contacted a VA medical facility by telephone to complain of ringing in his ear. He said that he had swelling of his face two weeks earlier and took Benadryl, Sudafed and nasal spray. Results of a May 2004 VA new provider examination revealed that the veteran had tinea versicolor, anterior chest. In a "To Whom It May Concern" letter dated in May 2003, the veteran's treating VA physician stated that the veteran had hypersensitivity reactions to a broad variety of foods, preservative, and non-food items such as cleaning chemicals. He said the veteran's illness had caused him to be isolated in order to avoid allergic reactions. He noted that the veteran carried Benadryl and an epinephrine pen with him. The veteran underwent a VA contract examination in August 2003 at which time he reported recurrent urticarial hive- like rashes since approximately 1982 or 1983. He said he was able to treat this relatively successfully with chronic and intermittent use of Benadryl, which almost always worked. He said the rashes worsened in the mid 1980s and in the early 1990s he saw a doctor who recommended an elimination diet which helped. He reported worsening eruptions since approximately 1991, as well as facial swelling, swelling of the neck, and airway constriction. He remarked that these recurrences were less frequent now, but had required emergency room visits on occasion in the past. He explained that over the last five to ten years he treated most of the episodes with Benadryl and the hives were less of an issue and occurred in a small amount, maybe once every day or two. The veteran went on to report that his skin reactions were triggered by environmental allergens, plant allergens, contact with paper, almost all processed meat and foods, airborne chemicals in certain stores, and chemicals on new clothing. On examination the veteran had no evidence of an urticarial or angioedema. His skin appeared normal. The examiner said the veteran did show him some slight redness on his dorsal forearm, but said it did not look to be urticarial. The examiner stated that an actual diagnosis was somewhat in question, though he did note that the veteran clearly had a history of some documented episodes of urticaria, beginning in service. In November 2003, the veteran underwent a VA nose, sinus, larynx, and pharynx examination and relayed a chief complaint of multiple inhalant and food allergies. On examination the veteran was symptom-free without any upper respiratory or other problems, but on a day-to-day basis, was noted to have frequent reactive episodes requiring treatment. In a notice of disagreement dated in May 2004, the veteran said that he felt that he was entitled to a 10 percent rating for urticaria. He said VA had supplied antihistamines since 1986 and he continued to average two to three urticaria episodes per week. He went on to state that with his very restricted diet, environmental avoidance and daily antihistamine use, the severity and duration of most outbreaks had been reduced. An April 2005 VA telecare note contains the veteran's request that his dosage of olanzapine be checked because of complaints of acne on his torso and arms. VA outpatient records dated in October and November 2005 show that the veteran was treated for athlete's foot. III. Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), found in 38 C.F.R. Part 4. The Board attempts to determine the extent to which the veteran's service- connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.10 (2006). Where there is a question as to which of two evaluations should be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2006). When a specific disability is not listed in the Rating Schedule, rating is done by analogy to a disability that is listed in the Rating Schedule. 38 C.F.R. § 4.20 (2006). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 3.102. Because the veteran has disagreed with the initial rating assigned for urticaria, rashes and hypersensitivity, the Board has characterized the issue in accordance with Fenderson v. West, 12 Vet. App. 119, 126 (1999). Moreover, although the RO increased the initial award to 30 percent during the pendency of this appeal, as a higher evaluation is available for this condition, and the veteran is presumed to seek the maximum available benefit for a disability, the claim for a higher initial evaluation remains viable on appeal. AB v. Brown, 6 Vet. App. 35, 38 (1993). It is important to note at the outset that the veteran is presently service connected for urticaria, rashes and hypersensitivity as residuals of inservice inoculations. This is the disability that has been assigned a noncompensable evaluation for and is the disability that is presently on appeal. With this said, the veteran has made additional claims for residuals inservice inoculations to include numbing, intense headaches, light and olfactory sensitivities, bleeding and nasal infection, ongoing digestive distress disorder, and chronic anaphylaxis condition. These residuals are presently being developed by the RO and are not part of the appeal that is presently before the Board. In short, the only residuals of inservice inoculations that are presently being considered for a higher, compensable, rating are the already service connected urticaria, rashes and hypersensitivity. The veteran's skin rash was initially evaluated by analogy to the rating criteria listed at Diagnostic Code 7806, eczema. 38 C.F.R. § 4.118 (2002). Dermatitis or eczema is rated utilizing the criteria listed at 38 C.F.R. § 4.118, Diagnostic Code 7806. However, during the pendency of this appeal, regulatory changes amended the VA Schedule for Rating Disabilities found at 38 C.F.R. Part 4 (2002), including the rating criteria for evaluating skin disabilities. See 67 Fed. Reg. 49596 (July 31, 2002) (effective August 30, 2002). (The veteran was notified of the change in criteria by way of the statement of the case (SOC) that was issued in November 2005.) In evaluating the veteran's skin rash claim, the Board must determine whether the revised version is more favorable to the veteran. See VAOPGCPREC 7-2003. However, even if the Board finds the revised version more favorable, the new criteria can be applicable no earlier than the effective date of that change. See VAOPGCPREC 3-2000. Under the criteria in effect prior to August 30, 2002 (old criteria), a non-compensable evaluation is for application with slight, if any, exfoliation, exudation, or itching, if on a nonexposed surface or small area. A 10 percent evaluation is assigned for exfoliation, exudation or itching, if involving an exposed surface or extensive area. 38 C.F.R. § 4.118, Diagnostic Code 7806 (2002). The rating criteria effective August 30, 2002 (new criteria) provide for a noncompensable evaluation for dermatitis or eczema when less than 5 percent of the entire body or less than 5 percent of exposed area is affected, and no more than topical therapy is required during the past 12-month period. A 10 percent rating is warranted when at least 5 percent, but less than 20 percent of the entire body, or at least 5 percent, but less than 20 percent, of exposed area is affected, or intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs was required for a total duration of less than six weeks during the past 12-month period. 38 C.F.R. § 4.118, Diagnostic Code 7806 (2005). Again, the February 2002 VA examiner found no current evidence of a rash, and a compensable evaluation is thus not warranted under the new Diagnostic Code 7806. The new criteria also include diagnostic codes for additional specific diseases of the skin, including urticaria, which is evaluated utilizing Diagnostic Code 7825. Id. Under Diagnostic Code 7825, a 10 percent rating is for application when there are recurrent episodes occurring at least four times during the past 12-month period, and the urticaria is responding to treatment with antihistamines or sympathomimetics. The Board is aware of the Court's decision in Ardison v. Brown, 6 Vet. App. 405, 408 (1994), a case that, like this one, concerned the evaluation of a service-connected disorder that fluctuated in its degree of disability, that is, a skin disorder that had "active and inactive stages" or was subject to remission and recurrence. See Ardison v. Brown, 6 Vet. App. at 408; see also Bowers v. Derwinski, 2 Vet. App. 675, 676 (1992) (holding that "it is the frequency and duration of the outbreaks and the appearance and virulence of them during the outbreaks that must be addressed."). Thus, the frequency, duration, and outbreaks of skin disease exacerbations must be addressed and the skin disorder should be considered, whenever possible, at a time when it is most disabling. See Bowers; Ardison. In this case, the veteran has been examined several times during the pendency of this appeal. During each evaluation, from as early as 1998 to 2003, there were no skin findings on examination. This is not entirely inconsistent with the veteran's report that the outbreaks last a few hours in duration mostly at night, and in consideration of the fact that the examinations are scheduled weeks in advance. Nevertheless, the veteran did submit photographs in 1998 showing an urticaria outbreak and his history is well outlined in the medical records. Accordingly, the Board finds that the evidence as a whole is sufficient to rate the veteran's skin disability. Applying the facts in this case to the criteria set forth above, and resolving all reasonable doubt in the veteran's favor, the Board finds that the criteria for a 10 percent rating for urticaria, rashes and sensitivity have been met, both under the old and new criteria. See 38 C.F.R. § 3.102. As set forth above, the veteran reports that his service- connected skin disability is manifested primarily by daily rashes that last a few hours and can lead to facial swelling. In terms of the old criteria under Code 7806, while the veteran's urticaria is well documented in the medical records, it is primarily documented by history and not by actual objective findings. This is because, as noted above, the veteran has not been evaluated during a period of flare- up. Thus, it is not entirely clear from the postservice evidence whether the veteran's urticaria involves exfoliation, exudation or itching. However, his service medical records do include a 1982 notation that the veteran's rash can be non pruritic or very pruritic. With this in mind, and considering the chronic nature of the veteran's skin disability and that he takes Benadryl to alleviate his symptoms, the Board finds that the veteran's urticaria involves itching. In addition, it is clear that the veteran's urticaria involves an extensive area. This is evident in the 1998 photographs that the veteran submitted to the RO showing a rash covering his back and sides. He also reported at that time that the rash had travelled to his shoulders/armpits and to his upper thigh/groin areas. Moreover, numerous medical records note that the urticarial hive-like rashes occur intermittently over various parts of his body. In addition, the rash is noted in a number of medical records to cause facial swelling, thereby affecting an exposed area as well as an extensive area. Affording the veteran the benefit of the doubt, therefore, the Board finds that the criteria for a 10 percent rating have been met under Diagnostic Code 7806, as in effect prior to August 30, 2002. The veteran likewise meets the criteria for a 10 percent rating under the new criteria (effective August 30, 2002). This criteria, which pertains specifically to urticaria, provides for a 10 percent rating when there are recurrent episodes occurring at least four times during the past 12- month period, and the urticaria is responding to treatment with antihistamines or sympathomimetics. In terms of frequency of outbreaks, the veteran reported during a VA contract examination in August 2003 that over the last five to ten years he treated most of the episodes with Benadryl and the hives were less of an issue and occurred in a small amount, maybe once every day or two. Then in a May 2004 notice of disagreement, the veteran stated that he continued to average two to three urticaria episodes per week. Based on these reports, the veteran's urticaria episodes clearly occur at least four times in a 12 month period. The evidence is also clear in showing that the condition is well controlled with antihistamines and that the veteran has been taking Benadryl since service. Specifically, there is a March 2000 VA outpatient record noting that the veteran's urticaria was well controlled with antihistamines, and a September 2001 VA outpatient clinic record noting that the veteran was getting a "good response" from Benadryl. Moreover, the veteran reported during an August 2003 VA contract examination that he was able to treat his recurrent urticarial hive-like rashes relatively successfully with chronic and intermittent use of Benadryl, "which almost always worked." Based on the foregoing, the veteran is entitled to a compensable, 10 percent, rating for urticaria, rashes and sensitivity, from the date of the grant of service connection. The criteria for a rating in excess of 10 percent, however, have not been met, either under the old or revised criteria. In terms of the old criteria, there has been no objective evidence of constant exudation or itching, extensive lesions, or marked disfigurement. Similarly, there is no evidence of systemic or nervous manifestations, or exceptional repugnance so as to warrant a rating in excess of 10 percent under the criteria in effect prior to August 30, 2002. 38 C.F.R. § 4.118, Diagnostic Code 7806 (2002). Similarly, the Board finds that a rating in excess of 10 percent is not warranted under the revised criteria pertaining to the evaluation of skin disorders. The veteran's service-connected skin condition has not been shown to affect 20 to 40 percent of his entire body or 20 to 40 percent of the exposed areas. Moreover, the veteran has never required systemic therapy such as corticosteroids or other immunosuppressive drugs. Thus, the criteria for a rating in excess of 10 percent under the revised version of Diagnostic Code 7806 have not been met. Lastly, the Board has also contemplated extraschedular evaluation for this appeal, but finds that there has been no showing that the veteran's service-connected urticaria has: (1) caused marked interference with employment beyond the interference contemplated in the now-assigned initial 10 percent rating; (2) necessitated frequent periods of hospitalization; or (3) otherwise rendered impracticable the regular schedular standards. In the absence of factors suggesting an unusual disability picture, further development in keeping with the actions outlined in 38 C.F.R. § 3.321(b)(1) (2004) is not warranted. See 38 C.F.R. § 4.1 (2004); Bagwell v. Brown, 9 Vet. App. 337, 339 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER An initial evaluation of 10 percent for service-connected urticaria, rashes and hypersensitivity is granted; subject to the law and regulations governing the payment of monetary benefits. ____________________________________________ V. L. JORDAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs