Citation Nr: 1146458 Decision Date: 12/20/11 Archive Date: 12/29/11 DOCKET NO. 05-01 962 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to an initial disability rating greater than 30 percent for irritable bowel syndrome. REPRESENTATION Appellant represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD P. Childers, Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from September 1967 to November 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2002 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri, which granted service connection for irritable bowel syndrome with a rating of 10 percent, effective April 28, 1994. The Veteran appealed the assigned rating. In December 2006, the Board remanded the matter for further procedural and evidentiary development. In a January 2009 rating decision, the RO increased the rating for the Veteran's service-connected irritable bowel syndrome from 10 percent to 30 percent rating, effective September 9, 2005. In a November 2010 decision the Board increased the rating for the Veteran's service-connected irritable bowel syndrome from 10 percent to 30 percent effective April 28, 1994, and denied the Veteran's request for an initial disability rating greater than 30 percent. The Veteran appealed the Board's decision to the Court of Appeals for Veterans' Claims (Court). In an Order dated in August 2011 the Court, on Joint Motion of the parties, vacated that part of the Board's decision only to the extent that it denied entitlement to an initial rating higher than 30 percent throughout the pendency of the appeal; and remanded the matter for further action. FINDINGS OF FACT 1. The Veteran's intestinal disorder, diagnosed post-service as irritable bowel syndrome, has been productive of loose watery stools with frequent toileting, and more or less constant abdominal distress throughout the appeal period. 2. The Veteran's intestinal disorder has not been diagnosed as ulcerative colitis at any time during the appeal period, and there is no sphincter impairment. CONCLUSION OF LAW The criteria for an initial disability rating greater than 30 percent, or for a separate disability rating, for a chronic intestinal disorder have not been met at any time during the appeal period. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.14, 4.114, Diagnostic Codes 7203, 7301, 7305- 7308, 7312, 7319, 7323, 7328-7330, 7332, 7333, 7334, 7336, 7338 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate a claim. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159. Duty to Notify Under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), when VA receives a complete or substantially complete application for benefits, it will notify the claimant of the following: (1) any information and medical or lay evidence that is necessary to substantiate the claim, (2) what portion of the information and evidence VA will obtain, and (3) what portion of the information and evidence the claimant is to provide. The notification requirements are referred to as Type One, Type Two, and Type Three, respectively. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). In a claim for increase, the VCAA notice requirements are the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (interpreting 38 U.S.C.A. § 5103(a) as requiring generic claim-specific notice and rejecting veteran-specific notice as to effect on daily life and as to the assigned or a cross-referenced Diagnostic Code under which the disability is rated). The VCAA notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). In this case the Veteran's claim for an increased rating stems from the initial grant of service connection. Once the claim of service connection has been substantiated, the filing of a notice of disagreement with the RO's decision rating the disability does not trigger additional 38 U.S.C.A. § 5103(a) notice. Therefore, further VCAA notice under 38 U.S.C.A. § 5103(a) and § 3.159(b)(1) in a claim for a higher initial rating after the initial grant of service connection is not warranted. Dunlap v. Nicholson, 21 Vet. App. 112, 116-117 (2007); Goodwin v. Peake, 22 Vet. App. 128 (2008). Duty to Assist The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records and VA treatment records are in the file. Additionally, private treatment records identified by the Veteran have been obtained and associated with the Veteran's claims file. The Veteran has at no time referenced outstanding records that she wanted VA to obtain or that she felt were relevant to the claim. The Board further notes that the Veteran was provided with an opportunity to present testimony before a Veterans Law Judge at the RO; which she initially requested, but later withdrew due to health reasons. The Veteran has not asked for a Board hearing since her initial request. The duty to assist also includes, when appropriate, provision to the Veteran of a thorough and contemporaneous examination. Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2010). The Veteran was afforded VA examinations in November 2004 and in April 2007. The Board has reviewed the examination reports and finds that they are adequate for a decision in this matter. In assessing the level of disability of the Veteran's service-connected irritable bowel syndrome, both examiners reviewed the Veteran's medical history, recorded her current complaints, and conducted appropriate physical examinations before rendering diagnoses and opinions that fully address the criteria relevant to rating the disability in this case. Although the November 2004 examiner did not indicate whether the claims file was available for review, the examiner did note that the Veteran's service treatment records were reviewed, and discussed certain post-service medical treatment records in assessing the severity of the Veteran's condition, thereby indicating that he had attempted to gain a complete picture of the Veteran's intestinal disorder. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (holding that an examination is considered adequate when it is based on consideration of the appellant's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one). Moreover, the claims file was reviewed during the April 2007 examination. Therefore, the Board finds that the evidence, collectively, is adequate for a decision in this matter. There is no medical evidence, or argument from the Veteran, of a material change in symptomatology since she was last examined. See 38 C.F.R. § 3.327(a). The duty to assist does not require that a claim be remanded solely because of the passage of time since otherwise adequate VA examinations were conducted. See VAOPGCPREC 11-95. As there is no indication of the existence of additional evidence to substantiate the claim, the Board concludes that no further assistance to the Veteran in developing the facts pertinent to the claim is required to comply with the duty to assist. Facts The Veteran's service treatment records indicate that in October 1972 she reported to military sick call with complaints of alternating constipation and diarrhea. It was noted that she had been chronically constipated punctuated by "frequent episodes of diarrhea" and lower abdominal cramps over the past two years. Diagnosis was "functional colitis." Private medical records dating from May 1994 to June 1995 reflect that the Veteran was seen on a regular basis by a private physician with complaints of abdominal pain, cramping and diarrhea. During a June 1995 treatment visit the Veteran reported that she had had several episodes of abdominal pain, including nausea, vomiting, and epigastric pain; the first lasting from five to six hours in duration. A January 1995 treatment record notes complaints of abdominal pain, epigastric pain, and diarrhea. During a March 1995 treatment visit, the Veteran said that she was "not doing well" and complained of recurring diarrhea. In April 1995 she complained of vomiting, cramping and diarrhea. During a December 1995 Decision Review Officer hearing, the Veteran reported having four to five bowel movements a day, as well as occasional incontinence and drainage. She stated that she was on a number of different medications including Prednisone (for asthma), as well as Imodium and Metamucil, and testified that due to her inability to control her bowel disorder she would frequently arrive late at her job. In a VA Fitness for Duty memorandum dated in November 1996 the Veteran was described as having suffered from chronic colitis for years "marked with frequent episodes of diarrhea which interfere with [her] work." The physician averred that the Veteran was precluded from effectively performing her work duties as a result of her various medical conditions. In a June 1997 letter, a private physician advised that the Veteran had been under his care for approximately five years. He noted that the Veteran had a history of "functional colitis" dating back to her time in the military in 1972, and advised that while her symptoms have been "fairly well controlled" with medication, her diarrheal symptoms could last up to ten days per month. He also noted that the in-service evaluation in 1972 revealed no structural defects, and averred that the Veteran's diarrheal symptoms would be better characterized as irritable bowel syndrome. A VA Gastroenterology Clinic record in March 1999 advises of intermittent diarrhea with constipation since service; which the physician diagnosed as irritable vs inflammatory bowel disease. A VA Gastroenterology Clinic record dated in May 1999 advises that a rectal biopsy showed no signs of any active or chronic colitis. The provider remarked that in reviewing the Veteran's military medical records, the first mention of any intestinal problems was in 1972, when the Veteran reported a history of constipation alternating with diarrhea for several months. He noted that the Veteran was then diagnosed as having functional colitis, and asserted that the correct diagnosis was irritable bowel syndrome. He added that the Veteran's irritable bowel syndrome initially presented in-service in 1972. There are no VA or private medical records dated prior to 1997 that show treatment for diarrheal symptoms claimed by the Veteran as colitis but diagnosed, unanimously, by the Veteran's private treating physician and VA physicians, including gastroenterology specialists, as irritable bowel syndrome. In a rating decision dated in March 2002 the RO granted service connection for irritable bowel syndrome with an evaluation of 10 percent effective April 28, 1994, under Diagnostic Code 7319. In a letter dated in May 2002 a private physician advised that the Veteran's irritable bowel symptoms included gas, bloating, abdominal tenderness, and frequent diarrhea. He noted that these symptoms persist despite the Veteran's consumption of high doses of Sertraline and Metamucil and frequent doses of Imodium, and that the Veteran's symptoms were exacerbated several times a month "with periods of severe abdominal discomfort associated with increase in diarrhea, abdominal spasms and nausea." He added that the Veteran's irritable bowel syndrome limited her activity because the urgency of the diarrhea required her to be near a bathroom facility. An August 2003 VA outpatient treatment record notes the Veteran's complaints of "a lot of diarrhea." On VA examination in November 2004, the Veteran complained of nausea, vomiting, constipation; and of diarrhea, ranging from small stains to large amount of stool. She said that she suffered from three to four episodes of diarrhea an hour, four to five days a week and described these episodes as lasting three to four hours. She further complained of a bloating sensation, abdominal pain in the bilateral lower quadrants of her abdomen, and flatulence ten days out of every month. She also complained of occasional incontinence, and said that she used Depends approximately three times a week. She added that she planned her life around her service-connected irritable bowel syndrome, including limiting her outings to the grocery store and church, and said that she preferred to stay home most of the time because she does not want to deal with the embarrassment of incontinence. The examiner noted that the Veteran had not had any weight loss or weight gain during the past twelve months. Physical examination found tenderness to palpation in the mid to lower abdomen, but bowel sounds were normal. Rectal examination was also normal, without any evidence of sphincter abnormality. Diagnosis was irritable bowel syndrome. The Board notes that while the examiner indicated that the Veteran had not had any weight loss or weight gain during the past twelve months, the evidence of record reflects a significant weight loss between the years 1999 and 2004. In a May 1999 VA progress report, the Veteran's weight was recorded as 336 pounds. However, as of January 2003, her weight was found to be 245 pounds, and by November 2004, she was down to 228 pounds. In November 2005 the Veteran advised VA gastrointestinal treatment providers that she had intentionally lost the weight. Genitourinary examination in September 2005 found "no difficulty." In September 2005 the Veteran reported to a VA emergency room with complaints of diffuse mid-abdominal pain, nausea without vomiting, and persistent diarrhea for the past eleven days. She was diagnosed with dehydration secondary to diarrhea and received 1.5 liters of saline intravenously. In a letter dated in November 2005 a private physician advised that he had known the Veteran for many years. He remarked that the Veteran had significant problems with irritable bowel syndrome, and added that she could at times become significantly incapacitated with greater than one diarrheal bowel movement per hour, necessitating the use of anti motility and anti spasmodic agents. He averred that these episodes could last for several weeks at a time and occur multiple times per year. He added that that in between these episodes, the Veteran had frequent diarrhea on the average of six to ten stools per day. In December 2005 the Veteran underwent a screening colonoscopy, which found a diminutive polyp in the descending colon and mild internal hemorrhoids. No ulcers were found. During a January 2006 VA office visit the Veteran reported multiple bouts of diarrhea, and said that she was currently experiencing four to five bowel movements a day, which she averred did not bother her too much. She added that her symptoms were much worse in the past, and said she did not want any additional therapy or changes to her anti-diarrheal regimen. On VA examination in August 2007, the Veteran complained of nausea, cramps, and diarrhea, and of a considerable increase in symptoms. She also complained of sudden bouts of incontinence about twice a month that were usually, but not always, preceded by coughing or sneezing; and said that she wore adult diapers during flare ups, which she changed twice a day. She added that she tended to limit her activities, avoided certain types of foods, and ate smaller meals throughout the day to try to control her irritable bowel syndrome. Physical examination found tenderness in the hypogastric and left lower quadrants, but bowel sounds were normal; there was no abdominal distension or bruits on auscultation; and other quadrants were asymptomatic on mild to moderate palpation. Diagnosis was irritable bowel syndrome. In a letter dated in September 2008 a private physician wrote that the Veteran had been seen at his office in September 2005 with complaints of diarrhea for fifteen days, including a history of thirty liquid stools per day associated with severe abdominal cramping. Physical examination found positive diffuse abdominal tenderness. Diagnosis was severe irritable bowel syndrome. Legal Criteria 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 C.F.R. § 4.1. Following an initial award of service connection for a disability, separate ratings can be assigned for separate periods of time based on facts found. Fenderson v. West, 12 Vet. App. 119, 126 (1999). 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. The evaluation of the same disability under various diagnoses is to be avoided. Both the use of manifestations not resulting from service-connected disease or injury in establishing the service-connected evaluation, and the evaluation of the same manifestation under different diagnoses are to be avoided. 38 C.F.R. § 4.14. The Veteran's service-connected irritable bowel syndrome is rated as 30 percent disabling under Diagnostic Code 7319. 38 C.F.R. § 4.114, Diagnostic Code 7319. Under Diagnostic Code 7319, a 10 percent rating is assigned for moderate irritable colon syndrome with frequent episodes of bowel disturbances with abdominal distress. A maximum 30 percent rating is assigned when there is severe diarrhea, or alternating diarrhea and constipation with more or less constant abdominal distress. 38 C.F.R. § 4.114, Diagnostic Code 7319. The Board notes that 38 C.F.R. § 4.114, involving disabilities of the digestive system, was revised in July 2001, during the pendency of the appeal; however, there were no changes to Diagnostic Code 7319 criteria. The Board further notes that 38 C.F.R. § 4.114 prohibits simultaneous evaluations under Diagnostic Codes 7301 to 7329, inclusive; Diagnostic Codes 7331 and 7342; and Diagnostic Codes 7345 to 7348. Words such as "moderate" and "severe" are not defined in the VA Schedule for Rating Disabilities. The Board observes in passing that "moderate" is defined as "of average or medium quality, amount, scope, range, etc." See Webster's New World Dictionary, Third College Edition (1988) 871. Although the word "severe" is not defined in VA regulations, "severe" is generally defined as "of a great degree: serious." See Webster's Ninth New Collegiate Dictionary (1990) 1078. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.114. Use of terminology such as "severe" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. See 38 C.F.R. §§ 4.2, 4.6. Analysis The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board acknowledges that the Veteran is competent to give evidence about what she has experienced; that is, she is competent to discuss her intestinal symptoms. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). The Board has considered the Veteran's allegations of frequent diarrhea and constant abdominal distress, and finds the Veteran to be credible. As noted before, the Veteran's intestinal disorder has been evaluated under the provisions of Diagnostic Code 7319 since the effective date of service connection; and the evidence, including that from VA examiners and private physicians (see, e.g., November 2005 letter from private physician and August 2007 VA examination report), confirms that the Veteran has suffered from chronic, severe diarrhea and constant abdominal complaints throughout the appeal period, diagnosed as irritable bowel syndrome. The Veteran has accordingly been assigned the highest possible rating of 30 percent under the irritable bowel syndrome provisions of Diagnostic Code 7319. The Board has considered the propriety of assigning a higher, or separate, rating under some other diagnostic criteria. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). The record contains no evidence of stricture of the esophagus, adhesions of the peritoneum, marginal or duodenal ulcer, hypertrophic gastritis, postgastrectomy syndrome, cirrhosis of the liver, so evaluation under Diagnostic Codes 7203, 7301, 7305- 7308, and 7312 is not warranted. See Colvin v. Derwinski, 1 Vet. App. 171 (1991) (holding that the Board must consider only independent medical evidence to support its findings rather than provide its own medical judgment). Evaluation under Diagnostic Code 7323 is likewise not warranted since the Veteran does not have ulcerative colitis. In this regard the Board notes that while a provisional diagnosis of functional colitis was proferred, during service, in 1972, that diagnosis was not confirmed; VA and private physicians (including VA examiners) have since consistently diagnosed the Veteran's symptoms as irritable bowel syndrome. Colvin, 1 Vet. App. 171 (the Board must consider only independent medical evidence to support its findings rather than provide its own medical judgment); see also 38 C.F.R. § 4.14 (evaluation of the same manifestation under different diagnoses is to be avoided). Although the Veteran is competent to describe her intestinal symptoms, such as nausea, cramps, and frequent diarrhea with loose, water stools, a diagnosis of ulcerative colitis is medical in nature, that is, not capable of lay observation. See Savage at 498 (On the question of whether the veteran has a chronic condition since service, the evidence must be medical unless it relates to a condition as to which, under case law, lay observation is competent); see Barr v. Nicholson, 21 Vet. App. 303 (2007) (Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation). And it is not argued or shown that the Veteran is qualified through specialized education, training, or experience to offer a diagnosis of ulcerative colitis. In any event, the December 2005 colonoscopy found no evidence of any ulceration. See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 390 (31st Ed. 2007) (defining ulcerative colitis as "chronic, recurrent ulceration in the colon, chiefly of the mucosa and submucosa, having an unknown cause"). The Board accordingly finds that evaluation of the Veteran's intestinal complaints under the ulcerative colitis provisions of Diagnostic Code 7323, for a separate or a higher rating, is not warranted. While the Board concurs with the Joint Motion that an evaluation under Diagnostic Codes 7319 and 7323 is not precluded by 38 C.F.R. § 4.114, that is not the relevant question in this case. The Veteran's service-connected disability has been diagnosed as irritable bowel syndrome, for which there is a specific diagnostic code. Diagnostic Code 7323 is simply not applicable when there has been no showing by medical evidence that she actually has ulcerative colitis. In fact, the 2005 colonoscopy definitively showed no colitis. Although a separate rating could theoretically be assigned, the facts and medical evidence in this case weigh against that proposition, because the Veteran does not have colitis. There is also no record of resection of the large or small intestine secondary to the Veteran's service-connected irritable bowel disease, or a history of fistula secondary to the Veteran's service-connected irritable bowel disease (or otherwise), so evaluation under Diagnostic Codes 7328, 7329 and 7330 is not warranted. As regards Diagnostic Code 7332, while the Veteran does have severe diarrhea with frequent toileting and occasional incontinence secondary to her service-connected irritable bowel syndrome, there is no medical evidence of any impairment of the sphincter. See Colvin, 1 Vet. App. 171 (the Board must consider only independent medical evidence to support its findings rather than provide its own medical judgment). Instead, treatment providers advise that the Veteran's frequent toileting and occasional incontinence is due to the loose, watery nature of her stools secondary to her irritable bowel disease. In fact, the November 2004 examiner specifically noted that there was no sphincter impairment. Accordingly, as there is no evidence of sphincter impairment at any time during the appeal period, the criteria, for a separate or a higher rating under the impairment of sphincter control provisions of Diagnostic Code 7332 are not met. Colvin; 38 C.F.R. § 4.114. A higher rating under Diagnostic Codes 7333, 7334, or 7338 is also not warranted because the Veteran has not been diagnosed with stricture or prolapse of the rectum or anus, or an inguinal hernia secondary to her service-connected irritable bowel disease. Colvin; 38 C.F.R. § 4.114. Additionally, while the December 2005 colonoscopy revealed the presence of mild internal hemorrhoids, the Veteran admits that these hemorrhoids do not bleed, so the criteria for a separate compensable rating for hemorrhoids, presumably due to the Veteran's frequent toileting as a consequence of her service-connected irritable bowel syndrome, is not warranted. 38 C.F.R. § 4.114, Diagnostic Code 7336. The Board accordingly finds that the criteria for a rating greater than 30 percent for irritable bowel syndrome under Diagnostic Code 7319, or for a higher or separate rating under some other diagnostic criteria, have not been met at any time during the appeal period, and the benefit of the doubt standard of proof does not apply. Extraschedular Evaluation Although the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance, the Board is not precluded from considering whether the case should be referred to the Director of VA's Compensation and Pension Service for such a rating. The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular rating for the service-connected disability is inadequate. This is accomplished by comparing the level of severity and symptomatology of the service-connected disability with the established criteria. If the criteria reasonably describe the disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular rating is therefore adequate and referral for an extraschedular rating is not required. Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). In this case the evidence does not reflect a disability picture that 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 Veteran's currently assigned 30 percent disability rating contemplate her symptoms, including continuous diarrhea with more or less constant abdominal distress, 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 the Veteran's service-connected irritable bowel syndrome presents 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). As the Veteran's disability picture is contemplated by the Rating Schedule, the assigned schedular rating is adequate, and referral for extraschedular consideration under 38 C.F.R. § 3.321(b)(1) is not warranted. ORDER Entitlement to an initial disability rating greater than 30 percent, including a separate disability rating, for the Veteran's service-connected intestinal disability/irritable bowel syndrome, is denied. ____________________________________________ MICHELLE L. KANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs