Citation Nr: 1800816 Decision Date: 01/05/18 Archive Date: 01/19/18 DOCKET NO. 13-11 354 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for peripheral neuropathy of the right lower extremity, to include as secondary to service-connected diabetes mellitus, type II (DM). 2. Entitlement to service connection for peripheral neuropathy of the left lower extremity, to include as secondary to service-connected DM. 3. Entitlement to service connection for peripheral neuropathy of the right upper extremity, to include as secondary to service-connected DM. 4. Entitlement to service connection for peripheral neuropathy of the left upper extremity, to include as secondary to service-connected DM. 5. Entitlement to an increased disability rating in excess of 20 percent for DM. 6. Entitlement to an initial disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD) with depressed mood. 7. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: Allen Gumpenberger, Agent ATTORNEY FOR THE BOARD M. Salazar, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1988 to March 1995. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Milwaukee, Wisconsin. Jurisdiction has since transferred to the RO in St. Louis, Missouri. See October 2017 Form VA 8. A June 2011 rating decision denied entitlement to TDIU. A May 2014 rating decision denied service connection for peripheral neuropathy of the bilateral upper and lower extremities. An April 2013 rating decision granted service connection for PTSD with depressed mood and assigned a 30 percent disability rating under Diagnostic Code 9411, effective September 3, 2010. A February 2014 rating decision continued a 20 percent disability rating for service-connected DM. When, as here, a Veteran seeks an increased evaluation, it will generally be presumed that the maximum benefit allowed by law and regulation is sought, and it follows that such claims remain in controversy where less than the maximum benefit available is awarded. See AB v. Brown, 6 Vet. App. 35, 38 (1993). In September 2016, the Board remanded the Veteran's claims to the Agency of Original Jurisdiction (AOJ) for further action consistent with the Board's remand directives. The claims are back before the Board for further appellate proceedings. FINDINGS OF FACT 1. The preponderance of the competent and credible evidence weighs against finding that the Veteran has right lower extremity peripheral neuropathy. 2. The preponderance of the competent and credible evidence weighs against finding that the Veteran has left lower extremity peripheral neuropathy. 3. The preponderance of the competent and credible evidence weighs against finding that the Veteran has right upper extremity peripheral neuropathy. 4. The preponderance of the competent and credible evidence weighs against finding that the Veteran has left upper extremity peripheral neuropathy. 5. The Veteran does not require regulation of activities to manage her DM. 6. Prior to April 7, 2016, the Veteran's PTSD with depressed mood was not manifested by symptoms resulting in occupational and social impairment with reduced reliability and productivity, total occupational and social impairment, or occupational and social impairment, with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood. 7. As of April 7, 2016, the Veteran's PTSD with depressed mood was manifested by symptoms resulting in occupational and social impairment with reduced reliability and productivity; however, total occupational and social impairment, or occupational and social impairment, with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood was not shown. 8. Prior to April 7, 2016, the Veteran does not meet the schedular requirements for a TDIU, her service-connected disabilities do not preclude her from obtaining and retaining substantially gainful employment, and referral for extraschedular consideration is not warranted. 9. As of April 7, 2016, the Veteran is not rendered unemployable as the result of her service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for service connection for right lower extremity peripheral neuropathy have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2017). 2. The criteria for service connection for left lower extremity peripheral neuropathy have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2017). 3. The criteria for service connection for right lower extremity peripheral neuropathy have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2017). 4. The criteria for service connection for left lower extremity peripheral neuropathy have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2017). 5. The criteria for an increased rating in excess of 20 percent for DM have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.119, Diagnostic Code 7913 (2017). 6. Prior to April 7, 2016, the criteria for an initial disability rating in excess of 30 percent for PTSD and depressed mood have not been met. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2017). 7. As of April 7, 2016, the criteria for an initial disability rating of 50 percent, but no higher, for PTSD with depressed mood have been met. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2017). 8. The criteria for entitlement to a TDIU have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in part at 38 U.S.C. §§ 5103, 5103A, and implemented in part at 38 C.F.R. § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate the claim. The duty to notify has been met. Neither the Veteran, nor her representative, has alleged prejudice with regard to notice. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that "[A]bsent extraordinary circumstances . . . it is appropriate for the Board and the [United States Court of Appeals for Veterans Claims] to address only those procedural arguments specifically raised by the veteran . . . ." Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015). In light of the foregoing, nothing more is required. The duty to assist includes assisting the claimant in the procurement of relevant records. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). The RO associated the Veteran's VA, Social Security Administration (SSA), and identified private treatment records with the claims file. No other relevant records have been identified and are outstanding. As such, the Board finds VA has satisfied its duty to assist with the procurement of relevant records. During the appeal period, the Veteran was afforded VA medical examinations in November 2010, March 2013, January 2014, May 2014, August 2015, April 2016, and August 2017. The Board has carefully reviewed the VA examinations and finds that the examinations, along with the other evidence of record, are adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). As noted in the Introduction, the Board last remanded the claim in September 2016. In pertinent part, the Board instructed the RO to readjudicate the claims on appeal in light of all the evidence of record, including records from the SSA received by VA in October 2014. The RO readjudicated the claims in an August 2017 supplemental statement of the case (SSOC). Thus, the Board's prior remand instructions have been complied with for the purposes of this decision. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure substantial compliance). The Veteran has not made VA aware of any additional evidence that must be obtained in order to fairly decide the appeal. She has been given ample opportunity to present evidence and argument in support of her claims. Pursuant to 38 C.F.R. § 3.655, all relevant evidence necessary for an equitable disposition of the Veteran's appeal of the issues have been obtained and the case is ready for appellate review. General due process considerations have been complied with by VA. See 38 C.F.R. § 3.103 (2017). II. Service Connection A Veteran is entitled to VA disability compensation if there is a disability resulting from personal injury suffered or disease contracted in the line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty in active service. 38 U.S.C. §§ 1110, 1131. Generally, to establish a right to compensation for a present disability, a Veteran must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that a disease was incurred in service. 38 C.F.R. § 3.303(d). Under 38 C.F.R. § 3.303(b), claims for chronic diseases enumerated in 38 C.F.R. § 3.309(a) benefit from a relaxed evidentiary standard. See Walker v. Shinseki, 708 F.3d 1331, 1339 (Fed. Cir. 2013). When a chronic disease is established during active service, then subsequent manifestations of the same chronic disease at any later date, however remote, will be entitled to service connection, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). In order to establish the existence of a chronic disease in service, the evidence must show a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Id. Thus, the mere manifestation during service of potentially relevant symptoms, such as joint pain for degenerative joint disease, does not establish a chronic disease at that time unless the identity of the disease is established and its chronicity may not be legitimately questioned. Id. If chronicity in service is not established, then a showing of continuity of symptoms after discharge is required to support the claim. Id. The Federal Circuit, however, has clarified that this notion of continuity of symptomatology since service under 38 C.F.R. § 3.303(b), which is an alternative means of establishing the required nexus or linkage between current disability and service, only applies to conditions identified as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). While peripheral neuropathy is not a disease specifically enumerated as a chronic disease under 38 C.F.R. § 3.309(a), organic diseases of the nervous system are listed as disabilities subject to presumptive service connection. Accordingly, service connection may be granted on a presumptive basis for peripheral neuropathy if it is shown to be manifest to a degree of 10 percent or more within one year following the Veteran's separation from active military service. 38 C.F.R. §§ 3.307, 3.309(a). Under section 3.310(a) of VA regulations, service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show: (1) a current disability; (2) a service-connected disability; and (3) a nexus between the current disability and the service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512 (1988). As to the third Wallin element, the current disability may be either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Where a service-connected disability aggravates a non-service-connected condition, a Veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. 7 Vet. App. at 448. Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. VA will not concede a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. See 38 C.F.R. § 3.310(b). In the absence of proof of a present disability, there can be no valid claim. Degmetich v. Brown, 104 F.3d 1328, 1332 (1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The requirement for service connection that a current disability be present is satisfied when a Veteran has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim even though the disability resolves prior to the Secretary's adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 322-23 (2007) (a service connection claim may be granted if a diagnosis of a chronic disability was made during the pendency of the appeal, even if the most recent medical evidence suggests that the disability resolved); see also Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013) (holding that when the record contains a recent diagnosis of disability prior to a Veteran filing a claim for benefits based on that disability, the report of diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996) (citing Gilbert, 1 Vet. App. at 54). The crux of this case hinges on whether the Veteran has current bilateral peripheral neuropathy of the upper and lower extremities. The Veteran was afforded VA examinations in November 2010 and May 2014 attempting to answer this question. At the first examination, the examiner determined that vibratory and monofilament sensation is intact in the upper and lower extremities. As such, the examiner concluded that Veteran did not have diabetic neuropathy. See November 2010 VA examination. Over three years later, a VA examiner, after acknowledging that the Veteran complained of numbness in her feet, determined that all physical examinations prior to and since May 1, 2013 revealed sensation intact with "no focual neuro deficits" on examination. See May 2014 VA examination. Further, she stated that her January 2014 VA examiner for DM did not find evidence of diabetic related neuropathy. Id. A month later, her VA provider noted her extremities' sensation intact. See February 2014 VA treatment record. For these reasons, the May 2014 VA examiner determined that there was "insufficient evidence to warrant [diagnoses] of diabetic related neuropathy involving both upper and lower extremities." See May 2014 VA examination. The Board finds that the evidence does not warrant service connection for bilateral upper and lower extremity peripheral neuropathy. The Veteran is competent to testify as to facts she personally observed or described; this includes recalling what she personally felt, saw, smelled, heard, or tasted. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, she is not competent to offer opinions on complex medical matters. Whether the Veteran has peripheral neuropathy cannot be determined by mere observation alone. This requires specialized training. The Board finds that determining the etiology of the Veteran's numbness is not within the realm of knowledge of a non-expert, and concludes that her opinion in this regard is not competent evidence and therefore not probative of whether she has peripheral neuropathy. Therefore, following a review of all available evidence, the record does not reflect a current diagnosis for bilateral upper and lower peripheral neuropathy. To that end, the Board notes that the existence of a current disability is the cornerstone of a claim for VA disability compensation. Degmetich v. Brown, 104 F.3d 1328, 1332 (Fed. Cir. 1997). As such, without a current disability, the Veteran lacks the evidence necessary to substantiate her claims for service connection. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Thus, the Board denies the Veteran's claim for entitlement to service connection for bilateral upper and lower extremity peripheral neuropathy because the evidence of record is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). III. Increased Rating Here, the Veteran has averred that her DM and PTSD are more severe than her current disability rating would indicate. She filed a notice of disagreement (NOD) to her 30 percent disability rating for PTSD effective September 3, 2010 in May 2013 and filed her increased rating DM claim in April 2013. Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where the question for consideration is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of a "staged" rating are required. See Fenderson v. West, 12 Vet. App. 199, 125-26 (1999). The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). A. DM The service-connected DM is currently evaluated as 20 percent disabling under Diagnostic Code 7913. Under this Diagnostic Code, a 20 percent evaluation is assignable where DM requires insulin and a restricted diet, or oral hypoglycemic agents and a restricted diet. A 40 percent rating is warranted for DM requiring insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities). A 60 percent rating is warranted for DM requiring insulin, a restricted diet, and regulation of activities 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 disability rating will be assigned when DM requires more than one daily injection of insulin, 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 a progressive loss of weight and strength or complications which would be compensable if separately evaluated. 38 C.F.R. § 4.119, Diagnostic Code 7913 (2017). Note (1) to Diagnostic Code 7913 provides that compensable complications of DM are to be rated separately unless they are part of the criteria used to support a 100 percent rating (under Diagnostic Code 7913). Noncompensable complications are considered part of the diabetic process under Diagnostic Code 7913. 38 C.F.R. § 4.119, Diagnostic Code 7913. Service connection for complications of diabetes is discussed in the section above. Regulation of activities is defined as the "avoidance of strenuous occupational and recreational activities." 38 C.F.R. § 4.119, Diagnostic Code 7913. In Camacho v. Nicholson, 21 Vet. App. 360, 363-365 (2007), the Court held that medical evidence is required to show that occupational and recreational activities have been restricted, holding that "in order for a claimant to be entitled to a 40 [percent] disability rating, the evidence must show that it is medically necessary for a claimant to avoid strenuous occupational and recreational activities." Hence, a regulation of activities is a dispositive criterion to obtain a higher rating for DM in this case. The Board finds that a rating in excess of 20 percent for DM is not warranted at any time during the appeal period. The preponderance of the evidence of record demonstrates that the DM is not productive of a requirement for regulation of activities. The Veteran underwent there separate VA examinations to determine the current severity of her DM. At the first examination, the examiner determined that the Veteran's activities were not restricted as a result of her diabetes. See March 2013 VA examination. A few months later, a VA examiner determined that the Veteran's DM did not require regulation of activities and did not impact her ability to work. See January 2014 VA examination. Over a year later, another VA examiner found that the Veteran's DM did not require regulation of activities and did not impact her ability to work. See August 2015 VA examination. No examiners found complications related to DM upon examination. Further, the Veteran's extensive VA treatment records did not show that it was medically necessary for her to avoid strenuous occupational and recreational activities. As regulation of activities is a requirement for every rating in excess of 20 percent under Diagnostic Code 7913, the Board finds the Veteran did not meet the criteria for a rating in excess of 20 percent at any time during the appeal period. See Gilbert v. Derwinski, 1 Vet. App 49, 55-57 (1990); 38 C.F.R. § 3.102. B. PTSD with Depressed Mood Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Importantly, the evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. However, when it is not possible to separate the effects of the service-connected disability from a nonservice-connected condition, such signs and symptoms must be attributed to the service-connected disability. Mittleider v. West, 11 Vet. App. 181, 182 (1998); 38 C.F.R. § 3.102. PTSD with depressed mood is rated under 38 C.F.R. §4.130, Diagnostic Code 9411. The rating criteria provide that a 30 percent evaluation is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. §4.130, Diagnostic Code 9411. A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing effective work and social relationships. Id. A 70 percent rating is warranted for 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); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted for 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. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. 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, 442 (2002). Although the Veteran's symptomatology is the primary consideration, the Veteran's level of impairment must be in "most areas" applicable to the relevant percentage rating criteria. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-19 (Fed. Cir. 2013). The words "mild," "moderate" and "severe" as used in the various diagnostic codes are not defined in the VA 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. A GAF (Global Assessment of Functioning) score is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. See Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing the Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994). This is more commonly referred to as DSM-IV. A GAF of 21 to 30 is defined as behavior considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriate, suicidal preoccupation) or an inability to function in almost all areas (e.g., stays in bed all day, no job, home or friends). A GAF of 31 to 40 is indicative of some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or any major impairment in several areas, such as work or school, family relations, judgment, thinking or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). A GAF of 41 to 50 is indicative of serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF of 51 to 60 is defined as moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF of 61 to 70 is indicative of mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. A GAF of 71 to 80 indicates that if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). The Board notes that an examiner's classification of the level of psychiatric impairment by a GAF score is to be considered, but is not determinative of the percentage rating to be assigned. VAOPGCPREC 10-95. Effective March 19, 2015, VA amended the portion of the Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations to remove outdated references to DSM-IV, and replace them with references to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). See 80 Fed. Reg. 53, 14308 (March 19, 2015). The provisions of the final rule apply to all applications for benefits that are received by VA or that were pending before the Agency of Original Jurisdiction on or after August 4, 2014. As the Veteran's claim was pending before this date, the amendment is not applicable. 1. Prior to April 7, 2016 VA treatment records indicate that in October 2010, the Veteran was assessed as having depression. She reported that it was hard getting up some days, felt very tired, and had no motivation. The Veteran further reported that she had suicidal thoughts on some days, but no plans, and felt hopeless daily. In April 2011, a VA depression screening was negative; however, the Veteran attended a psychology group therapy session and was diagnosed as having anxiety. In August 2011, the Veteran was seen for treatment of adjustment reaction with mixed emotions. The Veteran reported that she was under a lot of stress for the past few months due to factors including her DM being out of control, her financial situation, and her daughter struggling in school. She denied having suicidal or homicidal ideations. She was assessed as coping adequately with numerous stressors. In September 2011, the Veteran was coping with grief due to finding out that her long-term partner was seeing someone else. She reported feelings of anger, sadness, and betrayal, but no suicidal or homicidal ideations. She also reported feeling hopeless about her urticaria, and that she started taking college classes online. In May 2012, the Veteran was still being seen at VA for adjustment reaction with mixed emotion. She reported having a very stressful month due to several family and friends being seriously ill or passing away, causing her to overeat and gain weight. She also reported that she was starting a new job, which she was excited about because the hours were good and she would be able to do school work during down time. She indicated that she was sleeping well most nights with Zolpidem and using Trazodone occasionally. In October 2012, the Veteran reported that she was adjusting to living on her own, loved school, and was getting straight A's. In March 2013, the Veteran was afforded a VA PTSD examination. The Veteran's Axis I diagnosis was PTSD with depressed mood, with a GAF score of 61, which is indicative of mild symptoms and some difficulty in social and occupational functioning. The examining psychologist indicated that the Veteran's PTSD symptoms included depressed mood, anxiety, suspiciousness, and chronic sleep impairment. The examiner indicated the symptoms did not include panic attacks, near continuous panic, memory loss, flattened affect, abnormal speech, difficulty understanding complex commends, impaired judgment or thinking, impairment in thought processes or communication, disturbances in motivation or mood, difficulty establishing or maintaining relationships, difficulty adapting to stressful circumstances, suicidal ideation, obsessional rituals, impaired impulse control, spatial disorientation, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, neglect of hygiene, intermittent inability to perform activities of daily living or disorientation to time or place. The examiner opined that the Veteran experienced occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The examiner noted that the Veteran reported reduced efficiency when completing tasks at work and in schoolwork, social withdrawal, reduced care for her home, verbal arguments with romantic partners and family, and reduced recreational activities. In spite of the Veteran's mental health concerns, the examiner reported, the Veteran continued to engage in school, was motivated for school, maintained relationships with her daughter and friends, maintained a stable home, and cared for herself independently. The examiner concluded that overall, the Veteran maintained mild impairments in attention and concentration, and mild to moderate impairments in motivation and drive. In a July 2013 VA mental health outpatient treatment record, the Veteran reported struggling with depressed mood and anxiety over the past few months. She reported that she was not sleeping well and the prescribed Zolpidem had no effect. She also reported that she was eating more and gained weight. On the positive side, she was recently engaged, doing extremely well in school and thinking of pursuing a bachelor's degree, and moved to a nicer neighborhood. Her mood was euthymic with full affect and normal speech. On July 22, 2013, the Veteran reported having racing thoughts and insomnia. She reported drinking 1-2 beers per night, and reported a new onset of mild auditory hallucinations of hearing her name called when no one was there. She said her mood was up and down with anxiety, depression, and no middle ground. She was assessed as being hypomanic, but with no history of bipolar disorder, her presentation could have been secondary to lack of sleep, alcohol consumption, and stress. In November 2013, the Veteran again reported trouble sleeping over the past few weeks. She was upset about an incident with her mother and a disagreement with a longtime friend. She reported that she did not have too much anxiety during the day, as she was busy with school. On a few days, she did not want to get out of bed but tried to make herself do so. She was making new friends in school and enjoying the support of the new friends. Her daughter got married and they keep in regular contact by phone. She was also friends with her former significant other, had started dating someone new, and got a puppy. The Veteran's mood was found to be euthymic with full affect and normal speech. She did not have thoughts of suicide or homicide. In February 2014, the Veteran was assessed at VA as not meeting the criteria for continuing SSA disability benefits due to depression (and urticaria). Also in February 2014, during an appointment for diabetes management, the Veteran reported that her PTSD and anxiety were really bad and she was considering dropping her classes at school to get more control of things. She stated that depression started after her daughter and son-in-law moved out of her house, and admitted to overeating. In April 2014, the Veteran reported that her PTSD and anxiety had gotten a little better since she took the semester off of school. In June 2014, the Veteran underwent an SSA mental status examination. The Veteran reported to the psychologist that she was anxious and depressed at times. She indicated that she slept well over the past month, usually 6 hours per night with the aid of medication, and that her energy level was over the past month was good. She also reported being socially withdrawn 50 percent of the time and having frequent racing thoughts. The psychologist indicated that the Veteran showed a full range of affect and smiled often. She had rapid speech, which suggested bipolar disorder. She denied a history of suicide attempts, and last thought about harming herself one month ago. There was no indication of delusional or paranoid ideation. The psychologist reported that the Veteran denied symptoms of PTSD, and did not describe symptoms of a panic disorder. The psychologist diagnosed the Veteran with Axis I diagnoses of bipolar disorder not otherwise specified (NOS), rule out bipolar II disorder, rule out anxiety disorder NOS versus generalized anxiety disorder. Her GAF score was 58. Regarding her capacity to work, she would be able to understand, remember, and carry out simple instructions. The Veteran's ability to respond appropriately to supervisors and coworkers would be mildly limited, due to rapid speech that made it difficult at times to understand what she said. Her ability to maintain concentration, attention, and work pace is likely to be mildly-to-moderately limited at times due to racing thoughts and anxiety. Her ability to withstand routine work stress and adapt to changes on the job was also likely to be mildly-to-moderately limited at times. She would not require supervision of her finances. A July 2014 SSA mental residual functional capacity assessment report indicated that the Veteran was not significantly limited in her social interaction, despite her claim that she did not spend time with others. Her statements were found to be partially credible. The opining psychologist reported that despite her mental health impairments, she continued to engage in school, was motivated for school, maintained relationships, maintained a stable home, and cared for herself independently. VA treatment records indicate that in July 2014, the Veteran requested individual therapy to address anxiety and coping skills. She also stated that she had been doing very well since her last appointment - she was back in school, keeping up with assignments, and getting good grades. Her energy level was adequate, she was sleeping well most nights, anxiety was under adequate control, and she was taking her medication regularly with no troublesome side effects. Her mood was found to be euthymic, with full affect congruent to content, and normal speech. In July 2014, SSA notified the Veteran that her disability benefits would be stopped effective September 2014 because her health had improved and she was able to work. In April 2015, she moved to Missouri to live by her daughter. See April 2015 VA treatment record. At a mental health assessment that same month, she complained of panic, worry, depressed mood, hypervigilance, low motivation, anhedonia, fatigue, agitation, irritability, recurrent thoughts of trauma, social withdrawal, and no nightmares. Id. Two months later, she received individual psychotherapy. See June 2015 VA treatment record. She has continued psychiatric treatment through the present day. In April 2016, the Veteran was again afforded a VA examination to assess the current severity of her PTSD. After acknowledging the Veteran's symptoms, the examiner determined that the Veteran suffered from occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. See April 2016 VA examination. In support of this conclusion, the examiner discussed the Veteran's reported relationship history. As of the time of the examination, the Veteran lived in Missouri with her daughter and provided childcare to her grandchild. She described her relationship with her daughter as positive, as they went out once a week. The Veteran had an estranged relationship with her mother that she attributed to her mother's critical attitude toward her for the Veteran's daughter's marital conflicts. Id. Further, the Veteran maintained regular contact with her father, to whom she described feeling closer and talked to on weekends. The Veteran was also close to her sister, whom she talked to by phone, visits, or spent time with at least two times a month or as often as once a week. In terms of close friends, she talked to a high school friend from Wisconsin once a month, and another childhood friend, who lived in Illinois, every 2 months. She also talked to a friend, whom she had known since the 7th grade, by text or phone two times a month. Otherwise, the Veteran avoided cultivating new friendships or local friends, believing that others could not be trusted. She reported feeling close to no one, even with those with whom she spends her time, such as her daughter and sister. She stated that she never tells them completely about her ongoing sadness, guilt, shame, and thoughts about her past abusive marriage. As to loneliness, she cited to how she declined an invitation from a female neighbor, who is married and who "seemed pleasant enough." Id. In terms of her pursuits, she did puzzles, cared for 2 family dogs, played with her 1 year old grandchild, and watched TV to keep herself distracted from her own traumatic memories. She denied any interest or participation in any organizational or community activities. She was able to help with household chores, but she described her daily activities as minimal due to lack motivation, lack of interest, and general fear about going out. Therefore, her symptoms still continued to affect her as of April 7, 2016 and she also reported depression symptoms. See April 2016 VA examination. At her April 2016 VA examination, her functional impairment levels were assessed as "moderate almost severe." See April 2016 VA examination. Generally, she remained engaged in her family relationships and current friendships, and she also regularly engaged in her current recreational pursuits. However, as the examiner states, the Veteran's "avoidance of crowds through minimal outings reflect occasional reduction in functioning, while her rejection of offers of new friendships and intimate relationships are assessed as intermittent inability to function. This is consistent with moderate functional impairment." See April 2016 VA examination. Further, at the April 2016 VA examination, the Veteran reported that she discontinued school, because she "freaked out" when she had to learn how to draw blood. She also reported that she "stopped caring, lost [her] concentration," and "got overwhelmed." She eventually dropped out with a GPA of 2.5. Since her March 2013 VA examination, she had last worked at B&S in 2011, when she stopped working due to disability where she reported "having hives when under stress." Further, she worked for a 2-month period from January 2016 to March 2016 as a school bus driver, but discontinued work due to feeling overwhelmed about remembering routes and other procedures. She doubted her ability to adequately perform her job, although she denied ever receiving any negative comments about her performance. She, therefore, resigned. According to the examiner, "[a]lthough [the Veteran] subjectively perceived herself as unreliable, there [was] no objective indication for this. Therefore, her work functional impairment [was] inferred from her social functional level as moderate (i.e., generally adequate but for occasional reduction in functioning and intermittent inability to function)." See April 2016 VA examination. Further, the examiner detained that "[s]he will likely generally adequately work according to the work routine, but her avoidant tendencies, which is apparent in her personal life, will likely similarly present as avoidance of, even conflict with, others in the workplace if she were to work." Id. Prior to April 7, 2016, taking into account all relevant evidence, the Board finds that an initial disability rating in excess of 30 percent for the Veteran's service-connected PTSD is not warranted. Specifically, the evidence shows that the PTSD does not cause occupational and social impairment with reduced reliability and productivity, nor has the Veteran's PTSD been manifested by symptoms including flattened affect; circumstantial, circumlocutory, or stereotyped speech; difficulty in understanding complex commands; impaired judgment; impaired abstract thinking; or difficulty in establishing and maintaining effective relationships prior to April 7, 2016. Her predominate symptoms are depression, anxiety, sleep trouble and trouble getting up in the morning. Even considering these symptoms, they are not of such frequency or severity that they result in occupational and social impairment with reduced reliability and productivity. For instance, before her April 2016 VA examination, the Veteran has been taking college classes regularly since September 2011, taking only one semester off due to mental health reasons. She has maintained several close relationships, including with her daughter, friends, and partners. She has also made new friendships with classmates at school. She has maintained a stable home, cared for herself independently, and cared for her dog. Her mood has consistently been assessed as being euthymic with full affect, with only one instance in a nearly-four-year period in which she was assessed as being hypomanic. The June 2014 SSA psychologist indicated she could understand, remember and carry out simple instruction and although her racing thoughts and rapid speech may make things difficult at times it was noted to be a mild to moderate limitation. A VA psychologist and SSA psychologist both indicated that the Veteran had mild-to-moderate occupational impairments with intermittent periods of inability to perform occupational tasks. Her March 2013 GAF score of 61 indicates some mild symptoms, but generally functions pretty well and has some meaningful interpersonal relationships. The Board has considered the Veteran's June 2014 GAF score of 58, which reflects moderate symptoms, but finds it significant that the June 2014 psychologist also indicated that the Veteran would be impaired at work mildly-to-moderately at times, and that she was engaged in school, maintained relationships, maintained a stable home, and cared for herself independently. The Board also considered the report of auditory hallucinations in July 2013 and a thought of harming herself a month before her June 2014 appointment as these symptoms appear in the criteria for a higher rating. However, auditory hallucination was only reported once and although the Veteran reported one instance of thinking of harming herself, she consistently denied any suicidal or homicidal ideations during her treatment and VA examinations. Furthermore, as noted above, the overall picture reflected she was generally motivated in her classwork, did well in school, had good relationships and even formed new friendships over the course of the appeal. In sum, the Veteran's disability picture does not more nearly approximate the 50 percent rating criteria under Diagnostic Code 9411 prior to April 7, 2016. See 38 C.F.R. § 4.7. While the Veteran does exhibit some symptoms contemplated in total occupational and social impairment or occupational and social impairment with deficiencies in most areas, the symptomatology is not of sufficient severity, frequency, and duration to result in a higher rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013) (holding that a Veteran "may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration"). At worst, her symptoms appear consistent with no more than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. Thus, the criteria for a finding of a 50, 70 or 100 percent evaluation, the next higher evaluations, are not met. Accordingly, the claim for a higher initial rating in excess of 30 percent for PTSD with depressed mood prior to April 7, 2016 is denied. See Gilbert v. Derwinski, 1 Vet. App 49, 55-57 (1990); 38 C.F.R. § 3.102. 2. As of April 7, 2016 The Veteran received mental health treatment in May 2017 through VA. See May 2017 VA treatment record. There, she reported the following symptoms: problems with anxiety; poor sleep; flashbacks; abusive ex-husband and concern over her daughter's family; overeating, especially when up at night; diabetes; near daily flashbacks; and suffering from the loss of two brothers. Further, the Veteran explained that she lived with her fiancé in Cape, as her daughter recently moved to Seattle. Specifically, the Veteran moved to area around March "after her fiancé convinced her to move [there]" and they are "renting a duplex." See May 2017 VA treatment record. She gets along well with her fiancé and attends church regularly. At her May 2017 appointment, the Veteran appeared neat; she also displayed appropriate behavior and affect. Her speech was normal, but her mood was worried and sleep deprived. She had normal thought content, did not exhibit delusional thinking or experienced hallucinations, and denied suicidal and homicidal thoughts. She was oriented to person, place, time, purpose, and alert. The mental health professional stated she had "impaired concentration and memory, but normal intelligence." See May 2017 VA treatment record. Her treatment plan included individual psychotherapy and medication. Taking into account all relevant evidence, the Board finds that an initial disability rating in excess of 30 percent as of April 7, 2016 for the Veteran's service-connected PTSD is warranted. As noted above, in order to warrant an increased evaluation, the Veteran would have to be found to at least have 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 effective work and social relationships. The Board finds that these criteria have been met. The Veteran had shown a consistent pattern of symptoms since her April 2016 VA examination. However, they do not warrant total occupational and social impairment or occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood. As discussed above, the Veteran did not have gross impairment in thought processes or communication evidenced by her relationship with her fiancé, daughter, grandchild, and friends. The claims file also does not include evidence of persistent delusions or hallucinations as of April 7, 2016. The Veteran has not engaged in aggressive behavior toward others or grossly inappropriate behavior. Further, the record does not show evidence of the Veteran being a persistent danger of hurting herself or others. As discussed above, a VA examiner found the Veteran capable of performing activities of daily living without impairment as of April 7, 2016. Though the Veteran may have complained of impaired memory, no mental health professional has deemed her disoriented as to time or place. Further, the Veteran remembers her own name. In addition, the Veteran did not have suicidal ideations, obsessive rituals which interfered 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, neglect of personal appearance and hygiene, or inability to establish relationships as evidenced above. However, the Veteran's functional impairment levels were "assessed as moderate almost severe. Generally, she remains engaged in her family relationships and current friendships, and she also regularly engages in her current recreational pursuits. However, her avoidance of crowds through minimal outings reflect occasional reduction in functioning, while her rejection of offers of new friendships and intimate relationships are assessed as intermittent inability to function. This is consistent with moderate functional impairment." See April 2016 VA examination. Further, she has dropped out of school and a May 2017 VA treatment provider attested to the Veteran's impaired concentration and memory. Thus, the Veteran clearly had impaired short and long term memory, impaired judgment, and disturbances of motivation and mood. As such, the Board finds that ultimately, the Veteran's overall disability picture more nearly approximates the criteria for a 50 percent rating. While the Veteran does exhibit some symptoms contemplated in total occupational and social impairment or occupational and social impairment with deficiencies in most areas, the symptomatology is not of sufficient severity, frequency, and duration to result in a higher rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013) (holding that a Veteran "may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration"). At worst, her symptoms appear consistent with no more than occupational and social impairment with reduced reliability and productivity. The criteria for a finding of a 70 or 100 percent evaluation, the next higher evaluations, are not met. Thus, the preponderance of the evidence is for the Veteran's claim and the Board finds that the criteria for an initial disability rating of 50 percent as of April 7, 2016, but no higher, for PTSD with depressed mood are met. See Gilbert v. Derwinski, 1 Vet. App 49, 55-57 (1990); 38 C.F.R. § 3.102. IV. TDIU The Veteran contends that her service-connected disabilities cause her to be unemployable. Specifically, she argues that her PTSD and DM render her unemployable. Total disability will be considered to exist where there is present any impairment of mind and body that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that the Veteran meets the schedular requirements. Specifically, if there is only one such disability, this disability shall be ratable at 60 percent or more; if there are two or more disabilities, there shall be at least one disability that is ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). For the stated purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable; and (2) disabilities resulting from common etiology or a single accident. 38 C.F.R. § 4.16(a). "Substantially gainful employment" is that employment "which is ordinarily followed by the nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the veteran resides." Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). Marginal employment shall not be considered substantially gainful employment. 38 C.F.R. § 4.16(a) (2017). In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training, and previous work experience, but not to her age or to any impairment caused by non service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19 (2017). Nevertheless, even if the Veteran does not meet the threshold minimum percentage standards enunciated in 38 C.F.R. § 4.16(a), rating boards should refer to the Director of Compensation and Pension Service for extraschedular consideration all cases where the veteran is unable to secure or follow a substantially gainful occupation by reason of service-connected disability. 38 C.F.R. § 4.16(b); see also Fanning v. Brown, 4 Vet. App. 225 (1993). Thus, despite the Veteran not meeting the percentage requirements for TDIU, the Board must evaluate whether there are circumstances in the Veteran's case, apart from any non-service-connected conditions and advancing age which would have justified a TDIU. 38 C.F.R. §§ 3.341(a), 4.19; see Van Hoose v. Brown, 4 Vet. App. 361 (1993); see also Hodges v. Brown, 5 Vet. App. 375 (1993); Blackburn v. Brown, 4 Vet. App. 395 (1993). The Veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed. 38 C.F.R. § 4.16(b). The Veteran's service-connected disabilities include residual fibroid tumors with hysterectomy, rated as 30 percent disabling from May 1, 1996; PTSD with depressed mood, rated as 30 percent disabling prior to April 7, 2016, and 50 percent thereafter; DM, rated as 20 percent disabling from September 3, 2010; shin splints in each leg, rated non-compensable from March 2, 1995; and residuals of a left thumb fracture, rated as non-compensable from March 2, 1995. Prior to April 7, 2016, her combined rating is 60 percent; as of that date, her combined rating is 70 percent. Therefore, the schedular threshold requirements for establishing entitlement to TDIU prior to April 7, 2016 are not met as the Veteran does not have at least one disability ratable at 40 percent or more and there is no sufficient additional service-connected disability to bring the combined rating to 70 percent or more. As such, 38 C.F.R. § 4.16(a) is not for application prior to April 7, 2016. Nevertheless, 38 C.F.R. § 4.16(a) is applicable as of April 7, 2016. In this case, however, the Board does not find that consideration of an extraschedular rating under the provisions of 38 C.F.R. § 4.16(b) is in order, and schedular TDIU is not warranted as of April 7, 2016. As discussed more fully below, the most probative and credible evidence in this case fails to show that the Veteran's service-connected disabilities render her unable to obtain or maintain substantially gainful employment any time during the appeal period. Id. The Board finds that referral for consideration of a total rating based on unemployability due to service-connected disabilities prior to April 7, 2016 and schedular TDIU as of that date are not warranted. In her December 2010 and April 2015 applications for TDIU, the Veteran reported that her service-connected PTSD and urticaria impacts her ability to work. She reported last working in May 2010 and left her job because of these disabilities. In her May 2016 application for TDIU, she reported that her PTSD, DM, and high blood pressure impact her ability to work. The Board notes that the Veteran is not service-connected for her urticaria or high blood pressure. In her March 2013 VA examination, the Veteran reported resigning from her most recent employment due to her urticaria, angioedema, DM, and asthma. She reported receiving SSA disability benefits for these conditions. She related that she is currently attending school and is motivated there. She denied missing any school and is able to complete her homework. She stated that in her last job she did not miss work due to mental health reasons. The examiner opined that "[o]verall the veteran maintains mild to moderate impairments in interpersonal relationships, mild impairments in attention and concentration, and mild to moderate impairments in motivation and drive. Thus, it is less likely as not that the [V]eteran's functional impairments due to PTSD with depressed mood render her unemployable." The examiner described the Veteran's PTSD as only causing occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The March 2013 examiner also determined that the Veteran's DM, left thumb fracture, and shin splints did not impact her ability to work. When asked whether her gynecological condition impacted her ability to work, the examiner did not answer. Later in the examination report, however, the examiner noted no additional conditions impact the Veteran's ability to work. In the January 2014 and August 2015 VA examination reports, the examiners determined that the Veteran's DM did not impact her ability to work. During the April 2016 VA psychiatric examination, the Veteran reported that when she is stressed, she breaks out in hives and this has prevented her from working. See April 2016 VA examination. She reported last working in 2011 and stopped because of the hives. From January 2016 to March 2016, she worked as a school bus driver, but was overwhelmed by remembering routes and procedures. She resigned from the job due to her perceived inability to perform the necessary tasks. The examiner noted that although "she subjectively perceives herself as unreliable, there is no objective indication for this." The examiner determined that her PTSD causes moderate impact in her ability work, but she "will likely generally adequately work according to the work routine," but may exhibit avoidance tendencies in the workplace. The examiner opined that the Veteran's PTSD caused "[o]ccupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation." Having carefully reviewed the evidence of record, the Board finds that the preponderance of the evidence does not show that the Veteran is precluded from obtaining and maintaining gainful employment consistent with her education and occupational experience due to her service-connected disabilities. The evidence of record indicates the Veteran has held numerous jobs since service; in fact, she was most recently employed in early-2016. The Board notes that there is no objective evidence of record that the Veteran had to leave a job or had problems at any of her jobs due to her service-connected PTSD-despite her contentions of the same. The Veteran is competent to testify as to facts she personally observed or described; this includes recalling what she personally felt, saw, smelled, heard, or tasted. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, she is not competent to offer opinions on complex medical matters. Whether the Veteran's service-connected disabilities solely render her unemployable cannot be determined by mere observation alone. Importantly, the Veteran herself has contended that many of her problems with employment are due to her urticaria with angioedema, which as noted above, are not related to service or secondary to a service-connected disability. Moreover, the VA examiners over the years have found that the Veteran's PTSD causes, at most, a moderate impact on her occupation. None of the VA examiners have determined that her service-connected disabilities render her unable to obtain and maintain substantially gainful employment. Further, the Board is aware that the Veteran has been awarded SSA disability benefits due to her angioedema and hives. Again, she is not in receipt of service connection benefits for those conditions. Even if she was, the Board is not bound by SSA's findings. See Collier v. Derwinski, 1 Vet. App. 413, 417 (1991) (VA is not bound by the findings of disability and/or unemployability made by other agencies, including SSA); see also Martin v. Brown, 4 Vet. App. 136, 140 (1993) (while a SSA decision is not controlling for purposes of VA adjudication, it is "pertinent" to a Veteran's claim). Moreover, these records do not show that her service-connected disabilities render her unemployable. As such, though the Veteran, the VA medical examiners and her SSA examiner provided ample facts to make a decision, the responsibility for making the ultimate TDIU determination is placed on the adjudicator and not a medical examiner. See Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). A medical examiner's role is limited to describing the effects of disability upon the person's ordinary activity. See Floore v. Shinseki, 26 Vet. App. 376, 381 (2013). Nevertheless, the Board finds in this case that, while there is certainly evidence of interference with employment, a preponderance of the evidence is against finding that the Veteran's service-connected disabilities render her unable to secure or follow a substantially gainful occupation. The Board does not doubt that the Veteran's service-connected PTSD, residual fibroid tumors, DM, shin splints, and left thumb fracture impact her employability. However, the 30 percent schedular evaluation currently in effect prior to April 7, 2016 and 50 percent thereafter recognize significant industrial impairment resulting from her PTSD. Additionally, the 30 percent rating for residual fibroid tumors and the 20 percent rating for DM recognize significant industrial impairment. The ultimate question is whether a claimant is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Thus the sole fact that a claimant is unemployed or has difficulty obtaining employment is insufficient to establish entitlement to a TDIU. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Hence, for the reasons and bases set forth above, the preponderance of the evidence is against finding her service-connected disabilities are of such severity so as to preclude her participation in any form of substantially gainful employment, and referral for extraschedular consider under 38 C.F.R. § 4.16(b) prior to April 7, 2016 is not warranted. Further, schedular TDIU as of April 7, 2016 is not warranted. As such, the benefit of the doubt doctrine is inapplicable, and the claim must be denied. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). ORDER Entitlement to service connection for right lower extremity peripheral neuropathy is denied. Entitlement to service connection for left lower extremity peripheral neuropathy is denied. Entitlement to service connection for right upper extremity peripheral neuropathy is denied. Entitlement to service connection for left upper extremity peripheral neuropathy is denied. Entitlement to an increased rating in excess of 20 percent for DM is denied. Prior to April 7, 2016, an initial disability rating in excess of 30 percent for PTSD with depressed mood is denied. As of April 7, 2016, an initial disability of 50 percent, but no higher, for PTSD with depressed mood is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a TDIU is denied. ____________________________________________ KRISTI L. GUNN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs