Citation Nr: 1316982 Decision Date: 05/23/13 Archive Date: 05/31/13 DOCKET NO. 07-34 140 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for diabetic neuropathy of the left lower extremity. 2. Entitlement to an initial rating in excess of 10 percent for diabetic neuropathy of the right lower extremity. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Puerto Rico Public Advocate for Veterans Affairs ATTORNEY FOR THE BOARD Shamil Patel, Counsel INTRODUCTION The Veteran served on active duty from January 1971 to April 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico, which granted service connection for left and right lower extremity diabetic neuropathy and assigned a 0 percent rating for each condition effective from September 7, 2006. The RO also denied entitlement to a TDIU. These issues were previously remanded by the Board in March 2009. In an August 2010 rating decision, the Appeals Management Center (AMC) increased the assigned ratings for the Veteran's left and right lower extremity diabetic neuropathy each to 10 percent effective September 7, 2006. The Board then remanded the claims again in February 2012. The Board notes that the RO erroneously included several issues in a January 2013 supplemental statement of the case, including increased ratings for diabetes mellitus type II, a generalized anxiety reaction with depression, coronary artery disease, right upper extremity diabetic neuropathy, and left upper extremity diabetic neuropathy. These issues are not currently on appeal before the Board and will not be address in this decision. A portion of the Veteran's records are contained in the Virtual VA system. Instead of paper, a highly secured electronic repository is used to store and review every document involved in the claims process. The use of this system allows VA to leverage information technology in order to more quickly and accurately decide a Veteran's claim for benefits. Because the current appeal was processed as part of the Virtual VA system, any future consideration of this appellant's case should take into consideration the existence of this electronic record. FINDINGS OF FACT 1. Prior to July 13, 2009, the Veteran's left and right lower extremity diabetic neuropathy was manifested by some decreased sensation, with no significant impairment in motor strength, reflexes, or gait. 2. From July 13, 2009, the Veteran's left and right lower extremity diabetic neuropathy was manifested by decreased vibration and light touch sense, absent pain sense, absent reflexes, and mild to moderate impairment of activities of daily living. 3. The Veteran meets the schedular criteria for TDIU; the competent and credible evidence of record is at least in equipoise as to whether his service-connected disabilities prevent him from securing and following substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for left lower extremity diabetic neuropathy have not been met prior to July 13, 2009. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.124a, Diagnostic Code 8620 (2012). 2. The criteria for an initial 20 percent rating, but not higher, for left lower extremity diabetic neuropathy have been met from July 13, 2009. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.124a, Diagnostic Code 8620 (2012). 3. The criteria for an initial rating in excess of 10 percent for right lower extremity diabetic neuropathy have not been met prior to July 13, 2009. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.124a, Diagnostic Code 8620 (2012). 4. The criteria for an initial 20 percent rating, but not higher, for right lower extremity diabetic neuropathy have been met from July 13, 2009. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.124a, Diagnostic Code 8620 (2012). 5. The criteria for entitlement to a TDIU have been met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. § 4.16 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 A. Full Grant of Benefits In this case, the Board is granting the Veteran's claim for a TDIU. This represents a full grant of the benefit sought on appeal. Assuming that any error was committed with respect to the duty to notify or the duty to assist for this claim, such error was harmless and will not be further discussed. B. Duty to Notify Under the Veterans Claims Assistance Act (VCAA), when VA receives a complete or substantially complete application for benefits, it must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 C.F.R. § 3.159 (2012). Such notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if there is a favorable disposition of the claim. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107; 38 C.F.R. §§ 3.159, 3.326; see also Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). Prior to the initial adjudication of the Veteran's claims, a letter dated in September 2006 was sent to the Veteran in accordance with the duty to notify provisions of the VCAA. 38 U.S.C.A. § 5103; 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The Veteran was notified of the evidence that was needed to substantiate his claims; what information and evidence that VA will seek to provide and what information and evidence the Veteran was expected to provide, and that VA would assist him in obtaining evidence, but that it was his responsibility to provide VA with any evidence pertaining to his claims. See Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). Notably, the Veteran is challenging the initial evaluations assigned following the grant of service connection. In Dingess, the U.S. Court of Appeals for Veterans Claims (Court) held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. Thus, because the notice that was provided before service connection was granted was legally sufficient, VA's duty to notify with respect to his claims for increased ratings has been satisfied. C. Duty to Assist The Board most recently remanded the case in February 2012 in order to obtain recent VA treatment records and provide adequate VA examinations to assess how the Veteran's service-connected disabilities affected his employability. As of now, the claims file contains the Veteran's service treatment records, VA treatment records from throughout the appeal period, private treatment records, Social Security Administration (SSA) records, VA authorized examination reports, and lay statements. Moreover, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The VA examinations obtained in this case are adequate as they are collectively predicated on a review of the claims file; contain a description of the history of the disabilities at issue; document and consider the relevant medical facts and principles; and record the relevant findings for rating the Veteran's diabetic neuropathy. VA's duty to assist with respect to obtaining a VA examination or opinion for the issues on appeal has been met. 38 C.F.R. § 3.159(c)(4). In addition, the directives of the February 2012 remand have been completed. See Stegall v. West, 11 Vet. App. 268 (1998) (holding that a remand by the Court or the Board confers on the veteran or other claimant, as a matter of law, the right to compliance with the remand orders); see Dyment v. West, 13 Vet. App. 141 (1999) (holding that remand not required under Stegall where there was substantial compliance with remand directives). VA has provided the Veteran with the opportunity to submit evidence and argument in support of his claims. The Veteran has not made the Board aware of any additional evidence that needs to be obtained prior to appellate review, and no further action must be undertaken to comply with the provisions of 38 U.S.C.A. § 5103(a), § 5103A, or 38 C.F.R. § 3.159. Increased Ratings A. Applicable Law Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (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 rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3 (2012). Where entitlement to compensation has already been established and increase in disability rating is at issue, present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Therefore, although the Board has thoroughly reviewed all evidence of record, the more critical evidence consists of the evidence generated during the appeal period. VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim, a practice known as a "staged rating." See Fenderson v. West, 12 Vet. App 119 (1999). The Court has also held that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2008). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, irrespective of whether the Veteran raised them, as well as the entire history of his disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Generally, the Board has been directed to consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); but see Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding it appropriate to consider factors outside the specific rating criteria in determining level of occupational and social impairment). The Veteran is currently assigned a 10 percent rating under Diagnostic Code 8699-8620 for each of his lower extremity diabetic neuropathy conditions. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. When an unlisted disease or injury is encountered, it will be rated by analogy under a diagnostic code built up using the first 2 digits from that part of the Rating Schedule most closely identifying the body part or system affected and by using "99" for the last 2 digits. Id. Diagnostic Code 8620 addresses neuritis of the sciatic nerve. Neuritis of the peripheral nerves, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum rating equal to severe, incomplete, paralysis. The maximum rating that may be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. 38 C.F.R. § 4.123. Diagnostic Code 8520 pertains to paralysis of the sciatic nerve. Under this provision, mild incomplete paralysis warrants a 10 percent disability evaluation, and moderate incomplete paralysis warrants a 20 percent disability evaluation. A 40 percent rating is warranted for moderately severe incomplete paralysis. A 60 percent rating is warranted for severe incomplete paralysis with marked muscular atrophy. 38 C.F.R. § 4.124a, Diagnostic Code 8520. In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, and the relative impairment in motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. The terms "mild," "moderate," and "severe" are not defined in the rating schedule. Rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. The use of such terminology by VA examiners or other physicians, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. B. Evidence VA treatment records dated September 2006 show the Veteran had a normal gait and required no ambulatory aids. Records from November 2006 show normal sensation in the lower extremities. During a November 2006 VA examination, the Veteran reported episodes of numbness and cramping in his lower extremities below the knees. He stated that this sensation occurred daily, but that he was able to perform his activities of daily living. On examination, the Veteran had diminished sensation bilaterally below the knees. There was no gross motor deficit or gait abnormality. Deep tendon reflexes were normal. Additional records dated June 2007 show adequate strength in the lower extremities, with no sensory or motor deficits present. Sensation was again noted to be normal in June 2009. A July 2009 nerve conduction study revealed mild sensory, axonal and demyelinating neuropathy in the left lower extremity. The Veteran underwent a VA examination in July 2009. He reported cramps and pain in his lower extremities occurring intermittently on a daily basis. On examination, motor strength was 5/5 in all muscles of the lower extremities. However, sensation was decreased to light touch, vibration and position sense bilaterally. Pain sensation was absent. Lower extremity reflexes were 0/2, though plantar flexion was normal. There was no atrophy or abnormal movement present. The Veteran had normal balance and a normal gait. The examiner diagnosed mild bilateral lower extremity sensory neuropathy. Paralysis and neuralgia were absent, but neuritis was present. The conditions had moderate effects on chores, exercise, sports, and traveling activities. Shopping, recreation, bathing, dressing, and grooming were mildly affected. In April 2011, the Veteran was again noted as having no gross sensory or motor deficit. However, additional records dated October 2011 noted decreased monofilament sensation in the bilateral feet. No lower extremity weakness was present. In January 2012, the Veteran was again noted to have mildly decreased sensation. Motor strength was 3/5 in the right extremity, though this was due to a right hip condition being evaluated at the time. C. Analysis Based on the evidence, staged ratings are warranted for the Veteran's bilateral lower extremity. Prior to the July 13, 2009 VA examination, a rating in excess of 10 percent is not warranted for either lower extremity. Although the Veteran reported episodes of numbness and cramping in his lower extremities below the knees, records from this period reflect no significant impairments in sensation, motor strength, or reflexes, and the Veteran was able to ambulate normally without aids. However, from July 13, 2009, a 20 percent rating is warranted for each of the Veteran's lower extremities. Findings from the examination on that date noted absent lower extremity reflexes. The Veteran also had decreased sensation to vibration, position sense, and light touch. Pain sensation was absent. The conditions had moderate effects on physically-oriented activities such as sports and exercise, and even basic activities such as bathing, dressing and grooming were affected. Although the examiner and the results of the nerve conduction study noted "mild" neuropathy, these findings correspond to an overall level of impairment consistent with "moderate" incomplete paralysis. However, a higher 40 percent rating is not warranted for either lower extremity, as there was no indication of decreased motor strength or trophic changes. The Veteran had a normal gait and normal balance, and the examiner did not state that the Veteran's condition had any severe effects on physically demanding activities of daily living. These findings do not correspond to a "moderately severe" level of incomplete paralysis as contemplated by Diagnostic Codes 8520 and 8620. D. Extraschedular Consideration In evaluating the Veteran's claims for higher ratings, the Board also has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). As part of the evaluation for an extraschedular rating, the Board has considered the provisions of Mittleider v. West, 11 Vet. App. 181, 182 (1998), which holds that the benefit of the doubt applies to determinations of whether a symptom should be attributed to a service-connected condition. The Board has attributed all potentially service-connected symptoms to the Veteran's service-connected conditions in considering if the Veteran is entitled to an extraschedular rating. According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected disabilities is inadequate. A comparison between the level of severity and symptomatology of the Veteran's lower extremity diabetic neuropathy with the established criteria found in the rating schedule for those disabilities shows that the rating criteria reasonably describes the Veteran's disability level and symptomatology, as discussed above. The Veteran's symptoms of pain and decreased sensation and reflexes are expressly contemplated by the rating schedule. Additional symptoms such as decreased motor strength and an abnormal gait were not shown by the evidence, but would also be considered in the rating schedule. There is no indication that the Veteran's neuropathy results in any symptoms that fall so far outside the rating schedule as to render it inadequate. TDIU A. Applicable Law Total disability ratings for compensation based on individual unemployability may be assigned where the schedular rating is less than total if it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of (1) a single service-connected disability ratable at 60 percent or more, or (2) as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. See 38 C.F.R. §§ 3.340, 3.34l, 4.16(a). The degree of impairment in occupational functioning that is generally deemed indicative of unemployability consists of a showing that the Veteran is "[in]capable of performing the physical and mental acts required by employment," and is not based solely on whether the Veteran is unemployed or has difficulty obtaining employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). Rather, the record must demonstrate some factor which takes the claimant's situation outside the norm of such a case, since the VA rating schedule already is designed to take into consideration impairment that renders it difficult to obtain and keep employment. Id. See also 38 C.F.R. §§ 4.1, 4.15. In evaluating a claim for a TDIU, the central inquiry is whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability. See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Other factors that may receive consideration in determining whether a Veteran is unemployable include his employment history, level of education and vocational attainment. See 38 C.F.R. § 4.16(b); see also Ferraro v. Derwinski, 1 Vet. App. 326, 331-32 (1991). By comparison, the impact of any nonservice-connected disabilities, or the Veteran's age, are not factors taken into consideration for this purpose. 38 C.F.R. §§ 3.341, 4.16, 4.19. In addition, "marginal employment" shall not be considered substantially gainful employment. 38 C.F.R. § 4.16(a). See Faust v. West, 13 Vet. App. 342, 355 (2000). Rather, the Court has accepted the definition of substantially gainful employment as that "at which non-disabled individuals earn their livelihood with earnings comparable to the particular occupation in the community where the Veteran resides." Moore (Robert) v. Derwinski, 1 Vet. App. 356, 358 (1991), citing VA Adjudication Procedure Manual, M21-1 MR, Part IV, Subpart ii, Chapter 2 (December 13, 2005) (previously cited at M21-1, Part IV, paragraph 7.09). See also Ferraro, 1 Vet. App. at 332 (determining that substantially gainful employment suggests "a living wage"). B. Evidence In this case, service connection is in effect for diabetes mellitus type II (40 percent), generalized anxiety reaction with depression (30 percent), coronary artery disease (30 percent), right upper extremity diabetic neuropathy (30 percent from July 13, 2009), right lower extremity diabetic neuropathy (10 percent prior to July 13, 2009, and 20 percent thereafter), left lower extremity neuropathy (10 percent prior to July 13, 2009, and 20 percent thereafter), and left upper extremity diabetic neuropathy (10 percent from July 13, 2009). The Veteran's combined disability evaluation is 80 percent prior to July 13, 2009, and 90 percent thereafter, and therefore he meets the schedular requirements for a TDIU under 38 C.F.R. § 4.16(a). In his September 2006 application for TDIU benefits, the Veteran stated that he worked full time as a computer center director from 1987 to 1999. He had completed 2 years of college. The Veteran is service-connected for a psychiatric disorder, and his records contain Global Assessment of Functioning (GAF) scores. As described in the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM-IV), GAF scores range from 1 to 100, depending on the level of a person's occupational and social functioning. The GAF score is a scaled rating reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). In this case, evidence generated throughout the period on appeal consistently reflects GAF scores of 60. GAF scores ranging from 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). DSM-IV at 46-47. Though generated prior to the period on appeal, private records dated November 1999 noted that the Veteran could not cope with excessive demanding working conditions. SSA records show the Veteran had not engaged in substantially gainful activity since May 1999. Based on an opinion obtained by SSA, the Veteran was precluded from working based on his diabetes mellitus, hyperlipidemia, hypertension, mitral valve prolapse, coronary heart disease, neurocardiogenic syncope, and a depressive state. An October 2006 VA psychiatric examination stated that the Veteran did not have total occupational impairment as a result of his generalized anxiety disorder. The examiner stated that the condition resulted in no work-related deficiencies. During a November 2006 VA heart examination, the Veteran reported that he had experienced heart-related symptoms while working which required convalescence. Notably, records generated prior to the period on appeal reflect complaints of chest pain while working. Another VA psychiatric examination was conducted in June 2009. The examiner stated that the Veteran did not have total occupational impairment as a result of his generalized anxiety disorder. However, his capacity to initiate social contacts, interact and actively participate in group activities, and social maturity were moderately limited. This could limit his social function in work situations. His cognitive lacunae also moderately limited concentration and the pace at which he could complete complex tasks found in work situations. The Veteran underwent a VA peripheral nerves examination in July 2009. The examiner stated that the Veteran's condition did not render him unemployable, and that he was able to obtain and perform a substantially gainful occupation requiring sedentary or semi-sedentary work, such as an administrative clerk or other office work. A general VA examination from July 2009 stated that the Veteran was not unemployable due to his coronary artery disease and diabetes mellitus. Both conditions were stable and would not interfere with the Veteran's ability to do light desk-type work. A VA opinion was obtained in March 2012. The examiner reviewed the claims file. She stated that the Veteran's lower extremity peripheral neuropathy would require him to take a 15 to 20 minute break for every 2 hours of sitting, though he could stand and walk without assistance. His upper extremity neuropathy would preclude any pushing, pulling, lifting, or carrying of heavy objects. As a whole, his complications from diabetes would prevent him from performing physical labor but would not significantly limit sedentary or light jobs, such as a clerk or receptionist. His coronary artery disease was controlled with medication, and would similarly prevent physical labor but allow for sedentary duties. C. Analysis In this case, the Board finds that a TDIU is warranted. As noted above, the Veteran meets the schedular criteria for a TDIU, and the evidence is at least in equipoise as to whether his service-connected conditions would preclude him from obtaining and maintaining substantially gainful employment. There are no competent opinions which concluded that the Veteran is unemployable due to his service-connected disabilities, although no single opinion addressed the impact of all of his conditions together. The VA opinions obtained in this case are all in agreement that the Veteran's diabetes, associated neuropathy, and coronary artery disease would preclude any type of physically-oriented employment, but that he would be able to engage in sedentary duties, including working as a clerk, receptionist, or other administrative position. However, in rendering her opinion, the March 2012 examiner noted that the Veteran would require frequent breaks from sitting, up to 20 minutes every 2 hours. In addition, while the Veteran's psychiatric condition was not totally disabling, the June 2009 examiner noted that he would be moderately impaired in the social aspects of work situations, and that his limited concentration would affect his ability to complete certain tasks. When viewed collectively, these findings suggest a level of overall occupational impairment that is incompatible with even the sedentary forms of employment suggested by the VA examiners. Therefore, resolving all doubt in the Veteran's favor, the Board finds that a TDIU is appropriate in this case. ORDER An initial rating in excess of 10 percent for diabetic neuropathy of the left lower extremity is denied prior to July 13, 2009. An initial 20 percent rating for diabetic neuropathy of the left lower extremity is granted from July 13, 2009, subject to the laws and regulations governing the award of monetary benefits. An initial rating in excess of 10 percent for diabetic neuropathy of the right lower extremity is denied prior to July 13, 2009. An initial 20 percent rating for diabetic neuropathy of the right lower extremity is granted from July 13, 2009, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a TDIU is granted, subject to the laws and regulations governing the award of monetary benefits. ____________________________________________ P. M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs