Citation Nr: 1701559 Decision Date: 01/23/17 Archive Date: 02/09/17 DOCKET NO. 13-06 707A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for coronary artery disease (CAD). 2. Entitlement to an initial increased rating for left lower extremity peripheral neuropathy, evaluated as 0 percent disabling from March 25, 2009, and 20 percent disabling from September 22, 2011. 3. Entitlement to an initial increased rating for right lower extremity peripheral neuropathy, evaluated as 0 percent disabling from March 25, 2009, and 20 percent disabling from September 22, 2011. 4. Entitlement to an initial rating in excess of 20 percent for type II diabetes mellitus. 5. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD A. Vieux, Associate Counsel INTRODUCTION The Veteran had active service in the United States Army from October 1964 to August 1967, including service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from October 2010 and April 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Milwaukee, Wisconsin. In September 2015, the Board remanded this case for further evidentiary development. FINDINGS OF FACT 1. Prior to March 26, 2013, the Veteran's CAD was not manifested by more than one episode of acute congestive heart failure; workload of greater than 3 metabolic equivalents (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. 2. Since August 1, 2013, the Veteran's CAD has been manifested by a workload of greater than 3 METs but not greater than 5 METs resulting in fatigue. 3. The Veteran's peripheral neuropathy of the right and left lower extremities was manifested by mild incomplete paralysis prior to September 22, 2011. 4. The Veteran's peripheral neuropathy of the right and left lower extremities has not been manifested by moderately severe incomplete paralysis since September 22, 2011. 5. The Veteran's type II diabetes mellitus requires the use of insulin and a restricted diet but not regulation of activities. 6. The Veteran is not unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities. CONCLUSIONS OF LAW 1. Prior to March 26, 2013, the criteria for an initial rating in excess of 30 percent for CAD are not met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.104, Diagnostic Code 7005 (2016). 2. Since August 1, 2013, the criteria for a 60 percent rating, but no higher, for CAD are met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.104, Diagnostic Codes 7005-7017 (2016). 3. Prior to September 22, 2011, the criteria for an initial 10 percent rating, but no higher, for peripheral neuropathy of the left lower extremity are met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.123, 4.124, 4.124a, Diagnostic Code 8620 (2016). 4. Since September 22, 2011, the criteria for a rating in excess of 20 percent for peripheral neuropathy of the left lower extremity are not met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.123, 4.124, 4.124a, Diagnostic Code 8620 (2016). 5. Prior to September 22, 2011, the criteria for an initial 10 percent rating, but no higher, for peripheral neuropathy of the right lower extremity are met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.123, 4.124, 4.124a, Diagnostic Code 8620 (2016). 6. Since September 22, 2011, the criteria for a rating in excess of 20 percent for peripheral neuropathy of the right lower extremity are not met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.123, 4.124, 4.124a, Diagnostic Code 8620 (2016). 7. The criteria for a rating in excess of 20 percent for type II diabetes mellitus are not met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.119, Diagnostic Code 7913 (2016). 8. The criteria for entitlement to a TDIU are not met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2014); 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16, 4.18, 4.25 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Initially, the Board notes that in the September 2016 Post-Remand Brief, the Veteran's representative requested a remand for a new VA examination. The representative stated, "[t]he medical evidence of record used to render the S[upplemental] S[tatement] O[f the] C[ase] decision was for only one month in 2015. These medical records are over a year old and do not adequately address the true nature of the appellant['s] service-connected conditions." The representative has not indicated a worsening of the Veteran's service-connected disabilities since the March 2014 VA examination was conducted, and the evidence of record does not otherwise suggest that these conditions have diminished since that time such that a new examination is warranted. See Palczewski v. Nicholson, 21 Vet. App. 174, 182 (2007) (holding that the mere passage of time, without evidence of worsening, does not require a new examination); see also VAOPGCPREC 11-95. Increased Ratings Disability ratings are assigned in accordance with VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Separate diagnostic codes identify the various disabilities. See generally 38 C.F.R. Part 4. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. CAD The appeal period stems from March 25, 2009, the effective date of the award of service connection for his heart disease. Prior to March 26, 2013, the Veteran's CAD has been evaluated under 38 C.F.R. § 4.104, Diagnostic Code 7005 (arteriosclerotic heart disease). Under Diagnostic Code 7005, a 10 percent evaluation is warranted for a workload greater than 7 METs but not greater than 10 METs resulting in dyspnea (shortness of breath), fatigue, angina, dizziness, or syncope; or, continuous medication required. A 30 percent evaluation is warranted for a workload of greater than 5 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 evaluation 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 when a workload of 3 METs or less results 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 prior to Diagnostic Code 7005 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, Note (2). As of March 26, 2013, the Veteran's CAD has been evaluated under 38 C.F.R. § 4.104, Diagnostic Codes 7005-7017. See 38 C.F.R. § 4.27 (hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. The additional code is shown after the hyphen). Diagnostic Code 7017 provides ratings for coronary bypass surgery. For three months following hospital admission for surgery, a 100 percent rating is assigned. Thereafter, status post coronary bypass surgery resulting in workload of greater than 7 METs but not greater than 10 METs that results in dyspnea, fatigue, angina, dizziness, or syncope; or continuous medication is required, is rated 10 percent disabling. Status post coronary bypass surgery resulting in a workload of greater than 5 METs but not greater than 7 METs that results in dyspnea, fatigue, angina, dizziness, or syncope; or evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or x-ray, is rated 30 percent disabling. Status post coronary bypass surgery resulting in 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 that results in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of 30 to 50 percent, is rated 60 percent disabling. Status post coronary bypass surgery resulting in chronic congestive heart failure; or workload of 3 METs or less that results in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent, is rated 100 percent disabling. 38 C.F.R. § 4.104, Diagnostic Code 7017. The Veteran contends that because he had "two major medical heart occurrences and numerous minor heart problems in addition to heart surgery and fibrillation, my health and quality of life have deteriorated considerably." See December 2015 correspondence. An electrocardiogram (EKG) study conducted in April 2006 was normal. In August 2010, the Veteran was afforded a VA examination. At that time he denied ever experiencing symptoms of angina or congestive heart failure. He also denied dyspnea on exertion, fatigue, dizziness, or syncope. Further, he stated that his heart condition was currently completely asymptomatic, and he did not take any heart medications. Stress testing obtained in September 2010 revealed a peak workload of 7 METs that resulted in shortness of breath. A May 2011 private treatment record shows that the Veteran's atherosclerotic heart disease was "symptomatically stable." In his August 2011 notice of disagreement, the Veteran noted that since his last evaluation he had developed an irregular heartbeat. Nevertheless, an October 2011 private treatment record indicates that stress testing revealed a peak workload of 7 METs that resulted in fatigue, with an absence of exercise-induced ischemic symptoms. A March 2012 follow-up private treatment record shows that the Veteran was feeling well, and denied any chest pain or palpitations. An April 2012 private treatment record shows that he had done well symptomatically, and he did not have chest pain or shortness of breath. In addition, he did not have orthopnea, palpitations, lightheadedness, or syncope. Further, a December 2012 private treatment record shows that he did not have chest pain, palpitations, or shortness of breath. Based on the foregoing, the Board finds that an evaluation higher than 30 percent is not warranted from March 25, 2009 to March 26, 2013. During this period, there is no showing of a workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope. Rather, the Veteran's workload was 7 METs in September 2010 and October 2011. Further, there is no evidence of more than one episode of acute congestive heart failure during this period, and there was no evidence of left ventricular dysfunction with an ejection fraction of 30 to 50 percent. On April 17, 2013, the Veteran underwent coronary artery bypass graft. A March 2015 rating decision assigned a rating of 100 percent for CAD status post coronary artery bypass graft pursuant to Diagnostic Codes 7005-7017 effective March 26, 2013, and a rating of 30 percent from August 1, 2013. (Accordingly, the period from March 26, 2013 to July 31, 2013 will not be addressed herein.) The RO noted that on March 26, 2013 exercise stress test showed 1 METs and ejection fraction of 54 percent. In March 2014, the Veteran was afforded a VA examination. There was no evidence of cardiac hypertrophy or cardiac dilatation. EKG was normal. Interview-based METS test results revealed a workload of greater than 3 METs but not greater than 5 METs with fatigue, with the examiner noting that other non-cardiac conditions (foot pain/neuropathy and obstructive sleep apnea) limit his METs level. The Veteran reported that he was able to exercise and denied symptoms of CAD with exercise. Further, it was noted that he did not have congestive heart failure. An April 2014 VA treatment record shows a left ventricular ejection fraction of 55 percent, and severe coronary artery disease with prominent calcification of the left main with diffuse 50 percent stenosis of the left main. A June 2014 private treatment record shows that he was doing well overall with no specific symptomatic concerns. Further, he did not have chest pain, dyspnea on exertion or decrease in activity tolerance. In addition, it was noted that he did not have a history of orthopnea, paroxysmal nocturnal dyspnea, palpitations, lightheadedness, or syncope. A September 2014 VA treatment record shows left ventricular ejection fraction estimated at 60 to 65 percent. A November 2014 VA treatment record shows a normal global left ventricular systolic function with ejection fraction estimated at 55 to 60 percent. A May 2015 EKG was normal. After a careful review of the record, and affording the Veteran the benefit of the doubt, the Board finds that a 60 percent rating, but no higher, is warranted from August 1, 2013, as the only testing during this period revealed a workload of greater than 3 METs but not greater than 5 METs with fatigue. See March 2014 VA examination. While the VA examiner attributed the Veteran's METs workload to factors other than the service-connected heart condition, she was unable to attribute percentages to specific disabilities. Accordingly, the METs workload will be considered as due solely to the heart. Mittleider v. West, 11 Vet App. 181 (1998) citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996) (holding that the Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence that does so.). Based on the current evidence of record, the Board does not find that a higher, 100 percent rating, is warranted from August 1, 2013. From that date, there is no showing of chronic congestive heart failure; a 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. As noted above, the Veteran's left ventricular ejection fractions ranged from 55 to 65 percent. Giving the Veteran the benefit of the doubt, his claim for an increased evaluation for his CAD is partially granted in the form of a 60 percent evaluation effective August 1, 2013, but not prior to March 26, 2013. In all other respects, his claim for an increased rating for CAD is denied. The Board has considered whether staged ratings are appropriate, but, except as found above, further staged ratings are not warranted. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Bilateral Lower Extremity Peripheral Neuropathy The appeal period stems from March 25, 2009, the effective date of the award of service connection for his peripheral neuropathy. The Veteran's service-connected peripheral neuropathy of the right and left lower extremities is evaluated under the criteria found at 38 C.F.R. § 4.124a, Diagnostic Code 8620. Under Diagnostic Code 8620, disability ratings of 10 percent, 20 percent, and 40 percent are assignable for neuritis (the same ratings could be provided for incomplete paralysis of the sciatic nerve under Diagnostic Code 8520) which is mild, moderate, or moderately severe in degree, respectively. A 60 percent disability rating is warranted for severe incomplete paralysis of the sciatic nerve with marked muscle atrophy. The maximum 80 percent disability rating is warranted when there is complete paralysis of the sciatic nerve, which contemplates foot dangling and dropping, no active movement possible of muscles below the knee, and flexion of the knee weakened or (very rarely) lost. 38 C.F.R. 4.124a, Diagnostic Code 8620. The Board notes that in rating 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. 38 C.F.R. § 4.124a. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Id. The Board finds that prior to September 22, 2011 peripheral neuropathy of the right and left lower extremities was manifested by mild incomplete paralysis. Here, the Veteran contends that he has numbness in his feet and "they feel like they are asleep all the time." See August 2011 VA Form 21-4138. A December 8, 2005 private treatment record notes that he complained of having diminished sensation in the great toes. Light touch sensation was diminished in the right great toe, and he was diagnosed with mild peripheral neuropathy. In an August 2010 VA examination, the Veteran specifically denied having any problems such as numbness or tingling in his lower extremities. However, the examiner noted that a December 2005 EMG study indicated the presence of mild peripheral neuropathy affecting both lower extremities. Upon neurological examination, the examiner found that the Veteran demonstrated no sensory loss to his lower extremities. Further, his gait was normal and he was able to perform tandem walking, heel walking, and toe walking without any difficulty. Considering the 2005 EMG study, the 2010 VA examiner's finding of mild peripheral neuropathy and the Veteran's lay statements, prior to September 22, 2011, peripheral neuropathy of the lower extremities warrants a 10 percent rating, but no higher, in each extremity for mild incomplete paralysis. At the September 22, 2011 VA examination, the Veteran reported no pain in his lower extremities, only mild bilateral lower extremity numbness and moderate bilateral lower extremity paresthesias and/or dysesthesias. He had decreased reflexes 1+ for both of the knees, and absent reflexes 0 for both ankles. Nevertheless, strength testing was shown to be 5/5 normal on bilateral knee extension, knee flexion, ankle plantar flexion, and ankle dorsiflexion. Further, light touch/monofilament testing of the bilateral knee/thigh and bilateral ankle/lower leg were normal. In addition, position sense of the bilateral lower extremity was normal. However, light touch/monofilament testing of the bilateral foot/toes was decreased. Vibration sensation of the bilateral lower extremity was absent, and cold sensation of the bilateral lower extremity was decreased. Nevertheless, he did not have any muscle atrophy or trophic changes. The examiner found that the lower extremities were manifested by moderate incomplete paralysis. Further, he found that the Veteran's peripheral neuropathy did not impact his ability to work. In a March 2013 private treatment record, the physician noted that she could palpate the Veteran's pulses in his feet, and did not believe that he had a circulation issue. She also indicated that she would not start him on peripheral neuropathy medication. At the March 2014 VA examination, the Veteran reported moderate bilateral lower extremity paresthesias and/or dysesthesias and moderate bilateral lower extremity numbness. In addition, he had decreased reflexes 1+ for both of the knees and ankles. Nevertheless, strength testing was shown to be 5/5 normal on bilateral knee extension, knee flexion, ankle plantar flexion, and ankle dorsiflexion. Further, light touch/monofilament testing of the bilateral knee/thigh was normal, but was decreased in the bilateral ankle/lower leg and foot/toes. The examiner noted that he attended the gym and did some household chores. In addition, she indicated that he was independent with all activities of daily living. She found that he was able to do sedentary work. In view of the foregoing, the Board finds that ratings in excess of 20 percent are not warranted from September 22, 2011 because the record evidence shows that peripheral neuropathy of the right and left lower extremities has not been manifested by moderately severe incomplete paralysis. Specifically, his decreased and absent reflexes and vibration sensation in his ankles is accounted for in his currently assigned 20 percent ratings for moderate symptomatology. Crucially, the Veteran himself has only reported mild or moderate symptoms in relation to his bilateral peripheral neuropathy, and his treating physician has indicated that his condition is not of such a severity to warrant any type of medication. He has specifically denied any pain, and has evidenced normal strength testing on physical examination with no evidence of atrophy or trophic changes. For these reasons, ratings in excess of 20 percent are denied. The Board has considered whether staged ratings are appropriate, but, except as found above, further staged ratings are not warranted. Fenderson, supra. Diabetes Mellitus The Veteran contends that his diabetes mellitus has worsened since the October 2010 rating decision. See August 2011 VA Form 21-4138. He stated that he "takes 300% more insulin since the October 8th rating and Glyburide has increased 100%." Id. In a March 2013 VA Form 9, the Veteran contends that his diabetes worsened. He also claimed that the RO did not have any medical records to base their decision. See id. He contends that "disability has decreased mobility significantly." Id. He also noted that he takes 2 types of insulin. Id. The Veteran's service-connected type II diabetes mellitus is evaluated under the criteria found at 38 C.F.R. § 4.119, Diagnostic Code 7913. A 20 percent evaluation is assigned for diabetes mellitus that requires insulin and restricted diet or oral hypoglycemic agent and a restricted diet. A 40 percent evaluation is appropriate for diabetes mellitus that requires insulin, restricted diet, and regulation of activities. A 60 percent evaluation is assigned for diabetes mellitus that requires insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring at least one or 2 hospitalizations per year or twice a month visits to a diabetes care provider, plus complications that would not be compensable if separately evaluated. A 100 percent evaluation is applicable for diabetes mellitus that requires more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least 3 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 evaluated. 38 C.F.R. § 4.119, Diagnostic Code 7913. The Veteran contends that because he takes 2 types of insulin for his diabetes, he is entitled to a higher rating and that the February 2013 Statement of the Case (SOC) indicates "40 percent is not warranted unless there is diabetes requiring insulin." See March 2013 VA Form 9. However, that document specifically indicates that "a higher evaluation of 40 percent is not warranted unless there is diabetes requiring insulin, restricted diet, and regulation of activities." See February 2013 SOC at 16. The definition of "regulation of activities" in the criteria for a 100 percent rating, that is, the "the avoidance of strenuous occupational and recreational activities," also applies to the "regulation of activities" criterion for a 40 or 60 percent rating under Diagnostic Code 7913. In addition, the criterion of "regulation of activities" requires medical evidence that occupational and recreational activities have been restricted by the diabetes. Camacho v. Nicholson, 21 Vet. App. 360, 364 (2011). Moreover, because of the successive nature of the rating criteria, such that the evaluation for each higher disability rating includes the criteria of each lower disability rating, each of the criteria listed in the 40 percent rating must be met in order to warrant such a rating. The provisions of 38 C.F.R. § 4.7 pertaining to a higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating, do not apply. See Camacho at 366-367; see Tatum v. Shinseki, 23 Vet. App. 152, 156 (2011) (where there are successive rating criteria as in Diagnostic Code 7913, to grant a higher rating where only two out of three criteria are met would eviscerate the need for different ratings since symptoms established for either rating might be the same). The record evidence shows that throughout the appeal period the Veteran's diabetes has not manifested in regulation of activities. He was afforded a VA examination in August 2010 and the examiner noted that he was currently taking glyburide and 17 units of detemir insulin twice a day. He also indicated that current blood glucose readings showed borderline control between 120 to 160 in a fasting state. However, the Veteran's hemoglobin A1c readings were very well-controlled. He was following a low sugar restricted diet, but indicated that he was never instructed to restrict activities on account of his diabetes. The examiner also noted that he did not have any episodes of ketoacidosis or hypoglycemic reactions. The Veteran denied pruritus or loss of strength. The examiner found that the Veteran had "well-controlled" diabetes mellitus. The September 2011 VA examiner noted that the Veteran's diabetes was managed by a restricted diet and he was prescribed insulin, more than 1 injection per day. The examiner noted that he was taking glyburide and 30 units of detemir insulin twice a day. The examiner indicated that the Veteran did not require regulation of activities as part of management of his diabetes. Further, he did not have any hospitalizations for episodes of ketoacidosis or hypoglycemic reactions over the prior 12 months. The examiner found that his diabetes did not impact his ability to work. The March 2014 VA examiner noted that the Veteran's diabetes was currently treated with an oral hypoglycemic and insulin, requiring more than 1 injection per day. The examiner indicated that he did not require regulation of activities as part of medical management of his diabetes. He visited his diabetic care provider for episodes of ketoacidosis and hypoglycemia for less than 2 times per month. However, he did not have any episodes of ketoacidosis or hypoglycemic reactions in the prior 12 months that required hospitalization. The examiner noted that he had progressive unintentional weight loss and loss of strength attributable to diabetes. Nevertheless, the examiner found that his diabetes did not impact his ability to do sedentary work. She noted that he was able to attend the gym, do some household chores, and was independent with all activities of daily living. In view of the foregoing, the preponderance of the evidence thus reflects that the Veteran's diabetes does not require regulation of activities as that term is defined in the applicable regulation and a schedular rating higher than 20 percent is therefore not warranted at any point during the appeal period. In other words, there is no medical evidence that occupational and recreational activities have been restricted by the Veteran's diabetes. Moreover, as regulation of activities is required for higher ratings of 60 and 100 percent under Diagnostic Code 7913, those higher ratings are not warranted as well. Finally, with respect to all increased rating issues on appeal, the Veteran does not assert that referral for extraschedular consideration is warranted, and the record does not otherwise reasonably raise the matter. Yancy v. McDonald, 27 Vet. App. 484, 495 (2016). TDIU The Veteran contends that he became disabled to work on January 11, 2008 secondary to his service-connected diabetes mellitus and CAD. March 2013 VA Form 21-8940. Awards of TDIU are governed, in part, by 38 C.F.R. § 4.16(a). Under that regulation, total disability ratings for compensation can be assigned, where the schedular rating is less than total, 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 disabilities: provided that, if there is only one such disability, the disability must be ratable at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. See also 38 C.F.R. §§ 3.340, 3.341. Neither nonservice-connected disabilities nor advancing age may be considered in the determination. 38 C.F.R. §§ 3.341, 4.19; Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). As a result of this decision, the Veteran has a combined rating of 60 percent from March 25, 2009, 70 from September 22, 2011 and 80 percent beginning August 1, 2013. As all of his service-connected disabilities have a common etiology, they are considered "one disability." and he thus meets the schedular criteria for a TDIU for the entire appeal period. See 38 C.F.R. § 4.16(a)(1). He worked as a laborer since 1970 and was last gainfully employed on January 10, 2008. See March 2013 VA Form 21-8940. He has a high school education. See id. Thus, the remaining question is whether the Veteran's service-connected disabilities, alone, preclude him from securing or following substantially gainful employment. 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.16. Here, the September 22, 2011 VA examiner opined that the Veteran's diabetes, peripheral neuropathy, and ischemic heart disease did not impact his ability to work. Further, the March 2014 VA examiner indicated that CAD in and of itself would not likely limit gainful employment because coronary artery bypass graft remedied his CAD and fibrillation, he is able to exercise, and he denied symptoms of CAD with exercise. In addition, the examiner stated that the Veteran's diabetes in and of itself would not limit gainful employment that did not require heavy physical work. The examiner indicated that he is able to do sedentary work or light physical work as lifting, pushing, and moving less than 20 pounds intermittently with ability to sit periodically. Moreover, the examiner indicated that secondary to his peripheral neuropathy he would not likely be able to do work which required weight bearing for an entire 8-hour shift, but would be able to do sedentary work with brief periods of weight bearing and would benefit from weight bearing periodically as with exercise. She also noted that he would be able to lift and carry up to 20 pounds intermittently for short distances, but not likely to carry more than 20 pounds frequently or up stairs, etc. She noted that he was able to attend the gym, do some household chores, and was independent with all activities of daily living. The Board does not dispute the Veteran experiences some level of occupational impairment due to his service-connected diabetes and CAD. Indeed, the basis of disability evaluations is the ability of the body as a whole to function under the ordinary conditions of life, including employment. 38 C.F.R. § 4.10. However, while the Veteran is competent to report symptoms he experiences, he is not competent to assess whether his symptoms meet VA criteria for a TDIU. Here, the preponderance of the competent evidence of record reflects that the Veteran is not precluded from securing or following a substantially gainful occupation as a result of service-connected disabilities. Thus, the Board finds that the benefit sought on appeal must be denied. ORDER Prior to March 26, 2013, an initial rating in excess of 30 percent for CAD is denied. Since August 1, 2013, a 60 percent rating, but no higher, for CAD is granted. From March 25, 2009 to September 22, 2011, a 10 percent rating, but no higher, for peripheral neuropathy of the left lower extremity is granted. From March 25, 2009 to September 22, 2011, a 10 percent rating, but no higher, for peripheral neuropathy of the right lower extremity is granted. Since September 22, 2011, a rating in excess of 20 percent for peripheral neuropathy of the left lower extremity is denied. Since September 22, 2011, a rating in excess of 20 percent for peripheral neuropathy of the right lower extremity is denied. A rating in excess of 20 percent for type II diabetes mellitus is denied. Entitlement to a TDIU is denied. ______________________________________________ S. BUSH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs