BVA9500575 DOCKET NO. 92-25 014 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to an increased evaluation for arteriosclerotic heart disease with coronary artery bypass graft, currently evaluated as 60 percent disabling. 2. Entitlement to an increased rating in excess of 10 percent for psoriasis and skin rash, to include the issue of whether the reduction in the rating for psoriasis and skin rash, from 30 to 10 percent effective June 1990, was proper. 3. Entitlement to an increased evaluation for lumbosacral strain with arthritis, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Grace Jivens-McRae, Counsel INTRODUCTION The veteran served on active duty from July 1953 to May 1974. This appeal arises from an August 1990 rating decision of the Muskogee, Oklahoma, Department of Veterans Affairs (VA) Regional Office (RO). In that decision, the RO confirmed and continued a 10 percent evaluation for lumbosacral strain with arthritis. The rating action reduced the evaluation for psoriasis and skin rash from 30 percent to 10 percent as the RO determined that material improvement was shown in the veteran's service-connected skin condition. The rating action also indicated that the veteran was entitled to a total evaluation for one year for his second coronary artery bypass graft effective from the date following his one-month convalescence or August 1, 1990. Effective August 1, 1991, the rating for his second coronary artery bypass graft was to be reduced to 30 percent effective August 1, 1991. In a September 1991 rating action, the RO determined the veteran's service-connected arteriosclerotic heart disease with coronary artery bypass graft more closely approximated the 60 percent evaluation, and a 60 percent evaluation was made effective the date of reduction following his one-year temporary 100 percent evaluation in August 1991. An April 1991 rating action denied the veteran's claim that clear and unmistakable error was present in the 1986 reduction of the veteran's benefits for arteriosclerotic heart disease. No Statement of the Case was issued. The RO should address the issue of whether a timely Notice of Disagreement was filed with regard to the rating action of April 1991. It is noted that this issue is not inextricably intertwined with the issues before us. Additionally, in a Report of Contact, dated in May 1990, it appears that the veteran attempted to have all of his service- connected disabilities reevaluated. The issues of entitlement to a compensable evaluation for hemorrhoids and chronic prostatitis are not inextricably intertwined with the issues presently on appeal. They are referred to the RO for whatever action is deemed appropriate. CONTENTIONS OF APPELLANT ON APPEAL The veteran and his accredited representative contend, in essence, that the veteran's arteriosclerotic heart disease with coronary artery bypass graft is more severe than the current evaluation reflects. The veteran believes that he warrants a total rating for his arteriosclerotic heart disease as he has had no improvement in this condition. He asserts that he has had a heart attack, and two bypass surgeries. Also, he believes that an increased rating for his skin condition is warranted, and that the RO committed error when they reduced the rating for this disability from 30 percent to 10 percent. Finally, he contends that a rating in excess of 10 percent rating for lumbosacral strain with arthritis is warranted. 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 an increased evaluation for arteriosclerotic heart disease with coronary artery bypass graft. The evidence supports the veteran's claim that the reduction in the rating from 30 percent to 10 percent for service connected skin condition was not proper and that a rating of 20 percent is warranted for service connected back disability. The preponderance of the evidence is against the claim for a rating in excess of 30 percent for service connected skin disability. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained by the RO. 2. The veteran's arteriosclerotic heart disease with coronary artery bypass graft is productive of no more than a history of substantiated repeated anginal attacks with more than light manual labor not feasible. 3. The veteran's psoriasis and skin rash is productive of constant itching and exudation; evidence of systemic or nervous manifestations, ulceration, extensive exfoliation or crusting or an exceptionally repugnant condition has not been demonstrated. 4. The veteran's lumbosacral strain with arthritis results in complaints of pain, muscle spasm and no more than moderate limitation of motion. CONCLUSIONS OF LAW 1. An evaluation in excess of 60 percent for arteriosclerotic heart disease with coronary artery bypass graft is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, §§ 4.1, 4.2, 4.7, 4.100, Diagnostic Codes 7005, 7017 (1993). 2. A reduction in rating from 30 to 10 percent for psoriasis and skin condition was not proper; a rating in excess of 30 percent is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, Diagnostic Code 7806. (1993). 3. An evaluation of 20 percent for lumbosacral strain with arthritis is warranted. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, Diagnostic Codes 5003, 5292, 5295 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Entitlement to an Increased Evaluation in excess of 60 percent for Arteriosclerotic Heart Disease with Coronary Artery Bypass Graft At the outset, it is important to note that the veteran's claim is well grounded within the meaning of 38 U.S.C.A. § 5107(a). That is, he has presented a claim which is plausible. The Board is satisfied that all relevant facts have been properly developed, and that there is no further obligation to assist the veteran in the development of his claim as mandated by 38 U.S.C.A. § 5107(a). Some of the basic facts are not in dispute. Service connection is in effect for arteriosclerotic heart disease with coronary artery bypass graft. A 60 percent evaluation has been assigned for this disability under the provisions of Diagnostic Code 7017- 7005 of the VA's Schedule for Rating Disabilities, 38 C.F.R. Part 4. Service connection was established for arteriosclerotic heart disease by rating decision of January 1978. A 60 percent evaluation was assigned, effective from June 1977. By rating decision of February 1978, the veteran's evaluation was increased from 60 percent to 100 percent, effective from October 1977. In March 1986, pursuant to 38 C.F.R. § 3.105(e), the RO evaluated the veteran's heart disability. His evaluation of 100 percent was decreased to 60 percent, effective from July 1986. This rating has remained in effect except for a 100 percent evaluation which was assigned effective May 23, 1990 and continued until August 1, 1990. The 100 percent rating was assigned based on surgery for coronary artery bypass grafting. In this regard, the 100 percent rating was granted effective the date of his hospital admission. Effective July 1, 1990, he was held eligible for a one month period of convalescence. Effective August 1, 1990, he was held entitled to a total evaluation for one year in accordance with schedular criteria. The 60 percent was assigned following termination of the 100 percent rating. Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. The provisions of 38 C.F.R. § 4.1 require that each disability be viewed in relation to its history and that there be emphasis upon the limitation of activity imposed by the disabling condition. The provisions of 38 C.F.R. § 4.2 require that medical reports be interpreted in light of the whole recorded history and that each disability must be considered from the point of view of the veteran working or seeking work. These requirements for evaluation of the complete medical history of the claimant's condition operate to protect claimants against adverse decisions based on a single, incomplete or inaccurate report and to enable VA to make a more precise evaluation of the level of the disability and of any changes in the condition. Schafrath v. Derwinski, 1 Vet.App. 589 (1991). Moreover, VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. Under Diagnostic Code 7017, a 100 percent evaluation is warranted for one year following bypass surgery. The 100 percent rating commences after the initial grant of the 1-month total rating assigned under § 4.30 following hospital discharge. Thereafter, the evaluation is rated as arteriosclerotic heart disease with a minimum rating of 30 percent. Under Diagnostic Code 7005, a l00 percent rating will be assigned during and for six months following acute illness from coronary occlusion or thrombosis, with circulatory shock, etc. After six months, with chronic residual findings of congestive heart failure or angina on moderate exertion or more than sedentary employment precluded, a l00 percent will also be assigned. Following typical history of acute coronary occlusion or thrombosis as above, or with history of substantiated repeated anginal attacks, more than light manual labor not feasible, a 60 percent rating will be assigned. A review of the record shows that the veteran was seen in the Emergency Room of the Comanche County Memorial Hospital in May 1990 for evaluation of chest pain. He related recurrent substernal chest pains, recurring without exertion but relieved by one to two nitroglycerin tablets. He had recently been discharged from the hospital for unstable angina pectoris. He had undergone cardiac catheterization and was scheduled for repeat coronary bypass surgery later that month. He gave a history of two-vessel coronary bypass surgery performed in 1978. On recent cardiac catheterization, it was found that the graft revealed a 90 percent mid vessel stenosis. There was also total occlusion of the right coronary artery and a 75 percent stenosis of the circumflex artery. Cardiac examination revealed a regular rhythm with a 2/6 systolic murmur at the lower left sternal border and apex. No diastolic murmurs were audible. The abdomen was benign without organomegaly. The femoral pulses were palpable, and the extremities revealed no edema. An electrocardiogram was essentially unchanged from the previous electrocardiograms and revealed T-wave inversions in the inferior and lateral leads. The diagnostic impression was recurrent angina pectoris, history of three-vessel coronary artery disease, history of two-vessel coronary bypass surgery, and history of hypertension. The veteran was readmitted to the cardiac care unit where serial cardiac enzymes and electrocardiograms revealed no evidence of myocardial infarction. The veteran related that he felt well after admission and an elective coronary bypass surgery was performed two days later. He did well postoperatively with no problems. On the date of discharge, the veteran related he was feeling well, was ambulating the halls and was not having any significant pains or shortness of breath. The discharge diagnosis was three-vessel coronary artery disease, unstable angina pectoris, history of previous coronary bypass surgery, and history of hypertension. In August 1991, the veteran underwent a VA compensation and pension examination. He was described as a known patient of coronary artery disease who had his first two-vessel coronary artery bypass graft in 1978. He did relatively well although requiring medication. He began to have increasing problems with angina pain and apparently a diagnosis of unstable angina. He underwent a four-vessel coronary artery bypass graft in May 1990. He related he had a decrease in anginal pain with the last surgery but continued to complain of some easy fatigability and episodes of rather significant fatigue. He also had recurrent "chest tightness" and described pain compatible with angina with walking or increased exertion. He also indicated that he had more acute chest pain with some shortness of breath which was relieved by nitroglycerin. Normal activity was described as asymptomatic, although he felt like what he called normal activity now was actually limited compared to what he considered to be normal activity prior to his coronary artery bypass surgery. He indicated that he could walk approximately one-half mile. He did not have any symptoms of congestive heart failure. He was unable to do heavy lifting. He had problems going up and down stairs because of his cardiac symptoms. He indicated that he worked at an Army Hospital as a courier. Physical examination revealed the appearance of a well-nourished, well-developed individual who appeared to be in adequate health, in no distress, and had a normal gait. The fundi revealed arterial narrowing. The chest was symmetrical and the lungs were clear. He had a suprasternal surgical scar that was well healed and nontender. He had normal sinus rhythm with no murmurs heard. The heart sounds were normal and his peripheral pulses were adequate. There was no peripheral edema present. No bruits could be heard over the carotid arteries or the abdominal aorta. The diagnostic impressions were hypertension, under treatment, and coronary artery disease with two-vessel coronary artery bypass followed by recent four-vessel coronary artery bypass graft, symptomatic with symptomatology as described in history. Private outpatient treatment records covering the period from June 1990 to November 1991 were entered into the claims folder. In June 1990, the veteran indicated that he had been doing quite well, walking 2 miles a day and denying any complaints except for some slight pus drainage from a leg incision. In July 1990, the veteran again indicated that he was doing fairly well. He stated that he continued to have trouble sleeping, but denied chest pains, shortness of breath, or any other complaints. He was exercising on a bicycle and walking on a daily basis. He planned to return to work soon. The cardiac examination revealed a regular rhythm without murmurs. In October 1990, the veteran's subjective complaints included exhaustion and fatigability, particularly in the latter parts of an active day. He noticed some discomfort on the left side of his chest which the examiner noted might be secondary to the internal mammary sacrificing. He denied shortness of breath and indicated that he was walking 5 to 6 miles per day without difficulty. In March 1991, the veteran contacted his doctor's office to report that he had been seen earlier that week in the family practice clinic regarding his blood pressure. His blood pressure had been running 140 to 150/90 with a pulse of 90. He was continuing to walk 5 to 6 miles daily without shortness of breath or chest pain. In May 1991, the veteran stated that he was doing well but had occasional "pinches" in his chest, but no anginal pains. He still complained of some fatigue but admitted to working very had and keeping quite active. He denied exertional complaints. Later that month, he was seen complaining of some hoarseness, tingling in his arms and fingers and heaviness in his legs. He stated he was just overall fatigued. He had taken sublingual nitroglycerin tablets as well as using a nitroglycerin patch but was not sure whether they had helped him. He had a dull constant substernal ache but no pains similar to angina. He had no exertional complaints and stated when he was up and around, he actually felt better. He continued walking 5 to 6 miles per day with no complaints. In September 1991, the veteran noted that the fatigue he experienced previously had gone away after taking anti-depressant medication. He had continued to remain active and denied any exertional complaints. He had one episode of chest tightness while not doing anything. The chest tightness went away with the use of one sublingual nitroglycerin tablet. In November 1991, he again was doing well. He denied chest pains, shortness of breath, or any other pertinent complaints. In January 1992, the veteran was seen at Reynolds Army Hospital with a two-day history of chest discomfort. It was recommended that he be admitted to the intensive care unit. However, there were not beds available and he was transferred to Comanche County Memorial Hospital. The transfer diagnosis was unstable angina. On admission to Comanche County Hospital, the veteran reported a two day history of epigastric discomfort. Cardiac examination revealed a regular rhythm without murmurs, clicks, or gallops. The abdomen was soft without organomegaly. The femoral pulses were palpable. The extremities revealed no edema. An electrocardiogram performed on admission revealed nonspecific lateral ST-T-changes. The veteran was admitted to the coronary care unit where cardiac enzymes and electrocardiograms revealed no evidence of myocardial infarction. The electrocardiograms continued to reveal only nonspecific ST-T-changes. The next day he was transferred out of the coronary care unit and ambulated the halls freely. One day later, he stated that he was having no more discomfort and wanted to go home. He was discharged to home but was scheduled for an outpatient thallium stress test two days later. The final diagnoses were epigastric pain, unknown etiology, history of coronary bypass surgery, history of hypertension, and mild hypercholesterolemia. In January 1992, the veteran underwent a stress thallium examination. He was exercised on a treadmill using a Bruce protocol. He exercised 11 minutes, achieving maximum heart rate of 155 and a maximum blood pressure of 170/100. The test was terminated due to fatigue. He had no chest pains during or after the procedure. The nuclear images revealed a uniform uptake of isotope by the myocardium with no fixed or reversible defects seen. The diagnostic impression was no evidence of exertion or cardiac ischemia by thallium imaging. In May 1992, the veteran was again seen on an outpatient basis by his private physician. He stated that he was doing very well and denied any complaints. He continued to walk 6 miles a day without difficulty. The veteran noted overall, he was feeling great. The cardiac examination revealed a regular rhythm with a 1/6 systolic ejection murmur heard best over the aortic region. No diastolic murmurs were found. The extremities revealed no edema. He was scheduled for a follow-up appointment in six months. The veteran's arteriosclerotic heart disease is currently evaluated as 60 percent disabling. This evaluation contemplates a history of substantiated repeated anginal attacks with more than light manual labor not feasible. In order to warrant a 100 percent evaluation, the evidence must show chronic residual findings of congestive heart failure or angina on moderate exertion, or more than sedentary employment precluded. In evaluating the medical evidence of record, the Board notes that the veteran had had some problems with fatigue which was alleviated with anti-depressant medication and, on occasion, some chest pain. However, he has shown no findings of congestive heart failure or angina on moderate exertion. He continues to walk 6 miles a day without difficulty and on his most recent hospitalization n January 1992, was noted to have epigastric pain of unknown etiology. A stress thallium examination performed after his release from the hospital revealed no evidence of exertion or cardiac ischemia by thallium imaging. In fact, he admitted to working very hard, keeping very active, and being employed as a courier for the Reynolds Army Hospital. Based on the foregoing, the Board concludes that the preponderance of the evidence is against the veteran's claim for an increased evaluation to 100 percent. His currently assigned 60 percent evaluation contemplates the degree of disability resulting from his service-connected arteriosclerotic heart disease with coronary artery bypass graft. Additionally, his disability does not require frequent hospitalization or interfere with his employment to such an extent that would justify an extraschedular evaluation. 38 C.F.R. § 3.321 (1993). As indicated before, he is seen on a regular basis by his private physician, has only been hospitalized once in the last two years with epigastric pain of unknown etiology, and works as a courier for the Reynolds Army Hospital. Therefore, an increased evaluation for arteriosclerotic heart disease is not warranted. II. Entitlement to an Increased Evaluation for Psoriasis and Skin Rash, to Include the Issue of Whether the Reduction in Rating from Thirty to Ten Percent was Proper. The Board finds the veteran's claim to be well-grounded within the meaning of 38 U.S.C.A. § 5107(a). That is, he has presented a claim which is plausible. The Board is also satisfied that all relevant facts have been properly developed, and that no further development is required to comply with the duty to assist as mandated by 38 U.S.C.A. § 5107(a) (West 1991). Service connection is in effect for psoriasis and skin rash. A 10 percent evaluation has been assigned for this disability under the provisions of Diagnostic Code 7806 of the VA's Schedule for Rating Disabilities, 38 C.F.R. Part 4. Service connection for skin rash of both feet was established by rating decision of January 1978. A 10 percent evaluation was assigned, effective from June 1977. A VA dermatology examination performed in March 1989 revealed that in addition to his feet, the veteran developed a different appearing rash on the elbows, hands and scalp. The diagnoses were psoriasis and post inflammatory pigment of the ankles. By rating decision of April 1989, the disability was classified as psoriasis and skin rash, and the rating was increased from 10 percent to 30 percent, effective January 1989. By rating decision of August 1990, the evaluation for psoriasis and skin rash was decreased to 10 percent, effective June 1990. The RO determined that material improvement was shown in the veteran's service-connected psoriasis and skin rash as it was found to be in remission by the VA examiner in June 1990. Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. The provisions of 38 C.F.R. § 4.1 require that each disability be viewed in relation to its history and that there be emphasis upon the limitation of activity imposed by the disabling condition. The provisions of 38 C.F.R. § 4.2 require that medical reports be interpreted in light of the whole recorded history and that each disability must be considered from the point of view of the veteran working or seeking work. These requirements for evaluation of the complete medical history of the claimant's condition operate to protect claimants against adverse decisions based on a single, incomplete or inaccurate report and to enable VA to make a more precise evaluation of the level of the disability and of any changes in the condition. Schafrath v. Derwinski, 1 Vet.App. 589 (1991). Moreover, VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. Under Diagnostic Code 7806, a 50 percent evaluation for eczema requires ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or exceptionally repugnant. A 30 percent evaluation is warranted for eczema productive of constant exudation or itching, extensive lesions, or marked disfigurement. A 10 percent evaluation requires exfoliation, exudation or itching, if involving an exposed surface or extensive area. A review of the record shows that the veteran underwent a VA examination for compensation and pension purposes in June 1990. He gave a history of having annular lesions at one to four weeks at a time on the trunk of his body for the past year and one- half. He indicated that they fade out with the use of topical steroids but continue to recur. A biopsy was interpreted as most consistent with erythema annulare centrifugum. He also had a history of psoriasis for the past ten to twelve years involving mostly the elbows and scalp and mostly recurring during the winter months. Physical examination of the skin revealed generalized xerosis and evidence on the right upper back of a recently resolving annular lesion. The diagnoses were recurrent erythema centrifugum, presently in remission and psoriasis, presently in remission. From December 1989 to February 1990, the veteran was seen on a regular basis at the Ft. Sill Army Hospital outpatient treatment clinic for exacerbations of his skin rash. In December 1989, he was seen complaining of an off and on rash on his torso, usually treated with hydrocortisone ointment. It was noted that the veteran had three nummular lesions with erythematous borders and dry scaling centers. The assessment was tinea corpus. Two days later, he was seen in the dermatology clinic for verruca vulgaris on the right dorsal surface of the hand. It was noted that he had previously been treated for this disorder ten days earlier. Five days later, the veteran was seen in the Family Practice Clinic complaining of increased itching and increased rash. One week later, he was again seen in the Family Practice Clinic. He complained of increased rash and increased itching. The examiner noted that the rash had increased and spread to the upper arms, chest, and back. There was rawness noted and there was no response to the previous treatment. A dermatology consultation was made. One week later, he was seen in the dermatology clinic. It was noted that the eruptions were worse on the chest but appeared to be clearing on his back. The examiner noted that the veteran had annular, red, scaly patches on his shoulders, chest and elbows. In January 1990, he was seen again in the Dermatology Clinic. It was noted that the veteran had been treated for three and one-half weeks for tinea corpus with good response. Cultures were done three weeks prior to his examination that showed no growth. He complained of some recent exacerbations when he discontinued his medication. Physical examination revealed annular patches on the upper chest. The assessment was tinea corpus. In February 1990, he was again seen in the Dermatology Clinic. He gave a history of mildly pruritic eruptions of the back of one year duration. There was no history of increased eruptions with sun exposure. He noted that his skin rash had minimally improved over the past two months. Physical examination revealed scattered two to four cm. annular patches over the upper back and flanks. In reviewing the evidence of record, it is evident that the veteran exhibits a skin rash with flare-ups that erupt on his back, elbows, flanks, chest and upper arms. This skin rash is recurring and although determined to be in remission during the veteran's most recent VA examination of June 1990, the examiner noted generalized xerosis and evidence of a recently resolving lesion. In fact, the veteran indicated, in pertinent part, that his skin disability occurs most often during the winter months and during an examination in February 1990, he stated that there was no increase in eruptions with sun exposure. Throughout the winter, the veteran was seen on many occasions with complaints of increased eruptions and itching. Clearly, the veteran's skin disorder does not show ulceration or extensive exfoliation or crusting. No systemic or nervous manifestations have been demonstrated sufficient to warrant a 50 percent evaluation. However, his service-connected skin rash does most closely approximate the 30 percent evaluation, which is productive of symptoms most analogous to constant exudation or itching. Therefore, the reduction in the 30 percent rating was not proper. An extraschedular evaluation is not warranted for the skin condition as marked interference with employment or need for frequent periods of hospitalization have not been demonstrated. III. Entitlement to an Increased Evaluation for Lumbosacral Strain with Arthritis The Board finds the veteran's claim to entitlement to an increased evaluation for lumbosacral strain with arthritis to be well-grounded within the meaning of 38 U.S.C.A. § 5107(a). That is, he has presented a claim which is plausible. The Board is also satisfied that all relevant facts have been properly developed, and that no further development is required to comply with the duty to assist as mandated by 38 U.S.C.A. § 5107(a) (West 1991). Service connection is in effect for lumbosacral strain with arthritis. A 10 percent evaluation has been assigned for this disability under the provisions of Diagnostic Code 5295 of the VA's Schedule for Rating Disabilities, 38 C.F.R. Part 4. Service connection was established for lumbosacral strain with arthritis by rating decision of April 1989. A 10 percent evaluation was assigned, effective January 1989. The veteran continues to maintain a 10 percent evaluation to the present. Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. The provisions of 38 C.F.R. § 4.1 require that each disability be viewed in relation to its history and that there be emphasis upon the limitation of activity imposed by the disabling condition. The provisions of 38 C.F.R. § 4.2 require that medical reports be interpreted in light of the whole recorded history and that each disability must be considered from the point of view of the veteran working or seeking work. These requirements for evaluation of the complete medical history of the claimant's condition operate to protect claimants against adverse decisions based on a single, incomplete or inaccurate report and to enable VA to make a more precise evaluation of the level of the disability and of any changes in the condition. Schafrath v. Derwinski, 1 Vet.App. 589 (1991). Moreover, VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. Under Diagnostic Code 5295, a 20 percent evaluation is warranted for lumbosacral strain productive of muscle spasm on extreme forward bending, loss of unilateral motion in a standing position. A 10 percent rating contemplates characteristic pain on motion. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the joint involved is noncompensable under the appropriate diagnostic codes, a rating of l0 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. Part 4, Code 5003. Limitation of motion of the lumbar spine where slight will be assigned a l0 percent rating. Where moderate, a 20 percent rating will be assigned. 38 C.F.R. Part 4, Code 5292. The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. A longitudinal review of the record shows that during service the veteran complained of back pain. Early degenerative changes of the lumber spine were noted in service. In June l990, the veteran was examined by the VA. He complained of aching of the low back approximately 2 hours a day. He had no severe lumbosacral pain or limitation of motion. Physical examination showed the veteran could heel and toe walk and squat. He had trouble duck walking. Straight leg raising was accomplished to "9" degrees, bilaterally, with no pain. There was no paravertebral muscle spasm or tenderness. Flexion was accomplished to 90 degrees, extension to 25 degrees, lateral bending to 35 degrees and rotation to 35 degrees. X-ray examination revealed severe narrowing of the L5-S1 disc space with vacuum disc phenomenon noted. There was minimal narrowing of the L4-5 disc space. The diagnosis was low back pain with normal findings. During 1990, the veteran was seen at the Ft. Sill Army Medical Center outpatient treatment clinic with low back complaints. In March 1990, the veteran complained of low back pain for years in various locations. He indicated that he had a CT scan 6 months prior to the examination which showed degenerative disc disease. Reports in his chart indicated slight numbness in the left groin with sitting. There was no weakness or pain down the legs reported. Physical examination revealed full range of motion of the lumbar spine with moderate lumbosacral spasm and tenderness. The pertinent diagnostic impression was osteoarthritis and lumbosacral syndrome. The examiner instructed the veteran to get a lumbar spine CT scan and X-rays. The veteran underwent a CT scan of the lumbosacral spine in March 1990. The CT scan revealed a bulging disc at L4-5 with marked degeneration of the L5-S1 disc with arthritic changes. No herniated nucleus pulposus was present. X-ray examination of the veteran's lumbar spine was performed in April 1990. The examination showed the pedicles and spinous processes to be intact. The vertebral bodies were normal in height and alignment. Disc space degeneration was present to a slight degree at 12-1. There was also disc degeneration at L 1- 2. Severe disc degeneration was present at 5-1. The disc space was essentially obliterated and there was a vacuum disc present with prominent spurs present anteriorly and posteriorly. There was also degenerative arthritis at that level and also degenerative arthritis in the SI joints. The diagnostic impression was degenerative disc disease and degenerative arthritis of the lumbar spine with the most severe degenerative change at the 5-1 level; slight degenerative arthritis of the SI joints. The veteran was seen in April 1990 at the Fort Sill Army Medical Center. Moderate lumbosacral spasm was noted. When seen in September 1990, he complained of pain in the left flank of the back. There were no complaints of radiation of pain to the groin. It was noted he was unable to tolerate anti-inflammatory medication. Spasm was noted. The assessment was probable mechanical back pain. The veteran was given a physical therapy consultation for exercises. Later that month, he was seen in the physical therapy clinic. He complained of intermittent pain in variable sites. He indicated that the pain increased as the day wore on but that he was often active without pain. There were no complaints of distal symptoms. Physical examination revealed negative straight leg raising with no localized tenderness to palpation. Range of motion was described as within normal limits for the veteran's age. He complained of pain on extension only. The assessment was degenerative joint disease of the lumbar spine. He was given several exercises and heat packs for warm- ups. He was instructed to return to the clinic in 2 weeks. Private medical records pertaining to the veteran's heart indicate that in November 1991, he noted his primary problem was with his back. The veteran's lumbosacral strain with arthritis is currently evaluated as 10 percent disabling. This evaluation contemplates lumbosacral strain with characteristic pain on motion. In order to warrant a 20 evaluation, the evidence must show that the veteran's lumbosacral strain is productive of muscle spasm on extreme forward bending, with loss of unilateral spine motion in a standing position. After a thorough review of the medical evidence, the Board recognizes that the veteran has intermittent pain in various areas of his lumbar spine. He is also experiencing muscle spasm. Although he complained of slight numbness in the left groin in March 1990, no complaints of pain radiating down a lower extremity have been reported. Also, no more than slight limitation of motion has been demonstrated. Based on the foregoing, the Board concludes that the evidence warrants an increased evaluation to 20 percent. The veteran's back disability, although not productive of significant limitation of motion, does result in muscle spasm and pain. Additionally, his disability does not require frequent hospitalization or interfere with his employment to such an extent justifying an extraschedular evaluation. 38 C.F.R. § 3.321 (1993). He works as a courier and is often active without pain. Further, the need for frequent periods of hospitalization due to his back condition has not been demonstrated. Therefore, an increased evaluation for lumbosacral strain with arthritis is not warranted on an extraschedular basis. ORDER An increased evaluation for arteriosclerotic heart disease with coronary artery bypass graft is denied. An increased evaluation to 20 percent for lumbosacral strain with arthritis is granted, subject to the applicable criteria governing the payment of monetary benefits.. Restoration of a 30 percent evaluation for psoriasis and skin rash is granted, subject to the laws and regulations governing the effective dates of awards. An evaluation in excess of 30 percent for the skin condition is denied. I. S. SHERMAN 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.