Citation Nr: 1339347 Decision Date: 11/29/13 Archive Date: 12/13/13 DOCKET NO. 07-06 336 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to an increased evaluation for residuals of cancer of the larynx, currently rated as 10 percent disabling. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD K. Osegueda, Associate Counsel INTRODUCTION The Veteran had active service from June 1963 to June 1967. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from a September 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. In that rating decision, the RO reduced the evaluation for the residuals of cancer of the larynx from 100 percent to 10 percent, effective from December 1, 2006. In December 2010 and April 2013, the Board remanded the Veteran's claim for additional development. The case has been returned to the Board for appellate review. After completing the requested development, the Appeals Management Center (AMC) continued to deny the claim (as reflected in an October 2013 supplemental statement of the case (SSOC)) and returned the case to the Board for appellate review. In addition to the paper claims file, there are Virtual VA and Veterans Benefits Management System (VBMS) paperless files associated with the Veteran's claim. A review of the documents in the paperless claims files reveals a brief submitted by the Veteran's representative and VA treatment records that are relevant to the issue on appeal. However, they were of record and considered by the AMC in the October 2013 SSOC. FINDINGS OF FACT 1. The Veteran's residuals of cancer of the larynx are manifested by hoarseness, with inflammation of cords or mucous membranes; however, there is no evidence of hoarseness, with thickening or nodules of cords, polyps, submucous infiltration, or pre-malignant changes on biopsy. 2. There is no evidence of any new or recurrent cancer. CONCLUSION OF LAW The criteria for an increased disability rating higher than 10 percent for residuals of cancer of the larynx have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1-4.14, 4.97, Diagnostic Code 6516 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Upon receipt of a substantially complete application for benefits, VA must notify the claimant of what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and, (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. With regard to claims for increased disability ratings for service-connected conditions, the law requires VA to notify the claimant that, to substantiate a claim, the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability. 38 U.S.C.A. §5103(a); 38 C.F.R. § 3.159(b); Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated and remanded sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration. Finally, the notice must provide examples of the types of medical and lay evidence that the Veteran may submit (or ask the VA to obtain) that are relevant to establishing his or her entitlement to increased compensation. However, the notice required by section 5103(a) need not be specific to the particular Veteran's circumstances; that is, VA need not notify a Veteran of alternative diagnostic codes that may be considered or notify of any need for evidence demonstrating the effect that the worsening of the disability has on the particular Veteran's daily life. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). VCAA notice should be provided to a claimant before the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Pelegrini v. Principi, 18 Vet. App. 112, 115 (2004). However, the VCAA notice requirements may be satisfied notwithstanding errors in the timing or content of the notice if such errors are not prejudicial to the claimant. Id. at 121. Further, a defect in the timing of the notice may be cured by sending proper notice prior to a re-adjudication of the claim. Mayfield v. Nicholson, 444 F.3d 1328, 1333-1334 (Fed. Cir. 2006). VA's General Counsel issued a precedential opinion interpreting Pelegrini as requiring the Board to ensure that proper notice is provided unless it makes findings regarding the completeness of the record or other facts that would permit the conclusion that the notice error was harmless. See VAOGCPREC 7-2004. The United States Court of Appeals for the Federal Circuit reaffirmed the importance of proper VCAA notice in Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Mayfield and its progeny instruct that a comprehensive VCAA letter, as opposed to a patchwork of other post-decisional documents, is required to meet the VCAA's notification requirements. Id. at 1320. However, VCAA notification does not require a pre-adjudicatory analysis of the evidence already contained in the record. See, e.g. Mayfield v. Nicholson, 20 Vet. App. 537, 541 (2006). In this case, the requirements with respect to the content of the notice were met. Specifically, a letter was sent to the Veteran in October 2005 that notified him of the evidence needed to substantiate his claim for service connection for cancer of the larynx. A March 2006 letter also informed the Veteran of the division of responsibilities in obtaining the evidence to support his claims and explained how disability ratings and effective dates are determined. As noted in the December 2010 remand, and discussed above, in the September 2006 rating decision on appeal, the RO assigned a 10 percent rating for the residuals of cancer of the larynx, effective from December 1, 2006, following the expiration of a 100 percent rating. The Veteran appealed that decision, but he has not specifically argued as to the propriety of the reduction. Rather, his contentions essentially pertain to the evaluation of the severity of his condition since December 1, 2006. A letter was not sent to the Veteran that notified him of the evidence needed to substantiate his claim for an increased rating. However, in a February 2007 statement of the case (SOC), the RO notified him of the evidence needed to substantiate the claim. Specifically, he was provided with the rating criteria pertinent to respiratory system disabilities, to include chronic laryngitis and malignant neoplasms of any specified part of the respiratory system. The Board notes that the case was readjudicated by the AMC in February 2008, April 2012, and October 2013 SSOCs; therefore, there is no timing error in this case. Prickett v. Nicholson, 20 Vet. App. 370, 377-78 (2006) (VA cured failure to afford statutory notice to claimant prior to initial rating decision by issuing notification letter after decision and readjudicating the claim and notifying claimant of such readjudication in the statement of the case). Moreover, the Board notes that the Veteran and his representative have not alleged any prejudice as a result of the notification, nor has any been shown. See Shinseki v. Sanders, 29 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination.). The duty to assist the Veteran has also been satisfied in this case. The Veteran's service treatment records and all identified and available post-service medical records, including VA treatment notes and private treatment notes, have been associated with the claims file and were reviewed by both the RO and the Board in connection with the claim. Specifically, in the April 2013 remand, the Board directed the RO to obtain private treatment notes identified by the Veteran for the period from July 2005 to August 2009, and to obtain any outstanding VA treatment notes pertinent to treatment of the residuals of cancer of the larynx. Those records have been obtained and associated with the record, in accordance with the remand directives. The Veteran has not identified any other outstanding records that are pertinent to the issue currently on appeal. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, the Veteran was afforded VA examinations in February 2006, October 2007, and December 2010 in connection with his claim. There is also no objective evidence indicating that there has been a material change in the severity of the Veteran's residuals of cancer of the larynx since he was last examined. 38 C.F.R. § 3.327(a) (2012). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11-95. Thus, there is adequate medical evidence of record to make a determination in this case. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4) (2012). VA has further assisted the Veteran and his representative throughout the course of this appeal by providing them with a SOC and SSOCs, which informed them of the laws and regulations relevant to the Veteran's claim. The Board concludes that the Veteran was provided the opportunity to meaningfully participate in the adjudication of his claim, and he did, in fact, participate. Washington v. Nicolson, 21 Vet. App. 191 (2007). For these reasons, the Board concludes that VA has fulfilled the duty to assist the Veteran in this case. Hence, there is no error or issue that precludes the Board from addressing the merits of this appeal. The Veteran has not made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide the particular claim on appeal. He has been given ample opportunity to present evidence and argument in support of his claim. All relevant evidence necessary for an equitable disposition of the Veteran's appeal of this issue has been obtained, and the case is ready for appellate review. General due process considerations have been complied with by VA. See 38 C.F.R. § 3.103 (2012). Laws and Analysis Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.10 (2012). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, as in this case, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where, the question for consideration is a higher initial rating since the grant of service connection, evaluation of the medical evidence since the grant of service connection to consider the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). In this case, in a January 2006 rating decision, the RO granted service connection for cancer of the larynx and assigned a 100 percent rating, effective on August 9, 2005 (the date of claim), under 38 C.F.R. § 4.97, Diagnostic Code 6819. Subsequently, the Veteran was provided a VA examination to ascertain the severity of the residuals of cancer of the larynx. In a September 2006 rating decision, the Veteran's disability evaluation was decreased to 10 percent, effective from December 1, 2006. Under 38 C.F.R. § 4.97, Diagnostic Code 6819, malignant neoplasm, on any specified part of respiratory system exclusive of skin growths are temporarily rated at 100 percent. The note accompanying the diagnostic code indicates that a rating of 100 percent shall continue beyond the cessation of any surgical, x-ray, antineoplastic chemotherapy or other therapeutic procedure. Six months after discontinuance of such treatment, the appropriate disability rating shall be determined by mandatory VA examination; and if there has been no local recurrence or metastasis, the Veteran is to be rated based on any residuals. In this case, the Board finds that there has been no evidence of any new or recurrent cancer. In private treatment notes following his August 2005 laser removal of the carcinoma of his right vocal cord, the Veteran's treating ear, nose, and throat physician noted that there was no evidence of recurrence of cancer. In an April 2006 private treatment note, the physician noted that there was a whitish area on the right anterior vocal cord that he would watch, and if it persisted, he would re-biopsy the area. In a February 2006 VA examination report, the examiner noted that the Veteran underwent surgery for removal of the lesion on his vocal cords. He did not have any radiation or chemotherapy. A fiberoptic laryngoscopy showed no evidence of any recurrence of a lesion. Both vocal cords appeared to be normal, and there were no areas of the larynx that were suspicious. Palpation of the neck also revealed no evidence of any metastatic areas. The examiner stated that there was no evidence of recurrence of the carcinoma of the vocal cord. In a July 2006 private treatment note, the Veteran's treating ear, nose, and throat physician noted that he endoscoped the Veteran and observed his vocal cords looked better. There were no whitish areas. In a November 2006 private treatment note, the Veteran's treating ear, nose, and throat physician fiberoptic scoped the Veteran, and he saw no evidence of cancer. In a March 2007 private treatment note, the Veteran's treating ear, nose, and throat physician noted that he scoped the Veteran and saw a tiny white spot on the anterior of the right vocal cord. Four months later, in a July 2007 private treatment note, the Veteran's treating ear, nose, and throat physician noted that a fiberoptic scope showed that both vocal cords looked very good. He did not see any cancer. During an October 2007 VA examination, the Veteran reported that the carcinoma of his right vocal cord was removed two years ago and he did not have radiation therapy. He indicated that he had "virtually no symptoms" following the laser removal of the carcinoma. A fiberscopic laryngoscopy showed "absolutely no recurrence" of the lesion of the vocal cord or any other abnormality of the larynx. Palpation of the neck was normal. The examiner noted that there was no current evidence of any recurrence or other problems following the surgery for the carcinoma. In a February 2008 private treatment note, the Veteran's treating ear, nose, and throat physician noted that a fiberoptic scope showed a small area of leukopia on the anterior of the right vocal cord. There was no distinct lesion, but he indicated that he would monitor the area of leukoplakia. In an August 2008 private treatment note, the Veteran's treating ear, nose, and throat physician noted that the Veteran looked "excellent" with no evidence of recurrence of cancer after a fiberoptic scope. In a February 2009 private treatment note, the Veteran's treating ear, nose, and throat physician noted that there was no evidence of cancer recurrence. In an August 2009 private treatment note, the Veteran's treating ear, nose, and throat physician indicated that the Veteran was endoscoped and that there was no evidence of recurrent cancer. In a January 2010 private treatment note, the Veteran's treating ear, nose, and throat physician noted that the Veteran's vocal cord "look[ed] good from his cancer standpoint." In a December 2010 VA examination report, the Veteran reported that, after undergoing laser surgical treatment, he had regular follow-up evaluations with his private treatment provider and that there had been no evidence of recurrence of the cancer. He indicated that he was not currently being treated for it. The diagnosis was cancer of the larynx, in remission at the present time. The examiner noted that the larynx was not visualized due to a lack of ear, nose, and throat equipment, and it was recommended that the Veteran undergo an ear, nose, and throat examination for the condition. However, in a January 2011 private treatment note, the Veteran's treating ear, nose, and throat physician noted that he fiberoptic scoped the Veteran. He commented that the anterior vocal cord, which was the site of the cancer, looked normal. There was no evidence of any recurrence. In a January 2012 private treatment note, the Veteran's treating ear, nose, and throat physician performed a fiberoptic endoscopy. The scope showed no evidence of cancer. In a January 2013 private treatment note, the Veteran's treating ear, nose, and throat physician performed a fiberoptic endoscopy. There was no evidence of persistent squamous cell carcinoma. Given the absence of any recurrence of the Veteran's cancer, his disability is to be rated on the residuals of the cancer. Id. As indicated above, the Veteran is currently rated at 10 percent under 38 C.F.R. § 4.97, Diagnostic Code 6516, based on chronic laryngitis. Under Diagnostic Code 6516, a 10 percent rating is assigned where there is evidence of hoarseness, with inflammation of cords or mucous membranes. A 30 percent rating is warranted where there is evidence of hoarseness, with thickening or nodules of cords, polyps, submucous infiltration, or pre-malignant changes on biopsy. Id. In the February 2006 VA examination report, the examiner noted that the Veteran's only complaint was occasional hoarseness. A fiberoptic laryngoscopy showed that both vocal cords appeared normal and mobile. The examiner noted that there were no areas of the larynx that were suspicious, but there was some mild erythema of the arytenoids. In a July 2006 VA treatment note, the Veteran complained of gastrointestinal acid irritation of his throat status-post vocal cord excision from his nonservice connected gastroesophageal reflux disease (GERD). He was prescribed Omeprazole for acid suppression to prevent further irritation to his vocal cords. In a July 2007 private treatment note, the Veteran's treating ear, nose, and throat physician noted that a fiberoptic scope showed both vocal cords were "just a little swollen," but they looked "very good." He noted that the Veteran had purulent secretions in the right nasal fossa, and he prescribed Augmentin for his sinuses. In an August 2009 private treatment note, the Veteran's treating ear, nose, and throat physician noted that the Veteran's vocal cords were mobile. In a January 2010 private treatment note, the Veteran's treating ear, nose, and throat physician noted that the Veteran's pharynx was erythematous, but he also indicated that the Veteran had a cough, a lot of nasal congestion and drainage, and his nose had a lot of purulent secretions. In a January 2012 private treatment note, the Veteran's treating ear, nose, and throat physician reported that the Veteran had a little hoarseness and raspiness to his voice. A fiberoptic endoscopy was performed. The scope showed mild erythema of both vocal cords and slightly swollen arytenoids, but the vocal cords were mobile. The physician reported that the hoarseness "may be related to some scar from his cancer, also he does have reflux which could account for some." In a January 2013 VA treatment note, the Veteran complained of dysphagia. He indicated that he had occasional problems with swallowing, and he felt like he was being choked at times. In a January 2013 private treatment note, the Veteran's treating ear, nose, and throat physician noted that the Veteran complained of occasional coughing and an infrequent strangling sensation when he swallowed. The physician used a flexible fiberoptic scope to examine the Veteran's nasopharynx, hypopharynx, and larynx due to the Veteran gagging. He noted that the nasopharynx and hypopharynx were clear. The larynx and vocal cords were mobile without evidence of nodules, polyps, or tumors. The neck was also palpable without adenopathy or tenderness. There was no evidence of dysphagia. At no point during the course of the Veteran's appeal has there been evidence of hoarseness, with thickening or nodules of cords, polyps, submucous infiltration, or pre-malignant changes on biopsy. As such, his disability does not meet the schedular criteria for the assignment of a 30 percent rating under Diagnostic Code 6516. Nevertheless, the Board has also considered whether an increased evaluation would be in order under other relevant diagnostic codes. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Thus, the Board has considered the propriety of assigning a higher, or separate, rating under another diagnostic code. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). Under 38 C.F.R. § 4.97, Diagnostic Code 6518, a 100 percent rating is warranted where the Veteran has a total laryngectomy. The note accompanying the diagnostic code indicates that the residuals of a partial laryngectomy should be rated as laryngitis under Diagnostic Code 6516, aphonia under Diagnostic Code 6519, or stenosis of the larynx under Diagnostic Code 6520. The evidence shows that the Veteran has not had a total laryngectomy. Rather, private treatment notes dated in August 2005 showed that he had a nasal laryngoscopy. During the February 2006 VA examination, the Veteran reported that he underwent surgery for the removal of the carcinoma lesion of his vocal cord. In an August 2006 private treatment note and during the October 2007 VA examination, the Veteran indicated that his cancer was removed from his vocal cord with a laser. Under 38 C.F.R. § 4.97, Diagnostic Code 6519, a 60 percent rating is assigned for the constant inability to speak above a whisper; while the next higher evaluation, a 100 percent rating is assigned when there is constant inability to communicate by speech. The note accompanying the diagnostic code indicates that incomplete aphonia should be rated as chronic laryngitis under Diagnostic Code 6516, as discussed above. In the February 2006 VA examination report, the examiner noted that the Veteran's voice was "good." In the October 2007 VA examination report, the examiner noted that there may have been a slight change in the Veteran's voice following the removal of the carcinoma on his right vocal cord, but "in essence [it] appear[ed] to be normal." In a January 2010 private treatment note, the Veteran's treating ear, nose, and throat physician noted that the Veteran's voice was "extremely raspy," but he had a lot of nasal congestion and drainage, and his nose had a lot of purulent secretions. Additionally, he noted that the Veteran's vocal cord looked good from a cancer standpoint. In a January 2012 private treatment note, the Veteran's treating ear, nose, and throat physician noted that the Veteran had some raspiness to his voice. There was no indication that the Veteran was unable to speak above a whisper. At no point during the course of the Veteran's appeal has it been shown that the Veteran had a constant inability to speak above a whisper or a constant inability to communicate by speech. As such, his disability does not meet the schedular criteria for the assignment of a 60 or 100 percent rating under Diagnostic Code 6519. Based on the evidence of record described above, the Board finds that the Veteran's residuals of laryngeal cancer do not warrant a disability rating in excess of 10 percent. First, a higher rating is not warranted under Diagnostic Code 6819 because the Veteran does not have recurrence or metastasis of his laryngeal cancer. Second, a higher rating is not warranted under Diagnostic Code 6518 because the Veteran has not had a total laryngectomy. Third, a higher rating is not warranted under Diagnostic Code 6516 because the Veteran does not have hoarseness with thickening or nodules of the cords, polyps, submucous infiltration, or pre-malignant changes on biopsy. Finally, a higher rating is not warranted under Diagnostic Code 6519 because the Veteran does not have a constant inability to speak above a whisper. Therefore, no increase in the current 10 percent rating for residuals of laryngeal cancer is warranted. The Board has considered whether staged ratings under Hart, supra, are appropriate for the Veteran's service-connected residuals of laryngeal cancer; however, the Board finds that his symptomatology has been stable throughout the appeal. Therefore, assigning staged ratings for such disability is not warranted. In rendering this decision, the Board has considered the lay evidence of record, to include the Veteran's reports during VA examinations and during private treatment, in deciding this case. The Veteran is competent to report as to the symptoms he experiences, such as hoarseness and difficulty swallowing, and their history. Layno v. Brown, 6 Vet. App. 465 (1994); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). However, the Board finds that such lay evidence is outweighed by the objective examinations and testing provided by medical professionals with training and expertise. In summary, the Board finds that the Veteran's residuals of laryngeal cancer most closely approximate a 10 percent rating under Diagnostic Code 6516. Accordingly, the Board concludes that reasonable doubt does not apply, and the criteria for a rating in excess of 10 percent for the Veteran's residuals of laryngeal cancer have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.1-4 .14, 4.97, Diagnostic Codes 6516, 6518, 6519, 6819 (2012). In reaching this decision, the potential application of various provisions of Title 38 Code of Federal Regulations have been considered, whether or not they were raised by the Veteran. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In particular, the Board has considered the provisions of 38 C.F.R. § 3.321(b)(1). However, in this case, the Board finds that the record does not show that the Veteran's residuals of cancer of the larynx are so exceptional or unusual as to warrant the assignment of higher ratings on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). 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. See Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, 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. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and no extraschedular referral is required. Id., see also VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those provided by the extraschedular regulation (38 C.F.R. § 3.321(b)(1) ) as "governing norms" (which include marked interference with employment and frequent periods of hospitalization). The evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected disability is inadequate. A comparison between the level of severity and symptomatology of the Veteran's assigned rating with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. The Veteran's chief complaints of hoarseness and occasional difficulty swallowing are fully considered in the assignment of the 10 percent disability rating. Moreover, there are higher ratings available under the diagnostic codes for various symptoms of the disorder, but the Veteran's disability is not productive of such manifestations. Based on the foregoing, the Board finds that the requirements for an extraschedular evaluation for the Veteran's residuals of cancer of the larynx under the provisions of 38 C.F.R. § 3.321(b)(1) have not been met. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995); Thun v. Peake, 22 Vet. App. 111 (2008). ORDER An evaluation in excess of 10 percent for residuals of cancer of the larynx is denied. ____________________________________________ J.W. ZISSIMOS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs