Citation Nr: 1325153 Decision Date: 08/08/13 Archive Date: 08/13/13 DOCKET NO. 09-10 465 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to a rating in excess of 10 percent for right knee genu varum with degenerative joint disease. 2. Entitlement to a rating in excess of 10 percent for left knee genu varum with degenerative joint disease. 3. Entitlement to service connection for pemphigus foliaceus. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Amanda Christensen, Associate Counsel INTRODUCTION The Veteran had active military service from August 1978 to November 1978 and April 1979 to June 1995. This appeal comes to the Board of Veterans' Appeals (Board) from a December 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado. The Veteran testified before the undersigned Veterans Law Judge in May 2013, and a transcript is included in the record. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to insure a total review of the evidence. FINDINGS OF FACT 1. The Veteran's right and left knee disability has been manifested by extension to 0 degrees and flexion to at least 115 degrees, with no more than a 5 degree loss of range of motion of each on repetition, pain, and mild lateral instability in the left knee but not the right. 2. The Veteran's pemphigus foliaceus did not have its onset in service and is not the result of a disease or injury incurred in service. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for right knee genu varum with degenerative joint disease have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5010, 5256-5263 (2012). 2. The criteria for a rating in excess of 10 percent for left knee limitation of motion due to genu varum with degenerative joint disease have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5010, 5256, 5258-5263 (2012). 3. The criteria for a rating of 10 percent, but no more, for left knee lateral instability due to genu varum with degenerative joint disease have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.71a, Diagnostic Code 5257 (2012). 4. The criteria for service connection for pemphigus foliaceus have not been met. U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS A. Knees Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2012). However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14 (2012). Where, as here, entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are appropriate for an increased rating claim if the factual findings show distinct time periods where the service-connected disability exhibited symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The following discussion addresses the Veteran's level of disability from the time the increased rating claim was filed in January 2006. Francisco, 7 Vet. App. 55; Hart, 21 Vet. App. 505. The Veteran is currently rated under Diagnostic Code 5010 for arthritis, which is rated on the basis of limitation of motion for the specific joint involved unless it would be rated as noncompensable under the appropriate diagnostic code, in which case a 10 percent evaluation is awarded with x-ray evidence of involvement of two or more major joints or two or more minor joint groups. If there are also occasional incapacitating exacerbations, a 20 percent evaluation is awarded under Diagnostic Code 5010. 38 C.F.R. § 4.71a. The RO awarded the Veteran a 10 percent evaluation for painful or limited motion. Limitation of motion of the knee is addressed in 38 C.F.R. § 4.71a, Diagnostic Codes 5260 and 5261. Diagnostic Code 5260 provides for a 10 percent rating where flexion is limited to 45 degrees, 20 percent rating where flexion is limited to 30 degrees, and 30 percent rating where flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, DCs 5260. Diagnostic Code 5261 provides for a 10 percent rating where extension is limited to 10 degrees, 20 percent rating where extension is limited to 15 degrees, 30 percent rating where extension is limited to 20 degrees, 40 percent rating where extension is limited to 30 degrees, and 50 percent rating where extension is limited to 45 degrees. 38 C.F.R. § 4.71a, DC 5261. In DeLuca v. Brown, 8 Vet. App. 202 (1995), the Court of Appeals for Veterans Claims held that diagnostic codes that provide a rating solely on the basis of loss of range of motion must be considered with 38 C.F.R. §§ 4.40 and 4.45 (regulations pertaining to functional loss due to pain, etc.). Therefore, to the extent possible, the degree of additional range of motion loss due to pain, weakened movement, excess fatigability, or incoordination should be noted. However, when the maximum rating for limitation of motion of a joint has already been assigned, a finding of pain on motion cannot result in a higher rating. Johnson v. Brown, 9 Vet. App. 7 (1997). The knee is considered a major joint. 38 C.F.R. § 4.45(f). The normal range of motion of the knee is from zero to 140 degrees. 38 C.F.R. § 4.71, Plate II (2012). The Veteran has had multiple knee surgeries prior to 2006 and was fitted for a left knee brace at the VA in July 2006. The Veteran was afforded a VA examination in August 2006. The Veteran reported both knees have pain and swelling as well as catching, locking, and a feeling of giving way. He reported his left knee is worse than his right and he wears a brace on that knee. He did not report flare-ups of pain but did report increased pain with repetitive use. On examination, the examiner stated that both knees showed a mild varus alignment, mild effusion, extension to 0 and flexion to 135, no effusion, and no muscle atrophy. He also found both knees to have tender medial and lateral joint lines but negative McMurray's, negative Lachman, negative pivot, stable medial and lateral collateral ligaments, and negative posterior drawer. The knees showed increased pain with repetitive resisted extension but no increased pain with resisted flexion. The Veteran walked with mild analgia favoring the left knee. He had mild incoordination in motion, more on the left than the right. Both knees also showed mild retropatellar compression tenderness. The examiner diagnosed degenerative arthritis changes in both knees. He opined that the Veteran would have an additional 5 degrees of range of motion loss in knee extension considering the DeLuca factors. In March 2008 the Veteran was seen at the VA complaining of right knee pain. The examiner found his knee had flexion to 120 degrees and extension to 5 degrees. At an August 2009 VA physical the Veteran reported he had pain in his knees from time to time. The Veteran underwent another VA examination in November 2011. He reported pain with walking more than half a mile, some instability for which he wears a brace on his left knee, occasional popping in his right knee, swelling with significant walking that lasts about 24 hours, and stiffness with daily activity that resolves with rest. He did not report any locking. He did report flare-ups with weather changes lasting less than a day. The examiner measured the Veteran's right knee flexion to 120 degrees with painful motion at that point and his extension to 0 degrees with no evidence of painful motion. His left knee flexion was measured to 115 degrees with painful motion at that point and extension to 0 degrees with no evidence of painful motion. After repetitive use testing the Veteran had flexion in his right knee to 115 degrees but otherwise no change in his range of motion bilaterally. The examiner also found the Veteran had less movement than normal in both knees and instability in his left knee after repetitive use. The examiner noted the Veteran had tenderness or pain to palpation in both knees. His strength in each knee was measured as normal. Anterior instability and medial-lateral instability were not tested. Posterior instability tested normal. The examiner noted the Lachman and varus and valgus stress tests were not tested due to guarding. No evidence of patellar subluxation/dislocation was found. The Veteran testified at his May 2013 Board hearing that his left knee is worse than his right. He stated that he wears a prescribed brace on it due to instability, explaining that he needs the brace if he stands for a long period of time or walks. The Veteran said that when he is more active, such as in the summer, his knees swell and he also uses a cane. The Veteran testified that his day job is mostly sedentary and at his night job stocking he uses a cart to keep his balance and reduce the pain. He said both knees go out on him sometimes, but the left more frequently than the right. He reported his knee pain has increased over the years. He said he experiences weakness in his right knee as well as fatigability and creaking. He said he has pain 70 to 80 percent of the time. The Veteran said that he can't bend either knee all the way back and is able to extend them fully but can't bend them back. When getting up from a seated position he said he uses his hands to push off. Looking first at the limitation of motion of the Veteran's knee, the Board notes that his bilateral knee extension has consistently been measured to 0 degrees. For a 20 percent rating under Diagnostic Code 5261, extension must be limited to 15 degrees. The Veteran's left knee has shown some limitation of flexion, but not to the 30 degrees required for a 20 percent disability rating under Diagnostic Code 5260. In August 2006 at a VA examination flexion of left knee was measured to 135 degrees. In March 2008 at a VA appointment and in November 2011 at a VA examination flexion was measured to 120 degrees. Although the Veteran's flexion and extension has been consistently measured at beyond the thresholds for a higher rating under Diagnostic Codes 5260 and 5261, and in fact higher than the thresholds for the 10 percent rating he has been awarded, the Board has also considered DeLuca, 8 Vet. App. 202, and the provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45. The 2006 VA examiner estimated the Veteran's additional loss of range of motion after repetition at 5 degrees extension. The 2011 VA examiner found no additional loss in range of motion of knee extension, but measured a 5 degree loss in flexion with repetition. The 2011 examiner also found the Veteran had less movement than normal in both knees and instability in his left knee after repetitive use. The Veteran has also reported that with activity he experiences pain, swelling, and stiffness. However, the Board notes that there is some indication the Veteran's knee disability may not cause as much pain and functional loss as he has described. At an August 2009 VA physical examination the Veteran reported only that he has had pain in his knees only "from time to time." In May 2011 he was treated for ankle pain at the VA that was noted to be aggravated by playing racquetball. Overall, the Board finds that the Veteran's currently assigned 10 percent rating takes into consideration the minimal loss of range of motion on repetitive movement and functional loss noted by the VA examiners and the Veteran's complaints of pain, swelling, and stiffness, and his condition does not more accurately approximate the criteria for a 20 percent rating. As a preponderance of the evidence is against a higher rating, the benefit of the doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran has contended, including at his Board hearing, that he experiences knee instability, making his disability potentially ratable under Diagnostic Code 5257 for recurrent subluxation or lateral instability. A 10 percent rating is warranted for slight recurrent subluxation or lateral instability, a 20 percent rating if the impairment is moderate, and a 30 percent rating if it is severe. 38 C.F.R. § 4.71a. There is a general rule against the "pyramiding" of benefits. See 38 C.F.R. § 4.14; see also Brady v. Brown, 4 Vet. App. 203, 206 (1993). However, the Board acknowledges that a Veteran is entitled to separate disability ratings for different manifestations of the same disability when the symptomatology of one manifestation is not duplicative or overlapping of the symptomatology of the other manifestations. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). VA's General Counsel has held that a claimant who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257. VAOPGCPREC 23-97; 62 Fed. Reg. 63, 604 (1997). At the Veteran's August 2006 VA examination the examiner found the Veteran had a negative McMurray's, negative Lachman, negative posterior drawer, and stable medial and lateral collateral ligaments. The November 2011 VA examiner found the Veteran's posterior instability to be normal but was unable to test the Veteran's anterior and medial-lateral instability due to the Veteran's guarding, but did note instability in his left knee after repetitive use. VA records show the Veteran was prescribed a left knee brace in July 2006 and he has also used a cane since at least 2006, aids that the Veteran has stated are due to the instability in his knee. Giving the Veteran the benefit of the doubt, the Board finds he is entitled to a 10 percent rating for mild lateral instability in his left knee. A higher rating is not warranted as the evidence does not show the instability is moderate. Specifically, the November 2011 VA examiner noted the instability only with repetition and the Veteran suggested his knee brace is necessary only with activity such as long periods of standing. Further, the evidence suggests the Veteran has been able to play racquetball without an increase in knee symptomatology for which he sought medical treatment. Thus, the evidence supports that the Veteran experiences only a mild degree of lateral instability. The Board finds the Veteran is not entitled to a separate rating under Diagnostic Code 5257 for instability of his right knee. The Veteran has testified and the evidence shows that the Veteran's left knee is worse than his right. He has not been prescribed a brace for his right knee. The November 2011 VA examiner did not find any instability in the Veteran's right knee upon examination after repetitive movement. Additional diagnostic codes also apply to rating knee disabilities. 38 C.F.R. § 4.71a. Diagnostic Code 5256 (ankylosis), Diagnostic Code 5258 (dislocated semilunar cartilage), Diagnostic Code 5259 (removal of semilunar cartilage), and Diagnostic Code 5262 (impairment of tibia and fibular) do not apply as the evidence does not show the Veteran has any of those conditions. Diagnostic Code 5263 awards a maximum 10 percent evaluation for genu recurvatum, which the Veteran had upon entry into service, and would not apply to give the Veteran a higher rating. The Board has also considered whether referral for consideration of an extraschedular rating is warranted, noting that if an exceptional case arises where ratings based on the statutory schedules are found to be inadequate, consideration of an "extra-schedular" evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities will be made. 38 C.F.R. § 3.321(b)(1). The Court has held that the determination of whether a claimant is entitled to an extraschedular rating under § 3.321(b) is a three-step inquiry, the responsibility for which may be shared among the RO, the Board, and the Under Secretary for Benefits or the Director, Compensation and Pension Service. Thun v. Peake, 22 Vet. App. 111 (2008). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. This means that initially there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is adequate, and no referral is required. If the criteria do not reasonably describe the claimant's disability level and symptomatology, a determination must be made whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). See id. However, in this case, the medical evidence fails to show anything unique or unusual about the Veteran's service connected right and left knee disability that would render the schedular criteria inadequate. The Veteran's symptoms, including loss of range of motion, pain, and instability, are contemplated in the rating assigned. As such, it would not be found that his disability met the "governing norms" of an extraschedular rating. Accordingly, referral for consideration of an extraschedular rating is not warranted. Moreover, even if it were argued that the schedular rating criteria were inadequate, the Board finds no reason to refer the case to the Compensation and Pension Service to consider whether an extra-schedular rating is warranted. In this case, there is no evidence of any hospitalization associated with the Veteran's knee disability. In addition, the Board finds the record does not reflect that the Veteran's knee disability markedly interferes with his ability to work. See 38 C.F.R. § 4.1 (indicating that generally, the degrees of disability specified in the Rating Schedule are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability). The manifestations of the Veteran's disability are considered by the schedular rating. Based on the foregoing, the Board finds the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321; Thun v. Peake, 22 Vet. App. 111 (2008). B. Skin Condition Service connection will be granted if it is shown that the veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). To establish service connection, there must be a competent diagnosis of a current disability; medical or, in certain cases, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. Hickson v. West, 12 Vet. App. 247, 252 (1999); see Jandreau, 492 F.3d 1372. Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. No skin conditions were noted on the Veteran's 1978 entrance examination. The Veteran's service treatment records reflect that in April 1988 he sought treatment for itchy dry skin that he reported had been present on his back for six months and his chest for two months. The examining doctor noted the patches were dark brown and dry and diagnosed pityriasis rosea. He told the Veteran to apply Selsun shampoo as a cream and return if his condition worsened. There is no mention of the Veteran's skin again in his service treatment records until August 1989 when the Veteran was seen for cold symptoms and the physician's assistant noted the Veteran had dry skin on his chest and upper arms. Records do not reflect any treatment was prescribed. Finally, in October 1990 the Veteran was seen complaining of hyperpigmented lesions for the previous four months that started on his left arm and spread to his chest and back. He was diagnosed with tinea versicolor and told to treat with Selsun shampoo. At the Veteran's April 1995 discharge examination, the examiner noted the tinea versicolor diagnosis. On his report of medical history, the Veteran checked that he didn't know if he had a history of skin disease. Although the Veteran filed a compensation claim in July 1995, he did not claim he was entitled to benefits for a skin condition. However, at his September 1995 VA examination he told the examiner that during service he developed spots on his chest and back that were diagnosed as fungal infection. He said he was prescribed a cream that did not help and said the rash remains and may itch on occasion. In June 2001 the Veteran sought treatment with the VA reporting sores on his back and scalp. He reported the sores on his back had been present for about two months. The doctor assessed tinea corporis on his scalp with possible psoriatic reach and ordered a biopsy. The biopsy revealed a diagnosis of pemphigus foliaceus. He has been treated for pemphigus foliaceus through the VA since that time. The Veteran testified that the skin condition he had in service in 1988 and the condition he has currently look the same but bigger and more widespread. He described it as being itchy. He said he first sought treatment for his skin condition after service when he had a break out on his scalp. He testified that no biopsy was taken when he was diagnosed in service and contended that he was misdiagnosed at that time and in fact has had pemphigus foliaceus since service. The Veteran's wife submitted a statement in May 2006 that said that she first noticed dry spots on the Veteran's back and shoulders when he was in service and the spots increased after he returned from his first trip to the Middle East. She suggested he go see a doctor, which he did. Since moving to Colorado Springs, she stated that she saw bumps on the top of the Veteran's head that were leaking. After going to the emergency room twice, she said he was diagnosed with pemphigus foliaceus by a dermatologist. The Veteran underwent a VA examination in August 2006. He told the examiner that he has had a dry, itchy, blistering skin condition that has continued without resolving completely since service, but that it flared-up in 2001, causing him to seek treatment at the VA. The examiner noted the Veteran's 1988 diagnosis of pityriasis rosea but opined that it is less likely than not that the Veteran's current pemphigus foliaceus diagnosis was caused by or a result of his pityriasis rosea diagnosed in service. She stated that pemphigus foliaceus is an autoimmune reaction to proteins within the skin and pityriasis rosea is caused by a viral infection. She said that she could not state definitively that the Veteran was misdiagnosed in service. She noted that no medical records were available showing the Veteran had continually present pemphigus foliaceus between 1988 and 2001. She stated that the Veteran's description and his initial diagnosis in 1988 were interpreted as being more consistent with pityriasis rosea. Pityriasis rosea manifests as an asymmetric eruption that appears predominately on the chest, consisting of red papules surrounded by a scaling ring, often distributed in a Christmas tree pattern with the long axis conforming to skin cleavage lines. On the other hand, she said pemphigus foliaceus usually consists of small, superficial blisters that rapidly erode leaving a scaly crusted erosion on an erythematous base. The examiner opined that given the present severity of the Veteran's pemphigus foliaceus, it is unlikely that he would have had such an indirect course of the condition for ten years before presenting with severe disease in 2001. While the evidence shows the Veteran was diagnosed with two skin conditions in service, pityriasis rosea and tinea versicolor, and after service was diagnosed with another skin condition, pemphigus foliaceus, the competent medical evidence does not support either that the Veteran actually had pemphigus foliaceus in service or that it was caused by or a result of his skin conditions diagnosed in service. The Veteran and his wife are competent to report that the Veteran had a skin condition in service, and the evidence clearly supports that contention, however, they are not competent to opine as to the exact diagnosis, or misdiagnosis, of that condition as it is a complex medical question not capable of lay observation. As a lay person, the Veteran and his wife do not have the education, training and experience to offer a medical diagnosis or an opinion as to the onset or etiology of the Veteran's pemphigus foliaceus. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011); see also Jandreau v. Nicholson, 492 F.3d at 1376-77 (holding that "[l]ay evidence can be competent and sufficient to establish a diagnosis when ... a lay person is competent to identify the medical condition" and providing, as an example, that a layperson would be competent to identify a condition such as a broken leg, but would not be competent to identify a form of cancer). Accordingly, the Veteran's lay statements in this regard are not competent or probative evidence supporting his claim. See Davidson, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau, 492 F.3d at 1376-77. The only competent medical opinion in this case is that of the August 2006 VA examiner, who declined to opine that the Veteran was misdiagnosed in service in 1988 and has had pemphigus foliaceus since that time. She explained the different, though somewhat similar, manifestations of the two diseases and said the Veteran's 1988 description of his condition was more consistent with pityriasis rosea. She also found it unlikely that the Veteran would have had an indirect course of pemphigus foliaceus for ten years with a sudden onset of severity in 2001. The examiner also noted that subsequent to 1988, the Veteran's medical records do not reflect that medical practitioners noted he continued to have pityriasis rosea, suggesting the rash may have disappeared, or possibly that the medical practitioners had not noticed it. In fact, although the Veteran has contended he consistently had the same rash from 1989 to 2001, service treatment records reflect no mention of a skin condition from when he was diagnosed with pityriasis rosea in April 1988 until when a treatment note for an unrelated condition mentions dry skin in August 1989. More than a year later, in October 1990 is the next reference of a skin condition, at which time the Veteran reported he had had lesions for only four months and an entirely different skin condition was diagnosed, this one fungal. There is then no evidence of treatment for a skin condition for ten years until his June 2001 diagnosis of pemphigus foliaceus, at which time he reported the sores had been present on his back for only two months. Thus, the Board finds the evidence does support that the Veteran had the same continuous rash since 1988, particularly considering he reported an onset in June 2001 of only two months prior rather than more than a decade. Overall, the preponderance of the evidence is against the Veteran's claim for service connection for pemphigus foliaceus as the competent medical evidence weighs against his claim. In reaching this determination, the Board has considered the lay statements of the Veteran and his wife but finds that the evidence weighs against finding that the Veteran has had the same skin condition since service that was misdiagnosed at that time. Rather, the VA examiner has offered a reasoned opinion as to why the Veteran's pemphigus foliaceus is not related to his service. The Board acknowledges that VA is statutorily required to resolve the benefit of the doubt in favor of the Veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. That doctrine, however, is not applicable in this case because the preponderance of the evidence is against the Veteran's claim. See Gilbert, 1 Vet. App. at 55; 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3. C. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 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(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). Such notice should also address VA's practices in assigning disability evaluations and effective dates for those evaluations. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). While the required notice should be furnished prior to the issuance of the appealed rating decision, any initial errors of notice will not be prejudicial if: 1) corrective actions (e.g., issuance of a post-adjudication notice letter containing the required information) are taken, and 2) the appeal is readjudicated (e.g., in a Supplemental Statement of the Case). See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Here, the VCAA duty to notify was satisfied by way of a letter sent to the Veteran in February 2006. In the letter, the RO informed the Veteran of what evidence was required to substantiate his claims and of the Veteran's and VA's respective duties for obtaining evidence. In a March 2006 letter the RO provided notice with regard to how VA assigns disability ratings and effective dates. Thus, the duty to notify has been satisfied. VA also has a duty to assist the Veteran with the development of facts pertinent to the appeal. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). This duty includes the obtaining of "relevant" records in the custody of a federal department or agency under 38 C.F.R. § 3.159(c)(2), as well as records not in federal custody (e.g., private medical records) under 38 C.F.R. § 3.159(c)(1). VA will also provide a medical examination if such examination is determined to be "necessary" to decide the claim. 38 C.F.R. § 3.159(c)(4). The Board finds that all necessary development has been accomplished. The RO has obtained the Veteran's service treatment records and VA treatment records. The Veteran also submitted lay statements. Neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. The Veteran was afforded VA medical examinations in August 2006 and November 2011. The examiners, medical professionals, obtained an accurate history, listened to the Veteran's assertions, reviewed his claims file, and performed the necessary tests. The examiners who examined the Veteran's knees provided the Board with sufficient information to rate the Veteran's disability, and the August 2006 examiner who performed the dermatology examination provided an adequate examination with reference to the question of service connection for the Veteran's claimed skin disability. Therefore, the Board finds that the examinations are adequate and contains sufficient information to decide the issues on appeal. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio, 16 Vet. App. 183. Also, in Bryant v. Shinseki, the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. 3.103(c)(2) requires that the VLJ who conducts a hearing fulfill two duties to comply with the regulation. They consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. In this case, during the May 2013 Board personal hearing, the VLJ fully explained the issues on appeal. The Veteran was assisted at the hearing by an accredited representative from the Disabled American Veterans, and the VLJ and the representative asked questions regarding the nature and etiology of the Veteran's claimed disabilities, specifically regarding the history of his skin condition and the functional limitations of his knees. In addition, the VLJ sought to identify any pertinent evidence not currently associated with the claims file that might have been overlooked or was outstanding that might substantiate the claim, and specifically inquired as to when he first sought treatment at the VA for his skin condition. No pertinent evidence that might have been overlooked and that might substantiate the claim was identified by the Veteran or his representative. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2) or identified any prejudice in the conduct of the Board hearing. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2), and that any error in notice provided during the Veteran's hearing constitutes harmless error. [Continued on Next Page] ORDER A rating in excess of 10 percent for right knee genu varum with degenerative joint disease is denied. A rating in excess of 10 percent for left knee limitation of motion due to genu varum with degenerative joint disease is denied. A rating of 10 percent, but no higher, is granted for left knee lateral instability due to genu varum with degenerative joint disease, subject to the laws and regulations controlling the disbursement of monetary benefits. Service connection for pemphigus foliaceus is denied. ____________________________________________ MICHELLE L. KANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs