Citation Nr: 1323152 Decision Date: 07/19/13 Archive Date: 07/24/13 DOCKET NO. 07-20 953 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUE Entitlement to an increased initial rating for systemic lupus erythematosus (SLE), evaluated as 20 percent disabling prior to May 17, 2011, and as 60 percent disabling thereafter. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD T. Stephen Eckerman, Counsel INTRODUCTION The Veteran served on active duty from October 1996 to December 1999. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2005 rating decision of the RO in Indianapolis, Indiana, which granted service connection for SLE and assigned an initial 10 percent evaluation for this disability. The Veteran appealed the issue of entitlement to an increased initial evaluation. In August 2009, the RO granted the claim, to the extent that it increased the Veteran's evaluation to 20 percent. In February 2011, the Board remanded the claim for additional development. In June 2012, the claim was again granted, to the extent that a 60 percent evaluation was assigned, with an effective date of May 17, 2011. FINDING OF FACT As of May 24, 2005, the Veteran's service-connected systemic lupus erythematosus is shown to have been productive of exacerbations lasting a week or more, two or three times per year, but not an acute condition with frequent exacerbations, producing severe impairments of health. CONCLUSION OF LAW As of May 24, 2005, the criteria for an initial evaluation of 60 percent, and no more, for service-connected systemic lupus erythematosus have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.88b, Diagnostic Code 6350 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Increased Initial Evaluation - Systemic Lupus Erythematosus The Veteran asserts that she is entitled to an increased initial evaluation for her service-connected systemic lupus erythematosus. She argues the following: she has sustained damage to areas that include her liver, kidneys, cardiovascular system, colon and pancreas, and nerves. Her SLE has cause joint, muscle and tissue involvement with permanent hair loss and calcium deposits adhering to bone that caused inflammation. She has symptoms that include chronic pain, chronic fatigue, loss of body function due to pain and swelling, and sudden memory loss. See. e.g., Veteran's letter, received in July 2012. She has submitted numerous articles in support of her claim. With regard to the history of the Veteran's systemic lupus erythematosus, her service treatment reports do not show findings or a diagnosis of systemic lupus erythematosus. Between February and August of 1998, she was treated on several occasions for complaints of fatigue and poor sleep. The assessments were fatigue, and mild depression. As for the post-service medical evidence, VA progress notes show that between 2004 and 2005, the Veteran was noted to have alopecia, a rash, and arthralgias. These symptoms were noted to be compatible with mild lupus, and to be without renal involvement. See January 2005 VA progress note. An October 2005 VA immune system examination report notes a history of a first diagnosis of SLE in January 2005, with symptoms, i.e., a skin rash, beginning in February 2004. Service connection was apparently granted based on the examiner's observation that the cause of SLE was unknown, but there was some literature which shows "the possibility that lupus could be the result of mononucleosis." The examiner stated that the Veteran had been diagnosed with mononucleosis in 1999. The examiner stated that he agreed with another VA physician ("Dr. B"), and that it was at least as likely as not that the Veteran's SLE was related to her service. See 38 C.F.R. § 4.1 (2012). In May 2005, the Veteran filed her claim for service connection. In November 2005, the RO granted the claim, and assigned an initial 10 percent evaluation for this disability, with an effective date for service connection of May 24, 2005. The Veteran appealed the issue of entitlement to an increased initial evaluation. In August 2009, the RO granted the claim, to the extent that it increased the Veteran's evaluation to 20 percent. In February 2011, the Board remanded the claim for additional development. In June 2012, the claim was again granted, to the extent that a 60 percent evaluation was assigned, with an effective date of May 17, 2011. As the increases were not the highest possible ratings, the appeal continues. See AB v. Brown, 6 Vet. App. 35 (1993). Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. Part 4 (2012). When a question arises as to which of two evaluations shall be assigned, the higher evaluation will be assigned of the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). The Veteran is appealing the original assignment of disability evaluation following an award of service connection. In such a case, it is not the present level of disability which is of primary importance, but rather the entire period is to be considered to ensure that consideration is given to the possibility of staged ratings; that is, separate ratings for separate periods of time based on the facts found. Fenderson v. West, 12 Vet. App. 119, 126 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's systemic lupus erythematosus (SLE) is rated under 38 C.F.R. § 4.88b, Diagnostic Code (DC) 6350. Under DC 6350, SLE warrants a 10 percent disability rating where there are exacerbations once or twice per year or if the condition was symptomatic during the past two years. A 60 percent disability rating is warranted where there are exacerbations lasting a week or more, two or three times per year. Id. A 100 percent disability rating is warranted where the condition is acute, with frequent exacerbations, producing severe impairments of health. Id. A Note following this diagnostic code states that this condition may be evaluated either by combining the evaluations for residuals under the appropriate system, or by evaluating under DC 6350, whichever method results in a higher evaluation. Id. The medical evidence includes VA progress notes, dated between 2005 and 2012, which show that in June 2005, the Veteran was noted to be "doing dramatically better," with improved hair growth, sleep, and reach. She was noted to have no problems driving. She reported pain in the small joints of her hands, and some lower back pain, but no Reynaud's disease. He medications were noted to include doxycycline. On examination, there were mild erythematous patches on her back, right ankle, and shoulder, and she had dilated capillaries on her eyelids, but no malar rash. The assessment was SLE, with positive laboratory tests, and resolving alopecia, scalp rash, and arthralgia. A July 2005 report shows that she stated that she was feeling better from a physical standpoint, and that her lupus was controlled. A September 2005 report shows that the Veteran reported that she was feeling better "from a lupus standpoint" since she began Valcyclovir. She reported getting a rash when she was around cats. On examination, she had hives on her upper chest that were not inflamed. The assessments were lupus, depression, genital herpes, and hives. In October 2005, she reported a history of an intermittent reddened rash in various areas, for which she took Claritan, which helped although she still had itching. She further reported that Plaquenil helped her lupus symptoms. On examination, there were a few scattered areas on her back neck and legs that were mildly reddened without open areas, and she had some scratch marks. She was given Atarax. A November 2005 eye optometry consultation report notes a complaint of a weak left eye compared to the right. The Veteran stated that she had glasses for reading that had not gotten worse, and that Claritin had cleared up her eye allergies. On examination, she had 20/20 vision, bilaterally. The right eye had a full visual field, and the left eye had central defects, with low reliability. The examiner noted that the visual field and Amsler grid findings were questionable, and that they did not correlate with fundus findings. A December 2005 report notes complaints of left eye vision fluctuations. On examination, she had 20/20 vision, bilaterally, and the Amsler grid test showed that each eye had a small missing area. An addendum notes that the left eye had a small paracentral defect that was not consistent with the Amsler grid test. A January 2006 report shows that the Veteran reported that she was feeling much better, and that her skin rash had resolved. She was working in a customer service job, and expected to change to a better-paying position soon. The assessment was rash, resolved. A February 2006 report shows that the Veteran reported feeling much better due to increasing Plaquenil to twice a day, with less joint pain (which she rated as 5/10). She reported having mouth ulcers. Another February 2006 report notes complaints of morning stiffness lasting about 30 minutes, and that the Veteran denied currently having a rash. She complained of dry eyes. She stated that she was working three jobs. On examination, the skin had no rashes. There was no alopecia. There was a small ulcer on the upper gum. The impression noted SLE, primarily with rash, alopecia, arthralgias, and oral ulcers as symptoms, that was stable on hydroxychloroquine (Plaquenil). Topical steroids were to be used prn (as occasion requires). A June 2006 report notes complaints of body pains, which the Veteran rated as 6/10, with use of hydroxychloroquine. In a July 2006 report, the Veteran stated that she worked out every day. She reported a history of lupus and chronic joint pain that was not worse. An August 2006 report notes a diffuse popular erythematous rash on the torso and abdomen, and contains an impression noting SLE, primarily with rash, alopecia, arthralgias, and oral ulcers as symptoms, somewhat with worsening rash, on hydroxychloroquine. In November 2006, the Veteran reported that prednisone was helping her rash, and that she had "no new concerns flaring with Lupus." Another November 2006 report notes that the Veteran had 20/20 vision, bilaterally. The assessment was lupus with Plaquenil therapy without maculopathy, stable today, Amsler grid in improved per patient. In January 2007, the Veteran reported working in administration (customer service, with computer work) for a manufacturing company. See also May 2007 report (same). She stated that she walked 30 minutes per day five days a week, and that a prior rash was much improved. The assessment noted lupus, with an improved rash. A February 2007 report contains an impression noting SLE, primarily with rash, alopecia, arthralgias, and oral ulcers as symptoms, flaring on hydroxychloroquine and alternate day prednisone. In May 2007, she was treated for aqueous deficient dry eye, OU (both eyes). Vision was 20/20 bilaterally, and the red Amsler grid was irregular in small areas, bilaterally, "otherwise ok." A September 2007 report notes that there were no rashes or lesions. The assessment was migratory arthralgias with alopecia. A March 2008 report shows that the Veteran reported that she was discontinuing Plaquenil and prednisone because she wanted to get pregnant. Her skin was noted to have a rash and dryness, with a loss of hair. In September 2008, she reported working full-time, and taking seven semester hours. She complained of dry eyes, dry mouth, and a scattered fungal rash. In October 2008, she was noted to have no lesions or scales. She complained of ringworm, with no current active areas. In March 2009, she reported that she was taking all of her prescribed medications. In June 2009, she was noted to have 20/20 vision, bilaterally. In August 2009, she reported that she was doing well. She was noted to have aqueous deficient dry eye and secondary Sjogren's syndrome, and to be using low-dose prednisone without ocular side effects, and Plaquenil without retinopathy. In September 2009, the Veteran was noted to be pregnant; her laboratory values were noted to be appropriate and well-controlled. In April 2009, the Veteran's complements were noted to be appropriate and well-controlled. Subsequently dated reports show treatment for a wide variety of symptoms, to include joint pain. A March 2011 eye consultation notes that the Veteran had 20/20 vision, bilaterally, and aqueous deficient dry eye and secondary Sjogren's syndrome. A private treatment report, dated in June 2009, shows that the Veteran was noted to have 20/20 vision, bilaterally. Additional private treatment reports from November 2009 show that the Veteran was treated for molluscum contagiosum. The reports small lesions (3 millimeters or less) at the neck, inner thigh, and right shin, and states that they are clinically benign. Private treatment reports from Anthony Medical Center, dated in 2010, show that in July 2010, the Veteran complained of flank pain and thought something was happening to her kidneys. Examinations of her eyes, ears nose, throat, neck, respiratory system, cardiovascular system, abdomen, genitourinary system, and musculoskeletal system, skin, and neurological system, were all essentially unremarkable. The impressions were SLE and myalgia. In August 2010, her upper and lower extremities, to include the hands, wrists, elbows, shoulders, hips, knees, and ankles, were examined, and were all essentially normal, to include normal strength and a normal sensory examination. There was right-sided flank pain. The assessments noted Reynaud's syndrome, and leucopenia. The examiner concluded that clinical examination and detailed history taking does not demonstrate any clinical features of systemic lupus erythematous. Moreover, the Veteran was noted to have negative serologies for SLE. The examiner stated, "I am not currently convinced of this diagnosis." The examiner noted that an ultrasound of the kidneys revealed mild pelvic enlargement that was probably due to her pregnancy. However, she had flank pain and would be referred to urology. The Veteran was noted not to currently display any clinical features of SLE in spite of not being on active treatment for three years for pregnancy. In September 2010, the Veteran's SLE was noted to be in remission on two occasions. In October 2010, following increased complaints, the Veteran was noted to have SLE, and she was put on 5 milligrams of Prednisone daily. A March 2011 report contains a diagnosis noting severe aqueous deficient dry eye secondary to Sjogren's syndrome-collagen punctual plugs inserted today, continue using Genteal as needed and follow up in three months or prior if interested in permanent plugs. Plan on restarting Restasis once no longer breast feeding, and history of Plaquenil use without ocular side effects, monitor with six month exams if restarted. On examination, the Veteran's vision was 20/20, bilaterally. Visual fields were FTFC (full to finger counting), bilaterally. Private treatment reports from Wayne Rheumatology, dated in February 2011, show that the Veteran complained of symptoms that included headache, dry eyes, visual disturbances, black, tarry stool, indigestion, joint pain, muscle weakness, numbness and tingling. Her chief complaint was dry mouth and dry eyes. On examination, there was hair loss, and a rash at the ears, back and legs. The examiner stated that there was no Reynaud's phenomenon, dry mouth, oral ulcers, muscle pain, decreased memory or seizures, or difficulty breathing. It was noted that she was to take Plaquenil once she had quit breastfeeding. The assessment was SLE. A VA examination report, dated in October 2005, shows that the Veteran reported a rash on her whole body that had decreased and was now only on her low back and legs. It was very itchy. She also reported muscle pain in her neck, legs, and shoulders. On examination, there was an erythematous rash on her middle low back with significant scratches due to itching. To a lesser degree, there was a rash on both hips. Her eyes were "okay." The diagnoses included SLE, active, with significant functional impairment with periodic fever in the morning, up to 100 degrees. A VA examination report, dated in May 2009, shows that the examiner stated that the Veteran's claims file had been reviewed. The Veteran reported using Plaquenil between 2005 and 2009, and currently using steroids intermittently, to include current use for hair loss. She reported symptoms that included some near and far vision loss, and use of muscle relaxers for joint pain and aching, severe fatigue, intermittent fevers, difficulty breathing, and that her fingers and hands turned blue when they were cold. On examination, the skin had no rashes. The hair was very thin. The skin on her scalp was red and scaly. The elbows had full flexion and extension, and there was a full active range of motion in the shoulders and neck. Strength in the extremities was 5/5. The diagnosis notes SLE with frequent and nearly continuous exacerbations of muscle/joint pain, hair loss, and depression. A VA joints examination report, dated in March 2011, shows that the examiner stated that the Veteran's claims file had been reviewed. The Veteran reported that she had quit her last job because she was exposed to environmental contaminants. The diagnosis was polyarthralgia secondary to SLE. The report indicates the following: the disability was manifested by decreased mobility, problems with lifting and carrying, difficulty reaching, and pain. There were moderate effects on usual daily activities. The effects were characterized as "none" (bathing and feeding), "mild" (toileting, dressing, and traveling), "moderate" (driving, recreation, exercise, shopping, and chores), and "severe" (sports). A VA joints examination report, dated in March 2011, shows that the examiner stated that the Veteran's claims file had been reviewed. The Veteran reported experiencing polyarthritis symptoms of joint pain, stiffness, and swelling beginning in 2005 that had gotten progressively worse. The shoulders, knees, hips, elbows, and ankles were examined. On examination, there was pain, but no instability, weakness, incoordination, or flare-ups of joint disease. There was no ankylosis. X-rays of the knees, hands, and elbows were unremarkable. The effects on usual daily activities were: "none" (bathing and feeding), "mild" (grooming, toileting, dressing, traveling), and "moderate" (driving, recreation, exercise, shopping, and chores). A VA skin examination report, dated in March 2011, shows that the examiner stated that the Veteran's claims file had been reviewed. The report notes the following: the Veteran has a history of intermittent malar rashes since 2005. There were no systemic symptoms. Between 20 percent and 40 percent of the exposed areas were covered (head, face, neck, and hands), and between 20 percent and 40 percent of the total body area was affected. There was a faint malar rash on the fact, anterior trunk, and posterior trunk. The diagnosis was malar rash. A VA infectious, immune, and nutritional ("II&N") examination report, dated in March 2011, shows that the examiner stated that the Veteran's claims file had been reviewed. The report notes the following: the Veteran's history was noted to include losing hair in 2004, with joint pain beginning shortly thereafter. The Veteran reported having occasional fevers and that she gets sick "all the time." She reported a two-year history of molluscum contagiosum that was finally starting to go away, and a history of several lung infections, especially during pregnancy. She delivered a child in April 2010, and was not currently on any medications due to breastfeeding; she planned to discontinue breastfeeding when her baby was one year old. Her course since onset was characterized as "intermittent with remissions." There was fatigue and arthralgia. Her SLE was subject to exacerbations and remissions, with fair health between exacerbations. Exacerbations were monthly in frequency, lasting two days, with more than six exacerbations in the past 12-month period. Digestive symptoms were diarrhea, tongue thickening, and tongue tenderness. She had bleeding gums, and complained that she could not gain weight. She complained of constant diarrhea and urinary frequency. There were moderate pain symptoms at the shoulders, elbows, knees and hips. There were no malnutrition findings. The Veteran's SLE was symptomatic within the past two years, with signs of arthritis, indications of renal damage, skin rash, signs or symptoms of eye complications, neurological abnormalities, and Reynaud's phenomenon. The disease was currently present and active. There was alopecia. She weighed 145 pounds. The diagnosis was SLE with secondary Sjogren's syndrome, Reynaud's phenomenon, polyarthralgia, and intermittent malar rash. The effects on usual daily activities were: "none" (bathing and feeding), "mild" (grooming, toileting, dressing, traveling), and "moderate" (chores, shopping, recreation, exercise). The examiner stated that the Veteran typically had an exacerbation of symptoms every two months, lasting 2-3 days, and that she was not currently on any treatment due to breastfeeding, but planned to resume treatment in April. She had constant polyarthralgia, fatigue, alopecia, and dry eyes (Sjogren's syndrome) as well as intermittent Reynaud's, malar rash, mouth ulcers, joint swelling, and memory impairment. Her condition was not currently in an active phase. A VA "artery, veins, and miscellaneous" examination report, dated in March 2011, shows that the examiner stated that the Veteran's claims file had been reviewed. The report notes the following: there was a history of Reynaud's syndrome affecting the bilateral digitus of the upper extremities. Attacks lasted less than five minutes, and occurred less than once per week. The attacks were manifested by color changes (white, blue and red), pain, paresthesias, and numbness. Attacks were precipitated by exposure to cold. Exercise and exertion were not precluded, and there were no effects on daily activities. The diagnosis was Reynaud's syndrome. A VA genitourinary examination report, dated in March 2011, shows that the examiner stated that the Veteran's claims file had been reviewed. The report notes the following: there was no history of anorexia, nausea, vomiting, fever, chills, fatigue, lethargy, weakness, or lower abdominal or pelvic pain. There was flank or back pain, specifically, flank pain when she needed to urinate and was unable to get to a bathroom quickly. There were no urinary symptoms or leakage, history of obstructed voiding, history of renal failure or dysfunction, hydronephrosis, or cardiovascular symptoms. The diagnosis was vesicoureteral reflux, with no associated problems, and no effects on usual daily activities. The Board finds that an initial 60 percent evaluation is warranted for the Veteran's SLE. As an initial matter, the applicable diagnostic code, DC 6350, does not clearly define the term "exacerbations." In this regard, the medical evidence indicates that the Veteran has received essentially ongoing treatment for a wide variety of symptoms associated with her SLE ever since the date of service connection, i.e., May 24, 2005. Specifically, she is shown to have received essentially ongoing treatment for symptoms that primarily included rash, alopecia, arthralgias, oral ulcers, and aqueous deficient dry eye and secondary Sjogren's syndrome, with use of medications that included doxycycline Valcyclovir, Atarax, and Plaquenil. See e.g., VA progress notes, dated in August 2006 and February 2007. The diagnosis in the October 2005 VA examination report notes SLE with "significant functional impairment with periodical fever in the morning." The May 2009 VA examination report states that the Veteran has SLE "with frequent and nearly continuous exacerbations of muscle/joint pain, hair loss, and depression." To the extent that the Appeals Management Center's June 2012 decision assigned an effective date of May 17, 2011 for their increased evaluation of 60 percent, the Board first notes that this decision was based on VA examination reports that were, in fact, performed in March 2011. Furthermore, these VA examination reports include a finding that the Veteran's SLE was symptomatic within the past two years, with signs of arthritis, indications of renal damage, skin rash, signs or symptoms of eye complications, neurological abnormalities, and Reynaud's phenomenon. In summary, although there is evidence of remissions of the Veteran's SLE during the time period on appeal, see e.g., Anthony Medical Center reports, dated in July and August of 2010, these periods of remission are not clearly documented, and there is considerable evidence indicating essentially ongoing treatment for various SLE symptoms, to include continuous use of medications. Accordingly, affording the Veteran the benefit of all doubt, the Board finds that the evidence is at least in equipoise, and that the criteria for an initial evaluation of 60 percent are shown to have been met as of the date of service connection, i.e., May 24, 2005. An initial evaluation in excess of 60 percent is not warranted. The evidence is insufficient to show that the Veteran's SLE has been productive of a severe impairment to health at any time during the appeal period. The evidence indicates that the Veteran was working full-time during a great deal of the appeal period. VA progress notes, dated in February and November of 2006, state that her SLE was stable. A July 2006 VA progress note shows that the Veteran reported that she worked out every day. The Veteran apparently gave birth in April 2010. The March 2011 VA examination reports indicate that the Veteran's Reynaud's syndrome did not preclude exercise and exertion, and there were no effects on daily activities, that her vesicoureteral reflux had no associated problems, and that her SLE was subject to exacerbations and remissions, "with fair health between exacerbations." There is no competent opinion of record to the effect that the Veteran's SLE has been productive of a severe impairment to health at any time during the appeal period. Accordingly, the Board finds that the preponderance of the evidence shows that the criteria for a 100 percent evaluation under DC 6350 have not been met. To this extent, the claim must be denied. The Board has considered whether rating the Veteran's residuals of her SLE separately would result in a higher rating. See DC 6350, Note. In this regard, service connection is currently in effect for chronic fatigue syndrome, major depression, cervical strain, varicose veins of the bilateral legs, and mechanical low back syndrome. The symptoms of these disabilities therefore need not be considered, as the pyramiding of ratings for the same disability under various diagnoses are prohibited. 38 C.F.R. § 4.14 (2012). The Board notes that, to the extent that the Veteran has alleged memory loss, this symptom is rated in conjunction with her depression. See 38 C.F.R. § 4.130 (2012). The Veteran's SLE is primarily shown to have been manifested by skin, polyarthralgias, oral ulcers, aqueous deficient dry eye and secondary Sjogren's syndrome, vesicoureteral reflux, and Reynaud's syndrome. See e.g., August 2006 and February 2007 VA progress notes; March 2011 VA examination reports. With regard to her skin symptoms (primarily rash and alopecia), the March 2011 VA skin examination report shows that the Veteran had skin symptoms covering 20 to 40 percent of exposed areas, and total body area. There is no evidence to show that a greater percentage of total body area, or exposed areas, is affected by the Veteran's SLE, nor is the evidence sufficient to show that she required constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs during a 12-month period. This finding shows that the criteria for a 30 percent rating have been met under 38 C.F.R. § 4.118, DC 7806 (2012); see also DC 7809 (discoid lupus erythematosus, or systemic cutaneous lupus erythematosus) (as in effect prior to October 23, 2008). See 73 Fed. Reg. 54,710 (Sept. 23, 2008). There are no findings to show that the Veteran has scarring alopecia affecting 20 to 40 percent of the scalp, as required for a compensable rating. DC 7830 (2012). With regard to Reynaud's syndrome, under 38 C.F.R. § 4.104, DC 7122, a 10 percent rating is warranted where there is: Arthralgia or other pain, numbness, or cold sensitivity. The Veteran's symptoms appear to meet these criteria, therefore, a 10 percent rating is warranted. A rating in excess of 10 percent is not warranted, as the Veteran is not shown to have arthralgia or other pain, numbness, or cold sensitivity plus tissue loss, nail abnormalities, color changes, locally, impaired sensation, hyperhidrosis, or X-ray abnormalities (osteoporosis, subarticular punched out lesions, or osteoarthritis), as required for the next higher (20 percent) rating. Id. With regard to polyarthralgias, VA does not generally grant service connection for symptoms unaccompanied by a disease process or pathology. See e.g., Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999) (holding that "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."); dismissed in part and vacated in part on other grounds, Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001). In this case, none of the affected joints are shown to be productive of arthritis by X-ray or other clinical tests. See 38 C.F.R. § 4.71a, DC 5003; Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (noting that X-ray studies and other specific findings are needed to properly assess and diagnose arthritis); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); and Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). Furthermore, even assuming arguendo that the affected joints were shown to have been productive of a disease process, there is no evidence to show that any of the affected joints have a limited range of motion, or other symptoms, warranting a compensable evaluation. See 38 C.F.R. § 4.71a; March 2011 VA joints examination report; see also Mitchell v. Shinseki, 25 Vet. App. 32 (2011) (pain alone does not constitute functional loss under VA regulations that evaluate disabilities based upon loss of motion). Accordingly, a compensable rating is not warranted for any joint affected by SLE. With regard to oral ulcers, there are no findings to show that a compensable rating is warranted under any diagnostic code at 38 C.F.R. § 4.118, as this disorder is not shown to have been productive of scars, to require topical therapy, or to affect more than five percent of the entire body or exposed areas. With regard to aqueous deficient dry eye and secondary Sjogren's syndrome, during the pendency of this claim, the criteria for evaluating disabilities of the eye were revised. The revised criteria apply to claims filed on or after December 10, 2008. They do not apply to the Veteran's claim, which was filed in 2005. The Veteran is repeatedly shown to have had 20/20 vision, bilaterally, with no findings of conjunctivitis, or loss of visual fields to the required degree. Accordingly, a compensable rating is not warranted under 38 C.F.R. § 4.79, DCs 6009, 6018, 6066, 6080 (2008). With regard to vesicoureteral reflux, despite the Veteran's complaints, she is not shown to have had such symptoms as renal dysfunction, voiding dysfunction, urinary frequency, obstructed voiding, or urinary tract infection. Therefore, the criteria for a compensable rating under 38 C.F.R. § 4.115a (2012) are not shown to have been met. Given the foregoing, when rated separately, the Veteran's compensable ratings would consist of a 30 percent rating, and a 10 percent rating. This would result in a combined rating of 40 percent. See 38 C.F.R. § 4.25 (combined ratings table). Therefore, rating the Veteran's residuals of her SLE separately would not result in her receiving an initial evaluation in excess of 60 percent. Consideration has been given to whether the schedular evaluation is inadequate, thus requiring that the RO refer a claim to the Under Secretary for Benefits or the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1) (2012); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the veteran or reasonably raised by the record). In determining whether an extra-schedular evaluation is for consideration, the Board must first consider whether there is an exceptional or unusual disability picture, which occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a Veteran's service-connected disability. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, the Board must next consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Thun, 22 Vet. App. at 115-16. When those two elements are met, the appeal must be referred for consideration of the assignment of an extra-schedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1) (2012); Thun, 22 Vet. App. at 116. The schedular evaluation in this case is not inadequate. When comparing the Veteran's disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that manifestations of the service-connected SLE disability are congruent with the disability picture represented by the disability rating assigned herein. The criteria for the 60 percent rating assigned herein more than reasonably describe the Veteran's disability level and symptomatology. The Veteran's SLE is primarily shown to have been manifested by skin, polyarthralgias, oral ulcers, aqueous deficient dry eye and secondary Sjogren's syndrome, vesicoureteral reflux, and Reynaud's syndrome. The Veteran is shown to have rashes, joint pains, oral ulcers, dry eyes, and coldness in her fingers. As the Board finds that the Veteran's disability picture is contemplated by the rating schedule, the inquiry ends and the Board need not consider whether the disability picture exhibits other related factors such as marked interference with employment and frequent periods of hospitalization. Accordingly, referral for consideration of an extra-schedular rating is not warranted. The Board has considered the Veteran's statements that she should be entitled to a higher disability rating for her SLE. She has symptoms that include a rash, alopecia, polyarthralgias, oral ulcers, aqueous deficient dry eye and secondary Sjogren's syndrome, vesicoureteral reflux, and Reynaud's syndrome. The Board is required to assess the credibility and probative weight of all relevant evidence. McClain v. Nicholson, 21 Vet. App. 319, 325 (2007). In doing so, the Board may consider factors such as facial plausibility, bias, self interest, and consistency with other evidence of record. Caluza v. Brown, 7 Vet. App. at 511; see also Jandreau v. Nicholson, 492 F.3d 1372, 1376 (Fed. Cir. 2007); cf. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Board may consider the absence of contemporaneous medical evidence when determining the credibility of lay statements, but may not determine that lay evidence lacks credibility solely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d at 1331. Personal interest may affect the credibility of the evidence, but the Board may not disregard testimony simply because a claimant stands to gain monetary benefits. Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). The Veteran is competent to report her current SLE symptoms as these observations come to her through her senses. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board also acknowledges the Veteran's belief that her symptoms are of such severity as to warrant a higher rating. However, disability ratings are made by the application of a schedule of ratings which is based on average impairment of earning capacity as determined by the clinical evidence of record. Therefore, the Board finds that the medical findings, which directly address the criteria under which the disability is evaluated, are more probative than the Veteran's assessment of the severity of her disability. The VA examinations also took into account the Veteran's subjective statements with regard to the severity of her SLE. Finally, although the Veteran has submitted evidence of medical disability, and made a claim for the highest rating possible, she has not submitted evidence of unemployability, or claimed to be unemployable. See e.g., March 2011 VA joints examination report (in which the Veteran reported that she had quit her last job because she was exposed to environmental contaminants). Prior to this report, the Veteran had stated working at full-time employment in customer service and administration of a company. Therefore, the question of entitlement to a total disability rating based on individual unemployability due to a service-connected disability has not been raised. See Rice v. Shinseki, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). In reaching this decision, the Board considered the benefit-of-the-doubt rule; however, as the preponderance of the evidence is against the appellant's claim, such rule is not for application in this case. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). II. The Veterans Claims Assistance Act of 2000 The Board is required to ensure that the VA's "duty to notify" and "duty to assist" obligations have been satisfied. See 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012). The notification obligation in this case was accomplished by way of a letter from the RO to the Veteran dated in June 2005. Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F. 3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473, 484 (2006). In this regard, the June 2005 VCAA notice was issued in association with the Veteran's claim for service connection for SLE, and this claim was granted in November 2005. In such cases, where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice was intended to serve has been fulfilled; no additional § 5103(a) notice is required. Dingess, 19 Vet. App. at 491, 493. The RO has provided assistance to the appellant as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances in this case. It appears that all known and available service treatment reports, and post-service records relevant to the issue on appeal have been obtained and are associated with the Veteran's claims file. The RO has obtained the Veteran's VA and non-VA medical records. The Veteran has been afforded several examinations. Concerning these examinations, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Here, the VA examination reports show that the examiners reviewed the Veteran's medical history, recorded her current complaints, conducted an appropriate examination, provided the appropriate findings, and rendered diagnoses that are consistent with the remainder of the evidence of record. The Board concludes, therefore, that a decision on the merits at this time does not violate the VCAA, nor prejudice the appellant under Bernard v. Brown, 4 Vet. App. 384 (1993). Based on the foregoing, the Board finds that the Veteran has not been prejudiced by a failure of VA in its duty to assist, and that any violation of the duty to assist could be no more than harmless error. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). In February 2011, the Board remanded this claim. The Board's remand directed that an additional attempt be made to obtain all records of treatment since August 2009. This was done, and VA progress notes, dated up to 2012, have been added to the claims file. As directed by the Board, Veteran has also been afforded an examination (in fact, several examinations). Under the circumstances, the Board finds that there has been substantial compliance with its remands. See Dyment v. West, 13 Vet. App. 141, 146-147 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where Board's remand instructions were substantially complied with); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). The Board concludes, therefore, that a decision on the merits at this time does not violate the VCAA, nor prejudice the appellant under Bernard v. Brown, 4 Vet. App. 384 (1993). Based on the foregoing, the Board finds that the Veteran has not been prejudiced by a failure of VA in its duty to assist, and that any violation of the duty to assist could be no more than harmless error. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). ORDER An initial evaluation of 60 percent, and no more, for service-connected systemic lupus erythematosus is granted, subject to the laws and regulations governing the award of monetary benefits. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs