Citation Nr: 1544128 Decision Date: 10/15/15 Archive Date: 10/21/15 DOCKET NO. 13-15 616 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manchester, New Hampshire THE ISSUES 1. Entitlement to compensation under 38 U.S.C. § 1151 for splintered/fractured left femur, bladder infection, and injury to the skin. 2. Entitlement to compensation for an acquired psychiatric disorder, as secondary to splintered/fractured left femur, bladder infection, and injury to the skin. 3. Entitlement to service connection for posttraumatic stress disorder (PTSD). 4. Entitlement to a total disability rating based upon individual unemployability (TDIU), to include on an extra-schedular basis pursuant to 38 C.F.R. § 4.16(b). REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD B. Ogilvie, Senior Counsel INTRODUCTION The Veteran served on active duty from July 1970 to June 1971. This case is before the Board of Veterans' Appeals (Board) on appeal from March 2012 and July 2012 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Manchester, New Hampshire. A Board hearing was held before the undersigned at the White River Junction, Vermont, RO in September 2013. A transcript is of record. In February 2015, the Board remanded the issues on appeal for further development, and the appeal is again before the Board for appellate review. The characterization of the Veteran's claim of entitlement to compensation for an acquired psychiatric disorder, as secondary to splintered/fractured left femur, bladder infection, and injury to the skin, has changed during the pendency of this appeal. As discussed in more detail below, the medical evidence of record indicates that the Veteran's mental health disorder has been classified as PTSD, mood disorder, major depressive disorder, and anxiety disorder, not otherwise specified (NOS), as related to his hip disability. Thus, the Board is expanding this claim to encompass all acquired psychiatric disabilities, of which it has jurisdiction to consider. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that the Board must consider the scope of a Veteran's claim for service connection for PTSD as including any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record). This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C.A. § 7107(a)(2) (West 2014). FINDINGS OF FACT 1. On October 26, 2011, the Veteran underwent a left total hip arthroplasty at a VA facility. 2. The Veteran sustained a one-centimeter calcar fracture due to his October 2011 left total hip arthroplasty; no additional bladder or skin disabilities were incurred. 3. The weight of the probative evidence is against a finding that the Veteran's calcar fracture was proximately caused by carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing that treatment; or an event not reasonably foreseeable. 4. There is no nexus between the Veteran's PTSD and his in-service stressor. 5. The Veteran is currently service connected for tinnitus, currently rated as 10 percent disabling, and bilateral hearing loss, currently rated as noncompensably disabling, with a combined disability rating of 10 percent. 6. The Veteran's service-connected disabilities do not meet the minimum percentage requirements for award of a schedular TDIU, and these disabilities are not shown to prevent him from obtaining or retaining substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for entitlement to compensation under 38 U.S.C.A. § 1151 for a splintered/fractured left femur, bladder infection, and injury to the skin have not been met. 38 U.S.C.A. §§ 1151, 5107 (West 2014); 38 C.F.R. § 3.361 (2014). 2. The Veteran is not entitled to compensation for PTSD, a mood disorder, major depressive disorder, or anxiety disorder NOS, as secondary to splintered/fractured left femur, bladder infection, and injury to the skin, as a matter of law. 38 U.S.C.A. § 1151 (West 2014); 38 C.F.R. § 3.310 (2014); Sabonis v. Brown, 6 Vet. App. 426 (1994). 3. PTSD was not incurred as a result of the Veteran's active military service. 38 U.S.C.A. § 1110 (West 2014); 38 C.F.R. §§ 3.303, 3.304 (2014). 4. The criteria for TDIU are not met. 38 U.S.C.A. §§ 1155 (West 2014); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Pub. L. No. 112-154, §§ 504, 505, 126 Stat. 1165, 1191-93; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2014). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2014); 38 C.F.R. § 3.159(b) (2014); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1) (2014). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). For service-connection claims, this notice must address the downstream elements of disability ratings and effective dates. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Here, the VCAA duty to notify was satisfied by way of letters sent to the Veteran in November 2011, December 2011, and April 2012 that fully addressed all required notice elements and were sent prior to the initial RO decision in these matters. The letters informed the Veteran of what evidence was required to substantiate the claims and of his and VA's respective duties for obtaining evidence. VA also has a duty to assist a claimant in the development of the claims. This duty includes assisting the claimant in the procurement of service and other pertinent treatment records and providing an examination or medical opinion when necessary. 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159 (2014). In January 2012, the VA provided VA examinations related to the Veteran's left hip and depression. VA also provided a May 2015 VA examination on the issue of PTSD, and a June 2015 VA medical opinion for his claim pursuant to 38 U.S.C. § 1151. The Board finds the medical examinations and relevant opinions to be adequate as they were made after a review of the relevant evidence, and the examiners provided a rationale for the conclusions reached. The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran. Specifically, the information and evidence that have been associated with the claims file include the Veteran's service treatment records, VA treatment records and examinations, a private treatment report, private treatment records, lay statements, and hearing testimony. The Veteran was provided an opportunity to set forth his contentions on the claim during the September 2013 hearing before the undersigned. The Court has held that the requirements of 38 C.F.R. § 3.103(c)(2) apply to a hearing before the Board and that a Veterans Law Judge has a duty to explain fully the issues and to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010). The record reflects that at the September 2013 hearing the undersigned explained the issues, focused on the elements necessary to substantiate the claims, and sought to identify any further development that was required to help substantiate the claims. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor have they identified any prejudice in the conduct of the hearing. The case was remanded in October 2013 to obtain VA treatment records. The consent form and VA treatment records were obtained. The case was remanded again in February 2015 for a VA opinion and examination. The Veteran underwent a VA examination for PTSD in May 2015, and a medical opinion for his claim pursuant to 38 U.S.C. § 1151 was provided in June 2015. Accordingly, the requirements of the remands were ultimately accomplished and the prior remand instructions were substantially complied with. See Stegall v. West, 11 Vet. App. 268 (1998). Neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claims that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist under the VCAA. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). All necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). II. 1151 Claim In October 2011, the Veteran underwent a left total hip arthroscopy at a VA Medical Center (VAMC). He claims that additional disabilities of a fractured femur, infected bladder, and bruising to his skin resulted from this surgery due to VA's negligence and seeks compensation for such disabilities pursuant to 38 U.S.C. § 1151. A veteran who suffers disability resulting from hospital care or medical or surgical treatment provided by a VA employee or in a VA facility is entitled to compensation for the additional disability "in the same manner as if such additional disability . . . were service-connected" if the additional disability was not the result of willful misconduct and was proximately caused by "carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of [VA] in furnishing" that treatment or "an event not reasonably foreseeable." 38 U.S.C.A. § 1151(a)(1)(A), (B) (West 2014); Viegas v. Shinseki, 705 F.3d 1374, 1377-78 (Fed. Cir. 2013). Carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault in VA hospital care or medical or surgical treatment is established when such care or treatment caused the veteran's additional disability, and VA either "failed to exercise the degree of care that would be expected of a reasonable health care provider" or furnished the hospital care or medical or surgical treatment without the veteran's informed consent. 38 C.F.R. § 3.361(d)(1)(i), (ii) (2014). Alternatively, to establish that the proximate cause of a disability was an event not reasonably foreseeable, the evidence must demonstrate that a reasonable health care provider could not have foreseen the event. Id. (d)(2). The event does not have to be "completely unforeseeable or unimaginable" but it must "be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided." Id.; see Schertz v. Shinseki, 26 Vet. App. 362, 367-69 (2013). The Veteran alleges that he has additional disability, including a fractured femur, infected bladder, and bruising to his skin that developed after his left total hip arthroplasty performed at VA. On October 26, 2011 the Veteran had a left total hip arthroplasty performed at the VAMC in White River Junction, Vermont. The pre-operative and operative diagnoses were severe degenerative arthritis of the left hip. See October 2011 VA Operation Report. The procedures performed included a left total hip arthroplasty and a placement of cable for a nondisplaced calcar fracture. Id. At the time of surgery, the Veteran had severe degenerative changes present with deformity of the femoral head, osteophyte formation, and marked loss of articular cartilage. Id. During surgery, there was some difficulty removing the femoral head, and it was necessary to remove it in several pieces. Id. On placing compartments of the femoral reaming system, there was noted to be a small nondisplaced oblique fracture at the calcar. Id. The remainder of the femoral neck appeared stable. Id. The surgeons decided to place a cable around the femoral neck to prevent any further propagation. Id. Immediately after surgery, an X-ray was performed revealing no periprosthetic fracture within the femur. See October 26, 2011, VA Radiology Report. Two days after surgery, an X-ray revealed no fractures and a "satisfactory appearance status post left total hip arthroplasty." See October 28, 2011, VA Radiology Report. Five days after surgery, X-rays again revealed no obvious calcar fractures and "no radiographic evidence of complication." See October 31, 2011, VA Radiology Report. One month later, the Veteran's X-rays revealed general satisfactory appearance of the left total hip arthroplasty. See November 23, 2011, VA Radiology Report. The calcar fracture was not visible. Physical examination showed the left hip wound to be well healed without any sign of infection. In December 2011, the Veteran's physician reviewed the Veteran's X-rays and again noted that no calcar fracture was visible. During surgery, a urinary catheter was inserted without difficulty. See October 2011 VA Discharge Summary. Aseptic technique was used by the inserter, and the catheter was properly secured. Id. The catheter was removed on postoperative day 4. Id. One week after surgery, the Veteran complained of episodic dizziness and low blood pressure. See November 2011 VA consult. He was found to have hypotension, likely multifactorial in etiology including acute blood loss anemia that developed from his surgery. See November 2011 VA internal medicine note. The Veteran also had developed a urinary tract infection and was prescribed a 7-day regimen of antibiotics. See November 2011 VA consult request. On November 3, 2011, the Veteran received a transfusion, which he approved. See November 2011 VA blood banking transfusion note (acknowledging the existence of a current valid informed consent). Medical records indicate the presence of an area of skin irritation and discoloration (darkening) in the right lower quadrant area. See October 2011 Orthopedic Surgery Inpatient Notice. The Veteran has also credibly testified to, and provided a photograph of, a large bruise that resulted after his transfusion. In regard to the Veteran's urinary tract infection and bruising, these do not qualify as disabilities as the record clearly indicates that they were temporary issues that quickly resolved. The Veteran submitted a statement in September 2013 noting that his left arm discoloration lasted three to four weeks. See September 2013 Statement in Support of Claim. He was provided with a VA examination in January 2012, where it was noted that he did not have a current skin disability or a current male genitourinary system condition. There is also no indication from the record that the Veteran developed any further complications from his urinary tract infection after he completed his course of antibiotics. While subsequent VA treatment records reflect that the Veteran complained of "bashful bladder" because he was having difficulty voiding on demand for drug testing, the physician found that this was not a medical problem. See October 2013 VA urology consult. As such, the Veteran's urinary tract infection and bruising are not considered additional disabilities for which compensation may be granted under 38 U.S.C.A. § 1151, and the Veteran's claim for both of those alleged disabilities fails under this first element. Regarding the Veteran's allegation that he suffered a femur fracture during surgery, the evidence reflects that the Veteran suffered a one-centimeter femur fracture during his surgery. See October 2011 VA Operation Report. As discussed above, multiple postoperative X-rays revealed that the Veteran did not actually sustain a fracture of the femur, but subsequent records reflect a healed femur fracture. As such, the Board finds that the Veteran incurred a one-centimeter calcar fracture that healed subsequent to surgery. Turning to the question of whether VA's medical treatment (specifically, the left total hip arthroplasty) caused the Veteran's calcar fracture, the record clearly reflects that this calcar fracture was caused during the surgeon's placing of the compartments of the femoral reaming system. See October 2011 VA Operation Report. The Veteran's claim, however, fails on the element of proximate causation. The record reflects that VA did not fail to exercise the degree of care that would be expected of a reasonable health care provider or furnish the medical treatment without the Veteran's informed consent. 38 C.F.R. § 3.361(d)(1)(i), (ii) (2014). A June 2015 opinion of record states that there was no carelessness, negligence, lack of proper skill, error in judgment, or fault on the part of the VA. See June 2015 VA opinion. As rationale, the clinician noted that the small calcar fracture was unlikely and inherent to the reaming process without which the prosthesis could not be inserted. She also noted that the pre-operative X-rays described severe arthritis of the hip which would include the likelihood of osteoporosis, which would facilitate the minor fracturing of portions of the calcar during the reaming process. The Board affords this opinion strong probative weight due to the author's review of the claims file and clear and detailed rationale provided as a basis for her conclusion. Notably, there is no other opinion of record pertaining to this question. In an undated letter, the Veteran submitted an April 2015 bone scan, noting two areas of increased radiotracer uptake in the left greater trochanter and in the periprosthetic region of the left proximal femur just superior to the level of the lesser trochanter, which may represent prosthetic loosening or reactive bone remodeling from the left hip arthroplasty. In accompanying correspondence, the Veteran noted that this information was overlooked by the examiner providing the June 2015 opinion. While the Board notes that this evidence was not explicitly discussed by the examiner providing the June 2015 opinion (although she stated that she reviewed all VA treatment records), this does not render the opinion inadequate. Notably, the examiner considered and fully discussed a previous bone scan that reflected similar results. See, e.g., November 2012 bone scan (revealing no complication of the left hip prosthesis such as infection or fracture; diffuse mildly increased uptake in the left proximal femur shaft and trochanteric region was not specific and was most likely reactive to stress from the prosthesis; early loosening was not excluded but was not seen on radiographs). When considering the bone scan in conjunction with serial radiographs, including all imaging immediately following surgery indicating no progression of any fracture, loosening of the prosthesesis, or other complications at the site of the prosthesis, the examiner providing the June 2015 opinion concluded that there was a full healing of the calcar fracture. The record also supports this finding. See, e.g., December 2013 X-ray of bilateral hips reflecting no radiographic evidence of complication; see also March 2014 VA orthopedic surgery consult (noting X-rays revealed a "well-aligned implant with a healed femur fracture. No more sagging of the femoral implant compared with the previous x-ray starting October 2011"). Thus, the Board finds the June 2015 opinion adequate despite the lack of discussion concerning the April 2015 bone scan. Alternatively, to establish that the proximate cause of a disability was an event not reasonably foreseeable, the evidence must demonstrate that a reasonable health care provider could not have foreseen the event. 38 C.F.R. § 3.361(d)(2) (2014). Prior to his surgery, the Veteran signed a consent form. Section 11, "Known risks of treatment/procedure," includes "Fractures caused by instruments, hardware or implants used during the procedure." By signing his name, the Veteran attested that, inter alia, he had "been offered the opportunity to read the consent form" and that "[s]omeone ha[d] explained how this treatment/procedure could help . . . and things that could go wrong." As the evidence clearly indicates that the Veteran was provided with information regarding the risk of fractures caused by hardware used during the procedure, such a fracture was a reasonably foreseeable event. To this point, a June 2015 VA opinion of record also notes that "[a]lthough an uncommon event, a calcar fracture is a reasonabl[y] foreseeable risk of this type of surgery given the nature of the reaming process." Due to the facts of the case being conclusive on whether a fracture was a reasonably foreseeable outcome of a hip arthroplasty, the Board finds that the Veteran's fracture was not "an event not reasonably foreseeable." As the Veteran's claim fails on the element of an additional disability (for a bladder and skin disability) and the element of proximate causation (for a calcar fracture), the claim of entitlement to disability compensation pursuant to 38 U.S.C. § 1151 is denied. III. Acquired Psychiatric Disorder The Veteran claims entitlement to compensation for an acquired psychiatric disorder, as secondary to residuals from his left hip arthroplasty, to include splintered/fractured left femur, bladder infection, and injury to the skin. The Veteran has been diagnosed with a mood disorder, major depressive disorder, anxiety disorder, and PTSD. See November 2011 Report of Contact; January 2012 VA examination report; December 2013 private Disability Benefits Questionnaire. However, in view of the Board's decision denying entitlement to compensation under 38 U.S.C. § 1151 for splintered/ fractured left femur, bladder infection, and injury to the skin in the decision above, there is no legal basis for granting compensation for a mood disorder, major depressive disorder, anxiety disorder NOS, or PTSD on a secondary basis. See 38 U.S.C.A. § 1151 (West 2014); 38 C.F.R. § 3.310 (2014). Under these circumstances, the Board must deny the claim for a mood disorder, major depressive disorder, anxiety disorder NOS, and PTSD, on a secondary basis, as without legal merit. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). IV. PTSD Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110 (West 2014); 38 C.F.R. §§ 3.303, 3.304 (2014). Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (i.e., a diagnosis under the Diagnostic and Statistical Manual of Mental Disorders); a link, established by medical evidence, between current symptoms and a stressor event in service; and credible supporting evidence that the claimed stressor event in service occurred. 38 C.F.R. § 3.304(f) (2014). The Veteran has alleged that he developed PTSD after an incident in service where he was serving on the response crew at Whiting Field, and witnessed a T-28 aircraft crash shortly after takeoff. He claims that he was responsible for extracting the pilot who was injured, and that he was also concerned that the aircraft would catch on fire due to the sparks and gasoline. The record reflects a diagnosis of PTSD. See May 2015 VA examination report. As such, the first element of § 3.304(f) has been met. The Veteran also has a verified stressor. See Defense Personnel Records Information Retrieval System report (noting that a T-28 aircraft accident report revealed that on November 7, 1970, aircraft at Whiting Field experienced engine problems and required a skidded turn stall upon impacting on the ground). While no casualties were reported, the Board finds that the stressor comports with the Veteran's allegations that the pilot was injured but lived. The remaining inquiry pertains to whether the PTSD diagnosis is etiologically related to the Veteran's in-service stressor. The record contains two opinions related to the etiology of the Veteran's PTSD diagnosis. A December 2013, Disability Benefits Questionnaire completed by a private psychologist diagnosed the Veteran with PTSD, major depression, and anxiety disorder NOS. In an attached report, the clinical psychologist noted that the Veteran "does suffer from PTSD and Major Depression, as well as Anxiety Disorder NOS, all related to the stressor of the hip surgery." See December 2013 private psychological report. She noted that prior to the surgery, the Veteran was gainfully self-employed, motivated, had good relationships, and a social network, which all changed after his surgery. Id. Although the psychologist was aware of the in-service incident, she did not find that it contributed in any way to the Veteran's PTSD. Id. (noting, "[t]his psychologist is not aware of any other stressor that could have caused the pervasive deterioration described . . . other than the hip surgery and the difficulties that followed it"). The Veteran also told the examiner that "his current claim for PTSD [was] associated with the hip surgery and not with the alleged 1970 incident." Id. See also October 2013 VA mental health note ("Veteran claims he has PTSD from his hospitalization . . . for hip replacement surgery"; no mention of in-service stressor). In May 2015, the Veteran was provided with a VA examination. He was diagnosed with PTSD, but the examiner was unable to provide an opinion as to whether the Veteran's claimed stressor caused his PTSD without resort to speculation. See May 2015 VA medical opinion. As rationale, she explained that the Veteran's current mental distress was strongly influenced by his surgery experience in 2011 and ensuing pain, which significantly contributed to the current PTSD. Id. While she noted "it was possible that his experience was overlayed on pre-existing low-level PTSD due to the in-service stressor, his current mental health was extremely poor and overshadowed any prior symptoms." Id. As a result, it was not possible to conduct a valid assessment of symptoms related to the plane crash prior to the surgery given his current mental state. Id. The Board finds this opinion is valid, as the examiner provided a detailed rationale as to why she could not reach an opinion. See Jones v. Shinseki, 23 Vet. App. 382, 390-91 (2010). While the psychologist noted that it was "possible" that the Veteran's current mental distress was overlayed on pre-existing low-level PTSD due to an in-service stressor, this statement is also speculative in nature. The key word here is "possible," which is merely suggestive and, as such, is insufficient to establish a nexus. See, e.g., Obert v. Brown, 5 Vet. App. 30, 33 (medical opinion expressed in terms of "may" also implies "may or may not," and is too speculative to establish medical nexus). As this psychologist was unable to arrive at an opinion without resorting to speculation and provided adequate rationale for her inability to do so, this opinion will not be further discussed. See Bloom v. West, 12 Vet. App. 185 (1999) (holding that a medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty). The record contains no opinions in favor of the claim of entitlement to service connection for PTSD as due to an in-service stressor. As the only competent, probative opinion on the etiology of the Veteran's PTSD weighs against the claim on a direct basis, the claim fails on the nexus element. See December 2013 private psychological report. V. TDIU Under the applicable criteria, TDIU 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) (2014). In exceptional circumstances, where the veteran does not meet the aforementioned percentage requirements, a total rating may nonetheless be assigned upon a showing that the individual is unable to obtain or retain substantially gainful employment. 38 C.F.R. § 4.16(b) (2014). In this case, the Veteran does not meet the objective, minimum percentage requirements, set forth in 38 C.F.R. § 4.16(a), for award of a schedular TDIU, as service connection is in effect for tinnitus (rated as 10 percent disabling) and for bilateral hearing loss (rated as noncompensably disabling), for a combined rating of 10 percent. However, a total rating, on an extra-schedular basis, may nonetheless be granted, in exceptional cases, when the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. See 38 C.F.R. § 4.16(b) (2014). Hence, consideration of whether the Veteran is, in fact, unemployable, is still necessary in this case. 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 record reflects that the Veteran is unemployable. See July 2013 VA opinion (finding the Veteran unemployable due to pain from his hip replacement surgery). The above-noted facts clearly do not support a finding that the Veteran's service-connected disabilities-without consideration of his nonservice-connected disabilities, including those related to his hip surgery-are of sufficient severity to produce unemployability. As such, the requirements for TDIU simply are not met. Neither the record, nor the Veteran, has suggested that his bilateral hearing loss and tinnitus, individually or together, have caused his unemployability. For this reason, the claim for TDIU must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as no competent, probative evidence supports the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b) (West 2014); 38 C.F.R. § 3.102 (2014). (CONTINUED ON THE NEXT PAGE) ORDER Entitlement to compensation under 38 U.S.C. § 1151 for splintered/fractured left femur, bladder infection, and injury to the skin is denied. Entitlement to compensation for an acquired psychiatric disorder, to include a mood disorder, major depressive disorder, PTSD, and anxiety disorder NOS, as secondary to splintered/ fractured left femur, bladder infection, and injury to the skin is denied. Entitlement to service connection for PTSD is denied. Entitlement to TDIU, to include on an extra-schedular basis pursuant to 38 C.F.R. § 4.16(b), is denied. ____________________________________________ Donnie R. Hachey Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs