Citation Nr: 1755051 Decision Date: 11/30/17 Archive Date: 12/07/17 DOCKET NO. 12-11 639A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to a rating in excess of 20 percent for a lumbar spine disability. 2. Entitlement to a rating in excess of 20 percent for a left shoulder disability. 3. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Ashley Brooke Thomas, Attorney at Law ATTORNEY FOR THE BOARD T. Azizi-Barcelo, Counsel INTRODUCTION The Veteran served on active duty from February 1953 to February 1955, March 1955 to February 1958, March 1958 to March 1964, and February 1965 to March 1974. This matter comes to the Board of Veterans' Appeals (Board) from a July 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In connection with his appeal, the Veteran requested and was scheduled for a Board hearing, to be held in December 2016. In November 2016 correspondence, however, the Veteran's attorney withdrew the hearing request and asked that the claim be considered "based on the totality of the evidence in his file." This case was previously before the Board in February 2017. At that time, the Board added the TDIU issue to the appeal under Rice v. Shinseki, 22 Vet. App. 447 (2009), and then remanded the issues listed on the title page of this decision for further development. The Board notes that a September 2013 rating decision granted service connection for coronary artery disease status post bypass graft and assigned an initial 30 percent rating, effective May 28, 2010. The Veteran appealed for a higher rating. During the pendency of the appeal, in a rating decision in October 2016, the RO increased the disability rating for coronary artery disease, status post bypass graft, to 60 percent effective September 29, 2016. The February 2017 Board decision denied, in pertinent part, ratings in excess of 30 percent disabling from May 28, 2010 to September 29, 2016, and in excess of 60 percent thereafter. In September 2017 the Veteran filed a notice of disagreement with the October 2016 rating decision asserting that he was entitled to a 60 percent rating effective May 28, 2010. The AOJ erroneously notified the Veteran that the issue was "on appeal." This was erroneous, as the Board had already decided the claim on appeal in its February 2017 Board decision. As such, this matter is no longer before the Board. Should the Veteran wish to seek a rating in excess of 60 percent for his service connected coronary artery disease, he should file a claim in accordance with proscribed procedures, seeking the assistance of his attorney if necessary. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (West 2012). FINDINGS OF FACT 1. During the period on appeal, forward flexion of the thoracolumbar spine was greater than 30 degrees; additional functional loss was not shown; incapacitating episodes, favorable or unfavorable ankylosis, and neurological abnormalities were not shown. 2. The Veteran's service-connected left shoulder disability has not been shown to be manifested by fibrous union of the humerus; at its worst, it has been manifested by limited motion with forward flexion to 160 degrees, abduction to 140 degrees, external rotation was to 90 degrees, and internal rotation was to 65 degrees, and pain on movement and use, not productive of additional limitation of motion. 3. Prior to September 29, 2016, the Veteran's service-connected disabilities do not meet the schedular criteria for a TDIU, nor have they been shown, at any time during the period on appeal, to preclude him from securing and following a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for entitlement to a disability rating in excess of 20 percent for a lumbar spine disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.71a, Diagnostic Code Codes 5237-5242 (2017). 2. The criteria for entitlement to a disability rating in excess of 20 percent for a left shoulder disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.124a, Diagnostic Code 5202 (2017). 3. The criteria for entitlement to a TDIU, to include on an extraschedular basis, are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist Neither the Veteran nor his attorney has raised any issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the Veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). Increased ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. §§ 4.40, 4.45, 4.59 (2017). 1. Lumbar spine disability The regulations provide for evaluation of disabilities of the spine under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula). Intervertebral disc syndrome (IVDS) may alternatively be rated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (IVDS Formula), whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a, Note (6) (2017). The Veteran's service-connected lumbar spine disability, including residuals of a lumbosacral strain with degenerative disc disease, is currently rated under the General Rating Formula. This formula provides that the next higher rating of 40 percent is warranted where the disability is manifested by forward flexion of the thoracolumbar spine to 30 degrees or less. A higher 50 percent evaluation is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted if there is unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula (2017). In addition, any associated objective neurologic abnormalities are evaluated separately under the appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula, Note 1. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. 38 C.F.R. § 4.71a, General Rating Formula, Note (2); see also Plate V. Alternatively, intervertebral disc disease can be evaluated under the Formula for Rating Intervertebral Disc Syndrome (IVDS). Given the Veteran's diagnosis of degenerative disc disease, the Board has also considered application of these criteria. Under that Formula, a rating of 40 percent is warranted where there are incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months. A maximum rating of 60 percent is warranted where the evidence reveals incapacitating episodes having a total duration of at least six weeks during the past 12 months. Incapacitating episodes are defined as requiring bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, IVDS Formula (2017). On VA joints examination in June 2010, the Veteran complained of daily back pain in the middle of the lumbar spine, with stiffness, weakness and fatigability. He had to sleep on left side due his back symptoms. The Veteran denied flare-ups in symptoms. He denied lack of endurance or incapacitation. There were no bladder or bowel complaints. He endorsed limitations standing and walking due to back pain. Treatment consisted medications and some physical therapy. The examiner noted a that the Veteran was status post-surgery for degenerative disc disease of the lumbar spine, 1968. The Veteran denied any episodes of physician prescribed bed-rest in the preceding 12 months. There were no limitations on activities of daily living. The Veteran's posture and gait were normal. He required no assistive devices for ambulation. Back and neck were bilaterally symmetric without gross scoliosis. There was no exaggerated kyphosis or lordosis. There were no palpable spams or tenderness. There was no radiculopathy. Romberg test was negative. Flexion of the lumbar spine was to 65 degrees, extension was to 20 degrees, right lateral flexion was to 20 degrees, left lateral flexion was to 20 degrees, right lateral rotation was to 40 degrees, and left lateral rotation was to 30 degrees. Motion was limited by pain and stiffness. Straight leg raising was negative. There was no tenderness. There was no additional limitation of motion after three repetitions. X-rays of the lumbar spine revealed narrowing of disc spaces most pronounced at L5- S1, L4-L5. Anterior hypertrophic spondylosis, mild scoliotic curvature to the right. The examiner diagnosed lumbar degenerative disc disease at L5-S1, L4-L5, status post-surgery with no radiculopathy. It was noted that the Veteran was retired and had been employed by the state of Florida for 11 years. Functional limitations were noted to be mild. On VA spine examination in December 2016, the Veteran complained of daily aching low back pain without any radiation. His back would become painful with prolonged standing, sitting, and driving distance. He had a history of back surgery in service on two occasions, in 1966 and 1968. Reportedly, he was unable to lift greater than five pounds. He did not wear any back support. He required a cane for ambulation. The Veteran denied any flare-ups in symptoms. Forward flexion was to 90 degrees, extension was to 20 degrees, right lateral flexion was to 20 degrees, left lateral flexion was to 30 degrees, right lateral rotation was to 30 degrees, and left lateral rotation was to 30 degrees. The examiner noted mild pain with both active and passive range of motion of the lumbar spine, but pain did not result in/cause functional loss. There was no evidence of pain with weight bearing. There was no objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the thoracolumbar spine. There was no additional loss of function or range of motion after three repetitions. Pain, weakness, fatigability and incoordination did not significantly limit functional ability with repeated use over a period of time. There was no guarding or muscle spasm of the thoracolumbar spine. The Veteran denied any radicular pain or any other signs or symptoms due to radiculopathy, as well as any other neurologic abnormalities or findings related to the thoracolumbar spine. There was no ankylosis of the spine or IVDS. Imaging studies revealed arthritis. There was a surgical scar over the mid lumbar area that was 7cm long buy 1cm wide. It was stable, not painful. The Veteran's thoracolumbar spine condition had no impact on his ability to work. Initially, the Board notes that throughout the period on appeal the Veteran has not reported physician-prescribed bed rest. Additionally, none of the treatment records treatment records show incapacitating episodes as defined by VA regulation. As such, the Veteran does not satisfy the criteria for an increased rating under Diagnostic Code 5243 for IVDS because the record does not show documented periods of acute signs and symptoms of IVDS that required bed rest prescribed by a physician and treatment by a physician. Accordingly, the Board finds that he is not entitled to higher disability ratings based upon incapacitating episodes at any time throughout the period on appeal. As the Veteran is not entitled to increased ratings based upon incapacitating episodes, it is necessary to determine whether he is entitled to higher ratings under the General Rating Formula. The Board finds that the Veteran is not entitled to a rating in excess of 20 percent under the General Rating Formula To warrant the next higher rating of 40 percent, there must be evidence which shows the disability more nearly approximates limitation of flexion to 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a (2017). The only recorded range of motion findings show Veteran's flexion was limited to no more than 65 degrees with pain. There is no evidence that the Veteran experiences additional limitation due to pain on repetition. 38 C.F.R. § 4.40, 4.45 (2017). The VA examiner in 2016 noted that there was no pain on weight bearing in all planes of motion. While there was evidence of pain with both active and passive range of motion of the lumbar spine, the pain did not result in/cause additional functional loss and there was no notation that the passive and active range of motion findings were any different. See Correia, 28 Vet. App. 158. Significantly, the Veteran denied flare-up in symptoms. Further, there was no evidence of ankylosis or any limitation of motion that reasonable approximates ankylosis. Therefore, the Board finds that a rating in excess of 20 percent is not warranted. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5242 (2017). Consideration has been given to assigning a separate rating for neurological abnormalities related to the lumbar spine disability. There is no evidence of any neurological abnormalities of the lumbar spine that would provide a basis upon which to assign any separate compensable ratings. For this reason, separate ratings for objective neurological abnormalities are not warranted. Additionally, it is noted that the Veteran's lumbar spine disability involves a surgical scar. Therefore, the Board has considered whether the Veteran is entitled to a separate rating for the scarring. On VA examination in December 2016, the examiner noted that while there was surgical scarring, it was not painful or unstable, nor covering a total area greater than 39 square cm. Accordingly, a separate compensable rating is not warranted. See 38 C.F.R. § 4.118, Diagnostic Codes 7804, 7805 (2017). For the above reasons, the preponderance of the evidence is against a rating higher than 20 percent for the service-connected lumbar spine disability. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Left shoulder disability The Veteran's service-connected left shoulder disability is currently evaluated under Diagnostic Code 5202 for other impairment of the humerus. Specifically, the Veteran's left shoulder is rated 20 percent disabling. Because the Veteran is right arm dominant, his left shoulder disability is rated as the minor joint. Under Diagnostic Code 5202, other impairment of the minor extremity humerus warrants a 20 percent evaluation for malunion of the humerus with deformity. 38 C.F.R. § 4.71a, Diagnostic Code 5202. A 20 percent rating is warranted for recurrent dislocation of the humerus at the scapulohumeral joint with frequent or infrequent episodes and guarding of all arm movements or guarding of movement only at the shoulder level. A 40 percent rating is warranted if there is fibrous union of the humerus. A 50 percent rating is warranted for nonunion of the humerus (false flail joint). A 70 percent rating is warranted for loss of the humerus head (flail shoulder). Id. Normal range of motion of the shoulder is as follows: forward elevation (flexion) to 180 degrees; abduction to 180 degrees; internal rotation to 90 degrees; and external rotation to 90 degrees. 38 C.F.R. § 4.71, Plate I. On VA joints examination in June 2010 the Veteran complained of constant left shoulder pain, rated as 6 out 10, in the anterior shoulder and rotator cuff. He endorsed flare-ups in pain when lifting, but denied limitation in the range of motion. There was no weakness, instability or subluxation. The examiner noted that the Veteran was status post-left humerus surgery in 1972 and that he had had no new injuries or surgeries. He had treatment with injections in 2006. Deep tendon reflexes were normal in both biceps. There was no atrophy or hypertrophy. Strength testing to gravity and resistance was within normal limits. Grip strength was normal. Sensation to pinprick and light touch was normal. Left shoulder range of motion was limited from 0 to 160 degrees on abduction/flexion, internal/external rotation was 0 to 90 degrees. Range of motion was limited with stiffness. There was no tenderness in rotator cuff or instability. There was no painful motion, tenderness, spasms, edema, fatigability, lack of endurance, weakness or instability. There was no additional limitation of motion after three repetitions. X-rays of the left shoulder showed degenerative changes of the acromion and acromioclavicular joint. X-rays of the left humerus revealed mild cystic change in the head of the humerus with no other abnormality. The examiner diagnosed impairment of the upper arm humerus status post-surgery with no functional limitation, and left shoulder degenerative joint disease of the acromioclavicular joint and acromion, not caused by or related to military service. On VA examination in December 2016 the Veteran complained of recurrent left shoulder pain at night that at times woke him up at night. He denied loss in the range of motion of the shoulder. He did not wear any arm support. There was mild pain in both shoulders with active and passive range of motion, specifically on flexion, abduction, external rotation, internal rotation. However, pain did not result in additional functional loss. The Veteran denied flare-up in symptoms. Right shoulder range of motion was flexion 0 to 170 degrees, abduction was 0 to 165 degrees, external rotation was 0 to 80 degrees, and internal rotation was 0 to 70 degrees. Left shoulder flexion was 0 to 170 degrees, abduction was 0 to 140 degrees, external rotation was 0 to 90 degrees, and internal rotation was 0 to 65 degrees. There was no additional functional loss or range of motion after three repetitions. There was no pain with weight bearing. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue or crepitus. Pain, weakness, fatigability and incoordination did not significantly limit his functional ability with repeated use over a period of time. Muscle strength was 4/5 bilaterally. There was no muscle atrophy, ankylosis, rotator cuff condition, instability, acromioclavicular or sternoclavicular joint condition, or impairment of the humerus. The Veteran had a residual surgical scar in the anterior left shoulder measuring 27cm in length by 1 cm in width. X-rays showed left shoulder revealed slightly greater ac joint degenerative arthritic spurring. The examiner opined that the left shoulder condition had no impact on his ability to perform any type of occupational task. Based upon the relevant evidence of record, the Board concludes that the preponderance of evidence weighs against the Veteran's claim of entitlement to an evaluation in excess of 20 percent. To warrant an increased disability rating in excess of 20 percent, the Veteran's non-dominant left shoulder disability would have to result symptoms which more nearly approximate fibrous union of the humerus. Id. As set forth above, there has been no finding of fibrous union of the humerus. The Veteran's service-connected left shoulder has been manifested complaints of pain and limited motion. See 38 C.F.R. § 4.71a, Diagnostic Code 5202. The Board has therefore considered rating the Veteran's disability under the criteria pertaining to limitation of motion of the arm. 38 C.F.R. § 4.71a, Diagnostic Code 5201. In order to warrant a rating in excess of 20 percent, however, the record must show loss of motion to 25 degrees from the side. As set forth above, however, the range of motion testing conducted in connection with this claim shows that the Veteran retains motion well in excess of this. The Board has considered whether factors such as functional impairment and pain addressed under 38 C.F.R. §§ 4.10, 4.40, and 4.45 would warrant a higher rating for the Veteran's left shoulder disability during the rating periods under consideration. See DeLuca, 8 Vet. App. 202. The VA examination reports and treatment records establish that the Veteran has pain on motion of his left shoulder. However, such pain is not shown to have caused additional restriction warranting ratings in excess of 20 percent. See also Correia, supra. Additionally, while the VA examiner in December 2016, noted that there was surgical scarring, the scar was not painful or unstable, nor covering a total area greater than 39 square cm. Accordingly, a separate compensable rating is not warranted. See 38 C.F.R. § 4.118, Diagnostic Codes 7804, 7805 (2017). The Veteran is competent to describe his observable symptoms, including left shoulder pain resulting in limitation of motion or guarding. Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, to the extent that his reported symptoms are inconsistent with the objective medical evidence of, such statements are afforded less probative value, as the Veteran does not possess the medical or orthopedic expertise to assess the severity of a complex musculoskeletal or orthopedic condition. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). As such, the Board affords the most probative weight to the objective findings contained with the VA examination reports of record. The Board has also considered whether another potentially applicable diagnostic code would warrant an increased disability rating at any time during the period on appeal. See Schafrath, 1 Vet. App. at 595. Again, the evidence of record does not document the required severity of limitation or motion, nor is there ankylosis of scapulohumeral articulation, nonunion of the humerus (false flail joint), loss of head of humerus (flail shoulder), or impairment of the clavicle or scapula, including dislocation, nonunion, or malunion. Therefore, consideration of Diagnostic Codes 5200, and 5203 does not lead to the desired increased ratings for any period on appeal. See 38 C.F.R. § 4.71a, Diagnostic Codes 5200, 5201, 5203 (2017). In conclusion, the Board has carefully considered the lay and medical evidence of record, and finds that the preponderance of the evidence weighs against the Veteran's claim of entitlement to a disability rating higher than 20 percent for the left shoulder disability. As such, there is no reasonable doubt to be resolved, and the claim must be denied. 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 55. TDIU The Veteran claims that his service-connected disabilities prevent him from engaging in substantially gainful employment. Specifically, he asserts that the service-connected heart disease, lumbar spine disability and left shoulder disability render him unemployable. VA disability ratings are based, as far as practicable, on the average impairment of earning capacity attributable to disability resulting from all types of diseases and injuries encountered as a result of or incident to active service. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.10 (2017). Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. Id. Where the schedular rating is less than total, a total disability rating may nonetheless be assigned when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disability; provided that, in pertinent part, if there is only one such disability, the disability shall be rated at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability rated 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(a), 4.16(a). It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. Thus, in any case where the veteran is unemployable by reason of service-connected disabilities but has failed to meet the percentage standards discussed above, rating boards will submit the case to the Director, Compensation and Pension Service, for extra-schedular consideration under 38 C.F.R. § 4.16 (b). Entitlement to a total rating must be based solely on the impact of service-connected disabilities on the ability to keep and maintain substantially gainful employment. See 38 C.F.R. §§ 3.340, 3.341, 4.16 (2017). In reaching such a determination, 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). For VA purposes, the term "unemployability" is synonymous with an inability to secure and follow a substantially gainful occupation. VAOPGPREC 75-91; 57 Fed. Reg. 2317 (1992). Consideration may be given to the level of education, special training, and previous work experience in arriving at a conclusion. Individual unemployability, however, must be determined without regard to any nonservice-connected disabilities or advancing age. 38 C.F.R. §§ 3.341 (a), 4.16, 4.19 (2017); Van Hoose v. Brown, 4 Vet. App. 361 (1993). A high rating in itself is recognition that the impairment makes it difficult to obtain or maintain employment, but the ultimate question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose, 4 Vet. App. at 363. The ultimate issue of whether a TDIU should be awarded is not a medical issue, but rather is a determination for the adjudicator. See Moore v. Nicholson, 21 Vet. App. 211, 218 (2007) (ultimate question of whether a veteran is capable of substantial gainful employment is not a medical one; that determination is for the adjudicator), rev'd on other grounds sub nom, Moore v. Shinseki, 555 F.3d 1369 (Fed. Cir. 2009). Although VA must give full consideration, per 38 C.F.R. § 4.15, to "the effect of combinations of disability," VA regulations place responsibility for the ultimate TDIU determination on VA, not a medical examiner's opinion. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013); 38 C.F.R. § 4.16 (a); see also Smith v. Shinseki, 647 F.3d 1380, 1385-86 (Fed. Cir. 2011) (VA is not required to obtain an industrial survey from a vocational expert before making a TDIU determination but may choose to do so in an appropriate case). In this case, service connection is in effect for coronary artery disease, rated as 30 percent from May 28, 2101, and 60 percent from September 29, 2016; a left shoulder disability, rated as 20 percent from July 10, 1987; a low back disability, rated as 30 percent from July 10, 1987; hemorrhoids, rated as zero percent disabling from July 10, 1987; and surgical scars, rated as May 28, 2010. The Veteran's combined disability rating was 60 percent from May 28, 2010, and 70 percent from September 29, 2016. Thus, the Veteran did not meet the schedular criteria for a TDIU prior to September 29, 2016. From September 29, 2016, however, the Veteran meets the schedular criteria for TDIU as he had multiple service-connected disabilities with a combined rating of 70 percent and one service-connected disability rated at 40 percent or more. 38 C.F.R. § 4.16 (a). Regardless, the question before the Board is whether the Veteran is unemployable by reason of his service-connected disabilities, taking into account his educational and occupational background. The Board finds that the greater weight of the probative evidence is against a finding that the Veteran is unable to secure and follow a substantially gainful occupation by reason of his service-connected disabilities at any point during the period on appeal. Historically, the evidence reflects the Veteran completed high school. His occupational history included work in highway maintenance for the Florida Department of Transportation, for approximately 10 years. He was last employed in 1989. On VA joints examination in June 2010 the Veteran reported being employed for 11 years with the state of Florida doing highway maintenance until he retired in 1989. The examiner found that the Veteran's lumbar spine disability was productive of mild functional limitations, and the left shoulder condition did not cause any functional limitations. In an April 2012 Ischemic Heart Disease Disability Benefits Questionnaire form the Veteran's physician indicated that the Veteran's heart disability impacted his ability to work. The clinician noted that the Veteran was occupationally limited mostly by his peripheral vascular disease, but also by coronary artery disease and decreased vision. On VA heart examination in September 2016, the examiner found that the Veteran's heart disability affected him occupationally due to shortness of breath and fatigue when walking some distance and also leg cramps after walking more than 200 feet. His surgical scars were found to have no impact on his ability to work or function. When the Veteran's shoulder and spine were last examined in December 2016, the examiner opined that the left shoulder condition and lumbar spine disability had no impact on the Veteran's ability to perform any type of occupational task. A VA examiner in February 2017 indicated that the Veteran's coronary artery disease, status post bypass graft, was productive of mild functional limitation. The examiner determined that the Veteran was capable of light physical activity or sedentary desk work. While the Veteran's service-connected disabilities have been found to cause a significant impact on his daily functioning, that impact was considered in the scheduler ratings currently assigned. The Board finds that the evidence of record fails to support a finding that he is unemployable due solely to his service-connected disabilities at any point during the period on appeal. Therefore, the Board finds that the preponderance of the evidence does not show that the currently service-connected disabilities alone prevent the Veteran from obtaining and maintaining substantially gainful employment. In sum, the criteria are not met for the assignment of a TDIU on a scheduler or extraschedular basis. ORDER A rating higher than 20 percent for a lumbar spine disability is denied. A rating higher than 20 percent for a left shoulder disability is denied. Entitlement to a total disability rating based on individual unemployability due exclusively to service-connected disabilities, to include on an extraschedular basis, is denied. ____________________________________________ K. Conner Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs