Citation Nr: 1308054 Decision Date: 03/11/13 Archive Date: 03/20/13 DOCKET NO. 08-29 055 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUE Entitlement to a disability rating in excess of 30 percent for bronchial asthma. REPRESENTATION Appellant represented by: Daniel G. Krasnegor, Attorney at Law WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J.R. Bryant, Counsel INTRODUCTION The Veteran had active service from August 1964 to August 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2007 rating decision issued by the above Department of Veterans Affairs (VA) Regional Office (RO). In May 2011, the Veteran testified at a hearing before the undersigned Veterans Law Judge at the RO. A transcript of the hearing has been associated with the claims file and has been reviewed. This case was then remanded by the Board in September 2011 for additional development and readjudication. In this case, recent VA medical records, available through the Compensation and Pension Records Interchange (CAPRI), were uploaded to the Veteran's electronic Virtual VA folder in November 2011 and January 2012 and considered by the RO in the most recent Supplemental Statement of the Case. Because the current appeal includes records that are located only in the Virtual VA system, any future consideration of this Veteran's case should take into consideration the existence of this electronic record. In October 2012, VA obtained an advisory opinion from the Veterans Health Administration (VHA). See 38 U.S.C.A. § 7109 (West 2002); 38 C.F.R. § 20.901 (2012). The resulting VHA opinion was received by the Board the same month. The opinion was forwarded to the Veteran with no further evidence or argument presented. Accordingly, the Board will address the merits of the claim. FINDING OF FACT The Veteran's asthma has been managed by an anti-inflammatory medication and inhalational bronchodilator therapy on a daily basis, but has not required monthly visits to a physician or at least 3 courses of systemic corticosteroids per year. The weight of pulmonary function test findings show no worse than FEV-1 (Forced Expiratory Volume in one second) of 71 to 80 percent predicted, or FEV-1/FVC (Forced Expiratory Volume in one second to Forced Vital Capacity) of 71 to 80 percent. CONCLUSION OF LAW The criteria for a disability rating in excess of 30 percent for bronchial asthma are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.7, 4.97, Diagnostic Code (DC) 6602 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Duty to Notify and Assist Before addressing the merits of the issue on appeal, the Board notes that VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all five elements of a service-connection claim (veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. Neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). None is found by the Board. Indeed, VA's duty to notify has been more than satisfied. The Veteran was notified via letter dated in October 2006 of VA's duty to assist him in substantiating his claim under the VCAA, and the effect of this duty upon his claim. This letter also informed him of how disability ratings and effective dates are assigned. See Dingess, 19 Vet. App. at 484. Subsequent letters in July 2008, September 2008, and February 2010 notified the Veteran of the types of evidence that may reflect a worsening of his service-connected asthma, including the nature and symptoms of the condition; the severity and duration of the symptoms; and the impact of the condition and symptoms on employment and daily life. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The timing defect of this correspondence was cured by the RO's subsequent readjudication of the claim and issuance of a Statement of the Case in September 2008 and Supplemental Statement of the Case in February 2010. Together, these letters addressed all notice elements. Nothing more was required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). The Board also finds VA has satisfied its duty to assist the Veteran in the development of the claim adjudicated herein. His in-service and pertinent post-service treatment reports are of record and VA examinations were obtained in November 2006, May 2009, and January 2012. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the November 2006, and May 2009 VA examinations are more than adequate, as the Veteran underwent a physical evaluation (to include pulmonary function testing). In addition, both reports reflect a full review of all medical evidence of record and provide sufficient detail to rate the Veteran's service-connected asthma, including a thorough discussion of the effect of his symptoms on his functioning. 38 C.F.R. § 4.2 (2012); Abernathy v. Principi, 3 Vet.App. 461, 464 (1992) (citing Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (holding that if the examination report does not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate). However, the Veteran, through his representative, has challenged the adequacy of the January 2012 VA examination, on the basis that although the Veteran had been prescribed parenteral corticosteroids on a daily basis the examiner, a nurse, did not check the box indicating so. It was further argued that because the nurse did not consider the Veteran's use of inhaled corticosteroids, or explain why the Veteran did not require the daily use of high-dose corticosteroids, the opinion was inadequate and could not be used to deny a 100 percent rating. See Statement from Veteran's Attorney received in July 2012. As noted in the Introduction above, the Board obtained an VHA opinion in October 2012, which reflects that a medical expert reviewed the claims folder and rendered an appropriate opinion based on the questions presented to him by the Board. This opinion is adequate for decision-making purposes, as it included a full review of the Veteran's claims file, is supported by sufficient detail, and refers to specific documents and medical history, as well as provides a clear classification of the prescribed medications used to treat the Veteran's service-connected bronchial asthma. Copies of this opinion were sent to the Veteran and his representative in December 2012. They were both provided with a 60-day period to review this opinion and provide additional evidence. No additional argument or evidence was received. Thus, there is adequate medical evidence of record to make a determination in this case. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion concerning the issue being decided herein has been met. 38 C.F.R. § 3.159(c)(4) (2012). As noted above, the Veteran was provided with a Board hearing in May 2011. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that the provisions of 38 C.F.R. § 3.103(c)(2) (2012) require that the hearing officer who chairs a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issues, and (2) the duty to suggest the submission of evidence that may have been overlooked. The Board finds that both duties were met during the hearing. It was clear during the hearing that the Veteran had a full understanding of the issue on appeal. In addition, the undersigned left the claims file open for 30 days to allow the Veteran to submit additional supporting evidence. For the above reasons, the Board finds that, consistent with Bryant, VA has complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) and that the Board can adjudicate the claim based on the current record. It must be noted that neither the Veteran nor his representative have asserted that VA failed to comply with the provisions of 38 C.F.R. § 3.103(c)(2) nor identified any prejudice in the conduct of the Board hearing. Thus, the Board finds that VA has satisfied its duty to assist the Veteran in apprising him of the evidence needed, and in obtaining evidence pertinent to his claim under the VCAA. No useful purpose would be served in remanding this matter for yet more development. A remand would result in unnecessarily imposing additional burdens on VA, with no additional benefit to the Veteran. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); & Quartuccio v. Principi, supra. Law and Analysis The Veteran contends that his service-connected asthma disorder is more disabling than is reflected in the current 30 percent disability rating. He has reported that his use of Albuterol had increased to eight to ten inhalations a day. He also indicated that he had been instructed to take a steroid medication, Flovent, twice daily. See Notice of Disagreement, received in December 2007. He has also argued that he has daily asthma attacks, visits his private physician three to four times a year, and has used Prednisone by mouth. See May 2011 hearing transcript. More recently it appears that the Veteran and his attorney contend that the Veteran's prescribed daily use of corticosteroid inhalers is equivalent to daily parenteral use of corticosteroids and warrants the assignment of a disability rating in excess of 30 percent under the applicable rating criteria. See Statements from the Veteran's Attorney received in May 2012 and July 2012. Disability evaluations are determined by comparing a veteran's present symptoms with the criteria set forth in the VA Schedule for Rating Disabilities, which is based upon average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2012). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is considered when making disability evaluations. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1995). Although a review of the recorded history of a disability is necessary in order to make an accurate evaluation [38 C.F.R. §§ 4.2, 4.41], the regulations do not give past medical reports precedence over current findings where such current findings are adequate and relevant to the rating issue. Francisco v. Brown, 7 Vet. App. 55 (1994); Powell v. West, 13 Vet. App. 31 (1999). However, where the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. Fenderson v. West, 12 Vet. App. 119 (1999). The United States Court of Appeals for Veterans Claims (Court) has also held that staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis is undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The Veteran's bronchial asthma is currently assigned a 30 percent disability rating under DC 6602. This diagnostic code rates the severity of pulmonary disorders based primarily on objective numerical results of pulmonary function testing (PFT). Asthma is evaluated using the following tests: (1) Forced Expiratory Volume in one second (FEV-1) and (2) the ratio of FEV-1 to Forced Vital Capacity (FEV-1/FVC). 38 C.F.R. § 4.97. A revised regulation clarifying evaluation of respiratory conditions, 38 C.F.R. § 4.96(d), became effective October 6, 2006. See 38 C.F.R. § 4.96(d). The revision provides that when applying Diagnostic Codes 6600, 6603, 6604, 6825-6833 and 6840-6845, post-bronchodilator studies are required. Under DC 6602, a 10 percent evaluation is contemplated for FEV-1 of 71 to 80 percent predicted, FEV-1/FVC of 71 to 80-percent, or; intermittent inhalational or oral bronchodilator therapy. A 30 percent evaluation is contemplated for FEV-1 of 56 to 70 percent predicted, FEV-1/FVC of 56 to 70-percent, or; daily inhalational or oral bronchodilator therapy, or; inhalational anti-inflammatory medication. Assignment of a 60 percent evaluation is warranted where there is FEV-1 of 40 to 55-percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; at least monthly visits to a physician for required care of exacerbations, or; intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. For assignment of a 100 percent evaluation, there must be a showing of FEV-1 of less than 40 percent of predicted value, or; FEV-1/FVC of less than 40 percent, or; more than one attack per week with episodes of respiratory failure, or; requires daily use of systemic (oral or parenteral) high dose corticosteroids or immuno-suppressive medications. 38 C.F.R. § 4.97 (2012). The post-bronchodilator findings from the PFTs are the standard in pulmonary assessment. See 61 Fed. Reg. 46720, 46723 (Sept. 5, 1996) (VA assesses pulmonary function after bronchodilation as these results reflect the best possible functioning of an individual). It was also noted that using post-bronchodilation results would assure consistent evaluations. Id. at 46723. However, if the post-bronchodilator results are poorer than the pre-bronchodilator results, then the pre-bronchodilator results are used for rating purposes. See 38 C.F.R. § 4.96(d)(5) (2012). In a November 2006 VA respiratory examination report, the Veteran indicated that he was tried on steroid inhalers in the past but developed soreness of his throat, which required that particular form of therapy to be discontinued. He reported that he had not received steroids in the form of oral tablets or by any other method and that his symptoms were more or less uniform throughout the year without any seasonal intensification. Allergy etiology was not felt to be likely. The examiner commented that the Veteran worked in civilian community and automobile sales. With physical exercise, his symptoms may exacerbate and he would simply continue to use a meter dose inhaler (Albuterol) with two puffs every few hours as necessary. It was noted that the Veteran currently used his inhaler quite frequently during the day, up to five or six times when necessary, as well as occasionally at night. On physical examination, the lungs showed slightly decreased breath sounds generally as well as mild expiratory delay with forced expiration, but no wheezing. The clinical impression was chronic bronchial asthma. Corresponding PFT findings show a FEV-1 of 99 percent of predicted value before use of a bronchodilator, and 108 percent of predicted value after use of a bronchodilator. The Veteran's FEV-1/FVC was 74 percent, both pre- and post-bronchodilator. The examiner concluded the study showed spirometry with normal limits. Private treatment records include a statement from a private physician, who indicated that the Veteran had last been seen in April 2005 for his asthma. It was noted that his asthma was being treated with Albuterol (90 mcg) two puffs every four hours as needed. See Medical Statement from A. Campos, M.D, dated December 29, 2006. Also of record is a January 2007 prescription statement from a second private physician, indicated that the Veteran had been prescribed a Flovent inhaler. VA treatment records dated from 2006 to 2008 showed continued findings of asthma and complaints of exercise-induced symptoms. The Veteran reported past use of an unidentified oral steroid, but denied use of oral prednisone, and indicated he would to try levalbuterol MDI (metered dose inhaler). See VA outpatient treatment record dated November 7, 2006. A private treatment note reflects that the Veteran had been prescribed a course of Prednisone in April 2008. In a May 2009 VA respiratory examination report, the Veteran detailed that after service he required the use of Albuterol on more frequent levels to the point where he was getting short of breath with minimal exertion and using his inhaler 15 to 20 times daily. He indicated that he sought care from a private physician who prescribed Flovent and now used Albuterol two to five times daily as well as Flovent twice daily for treatment. He complained of daily coughing, wheezing when not using prescribed medications, and shortness of breath with exertion. It was noted that the Veteran was retired, working a part time job as a limousine driver, and that his problem did not limit his work. On physical examination, the Veteran had clear lungs, normal airflow, normal diaphragmatic movement with excursion with deep breaths to percussion, and no wheezes head to the chest. The examiner listed an assessment of asthma under treatment, noting that the Veteran required use of a steroid inhaler to control his symptoms, used daily medications, and had not used Prednisone recently. Corresponding PFT findings show FEV-1 was at 111 percent of predicted and FEV-1/FVC was at 76 percent pre-drug. It was indicated that post drug testing was not done secondary to normal pre-drug values. The Veteran admitted utilizing his Albuterol MDI 15-20 times a day. While he denied using his inhaler for at least four hours prior to testing, the examiner indicated that there was a strong possibility that he did use it. The Veteran further reported that his private physician was aware of the MDI overuse and had incorporated a steroid into his regimen in order to decrease Albuterol usage. A June 2009 addendum report listed a PFT interpretation of normal spirometry, lung volumes, and DLCO. A June 2009 fax report showed VA prescribed inhalation medications included use of Asmanex twisthaler as well as Formoterol twice daily. Additional VA treatment notes dated from 2009 to 2012 detail continued findings of asthma and prescribed medications including, Mometasone Formoterol, and Flovent, an inhaled corticosteroid. A June 2009 VA pulmonary consult record shows continued complaints of daily asthma symptoms with Albuterol use 15-20 times a day as well as weekly nighttime symptoms reported. The clinical impression was severe, persistent asthma with improving control, but still poorly controlled. The examiner noted that if the Veteran continued to have uncontrolled disease despite adding Formoterol, he would consider adding Singulair and Spiriva. An April 2011 medication list from a private treatment provider, which details the Veteran's prescribed medications including Asmanex, Flovent, and Albuterol. The remaining records show findings of asthma and prescribed medications of Albuterol, Mometasone, Symbicort 160/4.5 inhaler 2 puffs twice daily along with aerochamber, and Formoterol. See VA outpatient treatment record, dated September 30, 2011 The Veteran was most recently examined by VA in January 2012. At that time he reported that his prescribed medications included Budesonide by oral inhalation twice daily as well as use of daily rescue medication one to two times per night and during the day based on his activity level and the time of year. The examiner, a VA nurse practitioner, indicated that the Veteran had been diagnosed with asthma, which required intermittent courses or bursts of systemic (oral or parenteral) corticosteroids with zero courses or bursts in the last 12 months. It was further indicated that the Veteran's respiratory condition required the use of inhalational bronchodilator therapy on a daily basis and the use of inhalational anti-inflammatory medication on a daily basis. The Veteran did not require the use of antibiotics or oxygen therapy. He was also noted to have a history of asthma attacks or exacerbations with more than one attack per week, but no respiratory failure, no physician visits for required care of exacerbations, and no significant findings on 2006 chest X-ray. The Veteran was currently retired. On physical examination, the Veteran was noted to have abnormal breath sounds on the right and left with wheezes, moderation impairment between asthma attacks, and normal chest expansion and diaphragm excursion. After reviewing the claims file and examining the Veteran, the examiner found that reported symptoms were consistent with severe, persistent asthma. She indicated that there was no evidence to suggest that the Veteran had required oral steroid treatments to control his asthma condition since 2008, when there was documentation of a single short oral steroid prescribed after a flu illness caused exacerbation of the Veteran's asthma. It was reiterated that the Veteran denied frequent visits to his medical providers due to exacerbation of his asthma condition, as he reported that he saw his primary provider three to four times a year for regular follow-up on his asthma condition and was not seen in the VA pulmonology clinic since 2009. Corresponding PFT findings show a FEV-1 of 113 percent of predicted value before use of a bronchodilator, and 117 percent of predicted value after use of a bronchodilator. The Veteran's FEV-1/FVC was 80 percent pre-bronchodilator and at 79 percent post-bronchodilator. The examiner concluded the study showed spirometry with normal limits. A January 2012 addendum report listed a PFT interpretation of normal spirometry without significant improvement post bronchodilator and supranormal DLCO. In statements dated in May and July 2012, the Veteran's attorney argued that the January 2012 VA examination was inadequate, as the examiner found that the Veteran only required the use of oral or parental corticosteroids in intermittent courses or bursts, despite the fact that the Veteran had been prescribed daily parenteral use of corticosteriods. He charged that the examiner did not consider the Veteran's use of inhaled corticosteroids. He asserted that the Veteran had been prescribed a high dosage corticosteroid (Budesonide 160/Symbicort) and another corticosteroid (Albuterol) by VA for daily use. He argued that VA regulations provided that high dosage corticosteroids, such as Budesonide and Albuterol, which were taken orally or parenterally, entitled the Veteran to a 100 percent rating. He then cited to an internet treatise article that indicated that "parenteral" administration included "inhalation therapy" as well as other internet treatise articles discussing Beclomethasone oral inhalation and Prednisone. For further medical comment on this issue, the Board requested a VHA opinion in October 2012 from a pulmonologist who reviewed the detailed medical record, including facts pertinent to the Veteran's case. The Board received the expert medical opinion the same month. The VHA essentially concluded that the Veteran's various combination of drugs, including inhalant corticosteroids coupled with a long-acting bronchodilator, are not considered parenteral (i.e. not by mouth) or systemic use of corticosteroid therapy that would favor entitlement to a higher rating for more severe disease. In discussing the rationale of the opinion, the VHA noted that the Veteran has had bronchial asthma since 1965, and continued pulmonary function studies remain within predicted normal limits after aerosol bronchodilator administration, and therefore, by regulation, he is not entitled to compensation on the basis of any PFT abnormalities. In addition, over many examinations for more than 10 years, some by pulmonary disease specialists, this diagnosis has been confirmed and by current symptomatic classification would be termed asthma, chronic persistent, based on daily flares including some nocturnally. However, he has not apparently required repeated emergency room visits, multiple courses of intermittent or continued oral corticosteroids, hospitalization, or ICU care, and therefore should not be considered "severe." The VHA also determined that with multiple drug treatments, by VA and private physicians at several institutions, the Veteran has received almost all of the various asthma medications by commercial and chemical names, with the exception of significant use of intravenous or oral corticosteroids therapy, over this extensive time period. From the onset of recorded treatment to the present the Veteran has abused Albuterol and similar "rescue" bronchodilators by excessive daily frequency beyond any acceptable treatment guidelines. The examiner noted that this was particularly unfortunate for patients with established neuropsychiatric disorders, because of the known excess adrenergic stimulation of these drugs when taken in excessive amounts. However he went on to note that the Veteran had correctly received many inhalant corticosteroids drugs on a daily basis, even though he initially avoided this most important, "preventive" therapy, because of a sore throat side effect. In more recent care the Veteran has received a combination of drugs such as Symbicort or Advair that contain a higher doses of inhalant corticosteroid coupled with a long-acting bronchodilator in an attempt to modify his excessive use of the "rescue" bronchodilator usual Albuterol. However this is not parenteral (i.e. not by mouth) or systemic used of corticosteroid therapy that would favor entitlement to a higher rating for more severe disease. The Board finds, after a careful review of all pertinent evidence in light of the above-noted criteria, that the Veteran's respiratory symptomatology continues to meet or more nearly approximate the severity of bronchial asthma contemplated for the assigned 30 percent disability rating under DC 6602. In reaching this conclusion, significant weight is accorded to the findings from the three PFTs currently of record, none of which fall within the prescribed ranges for a higher rating (FEV-1 of 40-55 percent predicted or FEV-1/FVC of 40-55 percent). See VA PFT results from November 2006, May 2009, and January 2012 [noting a FEV-1 of at least 99 percent of predicted value pre-bronchodilator, and 108 percent post-bronchodilator and FEV-1/FVC of at least 74 both pre- and post bronchodilator]. In fact, the results from these PFTs reveal FEV-1 and FEV-1/FVC values that are higher than the ranges required for the currently assigned 30 percent disability rating for bronchial asthma (FEV-1 of 56-70 percent predicted or FEV-1/FVC of 56-70 percent). Accordingly, the Veteran's PFT testing results alone do not warrant an increased disability rating to 60 or 100 percent. With respect to medication, the record documents the Veteran's daily use of multiple medications, including an Albuterol inhaler, and other inhaled corticosteroids such as Flovent, Asmanex, and Mometasone Formoterol. In any case, there is no medical evidence that the Veteran requires intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. Crucially, DC 6602 distinguishes between "inhalational" therapy and "systemic" therapy. Specifically, if no more than "inhalational" therapy is required, a 10 or 30 percent disability rating is assigned. If treatment requires "systemic" therapy, higher ratings are assigned depending on frequency of use. By its own language, DC 6602 indicates that bronchial asthma treated by inhalational therapy alone is rated differently than those requiring non-inhalational, systemic therapy. See LaPointe v. Nicholson, 21 Vet. App. 411, 2006 WL 2797153 (Vet. App. 2006) (noting that "DC 6602 clearly makes a distinction between the intermittent or daily use of systemic corticosteroids and the intermittent or daily use of inhaled corticosteroids"). Indeed, the Court in LaPointe affirmed the Board's previous finding that DC 6602 "requires, among other things, the systemic use of oral or parenteral, not inhaled, corticosteroids to qualify for a rating higher than 30[%]." See id. [The Board acknowledges that LaPointe is a non-precedential decision, but notes that a non-presidential decision may be cited "for any persuasiveness or reasoning it contains." See Bethea v. Derwinski, 252, 254 (1992)]. The Board recognizes that the Veteran had been prescribed an oral steroid (Prednisone) in April 2008, but it was not prescribed frequently enough (three or more times per year) to warrant a 60 percent disability rating. With respect to the frequency of treatment, the evidence of record clearly shows the Veteran has an ongoing problem with his respiratory symptoms, however it does not establish that he requires monthly visits to a physician for exacerbations. Moreover, the Veteran has confirmed throughout the course of this appeal he has not required emergency room treatment or hospitalization. Therefore, the criteria for a disability rating in excess of 30 percent simply are not met. The Veteran has also supplemented his contentions with a link for internet treatise information, cited as www.wellness.com/reference/health-and-wellness/routes-of-administration, which he stated showed that parenteral administration encompassed his inhalation therapy. The Court has held that medical article or treatise evidence can provide important support when combined with an opinion of a medical professional. See Mattern v. West, 12 Vet. App. 222, 228 (1999) [citing Rucker v. Brown, 10 Vet. App 67 73-74 (1997) (holding that evidence from a scientific journal combined with doctor's statements "adequate to meet the threshold of plausibility")]. A review of that link does in fact show that routes of administration for medication are divided into four categories, including topical, enternal, parenteral, and other. While the "parenteral" category included inhalational therapy (e.g. inhalational anesthetics), the Board must draw specific attention to the "topical" category, which also specifically included inhalational therapy (e.g. asthma medications). To further the distinction between systemic (oral or parenteral) corticosteroids and inhaled corticosteroids, parenteral is defined as "not through the alimentary canal, but rather by injection through some other route, such as subcutaneous, intramuscular, intraorbital, intracapsular, intraspinal, intrasternal, and intravenous." See Dorland's Illustrated Medical Dictionary 1403 (31st ed. 2007). In this case, the internet research materials associated with the file are general in nature, do not specifically relate to the facts and circumstances surrounding this particular case, and are not accompanied by the opinion of any medical expert. In fact, the Veteran has submitted no medical opinion in support of his claim. Moreover the highly probative VHA's opinion establishes that the Veteran's combination of various inhalant corticosteroids and bronchodilator therapy was not considered the equivalent of parenteral or systemic corticosteroid therapy. Here, the only probative medical opinion of record is against the Veteran's claim. Therefore, while the Board has considered the Internet information, it is not sufficient to outweigh the 2012 VHA opinion. The Board has considered rating the Veteran's service-connected asthma under other diagnostic codes pertaining to restrictive lung disease, in order to provide him with the most beneficial rating. However, there is no evidence that he has diaphragm paralysis or paresis, spinal cord injury with respiratory insufficiency, kyphoscoliosis, pectus excavatum, pectus carinatum, traumatic chest wall defect, pneumothorax, hernia, post-surgical residuals, chronic pleural effusion of fibrosis, sarcoidosis, or sleep apnea. 38 C.F.R. § 4.97, DCs 6840-6847 (2012). The Board has considered the provisions of 38 C.F.R. § 3.321(b)(1), which provide for consideration of an extraschedular rating is in order when there exists such an exceptional or unusual disability picture so as to render impractical the application of the regular schedular standards. Therefore, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). In this case, the schedular evaluation in this case is adequate. The Veteran has not identified any factors which may be considered to be exceptional or unusual as to render impractical the application of the regular schedular standards, and the Board has been similarly unsuccessful. As discussed above, there are higher ratings available for the Veteran's service-connected asthma, but the required manifestations have not been shown in this case. Moreover, there is no evidence that the service-connected asthma has required hospitalization at any pertinent time during this appeal and the VA examination report and VA outpatient treatment records are void of any finding of exceptional symptomatology beyond that contemplated by the schedule of ratings. In addition, the Board has no reason to doubt that the Veteran's symptomatology adversely impacts his employability and does not dispute the Veteran's contentions that his asthma has caused him to alter his lifestyle and restrict his activities. Even so, such complaints have been taken into consideration in the decision to assign the current evaluation. In other words, the regular schedular standards contemplate the symptomatology shown. Accordingly, the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Finally, in reaching the above conclusions, the Board has not overlooked the Veteran's contentions, his complaints to healthcare providers, and is cognizant of the arguments put forth by the Veteran and his attorney, asserting that the Veteran had been prescribed daily parenteral use of corticosteriods. While the Board freely acknowledges that maintenance of the Veteran's asthma does require the daily use of corticosteroids, his prescribed medications during the appeal period are shown to be delivered via an inhaler. For all the foregoing reasons, the Veteran's claim for entitlement to an evaluation in excess of 30 percent for bronchial asthma must be denied. The Board has reviewed the claim mindful of the guidance of Hart, supra. The current level of disability shown is encompassed by the current disability rating assigned, and, with due consideration to the provisions of 38 C.F.R. § 4.7, a higher evaluation is not warranted for this disability for any portion of the time period under consideration. Lastly, the Court has recently held that a request for a total disability rating based on individual unemployability due to service-connected disability (TDIU), whether expressly raised by a claimant or reasonably raised by the record, is an attempt to obtain an appropriate rating for disability or disabilities, and is part of a claim for increased compensation. There must be cogent evidence of unemployability in the record. Rice v. Shinseki, 22 Vet. App. 447 (2009), citing Comer v. Peake, 552 F.3d 1362 (Fed. Cir. 2009). However, the holding of Rice is inapplicable here because the evidence of record does not illustrate that the Veteran's service-connected asthma prevents him from obtaining and maintaining gainful employment-nor has the Veteran so contended. Rather the Veteran is currently retired and working part time as a limousine driver. In fact, during the May 2009 VA examination, the Veteran specifically indicated that his service-connected disability did not limit his work as a part time limousine driver. At this point, therefore, there is no cogent evidence of unemployability due solely to this service-connected disability, and the issue of entitlement to a TDIU need not be addressed further. ORDER Entitlement to an evaluation in excess of 30 percent for bronchial asthma is denied. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs