Citation Nr: 1335666 Decision Date: 11/04/13 Archive Date: 11/13/13 DOCKET NO. 03-35 059 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUE Entitlement to an initial rating in excess of 10 percent for a digestive disability, to include gastroesophageal reflux disease (GERD) with steatosis of the liver with early fibrosis, and irritable bowel syndrome (IBS), prior to October 22, 2012 and in excess of 30 percent from October 22, 2012. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD F. Yankey, Counsel INTRODUCTION The Veteran served on active military duty from May 1985 to July 1986 and from October 1990 to February 2000. This case comes before the Board of Veterans' Appeals (Board) on appeal from a February 2002 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. Jurisdiction over the case was subsequently transferred to the VA RO in North Little Rock, Arkansas. The Board notes that, in addition to the paper claims file, there is a Virtual VA electronic claims file associated with the Veteran's claim. A review of the documents in the electronic file to date reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issue on appeal. This case was previously before the Board. In a March 2010 decision, the Board denied the issue currently on appeal. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In a September 2011 Memorandum Decision, the Court vacated the Board's decision with respect to the issue currently on appeal and remanded the case to the Board for action consistent with the Memorandum Decision. In July 2012 and April 2013, the case was remanded by the Board for additional development. The case has now been returned to the Board for further appellate action. The issue on appeal has been restated as shown on page one to comply with the provisions of 38 C.F.R. § 4.114 (2013). In the August 2013 Written Brief Presentation, the Veteran's representative stated that in July 2005, the Veteran's treating physician linked his GERD to his asthma and sleep apnea. He also stated that the Veteran had experienced ongoing problems with dysphonia and dysphagia. He argued that all of these problems should be service connected. Initially, the Board notes that the Veteran is currently service connected for reactive airway disease/asthma. See February 2002 rating decision. In an August 2006 rating decision, the previous denial of service connection for sleep apnea was confirmed and continued. Dysphagia is a recognized symptom for hiatal hernia, rated under 38 C.F.R. § 4.114, Diagnostic Code 7346. The Veteran's GERD has been rated as analogous to hiatal hernia. Thus, a separate grant of service connection is not required. Also, dysphagia is a symptom and not a disease or injury. It appears that the issue of entitlement to service connection for dysphonia, and a new claim to reopen the issue of entitlement to service connection for sleep apnea, have been raised by the record, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). The claims are referred to the RO for appropriate action. FINDINGS OF FACT 1. Throughout the entire period of the claim, the Veteran's GERD with steatosis of the liver with early fibrosis has been manifested by epigastric distress with dysphagia and substernal arm or shoulder pain, pyrosis, regurgitation, intermittent fatigue and nausea, and right upper quadrant pain; his symptoms have never been productive of considerable impairment of health, malaise, anorexia or incapacitating episodes. 2. For the period prior to October 22, 2012, the Veteran's IBS was manifested by no more than disturbances of bowel function with occasional episodes of abdominal distress. 3. For the period beginning October 22, 2012, the Veteran's IBS has been manifested by abdominal distress, alternating diarrhea and constipation, and frequent episodes of bowel disturbance. 4. The severity of the oveedrall disability does not warrant elevation to the next higher evaluation. CONCLUSIONS OF LAW 1. During the entire appeal period, the criteria for a rating in excess of 10 percent for GERD with steatosis of the liver with early fibrosis have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.14, 4.114, Diagnostic Codes 7345, 7346 (2013). 2. For the period prior to October 22, 2012, the criteria for a compensable rating for IBS have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.14, 4.114, Diagnostic Code 7319 (2013). 3. For the period beginning October 22, 2012, the criteria for a rating in excess of 30 percent for IBS have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.14, 4.114, Diagnostic Code 7319 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012) defined VA's duty to assist a Veteran in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Under the VCAA, VA 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. Pelegrini v. Principi (Pelegrini II), 18 Vet. App. 112, 120-21 (2004), see 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The appeal arises from disagreement with the initial rating following the grant of service connection. The courts have held that once service connection is granted the claim is substantiated, additional VCAA notice is not required; and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The Court has elaborated that filing a notice of disagreement begins the appellate process, and any remaining concerns regarding evidence necessary to establish a more favorable decision with respect to downstream elements (such as an effective date) are appropriately addressed under the notice provisions of 38 U.S.C.A. §§ 5104 and 7105. Goodwin v. Peake, 22 Vet. App. 128 (2008). Where a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to the downstream elements. Id. There has been no allegation or evidence of prejudice. The Duty to Assist The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). The VCAA also provides that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. VA has obtained records of treatment reported by the Veteran, including service treatment records, and VA and private treatment records. The Board remanded the claim in July 2012 to obtain outstanding VA treatment records dated from 2009 to the present, and to afford the Veteran a VA examination to evaluate the current severity of his service-connected GERD with steatosis of the liver with early fibrosis. The Veteran was afforded VA examinations in October 2012 for his service-connected GERD, as well as his liver condition and IBS. As the July 2012 remand directives were not adequately complied with in the October 2012 examination, the Board remanded the claim again in April 2013 for an addendum opinion from the October 2012 VA examiner. The addendum opinion was submitted in June 2013. When VA undertakes to provide an examination or obtain an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds the October 2012 VA examination reports, in conjunction with the June 2013 addendum opinion, to be thorough and adequate upon which to base a decision with regard to the Veteran's claim. Furthermore, the Veteran was sent a letter in April 2013, requesting that he provide the name and location of any VA medical facility where he had received treatment and the approximate dates of treatment so that any VA treatment records not currently on file could be retrieved. In August 2013, the Veteran responded that he did not have any additional evidence to submit. See August 2013 SSOC response. Accordingly, the Board finds that the remand instructions were thereby complied with. Stegall v. West, 11 Vet. App. 268 (1998). For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. The appeal is thus ready to be considered on the merits. Legal Criteria Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2013). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2013). Each disability must be considered from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2 (2013). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2013). At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). There are diseases of the digestive system, particularly within the abdomen, which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia and disturbances in nutrition. Consequently, certain coexisting diseases in this area, as indicated in the instruction under the title "Diseases of the Digestive System," do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in 38 C.F.R. § 4.14; 38 C.F.R. § 4.113 (2013). Disabilities of the digestive system are rated in accordance with 38 C.F.R. § 4.114, Diagnostic Codes 7200-7348. Section 4.114 provides that ratings under codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive, will not be combined with each other. A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. The Veteran's GERD with steatosis of the liver with early fibrosis has been rated as 10 percent disabling under 38 C.F.R. § 4.114, as analogous to Diagnostic Code 7346. Under Diagnostic Code 7346, hiatal hernia, a 10 percent disability rating is warranted when there are two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent disability rating is in order when 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 maximum 60 percent rating is in order when there are symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114. Diagnostic Code 7345 rates chronic liver disease without cirrhosis (including hepatitis B, chronic active hepatitis, autoimmune hepatitis, hemochromatosis, drug-induced hepatitis, etc., but excluding bile duct disorders and hepatitis C). 38 C.F.R. § 4.114, DC 7345. Under DC 7345, a 10 percent evaluation requires that there is 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 20 percent evaluation requires 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 40 percent evaluation requires 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 60 percent evaluation requires 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 twelve-month period, but not occurring constantly. A 100 percent rating for chronic liver disease without cirrhosis requires near constant debilitating symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain. Note (2) defines an "incapacitating episode" as a period of acute signs and symptoms severe enough to require bed rest and treatment by a physician. 38 C.F.R. § 4.114. The Veteran's service-connected IBS has been rated by the RO under the provisions of Diagnostic Code 7319. Under this regulatory provision, a rating of 0 percent is warranted where there is mild irritable colon syndrome (spastic colitis, mucous colitis, etc.) with disturbances of bowel function with occasional episodes of abdominal distress. A 10 percent rating is warranted for moderate irritable colon syndrome with frequent episodes of bowel disturbance with abdominal distress. A 30 percent rating is warranted for severe irritable colon syndrome with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. 38 C.F.R. § 4.114, Diagnostic Code 7319. Analysis The medical evidence of record shows that in May 1999, the Veteran was diagnosed with GERD. A January 2000 liver biopsy revealed steatosis, mild chronic inflammation, and early septal fibrosis. A November 2004 letter from Dr. Wade notes that liver fibrosis, with a non-alcoholic fatty liver, was diagnosed during service by a biopsy. Dr. Wade further discussed the interrelationship between the genitourinary system and other body systems, as well as the records which show the Veteran's epigastric symptoms, including dysphagia, nightly regurgitation accompanied by sore throat and slight loss of voice, substantial pain, and shoulder pain. An April 2005 upper endoscopy report notes Grade A esophagitis, hiatus hernia, and gastric polyps. Increasing Prilosec was recommended. A May 2005 VA fee basis examination report notes that the Veteran was diagnosed with esophagitis, Reincke's edema, and laryngeal reflux in 1998. He has gained over 30 pounds. He complained of difficulty swallowing, pain above the stomach, arm pain, passing black-colored old blood in stool, nausea, and vomiting, heartburn, pain behind the breast bone, vomiting blood, reflux, and regurgitation of stomach contents. Symptoms were constant. Treatment included use of Prilosec and other medication. He described decreased cognition, motivation, and energy, which kept him from speaking and communicating, and aggravated his gastric problems. His liver symptoms were near constant, daily, and debilitating. He was functional and sometimes was able to work. He also noted loss of work about three days a month. He complained of flank pain in the right upper side and substernal arm. The pain was constant. It caused easy fatigue, gastrointestinal disturbance, aches, joint pain, nausea, and loss of appetite. Examination of the abdomen was normal. Complete blood count was normal. Some liver function tests were elevated. It was noted that the Veteran had no ascites, hepatic encephalopathy, varicies, hemorrhage, portal hypertension, petal gastropathy, or jaundice. A September 2008 VA fee basis examination report notes that the Veteran's GERD did not affect his general body health. During the preceding 12 months, the Veteran had gained 40 pounds. He reported dysphagia, heartburn, epigastric pain, scapular pain, arm pain, passing of black-tarry stools, and nausea and vomiting. He had no hematemesis, reflux, or regurgitation of stomach contents. The symptoms described occurred constantly. The treatment was antacids and Zantac. The Veteran reported that he had never been hospitalized for this condition, nor had he had any surgery for this condition. He reported that he took extra antacids and Pepto Bismol for the condition. There was no malnutrition. The Veteran was afforded a VA intestinal condition examination in October 2012. He was diagnosed with irritable bowel syndrome. He complained of frequent abdominal pain and nausea, relived by bowel movement, passing gas or burping. He also complained of alternating diarrhea and constipation with about 1-2 days of normal bowel movements per week. He also complained of frequent bloating 45 minutes after eating, and as noted above, nausea about 3 times per week, which lasted for about 20 minutes, and was relieved by taking fiber or Gaviscon, burping or bowel movement. He indicated that he was taking Dicyclomine daily for the condition. He denied weight loss, malnutrition, serious complications or other general health effects attributable to the intestinal condition. The Veteran was also afforded a VA liver examination in October 2012. He was diagnosed at that time with steatosis of the liver with early fibrosis. He complained of intermittent fatigue, intermittent nausea, intermittent right upper quadrant pain, hepatomegaly, and dietary restrictions (low carb, low sugar diet), all attributable to the liver condition. He denied any incapacitating episodes due to the liver condition during the previous 12 months. The Veteran was also afforded a VA esophageal conditions examination in October 2012. He was diagnosed with GERD, a hiatal hernia, and esophagitis. He reported taking over the counter medications for his GERD, and complained of the following symptoms: persistently recurrent epiagstric distress; dysphagia; pyrosis; reflux; regurgitation; substernal arm or shoulder pain; sleep disturbance caused by reflux 4 or more times per year, for less than 1 day; and periodic nausea 4 or more times per year, for less than 1 day. In June 2013, a VA medical opinion was submitted, in accordance with the Board's April 2013 remand. After reviewing the medical evidence of record, the VA examiner opined that the Veteran's GERD symptoms do not cause severe or considerable impairment of health. In rendering his opinion, he noted that the Veteran's treatment was limited to over the counter medication. A review of the medical evidence of record shows that the Veteran has a multitude of symptoms for his GERD with liver steatosis with early fibrosis. However, none of these symptoms have been found to produce considerable impairment of health. The September 2008 VA examiner opined that the GERD with liver steatosis symptoms did not affect the Veteran's general health, and the June 2013 VA examiner concluded that the Veteran's GERD symptoms do not cause severe or considerable impairment of health. The Veteran has been noted on examination to have persistently recurrent epigastric distress with dysphagia and substernal arm or shoulder pain. He has also complained of pyrosis and regurgitation. However, the Veteran has not lost weight and he is not malnourished. Moreover, the epigastric distress with dysphagia and substernal arm or shoulder pain has never been found to be productive of considerable impairment of health. As such, a higher rating is not warranted under 38 C.F.R. § 4.114, Diagnostic Code 7346. A separate rating for the liver steatosis with early fibrosis is also not warranted. The 10 percent evaluation awarded under Diagnostic Code 7346 reflects, in the Board's opinion, the Veteran's predominant disability picture. Any attempt to assign an additional rating for the liver steatosis with early fibrosis under another Diagnostic Code would constitute impermissible pyramiding. 38 C.F.R. § 4.14. He does not meet the criteria for a 10 percent rating under Diagnostic Code 7345, as the evidence does not demonstrate incapacitating episodes (as defined in this diagnostic code) or anorexia. In fact, his weight has increased, over 40 pounds in the previous 12 months, as reported at a September 2008 VA fee basis examination. A rating in excess of 10 percent is also not warranted, as there is no evidence of daily fatigue, malaise and anorexia. There is no basis to conclude that the 10 percent rating under Diagnostic Code 7346, for hiatal hernia, should be elevated to the next higher evaluation due to the severity of the overall disability. Prior to October 22, 2012, symptoms which may be indicative of IBS were noted to include bloody stools. Complaints of diarrhea or constipation were not recorded at VA fee basis examinations in May 2005 or September 2008. Without evidence of bowel disturbance, a compensable evaluation for IBS under Diagnostic Code 7319 is not warranted. Therefore, the Board finds that the Veteran's service-connected GERD with steatosis of the liver with early fibrosis was appropriately rated as 10 percent disabling under Diagnostic Code 7346. A basis for a separate compensable evaluation for IBS is not warranted, nor is there evidence that IBS symptoms contributed to an overall disability picture which warrants elevation of the 10 percent rating previously assigned. The Board also notes that in a July 2013 rating decision, based on the results of the October 2012 VA examinations, including evidence of abdominal distress, alternating diarrhea and constipation, and frequent episodes of bowel disturbance, the RO increased the rating for the Veteran's service-connected irritable bowel syndrome (IBS) to 30 percent, effective October 22, 2012. This is the highest schedular rating available under Diagnostic Code 7319. Furthermore, the Board finds that the evidence of record does not show that the Veteran had symptoms of frequent episodes of bowel disturbance with abdominal distress, or diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress, required to meet the criteria for a compensable rating for his service-connected IBS, prior to October 22, 2012. In this regard, the Board notes that the Veteran's representative, in the August 2013 Written Brief Presentation, argues that the Court, in its September 2011 decision, listed several symptoms of record meriting a 30 percent rating under Diagnostic Code 7319 that have been in existence "for some time." A review of the Court's September 2011 decision shows that the Court noted that the Veteran's diagnosed gastrointestinal disorders, including GERD, IBS, and hiatal hernia, have caused symptoms such as nausea, loose stools, aspirating stomach contents, constipation, difficulty swallowing, pain above the stomach, gastrointestinal disturbance, and black stools containing blood. However, the Court did not indicate how long each of the symptoms had been manifested or to what extent. This information is required to adequately rate the Veteran under Diagnostic Code 7319 and all other applicable diagnostic codes. As noted above, the Board finds that, based on the evidence of record, including service treatment records, VA examinations, and VA outpatient treatment records, the criteria for a 30 percent rating under Diagnostic Code 7319 were not met prior to October 22, 2012. The Board has also considered whether a higher or separate rating is warranted under any other diagnostic code, but has found none. In this regard, the Board notes that the Veteran does not have diagnoses of pancreatitis, hepatitis C, hepatitis B, ulcer, ulcerative colitis, or diverticulitis. Moreover, he does not have splenomegaly, minor weight loss, or incapacitating episodes of at least two weeks but less than four weeks during the past 12 month period. His symptoms, although constant, do not affect his general health; he has gained weight, not lost weight; and he has never been found to be incapacitated. Therefore, a higher rating under any other diagnostic code is not in order. See 38 C.F.R. § 4.114, Diagnostic Codes 7304-7307, 7312, 7323, 7345, 7347. As there is not basis for a higher schedular rating under any pertinent diagnostic code or elevating a rating to the next higher evaluation due to the overall disability picture, this aspect of the Veteran's claim must be denied. Extra-Schedular Consideration Pursuant to § 3.321(b)(1), the Under Secretary for Benefits or the Director, Compensation and Pension Service, is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1) (2013). The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). Manifestations of the Veteran's gastrointestinal disability are consistent with the assigned schedular evaluations. The Veteran reported during his October 2012 VA examinations that his abdominal distress affects his ability to concentrate at work; that his liver disability limits his ability to perform strenuous physical activities; and that his GERD affects his ability to talk and communicate, due to his raspy voice, and that he has trouble concentrating at work due to heart burn. However, the rating schedule contemplates the effects of the disability on the Veteran's ability to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10 (2013). The rating schedule is meant to compensate for considerable time lost from work. 38 C.F.R. § 4.1 (2013). Referral for extraschedular consideration would not be warranted unless the rating criteria did not contemplate his symptoms. A review of the rating criteria for the appropriate diagnostic codes reflects that they consider and include the Veteran's complaints and pertinent symptoms. Higher evaluations are provided for greater symptomatology, which the Veteran does not demonstrate. The Board does not find that there is an exceptional disability picture. Therefore, referral of this case for extra-schedular consideration is not in order. See Floyd v. Brown, 9 Vet. App. 88, 95 (1996); Bagwell v. Brown, 9 Vet. App. 337 (1996). Total Rating for Compensation Based on Individual Unemployability (TDIU) The Court has held that TDIU is an element of all claims for an increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). TDIU is granted where a veteran's service-connected disabilities are rated less than total, but they prevent him from obtaining or maintaining all gainful employment for which his education and occupational experience would otherwise qualify him. 38 C.F.R. § 4.16 (2013). Where a veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability, the requirement in 38 C.F.R. § 3.155(a) (2013) that an informal claim "identify the benefit sought" has been satisfied and VA must consider whether the veteran is entitled to a total rating for compensation purposes based on individual unemployability (TDIU). Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). In this case there is no evidence that the Veteran's service-connected disabilities have caused unemployability. As noted above, the Veteran has reported that his disabilities interfere with his ability to perform certain components of his job, but he has not alleged, and there is no evidence showing, that he has had to resign his employment, or that he was ever fired or denied employment due to any of his service-connected disabilities, including his GERD or IBS. As there is no evidence of unemployability attributable to his service-connected disabilities, the Board finds that further consideration of entitlement to TDIU is not required. ORDER An initial rating in excess of 10 percent prior to October 22, 2012 for a digestive disability, to include GERD with steatosis of the liver with early fibrosis, and IBS is denied. An initial rating in excess of 30 percent from October 22, 2012 for a digestive disability, to include GERD with steatosis of the liver with early fibrosis, and IBS is denied. ____________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs