Citation Nr: 1329606 Decision Date: 09/16/13 Archive Date: 09/20/13 DOCKET NO. 07-21 706 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for discoid lupus. 2. Entitlement to an initial rating in excess of 10 percent for arthritis of the right knee. 3. Entitlement to an initial rating in excess of 10 percent for arthritis of the left knee. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD D. Schechter, Counsel INTRODUCTION The Veteran served on active duty from May 1985 to July 2005. The appeal comes before the Board of Veterans' Appeals (Board) from a March 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. During the pendency of the claims, a June 2007 decision increased the rating for the Veteran's lupus to 30 percent from the effective date of service connection, and assigned a separate 10 percent rating for each knee, from the effective the date of service connection. These increases did not satisfy the Veteran's appeal. The Veteran testified before the undersigned Veterans Law Judge at a hearing at the RO in October 2008. A transcript of that hearing is of record. When the case was most recently before the Board in November 2011, it was remanded the case for additional development. It has since returned to the Board for further appellate action. The Board in the Introduction to its November 2011 Remand referred to the Agency of Original Jurisdiction (AOJ) for appropriate action the issue of entitlement to service connection for Lyme disease. The issue had been raised by the record but had not been adjudicated by the AOJ. It appears from the record that the AOJ has still not adjudicated the issue. Accordingly, it is again referred to the AOJ for appropriate action. FINDINGS OF FACT 1. Throughout the initial rating period, the Veteran's discoid lupus has affected the skin of the head and face and has been manifested by five characteristics of disfigurement, and not more; it has not required system therapy during this period. 2. Throughout the initial rating period, the Veteran's right knee arthritis has been manifested by limitation of motion; flexion has not been limited to less than 45 degrees; extension has not been limited to more than 5 degrees; and the disability has not been manifested by lateral instability, recurrent subluxation or frequent episodes of locking, pain and effusion into the joint. 3. Throughout the initial rating period, the Veteran's left knee arthritis has been manifested by limitation of motion; flexion has not been limited to less than 45 degrees; extension has not been limited to more than 5 degrees; and the disability has not been manifested by lateral instability, recurrent subluxation or frequent episodes of locking, pain and effusion into the joint. CONCLUSIONS OF LAW 1. For the entire initial rating period, the criteria for a 50 percent rating, but not more, for discoid lupus have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. 38 C.F.R. § 4.118, Diagnostic Code 7800 (2008-2012). 2. At no time during the initial rating period have the criteria for more than a 10 percent rating for right knee arthritis been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Codes 5003, 5257, 5258, 5260, 5261 (2012). 3. At no time during the initial rating period have the criteria for more than a 10 percent rating for left knee arthritis been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Codes 5003, 5257, 5258, 5260, 5261 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. The Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103 , 5103A (West 2002 & Supp. 2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Board also notes the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) (West 2002), requires that notice to a claimant pursuant to the VCAA be provided 'at the time' that or 'immediately after' VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The timing requirement enunciated in Pelegrini applies equally to the initial-disability-rating and effective-date elements of a service-connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The record reflects that the Veteran was provided all required notice in letters mailed in January and May 2006. While he was not provided complete notice until after the initial adjudication of the claims, the Board finds that there is no prejudice to the Veteran in proceeding with the issuance of a final decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). In this regard, the Board notes that following the provision of the required notice and the receipt of all pertinent evidence, the originating agency readjudicated the claims. There is no indication or reason to believe that the ultimate decision of the originating agency on the merits of any of the claims would have been different had complete VCAA notice been provided at an earlier time. See Overton v. Nicholson, 20 Vet. App. 427, 437 (2006) (A timing error may be cured by a new VCAA notification followed by a readjudication of the claim). The Board also finds VA has complied with its duty to assist the Veteran in the development of his claims. In this regard, the record reflects that all pertinent available medical evidence identified by the Veteran has been obtained, to include private and VA outpatient treatment records. In addition, the Veteran has been afforded appropriate VA examinations in connection with the claims, most recently in November 2011. The Board has reviewed the November 2011 examination reports and finds that there has been substantial compliance with the directives of the Board's November 2011 remand. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The Veteran has not asserted, and the evidence of record does not show, that his discoid lupus or knee disabilities have increased significantly in severity since the most recent examination. The Veteran has also been afforded a hearing before the Board. Neither the Veteran nor his representative has identified any outstanding evidence that could be obtained to substantiate the claims; the Board is also unaware of any such evidence. Accordingly, the Board will address the merits of the claims on appeal. II. General Legal Criteria Disability evaluations are determined by the application of a schedule of ratings that is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 . Percentage evaluations are determined by comparing the manifestations of a particular disorder with the requirements contained in the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can practically be determined, the average impairment in earning capacity resulting from such disease or injury and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155 ; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if 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. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.3 (2012); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. III. Factual Background and Analysis In accordance with 38 C.F.R. §§ 4.1, 4.2 (2012) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected disabilities at issue in this appeal. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations which would warrant an exposition of remote clinical histories and findings pertaining to the disabilities. A. Discoid Lupus The criteria for rating skin disabilities, including scars, were revised effective on October 23, 2008. The revised criteria pertain to claims received on or after October 23, 2008 and in cases in which the claimant requests that the new criteria be considered. See 73 Fed. Reg. 54,710 -12 (Sept. 23, 2008); 38 C.F.R. § 4.118 (2012). In this case it appears that the originating agency has considered the new criteria. Therefore, the Board will also consider both sets of criteria. Discoid lupus erythematosus is rated as disfigurement of the head, face, or neck (DC 7800), scars (DC's 7803, 7804, or 7805) or dermatitis ( DC 7806), depending upon the predominant disability. 38 C.F.R. § 4.118, DC 7809 (2012). Prior to the October 2008 amendments, Diagnostic Code 7800 for the evaluation of disfigurement of the head, face or neck provided that a 10 percent disability rating is assigned when there is one characteristic of disfigurement. 38 C.F.R. § 4.118, Diagnostic Code 7800 (2008). Under Note (1), the eight characteristics of disfigurement are: a scar 5 or more inches (13 or more cm.) in length; a scar at least 1/4 inch (0.6 cm.) wide at widest part; surface contour of scar elevated or depressed on palpation; a scar adherent to underlying tissue; skin hypo- or hyper-pigmented in an area exceeding 6 square inches (39-sq. cm.); skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding 6 square inches (39 sq. cm.); underlying soft tissue missing in an area exceeding 6 square inches (39-sq. cm.); and skin indurated and inflexible in an area exceeding 6 square inches (39- sq. cm.). Id. Pursuant to Note (2), tissue loss of the auricle is to be rated under Diagnostic Code 6207 (loss of auricle) and anatomical loss of the eye is to be rated under Diagnostic Code 6063 as appropriate. Pursuant to Note (3), the adjudicator is to take into consideration unretouched color photographs when evaluating under these criteria. Id. Subsequent to the October 2008 change in the regulation, the diagnostic criteria remained essentially the same under Diagnostic Code 7800. However, the description was amended to clarify that ratings applied to burn scar(s) of the head, face, or neck; scar(s) of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck. 38 C.F.R. § 4.118 , Diagnostic Code 7800 (2012). The eight characteristics of disfigurement remained the same. However, additional explanatory notations were added which state that disabling effects other than disfigurement that are associated with individual scar(s) of the head, face, or neck, such as pain, instability, and residuals of associated muscle or nerve injury should be separately evaluated under the appropriate diagnostic codes. Also, the characteristic(s) of disfigurement may be caused by one scar or multiple scars; the characteristic(s) required to assign a particular evaluation need not be caused by a single scar in order to assign that evaluation. 38 C.F.R. § 4.118, Diagnostic Code 7800, Notes 4 and 5 (2012). Dermatitis or eczema warrants a 60 percent evaluation if it covers more than 40 percent of the entire body, more than 40 percent of exposed areas are affected, or if constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs have been required during the past 12-month period. Dermatitis or eczema covering 20 to 40 percent of the entire body, affecting 20 to 40 percent of exposed areas, or requiring systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of six weeks or more, but not constantly, during the past 12-month period warrants a 30 percent evaluation. Dermatitis or eczema covering at least 5 percent, but less than 20 percent, of the entire body; affecting at least 5 percent, but less than 20 percent, of exposed areas; or requiring intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than six weeks during the past 12-month period warrants a 10 percent evaluation. Dermatitis or eczema covering less than 5 percent of the entire body, affecting less than 5 percent of exposed areas; and requiring no more than topical therapy during the past 12- month period warrants a noncompensable evaluation. 38 C.F.R. § 4.118, Diagnostic Code 7806. The report of a VA examination in July 2009 with an addendum in August 2009, the report of a VA examination in November 2011, and unretouched color photographs of the scars provide reasonably consistent information about the disability, but the most recent examination report appears to provide more careful measurements. Accordingly, only the most recent examination's measurements are here recounted. By that examiner's report, the scars are four in number, as follows: 1. A scar on the right side of the face, above the right ear down to the mandibular notch, 13 centimeters (cm) long and from 3 cm wide down to 2 cm wide. 2. A scar on the left side of the face above the left ear to the cheek, 7 cm long and from 3 cm wide town to 2 cm wide. 3. A scar on the left cheek 4 cm long and 3/4 cm wide. 4. A scar on the top of the head, 8 cm long and 7 cm wide, in the hairline. The examiner noted that the scars were healed, not raised, without infection, pink in color, non-moveable, nontender, and without active flare-up. The scars are also not found or alleged to be tender or unstable or painful or to affect functioning of underlying parts, and hence ratings on those bases are not warranted. 38 C.F.R. § 4.118, Diagnostic Codes 7803 (2008), 7804, 7805 (2008, 2012). The scars from the Veteran's discoid lupus have five characteristics of disfigurement: scar at least 0.6 cm wide at widest part, scar 13 or more cm in length, skin hypo or hyper pigmented in an area exceeding 39 square cm, surface contour elevated or depressed (remarked as erythema by the July 2009 examiner, and clearly visible on photographs), and texture abnormal in area exceeding 39 square cm (again, clearly visible on photographs). Thus, the Veteran is entitled to a higher evaluation of 50 percent for his discoid lupus throughout the period of the claim. However, the evidence does not show more than 5 characteristics of disfigurement, as required for a rating in excess of 50 percent. Characteristics not present include the following: scar adherent to underlying tissue, underlying soft tissue missing in area exceeding 39 square cm, skin indurated and inflexible in area exceeding 39 square cm. Accordingly, a rating in excess of 50 percent is not warranted under the schedular criteria for rating disfigurement. While the Veteran's authorized representative at the hearing raised the question of whether the Veteran had been administered systemic corticosteroids, the November 2011 VA examiner indicated only the use of topical corticosteroids. Moreover, the Veteran has also not asserted that he has received systemic corticosteroid treatment for his discoid lupus. Therefore, the disability does not warrant a higher rating based on such treatment. The Board has considered whether there is any other schedular basis for granting this claim but has found none. The Board has also considered the doctrine of reasonable doubt but has determined that it is not applicable to this claim because the preponderance of the evidence is against the claim. B. Bilateral Knee Arthritis Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic code(s) for the specific joint(s) involved. 38 C.F.R. § 4.71a , Diagnostic Code 5003. Normal range of motion of the knee is to 0 degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71a , Plate II. Flexion of the leg limited to 60 degrees warrants a noncompensable rating, flexion limited to 45 degrees warrants a 10 percent rating, flexion limited to 30 degrees warrants a 20 percent rating, and flexion limited to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a , Diagnostic Code 5260. Extension limited to 5 degrees warrants a noncompensable rating, extension limited to 10 degrees warrants a 10 percent rating, extension limited to 15 degrees warrants a 20 percent rating, extension limited to 20 degrees warrants a 30 percent rating, extension limited to 30 degrees warrants a 40 percent rating, and extension limited to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a , Diagnostic Code 5261. In determining the degree of limitation of motion, the provisions of 38 C.F.R. § 4.40 concerning lack of normal endurance, functional loss due to pain, and pain on use and during flare-ups; the provisions of 38 C.F.R. § 4.45 concerning weakened movement, excess fatigability, and incoordination; and the provisions of 38 C.F.R. § 4.10 concerning the effects of the disability on the veteran's ordinary activity are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Knee impairment with recurrent subluxation or lateral instability warrants a 10 percent evaluation if it is slight, a 20 percent evaluation if it is moderate or a 30 percent evaluation if it is severe. 38 C.F.R. § 4.71a , Diagnostic Code 5257. Dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint warrants a 20 percent rating. 38 C.F.R. § 4.71a , Diagnostic Code 5258. Removal of semilunar cartilage warrants a 10 percent evaluation if it is symptomatic. 38 C.F.R. § 4.71a , Diagnostic Code 5259. The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14 (2012). 38 C.F.R. § 4.14 does not preclude the assignment of separate evaluations for separate and distinct symptomatology where none of the symptomatology justifying an evaluation under one diagnostic code is duplicative of or overlapping with the symptomatology justifying an evaluation under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). VA's General Counsel has held that a claimant who has arthritis and instability of a knee may be rated separately under Diagnostic Codes 5003 and 5257, while cautioning that any such separate rating must be based on additional disabling symptomatology. VAOPGCPREC 23-97 (July 1997); VAOPGCPREC 9-98, (August, 1998). Moreover, the General Counsel has also held that separate ratings may be assigned for disability of the same joint under Diagnostic Codes 5260 (for limitation of flexion) and 5261 (for limitation of extension). VAOGCPREC 9-2004 (September, 2004). The Veteran contends, in effect, that his knees are more disabled than is reflected by the 10 percent disability rating presently assigned for each knee. At the hearing the Veteran asserted that he had "[c]ontinual and constant pain and swelling of both knees." (hearing transcript, p. 8) He also reported that the right knee had been drained twice and that his knees had "gotten much worse" since they were examined in 2006. On the basis of that assertion of worsening disabilities, the Board remanded the knee claims for an additional examination. Upon the initial VA examination addressing his knees in January 2006, the Veteran reported a six-year history of pain and stiffness in both knees. He asserted that the pain and stiffness are constant and aggravated by cold weather and prolonged standing. He further contended that he had periodic swelling of both knees, and occasional locking of the left knee, though he denied a history of the knees buckling. A history of rheumatology evaluation was noted with a previously assigned diagnosis of idiopathic polyarthralgia, not limited to the knees. The Veteran was noted to be currently employed as a mechanic. The January 2006 examination disclosed no crepitus, deformity, erythema, effusion, instability, or tenderness of either knee. Range of motion was from zero degree of extension to 130 degrees of flexion on the right and from zero degrees of extension to 135 degrees of flexion on the left. The examiner tested the knees following repeated movement, and found no pain with any range of motion, and no additional range of motion loss due to pain, weakness, fatigue, incoordination, or lack of endurance. The Veteran denied flare-ups or incapacitation of the knees. February 2006 X-rays of the knees revealed "small osteophyte of the superior patella bilaterally," but with joint spaces "well maintained" and "no significant joint effusion." The examiner assessed minimal degenerative changes of the patella bilaterally with osteophytes. In a November 2006 notice of disagreement, the Veteran asserted that his knee difficulties were "multiplying" and that they included frequent fluid around the knees with activity, and the left knee having locked twice. An April 2007 VA treatment record notes that there was no swelling, tenderness, or erythema of the knees. In a June 2007 VA Form 9 the Veteran reported seeing his private physician for his knees and having swelling in the right knee, which was drained twice in three weeks. He added that an MRI of the right knee showed 50 percent of the cartilage absent. A June 2008 private orthopedic examination report reflects that the Veteran injured his left knee in the course of work as a mechanic in May 2008. The examiner noted that an MRI showed a medial meniscus tear. Physical examination revealed consistent tenderness along the medial joint line, and range of motion of the knee was from 5 to 115 degrees. McMurray's test was positive. X-rays showed mild to moderate osteoarthritis. The examiner noted that while the Veteran had pre-existing arthritis, "he was doing fine prior to the injury." The examiner opined that both the arthritis and the meniscal tear were contributing to his current difficulty. She treated the Veteran with a cortisone injection. Follow up private evaluation in July 2008 revealed the Veteran's left knee to be improved, with no swelling, no warmth or redness, and good range of motion. Upon VA examination for compensation purposes in July 2009, the Veteran reported having pain in both knees, but denied any locking up of the joints, reporting that he had 5/10 pain intensity in each knee, but with the pain increasing to 9/10 in each knee if he sat for too long. The Veteran also reported a left knee lateral meniscal tear from a twisting injury at work in February 2009 and that the tear had been repaired by arthroscopic surgery in February 2009. He complained of difficulties with prolonged sitting or standing, as well as climbing stairs, due to pain in his knees. The February 2009 examiner noted mild tenderness in the left knee and no tenderness in the right knee. Range of motion was from zero to 130 degrees on the right and zero to 120 degrees on the left, with pain in the left knee at 120 degrees, but no pain in the right knee with motion. The examiner found no additional loss of range of motion due to pain, fatigue, weakness, or lack of endurance with repetitive use. The examiner diagnosed osteoarthritic changes in the knees, but noted that the left knee injury in February 2009 was unrelated. In a September 2009 addendum to the February 2009 examination report, the examiner assessed osteophyte formation in each knee. The examiner also noted that it was not possible, absent speculation, for him to differentiate symptoms in the left knee from service-connected disability from that resulting from his post-service work injury with lateral meniscal tear. At a November 2011 VA joints examination, the Veteran complained of chronic pain in both knees, and reported having changed his occupation from mechanic to environmental technician. The Veteran denied flare-ups of his knee symptoms. The examination disclosed that active range of motion of the right knee was to 120 degrees flexion and zero degrees extension, and the same with repetitive use. Pain in the right knee was objectively present at 80 degrees flexion. The left knee demonstrated range of motion to 120 degrees flexion and zero degrees extension, and the same with repetitive use. Pain was present objectively in the left knee at 75 degrees. The November 2011 examiner did not find additional functional loss with repetitive use testing for either knee, including no loss of normal excursion, strength, speed, coordination, or endurance. The examiner also found full strength in both flexion and extension in each knee, and no instability or subluxation or dislocation in either knee. The examiner noted that the Veteran had frequent episodes of joint pain and frequent episodes of effusion, both in the left knee, associated with his post-service injury status post left knee surgery. The examiner noted that the Veteran had pain in both knees, and assessed that functional impairments associated with his bilateral knee arthritis consisted of difficulty with the following activities: climbing in and out of trucks, jumping, stooping, kneeling, and prolonged standing. The examiner further suggested that this was implicated in the Veteran's career change from mechanic to environmental technician. Recent VA treatment records reflect difficulty with obesity, including upon maintenance evaluation in March 2012, when gait impairment was noted to be associated with unsteadiness or difficulty rising to stand. The records do not attribute gait impairment to the Veteran's knee disabilities. Based on the evidence presented, the Board finds that both disabilities are manifested by limitation of motion, but even with consideration of all of the pertinent disability factors, no examination has disclosed that flexion of either knee is limited to less than 45 degrees or that extension of either knee is limited to more than 5 degrees. Therefore, neither knee disability warrants more than a 10 percent rating for limitation of motion. The objective medical evidence consistently shows that neither disability is manifested by lateral instability or recurrent subluxation. Therefore, a separate compensable rating is not warranted under Diagnostic Code 5257. While the most recent VA examiner determined that the Veteran does have frequent episodes of pain and effusion in the left knee, the examiner attributed these symptoms to the post- service injury. There is no medical evidence attributing these symptoms to the service-connected left knee disability. Therefore, a higher rating under Diagnostic Code 5258 is not warranted. The Board has considered whether there is any other schedular rating for granting a higher or separate rating for either knee disability but has found none. In reaching this decision, the Board has considered the Veteran's statements. However, his statements do not show that he has sufficient impairment to warrant a higher or separate rating for either knee. In this regard, the Board has determined that to the extent the Veteran's statements conflict with the medical evidence, the objective medical evidence prepared by skilled examiners is more probative. The Board has also considered the doctrine of reasonable doubt but has determined that it is not applicable to these claims because the preponderance of the evidence is against the claims. C. Other Considerations Consideration has been given to assigning a staged rating; however, at no time during the period in question have the disabilities warranted more than the assigned ratings, to include the increased rating granted herein. See Fenderson v. West, 12 Vet. App. 119 (1999). The Board has considered whether this case should be referred to the Director of the Compensation and Pension Service for extra-schedular consideration. In determining whether a case should be referred for extra-schedular consideration, the Board must compare the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extra-schedular consideration is required. Thun v. Peake, 22 Vet. App. 111, 115 (2008). As explained above, the evidence shows that the manifestations of the disabilities at issue are contemplated by the schedular criteria. Therefore, referral for extra-schedular consideration is not in order. (CONTINUED ON NEXT PAGE) ORDER A 50 percent disability rating, but no more, is granted for discoid lupus for the entire initial rating, subject to the criteria governing the payment of monetary awards. An initial rating in excess of 10 percent for right knee arthritis is denied. An initial rating in excess of 10 percent for left knee arthritis is denied. ____________________________________________ Shane A. Durkin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs