Citation Nr: 1626889 Decision Date: 07/06/16 Archive Date: 07/14/16 DOCKET NO. 07-38 371 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Providence, Rhode Island THE ISSUES 1. Whether new and material evidence has been received to reopen a claim of service connection for a back disability. 2. Entitlement to a disability rating greater than 50 percent for posttraumatic stress disorder (PTSD). 3. Entitlement to an initial rating greater than 10 percent for gastroesophageal reflux disease (GERD). 4. Entitlement to a total disability rating based on individual unemployability (TDIU) due exclusively to service-connected disabilities. REPRESENTATION Appellant represented by: John S. Berry, Attorney ATTORNEY FOR THE BOARD Michael T. Osborne, Counsel INTRODUCTION The Veteran had active service from August 1967 to March 1969, including in the Republic of Vietnam. This case has a long procedural history. It comes before the Board of Veterans' Appeals (Board) on appeal from a June 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Providence, Rhode Island, which denied, in pertinent part, the Veteran's claim of service connection for gastroesophageal reflux disease (GERD) (which was characterized as an esophageal condition) and also determined that new and material evidence had not been received to reopen a previously denied claim of service connection for a back disability. The Veteran disagreed with this decision in August 2009. He subsequently perfected a timely appeal. In November 2009, the Board remanded this matter to the Agency of Original Jurisdiction (AOJ) for additional development. A review of the claims file shows that there has been substantial compliance with the Board's remand directives. The Board directed that the AOJ attempt to obtain the Veteran's Social Security Administration (SSA) records. These records subsequently were associated with the Veteran's claims file. See Stegall v. West, 11 Vet. App. 268 (1998); see also Dyment v. West, 13 Vet. App. 141 (1999) (holding that another remand is not required under Stegall where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). This matter next is on appeal from a March 2010 rating decision in which the RO assigned, in pertinent part, a higher 50 percent rating effective July 20, 2009, for the Veteran's service-connected posttraumatic stress disorder (PTSD) and also denied a claim of service connection for GERD (which was characterized as GERD (also claimed as hiatal hernia and esophageal condition)). The Veteran disagreed with this decision in July 2010. He perfected a timely appeal in February 2011. In September 2011, the Board denied, in pertinent part, the Veteran's claims of service connection for a back disability and for an increased rating for PTSD. The Board also remanded the Veteran's claim of service connection for GERD (which was characterized as a gastrointestinal disability, to include irritable bowel syndrome and gastroesophageal reflux disease) to the AOJ for additional development. A review of the claims file shows that there has been substantial compliance with the Board's remand directives. The Board directed the AOJ to schedule the Veteran for appropriate VA examination to determine the nature and etiology of his GERD. The requested examination occurred and a copy of the examination report is included in the Veteran's claims file. See Stegall, 11 Vet. App. at 268; see also Dyment, 13 Vet. App. at 141, aff'd, 287 F.3d at 1377. Both the Veteran, through his attorney, and VA's Office of General Counsel, filed a Joint Motion for Remand ("Joint Motion") with the United States Court of Appeals for Veterans Claims ("Court") seeking a remand of the Board's September 2011 decision to the extent that the Board failed to adjudicate a reasonably raised claim of service connection for major depressive disorder in that decision. In March 2012, the Court granted the Joint Motion remanding the Board's September 2011 decision the extent that the Board failed to adjudicate a reasonably raised claim of service connection for major depressive disorder in that decision and otherwise dismissed the Veteran's appeal. Thus, the September 2011 Board decision is final with respect to the denial of the Veteran's claims of service connection for a back disability and for an increased rating for PTSD. See 38 U.S.C.A. §§ 7104, 7266 (West 2014); 38 C.F.R. § 20.1100 (2015). The Board does not have jurisdiction to consider a claim that has been adjudicated previously unless new and material evidence is presented. See Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). Therefore, the issue of whether new and material evidence has been received to reopen a claim of service connection for a back disability is as stated on the title page. Regardless of the RO's actions, the Board must make its own determination as to whether new and material evidence has been received to reopen this claim. That is, the Board has a jurisdictional responsibility to consider whether a claim should be reopened. See Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001). This matter next is on appeal from a January 2013 rating decision in which the RO denied, in pertinent part, the Veteran's claims for a disability rating greater than 50 percent for PTSD and entitlement to a total disability rating based on individual unemployability (TDIU) due exclusively to service-connected disabilities. The Veteran disagreed with this decision in March 2013. He perfected a timely appeal in February 2014 with respect to these claims. In February 2013, the Board remanded the Veteran's service connection claim for GERD to the AOJ for additional development. A review of the claims file shows that there has been substantial compliance with the Board's remand directives. The Board directed the AOJ to schedule the Veteran for another examination to determine the nature and etiology of his GERD. The requested examination occurred and a copy of the examination report is included in the Veteran's claims file. See Stegall, 11 Vet. App. at 268; see also Dyment, 13 Vet. App. at 141, aff'd, 287 F.3d at 1377. In October 2014, the Board granted, in pertinent part, the Veteran's claim of service connection for GERD, denied the Veteran's claim for a disability rating greater than 50 percent for PTSD, and remanded the Veteran's TDIU claim to the AOJ for additional development. A review of the claims file shows that there has been substantial compliance with the Board's remand directives. The Board directed the AOJ to schedule the Veteran for appropriate examination to determine the functional impact of his service-connected disabilities on his employability. The requested examination occurred in February 2015 and a copy of the examination report is included in the Veteran's claims file. Id. The Veteran did not appeal the Board's October 2014 decision to the Court so it is now final with respect to the denial of his increased rating claim for PTSD. In November 2014, the RO granted the Veteran's claim of service connection for GERD (which was characterized as GERD and gastritis (also claimed as a gastrointestinal condition to include diarrhea and colonic polyps)), assigning a 10 percent rating effective February 4, 2009. The Veteran disagreed with this decision in June 2015. He perfected a timely appeal in February 2016. This matter finally is on appeal from a May 2015 rating decision in which the RO denied the Veteran's claim for a disability rating greater than 50 percent for PTSD and determined that new and material evidence had not been received sufficient to reopen the Veteran's previously denied claim of service connection for a back disability. The Veteran disagreed with this decision in July 2015. He perfected a timely appeal in February 2016. Having reviewed the record evidence, the Board finds that the issues on appeal should be characterized as stated on the title page of this decision. This appeal was processed using the Virtual VA (VVA) and Virtual Benefits Management System (VBMS) paperless claims processing systems. Accordingly, any future consideration of this appellant's case should take into consideration the existence of these electronic records. FINDINGS OF FACT 1. In a decision dated on September 23, 2011, the Board denied, in pertinent part, the Veteran's claim of service connection for a back disability. 2. In an Order issued on April 3, 2012, the Court dismissed the Veteran's appeal of the Board's September 2011 denial of service connection for a back disability; thus, the September 2011 Board decision is final with respect to this claim. 3. The evidence received since September 2011 is either cumulative or redundant of evidence previously submitted in support of the Veteran's claim of service connection for a back disability and does not relate to an unestablished fact necessary to substantiate the claim. 4. The record evidence shows that the Veteran's service-connected PTSD is manifested by, at worst, poor sleep, mild panic symptoms, depression, flashbacks, nightmares, and irritability. 5. The record evidence shows that, prior to April 22, 2013, the Veteran's service-connected GERD symptoms were well controlled with daily medication. 6. The record evidence shows that, effective April 22, 2013, the Veteran's service-connected GERD is manifested by, at worst, pyrosis (heartburn), reflux, regurgitation, sleep disturbance which occurred 4 or more times per year and lasted for 1 to 9 days at a time, and mild nausea. 7. Service connection is in effect for PTSD, evaluated as 50 percent disabling effective July 20, 2009, bilateral hearing loss, evaluated as 20 percent disabling effective August 17, 2007, tinnitus, evaluated as 10 percent disabling effective August 25, 1995, and for GERD, evaluated as 10 percent disabling effective February 4, 2009. 8. The record evidence does not show that the Veteran is precluded from securing or following a substantially gainful occupation solely by reason of his service-connected disabilities. CONCLUSIONS OF LAW 1. The September 2011 Board decision, which denied the Veteran's claim of service connection for a back disability, is final. See 38 U.S.C.A. §§ 7104, 7266 (West 2014); 38 C.F.R. § 20.1100 (2015). 2. Evidence received since the September 2011 Board decision in support of the claim of service connection for a back disability is not new and material; accordingly, this claim is not reopened. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156 (2015). 3. The criteria for a disability rating greater than 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.130, Diagnostic Code (DC) 9411 (2015). 4. The criteria for an initial 30 percent rating effective April 22, 2013, for GERD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.114, DC 7307-7346 (2015). 5. The criteria for a TDIU due to service-connected disabilities have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.321, 4.16 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Before assessing the merits of the appeal, VA's duties under the Veterans Claims Assistance Act (VCAA) must be examined. The VCAA provides that VA shall apprise a claimant of the evidence necessary to substantiate his claim for benefits and that VA shall make reasonable efforts to assist a claimant in obtaining evidence unless no reasonable possibility exists that such assistance will aid in substantiating the claim. VA's duty to notify was satisfied by letters dated in September and November 2012 and in October 2014. See 38 U.S.C.A. §§ 5102, 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2015); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). The Veteran's higher initial rating claim for GERD is a "downstream" element of the AOJ's grant of service connection for this disability in the currently appealed rating decision. For such downstream issues, notice under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159 is not required in cases where such notice was afforded for the originating issue of service connection. See VAOPGCPREC 8-2003 (Dec. 22, 2003). Courts have held that once service connection is granted, the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d. 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). As will be explained below in greater detail, the evidence does not support reopening the Veteran's claim of service connection for a back disability. The evidence also does not support assigning an increased rating for the Veteran's service-connected PTSD or a higher initial rating for his service-connected GERD. The evidence finally does not support granting a TDIU. Because the Veteran was fully informed of the evidence needed to substantiate these claims, any failure of the AOJ to notify the Veteran under the VCAA cannot be considered prejudicial. Id. The Veteran also has had the opportunity to submit additional argument and evidence and to participate meaningfully in the adjudication process. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). With respect to the timing of the notice, the Board points out that the Court has held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim for VA benefits. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). Here, all relevant notice was issued prior to the currently appealed rating decisions; thus, this notice was timely. Because all of the Veteran's currently appealed claims are being denied in this decision, any question as to the appropriate disability rating or effective date is moot. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). And any defect in the notices provided to the Veteran and his attorney has not affected the fairness of the adjudication. See Mayfield, 444 F.3d at 1328. The Board also finds that VA has complied with the VCAA's duty to assist by aiding the Veteran in obtaining evidence and affording him the opportunity to give testimony before the AOJ and the Board although he declined to do so. It appears that all known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; the Veteran has not contended otherwise. Pursuant to the duty to assist, VA must obtain "records of relevant medical treatment or examination" at VA facilities. 38 U.S.C.A. § 5103A(c)(2). All records pertaining to the conditions at issue are presumptively relevant. See Moore v. Shinseki, 555 F.3d 1369, 1374 (Fed. Cir. 2009); Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). In addition, where the Veteran "sufficiently identifies" other VA medical records that he or she desires to be obtained, VA also must seek those records even if they do not appear potentially relevant based upon the available information. Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016) (citing 38 C.F.R. § 3.159(c)(3)). The Veteran's electronic paperless claims files in VVA and in VBMS have been reviewed. The Veteran's complete Social Security Administration (SSA) records also have been obtained and associated with the claims file. As to any duty to provide an examination and/or seek a medical opinion, the Board notes that in the case of a claim for disability compensation, the assistance provided to the claimant shall include providing a medical examination or obtaining a medical opinion when such examination or opinion is necessary to make a decision on the claim. An examination or opinion shall be treated as being necessary to make a decision on the claim if the evidence of record, taking into consideration all information and lay or medical evidence (including statements of the claimant) contains competent evidence that the claimant has a current disability, or persistent or recurring symptoms of disability; and indicates that the disability or symptoms may be associated with the claimant's active service; but does not contain sufficient medical evidence for VA to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). VA need not conduct an examination or obtain a medical opinion with respect to the issue of whether new and material evidence has been received to reopen a previously denied claim of entitlement to service connection because the duty under 38 C.F.R. § 3.159(c)(4) applies to a claim to reopen only if new and material evidence is presented or secured. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). As will be explained below in greater detail, because new and material evidence has not been received to reopen the Veteran's claim of service connection for a back disability, an examination is not required on this claim. The Veteran also has been provided with VA examinations which address the current nature and severity of his service-connected PTSD and GERD and the functional impact of his service-connected disabilities, alone or in combination, on his employability. Given that the pertinent medical history was noted by the examiners, these examination reports set forth detailed examination findings in a manner which allows for informed appellate review under applicable VA laws and regulations. Thus, the Board finds the examinations of record are adequate for rating purposes and additional examination is not necessary regarding the increased rating claim for PTSD, the higher initial rating claim for GERD, and the TDIU claim adjudicated in this decision. See also 38 C.F.R. §§ 3.326, 3.327, 4.2. In summary, VA has done everything reasonably possible to notify and to assist the Veteran and no further action is necessary to meet the requirements of the VCAA. New and Material Evidence Claim In September 2011, the Board denied, in pertinent part, the Veteran's claim of service connection for a back disability. A finally adjudicated claim is an action which has been allowed or disallowed by the agency of original jurisdiction, the action having become final by the expiration of one year after the date of notice of an award or disallowance, or by denial on appellate review, whichever is the earlier. 38 U.S.C.A. §§ 7104, 7105 (West 2014); 38 C.F.R. §§ 3.160(d), 20.302, 20.1103 (2015). As noted in the Introduction, although the Veteran initiated an appeal of the Board's September 2011 decision, the Court dismissed the appeal in April 2012 with respect to the Board's denial of service connection for a back disability. Accordingly, the Board's September 2011 decision became final with respect to this claim. The claim of service connection for a back disability may be reopened if new and material evidence is received. Manio v. Derwinski, 1 Vet. App. 140 (1991). The Veteran filed an application to reopen his previously denied service connection claim for a back disability on a VA Form 21-4138 which was date stamped as received electronically by VA on March 3, 2015. New and material evidence is defined by regulation. See 38 C.F.R. § 3.156(a) (2015). As relevant to this appeal, new evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with the previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. Id. In determining whether evidence is new and material, the credibility of the new evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). With respect to the Veteran's application to reopen a claim of service connection for a back disability, the evidence before VA at the time of the prior final Board decision in September 2011 consisted of his service treatment records and post-service VA and private outpatient treatment records and lay statements. The Board concluded that, although the record evidence (VA and private outpatient treatment records) demonstrated that the Veteran had experienced a back disability several decades after his service separation, it was not related to active service. Thus, the claim was denied. The newly received evidence includes additional VA outpatient treatment records and lay statements. The additional VA outpatient treatment records again show that the Veteran has complained of and been treated for a back disability in recent years. The Veteran's lay statements are to the effect that he currently experiences a back disability which is related to active service. With respect to the Veteran's application to reopen a claim of service connection for a back disability, the Board notes that the evidence which was of record in September 2011 did not show that the Veteran's current back disability could be attributable to active service. Despite the Veteran's assertions to the contrary, a review of the record evidence submitted since September 2011 still does not indicate that any current back disability could be related to active service. The newly received medical evidence and the Veteran's statements are cumulative and redundant of evidence previously considered by the Board. Moreover, the Veteran is not competent to testify as to etiology of his back disability as it requires medical expertise to diagnose. As noted elsewhere, the third prong of the McLendon test only requires "evidence" that indicates an association with service. See McLendon, 20 Vet. App. at 79. Although VA must consider the lay evidence and give it whatever weight it concludes the evidence is entitled to, a "conclusory, generalized lay statement" that an event or illness during service caused the claimant's current condition is insufficient to require the Secretary to provide an examination. See Waters, 601 F.3d at 1274. Thus, such evidence is insufficient to reopen the previously denied service connection claim for a back disability. The Board finally observes that, in Shade v. Shinseki, 24 Vet. App 110 (2010), the Court held that the phrase "raises a reasonable possibility of substantiating the claim" found in the post-VCAA version of 38 C.F.R. § 3.156(a) must be viewed as "enabling" reopening of a previously denied claim rather than "precluding" it. In this case, however, there is no reasonable possibility that the newly received evidence would enable rather than preclude reopening the Veteran's previously denied service connection claim for a back disability. Unlike in Shade, there is no evidence in this case - either previously considered in the September 2011 Board decision, which denied the Veteran's service connection claim for a back disability, or received since that decision became final - which demonstrates that this disability is related to active service or any incident of service. Thus, the analysis of new and material evidence claims that the Court discussed in Shade is not applicable to the Veteran's request to reopen his previously denied service connection claim for a back disability. In summary, as new and material evidence has not been received, the previously denied claim of service connection for a back disability is not reopened. PTSD and GERD Claims The Veteran contends that his service-connected PTSD is more disabling than currently evaluated. He also contends that his service-connected GERD is more disabling than initially evaluated. He specifically contends that he is entitled to a separate compensable disability rating for stricture or obstruction of the esophagus which is attributable to his service-connected GERD. Laws and Regulations In general, disability evaluations are assigned by applying a schedule of ratings that represent, as far as can be determined, the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria that must be met for specific ratings. The regulations require that, in evaluating a given disability, the disability be viewed in relation to its whole recorded history. 38 C.F.R. § 4.2; see Schafrath v. Derwinski, 1 Vet. App. 589 (1991). With respect to the Veteran's increased rating claim for PTSD, the Board notes that, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. See Francisco v. Brown, 7 Vet. App. 55 (1994). In Hart v. Mansfield, 21 Vet. App. 505 (2007), the Court held that "staged" ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The evidence of a factually ascertainable increase warranting a staged increased rating need not itself demonstrate that the scheduler criteria for an increased rating are met if additional later evidence otherwise satisfies the scheduler criteria. See Swain v. McDonald, 27 Vet. App. 219, 224-25 (2015). With respect to the Veteran's higher initial rating claim for GERD, the Board notes that, where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. Separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119 (1999). In Johnson, the Federal Circuit held that 38 C.F.R. § 3.321 required consideration of whether a Veteran is entitled to referral to the Director, Compensation Service, for consideration of the assignment of an extraschedular rating based on the impact of his or her service-connected disabilities, individually or collectively, on the Veteran's "average earning capacity impairment" due to such factors as marked interference with employment or frequent periods of hospitalization. See Johnson v. McDonald, 762 F.3d 1362 (2014); see also 38 C.F.R. § 3.321(b)(1). As is explained below in greater detail, following a review of the record evidence, the Board concludes that the symptomatology experienced by the Veteran as a result of his service-connected disabilities, individually or collectively, does not merit referral to the Director, Compensation Service, for consideration of the assignment of an extraschedular rating. In other words, the record evidence does not indicate that the Veteran's service-connected disabilities, individually or collectively, show marked interference with employment or frequent periods of hospitalization or otherwise indicate that the symptomatology associated with them is not contemplated within the relevant rating criteria found in the Rating Schedule. VA recently proposed amending 38 C.F.R. § 3.321(b)(1) to limit extraschedular consideration based on the impact of an individual service-connected disability. This proposed regulation is consistent with VA's longstanding practice of interpreting this regulation to provide an extraschedular rating for a single disability and not the combined effect of two or more disabilities. The proposed changes will clarify the regulation so that an extraschedular rating is available only for an individual service-connected disability but not for the combined effect of more than one service-connected disability. See 81 Fed. Reg. 23228-23232 (Apr. 20, 2016) to be codified at 38 C.F.R. § 3.321(b)(1). Until this proposed regulation becomes final, however, the requirement of extraschedular consideration for a Veteran's service-connected disabilities, individually or collectively, set out by the Federal Circuit in Johnson remains applicable. The Veteran's service-connected PTSD currently is evaluated as 50 percent disabling under 38 C.F.R. § 4.130, DC 9411. See 38 C.F.R. § 4.130, DC 9411 (2015). As relevant to this claim, a 50 percent rating is assigned under DC 9411 for PTSD manifested by 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 under DC 9411 for PTSD manifested by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, 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 the 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), or an inability to establish and maintain effective relationships. A 100 percent rating is assigned under DC 9411 for PTSD manifested by total occupational and social impairment due to such symptoms as gross impairment in thought process or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, and memory loss for names of close relatives, own occupation, or own name. Id. The Global Assessment of Functioning (GAF) is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. See Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing the Diagnostic and Statistical Manual of Mental Disorders (4th ed.1994). As relevant to this appeal, a GAF score of 51 to 60 is defined as indicating moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). See Carpenter v. Brown, 8 Vet. App. 240, 242-244 (1995). The Veteran's service-connected GERD is evaluated as 10 percent disabling effective February 4, 2009, by analogy to 38 C.F.R. § 4.114, DC 7307-7346 (hypertrophic gastritis-hiatal hernia). See 38 C.F.R. § 4.114, DC 7307-7346 (2015). A 10 percent rating is assigned under DC 7307 for chronic hypertrophic gastritis with small nodular lesions and symptoms. A higher 30 percent rating is assigned for chronic hypertrophic gastritis with multiple small eroded or ulcerated areas and symptoms. A maximum 60 percent rating is assigned under DC 7307 for chronic gastritis with severe hemorrhages or large ulcerated or eroded areas. See 38 C.F.R. § 4.114, DC 7307 (2015). A 10 percent rating is assigned under DC 7346 for hiatal hernia with 2 or more of the symptoms for a 30 percent rating of less severity. A 30 percent rating is assigned for a hiatal hernia with persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A maximum 60 percent rating is assigned for a hiatal hernia with symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia or other symptoms combinations productive of severe impairment of health. See 38 C.F.R. § 4.114, DC 7346 (2015). Factual Background and Analysis The Board finds that the preponderance of the evidence is against granting the Veteran's claim for a disability rating greater than 50 percent for PTSD. The Veteran contends that his service-connected PTSD is more disabling than currently evaluated. The record evidence does not support his assertions regarding an objective worsening of this disability. It shows instead that the Veteran's service-connected PTSD is manifested by, at worst, poor sleep, mild panic symptoms, depression, flashbacks, nightmares, and irritability throughout the appeal period. For example, on VA outpatient treatment in August 2009, the Veteran's complaints included continued poor sleep. Mental status examination of the Veteran showed he was slightly hyper with fast, fluent, and coherent speech, good eye contact, no tremors, goal-directed thought processes, thought content preoccupied with health issues, no gross abnormalities of concentration or memory, fair insight and judgment, full orientation, and no suicidal ideation. The Veteran's GAF score was 60, indicating moderate symptoms or moderate difficulty in social, occupational, or school functioning. The Axis I diagnoses included PTSD. On VA PTSD examination in September 2009, the Veteran's complaints included nightmares, flashbacks, self-isolation, mild panic symptoms, and depression. The Veteran stated that his relationship with his wife "is quite rocky. He reported that she is very critical of him." He had a good relationship with his mentally challenged sister who lived in his home with him and his wife. He reported good relationships with his adult children and his siblings. Mental status examination of the Veteran showed adequate hygiene, no evidence of mild psychomotor agitation, speech within normal limits, lucid and coherent thoughts, no obsessions or delusions, no evidence of any psychotic processes, no suicidal or homicidal ideation, no compulsions, ideas of reference, hallucinations, fears, hypomania, mania, or agoraphobia, no impairments in memory or concentration, and full orientation. The Veteran's GAF score was 55, indicating moderate symptoms. The Axis I diagnoses included chronic mild PTSD. On VA PTSD examination in May 2011, the Veteran's complaints included flashbacks, nightmares, being yelled at every day by his wife (from whom he was separated), and stress related to taking care of the property that he and his wife still owned following their separation. The Veteran still lived in the same house with his wife, an adult cousin, and an adult brother-in-law. He had good relationships with his adult siblings and children and grandchildren. Mental status examination of the Veteran showed no withdrawal or agitation, "no evidence of motor retardation or motor abnormalities," good eye contact, speech within normal limits, no auditory or visual hallucinations, full orientation, "no evidence of altered level of consciousness," unimpaired concentration, no obsessive thinking or compulsive behavior, no suicidal or homicidal ideation, no irritability or tearfulness, and no symptoms of mania or panic attacks. The Veteran's GAF score was 60. The Axis I diagnoses included chronic mild PTSD. On VA PTSD Disability Benefits Questionnaire (DBQ) in October 2012, no relevant complaints were noted. The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. The Veteran's PTSD symptoms were depressed mood, anxiety, chronic sleep impairment, impaired abstract thinking, and disturbances of motivation and mood. The VA examiner stated that the Veteran's service-connected PTSD resulted in 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. This examiner also stated that the Veteran's service-connected PTSD symptomatology "remain[s] at approximately the same level as was indicated" at his May 2011 VA examination. The Veteran's GAF score was 60. The Axis I diagnoses included PTSD. On VA PTSD DBQ in February 2015, the Veteran's complaints included excessive worry, avoidance of crowds, social withdrawal, irritability, and problems with sleep. The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. This examiner stated, "The Veteran's occupational and social impairment is primarily attributable to his PTSD." This examiner stated that, since the Veteran's October 2012 VA examination, he had lost his home due to foreclosure and had moved in to an apartment with his wife, a female cousin, and a friend of his deceased stepson who had custody of his 2 children every other weekend. "The Veteran is stressed by the crowded living conditions and angry at the bank for foreclosing on his house." His wife had multiple medical problems "and the couple argue frequently." He got along well with his cousin and the friend of his deceased stepson who was living with him. He also reported good relationships with his extended family. He remained unemployed. Mental status examination of the Veteran showed depressed mood, anxiety, chronic sleep impairment, impaired abstract thinking, and disturbances of motivation and mood. The VA examiner concluded, "The nature, frequency, and severity of the Veteran's psychiatric symptoms continue to meet the DSM criteria for PTSD...and remain at approximately the same level as was indicated" at his October 2012 VA examination. This examiner also concluded, "The Veteran's overall mental health functioning falls in the range of moderate to severe symptomatology as was indicated" at his October 2012 VA examination. This examiner further concluded that the Veteran's PTSD resulted in occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of an inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The diagnoses included PTSD. On VA PTSD DBQ in April 2015, the Veteran's complaints were unchanged. The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. Mental status examination of the Veteran was unchanged. The Veteran reported "positive relationships with his brothers, 2 of whom live nearby." The Veteran also reported that he was planning to move to Florida to be near the friend of his deceased stepson (whom he considered to be his "stepson") and relatives of this "stepson." There were no further changes noted on this examination. The diagnoses were unchanged. The Veteran has contended that his service-connected PTSD is more disabling than currently evaluated. The record evidence does not support his assertions. It shows instead that this disability is manifested by, at worst, complaints of poor sleep, mild panic symptoms, depression, flashbacks, nightmares, and irritability (as seen on VA examinations conducted during the pendency of this appeal). The Veteran's VA examinations also document the presence of a difficult and worsening relationship with his wife during the appeal period. VA examiners who saw the Veteran in May 2011, October 2012, and in February and April 2015 all documented that the Veteran's PTSD symptomatology essentially remained unchanged (and it appears that the Veteran may have been scheduled for his most recent VA PTSD DBQ in April 2015 in error, given that he had just been examined in February 2015 for the same disability). The Board acknowledges that, as the VA examiner stated in February 2015, "The Veteran's occupational and social impairment is primarily attributable to his PTSD." The Veteran's VA examiners in May 2011, October 2012, and in February and April 2015 all concluded that, at worst, the Veteran experienced "moderate to severe symptomatology" in occupational and social impairment. There is no indication that the Veteran's service-connected PTSD is manifested by at least occupational and social impairment with deficiencies in most areas or total occupational and social impairment (i.e., a 70 or 100 percent rating under DC 9411) such that an increased rating is warranted. See 38 C.F.R. § 4.130, DC 9411 (2015). The Board acknowledges in this regard that the Veteran has been unemployed throughout the appeal period. The VA examiner who saw him in February and April 2015 specifically found that it was less likely than not that the Veteran's PTSD symptoms would render him unemployable. The Veteran also has not identified or submitted any evidence, to include a medical nexus, demonstrating his entitlement to a disability rating greater than 50 percent for PTSD. Thus, the Board finds that the criteria for a disability rating greater than 50 percent for PTSD have not been met. The Board next finds that the preponderance of the evidence supports assigning an initial 30 percent rating effective April 22, 2013, for the Veteran's service-connected GERD. The Veteran contends that his service-connected GERD is more disabling than currently (and initially) evaluated. The record evidence does not support his assertions, at least prior to April 22, 2013. It shows instead that, prior to April 22, 2013 the Veteran's service-connected GERD symptoms were well controlled with the use of daily medication (omeprazole). For example, the Veteran's service treatment records show that his abdomen and viscera were normal clinically at his pre-induction (enlistment) physical examination in August 1967. These results were unchanged at his separation physical examination in March 1969. The post-service evidence also does not support assigning an initial rating greater than 10 percent prior to April 22, 2013, for the Veteran's service-connected GERD. For example, VA esophagogastroduodenoscopy (EGD) in August 1989 showed probable achalasia "given no evidence of intrinsic esophageal or gastric lesions to explain" the Veteran's dysphagia. "Also supporting the diagnosis is [the] absence of peristalsis seen on today's endoscopy as well as an abnormal barium swallow with a dilated upper esophagus with a distal stricture." The Veteran was hospitalized for 2 days in September 1989 for complaints of dysphagia, heartburn, 5 months of nausea/vomiting, and light food sticking. It was noted that prior dilatations had resulted in only transient improvement. Physical examination on admission showed a soft, non-tender abdomen with positive bowel sounds. The Veteran had a pneumatic dilatation of the esophagus which showed some retained barium but improved from a prior study and no perforations. He tolerated a regular diet well while hospitalized. The diagnosis was achalasia. The Board notes here that achalasia is defined as failure to relax of the smooth muscle fibers of the gastrointestinal tract at any point of junction of one part with another, specifically, failure of the esophagogastric sphincter to relax with swallowing, due to degeneration of ganglion cells in the wall of the organ. See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 15 (30th ed. 2003). VA barium swallow while hospitalized in September 1989 showed tapering of the distal esophagus with proximal dilatation and poor peristalsis which was consistent with achalasia. On VA outpatient treatment later that same month, the Veteran complained of transient dysphagia. A recent diagnosis of achalasia was noted. Physical examination showed a soft, non-tender abdomen with positive bowel sounds. The impression was improving achalasia with continued mild dysphagia. The Veteran was advised to undergo a repeat barium swallow. A repeat VA barium swallow in October 1989 showed "some holdup at the distal esophagus but it does pass through and appears to be [a] fairly patent opening of fairly good diameter." On VA outpatient treatment in February 1990, the Veteran stated that he "feels that food gets transiently hung up but is able to swallow and denies [weight loss]." He also stated that his "heartburn improved on Tagamet." Physical examination showed a soft, non-tender abdomen with positive bowel sounds. The impression was stable achalasia. In May 1990, the Veteran's complaints included continued mild dysphagia "but he can swallow and has been gaining weight." He also complained of heartburn at night. He denied any nausea or vomiting. Physical examination showed a soft, non-tender abdomen with positive bowel sounds. The impressions were achalasia and questionable GERD because it was unusual with achalasia. The Veteran was advised to take Tagamet 300 mg four times a day. In December 1990, the Veteran's complaints included intermittent dysphagia (which he described as a "choking sensation") and heartburn. He denied any weight loss, nausea, vomiting, or anorexia. Physical examination showed he was obese with a soft, non-tender abdomen and positive bowel sounds. The impressions included achalasia with increased symptoms and a question as to their cause. The Veteran was advised to increase his Tagamet to four times a day. In January 1991, it was noted that, although the Veteran had complained of increased heartburn and dysphagia, once he increased his Tagamet from twice a day to four times a day, he had been doing "very well" with no heartburn or dysphagia. He denied any nausea, vomiting, or melena. He was eating everything without difficulty. Physical examination showed a soft, non-tender abdomen with positive bowel sounds. The impressions included achalasia which was doing better on increased Tagamet. In September 1991, the Veteran complained of occasional heartburn. Physical examination showed a soft, non-tender abdomen with positive bowel sounds. The impression was achalasia with no apparent difficulty swallowing at this time. In August 1992, no relevant complaints were noted. A history of chronic gastritis and achalasia was noted. The Veteran was able to swallow solids and liquids "without difficulty." He also was "doing well on Tagamet syrup." The impression was stable achalasia cardia. On a visit to establish care at a new VA outpatient clinic in January 1995, the Veteran's only complaint was his GERD. He reported a history of stomach problems and heartburn "for years." He treated his GERD with liquid Tagamet. The assessment included GERD which was quiescent. The Veteran was advised to continue taking Tagamet. In April 1996, the Veteran's complaints included a minimal amount of heartburn. A history of GERD and achalasia was noted. The assessment included GERD and achalasia which was stable. The Veteran was advised to continue taking Tagamet. In September 1996, the Veteran's complaints included occasional heartburn. A history of achalasia and GERD was noted. The assessment included achalasia and GERD which was stable. On VA outpatient treatment in December 2008, it was noted that the Veteran's GERD was stable. The assessment included dyspepsia. The VA clinician stated that the Veteran previously had been referred to the gastrointestinal clinic "where he utterly refused [an] EGD." VA EGD in January 2009 showed a normal hypopharynx, esophagus, gastroesophageal junction, pylorus, and duodenum, and moderate erythema in the stomach. On VA outpatient treatment in February 2009, the Veteran complained of continued epigastric burning. He rated his pain as 3/10 on a pain scale (with 1/10 being the least pain). He stopped taking all medications 3 days earlier because he was not getting better "and has noted no difference." He had diarrhea 3 times the day before his outpatient treatment visit. Physical examination showed a soft, non-tender abdomen with positive bowel sounds and mild epigastric tenderness without rebound. The assessment included persistent dyspepsia previously associated with diarrhea and vomiting with questionable gastroenteritis slowly resolving. In May 2009, the Veteran was seen in the emergency room (ER) at a VA Medical Center complaining of epigastric abdominal pain. He rated his pain as 10/10 on a pain scale (or the worst imaginable pain). It was associated with nausea. A history of GERD was noted. Physical examination of the abdomen showed soft bowel sounds, distended, guarding rebound, epigastric tenderness. The final diagnosis was questionable gastritis. A different ER physician noted in an addendum that the Veteran had experienced significant relief with Mylanta, lidocaine, morphine, and Protonix. This ER physician stated that, although the etiology of the Veteran's abdominal pain was unclear, he suspected it was due to peptic ulcer disease and gastritis. On VA esophageal conditions DBQ in October 2011, the Veteran's complaints included infrequent episodes of epigastric distress, pyrosis (heartburn), and sleep disturbance caused by esophageal reflux which occurred 4 or more times per year and lasted for 1 day or less at a time. The Veteran took omeprazole 20 mg every morning to treat his GERD. He also experienced mild esophageal stricture symptoms, most of which disappeared after endoscopic surgery. The VA examiner stated that the Veteran had a well-documented history of hiatal hernia/GERD/esophageal strictures. This examiner also noted that the Veteran's esophageal strictures resolved following surgery with mesh placement several years after service separation. The diagnoses included GERD, hiatal hernia, and esophageal stricture. On VA esophageal conditions DBQ in October 2012, the Veteran's complaints included occasional reflux "but symptoms are well controlled on omeprazole." The VA examiner stated, "[The Veteran] has not had dysphagia in several years and no esophageal dilatations in over 20 years." The Veteran took omeprazole 20 mg every day to treat his GERD. He experienced no esophageal stricture. A 2009 biopsy was reviewed and showed chronic gastritis. The VA examiner concluded, "This Veteran has GERD and chronic gastritis, which is well controlled by medication and diet." The diagnoses were GERD and chronic gastritis. The Veteran contends that his service-connected GERD is more disabling than currently evaluated. The record evidence does not support his assertions regarding an objective worsening of the symptomatology associated with his service-connected GERD, at least prior to April 22, 2013. It shows instead that the symptoms associated with the Veteran's service-connected GERD were well controlled with daily medication (as the VA examiner noted in October 2012). The Board acknowledges that the Veteran initially experienced gastrointestinal symptoms (which were diagnosed as achalasia) beginning in the late 1980s and early 1990s. These symptoms appear to have been relieved with an esophageal dilatation in 1989 (as subsequent VA clinicians noted in the Veteran's medical records). The Veteran's GERD was noted to be stable on VA outpatient treatment in December 2008. Although he subsequently reported to the ER in April 2009 complaining of severe epigastric abdominal pain, the ER physicians who treated him suspected that this was due to (non-service-connected) peptic ulcer disease and gastritis and the etiology of his complaints ultimately was unclear. Critically, the October 2012 VA examiner also found that the Veteran controlled his GERD and chronic gastritis with medication (daily omeprazole) and diet. The evidence does not suggest that, prior to April 22, 2013, the Veteran's service-connected GERD was manifested by at least persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain or symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia or other symptoms productive of considerable or severe health impairment (i.e., a 30 or 60 percent rating under DC 7346) such that an initial rating greater than 10 percent is warranted for this time period. See 38 C.F.R. § 4.114, DC 7307-7346 (2015). The Veteran also has not identified or submitted any evidence, to include a medical nexus, demonstrating his entitlement to an initial rating greater than 10 percent prior to April 22, 2013, for GERD. Thus, the Board finds that the criteria for an initial rating greater than 10 percent prior to April 22, 2013, for GERD have not been met. In contrast, the Board finds that the Veteran is entitled to an initial 30 percent rating effective April 22, 2013, for his service-connected GERD. The record evidence shows that, on VA esophageal conditions DBQ on April 22, 2013, the Veteran's complaints included an "upset stomach" and heartburn since active service. The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. The Veteran took omeprazole 20 mg twice daily to treat his GERD. The Veteran experienced pyrosis (heartburn), reflux, regurgitation, sleep disturbance which occurred 4 or more times per year and lasted for 1 to 9 days at a time, and mild nausea as a result of his GERD. His esophageal stricture was asymptomatic. The diagnoses were GERD, hiatal hernia, esophageal stricture, and chronic gastritis. On VA esophageal conditions DBQ in January 2015, the Veteran complained that, although omeprazole controlled his overall GERD symptoms, he had to take TUMS "to control 'breakthrough symptoms'" after eating certain foods, a heavy meal, or eating dinner later than normal. The Veteran experienced dysphagia, reflux, regurgitation, substernal pain, sleep disturbance which occurred 4 or more times per year and lasted for 1 to 9 days at a time, and nausea which occurred 1 time per year and lasted for 1 to 9 days at a time. His esophageal stricture was asymptomatic. Physical examination of the abdomen showed it was soft, non-tender, with no masses or discrete masses. The diagnoses were GERD, hiatal hernia, and esophageal stricture. The Veteran contends that his service-connected GERD has worsened. The record evidence supports these assertions, at least effective April 22, 2013, because it clearly shows that the symptomatology associated with the Veteran's service-connected GERD worsened effective on that date. VA examination on April 22, 2013, showed the presence of multiple symptoms, including pyrosis (heartburn), reflux, regurgitation, sleep disturbance which occurred 4 or more times per year and lasted for 1 to 9 days at a time, and mild nausea, which were attributable to his service-connected GERD although his esophageal stricture was asymptomatic. The findings of worsening symptoms attributable to the Veteran's service-connected GERD on VA examination in April 2013 also are supported by similar findings on subsequent VA examination in January 2015. The latter examination indicates that the Veteran experienced what he labeled "breakthrough symptoms" of GERD which were not treated by his daily omeprazole and required him to take additional medication (TUMS). That examination also documented the presence of dysphagia, reflux, regurgitation, substernal pain, sleep disturbance which occurred 4 or more times per year and lasted for 1 to 9 days at a time, and nausea which occurred 1 time per year and lasted for 1 to 9 days at a time as a result of the Veteran's service-connected GERD. In other words, the disability picture presented by the Veteran's service-connected GERD is more consistent with the assignment of an initial 30 percent rating effective April 22, 2013. Id. The evidence does not indicate, however, that the Veteran experienced symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia or other symptom combinations productive of severe health impairment (i.e., a 60 percent rating under DC 7347) such that an initial rating greater than 30 percent is warranted effective April 22, 2013, for the Veteran's service-connected GERD. Id. In summary, and after resolving any reasonable doubt in the Veteran's favor, the Board finds that the evidence supports assigning an initial 30 percent rating effective April 22, 2013, for the Veteran's service-connected GERD. Extraschedular The Board must consider whether the Veteran is entitled to consideration for referral for the assignment of extraschedular ratings for his service-connected PTSD or for his service-connected GERD. 38 C.F.R. § 3.321; Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the Veteran or reasonably raised by the record). An extraschedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. Floyd v. Brown, 9 Vet. App. 88, 94 (1996). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. The Board finds that schedular evaluations assigned for the Veteran's service-connected PTSD and for his service-connected GERD are not inadequate in this case. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of each of these service-connected disabilities during the time periods at issue in this appeal. This is especially true because the 50 percent rating currently assigned for the Veteran's PTSD effective July 20, 2009, contemplates moderately severe disability. This is also true because the higher initial 30 percent rating assigned effective April 22, 2013, for the Veteran's GERD in this decision (as discussed above) reflects the worsening symptomatology attributed to this disability as of that date. Moreover, the evidence does not demonstrate other related factors such as marked interference with employment and frequent hospitalization. The VA examiner specifically found in February 2015 that it was less likely than not that the Veteran's service-connected PTSD symptoms would interfere with his employability. The Veteran has reported that, prior to his retirement, his service-connected GERD interfered with his job as a chauffeur because he had to take frequent breaks and was not focused. He also has reported that he was forced to retire from his former job as a chauffeur due to (non-service-connected) back problems. The Board acknowledges that the Veteran was hospitalized briefly in September 1989 for an esophageal dilatation. It does not appear that he has been hospitalized for treatment of his service-connected GERD since his 1989 esophageal dilatation. The record evidence does not indicate that the symptomatology associated with the Veteran's service-connected PTSD and GERD is not contemplated within the relevant rating criteria found in the Rating Schedule such that consideration of extraschedular ratings for either of these disabilities is warranted under Johnson. In light of the above, the Board finds that the criteria for submission for assignment of extraschedular ratings pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). TDIU The Veteran contends that he is entitled to a TDIU. He specifically contends that he was forced to retire from his former job as a chauffeur because of non-service-connected back problems. Laws and Regulations The schedular rating criteria are designed to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] 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." 38 C.F.R. § 4.1. A Veteran may be awarded a TDIU upon a showing that he is unable to secure or follow a substantially gainful occupation due solely to impairment resulting from his service-connected disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16 (2015). A total disability rating may be assigned where the schedular rating is less than total when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, or if there are two or more disabilities, there shall be at least one ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). Consideration may be given to a Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or the impairment caused by any non-service-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19 (2015). The term "unemployability," as used in VA regulations governing total disability ratings, is synonymous with an inability to secure and follow a substantially gainful occupation. See VAOPGCPREC 75-91 (Dec. 17, 1991). The issue is whether the Veteran's service-connected disability or disabilities preclude him from engaging in substantially gainful employment (i.e., work which is more than marginal, that permits the individual to earn a "living wage"). See Moore v. Derwinski, 1 Vet. App. 356 (1991). In a claim for TDIU, the Board may not reject the claim without producing evidence, as distinguished from mere conjecture, that the Veteran's service-connected disability or disabilities do not prevent him from performing work that would produce sufficient income to be other than marginal. Friscia v. Brown, 7 Vet. App. 294 (1995), citing Beaty v. Brown, 6 Vet. App. 532, 537 (1994). In determining whether the Veteran is entitled to a TDIU, neither his nonservice-connected disabilities nor his age may be considered. Van Hoose v. Brown, 4 Vet. App. 361 (1993). The Court has held that the central inquiry in determining whether a Veteran is entitled to a total rating based on individual unemployability is whether service-connected disabilities alone are of sufficient severity to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524 (1993). The test of individual unemployability is whether the Veteran, as a result of his service-connected disabilities alone, is unable to secure or follow any form of substantially gainful occupation which is consistent with his education and occupational experience. 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.16. Analysis The Board finds that the preponderance of the evidence is against granting the Veteran's claim of entitlement to a TDIU due exclusively to service-connected disabilities. The Veteran essentially contends that his service-connected disabilities preclude his employability. The record evidence does not support his assertions. It shows instead that the Veteran left his prior employment due to a combination of non-service-connected back and lower leg disabilities and he is not precluded from securing or following a substantially gainful occupation solely by reason of his service-connected disabilities. A review of the record evidence shows that the Veteran currently meets the scheduler criteria for a TDIU. See 38 C.F.R. § 4.16(a) (2015). Service connection is in effect for PTSD, evaluated as 50 percent disabling effective July 20, 2009, bilateral hearing loss, evaluated as 20 percent disabling effective August 17, 2007, tinnitus, evaluated as 10 percent disabling effective August 25, 1995, and for GERD, evaluated as 10 percent disabling effective February 4, 2009. As discussed above, the Board has assigned a higher initial 30 percent rating effective April 22, 2013, for the Veteran's service-connected GERD. The Veteran's current combined disability evaluation for compensation is 70 percent effective July 20, 2009 (and is likely to increase once the AOJ implements the Board's grant of a higher initial 30 percent rating effective April 22, 2013, for his service-connected GERD). See 38 C.F.R. § 4.25 (2015). The Board observes that, following the Board's October 2014 remand, in November 2015, the AOJ attempted to obtain the Veteran's employment history from him and his attorney. The Veteran and his attorney were advised by the AOJ in the November 2015 correspondence that it ultimately was the Veteran's responsibility to see that VA receive a completed VA Form 21-8940 and his employment records from his former employer and other information to support his TDIU claim. To date, neither the Veteran nor his attorney has responded. The Board notes in this regard that the Court has held that "[t]he duty to assist is not always a one-way street. If a Veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence." See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). It is not clear why neither the Veteran nor his attorney responded to VA's November 2015 request for assistance in supporting his TDIU claim by completing a VA Form 21-8940 and providing information regarding his employment history. Given the Veteran's failure to respond to this request, the Board notes that there is only limited evidence concerning the Veteran's employment history. The Board also notes that it cannot reject the Veteran's TDIU claim by relying on conjecture concerning his employment status (i.e., that he may be employed currently) rather than evidence or information concerning his current employment status and the impact, if any, of his service-connected disabilities on any current employment. See Friscia, 7 Vet. App. at 294 (citation omitted). Nevertheless, the Board finds that the medical evidence of record does not support granting a TDIU due exclusively to service-connected disabilities. Multiple VA examiners who have seen the Veteran for VA adjudication purposes during the pendency of this appeal have found that his service-connected disabilities do not preclude his employability. For example, following VA PTSD examination in September 2009, the VA examiner opined that "the Veteran's [PTSD] symptoms exert a moderate impact on his social and occupational functioning." Similarly, following VA PTSD examination in May 2011, a different VA examiner opined that the Veteran's service-connected PTSD symptomatology had only a "moderate negative impact on his ability to obtain and maintain physical or sedentary employment." Following VA esophageal conditions DBQ in October 2011, another VA examiner opined that the Veteran's service-connected GERD did not interfere with his employability. The rationale for this opinion was that the Veteran reported previously that he had worked as a limo driver and had stopped working because of a non-service-connected back condition. The VA examiner who conducted the Veteran's VA PTSD DBQ in October 2012 echoed the prior findings regarding the Veteran's service-connected PTSD symptoms having only a moderate impact on his occupational functioning. The October 2012 VA PTSD DBQ examiner also concluded that it was less likely than not that the Veteran's service-connected PTSD would render him unable to secure and maintain substantially gainful employment. Following VA hearing loss and tinnitus DBQ in January 2015, the VA audiologist stated: Audiology Compensation and Pension test results from today show Veteran to have a hearing loss which poses challenges for him to hear and understand normal conversational level speech. Veteran has been fit with hearing aids which he has been unable to procure from moving boxes since a move in May of 2014. With use of these aids, the Veteran is expected to understand speech better than without them, especially with the assistance of visual and contextual cues. The Americans with Disabilities Act (ADA) has provisions that a person not be discriminated against on the basis of disability. In terms of hearing, under the ADA an employer would make reasonable accommodations as necessary to facilitate communication, provide for a safe work environment, etc. Vocational Rehabilitation offers counseling and other services to assist people in securing employment, including deaf and hard-of-hearing individuals. Veteran would be expected to have significant difficulty hearing even with his hearing aids in adverse listening environments (i.e., background noise, on the telephone). However, with binaural amplification, use of visual and contextual cues, and ADA accommodations as appropriate, the Veteran would be expected to be able to obtain and/or maintain gainful employment and to be employable in a physical or sedentary capacity in non-adverse listening environments (not considering any other disabilities). The Board finds it highly significant that, on VA PTSD DBQ in February 2015, the Veteran himself reported that "his chronic back and leg pain, as well as recent numbness in his arm, prevent him from working." This persuasively suggests that the Veteran attributes his unemployability to non-service-connected orthopedic disabilities and not to his service-connected disabilities. The February 2015 VA examiner also noted that the Veteran's VA treating psychiatrist reviewed the Veteran's multiple medical problems, to include his non-service-connected disabilities, and concluded that he was unable to work. The Board again notes that non-service-connected disabilities are not considered in determining entitlement to a TDIU. See Van Hoose, 4 Vet. App. at 361. All of the VA examiner's opinions of record are to the effect that the Veteran is not precluded from securing or maintaining substantially gainful employment solely as a result of his service-connected disabilities. All of these opinions were fully supported. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (finding that a medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). The Veteran also has not identified or submitted any evidence, to include a medical nexus, which demonstrates his entitlement to a TDIU. In summary, the Board finds that the evidence does not support granting a TDIU due exclusively to the Veteran's service-connected disabilities. ORDER As new and material evidence has not been received, the previously denied claim of service connection for a back disability is not reopened. Entitlement to a disability rating greater than 50 percent for PTSD is denied. Entitlement to an initial 30 percent rating effective April 22, 2013, for GERD is granted, subject to the law and regulations governing the payment of monetary benefits. Entitlement to a TDIU due exclusively to service-connected disabilities is denied. ____________________________________________ WAYNE M. BRAEUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs