BVA9503267 DOCKET NO. 90-53 451 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to an increased rating for psoriatic arthritis (and gout) of multiple joints, currently assigned (in combination) a 40 percent evaluation. 2. Entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARINGS ON APPEAL The appellant ATTORNEY FOR THE BOARD Stephen F. Sylvester, Counsel INTRODUCTION The veteran in this case had active service from February 1943 to February 1946, from April 1947 to May 1950, and from May 1950 to May 1965. This appeal to the Board of Veterans' Appeals (Board) arises from a January 1988 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. This case was previously before the Board in January 1991 and April 1993, on which occasions it was remanded for additional development. Such development having been accomplished, the case has been returned to the Board for further appellate review. For reasons which will become apparent, the issue of entitlement to service connection for psoriatic arthritis of multiple joints (including the spine, hips, right knee, ankles, feet, wrists, and hands) has been recharacterized as entitlement to an increased rating for psoriatic arthritis of multiple joints. Accordingly, it is delineated as such on the title page of this decision. Finally, based upon a review of the current record, it is unclear whether the veteran seeks entitlement to an increased rating for service-connected psoriasis. Inasmuch as this particular issue has not been developed or certified for appellate review, it is not for consideration at this time. It is, however, being referred to the RO for appropriate clarification/action. REMAND A review of the record in this case raises some question as to the current severity of the veteran's service-connected psoriatic arthritis. In that regard, service connection is currently in effect for psoriatic arthritis and gout of both shoulders, and for psoriatic arthritis and gout of the left knee. In pertinent part, the veteran contends that his service-connected psoriatic arthritis is more severe than currently evaluated, in that it now involves joints other than just his shoulders and left knee. Specifically, it has been argued that the veteran's service- connected psoriatic arthritis now involves his "whole body," to include his back, ankles, right knee, both hips, both wrists, and both elbows. In addition, the veteran contends that the psoriatic arthritis affecting each of his shoulders is at least as severe, if not more severe, than previously evaluated, and that, therefore, the prior 20 percent evaluation assigned for each of his shoulders should not have been reduced (such reduction having been effectuated by a recent decision of November 1993). As noted above, service connection is currently in effect for psoriatic arthritis (of both shoulders and the left knee), a systemic condition. As such, the Board is of the opinion that it is more properly evaluated as analogous to rheumatoid arthritis, pursuant to the provisions of 38 C.F.R. Part 4, Codes 5002 and 5009 (1994). However, in order to do so, a determination must be made as to whether the veteran currently suffers from "active" psoriatic arthritis, or only chronic residuals thereof. This is, of course, in addition to a more basic determination as to which, if any, joints exhibit symptomatology consistent with psoriatic arthritis. Recently conducted VA and private medical examinations, while addressing the apparent presence or absence of psoriatic arthritis in various joints, are somewhat contradictory as to their findings. Finally, the Board notes that, subsequent to the issuance of the most recent supplemental statement of the case in April 1994, there were received at the Board rather extensive VA outpatient treatment records for the period from January 1989 to August 1994. As can best be determined, none of these records have as yet been considered by the RO in the context of the veteran's current claims. Pursuant to the provisions of 38 C.F.R. § 20.1304(c) (1994), any pertinent evidence submitted by the appellant or his representative which is accepted by the Board must be referred to the RO for review and preparation of a supplemental statement of the case unless this procedural right is waived by the appellant, or unless the Board determines that the benefit or benefits to which the evidence related may be allowed on appeal without such referral. This waiver must be in writing or, if a hearing on appeal is conducted, formally entered on the record orally at the time of that hearing. In the case at hand, the appellant has executed no such waiver. The Board notes that the VA has a duty to assist the veteran in the development of all facts pertinent to his claims. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.103(a) (1994). The United States Court of Veterans Appeals (Court) has held that this duty to assist the veteran in obtaining and developing available facts and evidence to support his claim includes obtaining adequate VA examinations, including examination by a specialist, when necessary. Littke v. Derwinski, 1 Vet.App. 90 (1990); see also Hyder v. Derwinski, 1 Vet.App. 221 (1991). Accordingly, in light of the aforementioned, the case is, once again, REMANDED to the RO for the following actions: 1. The veteran should be afforded an additional VA examination in order to more accurately determine the current severity of his service-connected psoriatic arthritis of multiple joints. This examination is to be conducted by a rheumatologist, with the understanding that any arthritis identified is presumed to be part of the veteran's systemic psoriatic arthritis, absent clear evidence to the contrary. Accordingly, the examiner should specifically comment as to whether the veteran currently suffers from active psoriatic arthritis, or only chronic residuals thereof. If active, consideration should be given to the presence of symptom combinations producing an impairment of health, objectively supported by examination findings, in conjunction with the number of incapacitating exacerbations. Should only chronic residuals of psoriatic arthritis be identified, such residuals should be addressed on the basis of limitation of motion, as confirmed by swelling, muscle spasm, or satisfactory evidence of painful motion. All pertinent symptomatology and findings should be reported in detail. The claims folder should be furnished to the examining rheumatologist prior to the evaluation in order to facilitate the study of the case. 2. The RO should then readjudicate the veteran's claims (for an increased evaluation for psoriatic arthritis of multiple joints and a total disability rating based upon individual unemployability) in light of the additional evidence obtained. Such action should specifically include consideration of recently submitted VA outpatient treatment records for the period from January 1989 to August 1994. Following completion of the above actions, should the veteran's claims remain denied, the veteran and his representative should be provided with an appropriate supplemental statement of the case, and be given an ample opportunity to respond. The case should then be returned to the Board for further appellate consideration. In this REMAND of the claim for further development, the Board does not intimate any opinion as to the ultimate determination warranted. No action is required of the appellant until he receives further notice. J. U. JOHNSON 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. Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1993).