Citation Nr: 1323158 Decision Date: 07/19/13 Archive Date: 07/24/13 DOCKET NO. 06-03 482A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois THE ISSUES 1. Entitlement to service connection for photosensitivity, claimed as due to an undiagnosed illness. 2. Entitlement to a disability rating in excess of 10 percent for left shoulder tendonitis for the period prior to February 1, 2012. 3. Entitlement to a disability rating in excess of 20 percent for left shoulder tendonitis for the period beginning February 1, 2012. 4. Entitlement to a compensable disability rating for gastroesophageal reflux disease (GERD) for the period from July 8, 2003, to February 16, 2005. 5. Entitlement to an initial disability rating in excess of 30 percent for GERD with irritable bowel syndrome (IBS) as of February 17, 2005. 6. Entitlement to a disability rating in excess of 30 percent for depressive disorder. 7. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Vietnam Veterans of America WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD G. Jackson, Counsel INTRODUCTION The Veteran served on active duty from December 1988 to December 1994, to include service in Southwest Asia during Operation Desert Shield/Desert Storm from August 1990 to April 1991. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from November 2004 and October 2006 rating determinations of the RO. The Veteran appeared at the RO and testified at travel Board hearing held in March 2008 before a Veterans Law Judge (VLJ). A transcript of that hearing has been made a part of the record. At the hearing, the VLJ agreed to hold the record open for 60 days to allow for the submission of additional evidence. Additional evidence, accompanied by a waiver, was submitted during that time period and has been associated with the claims file. The Board notes that the VLJ who conducted the March 2008 hearing has since retired. So, pursuant to 38 U.S.C.A. § 7107(c) and 38 C.F.R. §§ 20.707, 20.717, the Veteran was informed by letter dated in December 2012 of his right to have another hearing before a different Veterans Law Judge who would ultimately decide his appeal. The letter informed him that, if he did not respond in 30 days, the Board would assume he did not want another hearing. In January 2013, the Veteran responded that he did not want another hearing and requested that his claims be decided based on the evidence of record. In August 2008, the Board denied entitlement to service connection for photosensitivity, muscle pain, and joint pain, as well as entitlement to an increased disability rating for service-connected depressive disorder. The Veteran subsequently appealed to the Court of Appeals for Veterans Claims (Court). In a July 2009 Joint Motion for Remand, the parties (the Secretary of VA and the Veteran) determined that a remand was warranted as to these issues. By an August 2010 Order, the Court granted the Joint Motion for Remand, vacated the part of the August 2008 Board decision pertaining to these issues, and remanded the matter for readjudication. With regard to the remaining issues listed as being on appeal, the Board remanded such issues in its August 2008 decision for further evidentiary and procedural development. Subsequently, the Board remanded the issues on appeal for further development in April 2011. That development was completed and the case has been returned to the Board for appellate review. During the pendency of the appeal, the RO, in a September 2012 rating decision, granted service connection for fibromyalgia (claimed Gulf War Syndrome) and assigned a 0 percent rating for the disability, effective on July 8, 2003; the RO assigned a 40 percent rating effective on February 1, 2012. Therefore, his appeal concerning the issues of service connection for muscle pain and joint pain have been resolved. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (where an appealed claim for service connection is granted during the pendency of the appeal, a second NOD must thereafter be timely filed to initiate appellate review of the claim concerning the compensation level assigned for the disability). The Board points out that higher ratings have been granted for the Veteran's left shoulder tendonitis and GERD disabilities during the pendency of this appeal. Because higher ratings for these disabilities are assignable during the relevant time period and the Veteran is presumed to seek the maximum available benefit, the issues remain on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). Finally, the Board notes that, in addition to the paper claims file, there is a Virtual VA electronic claims file associated with the Veteran's claim. A review of the documents in the electronic file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issue on appeal herein decided. FINDINGS OF FACT 1. The Veteran has verified service in the Southwest Asia Theater of operations for the period from August 1990 to April 1991. 2. There is no credible evidence indicating that the Veteran has a "qualifying chronic disability" manifested by photosensitivity symptoms, nor is there any indication that the Veteran has a current disability, such as a chronic ocular disorder, manifested by such complaints for which service connection can be awarded. The complaints of sensitivity are considered to be normal. 3. Symptoms of the left shoulder tendonitis have most nearly approximated the functional equivalent of limitation of motion of the arm at shoulder level, throughout the appeal period. Limitation of motion of the arm to 25 degrees from the side is not demonstrated. 4. For the period from July 8, 2003, to February 16, 2005 the Veteran is shown to have GERD manifested by mild symptoms of pyrosis and epigastric distress. 5. From February 17, 2005, the Veteran's GERD with IBS is productive of a disability manifested by alternating diarrhea and constipation with more or less constant abdominal distress. Symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health have not been demonstrated 6. The symptoms of the Veteran's depressive disorder are indicative of no greater than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal). 7. The service-connected disabilities are not of such severity as to have precluded the Veteran from securing and following substantially gainful employment consistent with his work and education background. CONCLUSIONS OF LAW 1. The Veteran does not have a disability manifested by photosensitivity symptoms, including a chronic ocular disorder, that was incurred in or aggravated by active service and such symptoms are not due to a "qualifying chronic disability." 38 U.S.C.A. §§ 1110, 1117, 1131 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.317 (2012). 2. The criteria for a 20 percent rating for left shoulder tendonitis prior to February 1, 2012 are 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, 4.20, 4.40, 4.45, 4.71a Diagnostic Codes (DC) 5024, 5201 (2012). 3. The criteria for a rating in excess of 20 percent for left shoulder tendonitis are not 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, 4.20, 4.40, 4.45, 4.71a Diagnostic Code (DC) 5024, 5201 (2012). 4. The criteria for a 10 percent rating for GERD are met for the period from July 8, 2003, to February 16, 2005. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.114 including Diagnostic Code 7346 (2012). 5. The criteria for a rating in excess of 30 percent for GERD with IBS are not met for the period from February 17, 2005. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.114 including Diagnostic Codes 7319, 7346 (2012). 6. The criteria for a rating in excess of 30 percent for depressive disorder are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9434 (2012). 7. The criteria for the assignment of a TDIU rating were not. 38 U.S.C.A.§§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R.§§ 3.340, 3.341, 4.16, 4.18, 4.19 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION VA's Duties to Notify and Assist Under the Veterans Claims Assistance Act (VCAA), when VA receives a complete or substantially complete application for benefits, it must (1) notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, (2) which information and evidence VA will obtain, (3) and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a) (West 2002 &); 38 C.F.R. § 3.159 (2012). A review of the claims file reveals that letters sent to the Veteran in September 2003 and October 2009 satisfied VA's duty to notify requirements. See Dingess v. Nicholson, 19 Vet. App. 473, 484 (2006). Ideally, all of the notice contained in these letters should have been sent prior to the initial adjudication of the Veteran's claim in November 2004. Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). Nevertheless, the Board finds that there is no prejudice in proceeding with its determination because, following the issuance of the October 2009 letter the entire record was reviewed and the claim was readjudicated, most recently, in a September 2012 supplemental statement of the case. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (noting that a VCAA timing defect may be cured by the issuance of fully compliant notification followed by a re-adjudication of the claim). Turning to VA's duty to assist, the Board finds that VA has fulfilled its duty to assist the Veteran in making reasonable efforts to identify and obtain relevant records in support of the claim decided herein and providing an adequate VA examination, when necessary. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. §§ 3.159(c), 4.2 (2012). Service records have been associated with the claims file, including information pertaining to whether the Veteran served in Southwest Asia during the Gulf War period. The record also contains all VA and non-VA treatment records identified by the Veteran as relevant to the current appeal. He has not identified any additional relevant, outstanding evidence that needs to be obtained before deciding his appeal. In addition to the above development, the Veteran was afforded VA examinations, most recently in February 2012, which the Board finds adequate for its purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In this regard, the examining physician discussed the Veteran's various ocular complaints and symptoms and whether these might represent a chronic, diagnosed disorder or, alternatively, a chronic, undiagnosed disorder which might be attributable to the Veteran's Gulf War service. The examiner also discussed the current manifestations of the Veteran' left shoulder tendonitis, GERD and depressive disorder symptoms and the effects (or lack thereof) of these disabilities on the Veteran's ability to be employed. These opinions were obtained following an examination of the Veteran and a review of the claims file, and the rationale accompanying the report reflects consideration of scientific and medical principles; thus, they are adequate. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Under the circumstances of this case, "the record has been fully developed," and it is difficult to discern what additional guidance VA could have provided to the Veteran regarding what further evidence he should submit to substantiate his claims. Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). Therefore, the Board is satisfied that VA has complied with the duty to assist requirements of the VCAA and the implementing regulations and the record is ready for appellate review. Compliance with Prior Board Remand(s) The Board previously remanded the issues on appeal in August 2008 and April 2011. The purpose of this remands, in pertinent part, was to obtain a VA examinations to address the etiology of the claimed photosensitivity disorder and the current manifestations of the left shoulder, GERD and depressive disorder disabilities. As previously discussed, VA examinations and opinion were obtained in December 2009 and most recently in February 2012 which the Board finds adequate for its determination. Thus, there was substantial compliance with the relevant remand directives and the Board may continue with a decision at this time. See Stegall v. West, 11 Vet. App. 268 (1998); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Finally, during the hearing the retired VLJ clarified the issues and addressed the Veteran's contentions. It was clear from the hearing that the parties understood the issue and the VLJ accepted additional evidence with waiver of RO initial consideration. Such actions supplement VCAA and complies with 38 C.F.R. § 3.103. Laws and Regulations - Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); 38 C.F.R. § 3.303. Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). 38 U.S.C.A. § 1154(a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability or death benefits. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir.2007). In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Id. at 1376-77; see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept 14, 2009); Buchanan v. Nicholson, 451 F .3d 1331, 1337 (Fed. Cir.2006). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). Analysis The Veteran contends that he is entitled to service connection for photosensitivity. He asserts in statements and testimony throughout this appeal that since his Gulf service, he experienced extreme sensitivity to sun and light. Service treatment records reflect that the Veteran underwent an allergy work-up in February 1990, which was requested in conjunction with symptoms of chronic allergies, rhinitis, watery eyes and sinusitis. The record indicated that symptoms had begun in November 1989 at which time the Veteran had sinusitis. Upon evaluation allergic rhinitis was diagnosed. An August 1994 VA examination report revealed that, in pertinent part, the Veteran specifically denied having any eye trouble. The December 2003 report of VA examination reflects, in pertinent part, the Veteran's complaint that bright lights bothered his eyes and indicated that he had been sensitive to sun light since the Gulf War. The assessment, in pertinent part, included subjective sensitivity to light with normal eye examination and no eye pathology. The examiner observed that these symptoms were possibly related to allergic rhinitis with watery eyes. Pursuant to the April 2011 Board remand, the Veteran underwent additional VA examination in February 2012. The examiner recorded that the Veteran's complaint. On objective evaluation, no eye disorder was diagnosed. The examiner concluded that the Veteran's complaints of photosensitivity were less likely than not secondary to allergies, as there were no ocular findings on examination. The examiner explained that the Veteran's symptoms of photosensitivity were within normal range and there were no clinical objective findings. The examiner concluded that the symptoms the Veteran described were a normal physiological response and did not rise to the level of abnormality. Thus, the Board finds that the claim of service connection for photosensitivity must be denied. The Board emphasizes that Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C.A. §§ 1110, 1131; see also 38 C.F.R. § 3.310. Where, as here, evidence establishes that the Veteran does not have the disability for which service connection is sought, there can be no valid claim for service connection. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Here, the appellant is competent to report that he is sensitive to light as such is within his five senses. However, the medical opinion that his complaints are actually normal is more probative and credible than the appellant's own assertions that he has a disability. The Board has also considered whether service connection may be awarded for photosensitivity symptoms associated with an undiagnosed illness. According to the law, compensation may also be paid to a Persian Gulf veteran who exhibits "objective indications of a qualifying chronic disability" that became manifest either during active duty in the Southwest Asia theater of operations during the Persian Gulf War or to a degree of 10 percent or more before December 31, 2016, following such service, and such symptomatology by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C.A. § 1117 (West 2002 & Supp. 2012); 38 C.F.R. § 3.317 (2012); 71 Fed. Reg. 242, 75,669-72 (Dec. 18, 2006). Here, the Veteran's discharge document reflects that he is in receipt of the Southwest Asia Service Medal and the Kuwait Liberation Medal; there is also information of record which indicates that he served in the Gulf War Theater of Operations for the period from August 1990 to April 1991. As such, the Veteran meets the definition of "Persian Gulf veteran" for purposes of 38 U.S.C.A. § 1117. See also 38 C.F.R. § 3.317(d)(1)(2). As discussed above, however, the Veteran does not exhibit any objective indications of chronic photosensitivity disorder. In this regard, in the February 2012 examination, the examiner concluded that the symptoms the Veteran described were a normal physiological response. Absent objective indicators of unexplained photosensitivity problems, service connection for photosensitivity problems resulting from an undiagnosed illness is not warranted. See 38 U.S.C.A. § 1117(a)(2); 38 C.F.R. § 3.317(a). In sum, the competent and probative evidence of record demonstrates that the Veteran has no current disability manifested by photosensitivity. Therefore, with consideration of the Veteran's service treatment records, the various contemporaneous records, and the probative February 2012 VA examiner's report, the Board finds that a preponderance of the evidence is against the Veteran's claim of service connection for photosensitivity, to include as due to an undiagnosed illness. Consequently, the benefit of the doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Laws and Regulations - Increased Ratings Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). The Court has held that "staged" ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12Vet. App 119 (1999). The Board notes that, when evaluating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45 (2010); DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Left Shoulder Tendonitis Here the disability has not significantly changed and a uniform evaluation is warranted. The RO evaluated the Veteran's left shoulder disability under diagnostic codes (DC) 5024 and 5201. Diseases evaluated under diagnostic code 5024 are rated on limitation of motion of the affected part. See 38 C.F.R. § 4.71a. Under DC 5201, limitation of motion of the arm, a 20 percent evaluation is warranted for limitation of motion of the minor arm at shoulder level or midway between the side and shoulder level. A 30 percent rating is assigned for limitation of motion of the minor arm to 25 degrees from the side. The Veteran's claim for increased rating for his left shoulder disability was received in July 2003. In the appealed November 2004 rating decision, the RO denied entitlement to a compensable for the left shoulder disability. In a February 2010 rating decision, the RO increased the rating for the left shoulder disability to 10 percent, effective on July 8, 2003 (date of claim). In a September 2012 rating decision, the RO increased the rating for the left shoulder disability to 20 percent, effective February 1, 2012. These increases during the appeal did not constitute a full grant of the benefit sought. Therefore, the Veteran's claim for increased rating for the left shoulder disability remains on appeal. See AB v. Brown, 6 Vet. App. 35, 39 (1993). The Veteran underwent VA examination in December 2003. He complained of pain across the anterior shoulder and upper back a couple of times per month brought on by lifting. Therefore, in general, he avoids lifting in excess of 50 pounds. When he experienced pain, he tried to exercise and massage the shoulder and take Motrin or Tylenol, all of these things provided some relief. On examination, he had full, painless range of motion. December 2009 report of VA examination reflects that the Veteran was right hand dominant. He complained of constant diffuse left shoulder pain. The pain varied in intensity but there were no clear flare-ups of pain. He treated the left shoulder pain with ice, heat, Ibuprofen and Tylenol. Objectively, he had flexion: 0 to 180 degrees, extension: 0 to 20 degrees, abduction: 0 to 165 degrees, internal rotation: 0 to 90 degrees and external rotation: 0 to 90 degrees, with pain reported in all ranges of motion. He had no additional functional impairment with three repetitive motions A March 2010 VA physical therapy treatment record documents that the Veteran's left shoulder range of motion was flexion: 165 degrees (pain starting at 90 degrees), abduction: 160 degrees (pain starting at 90 degrees), internal rotation: 50 degrees (no increase in pain) and external rotation: 90 degrees (mild increase in pain). An August 2010 VA physical therapy treatment record reflects that the Veteran had normal range of motion of the left shoulder. However, he demonstrated pain in the left shoulder if he held his arm up for a prolonged time. February 2012 report of VA examination reflects that the Veteran was right hand dominant. Objectively, the Veteran's left shoulder flexion was to 135 degrees (with objective evidence of painful motion at 135 degrees); left shoulder abduction was to 125 degrees (with objective evidence of painful motion at 90 degrees). The Veteran was able to perform repetitive motions without additional loss of range of motion. However, as noted the Veteran's functional impairment was that he exhibited less movement than normal in the left shoulder. The Veteran did not have ankylosis of the left shoulder or impairment of the clavicle, scapula or acromioclavicular joint of the left shoulder. The Board finds that the medical and lay evidence reflects that the Veteran's left shoulder disability warrants increase to a 20 percent rating prior to February 1, 2012, and throughout the appeal period. The Board finds that the level of severity of the Veteran's left shoulder disability did not significantly change during the course of his appeal. In light of the Veteran's consistent reports of painful motion, evidence of decreased range of motion and the most recent examination (February 2012) documenting that objective evidence of painful abduction began at 90 degrees, the Board finds that the Veteran's left shoulder disability most nearly approximate the functional equivalent of limitation of motion of the minor arm at shoulder level. In light of the lay evidence, we are not convinced that the appellant became worse on the day of an adequate VA examination. Therefore, his left shoulder tendonitis warrants a 20 percent rating throughout the appeal period. In this regard, the Veteran's claim is granted. The Board has considered the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holdings in DeLuca. However, a higher evaluation for the Veteran's service-connected left shoulder disability is not warranted on the basis of functional loss due to pain or weakness in this case, as the Veteran's symptoms are supported by pathology consistent with the assigned 20 percent rating, and no higher. In this regard, the Board observes that the Veteran complained of pain. However, the effect of the pain in the Veteran's left shoulder disability was contemplated in the assigned 20 percent disability evaluation under Diagnostic Codes 5201. The Veteran's complaints do not, when viewed in conjunction with the medical evidence, tend to establish weakened movement, excess fatigability, or incoordination to the degree that would warrant an increased evaluation. The February 2012 VA examination documents that the Veteran did not have additional limitation in range of motion of the left shoulder following repetitive -use testing and the Veteran did not have functional loss and/or impairment of the left shoulder due to fatigue, weakness, lack of endurance, or incoordination after repetitive use. As limitation of the minor arm to 25 degrees from the side has not been demonstrated, a higher rating is not warranted at any time. Additionally, given that the Veteran is not shown to have experienced ankylosis or impairment of the humerus, clavicle or scapula, a higher rating under alternative diagnostic criteria contemplating shoulder disabilities is not warranted at any time. The Board has also considered the Veteran's assertions as to the severity of his symptoms; however, the Board finds the objective medical evidence, discussed above, to be more probative than his lay assertions in determining that his left shoulder tendonitis does not meet the criteria for a rating in excess of 20 percent. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Board has specifically considered the appellant's assertions. However, the current evaluation contemplates pain on motion and limitation of motion of the left arm greater than to 25 degrees from the side. Nothing in his assertions or the medical evidence suggests that his left shoulder is functionally limited to 25 degrees from the side. For all the foregoing reasons, the Board finds that a 20 percent, but no higher, ratings for left shoulder tendonitis is warranted throughout the appeal period, but that a rating in excess of 20 percent is not warranted at any time pertinent to this appeal. The Board has applied the benefit-of-the-doubt doctrine in determining that the criteria for 20 percent rating is met, but finds that the preponderance of the evidence is against assignment of higher ratings. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56(1990). GERD with IBS By way of background, the Veteran filed his original claim of service connection in February 1995. In an August 2002 rating decision, service connection was granted for GERD. A noncompensable disability rating was awarded effective December 13, 1994 (the day following his separation from service). Notably, the noncompensable rating was assigned pursuant to Diagnostic Code 7346 for "hiatal hernia." See 38 C.F.R. § 4.114. In February 2005, the Veteran filed his claim for service connection for IBS. Prior to the current appeal, the Veteran's GERD disability was always evaluated under Diagnostic Code 7346. In an October 2006 rating decision, the RO denied service connection for IBS. However, in a June 2007 rating decision, the RO granted service connection for IBS and assigned a 30 percent evaluation pursuant to DC 7319, effective February 17, 2005; the RO continued the noncompensable rating for the GERD pursuant to DC 7346. In a December 2007 rating decision, the RO found clear and unmistakable error (CUE) in the prior rating decision, combined the GERD with IBS and evaluated the disability pursuant to DC 7346-7319. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. 38 C.F.R. § 4.114 provides that ratings under diagnostic codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other. A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. Id. Under diagnostic code 7346 (hiatal hernia) a 10 percent rating is assigned for hiatal hernia with two or more symptoms for the 30 percent evaluation of less severity. A 30 percent evaluation is assigned for persistently recurrent epigastric distress with dysphagia, pyrosis and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 60 percent rating is assigned for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. Under diagnostic code 7319 (irritable colon syndrome), a noncompensable rating is assigned for mild irritable colon syndrome manifested by disturbances of bowel function with occasional episodes of abdominal distress. A 10 percent rating is assigned for moderate irritable colon syndrome manifested by frequent episodes of bowel disturbance with abdominal distress. A 30 percent rating is assigned for severe irritable colon syndrome manifested by diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. 30 percent is the maximum rating assignable under this diagnostic criteria. Factual Background A May 2003 VA treatment record indicates that the Veteran was evaluated for abdominal pain. He reported that the pain onset 3 days earlier and was a sub-sternal pain that radiated across his chest and into his back. He was evaluated in the emergency room where all tests were within normal limits. He described the pain as intermittent and sharp. Neither food nor changing positions affected the pain. He reported that he felt nauseated occasionally but had not vomited. There was no evidence of melena, fever or chills. Objectively, he was described as very obese. He demonstrated some tenderness in the epigastric area with deep palpation. Bowel sounds were positive. The assessment was abdominal pain and it was indicated that an ultrasound would be scheduled. A July 2003 endoscopy report indicated that the Veteran had been treated with PPI and was now symptom free. The endoscopy showed a solitary gastric polyp in the body of the stomach, status post "clod bx." Otherwise examination was normal. There was no evidence of esophagitis, gastritis, ulcer, etc. A December 2003 report of VA examination reflects the Veteran's report that he had very rare symptoms of acid reflux if he took his prescribed medication, Rebeprazole. Objectively, he weighed 227 pounds and was described as healthy and obese. The assessment was hiatal hernia well controlled with Rebeprazole. A July 2004 VA treatment record reflects the Veteran's report that the medication he was taking for gastric reflux was not providing any relief. He complained that he still had symptoms such as belching, gas and heartburn. He denied having severe abdominal pain, nausea or vomiting, persistent abdominal discomfort after belching or pain radiating to his back. A February 2005 VA treatment record reflects the Veteran's complaint of intermittent diarrhea alternating with constipation. The Veteran also complained of frequent abdominal cramping. A March 2005 treatment record reflects that the Veteran was referred to a dietician for a weight losing diet. The May 2007 report of VA examination documents the Veteran's complaint of alternating constipation and diarrhea. He reported that he has approximately 5 to 6 diarrhea bowel movements per day on some days, followed by a period of constipation for approximately 2 days. He had abdominal pain that seemed to improve with his bowel movements. He described the abdominal pain as a cramping pain, occurring approximately 4 times per week and rated 8 out of 10 in severity. He reported that he had gained about 50 pounds since leaving the Marine Corps and had not noticed any changes in his appetite or early satiety. His abdominal complaints have not limited his participation in riding bicycles and playing volleyball or prevented him from attending classes (he was a full-time student). He frequently felt bloated and had abdominal distension, especially when he used his CPAP machine at night. Objectively, he and his abdomen were described as obese. His abdomen was soft, nontender and had normal active bowel sounds. Hepatosplenomegaly could not be palpated. There was no tenderness or ascites. There was no peripheral edema and peripheral pulses were normal. An August 2007 VA treatment reflects that the Veteran was having daily bowel movements and was feeling better overall. A June 2008 treatment record reflects that the Veterans reflux was exacerbated by use of his CPAP. His worse symptom, belching, was experienced at night. It was reported that the Veteran did not follow most lifestyle modifications for anti-reflux measures. He had no weight loss or other red flag symptoms. A December 2009 report of VA examination reflects that Pantoprazole controlled his heartburn symptoms, most of the time. The Veteran complained of intermittent periods of gas and belching and having a nasty taste in his mouth. He did not have chronic vomiting, did not vomit blood and did not have melena or blood in his stools. Lab results had shown he was not anemic. His IBS manifested as intermittent constipation and diarrhea. He had a couple of accidents where he experienced fecal leakage after sneezing but was otherwise able to use the bathroom when he felt the urge. His weight had gradually increased over the years and the Veteran reported that his need to use the bathroom frequently interfered with his last job. Objectively, the abdominal examination was normal. The examiner commented that there was no significant limitation in the Veteran's employment as a result of his gastrointestinal disability other than he had to have access to a rest room. The February 2012 report of VA examination indicates that the symptoms of the Veterans GERD included pyrosis (heartburn), reflux, sleep disturbance (4 or more times per year) and transient nausea. These symptoms had no impact on the Veteran's ability to work. The examiner explained that the GERD did not restrict work in any way as it was fairly well controlled on medications. Symptoms of the Veteran's IBS were alternating diarrhea, abdominal distension and nausea. He had occasional episodes of bowel disturbance with abdominal distress with approximately 5 episodes of exacerbations or attacks of his IBS in the past year. The Veteran had experienced no weight loss, malnutrition, serious complications or other general health effects attributable to his IBS. The examiner reported that the Veteran's IBS impacted his ability to work in that the Veteran required a job that allows for frequent days off as needed for severe exacerbations of his IBS and access to a bathroom with breaks as needed for loose stools. Otherwise there were no work restrictions. Analysis Period from July 8, 2003, to February 16, 2005 After carefully considering the entire record in light of the applicable rating criteria, the Board determines that a rating of 10 percent is warranted for the GERD for the period from July 8, 2003, to February 16, 2005. In this regard, the evidence does tend to show that the Veteran's service-connected GERD was productive of such symptoms as heartburn (pyrosis) and some epigastric distress manifested by belching and gas. (July 2004 VA treatment record). The Board finds that this is indicative of two or more symptoms of the 30 percent rating of a lesser severity, contemplated by the 10 percent rating pursuant to Diagnostic Code 7346. Thus, the 10 percent rating is warranted. However, the Board concludes that a 10 percent rating is not warranted for GERD when evaluated under the diagnostic code for irritable colon syndrome (DC 7319). At no time during the period from July 8, 2003, to February 16, 2005 does the evidence suggest that the Veteran had frequent episodes of bowel disturbance with abdominal distress. To the contrary, the July 2004 reflects that the Veteran denied having severe abdominal pain or persistent abdominal discomfort. See 38 C.F.R. § 4.114, Diagnostic Code 7319. In finding that a 10 percent rating is warranted for the period from July 8, 2003, to February 16, 2005, the Board has considered the Veteran's assertions that he is entitled to an even higher increased rating. The Veteran is competent to state that his GERD is productive of a more significant impairment. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). However, the Board finds his assertions less credible when compared to the objective evidence of record which demonstrates that the Veteran's GERD was productive of such symptoms as heartburn and some epigastric distress of a minimal severity during this period in question. See Layno v. Brown, 6 Vet. App. 465 (1994). Persistently recurrent epigastric distress with dysphagia, pyrosis and regurgitation, accompanied by substernal or arm or shoulder pain productive of considerable impairment of health is not demonstrated. Thus, the Board finds that a rating in excess of 10 percent rating is not warranted. Additionally, the Board has considered other diagnostic criteria for rating digestive system disorders but finds none more applicable that would provide for a higher evaluation. Period from February 17, 2005 After carefully considering the entire record in light of the applicable rating criteria, the Board determines that a rating in excess of 30 percent is not warranted for GERD with IBS for the period from February 17, 2005 when evaluated under the diagnostic code for irritable colon syndrome. At most, the evidence consistently demonstrates that the Veteran's GERD with IBS is manifested at most by alternating diarrhea and constipation with more or less constant abdominal distress, consistent with the 30 percent rating assigned for this time period. In this regard, the Board notes that the 30 percent is the maximum rating assignable under this diagnostic criteria. A rating in excess of 30 percent is not warranted for GERD with IBS when evaluated under diagnostic code 7346. At no time during this time period has the Veteran's disability been productive of symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. The Veteran has consistently denied having vomiting, he had no material weight loss (just the opposite, the Veteran had a problem with weight gain and had been referred to a dietician for weight loss diet), he did not have melena and was not anemic. In short, he did not have any symptom combinations productive of severe impairment of health. To the extent that the Veteran argues entitlement to separate ratings for his GERD and for his IBS, the Board reiterates that 38 C.F.R. § 4.114 provides that ratings under diagnostic codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other. A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. Id. The Board has considered the Veteran's assertions that he is entitled to a rating in excess of 30 percent for his GERD with IBS for the period from February 17, 2005. The Veteran is competent to state that his GERD with IBS is productive of a more significant impairment. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). However, the Board finds his assertions less credible when compared to the objective evidence of record which demonstrates that the Veteran's GERD with IBS is productive of at most alternating diarrhea and constipation with more or less constant abdominal distress during this period in question. See Layno v. Brown, 6 Vet. App. 465 (1994). Symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health have simply not been demonstrated. Thus, the Board finds that a rating in excess of 30 percent rating is not warranted. Additionally, the Board has considered other diagnostic criteria for rating digestive system disorders but finds none more applicable that would provide for a higher evaluation. Depressive Disorder Here the disability has not significantly changed and a uniform evaluation is warranted. The rating for the Veteran's depressive disorder has been assigned pursuant to Diagnostic Code 9434. However, the actual criteria for rating the Veteran's disability are set forth in a General Rating Formula for evaluating psychiatric disabilities other than eating disorders. See 38 C.F.R. § 4.130. Under the formula, a 30 percent rating is assigned when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives, own occupation, or own name. Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). In this case, the Board finds that the weight of competent, probative evidence establishes that the criteria for a rating in excess of 30 percent for depressive disorder have not been met. A VA examination was conducted in December 2003 and the claims file was reviewed. The Veteran complained of symptoms of depression and denied having suicidal thoughts. He described having a hard time focusing and concentrating and complained of memory problems. He reported that he slept about 9 hours a day. He gave a past history of anxiety and panic attacks, controlled on Zoloft. He reported that he was in the process of separating from his second wife, but spent time with his daughters and was working in the heating and air conditioning business, and did not miss work due to depression. On examination the veteran was well oriented. Mood was reportedly very depressed, although the examiner observed that affect did not appear depressed. The Veteran denied having homicidal or suicidal ideation. There was no overt memory loss or impairment shown during the examination and the examiner observed that the Veteran appeared to be able to concentrate and focus on the examination interview. Insight and judgment were described as intact. Depressive disorder, not otherwise specified was diagnosed. A GAF score of 60 was assigned. The Veteran was seen by VA psychiatry in February 2004. He reported that his mood was depressed and noted symptoms of anxiety. Concentration was described as fair. Suicidal intent was denied. The report indicated that the Veteran might lose his job at a heating and air conditioning company as FMLA was to expire the next day. It was noted that the Veteran was under financial stress and that he was separated from his wife and almost divorced. Mental status examination revealed slowed speech; intact insight, judgment and cognitive function; no indication of suicidal or homicidal ideation; and logical thought. A diagnosis of a history of major depression, in partial remission was made and a GAF score of 55 was assigned. The Veteran underwent a VA examination for mental disorders in February 2005. At that time, it was noted that when last evaluated in 2003, the Veteran was experiencing several situational stressors including an impending divorce and employment related problems. The report indicated that the Veteran had worked full-time until November 2003, and worked occasionally from April to December 2004 in the heating and air conditioning field, with the reduction in work being attributed by the veteran to medical problems (60%) and depression (40%). It was noted that the Veteran was interested in returning to school, but had not done so yet. Socially, it was reported that the veteran's divorce was final in October 2004 and that he lived alone, but participated in various groups and went to church. The Veteran reported that his depression resulted in low energy, but generally functioning at a slower pace with less enthusiasm. Mental status examination revealed that the Veteran had no impairment of thought processes or communication and that there was no indication of delusions or hallucinations. He denied having homicidal or suicidal thoughts or obsessive or ritualistic behaviors. It was reported that he was well oriented and endorsed some short-term memory problems. Speech was within normal limits. The Veteran gave a history of experiencing panic attacks, but stated that he had not had any for over the past year. He denied having impaired impulse control. The Veteran reported having symptoms of depression and anxiety due to factors including financial status, employment and family issues. He indicated that sleep was fairly decent, averaging about 8 hours a night with the use of a CPAP nightly, but indicated that he was still sometimes tired during the day. A diagnosis of depressive disorder was made and a GAF score of 55 (indicating moderate symptoms) was assigned. The examination report indicated that the Veteran had made it clear to the examiner that he had difficulty working in heating and air conditioning due to a combination of depression and allergies which became aggravated by being in a dusty environment. In this regard, the examiner clarified that the Veteran had not claimed that depression had rendered him unemployable, but had reported that it made it more difficult for him to work in heating and air conditioning. It was noted that the Veteran reported having other conditions such as allergies which made it difficult for him to work in that environment. It was noted that the Veteran had returned to school to learn a new trade. The examiner opined that the Veteran's depression did not render him unemployable and observed that mental health records had not noted a significant impact from the Veteran's depression on his ability to work in heating and air conditioning, although there was some indication that this was likely to have some negative impact of his functioning while at work. It was generally noted that the Veteran's symptoms were slightly worse than when evaluated in 2004, but not significantly. At the travel Board hearing held in March 2008, the Veteran's representative urged that at least a 50% evaluation should be assigned for depressive disorder, inasmuch as the Veteran's other medical problems such as sleep apnea and joint pain caused increased symptomatology of depression. The Veteran testified that he had not worked for more than 4 years, but was attending school full-time and had a paid internship in which he was working about 30 to 32 hours a week, with some work missed due to medical appointments and sick days. February, May, August and December 2010 VA mental health treatment records reflect that the Veteran denied feeling hopeless about the future, having suicidal thoughts or making suicidal attempt. The diagnosis was history of major depression in remission and the examiner assigned the Veteran GAF scores ranging between 60 and 64. The examiner noted that the Veteran had some continued depression in the context of stressors of relationship with ex-wife/child support/custody issues as well as financial stress with ongoing appeals of VA claims. The February 2012 report of VA examination reflects that the Veteran had been divorced since October 2004. His ex-wife and two daughters lived in Maryland and he had visitations with his daughters over some holidays, spring breaks and summer vacation. He recently had gotten engaged and described the relationship with his fiancé as going well. He continued to go to church and participated in a variety of church groups. He had a supportive family and estimated that he has several good friends, mostly from church. His hobbies included remodeling, working on cars, riding bikes, camping and walking. He was currently unemployed (since 2004) but was back in school full-time , pursuing his bachelor's degree in project management. School was going fair; however, he had missed some school during the fall due to some medical problems. His goal was to earn his degree and look for work in his field. In terms of the impact his depression had on his work, the Veteran reported that when he makes it to the job, he generally functions but works more slowly and is not as enthusiastic or energetic as he used to be. In terms of the impact his depression had on his schooling, the Veteran reported that his depression made it hard to concentrate and made it hard to get motivated to do school work. The psychologist reported that the Veteran was doing well on his current medication. The Veteran still struggled with sleep and energy issues. The Veteran still noticed symptoms of depression in that he lacked enthusiasm or motivation, reporting that if he had something to do he was okay; otherwise, he felt "blah" and just didn't do anything. His depression was variable. Symptoms of his psychiatric disorder included depressed mood, mild memory loss and disturbance of motivation and mood. The psychologist concluded that the Veteran's depressive disorder was productive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The psychologist opined that the Veteran's depressive disorder did not render him unable to obtain or maintain substantially gainful employment, consistent with his education and occupational experience. The effects of the Veteran's depression included decreased interest, energy, motivation and work efficiency, problems with concentration and procrastination. However, despite these symptoms, the Veteran was doing very well in school and he hoped to get a job in the field that he was pursuing his degree in. The psychologist concluded that the Veteran's depression was of mild/moderate severity and assigned the Veteran a GAF score of 60. Based on the above, the evidence demonstrates that the Veteran's depressive disorder has been productive of symptomatology of a mild/moderate nature, i.e., he exhibits occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, and is adequately contemplated by the assigned 30 percent rating. As the U.S. Court of Appeals for the Federal Circuit recently explained, evaluation under § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed.Cir.2013). The symptoms listed in DC 9434 are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan, 16 Vet.App. at 442. In the context of determining whether a higher 50 percent disability evaluation is warranted, the DC requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment with reduced reliability and productivity and difficulty establishing and maintaining effective work and social relationships -i.e., "the regulation ... requires an ultimate factual conclusion as to the veteran's level of impairment ..." VazquezClaudio, 713 F.3d at 117-18; see 38 C.F.R. § 4.130, DC 9434. Here, the evidence does not indicate that the Veteran's depressive disorder caused occupational and social impairment with reduced reliability and productivity, particularly given the fact that the Veteran has not demonstrated more significant vocational impairment, and, has few of the symptoms listed in the criteria for a 50 percent rating. Here, there is some evidence of depression and at times anxiety. Although he underwent a divorce, he is in another relationship, establishing that he can maintain relationships. He has either been in school, employed or in an internship. He has complained of decrease in concentration, motivation and energy; however, his speech has never been circumstantial, circumlocutory or sterotyped. Affect has been appropriate. Although there is a complaint of concentration, nothing suggests that there are symptoms approximating forgetting to complete tasks or retention of only highly learned material. Similarly, there is no indication of symptoms such as impairment of impaired judgment or abstract thinking. In short, he does not have the constellation of symptoms indicative of a more severe disability. Thus, the Board finds that a 50 percent rating is not warranted. The Board has also considered the lay pleading and testimony and finds his assertions to be credible. However, his assertions taken with the totality of the other evidence of record persuades the Board to conclude that the Veteran's depressive disorder has at most approximated occupational or social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily with routine behavior, self-care and conversation normal). This is confirmed by the psychologist in the February 2012 report of VA examination. For the foregoing reasons, the preponderance of the evidence reflects that the Veteran's depressive disorder has most nearly approximated occupational and social impairment of a degree contemplated by the 30 percent rating already assigned 38 C.F.R. § 4.7. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against assignment of any higher rating, that doctrine is not applicable. See 38 U.S.C.A § 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.3 (2011); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Extra-schedular considerations The above determinations are based on application of pertinent provisions of VA's rating schedule. Additionally, the Board finds that at no point has the Veteran's left shoulder, GERD with IBS, and depressive disorder disabilities been shown to be so exceptional or unusual as to warrant the assignment of any higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321. Consideration of referral for an extraschedular rating requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating adequately contemplates the Veteran's disability picture. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. If the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the Veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether an extraschedular rating is warranted. The discussion herein above reflects that the symptoms and effects of the Veteran's left shoulder, GERD with IBS, and depressive disorder disabilities are fully contemplated by the applicable rating criteria. The Board's analysis above reflects that the symptoms, effects, and overall disability picture from the Veteran's left shoulder, GERD with IBS, and depressive disorder disabilities are contemplated by the ratings assigned, which take account of both the individual symptoms and the overall impairment caused by the left shoulder, GERD with IBS, and depressive disorder disabilities. Thus, consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required. In any event, the above evidence reflects that the effects of the left shoulder, GERD with IBS, and depressive disorder disabilities on the Veteran's employment did not constitute marked interference with employment, i.e., beyond that contemplated by the assigned ratings. See 38 C.F.R. § 4.1 ("Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability"). Moreover, there is no evidence of frequent hospitalization, or indication that the Veteran's symptoms have otherwise rendered impractical the application of the regular schedular standards. Therefore, referral for consideration of an extraschedular rating for left shoulder, GERD with IBS, or depressive disorder disabilities is not warranted. 38 C.F.R. § 3.321(b)(1). TDIU Under the applicable criteria, total disability ratings for compensation based upon individual unemployability may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or 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, 3.341, 4.16(a). It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated as totally disabled. Therefore, in the case of veterans who are unemployable by reason of service-connected disabilities, but who fail to meet these schedular percentage standards, the case should be submitted to the Director, Compensation and Pension Service, for extraschedular consideration. The Veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed. See 38 C.F.R. § 4.16(b). In this case, the Veteran has met the objective, minimum percentage requirements, set forth in 38 C.F.R. § 4.16(a), for award of a TDIU rating on a schedular basis; as of December 2004 (date of claim for TDIU), the combined rating for all of the Veteran's service-connected disabilities was 80 percent. Hence, the remaining question is whether the Veteran is, in fact, unemployable. The central inquiry is "whether a veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the Veteran's education, special training, and previous work experience, but not to his or her age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Van Hoose v. Brown, 4 Vet. App. 361 (1993). The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question, however, is whether a veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose, 4 Vet. App. at 363. Here, the Veteran is not shown to have been rendered unemployable due to service-connected disabilities. The February 2005 report of VA examination reflects the Veteran's complaint that he felt unemployable because he was unable to do a lot of physical labor and was tired all the time. However, the examiner opined that the Veteran's disabilities did not make him unemployable. It was explained that the Veteran would not be able to do heavy labor; however, he was capable of working. In the February 2005 report of VA mental disorders examination, the psychologist noted that the Veteran's depression did not have a significant impact on his ability to work in heating and air conditioning. The psychologist explained that while the Veteran's depression likely had some negative impact on his functioning while at work, he was not currently unemployable due to his depression. The report of December 2009 VA examination reflects the examiner's assessment that the Veteran's GERD and IBS had no significant limitation in his employment other than he has to have access to a rest room. The February 2012 report of VA examination of the left shoulder disability reflects only that the Veteran's left shoulder disability would restrict him from a job that required lifting above 10 pounds or repetitive activity above his head. The report of February 2012 headache examination reflects that the Veteran's headache disability would limit the Veteran to a job that allowed for infrequent time off as needed for headaches. February 2012 report of VA spine examination reflects that the Veteran would be limited to a sedentary job. February 2012 reports of VA esophageal disorder and hypertension examinations reflect that the Veteran's GERD and hypertension do not restrict work in any way. February 2012 report of VA intestinal disorders examination reflects that the Veteran requires a job that allows for infrequent days off as needed for severe exacerbations of his IBS and provides access to a bathroom with breaks as needed for loose stools. Otherwise work was not restricted by the IBS disability. February 2012 report of VA mental disorders examination reflects the psychologist's opinion that the depressive disorder did not render the Veteran unable to obtain or maintain substantially gainful employment, consistent with his education and occupational experience. In this case, the competent, persuasive evidence of record is against any finding that the service-connected disabilities are of such a severity either individually, or in concert to render the Veteran unemployable or unable to engage and maintain substantially gainful employement. The Board has considered the Veteran's assertions that he is unemployable due to his service-connected disabilities. The Veteran is competent to make such an assertion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). However, the Board finds his assertions less credible when compared to the objective evidence of record which clearly demonstrates that he has not been rendered unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. See Layno v. Brown, 6 Vet. App. 465 (1994). Finally, to the extent that the Veteran challenges the adequacy of the VA examinations, the Board finds that the examinations were adequate. In this case, the examining physicians reviewed the claims file, which included the Veteran's private treatment records, VA treatment records and lay assertions; described the disabilities; physically examined the Veteran; provided clinical findings; entered a diagnosis; provided medical opinions; and, provided a rationale for the medical opinions, which were based on a review of the medical records and taking into account the Veteran's lay assertions. The Veteran has not provided explanation of how the examinations were performed in an insufficient manner other than to suggest that it the examinations do not provide an opinion as to whether the disabilities in concert render the Veteran unemployable. It is clear that the examining physicians fully understood the basis for the Veteran's claim yet still declined to determine that the Veteran was unemployable. The Board is aware that certain examiner's indicated that the Veteran had certain employment restrictions; however, the Board notes that no examiner determined that the Veteran was unemployable as a result of his disabilities. Thus the Board finds that the examinations were fully adequate for the Board to make an informed decision. Thus, the Board finds that the claim of entitlement to a TDIU rating must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Entitlement to service connection for photosensitivity, claimed as due to an undiagnosed illness is denied. A 20 percent rating is granted for left shoulder tendonitis, prior to February 1, 2012, subject to controlling regulations governing the payment of monetary awards. A rating in excess of 20 percent for left shoulder tendonitis from February 1, 2012 is denied. A 10 percent rating is granted for the GERD for the period from July 8, 2003, to February 16, 2005, subject to controlling regulations governing the payment of monetary awards. A rating in excess of 30 percent for GERD with IBS from February 17, 2005 is denied. A rating in excess of 30 percent for depressive disorder is denied. Entitlement to a TDIU rating is denied. ____________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs