Citation Nr: 0126736 Decision Date: 11/26/01 Archive Date: 12/03/01 DOCKET NO. 94-39 480 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUE Entitlement to an increased rating for rheumatic heart disease with mitral insufficiency, currently rated as 10 percent disabling. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Elizabeth Spaur, Associate Counsel INTRODUCTION The veteran had active service from June 1946 to September 1947. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 1992 decision by the Department of Veterans Affairs (VA) Pittsburgh, Pennsylvania, Regional Office (RO). That decision denied an increased rating for rheumatic heart disease with mitral insufficiency. This matter was remanded by the Board in January 1997. The remand specified that the RO must obtain the veteran's private and VA treatment records and provide the veteran with a VA examination. In November 1999, the Board noted that the criteria for rating rheumatic heart disease had been revised, and remanded the claim for a new VA examination. In March 2001, the Board remanded the claim for a VA examination to determine the current severity of the veteran's disease as the previous examination did not address all the relevant rating criteria. The requested development has since been completed and the case is now ready for appellate review. FINDINGS OF FACT 1. All evidence necessary for review of the issue on appeal has been obtained. 2. The veteran has left ventricular dysfunction with an ejection fraction of 30 to 50 percent. CONCLUSION OF LAW The criteria for an increased rating of 60 percent for rheumatic heart disease with mitral insufficiency are met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.104, Diagnostic Code 7000 (2000). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Veterans Claims Assistance Act On November 9, 2000, the President signed into law the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000). The Act is applicable to all claims filed on or after the date of enactment, November 9, 2000, or filed before the date of enactment and not yet final as of that date. See Karnas v. Derwinski, 1 Vet. App. 308 (1991). The new law eliminates the concept of a well- grounded claim, and redefines the obligations of the VA with respect to the duty to assist in the development of claims. First, the VA has a duty to notify the veteran and his representative, if represented, of any information and evidence needed to substantiate and complete a claim. 38 U.S.C.A. §§ 5102 and 5103 (West Supp. 2001). Second, the VA has a duty to assist the veteran in obtaining evidence necessary to substantiate the claim. 38 U.S.C.A. § 5103A (West Supp. 2001). The Board finds that the VA's duties have been fulfilled. The veteran was provided with adequate notice as to the evidence needed to substantiate his claim. The Board concludes that the discussions in the decision, statement of the case (SOC), the supplemental statements of the case (SSOCs), and the letters sent to the veteran informed him of the information and evidence needed to substantiate the claim and complied with the VA's notification requirements. The RO supplied the veteran with the applicable regulations in the SOC. The Board also finds that all relevant facts have been properly developed, and that all evidence necessary for equitable resolution of the issue on appeal has been obtained. The evidence includes the veteran's private and VA treatment records, three VA examination reports, and the veteran's statements and testimony before a hearing officer at a hearing held at the RO in July 1993. For the reasons stated above, the Board concludes that all reasonable efforts were made by the VA to obtain evidence necessary to substantiate the veteran's claim. The Board finds that the evidence of record provides sufficient information to adequately evaluate the veteran's claim for entitlement to an increased rating for rheumatic heart disease with mitral insufficiency. Therefore, no further assistance to the veteran with the development of evidence is required. VA has issued final rules to amend adjudication regulations to implement the provisions of the VCAA. 66 Fed. Reg. 45,620 (Aug. 29, 2001) (to be codified as amended at 38 C.F.R §§ 3.102, 3.156(a), 3.159 and 3.326(a)). The intended effect of the new regulations is to establish clear guidelines consistent with the intent of Congress regarding the timing and the scope of assistance VA will provide to a claimant who files a substantially complete application for VA benefits, or who attempts to reopen a previously denied claim. The Board has reviewed the facts of this case in light of the new VCAA regulations. As discussed above, VA has made all reasonable efforts to assist the veteran in the development of his claim and has notified him of the information and evidence necessary to substantiate his claim. Consequently, the case need not be referred to the veteran or his representative for further argument as the Board's consideration of the new regulations in the first instance does not prejudice the veteran. See generally Sutton v. Brown, 9 Vet. App. 553 (1996); Bernard v. Brown, 4 Vet. App. 384 (1993); VA O.G.C. Prec. Op. No. 16-92 (July 24, 1992). II. Factual Background The veteran's service medical records indicate that he was admitted to the sick list several weeks after he entered training. He was diagnosed with rheumatic fever in July 1946. It was noted that a harsh apical systolic murmur was present. He was transferred to the USNH, Dublin, Georgia where he was hospitalized until August 1947. The diagnosis was valvular heart disease, mitral insufficiency. It was again noted that he had a harsh apical systolic murmur. The report of a medical survey conducted in August 1947 shows that he was found to be unfit for further service as a result of the disorder. Shortly after service, in November 1947, the veteran was service-connected for valvular heart disease with mitral insufficiency, rated as 30 percent disabling. A letter from a private physician, dated in December 1947, shows that he found that the veteran had "the typical mitral murmur of rheumatic heart disease." The RO subsequently confirmed the 30 percent rating in February 1948. The report of a VA exam conducted in November 1951 shows that the impression was rheumatic heart disease with organic mitral insufficiency. In November 1951, the RO reduced the veteran's disability rating from 30 to 10 percent. The RO's reasoning was that a recent examination had revealed no definite myocardial damage was shown on ECG and the x-ray was normal. The veteran appealed the decision, which was affirmed by the Board in September 1952. In June 1956, a consulting physician wrote a letter on the veteran's behalf. The physician had seen the veteran in consultation in June 1956 for evaluation of his cardiovascular system as regards a history of rheumatic heart disease. The physician noted a history consistent with the veteran's service medical records. He also indicated that, since 1952, the veteran had suffered several (at least four) episodes of "strep throat", one of which was accompanied by a slight swelling of one knee, but there had been no definite or prolonged joint disturbances or other symptomatology resembling recurrent acute rheumatic fever. The veteran noted no decreased exercise tolerance, no external dyspnea, no orthopnea, no chest pain, no nocturnal paroxysmal dyspnea, no ankle edema, no hemoptysis, no syncope, and no undue fatigability. On examination, the veteran's heart was not enlarged to percussion, the rhythm was regular sinus, and the heart sounds were of good quality. There was a somewhat harsh Grade I short early apical systolic murmur transmitted to the left axilla, which after exercise was intensified to Grade III. No diastolic murmurs were heard. The June 1956 letter further shows that the physician expressed the opinion that, based on the evidence, the veteran suffered from inactive rheumatic heart disease, with deformity of the mitral valve (mitral insufficiency), and abnormal ECG. The physician went on to state his belief that the valvular damage suffered by the veteran as a result of rheumatic fever was permanent and the veteran was a candidate for further heart damage from recurrent rheumatic episodes. The RO confirmed the 10 percent rating in a decision of August 1956. VA treatment notes from 1986 to 1989 indicate the veteran received treatment to monitor his heart condition. In September 1986, the veteran was seen for a six month check- up. He complained of occasional substernal discomfort which he described as pain without any radiation, dyspnea or diaphoresis. On examination, the veteran had a normal sinus rhythm with a Grade II/IV systolic murmur over the apex. At a follow-up in April 1987, the veteran indicated that he was continuing to have substernal pain. He denied having any dyspnea. In August 1987, the veteran sought treatment for occasional mild chest pains. A September 1987 echocardiogram found mild aortic insufficiency and an incidental finding of intact ventricular function with mild concentric left ventricular hypertrophy. Private treatment notes indicate that the veteran had a myocardial infarction in December 1991. He was hospitalized from December 9 to December 17, 1991. There was an acute inferior posterior myocardial infarction due to thrombotic occlusion of the dominant right artery. A cardiac catheterization was conducted while the veteran was in the hospital. The catheterization report noted a 60 to 70 percent long, diffuse narrowing in the proximal to mid portion of the right coronary artery which was dominant. Probable intraluminal thrombus was also noted. A 50 percent stenosis in a large minimal branch was present as well as 75 percent lesions in a small intermediate artery which were felt to be insignificant. Left ventriculography revealed inferior and inferobasal akinesis with moderate reduction of the left ventricular function and mild mitral regurgitation. A December 1991 chest x-ray noted that the heart was normal size without congestive heart failure. A December 1991 echocardiogram showed trivial mitral regurgitation and mild aortic insufficiency. The veteran's hospital discharge report noted the possibility of a soft systolic murmur. February 1992 stress tests noted that the veteran achieved an exercise heart rate of 162, which was 92 percent of his maximum predicted heart rate exercise. He experienced no chest discomfort during or post exercise. Immediately after exercising, the veteran underwent cardiolite imaging. The cardiolite imaging report noted an abnormal cardiolite stress test showing a fixed region of hypoperfusion indicating an inferior wall scar. In April 1992, the veteran requested an increased rating for his service-connected rheumatic heart disease with mitral insufficiency, currently rated as 10 percent disabling. A June 1992 VA examination report noted a history consistent with previous treatment records. On examination, the veteran had a regular rate and rhythm without murmurs, gallops or rubs. Despite an ECG report of aortic insufficiency, the examiner could not appreciate any systolic or diastolic murmurs. Circulation in all extremities was excellent with no signs of ischemia, cyanosis, venous stasis changes or varicose veins. The examiner noted a history of myocardial infarction in December 1991 with evidence on catheterization of an occlusion of the right coronary artery to the 60 to 70 percent range. Stress testing showed an inferior wall scar, but the ECG did not show any cardiac enlargement. The examiner also noted a history of rheumatic heart disease with no evidence of congestive heart failure at the time. The examiner appreciated no murmur at the time either, although the veteran stated that he had a history of a systolic murmur and the ECG did report a mild aortic insufficiency. The veteran had no obvious evidence of peripheral vascular disease at that time. The veteran testified at a hearing held at the RO before a hearing officer in July 1993. He stated that he has had check ups every three to six months since his separation from service. He indicated that he gets short of breath and light headed while walking. The veteran testified that his wife now handles the running of their store because he cannot do any physical work. An October 1993 echocardiogram showed mitral and aortic regurgitation. In addition, the veteran's global ejection fraction was estimated at 35 percent. An echocardiogram conducted in September 1994 indicated a mildly sclerotic aortic valve with trivial aortic insufficiency and moderate to severe reduction in left ventricle function with an ejection fraction of 30 percent. A VA examination was conducted in August 1997. The examiner reviewed the veteran's claim folder. The examiner noted the veteran's history of rheumatic heart disease and stated the veteran's recent echocardiograms indicated a mild mitral regurgitation. He indicated that there was nothing to indicate a connection between the rheumatic fever in the past and the veteran's myocardial infarction or coronary artery disease. A VA examination conducted in April 2000 notes a history consistent with previous treatment records. At the time of the exam the veteran had no history of peripheral edema. He had no chest pain, syncope or presyncope. The veteran stated that he was able to walk at his own pace for a mile around his housing complex. The examiner noted that the ejection fraction by left ventriculography in 1991 was approximately 45 percent. However, that study was not conducted in a manner to allow assessment of the valvular heart disease. On examination, the veteran was in no acute distress. Heart size was not enlarged on physical examination. There was a grade 2 systolic murmur. The examiner's assessments included atherosclerotic heart disease, prior inferior wall myocardial infarction and rheumatic valvular heart disease by history. An ECG done in May 2000 revealed a moderate left ventricle dysfunction with inferoposterior and lateral akinesia at the base and HK at the mid and distal wall. An exercise stress thallium done in June 2000 revealed a large severe inferolateral to inferior fixed defect. The infarcted zone was hypokinetic, with a moderate decrease in overall left ventricular function with an estimated injection fraction of 42 percent. Another VA examination was conducted in April 2001. The examiner reviewed the veteran's claim file and noted his history of rheumatic fever in service and history of chest pain in 1991. At the time of the examination, the veteran complained of easy fatigability that had become progressively worse over the past three to five years. The veteran denied orthopnea, lower extremity edema, syncope, presyncope, paroxysmal nocturnal dyspnea or any anginal or non-anginal chest pain. The veteran's ambulation was limited by a knee problem and dyspnea on exertion. The veteran stated that he could work at a slow pace for three to five hours as long as he rested prior to that. The veteran indicated he also developed dyspnea when climbing up stairs and with activities such as mowing the lawn. On examination, cardiac auscultation revealed a regular rate and rhythm. There was a holosystolic murmur at the left lower sternal border and apex with mild radiation to the axilla. The examiner commented on the echocardiogram done in May 2000. There was reduced ejection fraction, 35 to 45 percent, and focal wall abnormalities indicative of coronary artery disease. The left ventricle end systolic diameter was mildly increased. Left ventricle diastolic diameter was within normal limits. There were no significant valvular abnormalities noted. There was trivial mitral regurgitation, which was not considered significant. The April 2001 examiner noted that there was no significant documentation of valvular disease present in prior echocardiographic studies found in the claims file. An exercise test was not performed since the veteran was last evaluated less than twelve months prior to the VA exam. The examiner noted that in June 2000, the veteran exercised eight minutes and eight seconds completing stage 2 on a Bruce protocol to his maximum tolerated exercise capacity. The peak heart rate achieved was 167 bpm, which was 95 percent of the age-predicted maximum. The test was stopped due to dyspnea. The veteran did not develop chest pain during or following the exercise. The peak blood pressure was 180/100 and the estimated peak oxygen consumption was 10 METS. The blood pressure response was normal and the veteran's overall functional capacity was normal. There was some ECG evidence of ischemia that occurred relatively late into stress (seven minutes). After reviewing the veteran's claim file, the May 2000 echocardiogram report, the June 2000 stress test and conducting a physical examination, the April 2001 examiner diagnosed the veteran with significant coronary artery disease, status post myocardial infarction, a history of rheumatic fever, congestive heart failure with documented reduced left ventricle systolic function and some symptoms of congestive heart failure. The examiner noted the congestive heart failure was likely secondary to coronary artery disease and not valvular heart disease. The examiner expressed the opinion that the veteran has symptomatic left ventricular failure secondary to coronary artery disease with myocardial infarction. The examiner noted the evidence reviewed indicated no significant valvular disease and stated that to the examiner's knowledge the veteran's heart failure was unlikely to be related to his history of rheumatic fever. III. Criteria Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity in civil occupations. See 38 U.S.C.A. § 1155. Separate diagnostic codes identify various disabilities. The assignment of a particular diagnostic code is dependent on the facts of a particular case. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One Diagnostic Code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. In reviewing the claim for a higher rating, the Board must consider which Diagnostic Code or Codes are most appropriate for application of the veteran's case and provide an explanation for the conclusion. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). The Board notes that the veteran's heart disorder has been evaluated under 38 C.F.R. § 4.104, Diagnostic Code 7000. During the pendency of this appeal, the schedule for determining the disability evaluations to be assigned for disorders of the cardiovascular system were revised, effective January 12, 1998. See 62 Fed. Reg. 65219 (Dec. 11, 1997) (as amended at 63 Fed. Reg. 37779 (July 14, 1998). Where the law or regulations change while a case is pending, the version most favorable to the claimant applies, absent congressional intent to the contrary. Karnas v. Derwinski, 1 Vet. App. 308, 312-313 (1991). Accordingly, the Board will consider the veteran's claim for an increased rating under both the old and the new rating criteria. Pursuant to the criteria in effect prior to January 12, 1998 under 38 C.F.R. § 4.104, Diagnostic Code 7000 (1997), a 10 percent rating is warranted with identifiable valvular lesion, slight, if any, dyspnea, and the heart not enlarged following established active rheumatic heart disease. A 30 percent rating is warranted from the termination of an established service episode of rheumatic fever, or its subsequent recurrence, with cardiac manifestations, during the episode or recurring for three years, or diastolic murmur with characteristic EKG manifestations or a definitely enlarged heart. A 60 percent rating is warranted when the heart is definitely enlarged; there is severe dyspnea on exertion, elevation of systolic blood pressure, or such arrhythmias as paroxysmal auricular fibrillation or flutter or paroxysmal tachycardia; or more than light manual labor is precluded. A 100 percent rating is warranted where there is definite enlargement of the heart confirmed by a roentgenogram and clinically; dyspnea on slight exertion; rales, pretibial pitting at end of day or other signs of beginning congestive failure; or more than sedentary employment is precluded. A 100 percent rating is also warranted when the rheumatic heart disease is active and, with ascertainable cardiac manifestation, for a period of six months. The requirements (such as a definitely enlarged heart in the 30 percent criteria) are disjunctive as contemplated by the word "or" before "diastolic murmur" and before "definitely enlarged heart." 38 C.F.R. § 4.104, DC 7000. The use of the word "or" provides for an independent basis rather than an additional requirement. See Drosky v. Brown, 10 Vet. App. 251 (1997). See also Johnson (Gary) v. Brown, 7 Vet. App. 95, 97 (1994) (agreeing with memorandum by Secretary suggesting that criteria listed in 38 C.F.R. § 4.132, DC 9411, for 100% rating are each independent bases for granting such rating.) The regulatory revisions incorporate objective measurements of the level of physical activity, expressed numerically in metabolic equivalents (METs) at which cardiac symptoms develop. One MET is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. METs are measured by means of a treadmill test. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note 2. Pursuant to regulations effective January 12, 1998, under 38 C.F.R. § 4.104, Diagnostic Code 7000 (2000), a 10 percent rating is warranted when a workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, syncope; or where continuous medication is required. A 30 percent rating is warranted where a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or evidence of cardiac hypertrophy or dilations on electrocardiogram, or x-ray. A 60 percent ratings is warranted where there is more than one episode of acute congestive heart failure in the last year; or a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or with left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is warranted where there is chronic congestive heart failure; a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope; or where there is left ventricular dysfunction with an ejection fraction of less than 30 percent. A 100 percent rating is also warranted during active infection with valvular heart damage and for three months following cessation of therapy for the active infection. The Veterans Benefits Administration (VBA) Adjudication Procedure Manual M21-1, Part VI, (manual) provides that chronic rheumatic heart disease results from a single or repeated attacks of rheumatic fever which produce rigidity and deformity of the cusps, fusion of the commissures, or shortening and fusion of the chordae tendinae. The earliest evidence of organic heart disease is a significant murmur. The earliest evidence of hemodynamically significant valvular lesions is found on x-ray, fluoroscopy, and ECG study, since these will reveal the earliest stages of specific chamber enlargement. With a history of rheumatic fever in service, an aortic valve insufficiency that manifests some years later without other cause shown will be service connected. See M21-1, Part VI, paragraph 11.18d. Accepted medical principles do not concede an etiological relationship between rheumatic heart disease, and either hypertensive or arteriosclerotic heart disease. See M21-1, Part VI, paragraph 11.18e. Base additional compensation for hypertensive or arteriosclerotic heart disease developing after the presumptive period following discharge on the inability to satisfactorily dissociate or separate the effects of the conditions for rating purposes, rather than on the mere presence of arteriosclerotic or hypertensive heart disease. See M21-1, Part VI, paragraph 11.18f. In the absence of a verified rheumatic heart disease, such as valve pathology, or weakened heart muscles (congestive heart failure), the subsequent hypertensive and arteriosclerotic changes can be successfully dissociated, and service connection denied for these changes. See M21-1, Part VI, paragraph 11.18f(1). If verified rheumatic heart disease has been demonstrated, the effect of subsequent onset of hypertensive or arteriosclerotic heart disease which may also produce heart muscle changes and congestive failure cannot be satisfactorily dissociated from the rheumatic changes. Evaluate a combined cardiac disability as one entity under the service-connected rheumatic heart disease code. See M2- 1, Part VI, paragraph 11.18f(2). However, since medically there is no recognized relationship between rheumatic heart disease and the later developing hypertensive or arteriosclerotic changes, do not extend service connection to systemic manifestations or arteriosclerosis in areas remote from the heart. See M21-1, Part IV, paragraph 11.18f(3). The Board notes the VA General Counsel has held that certain provisions of the Manual M21-1 pertaining to claims involving rheumatic heart disease constitute regulations which are binding on the Board. See VAOPGCPREC 6-2000 (May 19, 2000). In particular, the General Counsel opinion stated that the last sentence of paragraph 11.18(d) and paragraph 11.18f(2) are considered substantive. The opinion further held that the introductory text of paragraph 11.18f, paragraph 11.18e, and the first three sentences of paragraph 11.18d of the manual are not substantive; however, the relevant factors discussed in the first three sentences of paragraph 11.18d and in paragraph 11.18e must be considered and addressed by the Board in assessing the evidence regarding a claim involving rheumatic heart disease in order to fulfill the Board's obligation under 38 U.S.C.A. § 7104(d)(1) to provide an adequate statement of reasons and bases for a decision. IV. Analysis The Board finds it to be significant that the veteran's service medical records indicate that he was diagnosed with rheumatic fever in July 1946, which resulted in valvular heart disease with mitral insufficiency. Also significant are early post-service treatment records which show valve damage such as a June 1956 consultation report indicated that the veteran had been diagnosed with inactive rheumatic heart disease, with deformity of the mitral valve (mitral insufficiency), and abnormal ECG. The physician also stated his opinion that the valvular damage suffered by the veteran as a result of rheumatic fever was permanent and the veteran was a candidate for further heart damage from recurrent rheumatic episodes. Since verified rheumatic heart disease has been demonstrated by records such as these, the Board concludes that the effect of subsequent heart disease cannot be satisfactorily dissociated from rheumatic changes. The Board notes also that aortic valve insufficiency which is noted in more recent treatment records is also considered to be service-connected. Accordingly, the Board must evaluate the combined cardiac disability as one entity under the service-connected rheumatic disease code. See M21-1, Part VI, paragraph 11.18f(2). The Board has noted the recent VA medical opinions which are to the effect that the veteran's current cardiac impairment is not related to his rheumatic heart disease; however, the Board is bound by the provisions of the manual. The VA exam in June 1992 showed an ejection fraction of 40 percent. A private echocardiogram, dated in October 1993, showed an ejection fraction of 35 percent. In addition, another private echocardiogram, dated in September 1994, showed an ejection fraction of 30 percent. Results from the veteran's May 2000 ECG indicate that he has left ventricular dysfunction with an ejection fraction between 35 and 45 percent. Under the revised Diagnostic Code 7000, a 60 percent disability rating is warranted when the veteran has left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Accordingly, the Board concludes that the veteran qualifies for a 60 percent disability rating under the revised Diagnostic Code. The veteran does not qualify for a 100 percent rating under either the previous or the revised criteria for Diagnostic Code 7000. He does not have a confirmed definite enlargement of the heart; dyspnea on slight exertion; rales, pretibial pitting at the end of the day or other definite signs of congestive heart failure; and more than sedentary employment is not precluded. In addition, the veteran does not have active rheumatic heart disease. See 38 C.F.R. § 4.104, Diagnostic Code 7000 (1997). The veteran does not suffer from chronic congestive heart failure; a workload of 3 METs or less does not result in dyspnea, fatigue, angina, dizziness, or syncope; and he does not have left ventricular dysfunction with an ejection fraction of less than 30 percent. See 38 C.F.R. § 4.104, Diagnostic Code 7000 (2000). Accordingly, the Board concludes that the criteria for a disability rating higher than 60 percent under Diagnostic Code 7000 have not been met. V. Extraschedular Consideration The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the disability. 38 C.F.R. § 4.1. The Board notes that in exceptional cases where evaluations provided by the rating schedule are found to be inadequate, an extraschedular evaluation may be assigned which is commensurate with the veteran's average earning capacity impairment due to the service-connected disorder. 38 C.F.R. § 3.321(b). However, the Board believes that the regular schedular standards applied in the current case adequately describe and provide for the veteran's symptoms and disability level. The record does not reflect a disability that is so exceptional or unusual that the normal provisions of the rating schedule would not adequately compensate the veteran for his service-connected disability. The Board notes that the disability has not recently required hospitalization. There is no evidence on the record of marked interference with employment and no medical evidence has been presented to support a conclusion that the veteran's service-connected disability significantly interferes with his employment. The Board also notes that his current rating contemplates a substantial degree of industrial impairment, and there is no reason to believe that the rating schedule does not adequately compensate the veteran for the impairment. In summary, the Board does not find that the veteran's case is outside the norm so as to warrant consideration of the assignment of an extraschedular rating. Therefore, referral of this matter for consideration under the provisions of 38 C.F.R. § 3.321 is not warranted. See Shipwash v. Brown, 8 Vet. App. 218, 227 (1995), and Floyd v. Brown, 9 Vet. App. 94-96 (1996). ORDER An increased rating of 60 percent for rheumatic heart disease with mitral insufficiency is granted, subject to the law and regulations applicable to the payment of monetary benefits. MICHAEL D. MARTIN Acting Member, Board of Veterans' Appeals