Citation Nr: 1320517 Decision Date: 06/26/13 Archive Date: 07/05/13 DOCKET NO. 09-08 194 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to an increased rating greater than 20 percent for a left shoulder disability (residuals of fracture left humeral head status post open reduction and internal fixation). 2. Entitlement to an increased rating greater than 10 percent for hepatitis C. REPRESENTATION Appellant represented by: Virginia Department of Veterans Services ATTORNEY FOR THE BOARD H.J. Baucom, Associate Counsel INTRODUCTION The Veteran had active service from August 1958 to July 1979. This matter comes before the Board of Veterans' Appeals (Board) from an August 2008 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO) in Roanoke, Virginia. The issue of an increased rating for left shoulder disability has been recharacterized for ease of use. The Veteran's "virtual VA" electronic claims folder has been reviewed in addition to the paper claims folder. FINDINGS OF FACT 1. The Veteran has malunion of the glenohumeral joint that results in deformity but without there being dislocations, loose movement, or ankylosis. 2. The Veteran's left shoulder disability results in limitation of motion midway between the side and shoulder level; however, even in considering his complaints of pain and functional loss, the Veteran's left shoulder disability is not shown to be limited to 25 degrees. 3. Symptoms of the Veteran's hepatitis C most nearly approximated daily fatigue, malaise, and anorexia (without weight loss or hepatomegaly), requiring continuous medication. 4. The Veteran's hepatitis C has not been manifested at any time during the appeal period by symptoms more nearly approximating daily fatigue, malaise, and anorexia, with minor weight loss and hepatomegaly; or by incapacitating episodes. CONCLUSIONS OF LAW 1. The criteria for a rating higher than 20 percent for residuals of a left shoulder fracture have not been met. 38 U.S.C.A. § 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 3.102, 3.159, 3.321, 4.1, 4.3, 4.74.71a, Diagnostic Code 5202 (2012). 2. The criteria for a separate 20 percent rating for limitation of motion of the left shoulder disability have not been met. 38 U.S.C.A. § 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 3.102, 3.159, 3.321, 4.1, 4.3, 4.74.71a, Diagnostic Code 5201 (2012). 3. The criteria for a rating of 20 percent for hepatitis C, but no higher, were met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.114, Diagnostic Code 7354 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Notice and Assistance VA has a 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. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a)(2012). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). These notice requirements apply to all five elements of a service-connection claim (Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. Neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). None is found by the Board. Indeed, VA's duty to notify has been more than satisfied. The Veteran was notified via letter dated in May 2008 of the criteria for establishing higher/increased ratings, the evidence required in this regard, and his and VA's respective duties for obtaining evidence. He also was notified of how VA determines disability ratings and effective dates if service connection is awarded. This letter accordingly addressed all notice elements and predated the initial adjudication by the AOJ/RO in August 2008. Nothing more was required. As for VA's duty to assist, the Veteran's service treatment records and identified private treatment records have been obtained. He did not identify any additional private or VA treatment records pertinent to the appeal. 38 U.S.C.A. § 5103A, 38 C.F.R. § 3.159. The Veteran has not indicated, and the record does not contain evidence, that he is in receipt of disability benefits from the Social Security Administration. 38 C.F.R. § 3.159 (c) (2). VA examinations were conducted in October 2007, June 2008 and March 2011. The Veteran has not argued, and the record does not reflect, that these examinations were inadequate for rating purposes. 38 C.F.R. § 3.159(c) (4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). The examinations were adequate as the examiners evaluated the Veteran's current disability level and provided findings to allow for proper application of the rating criteria. There is no indication in the record that any additional evidence, relevant to the issues decided, is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). Increased Ratings In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Separate ratings may be assigned for separate periods of time based on the facts found, however. This practice is known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119, 126-127 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). If the evidence for and against a claim is in equipoise, the claim will be granted. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. 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 the residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, premature or excess fatigability, or incoordination is demonstrated, assuming these factors are not already contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss due to pain is rated at the same level as functional loss where motion is impeded. Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Pursuant to 38 C.F.R. § 4.59, painful motion should be considered limited motion, even though a range of motion may be possible beyond the point when pain sets in. See Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995). The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or reasonably by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). It is important to note that although pain may cause functional loss, pain itself does not constitute functional loss. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011) (emphasis added). Rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," to constitute functional loss. Id.; see 38 C.F.R. § 4.40. Separate disabilities arising from a single disease entity are to be rated separately. See 38 C.F.R. § 4.25; see also Esteban v. Brown, 6 Vet. App. 259, 261 (1994). However, the evaluation of the same disability under various diagnoses is to be avoided, as this would violate VA's anti-pyramiding regulation. 38 C.F.R. § 4.14; Fanning v. Brown, 4 Vet. App. 225 (1993). 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). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as the Veteran's relevant medical history, his current diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). While the Veteran is competent to offer evidence as to the visible symptoms or manifestations of a disease or disability, his belief as to its current severity under pertinent rating criteria or the nature of the service-connected pathology is not probative evidence. Layno v. Brown, 6 Vet. App. at 470 (1994); Grottveit v. Brown, 5 Vet. App. at 92-93 (1993). In assessing the appropriateness of the rating for the disability at issue, the Board has reviewed all of the evidence in the Veteran's claims file and has an obligation to provide an adequate statement of reasons or bases supporting its decision. See 38 U.S.C.A. § 7104 (West 2002); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). While the Board must review the entire record, however, it need not discuss each piece of evidence, certainly not in exhaustive detail. See id. The analysis below therefore focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, concerning this claim. The Veteran must not assume the Board has overlooked pieces of evidence that are not explicitly discussed in this decision. See Timberlake v. Gober, 14 Vet. App. 122 (2000). The law requires only that the Board address its reasons for rejecting evidence favorable to him. Id. Left shoulder disability The Veteran fractured his shoulder in a February 1976 motor vehicle accident. A medical board report relates that he underwent closed manipulation, open reduction, and internal fixation. Post-service X-rays taken in August 1979 showed "marked deformity of the left humerus." Service connection for a fracture of the left humeral head was granted in October 1979. A noncompensable rating was assigned under DC 5202. By a rating action dated in September 1992, the rating was increased under DC 5202-5010 to 20 percent. Such was based on the deformity of the humeral head with degenerative changes and painful motion. The Veteran's left shoulder disability is presently rated under Diagnostic Code (DC) 5010-5201 for limitation of motion of the shoulder. The Veteran's left arm is his minor arm. DC 5201 provides for a 20 percent rating for the minor arm when limited to shoulder level; a 20 percent rating for the minor arm when limited to midway between the side and shoulder level; and a 30 percent rating for the minor arm when limited to 25 degrees from the side. DC 5010 for traumatic arthritis provides for a compensable rating when there is limitation of motion of a joint but it is not compensable under the joint specific diagnostic code. In this case a rating under DC 5010 is not applicable as limitation of motion is compensated under DC 5201 DC 5202 provides for assignment of a 20 percent rating when there is malunion of the humerus with moderate or marked deformity of the minor arm or where there is recurrent dislocation of the humerus at the scapulohumeral joint. Higher ratings are available under DC 5202 when there is fibrous union of the humerus, when there is nonunion of the humerus (false flail joint), and when there is loss of head of the humerus (flail shoulder). 38 C.F.R. § 4.71, Plate I provides guidance as to normal range of motion of the shoulder as well as what is meant by limitation of the arm at the shoulder level. The images in Plate I show that normal forward elevation, or flexion, of the shoulder is from 0 to 180 degrees and that flexion to the shoulder level is 90 degrees. Similarly, normal shoulder abduction is from 0 to 180 degrees with abduction to the shoulder level being 90 degrees. Normal external rotation and internal rotation are from 0 to 90 degrees, with 0 degrees representing the shoulder level. The Veteran has sought private treatment for his left shoulder disability. At a September 2007 shoulder evaluation by Dr AM, the Veteran reported severe arthritis with limited use, night pain, and difficulty reaching over head, with a worsening of his symptoms over the years. He reported occasional radiculopathy going down the arm. Physical examination noted forward elevation of "about 90" degrees, and abduction of 70 degrees on the left with slight decrease of sensation in the axillary or deltoid distribution. X-rays were noted to show a previous Hills-Sachs deformity with severe degenerative arthritis. Dr. AM suggested getting a MRI of the shoulder to evaluate the rotator cuff. On October 3, 2007 Dr. EL-P evaluated the Veteran noting glenohumeral abduction at 80 degrees and external rotation of 60 degrees with mild discomfort, no instability, and normal motor sensory examination. Dr. EL-P reviewed x-rays which included two views of cervical spine showing spondylitic change. Dr. EL-P expressed concern that the arm pain was secondary to the neck and not the arm and requested an MRI of the cervical spine. On October 26, 2007 Dr. EL-P reevaluated the Veteran's shoulder and neck pain. Upon examination there was mild swelling of the shoulder, active abduction of 60 degrees and external rotation of 60 degrees. Dr. EL-P's review of x-rays noted significant arthritis in the glenohumeral joint, and review of a MRI of the cervical spine found spondylotic changes with bilateral foraminal stenosis at 5-6 with broad-based disc protrusion at 3-4. In October 2007, the Veteran had a VA compensation examination to assess his left shoulder disability. At the examination he report sustaining a fracture of the left humeral head in service which was repaired surgically. The Veteran reported current symptoms of constant stiffness and pain without radiation to other regions. The Veteran described the pain as aching and occasionally sharp with a severity of 8/10. The pain was elicited with physical activity and relieved with rest or pain medication. He reported increased pain with any sudden movements of the shoulder. Range of motion findings for the left arm, in degrees, were flexion to 180 with pain at 30; abduction to 180 with pain at 40; external rotation to 90 with pain at 45; and internal rotation to 90 with pain at 35. After repetitive motion, the range of motion was further limited by pain but not fatigue, weakness, lack of endurance or incoordination. There was no additional limitation of motion. Radiographs of the left shoulder revealed evidence of juxta-articular cystic changes of the left humeral head, consistent with the history of fracture but no findings of a current fracture, dislocation or other acute abnormality were noted. In March 2011 the Veteran had an additional VA compensation examination to reassess his left shoulder disability. At the VA examination he reported that his left shoulder disability has gotten worse and he could not get his arm overhead of the opposite shoulder. The Veteran reported constant squeezing and aching pain which can be exacerbated by physical activity and relieved by rest and over the counter medications. He reported experiencing weakness, stiffness and locking. The Veteran denied redness, fever, giving way, debility, swelling, abnormal motion, heat and drainage. He reported functional impairment of not sleeping on the left side, not carrying anything with the left arm extended, and that he cannot move his arm overhead. Physical examination found tenderness and guarding of movement with no edema, instability, abnormal movement, effusion, weakness, redness heat, deformity, malalignment, drainage or subluxation. Range of motion findings, in degrees, were flexion to 80; abduction to 70; external rotation to 20; and internal rotation to 40. Repetitive range of motion was possible but the examiner determined there was no additional degree of limitation following repetition. There was no ankylosis upon examination. At the outset the Board notes that there is little question as to whether there is malunion of the humerus. Such is shown in multiple X-rays reports dating back to 1979. Those reports consistently describe deformity as being marked/severe. Such supports the presently assigned 20 percent rating. That 20 percent rating is maximum rating assignable for malunion/deformity of the humerus. Further, as none of the evidence of record shows fibrous union, nonunion, or loss head of the humerus, a higher rating under DC 5202 is not warranted. There is likewise no basis for assigning a higher and/or separate rating under DCs 5200 or 5203 as neither ankylosis of the scapulohumeral articulation or impairment of the clavicle or scapula is demonstrated. The assignment of a separate 20 percent rating based on limitation of the left shoulder is warranted. Both VA examinations clearly show that the Veteran experiences limitation of motion midway between the side and shoulder level. However, even in considering his complaints of pain and functional loss, the Veteran's left shoulder disability is not shown to be limited to 25 degrees. The above mention private treatment records and VA reports show that the left shoulder at most is limited to 70 degrees abduction. Pain, but not functional loss due to pain, was noted at 40 degrees at the earliest. The Board has also considered whether a separate rating is warranted for the Veteran's left shoulder surgical scars. However, the evidence does not show that the residuals scars are considered in any way disfiguring, or the equivalent of painful or unstable scars, and a separate rating under Diagnostic Codes 7800-7805 is not warranted. In deciding this claim, the Board acknowledges that the Veteran is competent to report symptoms of his left shoulder disability, and that his range of motion and daily activities are restricted. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465 (1994). Additionally, he is credible in his reports of symptoms and their effect on his activities. He is not however competent to identify a specific level of disability of his disability according to the appropriate diagnostic code. Such competent evidence concerning the nature and extent of the Veteran's service-connected left shoulder disability has been provided by VA medical professionals who have examined him. The medical findings directly address the criteria under which this disability is evaluated. The Board finds these records to be the only competent and probative evidence of record, and therefore is accorded greater weight than the Veteran's subjective complaints of increased symptomatology. See Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991). As noted, while the evidence objectively shows that the Veteran has limitation of motion of the left shoulder, it does not show that such limitation is restricted to 25 degrees which is required for a higher rating. Hepatitis C Schedule for ratings for the digestive system are contained in 38 C.F.R. § § 4.114 which states that ratings under diagnostic codes 7301 to 7329, 7331, 7342, and 7345 to 7348 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. Hepatitis C (or non-A, non-B hepatitis) is rated under DC 7354 based upon signs and symptoms due to hepatitis C infection. A 100 percent rating is provided for near-constant debilitating symptoms (such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain). A 60 percent rating is provided for 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 40 percent rating is provided for 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 20 percent rating is provided for 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. 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 sequelae. (See § 4.14.). Note (2): For purposes of evaluating conditions under diagnostic code 7354, "incapacitating episode" means a period of acute signs and symptoms severe enough to require bed rest and treatment by a physician. In June 2008 the Veteran had a VA compensation examination to assess his hepatitis C. He reported experiencing occasional mild fatigue without significant abdominal pain, hematemesis, melena, anemia, coma, ascites, liver transplantation, significant weight gain or weight loss, alcohol abuse or functional impairment. The examiner noted his general appearance was well developed, well nourished individual without signs of malaise. Examination of the abdomen was normal without evidence of organomegaly, tenderness, masses, ascites, distention or aneurysm. After diagnostic testing the examiner noted that it was unclear whether the mild anemia is related to the hepatitis C infection. The examiner found no evidence of active liver disease and that the conditions noted only minimally affect the claimant's ability to perform usual occupational and daily living activities. An October 2008 letter from Dr NB, the Veteran's treating physician, reported that he has hepatitis C which is maintained by medications. A November 2008 note from Dr. AD reported that the Veteran has had hepatitis C for many years. In March 2011 the Veteran had an additional VA compensation examination to reassess his hepatitis C. At the examination the Veteran reported experiencing weight loss of 29 pounds over the past five years, and that his liver condition causes easy fatigability and diarrhea. He denied gastrointestinal disturbances, nausea and vomiting, loss of appetite, jaundice and arthralgia. The Veteran stated that his symptoms are present at all times and he has to stay near a bathroom. He reported occasional abdominal pain, described as colic pain. There was no association with abdominal distension. The Veteran described his liver symptoms as daily and tolerable but denied incapacitation, vomiting blood, passing black tarry stools, abdominal tapping, coma or periods of confusion. The Veteran reported receiving treatment of Interferon Alpha for the last six months with poor response and side effects of loss of appetite and energy. He also reported taking Ribavirin for 2005 with poor response but no side effects. The examiner noted that continuous treatment is not needed to control the condition. Physical examination of the abdomen revealed no evidence of liver enlargement (hepatomegaly). The examiner diagnosis cirrhosis of the liver and hepatitis C. A higher rating is warranted as the overall symptoms of the Veteran's hepatitis C more nearly approximate the criteria for a 20 percent rating. The Veteran reports daily fatigue and malaise or lack of energy. He is receiving continuous treatment for his hepatitis C, based on his treating physician's statement that continuous medication is required. Resolving reasonable doubt in favor of the Veteran, the Board finds that a rating of 20 percent is warranted. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. A rating higher than 20 percent is not, however, warranted at any time during the appeal period because the symptoms have not more nearly approximated the daily fatigue, malaise, and anorexia, with minor weight loss and hepatomegaly required for a higher 40 percent rating. The evidence shows the Veteran has not had the majority of these symptoms, specifically anorexia (lack or loss of appetite), weight loss, or hepatomegaly (enlarged liver). Additionally the Veteran denied having any incapacitating episodes of any duration. As such, the Veteran's symptomatology does not meet the criteria for a 40 rating under DC 7345. A separate rating for cirrhosis is not permissible, as ratings under DC 7354 hepatitis C, and DC 7312 cirrhosis of the liver may not be combined. 38 C.F.R. § § 4.114 The Board has considered the Veteran's lay statements in assigning a rating for hepatitis. The Veteran is competent to report symptoms he experiences such as abdominal pain, fatigue, malaise or lack of energy and the Board has found his reports credible. Layno v. Brown, 6 Vet. App. 465 (1994). The Veteran is also competent to report additional subjective symptoms such as anorexia (lack or loss of appetite) or experiencing symptoms so severe as to require bedrest and treatment by a physician but he has not made any such reports. The Veteran is competent to report weight loss but the objective evidence of weight measured at the VA examinations does not completely support this report. Indeed, while he reported to the VA physician that he had lost nearly 30 pounds over the past five years, the Board notes that such is not necessarily established by the record as he weighed 187 pounds at the October 2007 VA examination, 170 pounds at the June 2008 VA examination, and 180 pounds at the March 2011 VA examination. Extraschedular Extraschedular consideration involves a three step analysis. Thun v. Peake, 22 Vet. App. 111 (2008). First, a determination must be made as to whether the schedular criteria reasonably describe a veteran's disability level and symptomatology. Id. At 115. If the schedular rating criteria do reasonably describe a veteran's disability level and symptomatology, referral for extraschedular consideration is not required and the analysis stops. Id. If the schedular rating criteria do not reasonably describe a veteran's level of disability and symptomatology, a determination must be made as to whether an exceptional disability picture includes other related factors, such as marked interference with employment and frequent periods of hospitalization. Id. At 116. If an exceptional disability picture including such factors as marked interference with employment and frequent periods of hospitalization exists, the matter must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. The schedular evaluation in this case is adequate. Ratings in excess of that assigned are provided for certain manifestations of the service-connected left shoulder disability and hepatitis C but the competent evidence reflects that those symptoms are not present in this case. The symptoms associated with the Veteran's left shoulder disability (i.e., limited motion) and hepatitis (i.e. fatigue, malaise, continuous treatment) are not shown to cause any impairment that is not already contemplated by the relevant diagnostic code, as cited above, and the Board finds that the rating criteria reasonably contemplates these disabilities. Finally, in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total rating based on individual unemployability (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. Here, the Veteran has made not report of being unemployable much less unemployable due to his service connected disabilities. The Board finds that the issue of entitlement to a TDIU is not expressly raised by the Veteran or reasonably raised by the record and, consequently, the Rice case is not for application. ORDER An increased rating greater than 20 percent for a left shoulder disability (residuals of fracture left humeral head status post open reduction and internal fixation) is denied. A separate 20 percent rating for limitation of motion of the left shoulder is granted. An increased rating of 20 percent, but no higher, for hepatitis C is granted. ____________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs