Citation Nr: 1314945 Decision Date: 05/06/13 Archive Date: 05/15/13 DOCKET NO. 09-13 276 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for left hip arthritis, to include as due to service-connected systemic lupus erythematosus, lupus nephritis. 2. Entitlement to service connection for right hip bursitis, to include as due to service-connected systemic lupus erythematosus, lupus nephritis. 3. Entitlement to an initial rating in excess of 10 percent for systemic lupus erythematosus, lupus nephritis. 4. Entitlement to an initial compensable evaluation for bilateral pes planus. REPRESENTATION Appellant represented by: Jodee C. Kayton, Attorney ATTORNEY FOR THE BOARD M. Katz, Counsel INTRODUCTION The Veteran served on active duty from June 1996 to December 2003. The issue of entitlement to an increased rating for lupus comes before the Board of Veterans' Appeals (Board) on appeal from an April 2007 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Pittsburgh, Pennsylvania. The claims of entitlement to service connection for right and left hip disabilities and entitlement to a compensable rating for pes planus come before the Board on appeal from a December 2009 decision of the VA RO in Cleveland, Ohio. The claims file is currently under the jurisdiction of the VA RO in St. Petersburg, Florida. In its February 2012 Remand, the Board referred the issue of entitlement to service connection for fibromyalgia to the RO for adjudication. Review of the claims file shows that RO has not yet adjudicated the issue. Accordingly, the Board again refers the issue of entitlement to service connection for fibromyalgia to the RO for appropriate action. The issue of entitlement to an initial evaluation in excess of 10 percent for lupus is addressed in the REMAND portion of the decision below, and is REMANDED to the Department of Veterans Affairs Regional Office. FINDINGS OF FACT 1. The evidence of record does not establish a current diagnosis of a right or left hip disability. 2. Since the initial grant of service connection, the Veteran's bilateral pes planus has been manifested by painful motion, callosities on both feet, and abnormal weight bearing alignment of the Achilles tendon described as valgus deformity. Arch supports were only partially effective at relieving symptoms. There was no evidence of marked deformity, accentuated pain on manipulation and use, or swelling on use. CONCLUSIONS OF LAW 1. The criteria for service connection a right or left hip disability have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 2. The criteria for an initial evaluation of 10 percent, but no more, for bilateral pes planus have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5276 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). A letter dated in July 2009 satisfied the duty to notify provisions, to include notifying the Veteran of regulations pertinent to the establishment of an effective date and of the disability rating. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Veteran's service treatment records, VA medical treatment records, and identified private medical treatment records have been obtained. 38 U.S.C.A. § 5103A, 38 C.F.R. § 3.159. The record does not reflect that the Veteran is in receipt of disability benefits from the Social Security Administration. 38 C.F.R. § 3.159(c)(2); Golz v. Shinseki, 590 F.3d 1317, 1320-21 (Fed. Cir. 2010). The Veteran underwent a VA examination with respect to his claims for entitlement to service connection for right and left hip disabilities in July 2012. Supplemental opinions with regard to the claimed right and left hip disabilities were provided in August 2012 and September 2012. The Veteran also underwent VA examinations addressing the severity of his service-connected bilateral pes planus in September 2009 and July 2012. The record does not reflect that the examination reports are inadequate for rating purposes. 38 C.F.R. § 3.159(c)(4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). The exams addressed the existence of a bilateral hip disability as well as evaluated the Veteran's pes planus in accordance with the rating schedule. The exams were thorough and all necessary evidence and testing was considered by the examiners. There is no indication in the record that any additional evidence, relevant to the issues decided herein, is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders, 129 S. Ct. 1696 (2009). I. Right and Left Hip Disabilities The Veteran contends that service connection is warranted for arthritis in the left hip and bursitis in the right hip. He contends that he was diagnosed with bursitis and arthritis during service, and that he has continued to have pain involving the hips since service. Service connection may be established for a disability resulting from diseases or injuries which are clearly present in service or for a disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Veteran's service treatment records reflect diagnoses of right hip bursitis and left hip arthritis during his active duty service. A March 1996 entrance examination reveals that the lower extremities were normal. In a report of medical history, completed at that time, the Veteran denied a history of arthritis, rheumatism, and bursitis. An October 2000 treatment record reflects that the Veteran complained of right hip pain. In December 2000, the Veteran complained of pain in the bilateral sacroiliac joints. The diagnosis was bilateral greater trochanteric bursitis. A May 2001 record notes the Veteran's reports of bilateral hip pain. The diagnosis was bilateral greater trochanteric bursitis. A May 2001 examination reflects that the Veteran's lower extremities were normal. In a report of medical history, completed at that time, the Veteran reported a history of arthritis, rheumatism, or bursitis. The physician noted that the Veteran had bursitis in the right hip and arthritis in the left hip. A March 2003 report of medical history notes the Veteran's report that he had bursitis in his right hip in December 2000. A July 2003 post-deployment health assessment reveals that the Veteran complained of swollen, stiff, or painful joints. However, the post-service medical evidence does not show diagnoses of right or left hip disabilities. A September 2005 private record indicates that there was no tenderness, synovitis, or warmth on examination of the hips. There was no proximal muscle tenderness in the quadriceps muscles, and there was full range of motion throughout the hip joints. A February 2006 private treatment record notes the Veteran's complaints of occasional pain in the right hip. He denied joint swelling and indicated that his symptoms were worse in the morning. There was no diagnosis made with respect to the right hip complaints. A February 2008 VA treatment record notes that the Veteran had full and painless range of motion in the bilateral hips with no trochanteric or gluteal tenderness, bilaterally. An October 2008 VA treatment record reflects that the Veteran's hips were painless with full range of motion, bilaterally, and there was no trochanteric or gluteal bursitis. November 2010 x-rays of the bilateral hips were normal. In July 2012, the Veteran underwent a VA hips examination. The examiner reviewed the Veteran's claims file and noted that, although there were occasional complaints of bilateral hip pain in the record, the Veteran was never evaluated, diagnosed, or treated for any hip disability, and bilateral hip X-rays performed in 2010 were normal. The Veteran complained of mild to severe hip flares, which limited his ability to do prolonged walking, sitting comfortably, or squatting at work. Physical examination was performed, which revealed right hip range of motion with flexion to 85 degrees, extension to 15 degrees, abduction to 30 degrees, adduction to 20 degrees, external rotation to 30 degrees, and internal rotation to 40 degrees. Left hip range of motion revealed flexion to 105 degrees, extension to 15 degrees, abduction to 40 degrees, adduction to 15 degrees, external rotation to 60 degrees, and internal rotation to 30 degrees. There was no localized tenderness or pain to palpation for joints or soft tissue of either hip. Muscle strength was 5/5 and there was no evidence of ankylosis in either hip joint. There was no malunion or nonunion of the femur, flail hip joint, or leg length discrepancy. There were no scars or other pertinent physical findings. The diagnoses were bilateral hip pain and resolved bilateral trochanteric bursitis. After reviewing the Veteran's claims file, the VA examiner stated that the Veteran had transient episodes of right and left hip discomfort caused by trochanteric bursitis, and the service records did not show chronicity of hip joint problems. Additionally, after the Veteran left service, hip problems were not documented to be problematic and were not evaluated, diagnosed or treated. Further, X-rays of the hips were normal in 2010. Consequently, the examiner concluded that there could be no association with the Veteran's in-service hip problems and his current complaints due to the transient nature of the condition during service and the fact that there is no ongoing treatment after service discharge. The examiner also concluded that there was no aggravation of a hip disability by the Veteran's active duty service. In an August 2012 addendum, the VA examiner who provided the July 2012 examination stated that there was no aggravation of the Veteran's hip problems. Additionally, the examiner noted that in-service events involving the hips did not result in a chronic condition that persisted either in or after the Veteran left service and that there was no relationship with in-service events. In a September 2012 addendum, the examiner reported that the Veteran's left and right hip complaints were less likely than not caused by or a result of or aggravated by a service-connected disability. After thorough consideration of the evidence of record, the Board concludes that the evidence does not establish that the Veteran has a current diagnosed bilateral hip disability. As noted above, the 2010 X-rays showed normal findings. Although there were diagnoses of arthritis and bursitis during service, the evidence of record on and after the Veteran filed his claim in June 2009 does not show a diagnosed bilateral hip disability. See McClain v. Nicholson, 21 Vet. App. 319 (2007) (holding that the requirement of a current disability is met when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim). The Board acknowledges the Veteran's reports of pain and that the July 2012 VA examination demonstrated a reduced range of motion in both hips. Nevertheless, the July 2012 VA examiner determined that the only current diagnosis was bilateral hip pain. Pain alone, without a diagnosed 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 diagnosis of resolved bilateral trochanteric bursitis does not reflect a current diagnosed disability, as it indicates that the condition is resolved. There is no other medical evidence suggesting that the Veteran currently has a bilateral hip disability. Despite the Veteran's reports of pain, the medical evidence does not reflect a currently diagnosed bilateral hip disability or document symptoms suggestive of such a disability. Without a currently diagnosed bilateral hip disability, a claim for service connection cannot be substantiated. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). There is also no diagnosis of a bilateral hip disability at any point during the claim or appeal period. McClain, 21 Vet. App. 319. For these reasons, the Veteran's claim must be denied. The preponderance of the evidence is against the claim. There is no doubt to be resolved, and service connection is not warranted. See 38 C.F.R. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). II. Pes Planus The Veteran contends that he is entitled to an initial compensable evaluation for his service-connected bilateral pes planus. In a January 2010 notice of disagreement, the Veteran reported that the evidence demonstrates pain, stiffness, and fatigability with fair response to prosthetic insoles, as well as callosities. He argues that this is sufficient to establish a 10 percent rating for his bilateral pes planus. Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2012). Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2012); see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). The primary concern in a claim for an increased evaluation for service-connected disability is the present level of disability. Although the overall history of the disability is to be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. VA has a duty to consider the possibility of assigning staged ratings in all claims for increase. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Service connection for bilateral pes planus was granted by a December 2009 rating decision, and a noncompensable evaluation was established, effective June 25, 2009, under the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5276. Under Diagnostic Code 5276, acquired flatfoot is rated as noncompensable when the symptoms are mild and relieved by built-up shoe or arch support. 38 C.F.R. § 4.71a, Diagnostic Code 5276. A 10 percent evaluation is warranted when symptoms are moderate with weight-bearing line over or medial to the great toe, inward bowing of the tendo achillis, pain on manipulation and use of the feet. Id. A 30 percent evaluation is for application for bilateral flatfoot when symptoms are severe with objective evidence of marked deformity, pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities. Id. A maximum 50 percent evaluation is warranted for bilateral flatfoot when symptoms are pronounced with marked pronation, extreme tenderness of the plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation with symptoms that are not improved by orthopedic shoes or appliances. Id. Since the initial grant of service connection, the medical evidence reflects complaints of foot pain, stiffness, and fatigability. An October 2008 VA treatment record reveals that the Veteran reported stiffness in his feet in the morning. A September 2009 VA examination notes the Veteran's complaints of foot pain. The Veteran stated that, at rest, he had foot pain; on standing, he had foot pain, stiffness, and fatigability; and while walking, he had foot pain and fatigability. He stated that he used prosthetic shoe inserts and that his response to such treatment was fair with no side effects. The examiner noted that the treatment with prosthetic insoles was fairly effective. The Veteran indicated that he was able to stand and walk for 15 to 30 minutes. Physical examination revealed painful motion with pain on the soles of the feet in both feet. Gait was normal. There was evidence of callosities on both feet, suggestive of abnormal weight bearing. There were skin changes on both feet in the form of dry skin. There were no vascular changes, and there was no evidence of hammertoes, high arch, or clawfoot. There was abnormal weight bearing alignment of the Achilles tendon, described as valgus deformity in the right foot and mild valgus in the left foot. Non-weight bearing alignment of the Achilles tendon was normal in both feet. The Achilles tendon alignment could be corrected by manipulation to a normal degree in both feet and there was no pain on manipulation of the Achilles tendon. There was no evidence of forefoot malalignment or midfoot malalignment in either foot, and there was no hallux valgus. X-rays of both feet were normal with no abnormalities noted. The examiner diagnosed bilateral pes planus, and concluded that the effect of the condition on the Veteran's usual occupation and daily activities was mild. A July 2012 VA examination reveals the Veteran's complaints of pain on use of the feet, but no pain on manipulation of the feet. There was no indication of swelling on use and there were no characteristic calluses. The examiner noted that the Veteran's symptoms were partially relieved by arch supports, but that both sides remained symptomatic despite arch supports or orthotics. There was no extreme tenderness of plantar surface of one or both feet. The Veteran had decreased longitudinal arch height on weight-bearing in both feet, but there was no objective evidence of marked deformity of the foot. There was no marked pronation of the foot and the weight-bearing line did not fall over or medial to the great toe. There was no lower extremity deformity other than pes planus causing alteration of the weight bearing line. The Veteran did not have "inward" bowing of the Achilles tendon and there was no marked inward displacement and severe spasm of the Achilles tendon on manipulation. There were no scars or other pertinent physical findings and the Veteran did not use any assistive devices other than corrective shoes or orthotic inserts. The examiner stated that there was no functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis due to the Veteran's flatfoot condition. The only functional impairment noted by the examiner was that the Veteran's pes planus caused difficulty in prolonged standing or walking. The diagnosis was bilateral pes planus. In an August 2012 addendum, the examiner noted that the Veteran had no additional functional impairment on the use of his feet and no limitation of motion due to the extent of his pain or from weakness, premature fatigability, incoordination, or otherwise, including during times when his symptoms were most problematic or during prolonged use that was evident during the examination of the Veteran's feet. After a thorough review of the evidence of record, and affording the Veteran the benefit of the doubt, the Board concludes that an initial 10 percent evaluation is warranted for the Veteran's bilateral pes planus. The September 2009 VA examiner found evidence of abnormal weight bearing alignment of the Achilles tendon, described as valgus deformity in the right foot and mild valgus in the left foot. Although there was no evidence of pain on manipulation of the Achilles tendon, the examiner noted that the prosthetic insoles were only fairly effective at controlling the Veteran's symptoms, suggesting that his symptoms were not completely relieved by the use of arch support. Additionally, the September 2009 VA examiner found evidence of callosities on both feet, suggestive of abnormal weight bearing. Similarly, the July 2012 examiner found that the Veteran's pes planus symptoms were only partially relieved by arch supports and that both sides remained symptomatic despite the use of arch supports. Although not all of the symptoms described in the rating criteria for a 10 percent evaluation are demonstrated by the evidence of record, the Board concludes that the Veteran's symptoms more nearly approximate the moderate symptomatology described in the criteria for an initial 10 percent evaluation, rather than the criteria for a noncompensable evaluation. Accordingly, affording the Veteran the benefit of the doubt, the Board concludes that an initial 10 percent rating is warranted for the Veteran's service-connected bilateral pes planus. However, the evidence does not support an initial evaluation in excess of 10 percent for the Veteran's pes planus. While the September 2009 examiner found evidence of callosities suggestive of abnormal weight bearing, the evidence does not show severe symptomatology with objective evidence of marked deformity, pain on manipulation and use accentuated, or indication of swelling on use. Thus, the evidence of record does not more nearly approximate the criteria for a 30 percent evaluation. The other exams and treatment records also provide insufficient support for a rating n excess of 10 percent. The July 2012 VA examination noted no extreme tenderness, no marked pronation of the foot, no assistive devise used to walk except corrective shoes and orthotic inserts. The only functional impairment noted was difficulty in prolonged standing or walking. The August 2012 addendum confirmed the finding of no significant additional functional impairment. Other diagnostic codes pertaining to the foot have been considered. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The evidence does not reflect diagnoses of weak foot, claw foot, anterior metatarsalgia, hallux rigidus, hammer toe, malunion of the tarsal or metatarsal bones, or other foot injuries. Accordingly, increased evaluations are not warranted under those diagnostic codes. See 38 C.F.R. § 4.71a, Diagnostic Codes 5277, 5278, 5279, 5280, 5281, 5282, 5283, 5284 (2012). Additionally, the evidence does not establish functional loss not contemplated by the rating assigned by this decision. 38 C.F.R. § 4.40, 4.45 (2012); DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Turner v. Shinseki, 2011 WL 1211054 (Vet. App. 2011) (nonprecedential) (citing to VAOPGCPREC 9-98 in noting that consideration of functional loss may still be required even for disabilities rated under Diagnostic Codes not involving limitation of motion). As noted above, in an August 2012 addendum, the examiner found that the Veteran's bilateral pes planus caused no functional impairment on the use of his feet and no additional limitation of motion due to pain, weakness, fatigability, incoordination, or otherwise, including during flare-ups or prolonged use. There is no objective evidence to suggest that the Veteran's bilateral pes planus causes additional functional loss not contemplated in the currently assigned rating. An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of an extraschedular evaluation. 38 C.F.R. § 3.321(b)(1 (2012). Otherwise, the schedular evaluation is adequate, and referral is not required. Thun, 22 Vet. App. at 116. The schedular rating in this case is adequate. A rating in excess of 10 percent is provided for certain manifestations of the service-connected bilateral pes planus, but the medical evidence reflects that those symptoms are not present in this case. The diagnostic criteria also adequately describe the severity and symptomatology of the Veteran's bilateral pes planus. He has not required hospitalization during the appeal period and marked interference of employment has not been shown. Therefore, the Veteran's disability picture is contemplated by the Rating Schedule; no extraschedular referral is required. Last, in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for entitlement to a total disability rating based on individual unemployability is part of an increased rating claim when such claim is raised by the record. In this case, the Veteran does not contend, and the evidence does not suggest, that he is unemployable as a result of his service-connected bilateral pes planus. Thus, the issue of entitlement to a total rating for compensation purposes based upon individual unemployability has not been raised by the evidence of record, and the issue is not before the Board at this time. For the reasons discussed above, the preponderance of the evidence is against the assignment of an initial rating greater than 10 percent for bilateral pes planus at any time during the pendency of this appeal. See 38 C.F.R. § 5107(b); Gilbert, 1 Vet. App. at 54-56. ORDER Entitlement to service connection for a left hip disability is denied. Entitlement to service connection for a right hip disability is denied. Entitlement to an initial rating of 10 percent, but no greater, for bilateral pes planus is granted, subject to the applicable regulations concerning the payment of monetary benefits. REMAND In its February 2012 Remand, the Board requested that the Veteran be provided a new VA examination to determine the current severity of his service-connected lupus. Although the Veteran was provided with a VA examination in July 2012, review of the examination report reflects that it is inadequate for rating purposes. Barr, 21 Vet. App. at 312 (holding that once VA undertakes the effort to provide an examination for a service-connection claim, even if not statutorily obligated to do so, it must provide an adequate one). The July 2012 VA examination found that the Veteran had no exacerbations of his lupus; no cutaneous manifestations of lupus; no findings, signs, or symptoms attributable to lupus; no other symptoms whatsoever attributable to lupus; no arthritis, recurrent ulcers, hematologic or lymphatic manifestations, pulmonary manifestations, cardiac manifestations, neurologic manifestations, renal manifestations, obstetric manifestations, gastrointestinal manifestations, or vascular manifestations. Nevertheless, review of the medical treatment records from the two years prior to the July 2012 examination show treatment for fatigue, body pain, joint pain, recurrent oral ulcers, and discoid lesions on the scalp associated with the Veteran's lupus. The medical records also reflect treatment for a history of alopecia, Raynaud's phenomenon, pleurisy, nephritis, leucopenia, photosensitive rash, and inflammatory arthritis due to the Veteran's lupus. Further, the Veteran, through his representative, alleged June 2011 that the Veteran had symptoms associated with his lupus including abdominal problems, Sjogren's syndrome, chronic fatigue, fevers, and headaches. The July 2012 VA examiner did not address any of these reported symptoms, did not clearly illicit a history of symptoms from the Veteran, and did not address the positive medical evidence in the claims which is clearly at odds with the VA examiner's findings. Thus, the Board does not find the July 2012 examination to be an accurate accounting of the Veteran's current lupus symptoms, and therefore, the examination is not adequate to determine the current severity of his lupus. Accordingly, the Veteran must be provided with a new VA examination which adequately addresses the current severity of his lupus symptoms. Additionally, the Board observes that, although the RO has considered the Veteran's claim for an increased rating under the appropriate diagnostic code for lupus, which is 38 C.F.R. § 4.88b, Diagnostic Code 6350, the RO does not appear to have considered the note accompanying that diagnostic code which directs that lupus be evaluated either by combining the evaluations for residuals under the appropriate system, or by evaluating Diagnostic Code 6350, whichever method results in a higher evaluation. 38 C.F.R. § 4.88b, Diagnostic Code 6350, Note (2012). Accordingly, the RO must address the Veteran's claim for an increased rating with consideration of the note accompanying Diagnostic Code 6350. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a new VA examination to determine the current severity of his service-connected lupus. The claims file and a copy of this Remand must be provided to and reviewed by the examiner. All pertinent symptomatology and findings must be reported in detail. Any indicated tests and studies must be accomplished. The VA examiner must identify all current symptomatology related to the Veteran's lupus, including the recent medical evidence showing fatigue, body pain, joint pain, recurrent oral ulcers, and discoid lesions; the medical evidence of a history of alopecia, Raynaud's phenomenon, pleurisy, nephritis, leucopenia, photosensitive rash, and inflammatory arthritis; and the Veteran's reports of abdominal problems, Sjogren's syndrome, chronic fatigue, fevers, and headaches. The examiner must also state whether the Veteran's symptoms of lupus include exacerbations lasting one week or more two to three times per year and whether the symptoms are acute with frequent exacerbations producing severe impairment of health. A complete rationale for all opinions must be provided. 2. The RO must notify the Veteran that it is his responsibility to report for all scheduled examinations and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). 3. After completing the above actions, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the Veteran's claim must be readjudicated. When readjudicating the Veteran's claim, the RO must consider and address the note following Diagnostic Code 6350, which directs that lupus be evaluated either by combining the evaluations for residuals under the appropriate system, or by evaluating Diagnostic Code 6350, whichever method results in a higher evaluation. If any benefit sought on appeal remains denied, the Veteran and his representative must be furnished a supplemental statement of the case and be given the opportunity to respond thereto. The appeal must then be returned to the Board for appellate review. 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. 2012). ______________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs