Citation Nr: 1746958 Decision Date: 10/20/17 Archive Date: 10/31/17 DOCKET NO. 17-00 626 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUES 1. Entitlement to an initial rating in excess of 20 percent for diabetes mellitus type 2. 2. Entitlement to an initial rating in excess of 10 percent for right lower extremity diabetic neuropathy. 3. Entitlement to an initial rating in excess of 10 percent for left lower extremity diabetic neuropathy. 4. Entitlement to an initial rating in excess of 30 percent for coronary artery disease/ischemic heart disease. 5. Entitlement to initial increases in the staged ratings (of 50 percent prior to December 7, 2013, and 70 percent since) for posttraumatic stress disorder (PTSD). 6. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: J. Michael Woods, Attorney ATTORNEY FOR THE BOARD Jarrette A. Marley, Counsel INTRODUCTION The Veteran had active service in the United States Army from June 1962 to June 1965, including service in the Republic of Vietnam from December 1963 to December 1964. These matters are before the Board of Veterans' Appeals (Board) on appeal from an April 2013 and January 2014 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). While the claims for increased ratings for diabetes mellitus, coronary artery disease, and PTSD have been characterized by the RO as being on appeal from a January 2014 rating decision, additional evidence pertinent to these issues was associated with the claims file with the appeal period of the April 2013 rating decision, and therefore the April 2013 rating decision is not final. See 38 C.F.R. § 3.156(b); Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011); see also Buie v. Shinseki, 24 Vet. App. 242, 251-52 (2010). The claims have been characterized accordingly. Evidence received during the pendency of this appeal, particularly a June 2016 VA PTSD examination, raised a claim for TDIU, pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009). Such is not a separate claim, but a part of the claims on appeal. Finally, in July 2017, the Veteran and his attorney submitted additional evidence, with a waiver of initial RO consideration. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2016). 38 U.S.C.A. § 7107(a)(2) (West 2014). FINDINGS OF FACT 1. At no time during the appeal period is the Veteran's diabetes mellitus shown to have required regulation of activities. 2. At no time during the appeal period is the Veteran's right lower extremity diabetic neuropathy shown to equate to moderate incomplete paralysis of the sciatic nerve. 3. At no time during the appeal period is the Veteran's left lower extremity diabetic neuropathy shown to equate to moderate incomplete paralysis of the sciatic nerve. 4. Throughout the appeal period, the Veteran's coronary artery disease/ischemic heart disease has been manifested by a workload of 7 METs and the use of continuous medication; congestive heart failure, a workload of 5 METs or less, or left ventricular dysfunction with an ejection fraction of 30 to 50 percent, have not been shown. 5. Throughout the appeal period, the Veteran's PTSD was productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 6. Throughout the appeal period, it is reasonably shown that the Veteran's service-connected disabilities preclude him from securing or following a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 20 percent for diabetes mellitus have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.7, 4.119, Diagnostic Code 7913 (2016). 2. The criteria for an initial rating in excess of 10 percent for right lower extremity diabetic neuropathy have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.7, 4.123, 4.124, 4.124a, Diagnostic Code 8520 (2016). 3. The criteria for an initial rating in excess of 10 percent for left lower extremity diabetic neuropathy have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.7, 4.123, 4.124, 4.124a, Diagnostic Code 8520 (2016). 4. The criteria for an initial rating in excess of 30 percent for coronary artery disease/ischemic heart disease have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.7, 4.104, Diagnostic Code 7005 (2016). 5. Effective from July 18, 2012, the criteria for an initial rating of 70 percent, but no higher, for PTSD are met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.7, 4.130, Diagnostic Code 9411 (2016). 6. Effective from July 18, 2012, the criteria for a grant of TDIU have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Increased Rating Claims Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. The percentage ratings in VA's Schedule for Rating Disabilities (Rating Schedule) represent as far as can practicably be determined the average impairment in earning capacity resulting from such disabilities and their residual conditions in civil occupations. 38 C.F.R. § 4.1. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more closely approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Where entitlement to compensation has already been established and increase in disability is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, "staged" ratings are appropriate where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); see also Fenderson v. West, 12 Vet. App. 119 (1999). Diabetes Mellitus The Veteran contends that he is entitled to an initial rating in excess of 20 percent for his diabetes mellitus. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Diabetes mellitus is rated under Diagnostic Code 7913, which provides for a 20 percent rating when insulin and a restricted diet, or, an oral hypoglycemic agent and a restricted diet are required. A 40 percent rating is warranted when insulin, restricted diet, and regulation of activities are required. A 60 percent rating is warranted when insulin, a restricted diet, and regulation of activities are required, along with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating requires more than one daily injection of insulin, a restricted diet, and regulation of activities, with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately rated. 38 C.F.R. § 4.119. Note 1 following Diagnostic Code 7913 provides that compensable complications of diabetes are evaluated separately unless they are part of the criteria used to support a 100 percent evaluation. Noncompensable evaluations are considered part of the diabetic process under Diagnostic Code 7913. What distinguishes the schedular criteria for the current, 20 percent, rating for diabetes from those for the next higher, 40 percent, rating is that in addition to requiring diet and insulin for control, the diabetes must also require regulation of activities (defined as the "avoidance of strenuous occupational and recreational activities"). 38 C.F.R. § 4.119, Code 7913 (defining term within criteria for a 100 percent rating). The Board notes that the criteria for the progressively increasing ratings for diabetes are stated in the conjunctive rather than the disjunctive, i.e., each level of increase in the rating requires additional criteria which must be met to warrant the increase in the rating. See Camacho v. Nicholson, 21 Vet. App. 360, 363-64 (2007). At the outset, the Board notes that the most recent VA examination of record to determine the current severity of the Veteran's diabetes mellitus was in December 2013. Inasmuch as there is no allegation or evidence that the disability has worsened since the most recent VA examination, the Board finds a new examination is not warranted. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007) (the passage of time alone, without an allegation of worsening, does not warrant a new examination). The Board finds that a rating in excess of 20 percent is not warranted at any period throughout the appeal period. There is no evidence that at any time during the appeal period the Veteran's diabetes has required regulation (avoidance of activities). See December 2013 VA diabetes mellitus examination; see also July 2012 VA diabetes mellitus examination. VA treatment records show no evidence, or suggestion, the Veteran was instructed to regulate his activities in order to treat his diabetes. Accordingly, the evidence does not show that at any time during the appeal period manifestations of the Veteran's diabetes mellitus satisfied, or approximated, the criteria for the next higher, 40 percent, rating. See 38 C.F.R. § 4.7. Consequently, such rating is not warranted. Furthermore, the record does not reflect any additional separately compensable complications of diabetes. Notably, neuropathy of the right and left lower extremities is already separately rated at 10 percent for mild incomplete paralysis of the sciatic nerve, and are addressed below. The Veteran has already been awarded service connection for bilateral cataracts as associated with his diabetes mellitus. See January 2014 rating decision. However, there is no evidence the Veteran's bilateral cataracts warrant a separately compensable rating. See November 2013 VA eye conditions examination. There is no evidence of, or suggestion, that the Veteran suffers from any other complication as a result of his service-connected diabetes mellitus. In reaching the conclusions above, the Board has considered the applicability of the benefit of the doubt doctrine. However, since the preponderance of the evidence is against the claim for a higher rating for the Veteran's diabetes mellitus, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). Right and Left Lower Extremity Diabetic Neuropathy The Veteran contends that he is entitled to an initial rating in excess of 10 percent for his right and left lower extremity diabetic neuropathy. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). At the outset, the Board notes that the most recent VA examination of record to determine the current severity of the Veteran's right and left lower extremity diabetic neuropathy was in December 2013. Inasmuch as there is no allegation or evidence that the disability has worsened since the most recent VA examination, the Board finds a new examination is not warranted. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007) (the passage of time alone, without an allegation of worsening, does not warrant a new examination). The Veteran's diabetic neuropathy is rated under Diagnostic Code 8520 for sciatic nerve impairment. 38 C.F.R. § 4.124a. Under Diagnostic Code 8520, complete paralysis of the nerve is rated as 80 percent disabling, contemplates foot dangling and dropping, no active movement possible of muscles below the knee, and flexion of the knee weakened or (very rarely) lost. Incomplete paralysis of the nerve warrants a 60 percent rating if it is severe with marked muscular atrophy, a 40 percent evaluation if it is moderately severe, a 20 percent evaluation if it is moderate or a 10 percent evaluation if it is mild. Id. 38 C.F.R. § 4.124a directs that for diseases of the peripheral nerves, the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. The United States Court of Appeals for Veterans Claims (Court) recently held in Miller v. Shulkin, 28 Vet. App. 376, 380 (2017) that the language of 38 C.F.R. § 4.124a provides for a maximum 20 percent rating for peripheral neuropathy when the involvement is wholly sensory. 38 C.F.R. § 4.123 provides that neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. The maximum rating which may be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. Id. In any event, the Board acknowledges that the terms "mild," "moderate," and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. The use of terminology such as "moderate" or "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. After a review of the evidence of record, the Board finds that a rating in excess of 10 percent is not warranted at any period throughout the appeal period for the right or left lower extremity diabetic neuropathy. On December 2013 VA peripheral nerves examination, the Veteran denied constant or intermittent pain in either lower extremity. It was noted he experienced mild bilateral lower extremity paresthesias and/or dysesthesias and numbness. Lower extremity strength testing was normal (5/5). Deep tendon reflexes were also normal (2+) except at the knee, where it was only decreased (1+). Light touch/monofilament testing was normal in the lower extremities. There was also no evidence of muscle atrophy. The diagnosis was mild incomplete bilateral sciatic nerve paralysis. The Board finds the December 2013 VA peripheral nerves examination and the findings therein are consistent with, and reflect, the currently assigned 10 percent rating for mild right and left lower extremity incomplete paralysis. At no point during the appeal period does the evidence reflect, or approximate, moderate incomplete paralysis. Accordingly, the evidence does not show that at any time during the appeal period manifestations of the Veteran's right and left lower extremity diabetic neuropathy satisfied, or approximated, the criteria for the next higher, 20 percent, rating. See 38 C.F.R. § 4.7. Consequently, such rating is not warranted. In reaching the conclusions above, the Board has considered the applicability of the benefit of the doubt doctrine. However, since the preponderance of the evidence is against the claim for a higher rating for the Veteran's right and left lower extremity diabetic (sciatic) neuropathy, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). Coronary Artery Disease/Ischemic Heart Disease The Veteran contends that he is entitled to an initial rating in excess of 30 percent for his coronary artery disease/ischemic heart disease. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). At the outset, the Board notes that the most recent VA examination of record to determine the current severity of the Veteran's coronary artery disease/ischemic heart disease was in December 2013. Inasmuch as there is no allegation or evidence that the disability has worsened since the most recent VA examination, the Board finds a new examination is not warranted. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007) (the passage of time alone, without an allegation of worsening, does not warrant a new examination). The Veteran's coronary artery disease/ischemic heart disease is rated under Diagnostic Code 7005, which provides for a 30 percent rating for a workload of greater than 5 metabolic equivalents (METs) but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent rating is warranted for more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs, resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is warranted for chronic congestive heart failure, or; workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104, Diagnostic Code 7005. A note underneath the Rating Schedule for diseases of the heart explains that one MET is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104. The Board finds that a rating in excess of 30 percent is not warranted at any period throughout the appeal period. There is no evidence that at any time during the appeal period the Veteran's coronary artery disease/ischemic heart disease has been manifested by congestive heart failure, acute or chronic, a workload of 5 METs or less, or left ventricular dysfunction with an ejection fraction of 50 percent or less. See December 2013 VA ischemic heart disease examination; see also July 2012 VA ischemic heart disease examination (finding a METs workload of 7). Specifically, the December 2013 examination noted that the Veteran's treatment involved taking continuous medication for his disability, but that the disability did not include congestive heart failure. Echocardiogram revealed left ventricular ejection fraction of 55 to 70 percent. Finally, the Veteran denied experiencing symptoms with any level of physical activity. Accordingly, the evidence does not show that at any time during the appeal period manifestations of the Veteran's coronary artery disease/ischemic heart disease satisfied, or approximated, the criteria for the next higher, 60 percent, rating. See 38 C.F.R. § 4.7. Consequently, such rating is not warranted. In reaching the conclusions above, the Board has considered the applicability of the benefit of the doubt doctrine. However, since the preponderance of the evidence is against the claim for a higher rating for the Veteran's coronary artery disease/ischemic heart disease, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). PTSD The Veteran contends that he is entitled to initial increases in the staged ratings (of 50 percent prior to December 7, 2013, and 70 percent since) for his PTSD. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). The Veteran's PTSD is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411 (the General Rating Formula for Mental Disorders (General Formula)), which provides for a 50 percent rating when the evidence shows 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 warranted when the evidence shows 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 worklike setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted when the evidence shows total occupational and social impairment, due to such symptoms as: gross impairment in thought processes 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; memory loss for names of close relatives, own occupation, or own name. Id. Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). When determining the appropriate disability evaluation to assign, however, the Board's "primary consideration" is the Veteran's symptoms. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). The Veteran's PTSD is currently rated 50 percent disabling, effective from July 18, 2012. After a review of the evidence of record, the Board finds that throughout the appeal period, the Veteran's PTSD warrants a 70 percent rating, and no higher. See August 2012 VA J.M., LCSW letter (noting the Veteran's PTSD symptoms include suicidal ideation). The Court has held that suicidal ideation generally rises to the level contemplated in a 70 percent rating. See Bankhead v. Shulkin, 29 Vet. App. 10, 19-20 (2017). The Court specified that VA must not require "more than thought or thoughts to establish the symptom of suicidal ideation," and may not require that the Veteran have been "hospitalized or treated on an inpatient basis" to establish suicidal ideation because that imposes a higher standard that the criteria in the Diagnostic Code for mental disorders. Id. at 20-21. Moreover, the Court cautioned VA not to conflate the risk of "suicidal ideation, which VA generally considers indicative of a 70 [percent] evaluation, and his risk of self-harm, the persistent danger of which VA generally considers indicative of a 100 [percent] evaluation." Id. at 21. As applied, the suicidal ideation reported in the August 2012 VA J.M., LCSW letter is sufficient to establish the suicidal ideation symptom consistent with a 70 percent rating in the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. The Board finds that the preponderance of the evidence is against a finding in excess of 70 percent. As provided above, in order to warrant a 100 percent rating, the Veteran's PTSD should be manifested by total occupational and social impairment. The Board acknowledges that on June 2016 VA PTSD examination, the Veteran's symptomatology was noted to include gross impairment in thought processes or communication, persistent hallucinations or delusions, grossly inappropriate behavior, and intermittent inability to perform activities of daily living. Specifically, the June 2016 VA examiner noted the Veteran had difficulty understanding and completing complex tasks, had impaired abstract thinking, and his speech was intermittently illogical, obscure, or irrelevant. In addition, the Veteran had delusional thinking, including being suspicious and distrusting of most people and feeling like people are watching, following, or talking about him at times, but denied any hallucinations. The Veteran also reported that he neglects household chores and yard work during severely depressed states, but denied any problems with minimal hygiene. While the Veteran continued to report suicidal ideation, there was no intent or plan. In addition, there is no evidence of disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name. Based on the above symptomatology found on June 2016 VA PTSD examination, it is clear the Veteran's PTSD is manifested by some of the symptomatology required for an increased (100 percent) rating. Nonetheless, the Veteran's PTSD must be severe enough to result in total occupational and social impairment. And the Board finds that the preponderance of the evidence is against a finding that at any time during the appeal period the Veteran's PTSD has been manifested by total occupational and social impairment. In this regard, the Board finds significant that after interview and examination of the Veteran, and significant notation of the Veteran's symptoms, the June 2016 VA examiner found the Veteran's level of impairment was consistent with occupational and social impairment with deficiencies in most areas, consistent with a 70 percent rating. As the opinion was provided by a medical professional competent to provide such an opinion, and was provided after review of the evidence of record, the Board finds the opinion to be persuasive. Notably, there is no competent medical opinion finding, or suggesting, that the Veteran's service-connected PTSD is of such severity to be consistent with, or approximate, total occupational and social impairment. Accordingly, the Board finds that the preponderance of the evidence is against a finding the Veteran's PTSD warrants a rating in excess of 70 percent at any point during the appeal period. In reaching the conclusions above, the Board has considered the applicability of the benefit of the doubt doctrine. However, since the preponderance of the evidence is against the claim for a higher rating for the Veteran's PTSD, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). TDIU A total disability rating 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 the result of service-connected disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. 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 nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Todd v. McDonald, 27 Vet. App. 79, 85-86 (2014). To qualify for a total rating for compensation purposes, the evidence must show: (1) a single disability rated as 100 percent disabling; or (2) that the veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities and there is one disability ratable at 60 percent or more, or, if more than one disability, at least one disability ratable at 40 percent or more and a combined disability rating of 70 percent. 38 C.F.R. § 4.16(a). For the purpose of establishing one 60 percent disability, or one 40 percent disability in combination, disabilities affecting a single body system are considered as one disability. Id. Disabilities that are not service connected cannot serve as a basis for a total disability rating. 38 C.F.R. §§ 3.341, 4.19. Unlike the regular disability rating schedule, which is based on the average work-related impairment caused by a disability, "entitlement to TDIU is based on an individual's particular circumstance." Rice v. Shinseki, 22 Vet. App. 447, 452 (2009) (quoting Thun v. Peake, 22 Vet. App. 111, 116 (2008)); see also Todd, 27 Vet. App. at 85-86. Therefore, in adjudicating a TDIU claim, VA must take into account the individual veteran's education, training, and work history. Hatlestad v. Derwinski, 1 Vet. App. 164, 168 (1991) (level of education is a factor in deciding employability); see Friscia v. Brown, 7 Vet. App. 294 (1994) (considering veteran's experience as a pilot, his training in business administration and computer programming, and his history of obtaining and losing 19 jobs in the previous 18 years); Beaty v. Brown, 6 Vet. App. 532 (1994) (considering veteran's 8th grade education and sole occupation as a farmer); Moore v. Derwinski, 1 Vet. App. 356 (1991) (considering veteran's master degree in education and his part-time work as a tutor). The Veteran contends that he is entitled to TDIU based on his service-connected disabilities. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). The Veteran's service-connected disabilities are PTSD, coronary artery disease/ischemic heart disease, diabetes mellitus, right and left lower extremity diabetic neuropathy, for a combined 80 percent rating since July 18, 2012, and 90 percent from December 16, 2013. Therefore, he satisfies the threshold schedular requirement for an award of TDIU benefits under 38 C.F.R. § 4.16(a) effective from July 18, 2012. What remains to be determined is whether the functional impairment associated with his service-connected disabilities is of such nature and severity as to preclude substantially gainful employment. The evidence shows that the Veteran's occupational history includes working in sales, as a teacher, and as a driver's education instructor. See July 2017 Dr. S.B. vocational assessment report. It is unclear as to the Veteran's educational background. The evidence shows that the Veteran retired as a teacher in approximately 2003. See, e.g. February 2013 VA PTSD examination. After a review of the evidence of record, the Board finds, resolving any reasonable doubt as mandated by law (38 U.S.C.A. § 5107; 38 C.F.R. § 3.102), that the evidence supports the conclusion that the Veteran's service-connected disabilities prevent him from securing and following substantially gainful employment. In reaching this determination, the Board notes that the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that determination of whether a veteran is unable to secure or follow a substantially gainful occupation due to service-connected disabilities is a factual rather than a medical question and that is an adjudicative determination properly made by the Board or the RO. See Geib v. Shinseki, 733 F.3d 1350 (Fed. Cir. 2013). Based on the evidence presented in this case, the Board finds that the evidence supports a finding that the functional impairment associated with the Veteran's service-connected disabilities is of such nature and severity as to preclude substantially gainful employment. See Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990) (holding that a veteran need only demonstrate an approximate balance of positive and negative evidence to prevail). The Board finds significant that the Veteran retired as a teacher. In addition, the June 2016 VA PTSD examiner noted the Veteran's symptoms include impaired abstract thinking, communication problems, difficulty understanding and completing tasks, difficulty concentrating, and forgetting things on a daily basis. The examiner also opined that the Veteran's symptoms were severe enough to disable and preclude him from sustaining substantial, gainful employment activity since the date of claim. This opinion is supported by a July 2017 Dr. S.B. vocational assessment report wherein it was opined that the Veteran was totally and permanently precluded from performing work at a substantially gainful level since the date of claim due to the severity of his service-connected PTSD, coronary artery disease/ischemic heart disease, diabetes mellitus with bilateral cataracts, and right and left lower extremity diabetic neuropathy. The Board further notes that there is no opinion contrary to that of the June 2016 VA PTSD examiner and Dr. S.B.'s July 2017 vocational assessment. Thus, given the evidence regarding the severity of the Veteran's service-connected disabilities, and opinions and evidence indicating the Veteran's functional limitations due to his disabilities, and in light of his individual work experience, training and education, the Board finds that the evidence shows he is entitled to an award of a TDIU rating effective from July 18, 2012. See Geib v. Shinseki, 733 F.3d 1350 (Fed. Cir. 2013). ORDER An initial rating in excess of 20 percent for diabetes mellitus is denied. An initial rating in excess of 10 percent for right lower extremity diabetic neuropathy is denied. An initial rating in excess of 10 percent for left lower extremity diabetic neuropathy is denied. An initial rating in excess of 30 percent for coronary artery disease/ischemic heart disease is denied. Subject to the applicable laws and regulations governing the payment of monetary awards, a rating of 70 percent, and no more, effective from July 18, 2012, for the Veteran's PTSD, is granted. Subject to the applicable laws and regulations governing the payment of monetary awards, entitlement to a total disability rating based on individual unemployability due to service-connected disabilities is granted, effective from July 18, 2012. ____________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs