Citation Nr: 21070251 Decision Date: 11/23/21 Archive Date: 11/23/21 DOCKET NO. 18-50 802 DATE: November 23, 2021 ORDER Entitlement to a rating in excess of 60 percent for psoriasis is denied. Entitlement to a rating in excess of 10 percent prior to March 31, 2021, and in excess of 20 percent thereafter, for a left knee disability manifested by limitation of motion in flexion, is denied. FINDINGS OF FACT 1. The Veteran has been assigned the maximum schedular rating available for psoriasis throughout the period on appeal. 2. Prior to March 31, 2021, the Veteran's left knee disability was not manifested by flexion limited to 30 degrees; since March 31, 2021, the Veteran's left knee disability has not manifested by flexion limited to 15 degrees. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating in excess of 60 percent for psoriasis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, Diagnostic Code 7816. 2. The criteria for entitlement to a rating in excess of 10 percent for left knee disability prior to March 31, 2021 and in excess of 20 percent thereafter have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003-5260. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1992 to April 1996. These matters are before the Board of Veterans' Appeals (the Board) on appeal from a rating decision issued in August 2017 by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ) in March 2020. A transcript of the hearing is of record. The Board remanded these matters in March 2020 for further development. As the actions specified in the remand have been substantially complied with, the case is again properly before the Board. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268, 271 (1998). While in remand status, the RO issued an April 2021 rating decision granting the Veteran an increased rating of 20 percent for his left knee disability, effective March 31, 2021. As the Veteran continues to appeal for a higher rating, the issue has been recharacterized accordingly to reflect the staged ratings. AB v. Brown, 6 Vet. App. 35 (1993) (a claimant is presumed to be seeking the maximum rating allowed by law). Duties to Notify and Assist Pursuant to the Veterans Claims Assistance Act (VCAA), VA has duties to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A; 38 C.F.R. § 3.159. Neither the Veteran nor the record have raised any issues regarding VA's duties to notify or assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). As such, the Board will proceed with appellate consideration of the issues on appeal. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 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 for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. The veteran's entire history is to be considered when making disability evaluations. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Fenderson v. West, 12 Vet. App. 119, 126 (1999); Francisco v. Brown, 7 Vet. App. 55, 58 (1994). 1. Entitlement to a rating in excess of 60 percent for psoriasis, is denied. The Veteran contends that the severity of his service-connected psoriasis is not adequately contemplated by his currently-assigned 60 percent rating. The Board notes that the criteria for rating skin disabilities have changed once during the period covered by this appeal, effective August 13, 2018. See 83 Fed. Reg. 32592 (July 13, 2018). When a law or regulation changes during the pendency of a Veteran's appeal, the version most favorable to the Veteran applies, absent congressional intent to the contrary. The amended rating criteria, if favorable to the claim, can be applied only for periods from the effective date of the regulatory change; however, the old regulations will be considered for the periods both before and after the change was made. See 38 U.S.C. § 5110 (g); 38 C.F.R. § 3.114; VAOPGCPREC 3-2000, 65 Fed. Reg. 33422 (2000); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Thus, the Veteran is entitled to application of the criteria that are most favorable to his claim, except that an award based on the amended regulations may not be made effective before the effective date of the change. Prior to August 13, 2018, under Diagnostic Code 7816 for psoriasis, a 10 percent rating is assigned for at least 5 percent, but less than 20 percent, of the entire body, or; at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is assigned for 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly during the past 12-month period. A 60 percent rating is assigned for more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. Effective August 13, 2018, skin disabilities rated under Diagnostic Code 7806 were evaluated under the General Rating Formula for the Skin. A 10 percent disability rating is warranted if there is one of the following: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. A 30 percent disability rating is warranted if there is one of the following: characteristic lesions involving 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent disability rating is warranted if there is at least one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required over the past 12-month period. The revised General Rating Formula for the Skin also provides that skin disabilities may be rated as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7804, 7805), depending upon the predominant disability. 38 C.F.R. § 4.118. However, the clinical evidence does not show that the Veteran's psoriasis caused scarring or disfigurement of the head, face, or neck. Consequently, Diagnostic Codes 7800, 7801, 7802, 7804, and 7805 do not apply. The Veteran was afforded VA exams in June 2017 and April 2021. Both of the Veteran's examiners agreed that the Veteran had a diagnosis of psoriasis. The June 2017 examiner noted that the Veteran's psoriasis involved more than 40 percent of his total body area and more than 40 percent of his exposed body area. The Veteran had not received any treatment in the prior 12 months, and had no debilitating episodes. The Veteran reported that he stopped taking his medications 6 years ago and was not following by providers due to financial hardship. The Veteran used coconut oil or olive oil to soothe psoriatic lesions on his scalp, elbows, hands, groin area, buttocks and knees. He endorsed burning sensation, pruritus, and pain that is not alleviated with the home remedies he has tried. In a September 2018 statement, the Veteran reported that he has used "every steroid cream" over a 10-year period to his detriment. The most pronounced damage is to his scrotal area, as his skin has thinned to a degree that it cracks and bleeds with average movements. The Veteran also stated his unconfirmed suspicion that, due to his condition, he is unable to procreate. See August 2018 Notice of Disagreement. A January 2020 VA treatment notes the provider's assessment of chronic plaque psoriasis with scarring of the neck, scalp, and elbows. See January 29, 2020 VA Treatment Note. At his March 2021 Board hearing, the Veteran testified as to the severity of his psoriasis. The Veteran's psoriasis covers the entire backside of his scalp, inside both ears, both elbows, both hands, and his groin area. The Veteran experiences skin cracking and bleeding. The Veteran experiences 24/7 fissuring, which has resulted in low grade ear infections for 20 years, and some hearing loss. The Veteran seeks annual treatment. Over the years the Veteran has tried "about everything you could be prescribed," including steroidal creams. Any type of average movements, even walking can result in the Veteran's skin bleeding, with it being particularly worse in the groin region. The Veteran described his condition as a constant "nightmare," and stated that it has impacted his ability to function in a workplace in that he struggles to focus as a result of his condition. Moreover, the Veteran reported that more than day of too much sitting or manual labor will result in missing work due to broken fissures and his trying to cope with the damage. In efforts to minimize the effects of his condition, the Veteran has started doing alternative therapies such as intermittent fasting, eating a "severely restricted diet," and applying animal fats and lipids to his skin as opposed to prescription medications which were more damaging to his skin. See March 2020 Board Hearing Transcript. The Veteran was afforded another VA examination in March 2021. The Veteran reported that his psoriasis has worsened. The Veteran reported symptoms of erythemic, flaky, scaly, rash to just below each nostril, the edge of his posterior scalp, inside both ear canals, both elbows, groin, scrotum, penis, and perineum. The Veteran also reported somewhat healed areas of his knees. The Veteran had not been treated in the 12 months prior for any skin condition. The Veteran had no scarring, and the examiner noted no functional impact. The examiner noted that the Veteran's psoriasis impacted between 5 to 20 percent of his total body area, and less than 5 percent of the exposed area. In an August 2021 statement, the Veteran reported that his life has been irrevocably altered physically, socially, and psychologically, due to his psoriasis. After decades of prescription creams, ointments, and pills, the Veteran's body has "completely rejected pharmaceuticals." The Veteran reported that his body is forever altered by the thinning of his epidermis which has led to fissuring and daily bleeding for the last 28 years. He reported that since discharged from service he has lived at or below the poverty level, been fired from almost every job he has held, and that his psoriasis has "cost him everything." See August 2, 2021 Lay Statement. As indicated above, a schedular rating higher than 60 percent is not available under the former or amended rating criteria for psoriasis. 38 C.F.R. § 4.118 (2017); 38 C.F.R. § 4.118 (2020); 83 Fed. Reg. 32664 (July 13, 2018). The Board finds that all symptoms, discussed above, are contemplated by the assigned 60 percent rating. Therefore, to the extent that the Veteran seeks a schedular rating higher than 60 percent for psoriasis, such rating is not warranted. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Finally, as noted above at his Board hearing the Veteran reported interference with his employment, in that his psoriasis caused him to miss work due to either sitting too long or moving or lifting too much, and impaired his ability to focus on work. The presence of marked interference with employment and frequent periods of hospitalization is one of the considerations when determining whether referral for extraschedular consideration is warranted. Thun v. Peake, 22 Vet. App. 111, 116 (2008). "Marked" is defined, in pertinent part, as having a distinctive or emphasized character. MERRIAM-WEBSTER'S COLLEGIATE DICTIONARY 760 (11 ed. 2003). "Distinct," in turn, is defined as presenting a clear unmistakable impression or is readily and unmistakably apprehended. Id. at 364. In this case, neither VA examiner indicated that the Veteran's psoriasis impacts his ability to work. Moreover, the only medical evidence of record reveals a work restriction by the Veteran's VA provider due to the Veteran's left inguinal hernia. See June 2019 VA Treatment Note. As the evidence does not reflect that the Veteran's disability results in marked interference with employment or frequent hospitalizations, referral for extraschedular consideration is not warranted in this case. Thun, 22 Vet. App. at 116; Chudy v. O'Rourke, 30 Vet. App. 34 (2018). 2. Entitlement to a rating in excess of 10 percent for left knee disability prior to March 31, 2021 and in excess of 20 percent thereafter, is denied. The Veteran generally contends that he is entitled to an increased rating for his service-connected left knee disability, diagnosed as patellofemoral pain syndrome and arthritis, because his symptoms are more severe than contemplated by his currently-assigned ratings. Prior to March 31, 2021, the Veteran is in receipt of a 10 percent rating for his left knee disability under Diagnostic Codes 5003-5260, based on functional loss due to painful motion, pursuant to 38 C.F.R. § 4.59. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional code to identify the basis for the rating assigned. See 38 C.F.R. § 4.27. From March 31, 2021, the Veteran is in receipt of a 20 percent rating based on limitation of flexion, with additional symptoms of painful motion and x-ray evidence of degenerative arthritis. VA amended the criteria for rating knee disabilities effective February 7, 2021. These new regulations apply to all applications for benefits received by VA or that are pending before the agency of original jurisdiction on or after February 7, 2021. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. The Board may not apply a current regulation prior to its effective date, unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. With respect to disabilities of the knee, Diagnostic Codes 5256 through 5263 set forth the relevant provisions regarding evaluating knee disabilities. However, in this case, the evidence does not demonstrate ankylosis of the knee (Diagnostic Code 5256), symptomatic removal of semilunar cartilage (Diagnostic Code 5259), or impairment of the tibia and fibula (Diagnostic Code 5262); thus, the Diagnostic Codes pertaining to such impairments are not applicable. Diagnostic Codes 5260 and 5261 were not changed by the February 7, 2021 amendments. Diagnostic Codes 5260 and 5261 provide for ratings of 0, 10, 20, or 30 percent where there is limitation of flexion of the leg to 60, 45, 30, or 15 degrees, respectively, and for ratings of 0, 10, 20, 30, 40, or 50 percent for limitation of extension of the leg to 5, 10, 15, 20, 30, or 45 degrees, respectively. Normal range of motion of the knee is to zero degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71, Plate II. In VAOPGCPREC 9-2004, the Office of General Counsel (OGC) held that separate evaluations under 38 C.F.R. § 4.71a, Diagnostic Code 5260, (limitation of knee flexion) and 38 C.F.R. § 4.71a , Diagnostic Code 5261, (limitation of knee extension) can be assigned without pyramiding. Despite the fact that knee flexion and extension both occur in the same plane of motion, limitation of flexion (bending the knee) and limitation of extension (straightening the knee) represent distinct disabilities. Prior to February 7, 2021, Diagnostic Code 5257 addresses recurrent subluxation or lateral instability of the knee. A 10 percent rating is warranted for slight recurrent subluxation or lateral instability. A 20 percent rating is warranted for moderate recurrent subluxation or lateral instability. A 30 percent rating is warranted for severe recurrent subluxation or lateral instability. 38C.F.R. §4.71a, Diagnostic Code 5257. Effective February 7, 2021, Diagnostic Code 5257, recurrent subluxation or instability, allows a 10 percent rating for sprain, incomplete ligament tear, or complete ligament tear causing persistent instability, without a prescription from a medical provider for an assistive device or bracing for ambulation. A 20 percent rating is warranted for either [1] sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device for ambulation or [2] unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device or bracing for ambulation. A 30 percent rating is warranted for an unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device and bracing for ambulation. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76453 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5257). Additionally, effective February 7, 2021, VA added patellar instability to Diagnostic Code 5257. For patellar instability, a 10 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. A 20 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane, or walker. A 30 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. Id. Note 1 to Diagnostic Code 5257 provides that for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Id. Under Diagnostic Code 5003, degenerative arthritis established by x-ray findings is to be rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint involved. 38 C.F.R. § 4.71a. As the Veteran's right knee disability manifests by painful motion, the disability will be rated based on the diagnostic codes concerning limitation of motion of the knee. The Board's analysis will begin with Diagnostic Code 5260, which contemplates the criteria for limitation of flexion of the knee, but all potentially applicable rating criteria will also be considered. For reference, normal range of knee motion is 140 degrees of flexion and zero degrees of extension. 38 C.F.R. § 4.71a, Plate II. In considering range of motion ratings, it is important to consider whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See also DeLuca v. Brown, 8 Vet. App. 202 (1995). A minimum compensable evaluation for a joint disability is warranted for painful motion under 38 C.F.R. § 4.59. However, a rating in excess of the minimum compensable rating must be based on demonstrated functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). Turning to the relevant evidence of record, the Veteran underwent a VA examination in June 2017. The Veteran reported flare-ups and functional loss. He reported that his last arthroscopic surgery was in 1998 and endorsed current symptoms of pain and grinding. The Veteran had discontinued all of his medications and doctor's visits and referred to coping with his pain as best he could. There was objective evidence of diffuse left knee pain. Initial range of motion testing of the right knee showed that the Veteran had flexion from 0 to 120 degrees, and extension 120 to 0 degrees. The examiner noted pain on flexion tested which resulted in functional loss. Repetitive testing was conducted and did not result in any additional ROM loss. There was no pain on weightbearing or non-weightbearing testing. Muscle strength testing was normal. The Veteran did not have ankylosis. Stability testing of the left knee was normal. There was no history of recurrent patellar subluxation or stress fractures, but a meniscus condition was noted, with the examiner noting the Veteran's frequent episodes of left-side joint pain. The Veteran did not use an assistive device. A March 2021 MRI of the Veteran's left knee revealed a remote ACL reconstruction with absent ALC indicating re-rupture and small anterior tibial translation with posterior bowing of the PCL. Large partial full-thickness cartilage loss of the medial tibial plateau with severe degenerative maceration of the medial meniscal body extending to the posterior horn. Small meniscal degeneration of the lateral meniscus free edge. Small knee effusion with large area of partial-thickness cartilage loss of the central femoral trochlea with up to 50 percent thickness. See March 11, 2021 VA MRI. A March 2021 VA treatment note documents the Veteran's knee as "very bad." The provider notes that the Veteran's ACL ligament has disintegrated and that he has "lots of arthritis." The Veteran was agreeable to an orthopedic referral and reported his belief that his knee was "pretty bad." He reported doing a certain type of squat last summer and that when he did, he "felt something let go and fill up with fluid." See March 16, 2021 VA Nursing Note. Pursuant to the March 2020 Board remand, the Veteran underwent an additional VA examination in March 2021. The Veteran reported flare-ups that "never really stop," several times per day. Normally knee pain in his left knee goes from 8 to 10/10 constantly but is even worse during flares. A week prior to the exam the Veteran began experiencing a burning in the back of his left knee up into his hamstring. Flares are precipitated by weather changes and alleviated by the Veteran "getting of [his] feet." The Veteran reported functional impairment of, staying in and not doing much activity. He cannot climb stairs, stand, or walk for prolonged periods. Descending stairs is worse than climbing up, and he cannot sit for prolonged periods. Initial active range of motion (ROM) testing of the left knee showed that the Veteran had flexion from 0 to 40 degrees, and full extension. ROM testing on all planes exhibited pain. Passive ROM testing was the same as active testing. The examiner noted objective evidence of localized tenderness or pain on palpation in the medial patella area of moderate severity. Repetitive testing was conducted and pain resulted in ROM loss with the Veteran's flexion recorded as 0 to 34 degrees, with full extension. Based on a review of all procurable information, the examiner estimated the Veteran's ROM for the left knee immediately after repetitive use and during flare-ups, as flexion from 0 to 30 degrees, with full extension. No instability was found. There was no history of recurrent patellar subluxation, stress fractures, or shin splints. The Veteran did not use an assistive device. The examiner found that the Veteran's condition impacted his ability to perform occupational tasks with regard to the fact that he cannot climb stairs, going down is worse than going up. He cannot sit for prolonged periods or do weight bearing activities like standing or walking for prolonged periods. He is in a constant state of severe left knee pain. In an August 2021 statement, the Veteran reported that his left knee is nearly useless and only serves "in a diminished capacity and as a source of additional pain." See August 2, 2021 Lay Statement. After a careful review of the medical and lay evidence of record, the Board finds that the preponderance of the evidence is against assigning increased ratings for the Veteran's left knee disability at any time during the period on appeal. Regarding the Veteran's left knee disability manifested by limitation of motion in flexion, the Veteran is currently in receipt of a 10 percent rating prior to March 31, 2021, and a 20 percent rating thereafter. Prior to March 31, 2021, the medical evidence of record shows that the Veteran's limitation of motion in flexion was no worse than 120 degrees in the left knee. Under Diagnostic Code 5260, a 20 percent rating is warranted for flexion limited to 30 degrees. At no time during the relevant period has the Veteran been shown to have flexion limited to 30 degrees. As such, a rating higher than 10 percent is not warranted under Diagnostic Code 5260 for the period prior to March 31, 2021. From March 31, 2021, the medical evidence of record shows that the Veteran's limitation of motion in flexion was no worse than 30 degrees in the left knee. Under Diagnostic Code 5260, a 30 percent rating is warranted for flexion limited to 15 degrees. At no time during the relevant period has the Veteran been shown to have flexion limited to 15 degrees, even considering flare-ups. As such, a rating higher than 20 percent is not warranted under Diagnostic Code 5260 for the period from March 31, 2021. In reaching the above conclusions, the Board is cognizant that the Veteran has consistently reported experiencing left knee pain, increased during periods of flare-up or after repetitive use. The Board has considered these reports, as well as any additional limitations of motion due to pain (including difficulty walking, standing, sitting, squatting, kneeling, and ascending and descending stairs). However, even considering additional limitation of motion or function of the knee due to pain or other symptoms such as weakness, fatigability, weakness, or incoordination (see 38 C.F.R. §§ 4.40, 4.45, DeLuca), the evidence still does not show that the left knee disability more nearly approximates the criteria for a higher rating under Diagnostic Code 5260 for limitation of motion in flexion. Moreover, neither of the VA examiners found evidence or history of recurrent subluxation or lateral instability in the knees at either of the Veteran's examinations. There was likewise no evidence of instability, malalignment, or weakness in the Veteran's left knee. Finally, the Veteran's VA treatment records do not contain any findings of left knee instability or laxity. Therefore, the Board finds that a separate rating under Diagnostic Code 5257 for other impairment of the knee is not warranted. Finally, the Board has also considered whether the Veteran is eligible for a separate rating under other potentially applicable diagnostic code. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In this regard, the Board notes that as there is no evidence during the appeal of ankylosis, dislocated semilunar cartilage, tibia and fibula impairment, or genu recurvatum, a higher or separate rating is not warranted under Diagnostic Codes 5256, 5258, 5262 or 5263. In reaching the above conclusions, the Board acknowledges that the Veteran sincerely believes his left knee disability and its associated symptoms to be more severe than contemplated by his currently-assigned disability ratings. The Board notes that the Veteran is competent to report on factual matters of which he has first-hand knowledge, such as experiencing an increased level of pain. Washington v. Nicholson, 19 Vet. App. 362, 368 (2005); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). However, he is not competent to report that his left knee disability is of sufficient severity to warrant higher ratings under the rating schedule, as such an opinion requires specialized medical expertise which falls outside the realm of the common knowledge of a layperson. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Board must rely on the medical evidence of record to assign the appropriate disability ratings in this case and, therefore, accords the objective medical findings greater weight than the Veteran's subjective complaints of increased symptomatology. In summary, to the extent any higher level of compensation is sought, the Board finds that the weight of the evidence is against the Veteran's claim. As such, the Veteran is not entitled to a rating in excess of 10 percent prior to March 31, 202, and in excess of 20 percent thereafter, for a left knee disability manifested by limitation of motion in flexion. As the evidence preponderates against the claim, the benefit-of-the-doubt rule is not for application and the Veteran's appeal must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 49. LESLEY A. REIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Gates The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.