Citation Nr: 1723682 Decision Date: 06/22/17 Archive Date: 06/29/17 DOCKET NO. 08-30 036 ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD), prior to April 5, 2011. 2. Entitlement to a rating in excess of 50 percent for PTSD from April 5, 2011. 3. Entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU) prior to October 21, 2015. 4. Entitlement to a TDIU from October 21, 2015. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD G. E. Wilkerson, Counsel INTRODUCTION The Veteran served on active duty from June 1969 to June 1973. These matters initially came before the Board of Veterans' Appeals (Board) on appeal of an October 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office in Washington, D.C. Jurisdiction was subsequently transferred to the RO in Huntington, West Virginia. During the course of the Veteran's appeal, the RO assigned an increased 50 percent rating for PTSD, effective April 5, 2011. As higher ratings for the disability are available prior to and from this date, the appeal continues. See AB v. Brown, 6 Vet. App. 35 (1993) (where a claimant has filed a notice of disagreement as to an RO decision assigning a particular rating, a subsequent RO decision assigning a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal). In May 2012, the Board issued a decision denying the claims for increased rating for nephropathy, right upper extremity peripheral neuropathy, left upper extremity peripheral neuropathy, right lower extremity peripheral neuropathy, and left lower extremity peripheral neuropathy. The Board also determined that the matter of entitlement to a TDIU had been raised by the record, and remanded the matter, along with the claim for increased initial rating for PTSD to the Agency of Original Jurisdiction (AOJ) for additional development. The case has since returned to the Board for the purpose of appellate disposition. Pursuant to the Board's remand request, the Veteran was asked to submit authorization to obtain any outstanding records, to include records of treatment from the Vet Center, and was afforded VA examinations to determine the nature and severity of his service-connected disabilities and their impact on his employability. For the foregoing reasons, the AOJ has complied with the Board's remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board acknowledges that the Veteran has been awarded a combined 100 percent rating since October 21, 2015; however, this matter remains on appeal for the entire appeal period. In Bradley v. Peake, 22 Vet. App. 280, 294 (2008), the Court determined that a separate TDIU rating predicated on one disability (although perhaps not ratable at the schedular 100 percent level) when considered together with another disability separately rated at 60 percent or more could warrant special monthly compensation under 38 U.S.C.A. § 1114(s). Thus, the Court reasoned, it might benefit the Veteran to retain the TDIU rating, even where a 100 percent schedular rating has also been granted. Accordingly, the Board will address whether entitlement to a TDIU is warranted for both periods, and the matter has been characterized as noted on the title page. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran's PTSD has been productive of occupational and social impairment, with deficiencies in most areas, due to such symptoms as unprovoked irritability, continuous anxiety, and suicidal thoughts. 2. Prior to October 21, 2015, the Veteran's service-connected disabilities did not render him unable to obtain and retain substantially gainful employment. 3. From October 21, 2015, as a 100 percent combined schedular rating has been assigned, the matter of entitlement to a TDIU rating is rendered moot. CONCLUSIONS OF LAW 1. The criteria for an initial 70 percent rating for PTSD prior to April 5, 2011 are met. 38 U.S.C.A. §§ 1155, 5107, 5110(b) (West 2014); 38 C.F.R. §§ 3.102, 3.400, 4.7, 4.130, Diagnostic Code 9411 (2016). 2. The criteria for an initial 70 percent rating for PTSD from April 5, 2011 are met. 38 U.S.C.A. §§ 1155, 5107, 5110(b) (West 2014); 38 C.F.R. §§ 3.102, 3.400, 4.7, 4.130, Diagnostic Code 9411 (2016). 3. The criteria for entitlement to a TDIU prior to October 21, 2015, have not been met. 38 U.S.C.A. § 1155 5107(b) (West 2014); 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.15, 4.16, 4.19 (2016). 4. The claim for a TDIU from October 21, 2015, is dismissed. 38 C.F.R. § 4.16(a) (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Increased Rating for PTSD The Veteran contends that he is entitled to an increased rating for his service-connected PTSD. Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). The Court has held that "staged" ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App 119 (1999). In this case, staged ratings for the Veteran's psychiatric disability on appeal have already been assigned. The Board will accordingly discuss the propriety of the rating assigned at each stage. The Veteran's PTSD is rated as 30 and 50 percent disabling pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. That diagnostic code provides that PTSD should be rated under the General Rating Formula for evaluating psychiatric disabilities other than eating disorders. Under the general formula, a 50 percent rating is assigned for 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; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives, own occupation, or own name. The symptoms listed in the rating schedule are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed.Cir. 2013) the Federal Circuit stated that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." It was further noted that "§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." To the extent that the medical evidence reflects diagnoses of other psychiatric disorders, where it is not possible to distinguish the effects of nonservice-connected conditions from those of a service-connected condition, the reasonable doubt doctrine dictates that all symptoms be attributed to the Veteran's service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). On March 2007 treatment, the Veteran reported that he experienced nightmares about his Vietnam experiences for over 30 years and got very little sleep at night. He reported feeling constant anxiety about any and all things in his life. He experienced emotional withdrawal, interpersonal distancing and social withdrawal. He had short-term memory impairment. Thought processes were within normal limits. Insight and judgment were good. Mood was anxious and depressed with periods of crying. The Veteran indicated that he experienced flashbacks, was avoidant, was easily irritated, socially alienated, and easily started. He had low energy. He stated that he sometimes had suicidal ideation. A GAF score of 55 was assigned. VA treatment records reflect that the Veteran presented for initial PTSD assessment in May 2007. He indicated that he frequently awoke at night with nightmares of dead or dying comrades and their physical injuries. He was hypervigilant, arising during the night to look up and down the street. He awoke early after 3 hours of sleep and could not return to sleep. He denied suicidal ideation, plan, or intent. On mental status examination, he was alert and oriented with good attention, judgment, and insight. Memory was intact. He had combat-related hallucinations. A diagnosis of PTSD, insomnia, and depression was noted, along with a GAF score of 50. On VA psychiatric examination in August 2007, the Veteran reported that he began going to a PTSD group at the Vet Center in 1998 due to symptoms of irritability, insomnia, and nightmares. He began seeing a psychiatrist in April 2007, and was prescribed Citalopram and Trazadone. Even with medication, he went to sleep around 1 a.m. and was up again around 3 a.m. The Veteran offered subjective complaints of irritability, anger, social avoidance, few friends, and poor sleep. With respect to work, the Veteran reported that he was angry with his coworkers and they irritated him. He also reported that he had many health problems, including swelling in the hands and feet, and that he had difficulty kneeling and rising. He had not worked since September 2005 and was retired with the D.C. government after 29 years of service. He served as a carpentry/roofing supervisor. The Veteran described his relationships with his wife and children as good. He spent a lot of time with his grandchildren and saw them almost daily. He did not have close friends of his own and spent most of his time with his grandchildren. He went to church, fixed things around the house, cooked, and went to his brother's house. He also traveled with his wife on senior trips. On mental status examination, there was no impairment of thought process or communication. The Veteran described delusions in that he saw bodies lying on the street that seemed real, but nothing was there. He reported fleeting suicidal thoughts once per month, but denied intent. He was oriented to person, place and time. He had short-term memory impairment. There was no obsessive or ritualistic behavior. He had panic attacks that occurred every few months, with night sweats. He reported that he felt "blue" since he stopped drinking, and it was hard for him to "get motivated." He also noted that it was hard from him to deal with his knee and health issues. He was also not sleeping enough. He denied any recent incidents of impaired impulse control. A psychiatric assessment revealed symptoms of intrusive thoughts, flashbacks, dreams, avoidance, detachment, hypervigilance, startle response, depressed mood, insomnia, anergia, and memory impairment. The severity of these symptoms was moderate. The examiner diagnosed PTSD and comorbid depressive disorder not otherwise specified and noted that the disability caused moderate effects on employment and relationships, but did not affect activities of daily living or routine responsibilities. The Veteran reported that he had work difficulties partially due to anger and irritability, and partially due to medical concerns. He engaged in limited social activity outside of his family. A GAF score of 46 was assigned. The examiner noted that the Veteran was not unemployable, though his difficulty getting along with others did contribute to his retirement decision. A September 2009 VA psychology not reflects that the Veteran still had difficulty sleeping, and that the pain from his knee kept him up at night. He reported that he lived with his wife and took care of his grandchildren on the weekend. On mental status examination, speech was logical and coherent and of normal rate and rhythm. He was oriented to person, place, and time. Concentration was impaired and short term memory was moderately impaired. Thought processes were within normal limits. Insight and judgment were fair. Interpersonal distancing was noted. He had trouble falling asleep, frequent waking with an inability to return to sleep, and had nightmares and nightsweats. Anergia was present and anxiety was moderate. He was described as volatile. Affect was appropriate and mood was depressed. He was diagnosed with PTSD and depression and a GAF score of 55 was assigned. On VA examination in April 2011, the Veteran reported that he had seen a VA psychiatrist a few times and had been prescribed Citalopram and Trazadone. The examiner noted that VA treatment records showed that he had not been seen by the psychiatrist since September 2009 but received medications through his primary care provider. He had been going to a PTSD group at the Vet Center once per week. He indicated that he continued to have the same problems: nightmares, night sweats, difficulty sleeping, and seeing images of dead people in his dreams. He still had images pop into his head while driving. He did not like to socialize with others. He indicated that the groups at the Vet Center helped, but overall, he felt like his symptoms had stayed the same. He stated that his wife was occasionally able to get him to leave his home. With respect to relationships, the Veteran reported that his relationship with his wife was fair though they constantly fought. He stated that he did not have any patience and everything irritated him. His relationship with his children was described as good. He kept in touch with his daughters and his grandchildren but did not want to deal with people other than that. He reported that he traveled once in awhile, but mostly stayed in his basement watching television or finding odds and ends to do in the yard. He got into arguments in stores with people who were not doing their jobs. On mental status examination, the Veteran presented as casually and neatly dressed and well-groomed. He was alert and oriented. There was no impairment of thought process or communication. He stated he saw dead bodies in front of him, and he heard the sound of mortars almost daily. He stated that with respect to suicidal/homicidal thoughts, he got annoyed with people and had "serious thoughts" about hurting them but did not think it was worth it. He stated that his short-term memory had gotten worse over the last few years. Obsessive or ritualistic behavior which interfered with routine activities was not present. Speech was normal and there were no panic attacks present. The Veteran indicated that he was angry all of the time and did not feel like being bothered by anyone. He had no energy or motivation to do anything. He had impaired impulse control and sleep impairment. The examiner commented that the Veteran's symptoms were chronic and continuous, and moderate in severity. The disability had mild impact on routine responsibilities, family role, and physical health. There was moderate impact on relationships, leisure activities and quality of life. The examiner diagnosed PTSD and assigned a GAF score of 54. On VA mental health treatment in April 2011, the Veteran presented with complaint of depressed mood, sleep disturbances, social withdrawal, decreased appetite, anergia, and anhedonia. Other symptoms included flashbacks, nightmares, decreased frustration tolerance, exaggerated startle response, anxious thoughts, and discomfort in crowds. He had nightmares on a nightly basis that prevented him from returning to sleep. The Veteran denied symptoms of mania and psychosis, or suicidal or homicidal ideation, plan, or intent. He reported a good relationship with his family. A mental status examination revealed that the Veteran had normal hygiene but was unkempt. Eye contact was good and he was oriented to person, place, and time. Attitude was cooperative and speech was of normal rate and rhythm. He reported that he was tense all of the time. Thought content and process were unremarkable. Recent and remote memory were deficient. His level of insight was partial and judgment was fair. He reported daily conflict with his wife. He denied arguing with others because he did not like to be around others. The Veteran indicated that he felt hopeless because he had been experiencing the same problem for 40 years. The examiner diagnosed PTSD and depressive disorder and assigned a GAF score of 62. On VA examination in August 2014, the Veteran continued to report chronic PTSD symptoms with no improvement since his last examination. He did not think his medication was effective. He reported fleeting thoughts of suicide without plan or intent. He continued to report significant intrusive thoughts and increased irritability. The examiner noted that the Veteran's last appointment with VA psychiatry was in 2011. He stated that irritability was his worst problem, and he avoided other people. The Veteran also noted decreased concentration and memory problems. He spent a lot of time with his grandchildren who "kept him going." The examiner indicated that the following symptoms applied to the Veteran's diagnosis: depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, flattened affect, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a work-like setting. The Veteran was casually dressed and well groomed. He was alert and oriented and maintained good eye contact. He was cooperative during the examination. Thought process was logical, coherent and goal-directed, with no evidence of a formal thought disorder. Content of thought was appropriate to context with no evidence of perceptual disturbance or delusional thinking. Insight and judgment were intact. Mood was mildly depressed, with a flat affect which was congruent to mood. He denied suicidal or homicidal ideation, intent or plan at that time, though recurrent fleeting thoughts of suicide crossed his mind. The examiner diagnosed PTSD, and indicated that the disability was productive of occupational and social impairment with reduced reliability and productivity. A July 2015 VA treatment report reflects that the Veteran reported sleeping difficulties due to nightmares, difficulties with concentration, daily flashbacks, and avoidance of crowds. On mental status examination, the Veteran was cooperative and attentive with good eye contact. He reported that with respect to his mood, his anger had been worse. His affect was reactive and stable. Thought processes were sequential and goal-directed. He denied suicidal or homicidal ideation or perceptual disturbances. Insight and judgment were fair/intact. On VA examination in October 2015, the Veteran reported that he lived with his wife of over 40 years. He indicated that he and his wife argued about "everything." He had two adult daughters with whom he talked to every week and saw once a month. He saw his grandchildren almost every weekend. Socially, he reported that he had a few friends. He had four of five guys from the military whom he saw once a year, and he called occasionally. He talked to his siblings on the phone occasionally. He had one brother whom he saw once a week. He spent his free time volunteering or at home. He went camping with his wife in the summer as often as possible. He was part of the VFW and had been the commander for the past 2 years. He went to meetings three times a month. He stated that he got along well with other VFW members. With respect to work, the Veteran reported that he was retired as carpenter foreman with the government. He had held this position for 22 years. He denied that he had been written up or had any behavioral problems at work. He was retired because he "got sick of the people [he] worked with" and "had enough." He volunteered through the VFW visiting veterans approximately 12 to 15 hours per week. The Veteran reported that he participated in mental health treatment at the VA medical center. He met with his psychiatrist every 3 months. Current medications were Fluoxetine, Trazadone, and Prazosin. He also went to the Vet Center for group therapy. The examiner indicated that the following symptoms actively applied to the Veteran's diagnosis: depressed mood, anxiety, suspiciousness, chronic sleep impairment, and disturbances of motivation and mood. The Veteran reported sleep onset difficulties. He could not fall asleep until 5:30 or 6 a.m., and awoke around 9 a.m. He got 3 to 4 hours of sleep at night and did not sleep during the day. He had sleep apnea and used a CPAP, but the machine was broken. He reported nightmares every night, and that he did not like to sleep as a result. He also indicated that he suffered from intrusive memories and physiological arousal. The Veteran noted that he hyperventilated at times. Other symptoms included avoidance, exaggerated startle response, frequent checking of doors, and anger. When he was working, he started verbal confrontations with his co-workers. The examiner diagnosed PTSD, which she found to be productive of occupational and social impairment with reduced reliability and productivity. The examiner expressed that the Veteran's PTSD did not preclude him from obtaining or maintaining employment. Continued VA mental health treatment records reflect symptoms of depression, irritability, low energy, social isolation, sleep difficulties, and nightmares. Affording the Veteran the benefit of the doubt, the Board finds that the aforementioned evidence demonstrates occupational and social impairment with deficiencies in most areas throughout the appeal period. Between 2007 and 2011, the evidence shows that the Veteran's PTSD has been manifested by continuous anxiety, emotional and social withdrawl, unprovoked irritability, sleep disturbances, suicidal thoughts, work difficulties due to anger and irritability, a "volatile" personality, depression, constant fighting with his wife, arguments in stores, hallucinations of dead bodies and mortar sounds, suicidal and homicidal thoughts, continuous anger, impaired impulse control, and constant tension. After 2011, although the Veteran demonstrated some apparently relief in symptomatology - particularly with regard to social avoidance - the evidence still reflects suidical thoughts, increased irritability, frequent checking of door locks, and depression. Such symptomatology is consistent with a higher 70 percent rating. Accordingly, the Board finds that a 70 percent rating is warranted throughout the appeal period. However, examinations and treatment records do not indicate that the Veteran's symptoms rise to the severity, frequency, and duration required of a 100 percent rating. Although the record appears to document incidents of hallucinations, the Veteran's overall disability picture does not rise to the severity of that indicated with a 100 percent rating. For example, at no point in the claims file was evidence found of persistent danger of hurting self or others, intermittent ability to perform activities of daily living, disorientation to time or place, or memory loss for names of close relatives, own occupation or own name, nor was evidence of a similar type and degree of such symptoms found. Rather, the Veteran consistently appeared appropriately groomed, capable of maintaining effective relationships with his children and grandchildren, maintained employment for nearly 30 years until his retirement, participated in a regular PTSD group, and during the latter part of the appeal period, the Veteran was volunteering and venturing out socially. Thus, affording the Veteran the benefit of the doubt, a 70 percent rating, but no higher, is warranted. The Board further notes that the GAF scores assigned support such a determination. Although most assigned scores reflect moderate symptoms, the evidence also showed two GAF scores of 46 and 50, which contemplate severe symptomatology. Overall, the disability picture presented by GAF scores reflect the moderate to severe symptomatology contemplated by a 70 percent rating. See DSM-V (GAF score ranging from 41 to 50 reflects severe symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job), while a GAF score ranging from 51 to 60 reflects 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-worker)). Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, No. 15-2818, 2017 U.S. App. Vet. Claims LEXIS 319, *8-9 (Vet. App. March 17, 2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record)." Accordingly, the Board finds that a 70 percent, but no higher, rating for PTSD is warranted for the entire appeal period prior to and from April 5, 2011. II. TDIU VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that the Veteran is precluded, by reason of his service- connected disabilities, from obtaining and maintaining substantially gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. Total disability ratings for compensation based on individual unemployability may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). For the above purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable; (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric, (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. Id. The central inquiry is, "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." 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 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, 363 (1993). In this case, prior to October 21, 2015, the Veteran was service-connected for PTSD (rated as 70 percent disabling), nephropathy (rated as 30 percent disabling), diabetes mellitus type II (rated as 20 percent disabling), peripheral neuropathy of the right and left lower extremities (each rated as 10 percent disabling), peripheral neuropathy of the right upper extremity (rated as 10 percent disabling), peripheral neuropathy of the left upper extremity (rated as noncompensable), and bilateral feet onychomycosis (rated as noncompensable) from April 19, 2007. From December 19, 2012, a 10 percent rating each for mass/cyst removal from the neck and left chest, each rated as 10 percent disabling. Thus, the Veteran met the schedular standards for TDIU prior to October 21, 2015. As October 21, 2015, the Veteran's peripheral neuropathy disabilities were recharacterized as diabetic peripheral neuropathy. A 20 percent rating for diabetes peripheral neuropathy of the left upper extremity (previously rated as peripheral neuropathy) is rated as 20 percent disabling under Diagnostic Code 8513. Peripheral neuropathy of the right upper extremity (previously rated as peripheral neuropathy) is rated as 20 percent disabling under Diagnostic Code 8513. A 20 percent rating for diabetes peripheral neuropathy of the left lower extremity (previously rated as peripheral neuropathy) under Diagnostic Code 8520 is also assigned. Diabetic peripheral neuropathy of the right lower extremity (previously rated as peripheral neuropathy) is rated as 20 percent disabling under Diagnostic Code 8520. In addition, 10 percent ratings for femoral peripheral neuropathy of the right and left extremities (femoral) under Diagnostic Code 8526 have been assigned. A 100 percent combined evaluation has been in effect since October 21, 2015. The record reflects that the Veteran retired from work in 2005 as a government carpentry foreman. The Veteran has not provided a VA Form 21-8940 Application for TDIU as instructed following the Board's remand, and has not provided any additional detail regarding his work history and educational background. Prior to October 21, 2015, VA treatment records discuss the Veteran's service-connected disabilities, and the Veteran was afforded various VA examinations regarding his service-connected disabilities in addition to the psychiatric examination discussed above. The evidence of record contains a December 2006 VA electromyography (EMG) study, which reflects the Veteran's reports of right wrist pain, difficulty bending the right hand, reduced right hand grip strength and reduced range of motion in the finger joints. Physical examination revealed painful/tender finger joints and was negative for muscle atrophy. The right hand was held at rest with fingers mildly bent but no clear ulnar claw deformity. Pain perception and light touch sensation were intact. EMG testing was essentially normal and there was no electrophysiological evidence of a focal neuropathy that affected the ulnar (or median nerve) in the Veteran's right hand. With respect to the lower extremities, the Veteran's ankle jerk reflexes were absent. Pain perception and light touch sensation were intact. The provider opined that a discrete sensory polyneuropathy was possible in the lower extremities due to the absent ankle jerks and the electrophysiological findings of sensory nerve action potentials with amplitudes at or near the low normal range. A January 2007 VA rheumatology treatment note reflected the Veteran's reports of limitation of flexion in the right fourth and fifth fingers and pain that radiated along the courses of the flexor tendons into his palm with motion. Physical examination found the right wrist to be without swelling, erythema or tenderness and the elbows normal without synovitis. There was a "cystic" mass along the tendon sheath between the MCP and proximal interphalangeal (PIP) of the right fourth digit. Assessments of gout and swelling of the tendon sheath between the right fourth metacarpal and PIP were made. An August 2007 VA general medicine examination reflected the Veteran's reports of foot discomfort when walking as well as foot burning and numbness. He also reported of a loss of function in his right ring finger. Range of motion of the fourth PIP joint was to 95 degrees with normal extension. There was no pain on motion. An accompanying right hand X-ray revealed osteopenia and arthropathy. An accompanying right hand magnetic resonance imaging (MRI) scan revealed a small infiltrating mass predominantly along the volvar surface of the flexor tendon of the ring finger; the most common diagnoses associated with such findings would include a giant cell tumor tendon sheath and fibromatosis. On VA diabetes mellitus examination in August 2007, it was noted that the Veteran was on an exercise program and could not perform strenuous activities. There was edema in all extremities. Examination showed overall decreased in strength and flexibility of the right hand and loss of sensation, increased sensitivity, and dysesthesia on the bottom of both feet. His diabetes was stable with use of oral medications. The examiner noted that the Veteran's peripheral neuropathy was productive of loss of sensation, increased sensitivity, and dysesthesia. The examiner noted that the Veteran retired in 2005 due to medical (physical) problems. The disability caused inability to work with the hands, kneel, or climb. A VA treatment report dated in July 2008 showed paresthesia of the bilateral lower extremities. A June 2009 VA podiatry treatment note reflected the Veteran's complaints of a burning sensation in both feet. Physical examination was negative for edema or erythema bilaterally. Pedal pulses were palpable bilaterally. Epicritic sensation was grossly intact with a monofilament wire. A September 2009 VA treatment note indicated that there was no paresthesia, dysesthesias or anesthesia. On VA examination in November 2009, the examiner noted that the Veteran was seen for diabetes about every 6 months. He had no visits for ketoacidosis or hyperglycemia. His diabetes was noted to be not incapacitating, did not prevent him from being employed, and caused no restrictions on functions or daily activities. With respect to the extremities, light touch sensation was intact. Posterior tibial pulses were appreciated. Dorsalis pedis pulses were 2+ on the right and 1+ on the left. The examiner also noted diagnosis of nephrosclerosis, with no urinary tract problems at the time of examination. A March 2010 VA treatment reported showed diminished protected sensation of the feet. December 2010 VA treatment note reflected the Veteran's reports of a weak grip and pain in his right hand that prevented him from opening jars or grasping items. Upper extremity strength was 5/5 bilaterally and a weak grip was found. Sensation was intact to light touch bilaterally. An assessment of asymmetric arthropathy was made. A December 2010 VA rheumatology treatment note indicated that the Veteran was unable to make a tight fist with his right hand and that there was swelling of the right third MCP. The provider noted that hand films were suggestive of chronic inflammatory changes secondary to previous gout flares and that his right hand stiffness was likely secondary to chronic gout. In February 2012, the Veteran was seen for complaint of right arm weakness involving all muscles of the arm but most severe in the wrist and hand. Possible etiologies included stroke or regional plexopathy, possibly due to crutch use following knee surgery. He was instructed to stop using crutches and return if there was no improvement in 6 weeks. An October 2013 VA treatment report reflects that there was erythema of the right hand with warmth and swelling of the middle MCP joint and limited flexion. He was assessed with gout. On VA examination in October 2013, the examiner noted that the Veteran did not require regulation of activities for his diabetes and required treatment less than 2 times per month. He determined that the Veteran's diabetes mellitus did not impact his ability to work. On VA examination in March 2014, the examiner indicated that the Veteran's diabetic nephropathy did not impact his ability to work. As for the Veteran's diabetes mellitus, the examiner likewise determined that the disability did not impact his ability to work. An August 2014 VA peripheral nerves examination, the Veteran endorsed pain, numbness, and paresthesia in the upper and lower extremities. After physical examination, the examiner concluded that the disability did not impact the Veteran's ability to work. On VA peripheral nerves examination in October 2015, the Veteran endorsed paresthesia, pain, and numbness. He reported that he retired about 10 years prior, when walking became difficult. After physical examination, the examiner indicated that the Veteran's peripheral nerves disabilities impacted his ability to work, noting that the Veteran retired due to increased difficulty with walking and that he was no longer able to climb ladders without increased risk of falling. VA examinations dated in February 2017 include the examiner's opinion that the Veteran's diabetes mellitus and related complications, including peripheral neuropathy, and his nephropathy did not affect his employability. VA treatment records also discuss treatment for a number of non-service connected disabilities, including low back pain and knee joint replacement. In this case, for the period prior to October 21, 2015, the evidence of record is against a finding that the Veteran's service-connected disabilities either individually or collectively render him unable to secure and follow a substantially gainful occupation. While there is indication that these disabilities preclude certain types of employment or work duties, total occupational impairment is not demonstrated. In this regard, in the multiple VA examinations documented, the examiners consistently conclude that the Veteran's diabetes mellitus, nephropathy, and peripheral neuropathy of the upper and lower extremities did not render him unemployable, and that the Veteran's service-connected PTSD, while productive of moderate occupational impairment, did not render the Veteran unemployable. These conclusions were based on interview of the Veteran, review of the claims file and examination of the Veteran. The Board acknowledges that the Veteran was not working during this period and the Veteran has indicated that his mental health and physical disabilities led him to retire. However, these records indicate that the Veteran's service-connected conditions interfered with his ability to perform his previous position, they do not establish that the Veteran was entirely precluded from all type of gainful employment for which he was suited. In addition, the Board acknowledges the findings of the October 2015 VA examiner noting that the Veteran's peripheral neuropathy impacted the Veteran's ability to climb ladders, stairs, and complete certain tasks at work. However, such interference with certain work duties are contemplated in the ratings assigned. Total occupational impairment for all types of employment consistent with the Veteran's background is not shown, and the Veteran has not provided detail on his work history or educational background that would allow the Board to conclude that all types of gainful employment consistent with his background were precluded. Moreover, VA treatment records reflect a variety of other non-service connected disabilities would contribute to his performance on physical tasks, including back and knee disabilities and gout. Accordingly, the Board concludes that a TDIU prior to October 21, 2015 must be denied. The benefit-of-the-doubt doctrine is therefore not for application, and the claim must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). With respect to the period from October 21, 2015, as indicated above, the receipt of a 100 percent schedular disability evaluation for a service-connected disability or disabilities does not necessarily moot the issue of entitlement to a TDIU. Bradley, 22 Vet. App. at 293-94. Although no additional disability compensation may be paid when a total schedular disability rating is already in effect, Bradley recognized that a separate award of a TDIU predicated on a single disability may form the basis for an award of special monthly compensation under 38 U.S.C.A. § 1114(s). Bradley, 22 Vet. App. at 293-94. However, Bradley also explains that a 100 percent combined evaluation does not qualify as "a service-connected disability rated as total" under the statute. 38 U.S.C.A. § 1114 (s); Bradley, 22 Vet. App. at 290. Here, the Board has considered whether a single service-connected disability, alone, can provide a basis for award of a TDIU. While the Veteran's peripheral neuropathy of the extremities affects employment and his ability to perform manual labor, no single extremity renders him unemployable without consideration of other service-connected and non-service-connected disabilities. In addition, while the Veteran's service-connected PTSD is productive of reduced reliability and productivity, as indicated above, it has not been shown to be productive of total occupational impairment. The Veteran's service connected diabetes mellitus, nephropathy, and scars have otherwise not been shown to affect employability. In addition, while the Veteran has reported that his various health conditions led him to retire, he has not identified a single disability that alone causes unemployability. Thus, a TDIU for the period from October 21, 2015 is moot. See Bradley, supra. As such, there remain no allegations of error of fact or law for appellate consideration, the Board has no jurisdiction to review this appeal for the issue of entitlement to TDIU from October 21, 2015, and it is dismissed in this regard. 38 U.S.C.A. § 7105(d)(5); 38 C.F.R. § 20.202. ORDER An initial 70 percent rating for PTSD prior to April 5, 2011 is granted, subject to the controlling regulations applicable to the payment of monetary benefits. An initial 70 percent rating for PTSD from April 5, 2011, is granted, subject to the controlling regulations applicable to the payment of monetary benefits. Entitlement to a TDIU prior to October 21, 2015 is denied. Entitlement to a TDIU from October 21, 2015 is dismissed. ____________________________________________ A. S. CARACCIOLO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs