Citation Nr: 1136732 Decision Date: 09/29/11 Archive Date: 10/11/11 DOCKET NO. 06-21 049 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Providence, Rhode Island THE ISSUES 1. Entitlement to an increase in a 10 percent rating for undifferentiated connective tissue disease with antiphospholipid antibody syndrome for the period prior to December 23, 2009. 2. Entitlement to an increase in a 60 percent rating for undifferentiated connective tissue disease with antiphospholipid antibody syndrome for the period since December 23, 2009. 3. Entitlement to a total disability rating based on individual unemployability (TDIU rating). REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Appellant and her husband ATTORNEY FOR THE BOARD S. D. Regan, Counsel INTRODUCTION The Veteran had verified active service from September 1987 to January 1991. She also reports additional service in the Navy Nurse Corps until 2001. Service connection and a 10 percent rating have been in effect for connective tissue disease since the day after separation from service in 1991. In May 2003, the Veteran submitted a claim asserting additional disability related to her service-connected connective tissue disease. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2005 RO rating decision that recharacterized the Veteran's service-connected undifferentiated connective tissue disease as undifferentiated connective tissue disease with antiphospholipid antibody syndrome, and continued a 10 percent rating. In September 2007, the Board remanded this appeal to schedule the Veteran for a Travel Board hearing at the RO. In November 2007, the Veteran testified at a Board videoconference hearing. In January 2008, the Board remanded this appeal for further development. A May 2010 RO decision increased the rating for the Veteran's service-connected undifferentiated connective tissue disease with antiphospholipid antibody syndrome to 60 percent, effective December 23, 2009. Since that grant does not represent a total grant of benefits sought on appeal, the claims for increase remain before the Board. AB v. Brown, 6 Vet. App. 35 (1993). The Board notes that in a September 2010 statement, the Veteran indicated that she disagreed with the effective date of the award of the 60 percent rating for her service-connected undifferentiated connective tissue disease with antiphospholipid antibody syndrome. She specifically stated that she disagreed with the finding that there were no definitive objective findings indicating exacerbations prior to December 23, 2009. By this decision, the Board is awarding an increased rating to 60 percent for the undifferentiated connective tissue disease with antiphospholipid antibody syndrome for the appeal period prior to December 23, 2009. With this award, the Board is essentially addressing, and resolving in the Veteran's favor, the contentions with regard to the effective date of the 60 percent rating during the pendency of her appeal. The issue of entitlement to a TDIU rating is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. For the period prior to December 23, 2009, the Veteran's undifferentiated connective tissue disease with antiphospholipid syndrome was manifested by no more than exacerbations lasting a week or more, two to three times per year. 2. For the period since December 23, 2009, the Veteran's undifferentiated connective tissue disease with antiphospholipid syndrome is manifested by no more than exacerbations lasting a week or more, two to three times per year. CONCLUSIONS OF LAW 1. The criteria for a 60 percent rating for undifferentiated connective tissue disease with antiphospholipid antibody syndrome for the appeal period prior to December 23, 2009, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.20, 4.88b, Diagnostic Code 6350 (2010). 2. The criteria for a rating in excess of 60 percent rating for undifferentiated connective tissue disease with antiphospholipid antibody syndrome for the period since December 23, 2009, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.20, 4.88b, Diagnostic Code 6350 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002) redefined VA's duty to assist the Veteran in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a). The notice requirements of the VCAA require VA to notify the veteran of what information or evidence is necessary to substantiate the claim, including what subset of the necessary information or evidence, if any, the claimant is to provide and what subset of the necessary information or evidence VA will attempt to obtain. The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Such notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, insufficiency in the timing or content of VCAA notice is harmless if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). In this case, in October 2004 and February 2008 letters, the RO provided notice to the Veteran regarding what information and evidence is needed to substantiate the claims for increased ratings, as well as what information and evidence must be submitted by the Veteran, what information and evidence will be obtained by VA, and the need for the Veteran to advise VA of or submit any further evidence in his possession that pertains to the claim. The February 2008 letter (noted above) as well as a March 2006 letter, also advised the Veteran of how disability evaluations and effective dates are assigned, and the type of evidence which impacts those determinations. The case was last readjudicated in May 2010. The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran. Specifically, the information and evidence that have been associated with the claims file include: the Veteran's service treatment records; post-service private and VA treatment records; records from the Naval Health Clinic New England; VA examination reports; articles submitted by the Veteran; and hearing testimony. As discussed above, the VCAA provisions have been considered and complied with. The Veteran was notified of and made aware of the evidence needed to substantiate these claims, the avenues through which she might obtain such evidence, and the allocation of responsibilities between herself and VA in obtaining such evidence. The Veteran was last afforded a December 2009 VA infectious, immunology, and nutritional disease examination, as well as an April 2010 addendum, involving her undifferentiated connective tissue disease with antiphospholipid antibody syndrome. The record contains no indication that such disability has grown more severe since the last examination. There is no indication that there is additional evidence to obtain, there is no additional notice that should be provided, and there has been a complete review of all the evidence without prejudice to the Veteran. As such, there is no indication that there is any prejudice to the Veteran by the order of the events in this case. See Pelegrini, supra; Bernard v. Brown, 4 Vet. App. 384 (1993). Any error in the sequence of events or content of the notice is not shown to have affected the essential fairness of the adjudication or to cause injury to the claimant. Thus, any such error is harmless and does not prohibit consideration of these matters on the merits. See Conway, supra; Dingess, supra; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Analysis The Board has reviewed all the evidence in the appellant's claims file, which includes the following: her contentions and hearing testimony; service treatment records; post-service private and VA treatment records; records from the Naval Health Clinic New England; VA examination reports; and articles submitted by the Veteran. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on her behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate each claim and what the evidence in the claims file shows, or fails to show, with respect to each claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. The Board interprets reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability. See 38 C.F.R. § 4.2. Any reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations apply, the higher of the two will be assigned where the disability picture more nearly approximates the criteria for the next higher rating. 38 C.F.R. § 4.7. The Board will evaluate functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity. See 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In general, the degree of impairment resulting from a disability is a factual determination and generally the Board's primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994); Solomon v. Brown, 6 Vet. App. 396, 402 (1994). The Court has held that in determining the present level of disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. In Fenderson v. West, 12 Vet. App. 119 (1999), it was held that the rule from Francisco does not apply where the appellant has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for that disability. Rather, from the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. The RO has rated the Veteran's undifferentiated connective tissue disease with antiphospholipid syndrome by analogy to systemic (disseminated) lupus erythematosus. 38 C.F.R. §§ 4.20, 4.88b, Diagnostic Code 6350. Given the nature of the Veteran's disability, the Board finds that the rating criteria applied by the RO are appropriate. Pernorio v. Derwinski, 2 Vet. App. 625 (1992); 38 C.F.R. §§ 4.20, 4.21 (2009). The Board can identify no more appropriate diagnostic code and the Veteran has not identified one. Butts v. Brown, 5 Vet. App. 532, 538 (1993). Accordingly, the Board will proceed with an analysis of the Veteran's disability under that diagnostic code. Under Diagnostic Code 6350, a rating of 10 percent is assigned for exacerbations once or twice per year, or symptomatic during the past two years. A rating of 60 percent is assigned for exacerbations lasting a week or more, two or three times per year. A rating of 100 percent is assigned for acute symptoms with frequent exacerbations, producing severe impairment of health. 38 C.F.R. § 4.88b, Diagnostic Code 6350. A note provides that such condition should be evaluated either by combining the evaluations for residuals under the appropriate system, or by evaluating Diagnostic Code 6350, whichever method results in the higher rating. 38 C.F.R. § 4.88b, Diagnostic Code 6350. The RO has rated the Veteran's undifferentiated connective tissue disease with antiphospholipid antibody syndrome as 10 percent disabling for the period prior to December 23, 2009. For the period since December 23, 2009, the Veteran's undifferentiated connective tissue disease with antiphospholipid antibody syndrome has been rated 60 percent disabling. Thus, the Board must consider whether the Veteran is entitled to a rating in excess of 10 percent for her undifferentiated connective tissue disease with antiphospholipid antibody syndrome prior to December 23, 2009, and a rating in excess of 60 percent for the period since December 23, 2009. I. Prior to December 23, 2009. Treatment records from the Naval Health Clinic New England dated from January 2004 to November 2004 show that the Veteran was treated for numerous disorders. A November 2004 VA hemic disorders examination report noted that the Veteran's claims file was reviewed. The Veteran reported that she was a nurse. She indicated that she did not smoke and rarely drank, and that she was married with three children. As to review of systems, the examiner reported that the Veteran was negative for a fever, chills, and sweats. The examiner indicated that the Veteran did have occasional headaches and that she did have fatigue. It was noted that the Veteran did not have chest pain or current rashes. The examiner stated that the Veteran did have chronic left lower quadrant pain with a negative work-up with multiple ultrasounds and computed axial tomography scans. The examiner reported that the Veteran had improved menstrual bleeding with birth control and that she did not complain of joint stiffness and swelling. As to the physical examination, the examiner reported that the Veteran's lungs were clear and that her heart was regular. The examiner stated that the Veteran's abdomen was soft and that her extremities were negative with no swelling at that time. It was noted that the Veteran's skin was negative and that her thyroid was full. The examiner reported that the Veteran did have fatigue and occasional headaches. The examiner stated that the Veteran did not have any infections, shortness of breath, or claudication and that she had not undergone a blood transfusion, phlebotomy, bone marrow transplant, or chemotherapy. It was noted that there was no end-organ pathology. The examiner indicated that the Veteran had exacerbations in remission with a positive antiphospholipid antibody with pregnancies and improved afterwards. The examiner stated that there was no evidence of edema, pallor, bone influx, or congestive heart failure. The examiner indicated that it did not appear that the Veteran's undifferentiated connective disorder had worsened in severity. The examiner reported that the Veteran's antiphospholipid antibody syndrome was related to her service-connected undifferentiated connective tissue disorder. The examiner remarked that antiphospholipid antibody syndrome was an acquired disorder and that it was seen in association with systemic lupus erythematous or other major autoimmune conditions such as undifferentiated connective tissue disorder. The impression was as above. Private and VA treatment records, as well as treatment records from the Naval Health Clinic New England, dated from December 2004 to March 2007, show that the Veteran was treated for multiple conditions, including undifferentiated connective tissue disease with antiphospholipid antibody syndrome. For example, a June 2005 report from the Naval Health Clinic New England indicated that the Veteran was seen for a follow-up and that she had conditions including an undifferentiated connective tissue disease process and antiphospholipid antibody syndrome. The Veteran reported that she had some generalized fatigue and periods of joint pain, mainly at select metacarpophalangeal joints, proximal interphalangeal joint joints, and at her knees. She indicated that she had occasional headaches, but denied that she had multiple sclerosis or cerebral ischemic type symptoms, chest pain, dyspnea, or new skin findings. The examiner reported that the Veteran's eyes were normal. The examiner indicated that the Veteran's elbows, shoulders and legs (below the knee) showed no abnormalities. As to the Veteran's hands, the examiner stated that both her right hand and her left hand were tender to palpation and that pain was elicited with motion. It was noted that pain was elicited with motion of both of the Veteran's knees, that the knees appeared normal and demonstrated normal movement, and that no tenderness was observed on ambulation. The assessment included antiphospholipid syndrome that would require clinical monitoring as events warranted over the longer term and disorders of connective tissue, with undifferentiated current joint pain with findings that may be manifestations of that condition. A November 2005 report from the Naval Health Clinic New England noted that the Veteran was seen for a follow-up visit for autoantibody related disease processes, including undifferentiated connective tissue disease, antiphospholipid antibody syndrome, and Hashimoto's thyroiditis. The Veteran reported that she had suffered from greater fatigue lately, perhaps in part due to her expanded work hours. She stated that she also had select hand digit, as well as knee joint, pain sometimes with swelling. It was noted that the Veteran also had a migraine type headache as well as some daily abdominal pain, mainly in the left lower quadrant. It was reported that the Veteran denied that she had focal neurologic symptoms, dyspnea, or chest pain. The examiner indicated that the Veteran had tenderness to palpation of both middle fingers and that pain was elicited by motion of the index finger and the middle fingers. It was noted that the Veteran had tenderness on palpation of the right index finger metacarpophalangeal joint and the middle finger metacarpophalangeal joint. As to the Veteran's left hand, she had tenderness on palpation of the index finger metacarpophalangeal joint and the index finger proximal interphalangeal joint. The assessment included antiphospholipid syndrome which required ongoing interval assessment, even if antibody levels were not present at that time since the Veteran had demonstrated a capacity on at least two previous visits to make the required antibodies and with clinical consequences on each occasion, and disorders of connective tissue, with a notation by the examiner that he hoped the Veteran could return to a part-time work status situation in the foreseeable future as a stress-related control measure. A March 2007 VA infectious, immune, and nutritional disabilities examination report noted that the Veteran reported that she was a nurse, that she did not smoke and rarely drank, and that she was married with three children. The examiner reported that a review of systems was really negative except for complaints of joint pain and swelling. The examiner indicated that the Veteran's skin and lungs were clear. It was noted that her heart was regular, S1, S2, with no murmurs. The examiner reported that the Veteran's abdomen was soft and that her extremities were negative with no swelling at that time. The examiner stated that the Veteran's thyroid was palpable and full with no nodules. As to a diagnosis, the examiner commented that the Veteran had connective undifferentiated tissue disorder and that the antiphospholipid antibody syndrome was probably related to that disorder, but with normal values in the past after pregnancies and no treatment. The examiner indicated that it was apparently not active. Private and VA treatment records, as well as treatment records from the Naval Health Clinic New England, dated from April 2007 to September 2009 refer to continued treatment. For example, a November 2007 statement from J. S. Fantes, M.D., indicated that the Veteran had been followed at the Naval Health Clinic New England for several medical conditions, including connective tissue disease with antiphospholipid antibody syndrome. Dr. Fantes stated that in addition to a positive ANA, the Veteran was photosensitive and experienced oral ulcerations and arthralgias. Dr. Fantes reported that the Veteran experienced the oral ulcerations three to four times per month and that she was treated with Temovate gel. It was noted that the Veteran also experienced daily arthralgias that were treated with Naprosyn one to two times per day. Dr. Fantes indicated that the Veteran also underwent intra-articular steroid injections for pain relief of the arthralgia and that the Veteran also took aspirin daily for anticoagulation therapy secondary to the anti-phospholipid antibody syndrome. A November 2007 statement from M. A. Royer, D.M.D., reported that the Veteran had been a patient in her office since August 2006 and that she had been seen for dental examinations and cleanings every four months. Dr. Royer stated that the Veteran generally had excellent hygiene, but that they had observed and documented the presence of ulcerative lesions at each visit. It was noted that the Veteran's tissue was erythematous. Dr. Royer indicated that despite trying various rinses and toothpastes, the Veteran always had ne ulcerative lesions present at her appointments. At the November 2007 Board hearing, the Veteran, who is a nurse, testified that she experienced daily arthralgia and pain and that she took anti-inflammatories daily for her symptoms. She stated that she was also treated with steroid injections for relief of such manifestations. The Veteran indicated that if she sat, stood, or lay down in the same position for twenty minutes or more, she would have pain and stiffness in her joints. She indicated that such involved all of her joints and specifically referred to her fingers, hands, wrists, elbow, shoulders, knees, ankles, and toes. The Veteran also reported that the joint stiffness was greatly increased in the morning hours and that it was a daily problem for her. She further indicated that another manifestation of her connective tissue disease was oral ulcerations and that she had experienced those as frequently as three to four times monthly. The Veteran stated that she had photosensitivity as well. She indicated that she considered her arthralgia and oral ulcerations to be an exacerbation of her service-connected undifferentiated connective tissue disease with antiphospholipid antibody syndrome. The Veteran's husband, L. E. M.D., who is a dermatologist, also testified at the hearing. He testified that the Veteran complained of arthralgia and that arthralgia was one of the most common manifestations of antiphospholipid antibody syndrome. He stated that he personally felt that the Veteran had lupus and that she clearly had photosensitivity and a positive ANA. He noted that the Veteran had oral ulcerations which were a manifestation of lupus and that she had arthralgia or arthritis, which was one of the criteria that involved more than two joints with swelling and tenderness. The Veteran's husband further stated that he could not see how the Veteran's condition was stable because it was an endemic disease. An April 2008 statement from N. C. Blumenthal, M.D., indicated that the Veteran suffered from disorders including connective tissue disease with antiphospholipid antibody syndrome. Dr. Blumenthal stated that as a result of such disease, the Veteran had several systemic manifestations including photosensitivity, frequent oral ulcerations, arthralgias, and fatigue. Dr. Blumenthal stated that the oral ulcerations could last up to a week and occur several times a month and that they were treated with Temovate gel. Dr. Blumenthal indicated that the Veteran had daily arthralgias related to her condition and that she was currently on non-steroidal medication such as Naprosyn. It was noted that the Veteran was on daily aspirin to treat her antiphospholipid antibody syndrome because that condition could cause clotting if left untreated. Dr. Blumenthal indicated that the Veteran also suffered from fatigue which was a common symptom of antiphospholipid antibody syndrome. Dr. Blumenthal specifically stated that she felt that the Veteran's fatigue was related to her connective tissue disease and antiphospholipid syndrome. Dr. Blumenthal commented that based on the Veteran's fatigue, oral ulcerations, and arthralgias, her connective tissue disease with antiphospholipid antibody syndrome was active and required ongoing therapy. In a September 2008 statement, Dr. L. E., the Veteran's husband and a dermatologist, reported that the Veteran's undifferentiated connective tissue disease was worsening and that she had developed antiphospholipid antibody syndrome as a complication. Dr. L. E. stated that the Veteran experienced joint pain, muscle aches, and fatigue every day. Dr. L. E. reported that the Veteran also had frequent oral ulcerations and that he believed her disease should be rated as 60 percent disabling. Dr. L. E. remarked that the Veteran clearly had exacerbations that would last a week or more and would occur two to three times per year. Dr. L. E. indicated that he believed that the Veteran now met the criteria for lupus and that she had photosensitivity, oral ulcerations, and a positive ANA test. It was noted that in order to be diagnosed with lupus a patient must meet four out of eleven criteria, which the Veteran had presently met. Dr. L. E. reported that he strongly disagreed with a view of one of the Veteran's physicians (the examiner at the March 2007 VA infectious, immune, and nutritional disabilities examination) that her undifferentiated connective disease with antiphospholipid antibody syndrome was not active. Dr. L. E. stated that the physician listed arthralgia in his review of her symptoms and that one of the most common symptoms of such disorder was arthralgia. Dr. L. E. indicated that the Veteran experienced the most common symptoms daily and that she took medications daily. Dr. L.E. reported that the Veteran's condition was active and that it had worsened since she left the military. Dr. L. E. stated that the Veteran warranted a higher rating for her condition. Upon consideration of the evidence of record, the Board finds that the evidence as whole shows that the Veteran's undifferentiated connective tissue disease with antiphospholipid antibody syndrome more nearly approximates the criteria for exacerbations lasting a week or more, two to three times per year, and thus the criteria for a 60 percent rating under Diagnostic Code 6350 for the period prior to December 23, 2009. It is important to note that despite being service-connected for lichen sclerosis and Hashimoto's thyroiditis, the Board is solely addressing the issues of increased ratings for the Veteran's service-connected undifferentiated connective tissue disease with antiphospholipid antibody syndrome. A November 2004 VA hemic disorders examination report noted that the Veteran did have fatigue and occasional headaches. The examiner specifically indicated that the Veteran had exacerbations in remission with a positive antiphospholipid antibody with pregnancies and improved afterwards. The examiner indicated that it did not appear that the Veteran's undifferentiated connective disorder had worsened in severity and that the Veteran's antiphospholipid antibody syndrome was related to her service-connected undifferentiated connective tissue disorder. Additionally, a March 2007 VA infectious, immune, and nutritional disabilities examination report noted that that a review of systems was really negative except for complaints of joint pain and swelling. As to a diagnosis, the examiner commented that the Veteran had connective undifferentiated tissue disorder and that the antiphospholipid antibody syndrome was probably related to that disorder, but with normal values in the past after pregnancies and no treatment. The examiner indicated that it was apparently not active. The Board observes, however, that June 2005 and November 2005 treatment reports from the Naval Health Clinic New England both noted that the Veteran reported symptoms including fatigue periods of joint pain in her knees and finger digits and headaches. The June 2005 report from the Naval Health Clinic New England related an assessment that included antiphospholipid syndrome that would require clinical monitoring as events warranted over the longer term and disorders of connective tissue, with undifferentiated current joint pain with findings that may be manifestations of that condition. The November 2005 report from the same facility related an assessment that included antiphospholipid syndrome which required ongoing interval assessment, even if antibody levels were not present at that time since the Veteran had demonstrated a capacity on at least two previous visits to make the required antibodies and with clinical consequences on each occasion, and disorders of connective tissue, with a notation by the examiner that he hoped the Veteran could return to a part-time work status situation in the foreseeable future as a stress-related control measure. Further, the Board notes that a November statement from Dr. Fantes indicated that the Veteran had been followed at the Naval Health Clinic New England for several medical conditions, including connective tissue disease with antiphospholipid antibody syndrome. Dr. Fantes stated that in addition to a positive ANA, the Veteran was photosensitive and experienced oral ulcerations and arthralgias. Dr. Fantes reported that the Veteran experienced the oral ulcerations three to four times per month and that she was treated with Temovate gel. It was noted that the Veteran also experienced daily arthralgias that were treated with Naprosyn one to two times per day. The Board also observes that an April 2008 statement from Dr. Blumenthal N. C. Blumenthal, M.D., indicated that the Veteran suffered from disorders including connective tissue disease with antiphospholipid antibody syndrome. Dr. Blumenthal stated that as a result of such disease, the Veteran had several systemic manifestations including photosensitivity, frequent oral ulcerations, arthralgias, and fatigue. Dr. Blumenthal commented that based on the Veteran's fatigue, oral ulcerations, and arthralgias, her connective tissue disease with antiphospholipid antibody syndrome was active and required ongoing therapy. In a September 2008 statement Dr. L. E. reported that the Veteran's undifferentiated connective diseases with antiphospholipid antibody syndrome was active and that it had worsened since she left the military. Dr. L. E. indicated that the Veteran experienced joint pain, muscle aches, and fatigue every day and that she also had frequent oral ulcerations. Dr. L. E. commented he believed the Veteran's illness should be rated as 60 percent disabling. The Board observes that as a whole, evidence shows that the Veteran's undifferentiated connective tissue disease with antiphospholipid antibody syndrome was active and that the Veteran suffered from symptoms including joint pain, photosensitivity, fatigue, and oral ulcerations for the entire appeal period prior to December 23, 2009. The Board is of the view that the recent treatment reports and physician statements show that the Veteran suffers from exacerbations lasting a week or more, two to three times per year, warranting a 60 percent rating under Diagnostic Code 6350 for that period. The Board notes that the evidence does not indicate that the Veteran's undifferentiated connective tissue disease with antiphospholipid antibody syndrome, alone, was indicative of acute symptoms with frequent exacerbation, producing severe impairment of health, as required for a 100 percent rating under Diagnostic Code 6350 for the period prior to December 23, 2009. The Board finds that the rating under Diagnostic Code 6350 results in a higher rating for the period prior to December 23, 2009, than a combined rating for residuals of undifferentiated connective tissue disease with antiphospholipid antibody syndrome. There is no evidence that joint pain (arthralgias), photosensitivity, fatigue, and ulcerated oral lesions, have resulted in impairments sufficient to warrant separate compensable ratings under appropriate diagnostic codes that would be higher than a 60 percent rating for the period prior to December 22, 2009. Therefore, a 60 percent rating under Diagnostic Code 6350 is more favorable to the Veteran than a combined rating for residuals of undifferentiated connective tissue disease with antiphospholipid antibody syndrome for that period. For the reasons set forth above, a 60 percent rating, and no more, is warranted for the Veteran's service-connected undifferentiated connective tissue disease with antiphospholipid antibody syndrome for the period prior to December 23, 2009. The Board has considered the benefit-of-the-doubt rule in making the current decision. 38 U.S.CA. § 5107(b); Gilbert v. Derwinski, 1 Vet.App. 49 (1990). II. Since December 23, 2009 Private treatment records from NHCC Medical Associates, Inc., and dated from March 2009 to September 2009, show that the Veteran was treated for multiple disorders. The most recent December 2009 VA infectious immunology and nutritional disease examination report noted that the Veteran had a history of a Cipro rash and daily joint pain/arthralgia which prevented her from getting a good night sleep. The examiner stated that the Veteran also had oral ulcers of unknown etiology three to four times a month. The examiner reported that the Veteran complained of fatigue all the time. It was noted that the Veteran also stated that she had photosensitivity if exposed to the sun for more than twenty minutes. The examiner indicated that if the Veteran developed a rash, she would require Prednisone and that she had been seen by cardiology for palpitations for which Diltiazem was prescribed. The examiner indicated that the activity of the Veteran's undifferentiated connective tissue disease with antiphospholipid antibody syndrome continued to be active with exacerbations, but apparently no remission. The examiner noted that a "urine" exacerbation indicated that the Veteran was fatigued and that she wanted to stay in bed most of time. It was noted that the Veteran's arthralgia caused whole body pain. The examiner reported that the Veteran was well developed, well nourished, alert, and cooperative. The examiner stated that the Veteran was in no acute distress and that her condition was still present. It was noted that the Veteran had remarkable weight changes and fair nutrition. The examiner indicated that the Veteran's general appearance was normal. As to the Veteran's eyes, the examiner reported that her pupils were equal, round, and reactive to light and accommodation. The examiner stated that the Veteran's extraocular muscles were intact. The examiner reported that the Veteran's visual field was normal by fundi and that she was unable to see well. The examiner related that the Veteran's face showed no deformity and no scars except for small scars on her upper lip. It was noted that the Veteran had full range of motion of her neck and that there were no bruits, the trachea was midline, and there was mild enlargement of the thyroids. The examiner indicated, as to the Veteran's lungs, that respiration showed inspection and that palpation showed unremarkable auscultation. It was noted that there was minimal end expiratory wheeze. The examiner reported that the Veteran's heart showed normal sinus rhythm with no murmur, gallop, fraction, or rub. The examiner stated that the point of maximal impulse was within the midclavicular line and that there was no cardiomegaly or congestive heart failure. The examiner indicated that the Veteran had multiple joint tenderness, but that there appeared to be no deformities, redness, or swelling. It was noted that the Veteran had mild stiffness in her back with paravertebral muscle spasms in the lower back. The examiner stated that the Veteran's abdomen showed no tenderness, distension, hepatosplenomegaly, ascites, hernia, or bruits. As to a neurological evaluation, the examiner remarked that the Veteran had good recent and remote memory and that cranial nerves II through VII appeared intact. It was noted that deep tendon reflexes were normal, bilaterally, and the pain, touch, and vibration sensation were all normal. As to the Veteran's extremities, the examiner reported that there was no leg edema, as well as no stasis, dermatitis, ulcer, or callus. The diagnosis was undifferentiated connective tissue disease with antiphospholipid antibody syndrome. In an April 2010 addendum to the December 2009 VA infectious immunology and nutritional disease examination report, the examiner reported that the Veteran had several active medical conditions. The examiner stated that the Veteran had a history of Hashimoto's thyroiditis for which she was followed by her endocrinologist and treated with Synthroid. It was noted that the Veteran also had genital lichen sclerosis, which was treated with Temovate a super potent topical steroid. The examiner indicated that the Veteran also suffered from connective tissue disease with an antiphospholipid antibody. The examiner stated that as a result of the Veteran's connective tissue disease with an antiphospholipid antibody, the Veteran had several systemic manifestations which included photosensitivity, frequent oral ulcerations, arthralgia, and fatigue. It was noted that the Veteran's oral ulcerations could last up to one week and would occur several times a month. The examiner related that the Veteran had daily arthralgia related to her condition and that she was frequently on nonsteroidal medication such as Naprosyn. It was noted that the Veteran also took daily aspirin to treat her antiphospholipid antibody syndrome. The examiner reported that the Veteran also suffered from fatigue, which was a common symptom of antiphospholipid antibody syndrome. The examiner indicated that the Veteran's connective tissue disease with antiphospholipid antibody syndrome was still active and required ongoing therapy. The examiner commented that with that syndrome, the Veteran had exacerbations about once or twice per year. The examiner also reported that the exacerbations most likely lasted two to three weeks and that the Veteran stated that she had symptomatic exacerbations two to three times per year. It was noted that the Veteran was not sure how many times the exacerbations exactly occurred, but that she complained of arthralgia, oral ulcerations, and severe fatigue when she had an exacerbation and that she was definitely not able to work. The examiner stated that the Veteran's condition would severely affect her occupation and daily activities. The Board observes that the evidence as whole demonstrates that the Veteran's undifferentiated connective tissue disease with antiphospholipid antibody syndrome is no more than 60 percent disabling for the period since December 23, 2009. The Board notes that the Veteran has no more than exacerbations lasting a week or more, two to three times per year, as required for a 60 percent rating under Diagnostic Code 6350. The most recent December 2009 VA infectious immunology and nutritional disease examination report related a diagnosis of undifferentiated connective tissue disease with antiphospholipid antibody syndrome. In an April 2010 addendum to the December 2009 VA infectious immunology and nutritional disease examination report, the examiner indicated that the Veteran's service-connected undifferentiated connective tissue disease with antiphospholipid antibody syndrome was still active and required ongoing therapy. The examiner specifically commented that with that syndrome, the Veteran had exacerbations about once or twice per year. The examiner also reported that the exacerbations most likely lasted two to three weeks and that the Veteran stated that she had symptomatic exacerbations two to three times per year. It was noted that the Veteran was not sure how many times the exacerbations exactly occurred, but that she complained of arthralgia, oral ulcerations, and severe fatigue when she had an exacerbation and that she was definitely not able to work. The examiner stated that the Veteran's condition would severely affect her occupation and daily activities. The Board notes that the evidence fails to indicate that the Veteran's undifferentiated connective tissue disease with antiphospholipid antibody syndrome, alone, is indicative of acute symptoms with frequent exacerbation, producing severe impairment of health, as required for a 100 percent rating under Diagnostic Code 6350 for the period prior since December 23, 2009. Additionally, the Board finds that the rating under Diagnostic Code 6350 results in a higher rating for the period since December 23, 2009, than a combined rating for residuals of undifferentiated connective tissue disease with antiphospholipid antibody syndrome. There is no evidence that joint pain (arthralgias), photosensitivity, fatigue, and ulcerated oral lesions, have resulted in impairments sufficient to warrant separate compensable ratings under appropriate diagnostic codes that would be higher than a 60 percent rating for the period since December 22, 2009. Therefore, a 60 percent rating under Diagnostic Code 6350 is more favorable to the Veteran than a combined rating for residuals of undifferentiated connective tissue disease with antiphospholipid antibody syndrome for that period. The Board has also considered whether the record raises the matter of extraschedular ratings under 38 C.F.R. § 3.321(b)(1). The Board notes that the April 2009 addendum to the to the December 2009 VA infectious immunology and nutritional disease examination report, noted that the Veteran's undifferentiated connective tissue disease with antiphospholipid antibody syndrome severely affected her occupation and daily activities. The evidence does not reflect, however, that the Veteran's undifferentiated connective tissue disease with antiphospholipid antibody syndrome, alone, has caused marked interference with employment (i.e., beyond that already contemplated in the assigned rating), or necessitated frequent periods of hospitalization, such that application of the regular schedular standards is rendered impracticable. Based on the foregoing, the Board finds that referral for consideration of assignment of extra-schedular ratings is not warranted. 38 C.F.R. § 3.3219(b)(1). As the preponderance of the evidence is against the claim for a rating in excess of 60 percent for undifferentiated connective tissue disease with antiphospholipid antibody syndrome for the period since December 23, 2009, the benefit-of-the-doubt rule does not apply, and that portion of the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet.App. 49 (1990). ORDER An increased rating of 60 percent, but not greater, is granted for undifferentiated connective tissue disease with antiphospholipid antibody syndrome for the appeal period prior to December 23, 2009, subject to the laws and regulations governing the disbursement of monetary benefits. An increased rating, in excess of 60 percent for undifferentiated connective tissue disease with antiphospholipid antibody syndrome for the period since December 23, 2009, is denied. REMAND The remaining issue on appeal is entitlement to TDIU. The Board finds that there is a further VA duty to assist the Veteran in developing evidence pertinent to this claim. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2010). The Board observes that a request for TDIU, whether expressly raised by a veteran or reasonably raised by the record, is not a separate claim for benefits, but rather part of the adjudication of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447 (2009). Thus, when TDIU is raised during the appeal of a rating for a disability, it is part of the claim for benefits of the underlying disability. Id at 454. The Board notes that a December 2009 VA infectious immunology and nutritional examination report related a diagnosis of undifferentiated connective tissue disease with antiphospholipid antibody syndrome. In an April 2010 addendum to the December 2009 VA infectious immunology and nutritional examination report, the examiner stated that the Veteran had connective tissue disease with phospholipid antibody syndrome that was still active and required ongoing therapy. The examiner reported that with that syndrome, the Veteran had exacerbations about once or twice a year. It was noted that the exacerbations would most likely last two to three weeks and that the Veteran stated that she had symptomatic exacerbations two to three times per year. The examiner remarked that the Veteran was not sure how many times she had the exacerbations, but that she complained of arthralgia, oral ulcerations, and severe fatigue. The examiner commented that when the Veteran had an exacerbation, she definitely was not able to work and that such condition severely affected her occupational and daily activities. The Board finds, therefore, that the record raises the issue of a TDIU claim in this matter. The Board also finds that the requirements of VA's duty to notify and assist the Veteran have not been met. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. The notice requirements of the VCAA require VA to notify the Veteran of what information or evidence is necessary to substantiate the claim, including what subset of the necessary information or evidence, if any, the claimant is to provide and what subset of the necessary information or evidence the VA will attempt to obtain. A review of the claims folder shows that the Veteran has not been specifically provided VCAA notice as to his claim for entitlement to TDIU. Thus, on remand the RO should provide corrective VCAA notice. Accordingly, the case is REMANDED for the following action: 1. Ensure that all notification and development action required by 38 U.S.C.A. §§ 5102, 5103 and 5103A (West 2002) are fully complied with and satisfied with respect to the issue of entitlement to a TDIU rating. The notice should include an explanation as to the information or evidence needed to establish a disability rating and effective date of any increase for the claim on appeal, as outlined by the Court in Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). 2. Thereafter, adjudicate the claim for entitlement to a TDIU rating. If any benefit sought on appeal is denied, issue a supplemental statement of the case to the Veteran and her representative, and provide an opportunity to respond before the case is returned to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). ______________________________________________ DENNIS F. CHIAPPETTA Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs