Citation Nr: 0814317 Decision Date: 04/30/08 Archive Date: 05/08/08 DOCKET NO. 97-25 899 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES Entitlement to an increased evaluation for irritable bowel syndrome (Crohn's disease), currently evaluated as 30 percent disabling. [The issues of entitlement to an increased evaluation for impaired sphincter control, separately rated as 30 percent disabling; and entitlement to special monthly compensation (SMC) on account of the need for aid and attendance at a higher level under 38 U.S.C.A. § 1114(r)(2) will be addressed in a separate decision with the same date and docket number]. REPRESENTATION Appellant represented by: Theodore R. Jarvi, Attorney at Law WITNESSES AT HEARINGS ON APPEAL Appellant and her husband ATTORNEY FOR THE BOARD A. A. Booher, Counsel INTRODUCTION The veteran had active service from July 1973 to March 1984. She was born in 1946. This appeal arose from a May 1997 rating action by the above Department of Veterans Affairs (VA), Regional Office (RO), which denied an evaluation in excess of 10 percent for the service-connected irritable bowel syndrome. In January 1998, the veteran testified at a personal hearing at the RO; in November 1998, the Hearing Officer issued a decision which continued the 10 percent disability evaluation assigned to the irritable bowel syndrome. In October 1999, the RO issued a rating action which increased the evaluation assigned to the irritable bowel syndrome to 30 percent. This rating action also granted compensation for the residuals of a gunshot wound to the left sternum under the provisions of 38 U.S.C.A. § 1151 and service connection for PTSD; an effective date of August 7, 1996 was assigned for both disabilities. In February 2000, the RO issued a rating action which awarded compensation for the residuals of a splenectomy and restrictive lung disease under the provisions of 38 U.S.C.A. § 1151; again, the effective date of this grant was August 7, 1996. The same rating action also confirmed and continued the 30 percent disability evaluation assigned for the service-connected irritable bowel syndrome. The veteran and her husband testified before the undersigned Veterans Law Judge of the Board of Veterans' Appeals (Board) at a Travel Board hearing at the VARO in January 2001. In April 2001, the Board denied entitlement to an effective date earlier than August 7, 1996, for the award of service connection for post traumatic stress disorder (PTSD); and granted entitlement to an effective date earlier than August 7, 1996, for the award of compensation for the residuals of a gunshot wound to the left sternum, a splenectomy and restrictive lung disease, under the provisions of 38 U.S.C.A. § 1151 (from June 3, 1992). The Board remanded the issue of entitlement to an evaluation in excess of 30 percent for irritable bowel syndrome. In a decision in October 2002, the Board denied entitlement to an evaluation in excess of 30 percent for irritable bowel syndrome. The veteran and her attorney filed an appeal of that decision with the United States Court of Appeals for Veterans Claims (Court) on the increased rating issue only. The Court vacated the Board decision and remanded the case for action in accordance with a Joint Motion. The veteran's motion to advance the case on the docket pursuant to 38 C.F.R. § 20.900(c) was granted by the undersigned Veterans Law Judge in August 2004. In August 2004, the Board remanded the issue of entitlement to an increased rating for irritable bowel syndrome. In a rating action by the VARO in June 2006, separate service connection was granted for impairment of sphincter control as a residual of the service-connected Crohn's disease, and a separate 30 percent rating was assigned from August 7, 1996. (Basic eligibility for Dependents Educational Assistance was also granted from April 13, 2006). The veteran and her spouse were present and provided testimony at a local hearing at the VARO in August 2006; a transcript is of record. In January 2008, the veteran and her spouse were present and provided testimony at a Travel Board hearing before another Veterans Law Judge at the VARO in January 2008; a transcript is of record. Service connection is now in effect for PTSD, rated as 100 percent disabling; restrictive lung disease, rated as 100 percent disabling; hysterectomy with right oophorectomy, rated as 30 percent disabling; inflammatory bowel disease rated as 30 percent disabling; impairment of sphincter control, rated as 30 percent disabling; splenectomy, rated as 20 percent disabling; residuals of gunshot wound to the left of the sternum, rated at 20 percent; and Morton's neuroma of the left foot, rated as noncompensably disabling. A TDIU was in effect from June 3, 1992 to August 6, 1996. The veteran is also in receipt of SMC on account of anatomical loss of a creative organ (38 U.S.C.A. § 1114(k); SMC on account of disabilities separately rated as 100 and 60 percent disabling from August 7, 1996, to April 22, 2004 (38 U.S.C.A. § 1114(s); and SMC on account of two disabilities independently rated as 100 percent disabling from April 22, 2004 (38 U.S.C.A. § 1114(p), 38 C.F.R. §§ 3.350(f)(4)). Aid and attendance (A&A) benefits were awarded from April 22, 2004. FINDINGS OF FACT 1. All reasonable development necessary for the disposition of the issue at hand has been completed. 2. Persuasive and credible medical evidence demonstrates that the veteran's irritable bowel syndrome (Crohn's disease) is currently manifested by periodic exacerbations, alternating diarrhea and constipation, with generally moderately severe impairment and stable weight; there is modest control with diet and medications, including steroids. 3. The additional associated and secondary symptoms of the veteran's Crohn's disease which involve sphincter control are rated separately and are not addressed in this decision, but in a separate decision of the same date and docket number. CONCLUSION OF LAW The criteria for a disability rating of in excess of 30 percent for service-connected irritable bowel syndrome are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.20, 4.113, 4.114, Diagnostic Code 7323 (2001, 2007). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits, as codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.159, 3.326(a) (2007). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant of the information and evidence not of record that is necessary to substantiate the claim; to indicate which information and evidence VA will obtain and which information and evidence the claimant is expected to provide; and to request that the claimant provide any evidence in the claimant's possession that pertains to the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The U.S. Court of Appeals for Veterans Claims has held that VCAA notice should be provided to a claimant before the initial RO decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, if VCAA notice is provided after the initial decision, such a timing error can be cured by subsequent readjudication of the claim, as in a Statement of the Case (SOC) or Supplemental SOC (SSOC). Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006). The rather convoluted adjudicative history of the current claim and its several separate facets are addressed above. With regard to the issue herein concerned only, numerous ratings actions since 1997 to date, as well as SOC and SSOCs, multiple Board and Hearing Officer hearings at the RO, remands by the Board and Court, and numerous other communications have fully apprised the veteran, her husband, and her attorney as to what is required to support her claim The U.S. Court of Appeals for the Federal Circuit has held that, if a claimant can demonstrate error in VCAA notice, such error should be presumed to be prejudicial. VA then bears the burden of rebutting the presumption, by showing that the essential fairness of the adjudication has not been affected because, for example, actual knowledge by the claimant cured the notice defect, a reasonable person would have understood what was needed, or the benefits sought cannot be granted as a matter of law. Sanders v. Nicholson, 487 F.3d 861 (Fed. Cir. 2007); petition for cert. filed (U.S. March 21, 2008) (No. 07-1209). The Board finds that the content of letters and other communications complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding VA's duty to notify. Any other defect with respect to timing was harmless error. See Mayfield, supra. She was advised of her opportunities to submit additional evidence after which additional data was obtained and entered into the record. The purpose behind the notice requirement has been satisfied, because the veteran has been afforded a meaningful opportunity to participate effectively in the processing of her claim. She has submitted additional data, and has indicated that she has no other information or evidence to give VA to substantiate the claim. The Board notes that extensive medical evaluations have been undertaken with regard to this issue. The results are in the file. Some examinations are more complete than others, and some assessments are more insightful that others; but in the aggregate, the evidence provides a sound basis for resolving this issue at present without further delay. It is certainly to the appellant's benefit to do so, and does not prejudice her in any way given other actions that have been taken along the way. The Board is mindful of the new guidelines which have recently been issued by the Court of Appeals for Veterans Claims with regard to increased ratings cases and mandatory notice in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). In this regard, the notifications to the veteran were entirely adequate to inform her, or any reasonable person for that matter, of what was required, and that she needed to provide evidence with regard to how her disabilities affect her in everyday, daily life; her responses confirm that she understood those ramifications and mandates. There is no prejudicial error either alleged or shown. In addition, it appears that all obtainable evidence identified by the veteran relative to her claim has been obtained and associated with the claims file, and that neither he nor her lawyer has identified any other pertinent evidence, not already of record, which would need to be obtained for a fair disposition of the current appeal. Neither the veteran nor her representative has suggested in any way that there is any prejudice due to a lack of proper VA notice or assistance. Development has taken place in this case, and various alternative ratings have been identified during the course of the present appeal. In the aggregate, the veteran and her lawyer have demonstrated actual knowledge of and have acted on the information and evidence necessary to substantiate the pending claim. See, e.g., Dalton v. Nicholson, 21 Vet. App. 23, 30 (2007) (Court was convinced that appellant and representative had demonstrated actual knowledge of the information and evidence necessary to establish the claim) and related notification requirements have been fulfilled as contemplated in Vasques-Flores, supra. In addition, to whatever extent the decision of the Court In Dingess v. Nicholson, 19 Vet. App. 473 (2006), requires more extensive notice in claims for compensation, e.g., as to potential downstream issues such as disability rating and effective date, the veteran was sent the information required by Dingess in a letter from the RO in March 2006. Moreover, the claimant has not demonstrated any error in VCAA notice, and therefore the presumption of prejudicial error as to such notice does not arise in this case. See Sanders v. Nicholson, supra. Accordingly, we find that VA has satisfied its duty to assist the veteran in apprising her as to the evidence needed, and in obtaining evidence pertinent to her claim under the VCAA. No useful purpose would be served in remanding this matter for yet more development on this issue. Such a remand [in the issue #1 herein] would result in unnecessarily imposing additional burdens on VA, with no additional benefit flowing to the veteran. The Court has held that such remands are to be avoided. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). With further respect to Vazquez-Flores v. Peake, supra, the Board finds that every effort has been made to inform the veteran as to what is required for increased compensation for the herein concerned disabilities, under whatever alternate diagnostic codes might be available; and she has affirmatively indicated by her actions and words that she fully comprehends what is required. Finally, the Board would again remind all concerned that the action taken herein on issue #1 does not stand alone, and is supplemental in substance to the action which, for primarily procedural reasons, has been taken by the Board in a separate decision this same date and under the same docket number, and should be considered jointly. II. Applicable Criteria Disability ratings are based upon schedular requirements that reflect the average impairment of earning capacity occasioned by the state of a disorder. 38 U.S.C.A. § 1155. Separate rating codes identify the various disabilities. 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 C.F.R. § 4.1. In determining the level of impairment, the disability must be considered in the context of the entire recorded history, including service medical records. 38 C.F.R. § 4.2. An evaluation of the level of disability present must also include consideration of the functional impairment of the veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. Also, where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are appropriate in an increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). 38 U.S.C.A. § 7104 indicates that Board decisions must be based on the entire record, with consideration of all the evidence. In Timberlake v. Gober, 14 Vet. App. 122 (2000), the Court held, in pertinent part, that the law requires only that the Board address its reasons for rejecting evidence favorable to the claimant. The Federal Circuit has also held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The regulations provide that there are diseases of the digestive system, particularly within the abdomen, which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia and disturbances in nutrition. Consequently, certain coexisting diseases in this area, as indicated in the instruction under the title "Diseases of the Digestive System," do not lend easily themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in 38 C.F.R. § 4.14. See 38 C.F.R. § 4.113. Nonetheless, in this case, a separation has been made and two separate diagnostic codes applied. Once undertaken, action which occurred subsequent to the Court decision and most recent Board remand, the Board is not prepared to consolidate these two entities into a single rating, but rather is herein concerned only with accurately rating the issue listed on the first page. Effective from July 2, 2001, the rating criteria used to determine the severity of disabilities affecting the digestive system were revised. However, Diagnostic Code 7323 was unaffected by such changes. Ratings under DCs 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other. A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. The Board has considered whether any alternate diagnostic codes could serve as a basis for a higher rating here. In this regard, DC 7319, for irritable colon syndrome, is relevant to the veteran's disability picture. Severe with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress warrants a 30 rating; moderate with frequent episodes of bowel disturbance with abdominal distress warrants a 10 rating; and mild with disturbances of bowel function with occasional episodes of abdominal distress warrants a noncompensable rating. Both before and as of the schedular revisions effective July 2, 2001, DC 7319 affords a maximum rating of 30 percent. As such, that code section cannot serve as a basis for an increased rating in the present case. Under 38 C.F.R. § 4.114, Diagnostic Code 7323, for ulcerative colitis, a 10 percent disability rating is awarded for moderate impairment, with infrequent exacerbations. A 30 percent disability rating contemplates moderately severe impairment, with frequent exacerbations. A 60 percent disability rating contemplates severe impairment, with numerous attacks yearly and with malnutrition, with health only fair during remissions. Finally, a 100 percent rating is warranted for pronounced impairment, resulting in marked malnutrition, anemia, and general debility, or with serious complications such as liver abscess. An additional alternative diagnostic code which could be relevant to the veteran's disability is DC 7332, for evaluation of the rectum and anus, or impairment of sphincter control. It provides that a 30 percent rating is appropriate if the impairment is manifested by occasional involuntary bowel movements that necessitate the wearing of a pad. A 60 percent rating is appropriate if the impairment is manifested by extensive leakage and fairly frequent involuntary bowel movements. A 100 percent rating is appropriate if there is a complete loss of sphincter control. Again, it must be noted that this particular aspect of the veteran's claim is addressed in a separate decision. III. Factual Background and Analysis Service medical records include a May 1973 enlistment examination report which noted the veteran's weight was 102 pounds (lbs.). She was treated for gastrointestinal problems in 1975 and 1976 with an initial diagnosis of sprue, but a diagnosis of Crohn's disease was subsequently provided. At her March 1984 separation examination the veteran reported a history of recurrent diarrhea with weight loss. Her weight at separation was 100 lbs. On her VA examination in July 1984 the veteran reported a history of Crohn's disease since 1975, and she indicated that the disorder had been quiescent for several months followed by spontaneous attacks of nausea, emesis, diarrhea, occasion melena, and weight loss. She reported the attacks lasted for varying lengths of time but were promptly relieved by Prednisone. Her most recent attack had been in May 1984 and required hospital treatment. The examiner noted slight tenderness at a point between the right upper and lower abdominal quadrants. The diagnoses included Crohn's disease. Her weight was 104 lbs. VA hospital records show the veteran underwent a period of observation and evaluation in October 1984 for possible Crohn's disease. It was noted she complained that she never felt well and did not have any energy. She reported her weight fluctuated and that during acute episodes she was awaken in the middle of the night with nausea, vomiting, and cramping. The discharge summary noted a diagnosis of recurrent documented diarrhea, present for 9 years, which was periodically disabling and moderately severe. It was noted that colonoscopy was only possible to 60 centimeters (cm) but that the distal colon revealed a great deal of spasm with mild edema of the mucosa. Gastrointestinal and small bowel series studies with special reference to the terminal colon were within normal limits. On her VA examination in July 1988, the veteran reported she continued to experience some nausea and unstable bowel function. She stated that the side effects of Prednisone seemed to be lessening but that she experienced bloating, a lack of energy, tiredness, and difficulty staying asleep. The examiner noted the veteran had recently been hospitalized and treated by the gastroenterology service. A VA hospital discharge summary shows she was hospitalized for approximately 2 weeks in June 1988, and provided a diagnosis of possible Crohn's disease versus history of depression with possible histrionic personality disorder. The July 1988 examiner's diagnosis was Crohn's disease. The veteran's weight was 134 lbs. Private hospital records dated in July 1994 show the veteran was treated for nausea, vomiting, and diarrhea secondary to a Crohn's disease flare-up. She complained of some abdominal cramping, which was typical of her Crohn's disease flares, and that she frequently had nausea and vomiting after eating which resolved without treatment. VA examination in November 1996 recorded that the veteran had Crohn's disease which had intermittently caused recurrent diarrhea, abdominal cramping on 2 occasions, and intestinal obstructions that did not require hospitalization. Her symptoms were usually controlled with Azulfidine but that with severe symptoms she used Prednisone. The examiner noted the veteran reported she had been given Prozac because of fatigue caused by her Crohn's disease and that she believed toxic doses of that medication led to her attempted suicide in 1990 when she shot herself in the chest. On examination, the veteran was noted to be well developed, well nourished, and in no acute distress. There was tenderness to light palpation of the right lower quadrant of the abdomen. There was no evidence of masses, guarding, or ascites. The diagnoses included Crohn's disease controlled with medication. A colon barium enema study revealed chronic inflammatory disease in the colon which, by history, was Crohn's disease of the colon. In her June 1997 substantive appeal the veteran stated her Crohn's disease was not well controlled by medication. She stated she experienced frequent exacerbations which often resulted in hospitalization and that she rarely had normal bowel function. She reported she experienced fluctuating bowel symptoms including short periods of constipation and long bouts of diarrhea. She stated she had been unable to obtain employment because of the frequent and recurring nature of her Crohn's disease. At her VA examination in October 1997 the veteran reported that currently her appetite varied from good to poor and that she had intermittent episodes of nausea and vomiting recurring every 2 to 3 months which lasted up to several days. Her current weight was 112 lbs. and her maximum weight over the previous 12 months had been 121 lbs. It was noted she used Lomotil for diarrhea control and took intermittent courses of Prednisone for her Crohn's disease. The examiner noted the veteran had some right lower quadrant tenderness and mild guarding. She had intermittent episodes of abdominal pain and cramping accompanied by bouts of diarrhea which might alternate with longer periods of constipation. The diagnoses included history and physical findings and laboratory and x- ray studies consistent with chronic inflammatory bowel disease, most likely segmental Crohn's colitis involving the transverse and descending colon. In December 1997, the veteran submitted documents in support of her claim including a statement describing her Crohn's disease symptoms as alternating constipation, sometimes lasting up to one week, and violent attacks of diarrhea accompanied by horrible cramping and nausea. She stated that her medical records documented the fact that she had learned, to a small degree, to control her attacks through diet and self-medication but that the attacks remained unpredictable and tortuous. At her personal hearing in January 1998 the veteran testified that her Crohn's disease made it virtually impossible for her to make any plans from day to day. She stated she had experienced 2 attacks of diarrhea since arriving for the hearing that day and noted the episodes were caused by stress in many instances. She reported she had experienced periods of remission of up to 3 months but that within the last year the disorder had increased in severity. She stated she had experienced more frequent constipation, which led to cramping and diarrhea, and she described her attacks as occurring as often as every day but at other times only one or 2 attacks in a month or 2 months. She described the severity of her cramping pain as 9 or 10 out of a possible 10 point scale and reported she had to watch her diet because certain foods caused almost instant diarrhea. She stated she had gained and lost weight over the previous year. VA examination in February 1999 noted that the veteran's chief gastrointestinal complaints had remained essentially the same with chronic poor appetite, occasional intermittent episodes of dysphasia to solid foods, and acute exacerbations of diarrhea approximately 5 to 6 days each month with severe nausea, some vomiting, and diarrheal cramping. It was noted that she would pass up to 20 watery stools each day with frequent incontinence which required the use of pads to protect her clothing. She stated she had rarely seen any blood in her diarrhea in the past few years and that she took Lomotil and recurrent tapering doses of Prednisone to control the symptoms. The examiner noted the veteran had moderately severe right- side tenderness. It was the examiner's opinion that the veteran probably had one form of inflammatory bowel disease but that it could not be definitely determined whether this was Crohn's disease, granulous inflammatory bowel disease, or ulcerative colitis. The examiner noted her history was quite consistent with a chronic inflammatory bowel disease syndrome, for which she had been treated over the years with steroids and/or diarrheal agents. It was also noted that her current nutritional status was acceptable and that her present primary disability was due to frequent episodes of diarrhea with severe cramping and frequent episodes of fecal incontinence. A VA general medical examination in December 1999 noted the Crohn's disease symptoms were much the same but that she had experienced a flare-up plus a probable clostridium difficile infection in November 1999. It was noted she was still experiencing multiple stools per day and had gained weight to 100 lbs. from 91 lbs. at hospital discharge. Her normal weight fluctuated from 90 to 105 lbs. At her Travel Board hearing before the undersigned in January 2001, the veteran testified that a statement she was submitting included her current disability manifestations. In this statement the veteran described events before and after her self-inflicted gunshot wound and reported that she kept a "potty-chair" next to her bed because of explosive episodes of uncontrollable diarrhea. She also stated that during these episodes she wore adult diapers. She claimed she was unable to provide much help around the house because of her present disabilities and that she was dependent upon her husband most of the time. An April 2001 VA aid and attendance examination included a diagnosis of Crohn's disease. In a July 2001 examination report addendum the examiner stated that she experienced a severe flare-up of her Crohn's disease. Upon a VA examination in June 2002, it was noted that the veteran had been treated intermittently with Prednisone and that the last course was approximately 6 or 8 months prior to the examination. She used Lomotil for intermittent periods of diarrhea and Pro-Banthine for episodes of cramping abdominal pain. Her appetite was poor and her diet was restricted to any raw fruits or vegetables with only limited amounts of dairy products. Her current weight was 110 lbs., and this was her maximum weight over the past year. It was noted that approximately one year earlier her weight had been 100 lbs., but that it was not uncommon for her to have short periods of profound weight loss during flare-ups of her bowel disease. The veteran reported her bowels were presently inactive with only 2 formed, very hard stools per week and that at times she used mineral oil or laxatives to effect a bowel movement. She complained of intermittent, moderate to severe colicky pains to the mid-abdomen approximately 3 to 4 times per week, which occasionally became severe and prolonged. She stated that during these episodes her bowel habits would change from constipation to severe watery diarrhea with a dozen or more stools per day. The examiner noted that the veteran's abdomen was soft and nontender except for some mild left-sided tenderness with deep palpation. A recent work up included negative ovum parasite, white blood count, and pathogen culture studies and routine laboratory testing within normal limits. The examiner's impression, based upon a review of the claims file and the present examination, was that the veteran had chronic inflammatory bowel disease, most likely Crohn's disease of the left colon, dating from approximately 1975. The current symptom manifestations were described as primarily constipation interrupted by periodic bouts of cramping abdominal pain associated with profuse watery diarrhea. It was noted that in between severe episodes she required intermittent antispasmodic and antidiarrheal agents and diet restrictions. The examiner stated that her current weight and nutritional status was adequate and stable. Ongoing clinical evaluations of record show that the veteran takes pain medications while waiting for a lung transplant. Her overall health has been described as fragile. It is noted that she has myriad disabilities, most of which are service-connected. Upon a VA assessment in May 2006, the veteran said that use of stool softeners and mineral oil daily had improved her symptoms. She was having less constipation and mostly normal bowel movements. On occasion, she had flare-ups. The veteran and her spouse have repeatedly provided testimony with regard to her current symptoms. In assessing the singular aspects of the veteran's service- connected irritable bowel syndrome (as opposed to the facet of that disability manifested in actual sphincter control), the Board finds that DC 7323 is the most appropriate. (A separate Board decision is being issued on the other claims in appellate status, entitlement to a rating in excess of 30 percent for impaired sphincter control and entitlement to a higher rate of special monthly compensation (SMC), grants an increased rating for impaired sphincter control to 60 percent, along with entitlement to SMC based upon the need for aid and attendance at a higher level under 38 U.S.C.A. § 1114(r)(2). This latter decision d is from the Veterans Law Judge who presided over a Board hearing on these latter two claims.) The evidence in this case shows that the veteran's Crohn's disease has been primarily and consistently manifested by intermittent, recurrent diarrhea, abdominal cramping, and intestinal obstructions that did not require hospitalization. Her symptoms are usually controlled with medication, albeit of varying degrees and dosages. She had learned to control her attacks to some extent through diet and self-medication although she has understandably described the attacks as unpredictable and tortuous. After using Prednisone, her weight has become stable, although only 100 to 110 pounds at most, but she has not been heavier and occasionally less heavy than that for years. She has intermittent colicky pains in the mid-abdomen approximately 3 to 4 per week, which occasionally became severe and prolonged. She has said that during these episodes her bowel habits have in the past changed from constipation to severe watery diarrhea with a dozen or more stools per day. Between episodes she has required intermittent antispasmodic and antidiarrheal agents and diet restrictions. The Board notes that the Rating Schedule provides a maximum 30 percent rating for a severe disability with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress pursuant to 38 C.F.R. § 4.114, Diagnostic Code 7319. Although the veteran's disability is shown to be severe with alternating constipation and diarrhea, a higher schedular rating is not possible under this diagnostic code. Alternatively, however, the Rating Schedule provides higher ratings for severe ulcerative colitis with numerous attacks per year, malnutrition, and with health being only fair during remissions, or where the disorder is pronounced with marked malnutrition, anemia, and general debility, or with serious complications such as liver abscesses. See 38 C.F.R. § 4.114, DC 7323. While the veteran's present disability may be described as severe with numerous attacks per year, recent medical evidence shows her nutritional status was adequate and there is no objective medical evidence of malnutrition, anemia, general debility, liver abscesses, or only fair health due to this disorder during periods of remission. Her weight historically has fluctuated during symptom flare-ups but she responds well to Prednisone treatment. Absent more than moderately severe involvement, a rating higher than 30 percent is not warranted under DC 7323. Parenthetically, although it should be noted that under pertinent regulations cited above, the 30 percent assigned herein for irritable bowel syndrome could be added and combined with the associated facets of sphincter control, this would not provide the veteran with any more (but in fact less) overall compensation for the aggregate disability than she will receive based on the totality of the actions taken by the Board in the two decisions reached today. In exceptional cases where the schedular evaluation is found to be inadequate, pursuant to 38 C.F.R. § 3.321(b)(1), the Under Secretary for Benefits or the Director of the VA Compensation and Pension Service may approve an extra- schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. In the instant case, there is no evidence that the service- connected irritable bowel syndrome disability alone is manifested by marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. The disability picture is not unusual or exceptional; the veteran's symptoms are consistent with the criteria in the Rating Schedule for this particular disability. As noted above, among the veteran's other service connected disabilities is impaired sphincter control, rated 60 percent pursuant to the other Board decision adjudicating the current claims in appellant status. Thus, the ratings for the veteran's irritable bowel syndrome (or Crohn's disease) and its complications take into account significant industrial impairment. Therefore, a referral for consideration of an extraschedular rating is not warranted. See 38 C.F.R. § 3.321(b)(1). See Shipwash v. Brown, 8 Vet. App. 218 (1995). The Board parenthetically notes that the veteran has been in receipt of a 100 percent combined service-connected rating since August 1996. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application in the instant case. ORDER An increased evaluation for irritable bowel syndrome (Crohn's disease), currently evaluated as 30 percent disabling, is denied. ________________________________ R. F. WILLIAMS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs