BVA9507172 DOCKET NO. 93-18 606 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to separate disability ratings for fibrositis syndrome of the left knee and chondromalacia of the left knee. 2. Entitlement to service connection for a left knee prosthesis. 3. Entitlement to a temporary total disability rating based on post operative convalescence following hospitalization from March 28 to April 1, 1993, for left knee surgery. 4. Entitlement to an increased rating for fibrositis syndrome of the left knee with chondromalacia, currently rated as 10 percent disabling. 5. Entitlement to an increased total combined disability evaluation of 70 percent for the service-connected fibrositis of multiple joints. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. R. Olson, Counsel INTRODUCTION The veteran's active military service extended from June 1956 to July 1958. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions by Regional Offices (RO's) of the Department of Veterans Affairs (VA). In March 1992, the Regional Office (RO) in Togus, Maine confirmed 10 percent ratings for fibrositis of each of the following joints: cervical spine, dorsal spine, lumbar spine, right shoulder, and left shoulder. Those ratings had been in effect since August 1990. The March 1992 rating decision found that there was clear and unmistakable error in the October 1990 rating decision, in that it had not included the service-connected left knee. Fibrositis syndrome of the left knee with chondromalacia was rated as 10 percent disabling, effective in August 1990. The 10 percent rating for pilonidal cyst residuals was also continued. The total combined rating was continued at 50 percent. In April 1992, the RO received a communication from the veteran styled "Motion to Appeal to the Board of Veteran Appeals and Request for a Personal Hearing." The veteran reported that he had moved and asked that his file be transferred to Florida. In September 1992, the RO in St. Petersburg, Florida issued a rating decision which continued the determinations made in the March 1992 rating decision. In October 1992, the veteran's April 1992 motion was accepted as a notice of disagreement. A statement of the case was issued in December 1992. A personal hearing was held at the RO in January 1993. The veteran's January 1993 hearing presentation was accepted in lieu of as his formal appeal. In a November 1993 rating decision, the St. Petersburg, Florida, RO denied service connection for a prosthetic replacement of the veteran's left knee and also denied entitlement to a temporary total convalescence rating under the provisions of 38 C.F.R. § 4.30. The veteran's subsequent appeal on that issue, dated in February 1994, included a request for a total rating based on individual unemployability. The total rating issue has not been developed for appellate consideration and is not before the Board at this time. It is referred to the RO for appropriate action. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that the RO's committed error in denying the benefits he seeks. He avers that he has a protected 40 percent rating for his service-connected left knee disorder and that the March 1992 rating decision improperly reduced the rating. He asserts that with a 10 percent rating assigned for each of the 6 joints affected by fibrositis, the disability should be rated at 70 percent rather than the combined rating of 50 percent. He argues that the service-connected left knee disability increased in severity and warrants a rating higher than the current 10 percent. He particularly contends that the report of his private physician links the recent left knee replacement to the service- connected chondromalacia. He also asserts that a temporary total rating is warranted for convalescence following the left knee surgery. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against the claim for a separate 40 percent rating for the veteran's service- connected left knee fibrositis, which is separate from the rating for his left knee chondromalacia. The preponderance of the evidence is also against service connection for a left knee prosthesis, a temporary total disability rating based on post operative convalescence following hospitalization from March 28 to April 1, 1993, for left knee surgery, an increased rating for the service connected left knee fibrositis with chondromalacia, and an increased combined rating for the service-connected fibrositis of multiple joints. FINDINGS OF FACT 1. The RO has obtained all relevant evidence necessary for an equitable disposition of the veteran's appeal. 2. Fibrositis of the left knee and chondromalacia of the left knee contribute to the same manifestations of left knee disability. 3. The service-connected chondromalacia and fibrositis of the left knee did not require the implantation of a left knee prosthesis. 4. The left knee prosthesis was required by meniscal injuries and degenerative osteoarthritis which were not manifested during service or within the first post service year. 5. The left knee prosthesis, meniscal injuries and degenerative osteoarthritis were not the result of disease or injury during service or a service-connected disability. 6. A service-connected disability did not require the left knee surgery during the hospitalization from March 28 to April 1, 1993, or the subsequent convalescence from the surgery. 7. The veteran's service-connected fibrositis syndrome of the left knee with chondromalacia is manifested by complaints of pain and discomfort. 8. The service-connected fibrositis syndrome of the left knee with chondromalacia does no result in more than slight disability. 9. The veteran's disabilities do not present an exceptional or unusual disability picture rendering impractical the application of the regular schedular standards that would have warranted referral of the case to the Director of the Compensation and Pension Service. 10. The fibrositis syndrome is assigned a 10 percent rating for each of the following joints: cervical spine, dorsal spine, lumbar spine, right shoulder, left shoulder, and left knee. The right and left shoulders are the only bilateral joints for which service connection has been established. CONCLUSIONS OF LAW 1. Separate disability ratings for fibrositis of the left knee and chondromalacia of the left knee are not warranted. 38 U.S.C.A. § 110 (West 1991); 38 C.F.R. § 4.14 (1994). 2. The left knee prosthesis was not required by disease or injury incurred in or aggravated by active military service and is not proximately due to or the result of a service-connected disease or injury, and arthritis may not be presumed to have been incurred in service. 38 U.S.C.A. §§ 101(16), 1101, 1112, 1131, 1137 (West 1991); 38 C.F.R. §§ 3.307, 3.309, 3.310(a) (1994). 3. The criteria have not been met for a temporary total disability rating based on post operative convalescence following hospitalization from March 28 to April 1, 1993, for left knee surgery. 38 C.F.R. § 4.30 (1994). 4. The criteria for a rating in excess of 10 percent for fibrositis syndrome of the left knee with chondromalacia have not been met. 38 U.S.C.A. §§ 1155 (West 1991); 38 C.F.R. Part 4, including §§ 4.7, 4.20 and Code 5257 (1994). 5. Failure of the RO to consider or document its consideration of an extraschedular rating and the failure to refer the case to the Director of the Compensation and Pension Service is no more than harmless error. 38 C.F.R. § 3.321(b)(1) (1994). 6. The criteria have not been met for a combined rating of 70 percent for the service-connected fibrositis of multiple joints. 38 C.F.R. §§ 4.25, 4.26 (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The veteran's claims are "well grounded" within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). That is, he has presented claims which are plausible. All relevant facts have been properly developed and no further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a). I. Separate Ratings for Fibrositis and Chondromalacia of the Left Knee An August 1960 rating decision granted service connection for a post traumatic chondromalacia of the left patella and assigned a 10 percent rating. A July 1962 rating decision noted that an arthrotomy had not revealed any gross pathology and reduced the rating to noncompensable. The disability was described in the rating decision as chondromalacia, post-traumatic, left patella, with quadriceps weakness, operated. A May 1963 rating decision granted a 10 percent rating noting a recent diagnosis of rheumatoid arthritis of the left knee. The service-connected disability was listed as rheumatoid arthritis, left knee (formerly rated as chondromalacia, post-traumatic, left patella, with quadriceps weakness, operated). A March 1964 rating decision shows that the RO considered symptoms involving joints throughout the veteran's upper and lower extremities (including the left knee). It assigned a 40 percent rating under the Code 5002 for active rheumatoid arthritis. The service-connected disability was listed as "Rheumatoid Arthritis, Generalized." In a February 1967 rating decision, it was reported that a medical examiner had found no evidence of rheumatoid arthritis. He diagnosed fibromyositis of multiple joints (possible rheumatoid arthritis). The nomenclature of the service-connected disability was again changed to fibromyositis, multiple joints (formerly rated as rheumatoid arthritis, generalized). Code 5021 for myositis was used and the 40 percent rating was continued. In an October 1970 rating decision, it was noted that the condition had recently been diagnosed as rheumatoid arthritis. The classification of the service-connected disability was changed to rheumatoid arthritis, generalized (formerly rated as fibromyositis, multiple joints). The 40 percent rating was continued under Code 5002, for active arthritis. A May 1971 rating decision increased the rating to 60 percent with a temporary total rating for hospitalization. The disability was described as rheumatoid arthritis, multiple joints (active) with associated fibrositis syndrome. The 60 percent rating was assigned under Code 5002 for active rheumatoid arthritis. A November 1981 rating decision reduced the evaluation to 40 percent. A March 1985 rating decision again changed the nomenclature of the disability to fibrositis syndrome (formerly rheumatoid arthritis, multiple joints with associated fibrositis syndrome). The 40 percent rating under Code 5002 was continued. In March 1986, the Board affirmed the denial of a rating in excess of 40 percent for the fibrositis. An October 1990 rating decision reviewed the current medical findings and ended the 40 percent rating for fibrositis syndrome under Code 5002. It was replaced by separate ratings of the joints affected under the codes pertaining to those joints. Fibrositis syndrome, cervical spine was rated as 10 percent disabling under Code 5290. Fibrositis syndrome, dorsal spine was rated as 10 percent disabling under Code 5291. Fibrositis syndrome, lumbar spine was rated as 10 percent disabling under Code 5292. Fibrositis syndrome, right shoulder was rated as 10 percent disabling under Code 5203. Fibrositis syndrome, left shoulder was rated as 10 percent disabling under Code 5203. The veteran disagreed with the rating in a letter received in December 1990. A December 1990 statement of the case covered the issues of evaluation of service-connected fibrositis syndrome, cervical spine; fibrositis syndrome, dorsal spine; fibrositis syndrome, lumbar spine; fibrositis syndrome, right shoulder and fibrositis syndrome, left shoulder. It also dealt with the evaluation of the service-connected pilonidal cyst and evaluation based on individual unemployability. A timely appeal was not received. The next information pertaining to the veteran's claims was received in February 1992. The March 1992 decision found that the omission of the left knee from the list of joints affect by fibrositis was clear and unmistakable error. It amended the list of service-connected disabilities to include a 10 percent rating for fibrositis syndrome left knee with chondromalacia. The veteran contends that he had a 40 percent rating for his service-connected left knee disorder which was protected by law and improperly reduced by the March 1992 rating decision. The law provides that a disability which has been continuously rated at or above an evaluation for 20 years or more shall not be reduced thereafter, except upon a showing that the rating was based on fraud. 38 U.S.C.A. § 110 (West 1991). Review of the rating history in this case shows that the service- connected joint disorder has presented diagnostic complexities. Over the years, the RO has attempted to properly rate the disorder in a manner consistent with the best medical opinion of the diagnosis at the time. The left knee, by itself, has never been rated as more than 10 percent disabling. The 40 percent rating was first assigned because the medical evidence indicated that several other joints were involved. The subsequent rating decisions continued the 40 percent rating because the evidence showed continued involvement of multiple joints. The 40 percent rating was never based solely on the left knee. The October 1990 decision which assigned separate ratings for each joint affected by fibrositis did not reduce the combined rating for the service- connected fibrositis below 40 percent. The March 1992 rating decision corrected a clear and unmistakable error in the omission of the rating for the left knee. This addition of a 10 percent rating for the left knee did not reduce the combined rating for the fibrositis. The evidence in this case does not show that any disability evaluation in effect for 20 years or more has been reduced. The record here shows that the service-connected knee disorder has had various diagnoses over the years. However, the various ratings assigned over the years for the service-connected left knee disorder have been based on the disability manifestations. 38 C.F.R. § 4.45 (1994). The evaluation of the same disability under various diagnoses is to be avoided. The evaluation of the same manifestation under different diagnoses is also to be avoided. 38 C.F.R. § 4.14 (1994). The separate ratings requested by the veteran would result in rating the same disability manifestation twice. Such "pyramiding" would be contrary to the applicable regulations. II. Left Knee Prosthesis The service medical records show that the veteran complained of a trick left knee in September 1957. The diagnosis was a possible sprained knee. Recommended treatment included medication and an ace bandage. No further knee complaints were noted during the remainder of the veteran's active military service. His lower extremities were normal when he was examined for separation from service in May 1958. The veteran was treated at a VA hospital from May to July 1960, primarily for his pilonidal cyst. During that time, the veteran reported that he had fallen during service and struck the left pole of his patella on a steel pole. He reported chronic discomfort and weakness in the knee, with a tendency to buckle and two episodes of locking. Examination disclosed a normal range of motion without instability or atrophy. There was moderate quadriceps weakness, tenderness to palpation and bilateral crepitus. X-rays were normal. The diagnosis was chondromalacia, post traumatic, left patella. There were similar findings on VA orthopedic examination in November 1961 and VA hospitalization in June 1962. An exploratory arthrotomy, in July 1962, revealed no gross pathology. The diagnosis was quadriceps weakness, moderate, secondary to old knee injury. A report date in November 1962 indicates that the veteran still had significant muscle weakness despite physical therapy. A possible inflammatory process was considered. A VA medical record dated in January 1963 shows that the veteran had been tested and evaluated. It was thought that he had rheumatoid arthritis of the left knee. A physician specified that the diagnosis took the place of previous diagnoses of arthropathy left knee and chondromalacia, post traumatic, left patella. The report of the June 1963 VA orthopedic examination shows that it had originally been thought that the veteran had chondromalacia of the patella but that an arthrotomy in July 1962 did not disclosed any gross pathology. The diagnosis was service-connected quadriceps weakness and possible rheumatoid arthritis. July 1963 VA x-rays showed no arthritic or destructive lesions in the left knee. In July 1963, the veteran was examined by the VA orthopedic specialist who had performed the arthrotomy in July 1962. The physician noted that the previous diagnosis of chondromalacia was not substantiated on the 1962 arthrotomy. It was also noted that the diagnosis of rheumatoid arthritis was not well supported. The examiner was at a loss to explain why the veteran was having as much knee trouble as he described. Supervised quadriceps exercises were recommended. The veteran was rehospitalized at a VA facility from October 1963 to January 1964. The left knee had a limitation of motion and was slightly larger than the right. A probable rheumatoid arthritis was diagnosed. VA arthritis rounds notes of August 1964 show a limitation of motion and continued the diagnosis. An arthritis rounds note dated later in August 1964 commented that an element of psychogenic overlay tended to put the veteran in the fibromyositis category. Left knee limitation of motion and enlargement were again found on VA examination in March 1965. Probable rheumatoid arthritis was the diagnosis. The earliest x-ray evidence of change in the left knee was reported on December 1966 studies. There was moderate arthritic change in the form of posterior lipping of the patella margins. Multiple soft tissue calcifications were seen in the area of the supra patella bursa. The December 1966 VA arthritis examination revealed knee pain on all motion, although motion was relatively normal. There was some tenderness to palpation. The diagnoses were fibromyositis multiple joint (probable rheumatoid arthritis) and arthritis of the left knee joint. An October 1967 VA arthritis rounds note shows both knees had a full range of motion without swelling. There was bilateral quadriceps atrophy, greater on the left. The doctor commented that except for some ill defined difficulty of the left knee, it was difficult to make a diagnosis. The veteran would probably be in the spectrum of fibrositis syndrome, more toward psychogenic rheumatism. A mild rheumatoid arthritis could not be completely discounted. On VA examination in June 1968, x-rays reportedly showed no knee abnormality. The knee was mildly tender with swelling and a full range of motion. The examiner diagnosed fibromyositis of several joints, including the knees. August 1969 VA x-ray studies were interpreted as showing no definite evidence of arthritic process in the left knee. There were soft tissue calcifications anterior to the distal end of the femur. Examination disclosed left quadriceps weakness and the left knee was larger than normal. There was pain on all left knee motion. Additional VA medical records through 1972 show continued knee symptoms such as complaints of pain and limitation of motion. Despite further evaluations, the disability entity was not clear cut. The report of a private osteopath, W. E. Wyatt, D.O., dated in December 1976 and the reports of VA examiners in December 1976, February 1977 and December 1977 show that the veteran's was seen for orthopedic disabilities, primarily involving his back. He did not report any left knee symptoms and, in December 1977, the examining physician noted that the range of knee motion was within normal limits. An operative report from the Weber Hospital, dated in April 1980, shows that the veteran had fallen and injured his left knee at work in December 1979. Tests reveled a tear of the left medial meniscus and a left medial meniscectomy was performed. A VA clinical note dated in May 1980 shows that the veteran reported that his knee had started bothering him and his private physician removed the left medial meniscus. The accident at work was not reported. During the VA psychiatric hospitalization from September to November 1980, the veteran told of braking two menisci and sustaining other injuries at work in 1979. On the December 1980 VA orthopedic examination, the veteran reported that he had been going to a private physician for his knee disability. There was no indication of the 1979 industrial accident. X-rays of both knees showed minimal degenerative changes. Subsequent VA and private medical records show continued knee complaints. In December 1982, the Board denied service connection for the postoperative residuals of torn medial menisci of the right and left knees. It was determined that the meniscal injuries were the result of the 1979 industrial accident and were not the result of a service-connected disability or disease or injury during service. The report of hospitalization at the Highlands Regional Medical Center, in March and April 1993, shows that a total knee replacement was done. The veteran's surgeon, D. D. Carr, M.D., reviewed the case in an August 1993 letter. She expressed the opinion that the removal of the meniscus had resulted in early degenerative changes, which in turn necessitated the prosthesis. As noted above, the Board had denied service connection for the meniscus tear in 1982. Decisions of the Board are final. 38 U.S.C.A. § 7104(b) (West 1991). However, the case can be reopened if new and material evidence is submitted. 38 U.S.C.A. § 5108 (West 1991). Here there is no dispute that the meniscal injury resulted in the need for a prosthetic left knee implant. Normally, evidence of progression of the disorder for which service connection has been denied is not new and material evidence. To establish service connection the veteran must show that the meniscal injury was the result of disease or injury during service or was due to the service-connected knee disorder. 38 C.F.R. § 3.156 (1994). Dr. Carr addressed this aspect of the claim in her letter. She asserted a connection between the service-connected chondromalacia and the meniscus injury. It appears that the RO accepted this statement and reopened the claim for service connection for the left knee prosthesis, as a residual of the meniscectomy. Dr. Carr's opinion is to the effect that an arthroscopy during service, in 1962, revealed chondromalacia. The chondromalacia was a softening and degeneration of the cartilage. As it progressed, degenerative arthritis occurred. The meniscus acts as a shock absorber and its removal speeds degenerative disease. It was assumed that part of the meniscus was removed in 1962, as the veteran was found to have only a partial meniscus on arthroscopy in 1980. The physician argued that service-connected chondromalacia and removal of part of the meniscus in 1962 brought about the degeneration which required the knee replacement. The original grant of service connection for the left knee included chondromalacia. The nomenclature was changed after further studies showed it was not present. The possibility of chondromalacia was part of the reason for the 1962 arthrotomy. The VA physician who performed the procedure subsequently reported that the diagnosis of chondromalacia was not substantiated on the arthrotomy in 1962. The Board notes that the RO has recently used the term chondromalacia to describe the service-connected left knee disorder. However, adjudicative determinations must be based on the medical evidence. The medical evidence in this case does not show that chondromalacia was in fact part of the service-connected left knee disorder. Therefore, Dr. Carr's opinion that a service-connected chondromalacia led to the degenerative changes which required the prosthesis is not adequately supported. Dr. Carr also expressed the opinion that the 1962 procedure involved removal of part of the meniscus; although she acknowledged that she had not read the reports of the procedure. A report of the July 1962 VA hospitalization discusses the procedure and the VA physician who performed the procedure discussed his findings in the report of his July 1963 examination of the veteran. It was specified that there was no gross pathology. There was no indication of any surgery on the meniscus or that there was any need for such surgery. The report of the 1980 procedure reflects surprise that the veteran had a medial meniscus in light of the history he provided. Arthroscopy prior to surgery revealed almost an entire meniscus. The findings were considered to be consistent with a tear. No findings consistent with a partial meniscectomy were reported. Surgery was performed and the entire medial meniscus removed. With due regard to the recent opinion of Dr. Carr, the records made at the time of the procedures, by the physicians who performed those procedures, demonstrate that the meniscus or part of it was not removed due to the service-connected knee disorder. The meniscal injury was reportedly due to an accident long after service. The degenerative changes which followed the removal of the meniscus, and which later required a total replacement of the left knee, cannot reasonably be associated with the service- connected left knee disorder. Consequently, the Board finds that the preponderance of the evidence demonstrates that arthritic changes were first manifested to a degree of 10 percent or more many years after service and that the left knee prosthesis was not the result of a service-connected disability or of disease or injury during service. 38 U.S.C.A. §§ 101(16), 1101, 1112, 1131, 1137 (West 1991); 38 C.F.R. §§ 3.307, 3.309, 3.310(a) (1994). III. Temporary Total Disability Rating Temporary total ratings will be assigned if treatment of a service-connected disability resulted in surgery necessitating at least one month of convalescence or surgery with severe postoperative residuals. 38 C.F.R. § 4.30 (1994). The record in this case shows that the hospitalization from March 28 to April 1, 1993, was for a total left knee replacement with a prosthesis. As discussed above, the prosthesis is not part of the service- connected disability. Since the surgery was not for a service- connected disability, a temporary total rating cannot be awarded under 38 C.F.R. § 4.30 (1994). IV. Fibrositis Syndrome of the Left Knee with Chondromalacia Service-connected disabilities are rated in accordance with a schedule of ratings which are based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part 4 (1994). The service connected fibrositis syndrome of the left knee with chondromalacia is currently rated as 10 percent disabling under diagnostic code 5257. That rating contemplates a slight knee impairment. It is commensurate with the pain and discomfort reported by the veteran and with the muscle calcifications noted on x-ray studies. The next higher rating, 20 percent, requires a moderate impairment. The medical evidence in this case indicates that the veteran may have limitations of motion and other symptoms related to the nonservice-connected prosthesis in the left knee. The record does not show that the service-connected left knee disability approximates more than slight impairment. 38 C.F.R. Part 4, including §§ 4.7, 4.20 and Code 5257 (1994). Therefore, a higher rating is not warranted. This case does not present an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (1994). Any failure by the RO to refer the case to the Director of the Compensation and Pension Service for extraschedular consideration was harmless error. V. The Combined Rating for Fibrositis of Multiple Joints The ratings assigned for service-connected disabilities are not added. They are combined in accordance with the provisions of the rating code. 38 C.F.R. §§ 4.25, 4.26 (1994). The bilateral disabilities are combined first. The rating for the fibrositis of the left shoulder (10 percent) is combined with the rating for the fibrositis of the right shoulder (10 percent) for a combined total of 19 percent. A bilateral factor equaling 10 percent of the combined rating is then added. That would be 1.9 percent added to the combined rating for the shoulders and rounded for a combined 21 percent. 38 C.F.R. § 4.26 (1994). The 10 percent rating for the fibrositis syndrome of the cervical spine is then combined with the 21 percent for a combined rating of 29 percent. 38 C.F.R. § 4.25 (1994). The 10 percent rating for the fibrositis syndrome of the dorsal spine is then combined with the 29 percent for a combined rating of 36 percent. 38 C.F.R. § 4.25 (1994). The 10 percent rating for the fibrositis syndrome of the lumbar spine is then combined with the 36 percent for a combined rating of 42 percent. 38 C.F.R. § 4.25 (1994). The 10 percent rating for the fibrositis syndrome of the left knee is then combined with the 42 percent for a combined rating of 48 percent. 38 C.F.R. § 4.25 (1994). The veteran's only other compensable service-connected disability is the postoperative residuals of a pilonidal cyst rated at 10 percent. When this 10 percent is combined with the 48 percent for the fibrositis, the combined rating is 53 percent. The conversion to the nearest degree divisible by 10 will be done following the combining of all disabilities, and will be the last procedure in determining the combined degree of disability. 38 C.F.R. § 4.25(b) (1994). In this case the total combined rating would be 50 percent. 38 C.F.R. § 4.25 (1994). As review shows the service-connected disability ratings to have been properly combined, a higher combined rating is not warranted. ORDER A separate disability rating for the veteran's service-connected fibrositis and left knee chondromalacia is denied. Service connection for a left knee prosthesis is denied. A temporary total disability rating based on convalescence following hospitalization from March 28 to April 1, 1993, for left knee surgery is denied. An increased rating for the service-connected left knee disability, rated as fibrositis syndrome of the left knee with chondromalacia, is denied. An increased combined rating for the service-connected fibrositis of multiple joints is denied. JOAQUIN AGUAYO-PERELES Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.