Citation Nr: 1124635 Decision Date: 06/29/11 Archive Date: 07/06/11 DOCKET NO. 09-39 836 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUE 1. Entitlement to an increased rating for acid peptic ulcer disease with dyspepsia, currently evaluated as 30 percent disabling. 2. Entitlement to an increased rating for a right orchiectomy, currently evaluated as 10 percent disabling. ATTORNEY FOR THE BOARD Shabnam Keyvan INTRODUCTION The Veteran served on active duty from July 1980 to April 1987. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from the April 2009 rating decision of the Department of Veterans' Affairs (VA) Regional Office (RO) in Cleveland, Ohio, which in pertinent part, increased the disability evaluation for the Veteran's service-connected acid peptic ulcer disease with dyspepsia from 10 percent to 30 percent, effective February 10, 2009 (date of receipt of his claim for an increased rating for this disorder) and denied a disability evaluation greater than 10 percent for the service-connected orchiectomy. [Due to the location of the Veteran's residence, the jurisdiction of his appeal remains with the RO in North Little Rock, Arkansas.] FINDINGS OF FACT 1. The Veteran's acid peptic ulcer disease is manifested by symptoms of pain, vomiting and scant hematemesis, but not by material weight loss with moderate anemia, or other symptom combinations productive of severe impairment of health. Indeed, the disability is not manifested by any anemia or weight loss or recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year. 2. The Veteran's right testicle was removed via orchiectomy in October 1985, and his remaining left testicle is atropic and has therefore been rendered nonfunctioning. CONCLUSIONS OF LAW 1. The criteria for a disability evaluation greater than 30 percent for the acid peptic ulcer disease with dyspepsia have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.20, 4.114, Diagnostic Codes 7305, 7346 (2010). 2. Resolving all reasonable doubt in the Veteran's favor, the criteria for a 30 percent evaluation, but no more, for the service-connected right orchiectomy have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.104, 4.115(b), Diagnostic Code 7524 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Upon receipt of a substantially complete application for benefits, VA must notify the claimant of what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence that claimant is expected to provide. Further, in Dingess v. Nicholson, 19 Vet. Ap. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service connection claim, VA is required to review the evidence presented with the claim and to provide the claimant with notice of what evidence not previously provided will help substantiate his/her claim. See also 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Specifically, VA must notify the claimant of what is required to establish service connection and that a disability rating and effective date for the award of benefits will be assigned if service connection is awarded. Here, the Veteran filed his claim seeking an increased rating for his service-connected acid peptic ulcer disease in February 2009. A letter dated in February 2009 satisfied the duty to notify provisions concerning an increased rating claim. In particular, the correspondence informed the Veteran of the need for evidence of a worsening of this service-connected disorder. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, at 187. See also Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (VCAA notice in a claim for increased rating need not be "veteran specific"). The Veteran was informed of the types of evidence that could substantiate his claim, such as medical records or lay statements regarding personal observations. He was asked to provide information as to where he had been treated for his service-connected disability and informed that VA was responsible for obtaining any federal records, VA records, and any medical examinations, if necessary. The Veteran subsequently underwent a VA examination in March 2009 which included an evaluation and discussion of his service-connected right orchiectomy. This was received by the RO in March 2009 and accepted as an informal claim for increased benefits. See 38 C.F.R. § 3.157(a) and (b) (receipt of VA outpatient or hospital examination or admission reports will be accepted as an informal claim for increased benefits or an informal claim to reopen.) While the Veteran was not provided with a separate notification letter concerning this particular claim, this was not prejudicial to him, as the February 2009 notice letter actually informed him as to the type of evidence necessary to substantiate this increased rating claim. Furthermore, as will be discussed below, the March 2009 VA examination addressed the applicable rating criteria necessary to evaluate the Veteran's service-connected right orchiectomy. In addition, the Board notes that the March 2009 letter also notified the Veteran of how VA determines disability ratings and effective dates at the time of the initial adjudication of his claims. See Dingess v. Nicholson, 19 Vet. App. 473, 491 (2006). As such, there is no timing error with respect to VCAA notification. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records and VA medical records are in the claims file and were reviewed by both the RO and the Board in connection with the Veteran's claim. Indeed, at no time has the Veteran referenced outstanding records that he wanted VA to obtain or that he felt were relevant to his claim. The duty to assist includes obtaining a medical examination/opinion when such is necessary to make a decision on the claim, as defined by law. As previously discussed above, a VA examination with respect to the issues on appeal was obtained in March 2009. 38 C.F.R. § 3.159(c)(4). To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examination obtained in this case is adequate, as it was predicated on a review of the Veteran's medical records, an interview of the Veteran and a discussion of his medical history, and the examination fully addresses the rating criteria that is relevant to rating the disabilities in this case. Thus, there is adequate medical evidence of record to make a determination in this case. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination concerning the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4). In this regard, the Board acknowledges that the record reflects that the Veteran's claims file was not available for review during his VA examination. However, the Board observes that review of the claims file is only required where necessary to ensure a fully informed examination or to provide an adequate basis for the examiner's findings and conclusions; necessity for pre-examination records review is to be determined according to the facts of each individual case. See VAOPGCPREC 20-95; 61 Fed. Reg. 10,064 (1996). Here, resort to the Veteran's claims file was not necessary because the Veteran provided an accurate account of his medical history, thus ensuring a fully informed examination. Also, the claims file was not necessary for the examiner to provide findings as to the Veteran's current gastrointestinal and genitourinary symptoms, which are the questions at issue in this case. The examiner was not asked to resolve conflicting medical opinions or diagnoses. So, review of the file was not needed, and a remand for further examination with respect to the Veteran's increased rating claims would only delay the Veteran's appeal and would likely not result in a different outcome. Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements in the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran). With no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. 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 ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. 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 for that rating. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where an increase in the disability rating is at issue, the "present level" of the Veteran's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where VA's adjudication of an increased rating claim is lengthy, a claimant may experience multiple distinct degrees of disability that would result in different levels of compensation from the time the increased rating claim was filed until a final decision on that claim is made. Thus, VA's determination of the "present level" of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased rating claim has been pending. Hart v. Mansfield, 21 Vet. App. 505 (2007). A. Acid Peptic Ulcer Disease The Veteran asserts that he is entitled to a disability evaluation in excess of 30 percent for his service-connected acid peptic ulcer disease. In this case, the Board observes that in the appealed April 2009 rating decision, the Veteran's service-connected acid peptic ulcer disease is shown to have been rated by analogy as 30 percent disabling under 38 C.F.R. § 4.114, Diagnostic Codes (DC) 7305-7346. DC 7305 rates impairment resulting from a duodenal ulcer and DC 7346 rates impairment resulting from the hiatal hernia. However, in the September 2009 Statement of the Case (SOC) and March 2010 Supplemental Statement of the Case (SSOC), the RO evaluated the Veteran's disability under DC 7346. In analyzing the pertinent evidence of record, the Board has determined that both these diagnostic codes adequately address the Veteran's symptomatology. Accordingly, the Board will use both DCs 7305 and 7346 in evaluating the Veteran's service-connected acid peptic ulcer disease. Under DC 7305, a mild duodenal ulcer with recurring symptoms once or twice a year warrants a 10 percent rating. A moderate duodenal ulcer with recurring episodes of severe symptoms two or three times a year averaging ten days in duration or with continuous moderate manifestations warrants a 20 percent rating. Moderately severe duodenal ulcer, manifested by symptoms less than "severe" but with impairment of health manifested by anemia and weight loss; or recurrent incapacitating episodes averaging ten days or more in duration at least four or more times a year warrants a 40 percent rating. Severe duodenal ulcer, with pain only partially relieved by standard ulcer therapy, periodic vomiting, recurrent hematemesis or melena, with manifestations of anemia and weight loss productive of definite impairment of health warrants a 60 percent disability rating. 38 C.F.R. §4.114, DC 7305. Pursuant to DC 7346, a 60 percent evaluation is warranted where there are symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia, or other symptoms combinations productive of severe impairment of health. A 30 percent rating is warranted where there is persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain productive of considerable impairment of health. A 10 percent evaluation is warranted when two or more of the symptoms for the 30 percent evaluation are present with less severity. 38 C.F.R. § 4.114, DC 7346 (2010). In his September 2009 substantive appeal, the Veteran asserts that he experiences heart burn and acid reflux on a daily basis as a result of his peptic ulcer disease. He also describes symptoms of pain, vomiting, weight loss and some anemia. According to the Veteran, these symptoms support a disability rating in excess of 30 percent for his service-connected gastrointestinal disability. The Veteran's statements describing his symptoms are considered to be competent evidence. See Charles v. Principi, 16 Vet. App. 370, 374 (2002) (finding veteran competent to testify to symptomatology capable of lay observation); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (noting competent lay evidence requires facts perceived through the use of the five senses). However, these statements must be viewed in conjunction with the objective medical evidence as required by the rating criteria. In this regard the competent medical evidence discussed below is of far greater probative value. In August 2007, the Veteran underwent an esophagogastroduodenoscopy (EGD) procedure, the findings of which revealed esophagitis in the lower third of the esophagus, a "diffuse area of moderately severe gastritis in the antrum" of the stomach, and signs of "moderately severe duodenitis in the duodenal bulb." During a June 2008 VA gastroenterology consultation, the Veteran denied experiencing any clay stools, diarrhea, dysphagia, gallbladder disease, hematemesis, hematochezia, hemorrhoids, hernias, indigestion, nausea, vomiting, or rectal bleeding. The physician noted the Veteran's history of constipation, and that he was being followed by a gastrointestinal specialist. Upon physical examination, the Veteran's weight was recorded at 216 pounds, and his abdomen was described as soft, flat, nondistended and nontender, with active bowel sounds in all four quadrants. A November 2008 VA treatment report reflects the Veteran's complaints of constipation and rectal bleeding, but the Veteran did not report any pain, nausea, vomiting or hematemesis. The report also reflects that the Veteran was evaluated by a gastrointestinal specialist in September 2008, and assessed with "simple chronic colonic inertia." The physician prescribed the Veteran with Miralax, and wrote that if his problems persisted, he should undergo a "Sitzmark study" to determine whether an "anorectal manometry" procedure is necessary. During the November 2008 treatment visit, the physician discussed the Veteran's medical history and noted his August 2007 EGD procedure, as well as his visit to the Emergency Room in October 2007 due to his diarrhea and gastroenteritis - problems which were eventually resolved. It was further noted that the Veteran had a history of constipation and colon inertia with rectal bleeding once the day before. The physician provided him with hemorrhoid cream and recommended that he refill his prescription for Miralax and begin taking it at once. During his March 2009 VA examination, the physician observed that the Veteran's condition had worsened since his last VA exam. He reviewed the August 2007 EGD report, the results of which showed findings of esophagitis, duodenitis, and gastritis. The Veteran described daily heartburn with reflux which causes him to choke frequently - particularly at night. The Veteran also reported to experience episodic chest pain and shoulder pain as a result of his reflux, and explained that he occasionally vomits food infrequently with rare scant hematemesis. The Veteran further described intermittent dysphagia which occurs three times a week from the reflux, as well as occasional bright red blood per rectum and dark stools. The examiner noted that the Veteran was taking prescribed, as well as over-the-counter medication twice daily with continuing symptomatology, and described his weight as "stable" and his appetite as "good" during this time. Physical examination of the Veteran revealed a soft and nontender abdomen, "without organomegaly, masses, or tenderness." Based on his interview with the Veteran, as well as the physical examination, the examiner diagnosed the Veteran with peptic ulcer disease. During an October 2009 VA treatment visit, the Veteran's weight was recorded at 221 pounds, and the physician recommended adding some form of diuretic to his diet. Although the Veteran's weight fluctuated slightly throughout the years, VA treatment records dated from March 2008 to October 2009 reflect an overall consistency in his weight. Indeed, it appears the Veteran even gained a few pounds during this time. In considering the evidence of record under the laws and regulations as set forth above, the Board finds that the Veteran's service-connected acid peptic ulcer disease is not entitled to a disability rating in excess of 30 percent under Diagnostic Code 7346. While the March 2009 VA examination report reflects the Veteran's complaints of chest and shoulder pain, and his claim that he vomits food infrequently and experiences rare scant hematemesis, the evidence does not show that these symptoms are accompanied by moderate anemia or material weight loss. Indeed, the medical evidence of record is clear for any complaints, notations, signs or treatment of anemia, and the VA treatment records do not reflect a significant loss in the Veteran's weight. In fact, VA treatment records dated between March 2008 to October 2009 reflect an overall consistency in the Veteran's weight. Furthermore, the examiner described the Veteran's weight as "stable" and his appetite as "good," and determined that his service-connected disabilities have not affected his occupational duties as a peer supervisor. As such, the Board does not find that symptoms attributed to the Veteran's service-connected acid peptic ulcer disease have resulted in a severe impairment of his health. Accordingly, the Board concludes that the evidence of record does not support the criteria required for the next higher rating of 60 percent for this service-connected disability under DC 7346. The Board also finds that the Veteran's service-connected acid peptic ulcer disease is not entitled to a disability rating in excess of 30 percent under Diagnostic Code 7305. The Veteran's acid peptic ulcer disease is not manifested by anemia and weight loss nor has it resulted in recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year. Moreover, the record is negative for any signs of anemia or weight loss, and there is no indication that the Veteran has suffered from any incapacitating episodes as a result of his service-connected acid peptic ulcer disease. Accordingly, the Board concludes that the evidence of record does not support the criteria required for the next higher rating of 40 percent for this service-connected disability under DC 7305. The Board has also considered whether a higher evaluation would be in order under other relevant diagnostic codes. The assignment of a particular code is "completely dependent on the facts of a particular case." 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. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Thus, the Board has considered the propriety of assigning a higher, or separate, rating under another diagnostic code. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). However, a higher rating is not warranted under another diagnostic code. In this regard, DC 7306 is not for application as the Veteran does not have a diagnosis of a marginal ulcer. In addition, a higher rating is not supported under DC 7307. While the August 2007 EGD results revealed findings of diffuse gastritis in the stomach, the Veteran has not been diagnosed with hypertrophic gastritis, and the evidence does not reflect chronic symptoms displayed by severe hemorrhages, or large ulcerated or eroded areas. In addition, while the August 2007 EGD results revealed findings of esophagitis in the lower third of the esophagus, a higher rating is not supported under DC 7203 because the evidence does not show that such condition has caused the Veteran to experience stricture of his esophagus, nor does it show that he can only swallow liquids. Indeed, the medical evidence shows that the Veteran's weight is stable and his appetite is good and there is no indication that the Veteran has experienced any difficulty swallowing solid food as a result of his esophagitis. Furthermore, the Veteran has not been shown to have adhesions of the peritoneum, a gastric ulcer, postgastrectomy syndrome, stenosis of the stomach, residuals of a stomach injury, residuals of an injury of the liver, cirrhosis of the liver, chronic cholecystitis or an inguinal hernia. Therefore Diagnostic Codes 7301, 7304, 7308 -7314 and 7338 are inapplicable. Additionally, Diagnostic Code 7323 is not applicable as the Veteran has not been diagnosed with ulcerative colitis. Also, the Veteran has not undergone a resection of his large or small intestine, and has no history of a fistula, therefore Diagnostic Codes 7328, 7329 and 7330 are not applicable. Furthermore, impairment of sphincter control of the rectum and anus, stricture of the rectum and anus, as well as a prolapsed rectum has not been shown, and there are no signs of internal or external hemorrhoids. Therefore Diagnostic Codes 7332, 7333, 7334 and 7336 are not applicable. 38 C.F.R. §4.114. Additionally, as the record contains no evidence showing that the Veteran is entitled to a higher rating for his service-connected gastrointestinal disorder at any point during the instant appeal, no staged ratings are appropriate. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Thus, the Board finds that the current 30 percent evaluation is appropriate for the entirety of the rating period. 38 C.F.R. § 4.114, Diagnostic Codes 7305, 7346 (2010). B. Right Orchiectomy The Veteran's service treatment records reflect that he was diagnosed with right testicular torsion, and underwent a right orchiectomy (removal of the right testicle) in October 1985 while serving in the military. In the June 1994 rating decision, the Veteran was service connected for his right orchiectomy and granted a 10 percent disability rating. [The Veteran submitted his claim for service connection for the right orchiectomy in October 1993. Therefore he was rated based on the regulations in effect prior to February 17, 1994]. Because the Veteran submitted the most recent claim seeking an increased rating for his service-connected right orchiectomy in 2009, the current regulatory provisions which went into effect on and after February 17, 1994 are applicable. According to 38 C.F.R. § 4.115(b), Diagnostic Code 7524, a noncompensable disability evaluation is granted for the loss of one testis and a 30 percent disability evaluation for removal of both testes. A note under this Diagnostic Code provides that, in cases of the removal of one testis as the result of a service-incurred injury or disease, other than an undescended or congenitally undeveloped testis, with the absence or nonfunctioning of the other testis unrelated to service, a 30 percent rating will be assigned for the service-connected testicular loss. An undescended or congenitally-undeveloped testis is not a ratable disability. 38 C.F.R. §4.114, Diagnostic Code 7524 (effective on and after 17 February 1994). In addition to the assignment of a 10 percent disability rating for the loss of one testicle, the Veteran is also in receipt of special monthly compensation pursuant to 38 C.F.R. § 3.350 because of this disability. During the March 2009 VA examination, the examiner noted that the Veteran had erectile dysfunction, manifested by his ability to obtain a semirigid erection with some difficulty during penetration. According to the Veteran, he experiences occasional impotence, and the duration of his intercourse is 10 percent of what it normally would be. He also indicated that his ability to experience an orgasm is markedly diminished, and that he occasionally experiences urinary incontinence at night and places a towel in his underwear at bed time specifically for this reason. He does not wear pads and voids four times daily and two times at night. The examiner discussed the Veteran's medical history, to include the orchiectomy of the right testis and varicocelectomy of the left testis, which the Veteran claims causes frequent pain in his groin region with intercourse. Physical examination of the penis revealed a normal alignment of his penis shaft, without any deformity, masses, or tenderness. The examiner observed that the Veteran had been circumcised and that his right testicle was absent due to his prior surgery. The examiner further noted that the Veteran's left testicle felt atrophic and small, that his sensation as well as his cremasteric reflexes were normal, and that there were no palpable masses noted in the genitourinary region. Based on his discussion with the Veteran and physical examination, the examiner determined that testicle atrophy had been shown. Based on the most recent examination results, the Veteran's left testicle is still present and has not been removed. However, the examiner did describe the Veteran's left testis as "atrophic and small." The Board notes that according to Dorland's Illustrated Medical Dictionary 177 (31st Ed. 2007), atrophy is defined as "a wasting away; a diminution in the size of a cell, tissue, organ or part." Atrophic is defined as "pertaining to or characterized by atrophy." Id. at 177. In a claim for VA benefits, "a Veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1994). Entitlement need not be established beyond a reasonable doubt, by clear and convincing evidence, or by a fair preponderance of the evidence. Under the benefit of the doubt doctrine, when the evidence is in "relative equipoise, the law dictates that the Veteran prevails." Id. While the examiner did not specifically state that the Veteran's left testicle is nonfunctioning, the Board resolves reasonable doubt in the Veteran's favor and concludes that atrophy, and a wasting away, of the remaining left testicle renders it nonfunctioning. As such, pursuant to the Note following Diagnostic Code 7524, the Board finds that the Veteran is entitled to an increased disability evaluation for his right orchiectomy as well as his nonfunctioning remaining testicle. For these reasons, the Board finds that 30 percent evaluation for the right orchiectomy is warranted under 38 C.F.R. § 4.115b, Diagnostic Code 7524. A higher schedular rating is not warranted under this diagnostic code or indeed under any other diagnostic code evaluating impairment resulting from a genitourinary disability. C. Extraschedular Consideration The Board has also considered the potential application of other various provisions, including 38 C.F.R. § 3.321(b)(1), for exceptional cases where schedular evaluations are found to be inadequate. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulations, an extraschedular disability rating is warranted upon 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 that would render impractical the application of the regular scheduler standards. 38 C.F.R. § 3.321(b)(1) (2010); Fanning v. Brown, 4 Vet. App. 225, 229 (1993). In Thun v. Peake, 22 Vet. App. 111, 115-116 (2008), the Court set forth a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, as a threshold issue, the Board must determine whether the Veteran's disability picture is contemplated by the rating schedule. If so, the rating schedule is adequate and an extraschedular referral is not necessary. If, however, the Veteran's disability level and symptomatology are not contemplated by the rating schedule, the Board must turn to the second step of the inquiry, that is, whether the Veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." These include marked interference with employment and frequent periods of hospitalization. Third, if the first and second steps are met, then the case must be referred to the VA 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. Here, the evidence of record does not reflect that the Veteran's disability picture is so exceptional as to not be contemplated by the rating schedule. There is no unusual clinical picture presented, nor is there any other factor which takes the disability outside the usual rating criteria. The rating criteria for the service-connected disabilities discussed herein contemplate the Veteran's symptoms, and there are no symptoms left uncompensated or unaccounted for by the assignment of a schedular rating. As such, the threshold issue under Thun is not met, and any further consideration of governing norms or referral to the appropriate VA officials for extraschedular consideration is not necessary. In short, the evidence does not support the proposition that this service-connected disability present such an exceptional or unusual disability picture as to render impractical the application of the regular scheduler standards and to warrant the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (2010). Thus, referral of either issue to the appropriate VA officials for consideration of an extraschedular evaluation is not warranted. ORDER Entitlement to an evaluation in excess of 30 percent for the service-connected acid peptic ulcer disease with dyspepsia is denied. Entitlement to a 30 percent evaluation, but no more, for the service-connected right orchiectomy, is granted, subject to the laws and regulations controlling the award of monetary benefits. ____________________________________________ THERESA M. CATINO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs