Citation Nr: 1018533 Decision Date: 05/19/10 Archive Date: 06/04/10 DOCKET NO. 08-13 644 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUE Entitlement to an initial increased evaluation for service- connected ulcerative colitis, currently rated as 30 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant/Veteran and his Wife ATTORNEY FOR THE BOARD A. A. Booher, Counsel INTRODUCTION The Veteran had active service from August 1986 to August 31, 2006. He was born in 1967. This appeal to the Board of Veterans Appeals (the Board) is from action taken by the above Department of Veterans Affairs (VA) Regional Office (RO) on March 22, 2007, in which service connection was granted for ulcerative colitis and a 30 percent rating was assigned from September 1, 2006, the day following separation from service. A Notice of Disagreement (NOD) with the rating assigned was accepted via the Veteran's Congressman on September 2007; the Veteran filed a subsequent clarifying NOD of his own in October 2007. Service connection is also in effect for obstructive sleep apnea with periodic limb movement claimed as restless leg syndrome, now rated as 50 percent disabling; and hallux valgus, right; sinusitis; hemorrhoids; sliding hiatal hernia with gastroesophageal reflux (GERD); and psoriasis, each rated as noncompensably disabling. The Veteran and his wife provided testimony before the Board at the VARO in August 2009. A transcript is of record. Tr. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the Veteran's appeal has been obtained. 2. The Veteran has Remicade (infliximab) infusions every 8 weeks, takes daily Imuran, and is periodically on tapered steroids; he does not exhibit marked malnutrition, or any sign of serious complications such as liver abscess; any anemia is minimal at worst; and while has overall severe impairment with numerous episodes during the year with fair health during whatever remissions he may have, more often than not, he does not have overall pronounced impairment. 3. The Veteran's severe ulcerative colitis may be refractory to treatment, has deteriorated in some aspects and it has been suggested that his last option is surgery, but for the most part, symptoms have been at a relatively static level of no more than severe impairment since service separation. 4. The Veteran also has service connection for hemorrhoids, a sliding hiatal hernia and GERD, all of which impact his gastrointestinal tract to one extent or another. 5. The manifestations of the Veteran's ulcerative colitis disability are contemplated by the schedular criteria for rating disabilities of the gastrointestinal system; he is working full time, and while he has had hospitalization in the past, he now only has emergency room visits without frequent or sustained hospitalizations required. CONCLUSION OF LAW Criteria for a rating of 60 percent, and no higher, for the Veteran's service-connected ulcerative colitis disability have been met for all periods on appeal. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.20, 4.71, 4.114, Diagnostic Code 7323 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSION Before assessing the merits of the appeal, VA's duties under the Veterans Claims Assistance Act of 2000 (VCAA) must be examined. The VCAA provides that VA shall apprise a claimant of the evidence necessary to substantiate his/her claim for benefits and that VA shall make reasonable efforts to assist a claimant in obtaining evidence unless no reasonable possibility exists that such assistance will aid in substantiating the claim. In an initial letter dated in September 2006, VA notified the Veteran of the information and evidence needed to substantiate and complete his claim for service connection for ulcerative colitis, including what part of that evidence he was to provide and what part VA would attempt to obtain for him. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that once service connection is granted, the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. See Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). Because the underlying service-connection claim was granted, the Board finds that VA met its obligation to notify the Veteran with respect to his claim on appeal and no further notice is needed. Notwithstanding that fact, the Board notes that additional notice with respect to the initial rating aspect of the claim was provided in December 2007. Accordingly, the Board finds that VA met its duty to notify the Veteran of his rights and responsibilities under the VCAA. The Board also finds that VA has complied with the VCAA's duty to assist by aiding the Veteran in obtaining evidence, affording him physical evaluations, obtaining medical opinions as to the severity of disabilities, and by affording him the opportunity to give testimony before the Board at the VARO in August 2009. It appears that all known and available records relevant to the issue on appeal have been obtained and are associated with the Veteran's claims file, and the Veteran does not contend otherwise. Additionally, the examinations provided and medical opinions obtained are adequate for rating purposes as the examinations were performed based upon a review of the pertinent medical evidence and complaints of the Veteran and the opinions provided include well-reasoned rationale. Thus, the Board finds that VA has done everything reasonably possible to notify and to assist the Veteran and that no further action is necessary to meet the requirements of the VCAA. As such, the Board will now turn to the merits of the Veteran's claim. The Veteran requests a higher rating be assigned for his ulcerative colitis because he experiences severe symptoms on a daily basis and has been advised that his only real option for additional treatment is to have his colon removed. The Veteran and his wife appeared before the Board and provided credible testimony as to the effects of the Veteran's disability on his daily life and ability to work. The Veteran continues to work as a field technician, but misses some time from work as a result of his various disabilities. 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. 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 a Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. VA has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Disability evaluations are determined by the application of the schedule of ratings which is based on average impairment of earning capacity. See 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. Where entitlement to compensation has been established and a higher initial disability rating is at issue, the level of disability at the time entitlement arose is of primary concern. Consideration must also be given to a longitudinal picture of the Veteran's disability to determine if the assignment of separate ratings for separate periods of time, a practice known as "staged" ratings, is warranted. See Fenderson v. West, 12 Vet. App. 119 (1999). It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C.A. § 7104(a). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (Court) held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. The Court has also stated, "[i]t is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996). When an unlisted condition is encountered, it will be permissible to rate the condition under a closely related disease or injury in which not only the functions affected but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. Regulations provide that ratings under diagnostic codes 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 (2009). Under Code 7301 for adhesions of the peritoneum, when severe, with definite partial obstruction shown by X- ray, with frequent and prolonged episodes of severe colic distension, nausea or vomiting, following severe peritonitis, ruptured appendix, perforated ulcer, or operation with drainage, 50 percent is warranted. When moderately severe with partial obstruction manifested by delayed motility of barium meal and less frequent and less prolonged episodes of pain, 30 percent is warranted. When moderate with pulling pain on attempting work or aggravated by movements of the body, or occasional episodes of colic pain, nausea, constipation (perhaps alternating with diarrhea) or abdominal distension, 10 percent is warranted. When mild, a noncompensable rating is warranted. Note: Ratings for adhesions will be considered when there is history of operative or other traumatic or infectious (intraabdominal) process, and at least two of the following: disturbance of motility, actual partial obstruction, reflex disturbances, presence of pain. 38 C.F.R. § 4.114, Diagnostic Code 7301 (2009). The criteria found at 38 C.F.R. § 4.114, DC 7346, is for rating hiatal hernia/GERD. With symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. a 60 percent rating is assignable. With persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health a 30 percent rating is assignable. [Note: The Veteran also has separate service connection for hiatal hernia with GERD, but that is not part of the current appeal]. Under Code 7319 for irritable colon syndrome (spastic colitis, mucous colitis, etc.), when severe, with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress, 30 percent is warranted. When moderate with frequent episodes of bowel disturbance with abdominal distress, 10 percent is warranted. When mild with disturbances of bowel function with occasional episodes of abdominal distress, a noncompensable rating is warranted. 38 C.F.R. § 4.114, Diagnostic Code 7319 (2009). Under Code 7327, diverticulitis will be rated as for irritable colon syndrome, peritoneal adhesions, or colitis, ulcerative, depending upon the predominant disability picture. 38 C.F.R. § 4.114, Diagnostic Code 7327 (2009). Under Code 7332, impairment of sphincter control of the rectum and anus, when there is complete loss of sphincter control, 100 percent is warranted. When there is extensive leakage and fairly frequent involuntary bowel movements, 60 percent is warranted. When there are occasional involuntary bowel movements, necessitating wearing of pad, 30 percent is warranted. When there is constant slight, or occasional moderate leakage, 10 percent is warranted. When healed or slight, without leakage, a noncompensable rating is warranted. 38 C.F.R. § 4.114, Diagnostic Code 7332 (2009). The criteria under which the Veteran's disability is now rated, and which appear to most accurately reflect the Veteran's ulcerative colitis, are contained in Diagnostic Code 7323. Specifically, there must be evidence of pronounced disability, resulting in marked malnutrition, anemia, and general debility, or with serious complication as liver abscess for the assignment of a 100 percent rating; severe, with numerous attacks a year and malnutrition, the health only fair during remissions, for the assignment of a 60 percent rating; and, moderately severe, with frequent exacerbations for the assignment of the 30 percent rating. See 38 C.F.R. § 4.114, Diagnostic Code 7323. It is also noted that in this, as in any other case, it remains the duty of the Board as the fact finder to determine credibility in any number of contexts, whether it has to do with testimony or other lay or other evidence. See Culver v. Derwinski, 3 Vet. App. 292, 297 (1992). In any event, the Board has the clear duty to assess the credibility and weight to be given the evidence. The Board is not competent to supplement the record with its own unsubstantiated medical conclusions. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991); however, following the point at which it is determined that all relevant evidence has been obtained, it is the Board's principal responsibility to assess the credibility and, therefore, the probative value of proffered evidence of record in its whole. Owens v. Brown, 7 Vet. App. 429, 433 (1995); Elkins v. Gober, 229 F. 3d 1369 (Fed. Cir. 2000). The Board has an obligation to provide adequate reasons and bases supporting this decision, but there is no requirement that every item of evidence submitted by the appellant or obtained on his behalf be discussed in detail. The Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Service treatment records reflect that ulcerative colitis was diagnosed in 1999 and the Veteran was thereafter treated on repeated occasions and hospitalized for the disorder. Symptoms included diarrhea, weight gain and colonoscopic confirmation of the diagnosis. Just before separation in April 2006, a gastroenterology report was generated and cited ulcerative colitis shown on colonoscopy with a notation that his symptomatic activity had increased over the past several months. Medications were adjusted and a prednisone regimen continued. The Veteran filed for compensation for his ulcerative colitis concurrent with his separation from service at the end of August 2006. In that regard, it is noted that he also now has been granted service connection for a hiatal hernia with GERD and hemorrhoids, both of which have gastrointestinal impact but are rated separately from his colitis, and as such, are not part of the current appeal. At the time he filed his initial VA Form 21-526, the Veteran submitted a VA Form 21-4138 in which he described his ulcerative colitis symptoms as including acute and frequent flare-ups causing nausea, severe cramping of the colon, bleeding, bowel movements in excess of 10 times a day, requiring frequent hospital stays with multiple medications to control including steroids and auto-immune suppressants. A VA clinical report from September 2006 noted that the Veteran was there for his Remicade infusion and had a history of ulcerative colitis. An additional assessment dated in September 2006 showed that his colitis had been maintained with the Remicade infusion every 8 weeks and the next infusion was planned for that week-end in the emergency room. Home infusion was not yet available but was to be arranged. On a visit to a VA facility in October 2006, it was noted that the Veteran's ulcerative colitis had been refractory to treatment with steroids. Remission had been achieved with the use of Remicade but he appeared to be developing antibodies to that as the duration to the response to the successive Remicade injections was not complete and the duration of the response was becoming shorter. Specifically, the colitis had been continuously active and the Veteran had to be kept on the Remicade, but had also been started on Imuran at the time of the initial infusion. The daily initial dose was 50 mg. which was increased to 100 mg. It was then stopped because of concerns about double immunosuppression. He felt his colitis was again becoming mildly active. He had increased cramping and bowel frequency. The physician suggested the best option would be a colectomy and ileo-anal anastomosis, but he declined that option. It was noted that he had not yet received an adequate trial of Azathioprine in a sufficient dose. On VA examination in November 2006, the Veteran confirmed that he was taking a number of medications including bimonthly Remicade. At one point, he denied weight loss or gain. On the examination, he reported a weight loss of 28 pounds followed by a 34 pound weight gain. He also said he had vomiting and nausea, and diarrhea which occurred over fifteen times a day and was severe in nature. He gave a history of having a fistula on one occasion in the past two years lasting two weeks with the amount of fecal discharge unknown as it was liquid. It was noted that he had anemia with fatigue, hemorrhoids and GERD without dysphagia and moderate to severe pyrosis. He described a history of fever and nausea secondary to flare-ups of his colitis. On a clinical visit at a service facility in January 2007, it was noted that he had had flare-ups in service including in March 2006 requiring back-to-back hospitalizations. After having been on both Remicade and Imuran, he was now on maintenance Remicade home infusions of 5 mg. every 8 weeks. He was having 6-7 loose stools daily without blood. His liver was normal to palpation. His pan- ulcerative colitis was described as causing mild symptoms. Since he had not required hospitalization since being on Remicade, the physician recommended that the treatment be continued and opined that it was reasonable to continue the monotherapy. On a visit to the same facility in July 2007, the dosage of the Remicade was doubled (from 5 mg. to 10 mg.) every 8 weeks; Colazoi was discontinued and Imuran started at 50 mg., four times a day, with a goal of reaching 150 mg. The various potential side-effects including bone marrow suppression and pancreatitis had been discussed with the Veteran. Another July 2007 notation at the service facility was that the Veteran's ulcerative colitis was now manifest by anywhere from four to seven loose stools a day, sometimes associated with abdominal cramping. He denied fever, chills or significant weight loss. He recalled that his last colonoscopy in November 2006 had shown a bowel perforation which required a prolonged hospital stay. He said he had had inflammatory polyps. On a clinic visit in August 2007, the Veteran related that he was working outside which was not helpful to his disability. He was not near bathroom facilities and his medications required that he avoid sun. He sought a letter to support his filing for vocational rehabilitation. A colonoscopy was undertaken in September 2007. The Remicade therapy had been increased to 100 mg. daily, and Imuran was given 100 mg. four times a day. He was still having multiple stools daily with some blood. From the rectum to the cecum, there was severe pancolitis with erythema, hemorrhage and segments covered with small finger-like polyps consistent with inflammatory polyps. The inflammation of the left colon was greater than the right. Four quadrant biopsies, were done at 10 cm. intervals. A letter from the Chief of Gastroenterology of the service medical center, dated in September 2007, described the history of his care, noting that in July 2007, the symptoms were felt to be moderate with four to seven bowel movements daily, some with blood. He was also noted to have had some microcytic anemia with a hematocrit of 32 or so. Based on the finding after the coloscopy in September, medications included additional prednisone; Imuran was increased to 150 mg. a day. The physician said that it was his opinion that it was unlikely that he would achieve a complete response and stay in remission and recommended a second opinion be undertaken. A pathology report from the biopsies, dated in September 2007, was later added to the file showing severe (active, chronic) pancolitis with inflammatory polyps; dysplasia was not found in random samples on both sides. Blood studies showed some mild abnormalities, e.g., low hemoglobin and hematocrit. According to the Veteran's Substantive Appeal, a consultative opinion was to the effect that a colectomy should be undertaken. He also noted that taking Remicade and Imuran placed him at higher risk for severe infections and could also cause liver problems requiring constant vigilance. He also noted that he was at a greater risk for tuberculosis as a result of the medications. He suggested that a 100 percent rating should be assigned. A copy of a statement from the gastroenterological consultant is of record, dated in October 2007, noting that even with Remicade, (10 mg./kg every 8 weeks), Imuran, 150 mg. and a tapering dose of prednisone, the Veteran still had four to five loose bowel movements daily with some blood. He also had significant abdominal pain. Coloscopy had shown significant mucosal disease. Periodic reports show that the Veteran has infusions every 8 weeks. On VA examination in June 2008, the Veteran said his gastrointestinal situation had worsened since the VA examination 2006. He reported having been hospitalized in service. When asked about flare-ups, he said his attacks were continuous with symptoms of nausea and vomiting. He also would get dry heaves but no constipation. There was no set pattern to his diarrhea; one day he might have one stool, the next four to five and then eight the next day. Even with the use of Remicade, he had an average of two to five stools per day, and sometimes one and sometimes five daily. Some days were loose and other days the stools were semisolid; this was not episodic and duration was continuous. Treatment included ongoing Remicade and Imuran. He was no longer on Asacol. He had previously but no longer used enemas; he had had hydrocortisone since June 2007 as needed. On inquiry about his abdominal pain, he said he had a pressure sensation, pushing, blown-up irritation sensation on a daily basis. The pain was over the lower quadrant on the left side but he also would get abdominal cramping, distention and a bloating sensation on a daily basis, or every other day. This would last for an hour up to six hours without a set pattern. He again reiterated that there was no remission and since onset, he had continuous symptoms. As for the impact on his work, he said he worked as a material tester for an engineering firm, and had to go to the bathroom frequently due to his bowel problem. He said he had to have frequent breaks, and often had to stop work to do so. Inside or outside, he had some urgency of his bowels. He had had hospitalization in the past from 2005-2007; he related having had lifting restrictions in the past, but could now do activities of normal living. He reported daily multiple loose bowels, five to six times a day, some with blood. He also had frequent boils and a rash over the beard area and some in the scrotal area, and signs of inflammatory, migratory arthropathy which had required some emergency care at the military facility. His detailed history was recorded including the microscopic anemia with hematocrit of 32; and notwithstanding he was feeling better and had fewer stools, the endoscopic evidence was of ulcerative colitis with edema, ulceration, loss of vasculature and inflammatory pseudopolyps scattered throughout the colon. He had then added prednisone to his regimen and the dosage of other medications had been increased as well as noted above. Opinions had been provided that he should undergo a total colectomy which he said was pending. On examination, the Veteran had tenderness in the left side of the abdomen and in the lower quadrant. He had no signs of significant anemia or malnutrition. He had lost weight in 1998-1999 (175 from 190), but now weighed 200 and had recently gained weight. The Veteran was noted to have had mild anemia (hemoglobin and hematocrit being slightly low), but there was no malnutrition or general debility. In his representative's written presentation in lieu of a VA Form 646, filed in July 2009, it was suggested that the Veteran meets the criteria for the next higher evaluation, which under the rating schedule is 60 percent. The Veteran, however, has not limited his claim to only seeking 60 percent rating so the Board will consider all potentially applicable rating criteria for the most beneficial rating. At the hearing held before the undersigned at the VARO in August 2009, the Veteran and his wife provided information as to his current situation. The Veteran testified that he was working as a field technician for an engineering company. There were certain jobs he missed because they simply did not have facilities for him, and he would lose an averages of five to six days from work every two months due to the disability. Tr. at 3. He had been seen at the hospital in November 2006, February 2007 and twice in March or May 2007 in the emergency room. Tr. at 3. When admitted he had stayed five to ten days. Tr. at 4. He continued getting Remicade by infusion and the immune suppressant, Imuran, on a daily basis. For the infusion he usually took two days off work and had side effects for about a week including migraine headaches which could be incapacitating. Tr. at 4. The Veteran's wife characterized the Veteran's life and health as a roller coaster and described him when the condition was exacerbating. Tr. at 5. She confirmed that he missed four or five days every two months or so from work; that there were no further alternative treatments but the surgery where the colon would be removed. Tr. at 5-6. The Veteran described his earlier hospital symptoms, and said that with flare-ups, he had mild pain, bloating and some spotting and blood. Tr. at 6. He would go to the rest room ten to twelve times daily. Tr. at 6. He kept a supply of Tucks and hand sanitizer with him at all times. Tr. at 7. He also had to take clean underclothing with him, and sometimes, four or five times a year, he had accidents. Tr. at 7-8. He admitted he might pick a restaurant or shopping facility based on their bathroom facilities. Tr. at 9. He reported that he would get up twice a night to go to the bathroom on a good day; on a worse day, three to four times a night. Tr. at 9-10. Whenever he has signs of infection, e.g., fever, he was instructed to go to the emergency room. Tr. at 10. He admitted postponing the suggested surgery as he was afraid of the effects. Tr. at 11-12. He said his boss worked with him to accommodate his needs, and on some jobs, he had to stay in the office, but for the most part, he worked forty hours per week. Tr. at 12-13. It was noted that there was always the concern that the medications were no longer efficacious and then he would have no choice but to have the colon removed. Tr. at 13-14. From the outset, the Board would note that the Veteran and his wife's sworn testimony, and other written communications in the file, are both competent and credible, and provide a helpful basis for adding to the medical analysis of the current disability picture. They are both excellent observers, and no one can better provide the detailed day-to- day assessment as to the impact his disability has on his daily living. The Veteran is both able and entitled to address these ongoing symptoms, and how they impact his life, and he has done so quite candidly and articulately. As such, the Board has given great weigh to the testimony of the Veteran and his wife. The Board fully recognizes that the disability here being evaluated is of such a nature that the symptoms and manifestations are not only painful and difficult, but depending on their frequency and precipitousness, often downright embarrassing and humiliating. At the very least, the Veteran and his family must be proactive when doing even mundane chores such as shopping and eating out, checking out the locations and accessibility of the bathroom. They have characterized the disability as a roller coaster and the record certainly reflects that it is. These are all collateral factors, but go to the overall severity of the chronic problem. As such, the Board has considered all testimony and evidence in light of the worst case scenario when determining the level of severity at which to rate the disability. As noted above, the Veteran has separate service-connected ratings for hemorrhoids and a sliding hiatal hernia with gastroesophageal reflux (GERD); these are not part of the current appeal and are not considered when addressing the ulcerative colitis disability and the appropriate compensation therefor. In any event, the provisions of the 38. C.F.R. § 4.114 direct that these disabilities may well overlap, and that a single rating is assigned for the prevailing symptoms. Nonetheless, the bases for assigning a degree of compensation is primarily based on the demonstrated clinical findings, which are then compared to the criteria of the rating schedule. In this case, it appears that the best Diagnostic Code for the prevalent symptoms is for ulcerative colitis. As outlined above, prior to service separation, the Veteran had repeated hospitalizations, some fairly extensive. However, since medications, particularly the Remicade therapy have been instituted, along with Imuran and often a steroidal supplement, his hospitalizations have been limited and much more infrequent. And while history is important in the long run to understand the course of the illness, of course it is only the extent of his disability since September 1, 2006, that is at question here since it is for that period that he is seeking increased compensation from VA. Since virtually the date of separation, with the use of powerful medications, the Veteran has had ongoing symptoms which certainly are tantamount to "numerous" attacks; his health is marginalized when the symptoms are not in a state of flare-up. However, he has demonstrated little if any anemia and no significant sign of malnutrition. While the bowel and any associated abdominal symptoms are more often than not closer to severe than moderate, they have not ever consistently approached a sustained level of being pronounced with marked malnutrition and other findings warranting a 100 percent schedular rating. Because these symptoms have generally been severe in nature since service separation, a 60 percent rating is in order from that date. Staging of the rating is not required as the evidence reflects a fairly consistent level of severity throughout the entire period here in question. Criteria for the higher 100 percent rating, however, is not met. Parenthetically, even if the Veteran were to be rated under any of the other cited Diagnostic Codes based on isolated symptoms such as the need for pads, etc., as outlined above, he would not warrant a rating in excess of 60 percent. The Veteran has expressed an understandable concern that his medications are the source of worry, namely that they will either stop being efficacious or will cause some secondary disability, either or both of which is a possibility; and if they do, he will require surgical removal of the colon. This is a potential that has been suggested by more than one specialist, and is something he has faced with strength. However, this day has not yet happened, so he is not to be compensated as if it had. Should that day ever arrive, he is certainly free to reopen his claim for an increase at that time based on the evidence of such symptomatic increase and/or deterioration. The VA schedule of ratings will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). As to whether an extraschedular rating is warranted, higher ratings may be awarded on an extraschedular basis when the evidence shows that the rating criteria found in the schedular are inadequate. The Court has recently clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, VA must determine whether the Veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. Following a complete review of the record, the Board finds that the evidence does not present such an exceptional disability picture that the available schedular evaluations are inadequate. Here, the schedular evaluation contemplates the Veteran's level of disability and his generally severe but less than pronounced symptomatology. In this regard, it is noted that the Veteran has suggested some modest accommodations may have been made for him at work due to his bathroom needs, but these are contemplated within the schedular criteria; and in any event, for the most part, he still works full time. He has asked about VA vocational rehabilitation but there is no evidence that he has yet availed himself of such. Additionally, the Veteran states that he does not generally miss work or require treatment due to the symptoms of his service-connected colitis other than for appointments such as for his infusions every 8 weeks (when not done at home) and a brief restorative time thereafter, things that might take him outside the norm for rating within the schedule. Otherwise, the symptoms supportive of a 60 percent schedular rating encompass all demonstrated clinical and practical factors at present. Consequently, on review of the overall evidence, the Board finds that a referral for extraschedular consideration is not required. ORDER An initial increased evaluation for service-connected ulcerative colitis to 60 percent disabling is granted, subject to the pertinent regulatory guidelines for the payment of monetary awards. ____________________________________________ Kristi Barlow Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs