Citation Nr: 0813016 Decision Date: 04/18/08 Archive Date: 05/01/08 DOCKET NO. 02-17 872A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for chest pain. 2. Entitlement to service connection for arthritis of the right shoulder. 3. Entitlement to service connection for arthritis of the right elbow. 4. Entitlement to service connection for arthritis of the left elbow. 5. Entitlement to an initial disability rating higher than 30 percent for psoriasis. ATTORNEY FOR THE BOARD D. M. Ames, Associate Counsel INTRODUCTION The veteran served on active duty from July 1973 to July 1976 and from March 1978 to June 1985. This appeal to the Board of Veterans' Appeals (Board) is from a September 2002 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. The Board remanded this case in December 2003. At the time, there were twelve claims on appeal, all for service connection except for a claim for a higher initial rating for the psoriasis (it was then rated at the 10 percent level). In a November 2007 decision on remand, however, the Appeals Management Center (AMC) increased the rating for the psoriasis to 30 percent, with the same retroactive effective date as the prior rating. The AMC also granted service connection for a left eye disorder, for arthritis affecting multiple areas (the thoracolumbar segment of the spine, left shoulder, cervical spinal segment, right knee, and left knee), as well as for instability of the right knee and for bilateral hearing loss. The veteran has since continued to appeal for an even higher rating for his psoriasis. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (indicating the veteran is presumed to be seeking the highest possible rating unless he expressly indicates otherwise). But he has not appealed either the initial ratings or effective date assigned for the several other conditions that were service connected in that decision. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (indicating he must separately appeal these downstream issues). So the only claims that remain concern whether the veteran is entitled to a rating higher than 30 percent for his psoriasis and whether he is entitled to service connection for chest pain, a right shoulder disorder, and a bilateral (meaning right and left) elbow disorder. FINDINGS OF FACT 1. The veteran's chest pain is not attributable to his military service. 2. The veteran does not have current diagnoses of a right shoulder disorder or of right and left elbow disorders, including X-ray confirmation of arthritis. 3. The veteran's psoriasis does not cause ulceration, extensive exfoliation, or curing, and systemic or nervous manifestations, or exceptionally repugnant appearance. The disease also does not cover more than 40 percent of his entire body or more than 40 percent of exposed areas. As well, constant or near-constant systemic therapy - such as corticosteroids or other immunosuppressive drugs, has not been required during the past 12 months. CONCLUSIONS OF LAW 1. The veteran does not have chest pain due to disease or injury incurred in or aggravated by his military service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2007). 2. The veteran does not have arthritis in his right shoulder due to disease or injury incurred in or aggravated by his military service, and arthritis also may not be presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113. 1131, 1137, 5107 (West 2002); 38 C.F.R. § 3.303 (2007). 3. The veteran does not have arthritis in his right elbow due to disease or injury incurred in or aggravated by his military service, and arthritis also may not be presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113. 1131, 1137, 5107 (West 2002); 38 C.F.R. § 3.303 (2007). 4. The veteran does not have arthritis in his left elbow due to disease or injury incurred in or aggravated by his military service, and arthritis also may not be presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113. 1131, 1137, 5107 (West 2002); 38 C.F.R. § 3.303 (2007). 5. The criteria are not met for an initial rating higher than 30 percent for psoriasis. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1-4.7, 4.21, 4.118, Diagnostic Codes (DCs) 7806, 7816 (2002 and 2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Duties to Notify and Assist Review of the claims files reveals compliance with the Veterans Claims Assistance Act of 2000 (VCAA), 38 U.S.C.A. § 5100 et seq. See also 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). That is, by way of letters dated in June 2001, August 2005, and May 2006, the RO and AMC advised the veteran of the evidence needed to substantiate his claims and explained what evidence VA was obligated to obtain or to assist him in obtaining and what information or evidence he was responsible for providing. 38 U.S.C.A. § 5103(a). See Quartuccio v. Principi, 16 Vet. App. 183 (2002). Consider, as well, that the RO issued the first VCAA notice letter prior to initially adjudicating the claims - the preferred sequence. Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004) (Pelegrini II). That initial letter did not specifically ask the veteran to provide any evidence in his possession pertaining to his claims. Id. at 120-21. However, the more recent August 2005 VCAA letter did make this specific request and, in any event, VA's Office of General Counsel has indicated requiring VA include such a request as part of the notice provided to a claimant under those provisions is obiter dictum and, therefore, not binding on VA. See VAOPGCPREC 1-2004 (Feb. 24, 2004) (OGC discussed this in response to the holding in Pelegrini v. Principi, 17 Vet. App. 183 (2002) (Pelegrini I), but the Court used basically the same language in Pelegrini II, so it is equally applicable). The Board is bound by the precedent opinions of VA's General Counsel, as the Chief Legal Officer of the Department. See 38 U.S.C.A. § 7104(c) (West 2002). The RO and AMC have ultimately provided all notice required by § 5103(a). Therefore, any failure to make this specific request in the initial VCAA letter is non-prejudicial, harmless error. Bernard v. Brown, 4 Vet. App. 384, 392-94 (1993); Sutton v. Brown, 9 Vet. App. 553 (1996); see also 38 C.F.R. § 20.1102. Moreover, the veteran has not made any showing or allegation that the content of the VCAA notice resulted in any prejudice. But see Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007) and Simmons v. Nicholson, 487 F.3d 892 (Fed. Cir. 2007) (where the Federal Circuit Court held that any error by VA in providing the notice required by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)(1), concerning any element of a claim, is presumed prejudicial and that once an error is identified, the burden shifts to VA to show it was harmless). Since providing the veteran additional VCAA notices in August 2005 and May 2006, the AMC has gone back and readjudicated his claims in a November 2007 supplemental statement of the case (SSOC). This is important to point out because the Federal Circuit Court has held that a statement of the case (SOC) or supplemental SOC (SSOC) can constitute a "readjudication decision" that complies with all applicable due process and notification requirements if adequate VCAA notice is provided prior to the SOC or SSOC. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV). As a matter of law, the provision of adequate VCAA notice prior to a readjudication "cures" any timing problem associated with inadequate notice or the lack of notice prior to an initial adjudication. See also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). If there arguably is any deficiency in the notice to the veteran or the timing of the notice it is harmless error. See Overton v. Nicholson, 20 Vet. App. 427, 435 (2006) (finding the Board had erred by relying on various post- decisional documents for concluding adequate 38 U.S.C.A. § 5103(a) notice had been provided to the appellant, the Court nonetheless determined the evidence established the veteran was afforded a meaningful opportunity to participate effectively in the adjudication of his claims, and therefore found the error harmless). That is to say, if there was any deficiency in the notice to the veteran, the Board finds that the presumption of prejudice on VA's part has been rebutted: (1) based on the communications sent to the veteran over the course of this appeal, he clearly has actual knowledge of the evidence he is required to submit; and (2) based on his contentions and the communications provided to him by VA over the course of this appeal, he is reasonably expected to understand from the notices provided what was needed. It equally deserves mentioning that, in the November 2007 SSOC and in a February 2008 letter, the veteran also received information concerning both the downstream disability rating and effective date elements of his claims. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). See, too, Dunlap v. Nicholson, 21 Vet. App. 112 (2007). And as for the duty to assist, the RO and AMC obtained the veteran's service medical records, private medical records, and the reports of his VA compensation examinations. As there is no other indication or allegation that relevant evidence remains outstanding, the Board finds that the duty to assist has been met. 38 U.S.C.A. § 5103A. The veteran is currently incarcerated. The Court has held that VA must tailor its assistance to the peculiar circumstances of obtaining examination of an incarcerated veteran. Bolton v. Brown, 8 Vet. App. 185 (1995). The Bolton Court indicated that alternative means to obtain examination of an incarcerated veteran include: (1) attempting to arrange transportation of the veteran to a VA facility for examination; (2) contacting the correctional facility and having their personnel conduct an examination according to VA examination worksheets or (3) sending a VA examiner to the correctional facility to conduct the examination. This case was remanded in December 2003 so the veteran could undergo VA examinations, which were arranged through his prison. The AMC complied with all of the Board's remand directives, including insofar as the veteran's claim concerning his heart (chest pain). The medical examiner who traveled to the prison where the veteran is incarcerated concluded that, based upon review of the claims files and all relevant medical records, a heart examination was unnecessary. This examiner provided a medical opinion and rationale based on his review of the record, and since he did not believe an examination was necessary to provide responses to the questions the Board had posed in the remand, the Board may go ahead and decide this claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006), citing 38 U.S.C.A. § 5103A(d) and 38 C.F.R. § 3.159(c)(4). The Board is therefore satisfied as to compliance with its December 2003 remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). Service Connection Claims Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active military service, or for aggravation during service of a pre- existing condition beyond its natural progression. 38 U.S.C.A. §§ 1110, 1131, 1153; 38 C.F.R. §§ 3.303(a), 3.306. Degenerative joint disease (DJD, i.e., arthritis) will be presumed to have been incurred in service if manifested to a compensable degree of at least 10 percent within one year after service. This presumption, however, is rebuttable by probative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. So service connection may be established either by showing direct service incurrence or aggravation or by using applicable presumptions, if available. Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Direct service connection generally requires evidence of a current disability with a relationship or connection to an injury or disease or some other manifestation of the disability during service. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). A disorder may be service connected if the evidence of record reveals that the veteran currently has a disorder that was chronic in service or, if not chronic, that was seen in service with continuity of symptomatology demonstrated subsequent to service. 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488, 494-97 (1997). Evidence that relates the current disorder to service must be medical unless it relates to a disorder that may be competently demonstrated by lay observation. Savage, 10 Vet. App. at 495-97. For the showing of chronic disease in service, there is a required 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." 38 C.F.R. § 3.303(b). Disorders diagnosed after discharge may still be service connected if all the evidence, including relevant service records, establishes the disorder was incurred in service. 38 C.F.R. § 3.303(d). Where the determinative issue involves medical causation or a medical diagnosis, there must be competent medical evidence to the effect that the claim is plausible; lay assertions of medical evidence do not constitute competent medical evidence. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is resolved in favor of the veteran. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. A layperson is generally incapable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997). See also Bostain v. West, 11 Vet. App. 124, 127 (1998) citing Espiritu v. Derwinski, 2 Vet. App. 492 (1992) (a layperson without the appropriate medical training and expertise is not competent to provide a probative opinion on a medical matter, to include a diagnosis of a specific disability and a determination of the origins of a specific disorder). Lay testimony is competent, however, to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). When a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As mentioned, the first and perhaps most fundamental requirement for any service-connection claim is competent evidence of the existence of a current disability. Boyer, 210 F.3d at 1353; Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (indicating service connection presupposes a current diagnosis of the condition claimed, to confirm the veteran at least has it). Here, the veteran has a current diagnosis of a heart problem to support his claim for chest pain. But he does not have diagnoses of a right or left elbow disability, including X- ray confirmation of arthritis. See 38 C.F.R. § 4.71a, DC 5003. During the May 2007 VA examination on remand, the evaluating physician observed the veteran's elbows were not painful, and his the ranges of motion were normal to 145 degrees. He had psoriatic plaques on his elbows that caused them to itch, but this did not affect his ranges of motion. And the psoriasis is already service connected and being separately evaluated in this decision. X-rays also were negative, including for radiographic indications of arthritis. The examiner concluded there was no pathology to render a diagnosis for either elbow. Hence, as there is no diagnosis of a disability involving either elbow - including arthritis, these claims must be denied. See Degmetich v. Brown, 8 Vet. App. 208 (1995); 104 F.3d 1328, 1332 (1997) (holding that compensation may only be awarded to an applicant who has a disability existing on the date of the application, not for a past disability) The veteran also does not have a current diagnosis of arthritis in his right shoulder. At his May 2007 VA examination, his right shoulder had no swelling, tenderness, or laxity. His range of motion was 170 degrees of active flexion, 180 degrees of passive flexion, and 170 degrees of flexion after fatigue. His abduction was 180 degrees active, passive, and fatiguing. Internal and external rotation was to 90 degrees. All movements caused pain at the end of motion and was relieved when the movement stopped. An x-ray of his right shoulder was negative. And the examiner again concluded there was no pathology of the right shoulder to render a diagnosis. So this claim also must be denied because pain, alone, without a diagnosis or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted. Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999), appeal dismissed in part, and vacated and remanded in part sub nom. Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001). The Board realizes the veteran was treated for a "frozen right shoulder" in October 2005. However, that condition apparently has resolved, as evidenced by the results of his May 2007 examination. So, as there is no diagnosis of a current right shoulder disability, the claim must be denied. See again Degmetich v. Brown, 8 Vet. App. 208 (1995); 104 F.3d 1328, 1332 (1997) (holding that compensation may only be awarded to an applicant who has a disability existing on the date of the application, not for a past disability). Chest Pain The veteran's service medical records (SMRs) show he complained of chest pain twice during his second period of service. His initial complaint was in June 1983, which was described as related to job stress. A cardiac workup was performed and the results were within normal limits. His other complaint was in March 1984. The diagnosis was acute costochondritis (noting no cardiac condition was found). His separation physical also did not reveal a cardiac condition or medications for a cardiac condition. So his chest pain in service was acute and transitory, not chronic, and resolved prior to his discharge. Consequently, there must be evidence of continuity of symptomatology since service and/or medical evidence otherwise linking any current cardiac disability to the veteran's military service. 38 C.F.R. § 3.303(b) and (d). In May 2007, the veteran had a VA examination for other claimed disabilities. The Board's December 2003 remand had specified that he was to receive a heart examination so that a physician could determine the etiology of any current cardiac disability. However, as already alluded to, the examiner concluded the veteran did not need a separate heart examination for such an opinion to be given. The examiner reviewed the veteran's claims files, including his SMRs and post-service treatment records. And the examiner determined "there was no connection" between the veteran's two complaints of chest pain in service and his current coronary heart condition. The examiner stated that "[t]his veterans [sic] current coronary heart condition is NOT related to his two isolated episodes of chest discomfort (pain) while in the military." This examiner's rationale was that the two isolated incidents of chest pain in service were deemed to not have been cardiac in nature, and since the veteran had no history of cardiac problems until well after his discharge from the military. The examiner elaborated that the veteran's current heart problem is multi-factored, and that one factor may be his cocaine abuse. So the veteran has not established the required linkage between his current cardiac disability and his military service, including the two isolated instances of treatment while in the military. See Watson v. Brown, 4 Vet. App. 309, 314 (1993) ("A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service."). See, too, Maggitt v. West, 202 F.3d 1370, 1375 (Fed. Cir. 2000); D'Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000); Hibbard v. West, 13 Vet. App. 546, 548 (2000); and Collaro v. West, 136 F.3d 1304, 1308 (Fed. Cir. 1998). In the absence of any medical nexus evidence providing this necessary link between the veteran's current heart problem and the two instances of chest pain in service, the claim must be denied because the preponderance of the evidence is unfavorable, in turn meaning the benefit-of-the-doubt doctrine does not apply. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Increased Evaluation Claim Disability ratings are determined by applying the criteria established in VA's Schedule for Rating Disabilities, which is based upon the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.20 (2006). If, as here, there is disagreement with the initial rating assigned following a grant of service connection, separate ratings can be assigned for separate periods of time, based upon the facts found. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). In other words, the veteran's rating may be "staged" to compensate him for times since the effective date of his award when his disability may have been more severe than others. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, irrespective of whether the veteran raised them, as well as the entire history of his disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The veteran believes his psoriasis is even more severe than 30-percent disabling under the applicable regulation, 38 C.F.R. § 4.118, DC 7816. The veteran filed his claim in March 2001. During the pendency of this appeal, regulatory changes amended VA's Schedule for Rating Disabilities, 38 C.F.R. Part 4 (2007), including, effective August 30, 2002, the rating criteria for evaluating skin disorders such as psoriasis. See 67 Fed. Reg. 49,590-49,599 (July 31, 2002). Therefore, the Board will evaluate the veteran's psoriasis under both the former and revised criteria. However, VA's Office of General Counsel has determined in a precedent opinion that the amended rating criteria, if more favorable to the claim, can be applied only prospectively for periods from and after the effective date of the regulatory change. The Board can apply only the prior regulation to rate the veteran's disability for periods preceding the effective date of the regulatory change. See VAOGCPREC 3-2000 (Apr. 10, 2000). See also VAOPGCPREC 7-2003 (Nov. 19, 2003); 38 U.S.C.A. § 5110(g); 38 C.F.R. § 3.114; Rhodan v. West, 12 Vet. App. 55 (1998); and Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). The RO addressed the previous and amended criteria in the November 2002 SOC and November 2007 SSOC. Therefore, the Board may also consider these amendments without first determining whether doing so will be prejudicial to the veteran. Bernard v. Brown, 4. Vet. App. 384, 392-94 (1993). Under the older criteria, the veteran's psoriasis was rated under DC 7806, for eczema. And according to DC 7806, a 30 percent evaluation is warranted when there is exudation or constant itching, extensive lesions, or marked disfigurement. A 50 percent evaluation requires ulceration, extensive exfoliation, or curing, and systemic or nervous manifestations, or exceptionally repugnant appearance. 38 C.F.R. § 4.118 (2002). Under the amended criteria, psoriasis is rated under DC 7816. A 30 percent evaluation is warranted when 20 to 40 percent of the veteran's entire body is affected, or when 20 to 40 percent of exposed areas are affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of six weeks or more, but not constantly, during the past 12 month period. A 60 percent evaluation is warranted when more than 40 percent of the entire body or more than 40 percent of exposed areas are affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs were required during the past 12 month period. 38 C.F.R. § 4.118 (2007). The rater is also given the option of rating psoriasis as disfigurement of the head, face, or neck (DC 7800), or scars (DCs 7801-7805), depending on the predominant disability. 38 C.F.R. § 4.118. (2007). The prior and amended versions of DCs 7802, 7803, and 7804 are not favorable to the veteran because the highest evaluation available under these DCs is 10 percent, and he already has a higher 30 percent evaluation. The previous and amended versions of DC 7805 also are not favorable to him because it instructs the rater to evaluate based on limitation of function of the affected part, and the veteran is already compensated for limitation of function of the affected parts with the several separate ratings for his arthritis. Separate ratings for limitation of function due to a painful scar would constitute impermissible pyramiding. See 38 C.F.R. § 4.14. DC 7800 is not favorable to the veteran because disfigurement of the head, face, or neck is not the predominant manifestation of his psoriasis. In May 2007, the veteran had a VA skin examination. The examiner noted that the veteran has had psoriasis since he was in the military, and that it was constant and present at all times, but varied in intensity. His symptoms were itching and patchy rashes on his skin. He had no systemic symptoms. He reported minor relief from scaling of his skin with topical creams, but no relief from itching. He used two creams every day to treat his psoriasis. The examiner stated that neither of the veteran's medications were corticosteroids or immunosuppressive. On objective physical examination, the veteran had psoriatic- type lesions on his forehead, between his eyebrows, slightly on his cheeks, on the tip of his nose, on the helix of both ears, both elbows, and the knuckles of his hands. The lesions were "discrete silvery white scaling plaques." The veteran also had lesions on his knees, left thigh, and left buttock. The plaques were scaly and thick with lichenification on the elbows. Both knees were covered with lesions (14 centimeters by 6 centimeters on each knee). The thigh of his left leg had lesions measuring 7 centimeters by 5 centimeters and 5 centimeters by 3.5 centimeters. The examiner indicated less than 10 percent of the exposed area was covered, and that less than 20 percent of the veteran's entire body. The examiner was unable to take photographs of the veteran because he was incarcerated, but it was noted that the condition on his face was about 5 percent more severe than it was in color photographs taken in December 2002. In April 2005, the veteran submitted buddy statements from fellow inmates. M. K. stated that the veteran had to buy new shirts and pants every three to four months because the ointment he used to relieve his psoriasis stained his sleeves and pants legs. D. G. stated the veteran often stayed in his room because the skin creams made his arms, legs, and face greasy. J. M. stated he was housed in the same unit as the veteran and worked with him in the prison. He noted that the veteran's itchy skin caused him extreme distress on a daily basis, and limited his ability to work in the prison. J. M. also said the veteran could not sit down to work for long periods of time because his skin would crack. The results of the veteran's VA compensation examination and these lay statements do not support assigning a rating higher than 30 percent, under either the former or revised standards. Under the older criteria, this evidence does not show ulceration or extensive exfoliation or curing. The VA examiner stated there were no systemic manifestations. And as only 10 percent of the veteran's exposed body areas are affected, and the lesions on his face were described as "discrete," the condition is not exceptionally repugnant. Therefore, a 50 percent evaluation cannot be granted under the older criteria. 38 C.F.R. § 4.118, DC 7806 (2002). The veteran also is not entitled to a higher rating under the amended criteria. The examiner reported that the veteran did not use corticosteroids or immunosuppressive treatment for his psoriasis. The examiner also noted that 10 percent of the exposed area was affected, or 20 percent of the veteran's total body. Hence, as the skin condition does not affect more than 40 percent of the whole body or the exposed areas, a higher evaluation cannot be granted. 38 C.F.R. § 4.118. DC 7816 (2007). Since the veteran's psoriasis does not satisfy the requirements for a higher rating under either the former or revised criteria, his claim must be denied. That is to say, 30 percent is the best approximation of the severity of this condition, so this rating must remain in effect 38 C.F.R. § 4.7. The preponderance of the evidence is against a higher rating, so no reasonable doubt. 38 C.F.R. § 4.3. Also, the condition has never been more than 30-percent disabling since the effective date of the grant, so the rating may not be "staged," either. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Finally, the Board finds no reason to refer this case to the Compensation and Pension Service for consideration of an extra-schedular evaluation under 38 C.F.R. § 3.321(b). That is, there is no evidence of exceptional or unusual circumstances, such as frequent hospitalization or marked interference with employment, to suggest the veteran is not adequately compensated by the regular rating schedule. VAOGCPREC 6-96. See also 38 C.F.R. § 4.1, indicating that, generally, the degrees of disability specified in the Rating Schedule are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. ORDER Service connection for chest pain is denied. Service connection for arthritis of the right shoulder is denied. Service connection for arthritis of the right elbow is denied. Service connection for arthritis of the left elbow is denied. An initial disability rating higher than 30 percent for psoriasis is denied. ____________________________________________ KEITH W. ALLEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs