Citation Nr: 1307683 Decision Date: 03/07/13 Archive Date: 03/11/13 DOCKET NO. 07-01 658 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to service connection for bowel disease secondary to service-connected hepatitis C. 2. Entitlement to an initial disability rating for service-connected hepatitis C, in excess of 10 percent from February 5, 2001, and in excess of 40 percent from October 5, 2012. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD K. K. Buckley, Counsel INTRODUCTION The Veteran served on active duty from October 1968 to April 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions dated in May 2005 and June 2006 of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio In his December 2006 VA Form 9, the Veteran requested a personal hearing before a Veterans Law Judge. However, in September 2011, the Veteran, through his representative, withdrew the hearing request. In December 2011, the Board remanded for further evidentiary development. As will be discussed below, a review of the record reflects substantial compliance with the Board's Remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In an October 2012 rating decision, the VA Appeals Management Center (AMC) increased the evaluation assigned for the service-connected hepatitis C to 40 percent from October 5, 2012. The Veteran has not expressed satisfaction with the increased disability rating. This issue thus remains in appellate status. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (when a veteran is not granted the maximum benefit allowable under the VA Schedule for Rating Disabilities, the pending appeal as to that issue is not abrogated). The AMC issued a supplemental statement of the case (SSOC) in October 2012. The Veteran's VA claims file has been returned to the Board for further appellate proceedings. FINDINGS OF FACT 1. The Veteran's bowel disease was not caused or made chronically worse by his service-connected hepatitis C. 2. Prior to October 5, 2012, the Veteran's hepatitis C was characterized by no more than intermittent fatigue, malaise, and anorexia; there were no incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least two week during a 12-month period. 3. From October 5, 2012, the Veteran's hepatitis C has been characterized by no more than daily fatigue, malaise, and anorexia, with minor weight loss and hepatomegaly; there have been no incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least six weeks during a 12-month period. CONCLUSIONS OF LAW 1. The Veteran's bowel disease is not proximately due to, or aggravated by, his service-connected hepatitis C. 38 U.S.C.A. §§ 5103, 5103A, 5017 (West 2002 & Supp. 2012); 38 C.F.R. § 3.310(a) (2012). 2. Prior to October 5, 2012, the criteria for a rating in excess of 10 percent for hepatitis C were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.10, 4.114, Diagnostic Code 7354 (2012). 3. From October 5, 2012, the criteria for a rating in excess of 40 percent for hepatitis C have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.10, 4.114, Diagnostic Code 7354 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). 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 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. With respect to the service-connected hepatitis C, the claim for higher disability rating is a "downstream" issue in that it arose from an initial grant of service connection. Prior to the May 2005 rating decision, the RO issued letters in March 2004 and August 2004 that advised the Veteran of the evidence necessary to substantiate his claim for service connection and of his and VA's respective obligations with regard to obtaining evidence. Importantly, where, as here, service connection has been granted and the initial rating and effective date has been assigned, the claim for service connection has been more than substantiated and proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice was intended to serve has been fulfilled. Once a claim for service connection has been substantiated, the filing of a notice of disagreement with the rating of the disability does not trigger additional § 5103(a) notice. See Dingess, 19 Vet. App. at 490-91; Dunlap v. Nicholson, 21 Vet. App. 112 (2007). In addition, a February 2006 letter informed the Veteran of the evidence needed to sustain a claim of secondary service connection. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, at 187. He was also informed of the types of evidence that could substantiate this claim, such as medical records or lay statements regarding personal observations. He was asked to provide information as to where he had been treated and was informed that VA was responsible for obtaining any federal records, VA records, and any medical examinations, if necessary. Accordingly, the Board concludes that VA has met its duty to notify the Veteran with respect to both issues on appeal. Regarding VA's duty to assist, the RO obtained the Veteran's service treatment records (STRs), service personnel records, as well as VA and private treatment records in furtherance of his claims. There is no indication that any additional action is needed to comply with the duty to assist. The Veteran was recently afforded VA examinations in October 2012 as to his Crohn's disease claim and in October 2012 as to his hepatitis C claim. The examination reports and medical opinions reflect that the VA examiners thoroughly reviewed the Veteran's past medical history, documented his medical conditions, and provided opinions that appear to be consistent with the remainder of the evidence of record. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and sound reasoning for the conclusion). The Board therefore concludes that the October 2012 VA examination reports are adequate for evaluation purposes. See 38 C.F.R. § 4.2 (2012); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). Thus, given the standard of the regulation, the Board finds that VA did not have a duty to assist that was unmet. II. Analysis-Service Connection Claim Service connection may be granted for a disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310(a) (2011); Harder v. Brown, 5 Vet. App. 183, 187 (1993). Additional disability resulting from the aggravation of a nonservice-connected condition by a service-connected condition is compensable under 38 C.F.R. § 3.310(a). Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to establish service connection for a claimed disability on a secondary basis, there must be (1) medical evidence of a current disability; (2) a service-connected disability; and (3) medical evidence of a nexus between the service-connected disease or injury and the current disability. See Wallin v. West, 1 Vet. App. 509, 512 (1998). Initially, the Board notes that the Veteran has specifically raised the matter of his entitlement to service connection for bowel disease on a secondary basis only. See the Veteran's claim dated January 2006 & the VA Form 9 dated December 2006. There is nothing in the Veteran's presentation, or elsewhere in the record, that leads the Board to believe that service connection on a direct basis need be addressed. See Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009) (holding that where a claimant has raised an issue of service connection, the evidence in the record must be reviewed to determine the scope of that claim. Claims that have no support in the record need not be considered by the Board, however, as the Board is not obligated to consider "all possible" substantive theories of recovery. Where a fully developed record is presented to the Board with no evidentiary support for a particular theory of recovery, there is no reason for the Board to address or consider such a theory). Thus, the Board will consider the Veteran's claim on a secondary service connection basis and not on a direct service connection basis. Here, the Veteran asserts that he suffers from Crohn's disease that has been caused or aggravated by his service-connected hepatitis C. See the Veteran's VA Form 9 dated December 2006. As will be explained below, the Board finds that the evidence does not support the Veteran's contentions. An August 2005 private Colonoscopy Procedure Report indicated the following findings: "1. Colitis of the rectum, the sigmoid, the descending colon, the transverse colon, the ascending colon, and the cecum; 2. A few aphthous ulcers; 3. There was diffuse involvement found." A differential diagnosis including Crohn's disease and ulcerative colitis was noted. In a September 2005 letter, Dr. M.S.T. indicated that while the Veteran "did obtain some serologic markers for inflammatory bowel disease...These have returned positive - most likely [the Veteran] does have Crohn's colitis." See the letter from Dr. M.S.T. dated September 2005. Continuing diagnoses of inflammatory bowel disease and/or Crohn's disease were subsequently documented in the record. See private treatment records dated September 2005; VA treatment records dated May 2009. The Veteran was afforded a VA examination in October 2012 at which time the examiner confirmed the diagnosis of Crohn's disease. The examiner interviewed and examined the Veteran and concluded that "[t]he claimed condition is less likely than not (less than 50% probability) proximately due to or the result of the Veteran's service-connected condition." The examiner explained that "Crohn's disease is unrelated to [the] Veteran's hepatitis C; per review of literature including Harrison's internal medicine textbook, hepatitis C does not cause or exacerbate Crohn's disease." The October 2012 VA medical opinion was based upon review of the record and analyses of the Veteran's entire history, including his medical history as to the service-connected hepatitis C. Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"). Moreover, aside from discussing the Veteran's pertinent medical history, the examiner explicitly reviewed the available medical literature in reaching his conclusion. The examiner pointed to medical authority to support the conclusion reached in this case. Additionally, the Veteran has not produced a medical opinion to contradict the conclusions set forth in the October 2012 VA medical opinion. As was explained in the VCAA section above, the Veteran has been afforded ample opportunity to present competent medical evidence in support of his claim but has not done so. See 38 U.S.C.A. § 5107(a) (West 2002) (it is the claimant's responsibility to support a claim for VA benefits). Thus, the October 2012 VA medical opinion stands unchallenged as competent medical evidence on the crucial question of medical nexus and aggravation. In this regard, the Board acknowledges that the Veteran has submitted his own statements to support his claim of service connection. As a lay person, the Veteran is competent to testify to observable symptoms. See Washington v. Nicholson, 21 Vet. App. 191, 195 (2007) (holding that, "[a]s a layperson, an appellant is competent to provide information regarding visible, or otherwise observable symptoms of disability); see also Barr, supra; Layno v. Brown, 6 Vet. App. 465 (1994). However, the Veteran is not competent to provide medical conclusions as to whether a disability is due to hepatitis C. See Buchanan v. Nicholson, 451 F.3d 1331-37 (Fed. Cir. 2006); see also Miller v. Derwinski, 3 Vet. App. 201, 204 (1992). Therefore, to the extent that the Veteran claims that his Crohn's disease is caused or aggravated by his service-connected hepatitis C, laypersons without medical training, such as the Veteran, are not competent to comment on medical matters. See 38 C.F.R. § 3.159(a)(1) (2012). The Board further observes that the Veteran's contentions in support of dependent and/or aggravated symptomatology are contradicted by the findings of the October 2012 VA examiner who specifically considered the Veteran's lay assertions and any such inferences contained in the record. The Board has considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. Therefore, the Board is unable to identify a reasonable basis for granting service connection. Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990); 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012). For the reasons expressed above, especially the uncontradicted medical opinion evidence, the Board concludes that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for bowel disease secondary to his service-connected hepatitis C. The benefit sought on appeal is accordingly denied. III. Analysis-Rating Claim Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. A determination is made as to the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.10. Where there is a question as to which of two ratings should be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Veteran's entire history is reviewed when making disability evaluations. See generally 38 C.F.R. § 4.1 (2012); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). Here, the Veteran has been assigned a 10 percent disability rating for his service-connected hepatitis C from February 5, 2001 (the date of award of service connection) and a 40 percent disability rating from October 5, 2012 (the date of the most recent VA examination). As will be explained below, the Board finds that the evidence does not support a finding that higher evaluations for this disability are warranted at any time during the appeal period. Hepatitis C is rated under Diagnostic Code 7354, which provides that a rating of 10 percent is assigned where the Veteran has serologic evidence of hepatitis C infection and the following signs and symptoms due to hepatitis C infection: intermittent fatigue, malaise, and anorexia, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least one week, but less than two weeks, during the past 12-month period. A rating of 20 percent is assigned where the Veteran has serologic evidence of hepatitis C infection and the following signs and symptoms due to hepatitis C infection: daily fatigue, malaise, and anorexia (without weight loss or hepatomegaly), requiring dietary restriction or continuous medication, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least two weeks, but less than four weeks, during the past 12-month period. A rating of 40 percent is assigned where the Veteran has serologic evidence of hepatitis C infection and the following signs and symptoms due to hepatitis C infection: daily fatigue, malaise, and anorexia, with minor weight loss and hepatomegaly, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least four weeks, but less than six weeks, during the past 12-month period. A rating of 60 percent is assigned where the Veteran has serologic evidence of hepatitis C infection and the following signs and symptoms due to hepatitis C infection: daily fatigue, malaise, and anorexia, with substantial weight loss (or other indication of malnutrition), and hepatomegaly, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least six weeks during the past 12-month period, but not occurring constantly. A rating of 100 percent is assigned where the Veteran has serologic evidence of hepatitis C infection and the following signs and symptoms due to hepatitis C infection: near-constant debilitating symptoms (such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain). 38 C.F.R. § 4.114, Diagnostic Code 7354 (2012). Sequelae, such as cirrhosis or malignancy of the liver, are to be rated under an appropriate diagnostic code, but the same signs and symptoms should not be used as the basis for rating under both diagnostic codes. 38 C.F.R. § 4.114, Diagnostic Code 7354, Note (1) (2012). An incapacitating episode means a period of acute signs and symptoms severe enough to require bed rest and treatment by a physician. 38 C.F.R. § 4.114, Diagnostic Code 7354, Note (2) (2012). The Veteran's hepatitis C disability has been assigned a rating of 10 percent from February 5, 2001, and 40 percent from October 5, 2012. The Board finds that a rating in excess of 10 percent is not warranted for the period prior to October 5, 2012, because the Veteran did not have daily fatigue, malaise, and anorexia, requiring dietary restriction or continuous medication, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least two weeks, but less than four weeks during a 12-month period. Specifically, the Veteran was afforded a VA examination in March 2005 at which time it was noted that, although he was initially started on interferon, he did not tolerate the medication and his treatment was stopped. The examiner indicated that the Veteran watched his diet but was on no other treatment for his hepatitis C. The Veteran denied experiencing vomiting, hematemesis, or melena. The examiner observed that the Veteran did report having some fatigue, weakness, depression, and anxiety, although he was not on any medications. The Veteran's weight was 205 pounds with normal muscle strength and no evidence of wasting. Incapacitating episodes were not reported by the Veteran. Private treatment records dated in August 2005 and September 2005 documented the Veteran's weight as 197 pounds and 200 pounds, respectively. A VA treatment record dated in May 2009 shows that the Veteran experienced "some depression" and has "occasional nausea and reflux." Another May 2009 VA treatment record indicated that the Veteran has "chronic abdominal pain and severe fatigue" it was noted that he very rarely experiences nausea. The treating physician noted the Veteran's complaints of right-sided kidney pain, diffuse fatigue, and body aches possibly due to his hepatitis C. VA treatment records dated in June 2009 noted that, as a result of his multiple medication problems, the Veteran reports "a hard time doing things without getting too tired, which makes him irritable at times." It was also noted that the Veteran has felt chronically tired and fatigued now for at least three to four years. The Veteran was afforded a second VA examination in October 2009 as to his service-connected hepatitis C. The examiner noted the Veteran's report of experiencing diarrhea. The Veteran reported dietary restriction since 2000 with an "okay" response to treatment. He endorsed incapacitating episodes, but further stated that he had experienced no attacks in the past twelve months. The Veteran endorsed daily fatigue, but the examiner indicated the Veteran had no anorexia, weight loss, right upper quadrant pain, or liver enlargement. Intermittent, mild abdominal pain was noted. The examiner further stated that the Veteran had no jaundice, palmar erythema, spider angiomata, or evidence of malnutrition. With respect to the period prior to October 5, 2012, the Board acknowledges that the Veteran's report of daily fatigue as well as dietary restrictions. See the October 2009 VA examination report. However, the Board finds that a rating higher than 10 percent is not warranted from February 5, 2001 to October 5, 2012 because Diagnostic Code 7354 is conjunctive at the 20 percent level and requires daily fatigue, malaise, and anorexia, requiring dietary restriction or continuous medication. As there is no evidence of anorexia during the period prior to October 5, 2012, the Board finds that a higher rating is not warranted. Moreover, there is no evidence of incapacitating episodes having a duration of at least two weeks during the period under consideration, as is alternatively required to warrant a 20 percent rating under Diagnostic Code 7354. Additionally, the Board finds that a rating in excess of 40 percent is not warranted for the period since October 5, 2012 because the Veteran does not have daily fatigue, malaise, and anorexia, with substantial weight loss and hepatomegaly (enlarged liver), or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least six weeks during the past 12-month period, but not occurring constantly. Specifically, at his October 2012 VA examination, the Veteran reported experiencing daily fatigue, malaise, and anorexia, as well as, intermittent right upper quadrant pain. Nausea, vomiting, arthralgias, and hepatomegaly were not reported. Moreover, he did not report any incapacitating episodes. He weighed 170 pounds in October 2012, which was a 30-pound weight loss from the examination in October 2009. However, the examiner noted that the Veteran's weight loss was not sustained for three months or longer. The examiner reported that the Veteran was now diagnosed with cirrhosis of the liver, but he did not identify any specific symptoms pertinent to the cirrhosis. Moreover, the examiner noted that the Veteran's "hepatitis C has progressed, and he has symptoms of daily malaise, anorexia, fatigue, and intermittent right upper quadrant pain. Veteran has not had any incapacitating episodes in the last six months." The Board acknowledges that the Veteran had daily fatigue, malaise, and anorexia on or after October 5, 2012. However, the Board finds that a rating higher than 40 percent from October 5, 2012 is not for application because the Veteran did not have hepatomegaly or substantial weight loss (or other indication of malnutrition) during that time. Specifically, there is no evidence that the Veteran's weight loss was "substantial" pursuant to 38 C.F.R. § 4.112 in that he did not have a loss of greater than 20 percent of his baseline weight sustained for three months or longer. See the October 2012 VA examination report. Diagnostic Code 7354 is conjunctive at the 60 percent rating level and it requires daily fatigue, malaise, and anorexia, with substantial weight loss and hepatomegaly. As there is no evidence of substantial weight loss or hepatomegaly during the period beginning on October 5, 2012, the Board finds that no higher rating is warranted. As indicated above, the October 2012 VA examiner indicated that the Veteran's hepatitis C had progressed to cirrhosis of the liver. Diagnostic Code 7354 states that sequelae of hepatitis C, such as cirrhosis or malignancy of the liver, are to be rated under an appropriate diagnostic code, but the same signs and symptoms should not be used as the basis for evaluation under both diagnostic codes. 38 C.F.R. § 4.114, Diagnostic Code 7354, Note (1) (2012). Pursuant to Diagnostic Code 7312, cirrhosis of the liver is rated at 10 percent where there are symptoms such as weakness, anorexia, abdominal pain, and malaise. A 30 percent rating applies where there is portal hypertension and splenomegaly (enlargement of the spleen), with weakness, anorexia, abdominal pain, malaise, and at least minor weight loss. A 50 percent rating applies where there is a history of one episode of ascites, hepatic encephalopathy, or hemorrhage from varices or portal gastropathy (erosive gastritis). A 70 percent rating applies where there is a history of two or more episodes of ascites, hepatic encephalopathy, or hemorrhage from varices or portal gastropathy (erosive gastritis), but with periods of remission between attacks. A 100 percent rating applies where there is generalized weakness, substantial weight loss, and persistent jaundice, or; with one of the following refractory to treatment: ascites, hepatic encephalopathy, hemorrhage from varices or portal gastropathy (erosive gastritis). 38 C.F.R. § 4.114, Diagnostic code 7312 (2012). The evidence demonstrates that the Veteran's cirrhosis is a sequela of hepatitis C. See the VA examination report dated October 2012. Nevertheless, neither the October 2012 VA examiner, nor the Veteran, has identified any symptoms of cirrhosis that are distinct from his service-connected hepatitis C. See 38 C.F.R. § 4.114, Diagnostic Code 7354, Note (1) (evaluate sequelae, such as cirrhosis or malignancy of the liver, under an appropriate diagnostic code, but do not use the same signs and symptoms as the basis for evaluation under DC 7354 and under a diagnostic code for sequalae). Accordingly, the Board finds that an additional rating for cirrhosis is not warranted during the claim period. The Board also finds that evidence does not show an exceptional or unusual disability picture as would render impractical the application of the regular schedular rating standards. See 38 C.F.R. § 3.321 (2012). In this regard, the Board does not dispute that the service-connected hepatitis C has had an adverse effect on employability, but it bears emphasis that the schedular rating criteria are designed to take such factors into account. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1 (2012). Here, the very problems reported by the Veteran are contemplated by the criteria discussed above. 38 C.F.R. §§ 4.10, 4.40. Thus, given the lack of evidence showing unusual disability not contemplated by the rating schedule, the Board concludes that a remand to the RO for referral of this issue to the VA Central Office for consideration of extraschedular evaluations is not warranted. ORDER Entitlement to service connection for bowel disease secondary to hepatitis C is denied. Entitlement to a disability rating in excess of 10 percent from February 5, 2001, to October 5, 2012, for hepatitis C is denied. Entitlement to a disability rating in excess of 40 percent from October 5, 2012, for hepatitis C is denied. _________________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs