Citation Nr: 21012334 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 15-23 405 DATE: March 4, 2021 ORDER Entitlement to service connection for obstructive sleep apnea (OSA) is denied. Entitlement to an initial 60 percent rating for psoriasis is granted, subject to the regulations governing payment of monetary awards. Entitlement to an initial 20 percent rating for psoriatic arthritis is granted, subject to the regulations governing payment of monetary awards. Entitlement to a total rating for compensation purposes based on unemployability due to service-connected disabilities (TDIU) is denied. FINDINGS OF FACT 1. OSA was not manifested during service and it is less likely than not related to the Veteran’s military service. 2. Throughout the appeal, the Veteran’s psoriasis was treated with near-constant immunosuppressive medication. 3. Throughout the appeal, the Veteran’s psoriatic arthritis was manifested by at least two to three exacerbations a year; at no time was the disability manifested by a combination of symptoms that produced definite impairment of health objectively supported by examination findings or three or more incapacitating exacerbations a year. 4. The Veteran’s service-connected disabilities meet the schedular requirements for at TDIU, but they do not preclude him from securing or following substantial gainful employment. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for OSA have not been met. 38 U.S.C. §§ 1110, 1117, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for entitlement to an initial 60 percent rating, but no higher, for psoriasis have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.118, Diagnostic Code 7816 (prior to and after August 2018). 3. The criteria for entitlement to an initial 20 percent rating, but no higher, for psoriatic arthritis have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5002, 5003. 4. The criteria for entitlement to a TDIU have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 2001 to July 2004. This appeal to the Board of Veterans’ Appeals (Board) is from March 2014 and May 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). In October 2018, the Veteran testified before the undersigned Veterans Law Judge during a video conference hearing. In November 2018, the case was remanded. Service Connection Generally, to establish service connection a veteran must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.” Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 C.F.R. § 3.102. When all of the evidence is assembled, 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 fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 1. Entitlement to service connection for OSA. The Veteran has a current diagnosis of OSA that was first diagnosed in November 2010 after he reported snoring and daytime sleepiness in July 2010. See March 2015 CAPRI records. However, there is no probative evidence that links it to service. During the October 2018 hearing, the Veteran’s representative stated that the Veteran was diagnosed with, treated, and seen in the military for the possibility of OSA. He indicated that complaints were clearly documented while on active duty. He specifically noted that there was something in an April 2004 post-deployment checklist, approximately a week after returning from a deployment in Iraq, that was related to OSA but he did not specifically state what was in the record. See October 2018 Hearing Transcript. The Board’s review of the service treatment records did not reveal the aforementioned post-deployment checklist or anything related to OSA from his period of active duty and VA examiners found no evidence of the record either. Furthermore, the Veteran’s hearing testimony states that he did not report sleep apnea and that it was not medically noted. Thus, the Board finds there is no support for the representative’s assertion that it was noted in a post-deployment checklist. Based on the record, there is no evidence showing the Veteran was diagnosed with OSA while on active duty. Service treatment records from the Veteran’s period of active duty contain no reference to OSA or sleep difficulty. Notably, a March 2004 post-deployment health assessment, the day after his deployment was completed, shows that he denied feeling tired after sleeping. See January 2014 STR – Medical. Similarly, during his subsequent service in the Reserve a February 2007 medical history report shows that he checked the box indicating he never had frequent trouble sleeping. The accompanying medical examination is also silent for complaints, findings, or a diagnosis of OSA. See August 2011 STR – Medical. As noted previously, the diagnosis was initially made in November 2010 at a VA medical facility, which was six years after he separated from service. Although an April 2013 physical profile noted the Veteran had OSA among other disorders, it was managed with the use of a CPAP and was not a factor in him being found physically unfit for continued service in the Reserve. See September 2013 Physical Evaluation Board Proceedings and December 2013 Military Personnel Records. These records were not during his active duty or a period of active duty for training. There is also no nexus evidence that links the Veteran’s OSA to his service. On August 2019 VA examination, the examiner opined that it was less likely than not incurred in or caused by service. He stated that based on the Veteran’s medical records, he found no evidence of an illness or event in the service that pertains to sleep apnea during service. He added that psoriatic arthritis has no correlation to sleep apnea from reviewing medical evidence. The Board acknowledges the Veteran reported that when he was in service other soldiers complained about his snoring. See September 2014 NOD. However, the Veteran is not competent to state that any snoring in service was a manifestation of his current OSA, as the etiology of his OSA falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Furthermore, the examiner who reviewed the file found no correlation between service and the Veteran’s OSA. The opinion is supported by a rationale and probative. Notably, no evidence to the contrary has been submitted or obtained. The Board has also considered his Persian Gulf service, which is noted on his service personnel records; however, service connection is not available on a presumptive basis under 38 C.F.R. § 3.317. OSA is a known clinical diagnosis, so it does not qualify as an undiagnosed illness; thus, the provisions pertaining to undiagnosed illnesses do not apply. See U.S.C. §1117; 38 C.F.R. § 3.317. For these reasons, the Board finds that a preponderance of the evidence is against service connection for OSA. As there is no reasonable doubt in this matter, the claim is denied. See Gilbert, supra. Increased Rating Disability ratings are based on average impairment in earning capacity resulting from a particular disability and are determined by comparing symptoms shown with criteria in VA’s Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. In determining the disability evaluation, VA has a duty to acknowledge and consider all regulations, which are potentially applicable, based upon the assertions and issues raised in the record and to explain the reasons and bases for its conclusion. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as “staged ratings,” whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two evaluations apply, 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. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 U.S.C. § 5107; 38 C.F.R. § 4.3. 2. Entitlement to an initial compensable percent rating for psoriasis. The Veteran contends his psoriasis should be assigned a 60 percent rating. During the appeal, the rating criteria related to skin disabilities have undergone a revision, effective August 13, 2018. See 38 Fed. Reg. 32,592 (July 13, 2018). Prior to August 13, 2018, the Board will consider the former version of the diagnostic codes only, but for the period beginning August 13, 2018 the Board will consider both the former and amended version of the diagnostic code and rate based on whichever is most favorable to the Veteran. Prior to August 13, 2018, a noncompensable disability rating was assigned under Diagnostic Code 7816 when there is less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy is required during the past 12-month period. A 10 percent rating was assigned when the skin disability covered 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; when intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs was required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating was warranted if the skin condition covered 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; when systemic therapy such as corticosteroids or other immunosuppressive drugs was required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent evaluation was assigned if the skin condition covered 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. 38 C.F.R. § 4.118, Diagnostic Code 7816. VA published a final rule amending its regulations on skin disabilities effective August 13, 2018. The amendment, in pertinent part, added a “General Rating Formula for the Skin” for Diagnostic Codes 7806, 7809, 7813-7816, 7820-7822, and 7824, and amended Diagnostic Codes 7801,7802,7817,7819,7825, 7826, 7827,7829. See 83 Fed. Reg. 32,592 (July 13, 2018). Under the new General Rating Formula for the Skin, pursuant to Diagnostic Codes 7806, 7809, 7813-7816, 7820-7822, and 7824, a noncompensable rating is assigned when no more than topical therapy is required over the past 12-month period and at least one of the following: characteristic lesions involving less than 5 percent of the entire body affected; or characteristic lesions involving less than 5 percent of exposed areas affected, or rate as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7804, or 7805), depending upon the predominant disability. This rating instruction does not apply to Diagnostic Code 7824. A 10 percent rating will be assigned if the disability meets 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, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. A 30 percent rating will be assigned if the disability meets one of the following: characteristic lesions involving 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas; 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 rating will be assigned if the disability meets one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas; 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. 38 C.F.R. § 4.118, Diagnostic Code 7806 (2018). Also, under the new General Rating Formula for the Skin, the rating criteria notes that for the purposes of that section, systemic therapy is treatment that is administered through any route (orally, injection, suppository, intranasally) other than the skin, and topical therapy is treatment that is administered through the skin. The Federal Circuit Court has held that within the purview of Diagnostic Code 7806 in effect prior to August 13, 2018, systemic therapy meant “treatment pertaining to or affecting the body as a whole,” whereas topical therapy meant treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it was applied, and that nothing in Diagnostic Code 7806 displaced the accepted understanding of systemic therapy and topical therapy to permit a topical therapy that affected “only the area to which it [was] applied” to count as a systemic therapy under that code. Prior to August 13, 2018, the use of a topical corticosteroids could be considered either systemic therapy or topical therapy based on the factual circumstances of each case. The use of topical corticosteroids did not automatically mean systemic therapy because Diagnostic Code 7806 distinguished between systemic and topical therapy. Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017) (The use of “such as” in Diagnostic Code 7806 does not mean that all forms of treatment with “cortico-steroids and other immunosuppressive drugs,” no matter how narrowly localized in their impact, count as “systemic therapy.”). Although this case refers to Diagnostic Code 7806, the Board notes that Diagnostic Code 7816 uses the same terminology, so it is equally applicable. The Boards finds that a 60 percent is assignable for the entire period on appeal due to the fact that the Veteran was treated with immunosuppressive drugs either every week or every two weeks. An April 2012 private treatment record shows the Veteran was prescribed weekly doses of methotrexate, which suppresses the immune system, to treat his psoriasis. This medication proved to be ineffective. See September 2013 and October 2013 Medical Treatment Record - Non-Government Facility. The Veteran was subsequently prescribed Humira, which according to the March 2014 VA examination resolved his psoriasis symptoms. See October 2013 Medical Treatment Record – Non-Government Facility and March 2014 and March 2015 CAPRI records. October 2014 and June 2015 treatment records indicate Humira has been taken by injection every two weeks and that the Veteran has declined having weekly injections. See March 2015 CAPRI records and June 2015 and April 2020 Medical Treatment Record – Government Facility. As his use of the immunosuppressant has been ongoing for years on a regular basis without breaks, the Board finds that his skin disability meets the criteria for a 60 percent rating under the former and amended criteria for Diagnostic Code 7816, which is the maximum rating regardless of which criteria are used. 3. Entitlement to an initial compensable rating for psoriatic arthritis. The Veteran contends that his psoriatic arthritis should be assigned a 60 percent rating. See September 2014 NOD. The Veteran’s disability is rated under Diagnostic Codes 7816-5009. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. Here, Diagnostic Code 7816 relates to the Veteran’s underlying psoriasis and Diagnostic Code 5009 relates to the arthritis associated with it. Diagnostic Code 5009 instructs that the disability should be rated using the criteria for rheumatoid arthritis, which is Diagnostic Code 5002. See 38 C.F.R. § 4.71a. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov 30, 2020). These amendments revised select diagnostic codes “to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities.” Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g); see also Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110; Kuzma, 341 F. 3d 1327. Therefore, the Board will consider the Veteran’s claim under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. Prior to the regulatory change, Diagnostic Code 5002 related to active disease process and provided a 20 percent rating with one or two exacerbations a year in a well-established diagnosis. A 40 percent rating was assigned for symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring three or more times a year. A 60 percent rating is assigned for less than the criteria for 100 percent, but with weight loss and anemia productive of severe impairment of health or severely incapacitating exacerbations occurring four or more times a year or a lesser number over prolonged periods. Finally, a 100 percent rating was assigned for constitutional manifestations associated with active joint involvement that was totally incapacitating. 38 C.F.R. § 4.71a, Diagnostic Code 5002 (prior to February 7, 2021). For chronic residuals, for residuals such as limitation of motion or ankylosis, favorable or unfavorable, they were to be rated under the appropriate diagnostic code for the specific joints involved. Where, however, the limitation of motion of the specific joint or joints involved is noncompensable under the codes a rating of 10 percent is for application for each such major joint or group of minor joins affected by limitation of motion, to be combined, not added under diagnostic code 5002. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Note: The ratings for active process will not be combined with the residual ratings for limitation of motion or ankylosis. The higher evaluation is to be assigned. Id. As of February 7, 2021, under the amended criteria, the criteria for the ratings of 20 percent through 100 percent under Diagnostic Code 5002 did not change; instead, the information following the criteria was removed and replaced by three notes. Note (1): Examples of conditions rated using this diagnostic code include, but are not limited to, rheumatoid arthritis, psoriatic arthritis, and spondyloarthropathies. Note (2): For chronic residuals, rate under diagnostic code 5003. Note (3): The ratings for the active process will not be combined with the residual ratings for limitation of motion, ankylosis, or diagnostic code 5003. Instead, assign the higher evaluation. Although Diagnostic Code 5002 does not define an “incapacitating exacerbation,” the term is defined elsewhere in the Rating Schedule, both within the same chapter regarding evaluating disability of the musculoskeletal system, specifically intervertebral disc syndrome, and in the rating schedule regarding the digestive system. As used therein, an incapacitating episode is a period of acute signs and symptoms that require bed rest prescribed by a physician and treatment by a physician. See 38 C.F.R. § 4.71a, Diagnostic Code 5243, Note 1; 38 C.F.R. § 4.114, Diagnostic Codes 7345 and 7354, Note (2). For rating purposes, normal range of motion in a knee joint is from 0 to 140 degrees of flexion. See 38 C.F.R. § 4.71, Plate II. Normal range of motion for the wrist is extension from 0 to 70 degrees, palmar flexion from 0 to 80 degrees, forearm pronation 0 to 80 degrees, forearm supination 0 to 85 degrees, ulnar deviation from 0 to 45 degrees, and radial deviation from 0 to 20 degrees. See 38 C.F.R. § 4.71, Plate I. March 2013 correspondence from the Veteran’s private doctor noted that the Veteran’s psoriatic arthritis involved his wrists, MCP joints, knees, and feet. The Veteran noticed significantly increased pain in these areas with associated fatigue over the past three years. He also had severe morning stiffness through lunch and the stiffness did not resolve through the course of the day. His persistent and active inflammation were unresponsive to prednisone, full dose methotrexate, and nonsteroidal anti-inflammatory medication. The severity of his disorder required even stronger medication in the form of anti-TNF therapy. The physician stated that due to the severity of the active inflammation of joints in the upper and lower extremities, along with severe fatigue, the Veteran currently could not perform activities of daily living even in the setting of minimal activities. He believed that with stronger medication the Veteran’s joint inflammation and function might improve. See September 2013 Medical Treatment Record – Non-Government Facility. An October 2013 private treatment record shows he was prescribed Humira. See October 2013 Medical Treatment Record – Non-Government Facility. On March 2014 VA examination of the knees, the clinician noted that the Veteran was diagnosed with psoriatic arthritis and was started on medication that helped. Since being on Humira he had less pain and discomfort. The Veteran denied having flare-ups and range of motion tests showed flexion was to 140 degrees or greater and extension was full, bilaterally. There was no evidence of painful motion. After repetitive use testing there was no change in the range of motion, bilaterally. The examiner found no evidence of functional impairment or loss. Muscle strength was 5/5 and there was no evidence of instability. The Veteran’s psoriatic arthritis did not impact his ability to work, and the physician commented that when there was a flareup and there was repetitive motion or frequent use, there was no additional loss of range of motion or joint function due to pain, fatigue, or lack of endurance, with regards to bilateral knees. See April 2014 CAPRI records. He also had a VA examination in April 2014 for arthritis. He reported Humira worked well for his arthritis and that it involved his toes, knees, hands, left Achilles tendon, and possibly his left wrist. He was on continuous medication every two weeks to treat it and he denied weight loss and anemia due to his psoriatic arthritis. The Veteran had pain attributed to his arthritis in his hands, bilateral fingers, feet, and bilateral toes. His right third MCP was mildly swollen as was his right great toe. The fourth toe had trace tenderness but was not swollen. Neither knee was swollen. His left wrist and first and third MCP were mildly swollen. His left second and third toes had trace tenderness but were not swollen. The left Achilles tendon was mildly swollen and tender. There was no limitation of motion or joint deformity attributable to psoriatic arthritis and the Veteran had no incapacitating or non-incapacitating exacerbations. The physician stated that the Veteran’s psoriatic arthritis would prevent him from doing manual labor and that under usual conditions it did not bother the Veteran, but if doing activities such as yard work the joint pain prevented him from working as hard as he needed. See April 2014 CAPRI records. An August 2014 VA treatment records indicates that the Veteran’s joint symptoms cleared up once he started being treated with Humira. See March 2015 CAPRI records. In March 2015, the Veteran reported that he was in pain every day despite taking Humira. An April 2015 treatment record shows that the Veteran reported an exacerbation of his joint disease with hand arthralgia and knee discomfort. An examination showed no evidence of active inflammatory arthritis of the hands, but the Veteran did have discomfort on motion of the knees without evidence of effusions. The clinician indicated that there was possibly less than optimal control of the inflammatory joint disease. In June 2015, he reported no real bouts of aggravated arthralgia, but he had some difficulty with his knees getting up from the floor. No active inflammatory arthritis was found on examination. A June 2015 Gulf War examination notes his complaints of generalized weakness, body ache, fatigue, joint pain, swelling, stiffness, and myalgias. See June 2015 Medical Treatment Record – Government Facility. In January 2016, the Veteran requested a medical note for a standing desk for his job. He stated that due to his joint pain, sitting all day at work was a strain for him. An October 2016 VA treatment record notes that when the Veteran’s prescription had lapsed, he became symptomatic for joint distress. He had some hand discomfort/some difficulty with tasks such as washing the dishes. In January 2017, he reported that he was doing well. There was no joint swelling but at times he had quite bothersome arthralgia in spite of no swelling. The examination of his joints revealed no evident active peripheral inflammatory arthritis. See August 2019 CAPRI records. In March 2017, the Veteran reported that he had some joint pain at times, but that the Humira appeared to be working. He had no interval febrile illness or infections and there was no evidence of active arthritis on examination. In March 2018, he denied having fatigue, anorexia, or involuntary weight change. There was no muscle or joint pain or swelling in his extremities. See April 2020 Medical Treatment Record – Government Facility. During the October 2018 hearing, the Veteran testified that his psoriatic arthritis flared up several times a year. During past 12 months it was exacerbated to the point where he sought treatment two or three times. Exacerbation involved severe foot pain and, on the calves, and that he was not able to walk. It has also involved his knees. He missed work about once a month due to psoriatic arthritis and had been unable to deploy due to his disability. His representative commented regarding the 2014 VA examination that the doctor found no symptoms but on the same examination the physician confirmed pain in right hand fingers, knee, feet, toes; left wrist, hand, fingers, knee on the other side (inaudible) but again noted no symptoms or functional impairment. He also had an issue doing manual labor. The Veteran believed that a lot of his symptoms were masked due to Humira. See October 2018 Hearing Transcript. In November 2018, the Veteran reported that he had attempted a trial period of going off Humira several months ago that resulted in exacerbated distress including polyarthralgia, and difficulty with handling tools with his hands. He was currently in no obvious painful distress but there was mild swelling in the PIP joints of the right second and third fingers. See April 2020 Medical Treatment Record – Government Facility. In July 2019, the Veteran reported having stiffness at times and that he did not always take Humira every two weeks. There was no evidence of active inflammatory arthritis on examination. See April 2020 Medical Treatment Record – Government Facility. In August 2019, he underwent VA examinations of the hands, fingers, wrists, knees, and lower legs. He reported that his pain was currently 3/10 and that it worsened to 7/10 at times, but less frequently. He denied having flare-ups and reported being unable to exercise due to the psoriatic arthritis. Regarding the hands and fingers, he had full range of motion in his fingers with passive and active motion. Pain was noted on the examination in all fingers on the right hand and all fingers on the left hand except for the index finger, but it did not result in or cause functional loss. There was mild tenderness in the MCP and PIP joints in both hands. There was no decrease in the range of motion after repetitive testing, no ankylosis, and no pain in non-weight bearing. Pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time. Hand grip was 5/5 bilaterally and there was no ankylosis in any fingers. The Veteran also had full range of passive and active motion in his wrists and there was no change in range of motion after three repetitions. Pain was noted on the examination with palmar flexion and dorsiflexion, but it did not result in or cause functional loss. There was pain at rest but not with weight bearing. Mild tenderness was note in both wrists. Bilateral wrist strength was 5/5. Pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time or cause functional loss. The knees demonstrated full range of motion and while there was evidence of painful motion it did not result in or cause functional loss. There was no additional pain with repetition, and pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time or cause functional loss. There was no pain with weight bearing, strength was 5/5, and there was no ankylosis. The Veteran did not use any assistive devices. The physician stated that Veteran has been getting ongoing treatment for psoriatic arthritis with biologics, so it had been under control since 2013 without any exacerbations. He had no complications of weight loss, or anemia reported. The Veteran had not had any hospitalizations for psoriatic arthritis. The primary joints affected were his hands, knees and wrist. Although Veteran had joint involvement from psoriatic arthritis, they had been under control with treatment and the examiner indicated there was no anemia, weight loss, severe impairment of health, or incapacitating episodes. Full range of motion was preserved during active and passive range of motion testing as reported on respective examinations and he did not report flare-ups. See October 2019 C&P Exams. A December 2019 treatment record indicated there was reasonable clinical control of the inflammatory joint disease. In February 2020, the Veteran reported he had been working out for the past four weeks. The examination revealed no edema in the extremities and his psoriatic arthritis was stable. See April 2020 Medical Treatment Record – Government Facility. The Board notes that throughout most of the appeal, the Veteran regularly used Humira to successfully treat the symptoms associated with his psoriatic arthritis. It is worth noting that the criteria for rating this disability does not contemplate the ameliorative effect of medication and that under Jones v. Shinseki, the Board may not consider the ameliorative effect since relief due to medication is not mentioned in the rating criteria under the applicable diagnostic code. See Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). Thus, while the Board will consider all of the evidence, specific attention will be place on the evidence at times when the Veteran was not on medication or when the medication was used but was not successful. The most recent VA examination notes that the Veteran’s disability had been under control since 2013 with medication and that there had been no exacerbations; however, the record shows that while Humira controls most of the Veteran’s symptoms, he still has periods when it is worse and beyond his normal level of symptomatology. The Board finds these to be periods of exacerbation, during which he complained of discomfort and stiffness. There were also two instances when the Veteran was not taking Humira because his prescription had either lapsed, or he was trying a different drug. At these times, his symptoms appeared to be worse than the exacerbations he had when he was on Humira. He did not experience fatigue, but he was noted to have polyarthralgia and significant problems with his hands that made certain activities involving his hands difficult. Since the Board finds that the disability has resulted in exacerbations, the criteria for a 20 percent rating are met throughout the appeal. A preponderance of the evidence, however, is against a rating greater than 20 percent. The record shows that the Veteran’s psoriatic arthritis was not productive of incapacitating episodes. VA examinations in March 2014 and August 2019 VA indicate there were no incapacitating episodes. Furthermore, incapacitating episodes are not noted in treatment records. The evidence also does not suggest that his psoriatic arthritis produced definite impairment of health supported by examination findings. On the two occasions when the Veteran was off Humira and his symptoms worsened, he only had greater pain in multiple joint and impaired hand function. There are no objective findings that indicate his pain and decreased hand function produced definite impairment of health. Although this term is not defined, the Board interprets it as meaning there was some obvious, noticeable degradation in his overall health but not to the degree of severe impairment, which the criteria states is associated with weight loss and anemia. Thus, while these records indicate pain and difficulty with bilateral hand function, they do not show there was any obvious diminishment in his health. The Board also considered the March 2013 statement from his private physician that described the Veteran’s symptoms when the prescribed medication was ineffective in controlling his symptoms. The physician described weight gain, increased pain in multiple joints, severe fatigue, and active inflammation. While the severity of symptoms in his bilateral upper and lower extremities resulted in him being unable to perform activities of daily living, the physician offered no specific objective examination findings to support the conclusion that the combination of symptoms produced definite impairment of health. For these reasons, a preponderance of the evidence is against an initial rating greater than 20 percent. The Board has also considered whether it would be more advantageous to rate the disability based on limitation of motion, which is permissible under the former and current versions of the regulations, but VA examinations have shown that there is no limitation of motion in the joints affected by psoriatic arthritis. Thus, rating it based on the criteria under Diagnostic Code 5002 is more appropriate. 4. Entitlement to a TDIU. It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. See 38 C.F.R. § 4.16. A finding of total disability is appropriate “when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation.” See 38 C.F.R. §§ 3.340(a)(1), 4.15. TDIU may be assigned where the schedular rating is less than total and it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of either (1) a single service-connected disability ratable at 60 percent or more, or (2) two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). An extraschedular total rating based on individual unemployability may be assigned in the case of a veteran who fails to meet the percentage requirements but who is unemployable by reason of service-connected disability. 38 C.F.R. § 4.16(b). If a sufficient rating is present, then it must be at least as likely as not that the veteran is unable to secure or follow a substantially gainful occupation as a result of that disease. See 38 C.F.R. § 4.16 (a). The central inquiry is “whether the veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability.” Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). The issue is not whether the veteran can find employment generally, but whether the veteran is capable of performing the physical and mental acts required by employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Consideration may be given to the veteran’s education, special training, and previous work experience, but not to his age or to the impairment cause by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Van Hoose, 4 Vet. App. at 363. The Veteran has a service-connected mental health disability and with the increased ratings for psoriasis and psoriatic arthritis, his disabilities meet the schedular requirements for a TDIU. However, since the record shows that his service-connected disabilities do not preclude him from securing and maintaining substantial gainful employment the claim must be denied. The Veteran reported in January 2015 that his disabilities caused a loss of income because it prevented him from deploying, which made him less competitive for promotion; however, he does not state, and the record does not show that it prevents substantial gainful employment. See January 2015 Statement in Support of Claim. A January 2015 statement from the Veteran shows he was gainfully employed in a government job. A June 2015 treatment record also shows he is a government employee. See June 2015 Medical Treatment Record – Government Facility. A January 2016 treatment record shows he held a desk job. See August 2019 CAPRI records. Most recently, his hearing testimony shows he is employed. See October 2018 Hearing Transcript. While his service-connected disabilities may be an obstacle in promotion potential and greater income, it has not prevented him from obtaining and maintaining gainful employment. His disability benefits already compensate him for impairment in earning capacity. For these reasons, a preponderance of the evidence is against entitlement to a TDIU. The claim is denied. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Bredehorst 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.