Citation Nr: 18143649 Decision Date: 10/19/18 Archive Date: 10/19/18 DOCKET NO. 14-31 314 DATE: October 19, 2018 ORDER Entitlement to an initial disability rating in excess of 20 percent for right knee gout prior to January 11, 2018, is denied. Entitlement to a disability evaluation of 60 percent, but no greater, for right knee gout beginning January 11, 2018, is granted. Entitlement to an initial compensable rating for hypertension prior to January 11, 2018, and in excess of 10 percent disabling, thereafter, is denied. Entitlement to an initial compensable rating for hepatitis B prior to December 28, 2011, is denied. Entitlement to a disability evaluation of 10 percent, but no greater, beginning December 28, 2011, for hepatitis B, is granted. Entitlement to a disability evaluation of 20 percent, but no greater, beginning September 21, 2015, for hepatitis B, is granted. Entitlement to service connection for liver failure, as secondary to hepatitis B is denied. Entitlement to service connection for prostate cancer is denied. Entitlement to service connection for right wrist carpal tunnel is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) is granted. FINDINGS OF FACT 1. Prior to January 11, 2018, the Veteran’s right knee gout was manifested by no more than one or two exacerbations a year in a well-established diagnosis. Beginning January 11, 2018, the Veteran’s right knee gout was manifested by weight loss and anemia productive of severe impairment of health and severely incapacitating exacerbations occurring four or more times per year but not by totally incapacitating constitutional manifestations associated with active joint involvement. 2. Prior to January 11, 2018, the Veteran’s hypertension was manifested by diastolic pressure predominantly less than 100 and systolic pressure predominantly less than 160. Although the Veteran took medication for this condition, he did not have a history of diastolic pressure predominantly 100 or more. 3. Beginning January 11, 2018, the Veteran’s hypertension has been manifested by diastolic pressure predominantly 100 or more but less than 110 and systolic pressure predominantly 160 or more but less than 200. 4. Prior to December 28, 2011, the Veteran’s hepatitis B was non-symptomatic. From December 28, 2011, to September 20, 2015, the Veteran’s hepatitis B was manifested by intermittent fatigue, malaise, and anorexia. Beginning September 21, 2015, the Veteran’s hepatitis B has manifested as daily fatigue, malaise, and anorexia, requiring dietary restriction or continuous medication. At no time during the appellate period has the Veteran’s hepatitis B manifested as daily fatigue, malaise, and anorexia with minor weight loss and hepatomegaly, or; incapacitating episodes having a total duration of at least four weeks, but less than six weeks, during the past 12-month period. 5. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, currently diagnosed liver failure, as secondary to hepatitis B. 6. The preponderance of the evidence is against finding that prostate cancer began during active service, or is otherwise related to an in-service injury, event, or disease. 7. The preponderance of the evidence is against finding that right wrist carpal tunnel syndrome began during active service, or is otherwise related to an in-service injury, event, or disease. 8. The evidence of record favors a finding that the Veteran’s service-connected disabilities prevent him from securing or following gainful employment. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 20 percent prior to January 11, 2018, for right knee gout are not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.104, Diagnostic Codes 5017, 5002. 2. The criteria for a 60 percent disability rating, but no higher, beginning January 11, 2018, for right knee gout have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.104, Diagnostic Codes 5017, 5002. 3. The criteria for a compensable disability rating prior to January 11, 2018, and in excess of 10 percent disabling, thereafter, for hypertension are not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.104, Diagnostic Code 7101. 4. The criteria for a compensable disability rating prior to December 28, 2011, for hepatitis B are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.104, Diagnostic Code 7354. 5. The criteria for a 10 percent disability rating, but no higher, beginning December 28, 2011, and for a 20 percent disability rating, but no higher, beginning September 21, 2015, for hepatitis B have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.104, Diagnostic Code 7354. 6. The criteria for service connection for liver failure are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.310(a). 7. The criteria for service connection for prostate cancer are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 8. The criteria for service connection for right wrist carpal tunnel are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 9. The criteria for entitlement to a TDIU are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.3, 4.16, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1973 to September 1993. This appeal was previously remanded by the Board in October 2016. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. 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. All benefit of the doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. A veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation has already been established and increase in disability rating is at issue, present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Thus, although the Board has thoroughly reviewed all evidence of record, the more critical evidence consists of the evidence generated during the appeal period. Further, the Board must evaluate the medical evidence of record since the filing of the claim for increased rating and consider the appropriateness of a “staged rating” (i.e., assignment of different ratings for distinct periods of time, based on the facts). See Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability evaluations are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Although all the evidence has been reviewed, only the most relevant and salient evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). 1. Entitlement to an initial rating in excess of 20 percent for right knee gout. The Veteran was awarded service connection for right knee gout and assigned a 20 percent disability rating, effective March 26, 2010. The Veteran’s gout is evaluated under Diagnostic Code 5017 and 5260. 38 C.F.R. § 4.71a. Gout is rated under Diagnostic Code 5017. According to the Rating Schedule, diseases rated under Diagnostic Codes 5013 through 5024 are to be rated based on limitation of motion of the affected parts as degenerative arthritis, except for gout, which is rated under Diagnostic Code 5002. 38 C.F.R. § 4.71a. Diagnostic Code 5002 assigns various ratings based on whether rheumatoid arthritis is an active process or is manifested by chronic residuals. Moreover, the ratings for the active process are not to be combined with the residual ratings, and the higher evaluation is to be assigned. 38 C.F.R. § 4.71a, Diagnostic Code 5002. When rating gout as an active process under Diagnostic Code 5002, a minimum 20 percent rating is warranted for one or two exacerbations a year in a well-established diagnosis. 38 C.F.R. § 4.71a. A 40 percent disability evaluation is warranted when there are symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring three or more times a year. Id. A 60 percent disability evaluation is warranted when there is less than the criteria for a 100 percent disability evaluation but with weight loss and anemia productive of severe impairment of health or severely incapacitating exacerbations occurring 4 or more times per year or a lesser number over prolonged periods. A 100 percent disability evaluation is warranted with constitutional manifestations associated with active joint involvement, or totally incapacitating episodes. Diagnostic Code 5002 further provides that chronic residuals, such as limitation of motion or ankylosis, are to be rated under the appropriate diagnostic codes for the specific joints involved. Where, however, the limitation of motion of the specific joint or joints involved is noncompensable under the codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion to be combined, not added, under Diagnostic Code 5002. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5002. An April 2011 VA examination confirmed a diagnosis of gout with treatment by medication management. The examination report noted functional limitation on standing and walking. However, no significant effect on general occupation or daily activities was found. A December 2011 VA examination report endorsed symptoms of weakness, stiffness, swelling, heat, redness, giving way, locking and pain. However, no periods of incapacitation were noted. Functional impact included the inability to walk or sit for long periods of time. The examiner opined that the Veteran’s gout condition did not impact his ability to work. In September 2012, the Veteran underwent VA examination. The Veteran reported flare-ups of his right knee gout occurring every three months and lasting for seven to eight days. He indicated that his right knee gout was aggravated by cold weather, certain foods, and extended walking. Range of motion testing was conducted with right knee flexion ending at 70 degrees with objective evidence of painful motion beginning at 70 degrees. Functional loss or impairment was noted to include less movement than normal, weakened movement, pain on motion, disturbance in locomotion, and interference with sitting, standing and weight-bearing. In January 2018, the Veteran underwent another VA examination. The examiner noted that the Veteran had lost weight and had anemia due to this condition and that both weight loss and anemia caused impairment of his health. The examiner reported that the Veteran’s inability to walk due to his gout symptoms was stopping him from physical exercise on a daily basis and that his gout had stopped him from everyday living. Further the examiner noted incapacitating exacerbations with a frequency of four or more per year with a total duration of incapacitation of one week but less than two weeks over the past 12 months. The examiner opined that the Veteran’s right knee gout impacted his ability to be employed in an environment that entailed standing, walking, lifting, climbing, or repetitive bending, as well as sitting for an extended period of time. Prior to January 2018, a disability evaluation in excess of 20 percent is not warranted because the probative evidence of record does not establish symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring three or more times a year. Id. Beginning January 11, 2018, a disability evaluation of 60 percent, but no higher, is warranted as the probative evidence of record establishes weight loss and anemia productive of severe impairment of health and severely incapacitating exacerbations occurring 4 or more times per year or a lesser number over prolonged periods. A higher rating is not warranted as the evidence of record does not establish constitutional manifestations associated with active joint involvement, or totally incapacitating episodes. 2. Entitlement to a compensable rating for hypertension prior to January 11, 2018, and in excess of 10 percent disabling thereafter. In this case, service connection for hypertension has been in effect since March 2010 and was initially rated as noncompensable. The agency of original jurisdiction (AOJ) granted a 10 percent disability rating effective January 11, 2018. Hypertension is evaluated pursuant to 38 C.F.R. § 4.104, Diagnostic Code 7101, and is assigned a 10 percent rating for diastolic blood pressure predominantly 100 or more, or; for systolic blood pressure predominantly 160 or more, or; as the minimum evaluation for an individual with a history of diastolic blood pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is warranted for diastolic pressure of predominantly 110 or more, or; systolic pressure that is predominantly 200 or more. A 40 percent rating is assigned for diastolic pressure that is predominantly 120 or more. A 60 percent rating is assigned where diastolic pressure is predominantly 130 or more. Review of the blood pressure readings contained in the VA examination reports and private treatment records prior to January 11, 2018, indicate that the Veteran’s hypertension did not manifest in diastolic pressure of predominantly 100 or more, or for systolic blood pressure predominantly 160 or more, or indicate that the Veteran had a history of diastolic blood pressure predominantly 100 or more and required continuous medication for control. In this regard, VA examination reports and private treatment records indicate blood pressure readings as follows: 138/82 in March 2010; 134/78 in July 2010; 158/92 in October 2010; 136/97 in May 2011; in December 2011 three readings were 146/80, 142/80, and 144/82; 127/64 in November 2012, in August 2015 three readings were 160/94, 154/90, 150/92; 141/77 in July 2015; and 120/65 in October 2016. Therefore, an initial compensable rating prior to January 11, 2018, is not warranted. Review of blood pressure readings contained in the January 2018 VA examination report indicate that, beginning January 11, 2018, the Veteran’s hypertension did not manifest in diastolic pressure of predominantly 110 or more, or; systolic pressure that is predominantly 200 or more. In this regard, the January 2018 VA examination report indicates blood pressure readings as follows: 172/100; 174/100; and 180/100. Therefore, a disability rating in excess of 10 percent is not warranted. The Board observes that for the entire period on appeal, the Veteran has been prescribed prescription medication to treat his hypertension. However, the Veteran’s blood pressure averages are well below the findings required for the next higher evaluation at all points pertinent to the appellate period. Additionally, the records do not indicate any instances of diastolic pressure over 110 or systolic pressure over 200. As such, the evidence does not support a finding of diastolic pressure of predominantly 110 or more, or systolic pressure predominantly 200 or more. In reaching the above conclusions, the Board has considered the Veteran’s lay statements regarding the severity of his hypertension. While the Board appreciates the Veteran’s belief that his hypertension is worse than his current evaluation reflects, the Board must evaluate the disability according to the prescribed rating schedule. Based on a review of the evidence of record, the Board finds that an initial compensable rating prior to January 11, 2018, and an evaluation greater than 10 percent thereafter for the Veteran’s hypertension disability is not warranted under Diagnostic Code 7101. See 38 C.F.R. § 4.104. 3. Entitlement to an initial compensable rating for hepatitis B prior to January 11, 2018, and in excess of 20 percent disabling thereafter. The Veteran asserts that his service-connected hepatitis B is more disabling than reflected by the noncompensable rating assigned prior to January 11, 2018, and by the 20 percent disability rating assigned, thereafter. His disability is currently rated under DC 7345, which provides the rating criteria for chronic liver disease without cirrhosis (including hepatitis B.) 38 C.F.R. § 4.114. A 10 percent disability rating is warranted for intermittent fatigue, malaise, and anorexia; or; incapacitating (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least one week, but less than two weeks, during the past 12-month period. A 20 percent disability rating is assigned for daily fatigue, malaise, and anorexia (without weight loss or hepatomegaly) that requires dietary restriction, continuous medication; or incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least two weeks, but less than four weeks, during the past 12-month period. A 40 percent disability rating is warranted for daily fatigue, malaise, and anorexia (with minor weight loss and hepatomegaly); or incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least four weeks, but less than six weeks, during the past 12-month period. A 60 percent disability rating is warranted for daily fatigue, malaise, and anorexia with substantial weight loss (or other indication of malnutrition), and hepatomegaly; or incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least six weeks during the past 12-month period, but not occurring constantly. The maximum 100 percent disability rating is warranted for near-constant debilitating symptoms (such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain). An “incapacitating episode” is a period of acute signs and symptoms that requires bed rest and treatment by a physician. Id., Note 2. The Veteran underwent VA examination in May 2011. The examination report indicated that the Veteran’s hepatitis B was stable since onset with the current treatment being medication. Upon examination, the Veteran weighed 180 pounds and there was no evidence of malnutrition. His abdominal exam was normal. Liver function tests were normal. No current symptoms of chronic liver disease ere endorsed and no incapacitating episodes during the last 12-month period were noted. The Veteran again underwent VA examination in December 2011. Upon examination, he weighed 180 pounds and there was no evidence of liver enlargement. The Veteran endorsed easy fatigability, arthralgia, loss of appetite, and occasional abdominal pain in the stomach area. While the examination report indicated that the Veteran’s symptoms occurred near-constantly and were debilitating, the Veteran reported that his condition did not cause incapacitation and that all symptoms were responsive to therapy or treatment. Further he stated that he did not experience an overall functional impairment from his Hepatitis B. The Veteran underwent another VA examination in September 2015. The Veteran endorsed daily symptoms of fatigue and arthralgia with no incapacitating episodes during the past 12 months. Continuous medication was required to control the Veteran’s liver condition. Neither weigh loss or hepatomegaly were noted. Active hepatitis B was noted on diagnostic testing. Additionally, the examination report indicated that the Veteran was not a liver transplant candidate. Private treatment records in May 2015 and July 2015 indicate that the Veteran denied abdominal distension, pedal edema, jaundice, change in bowel habits, weight loss or any other pertinent symptoms. Upon diagnostic testing, the Veteran’s liver appeared normal size with smooth contours and normal echotexture. A January 2018 VA examination report indicated the continuous use of medication to control the Veteran’s liver condition. The Veteran endorsed near-constant and debilitating fatigue, as well as daily malaise. No incapacitating episodes were reported during the past 12 months. Weight loss and hepatomegaly were not noted. The examiner noted that the hepatitis B impacted the Veteran’s employment due to increased fatigue which made completing tasks, doing heavy lifting, and carrying difficult. Additionally, the examination report indicated that the Veteran was not a liver transplant candidate. Upon consideration of the evidence, the Board finds that an initial compensable rating prior to December 28, 2011 is not warranted. A disability rating of 10 percent, but no higher, is warranted from December 28, 2011, to September 20, 2015. Further, a disability rating of 20 percent, but no higher, is warranted beginning September 21, 2015. Prior to December 28, 2011, the Veteran exhibited no symptoms of chronic liver disease and endorsed no incapacitating episodes during the prior 12-month period. The Veteran’s hepatitis B was noted as stable since onset and was treated with medication. There was no evidence of malnutrition. An abdominal exam and liver function testing were normal. During this time period, the Veteran’s hepatitis B more closely approximated a noncompensable disability rating under Diagnostic Code 7345. The above evidence reflects that the Veteran’s hepatitis B was not manifested by for intermittent fatigue, malaise, and anorexia; or; was incapacitating (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least one week, but less than two weeks, during the past 12-month period. From December 28, 2011, to September 20, 2015, the Veteran exhibited symptoms of easy fatigability, arthralgia, loss of appetite, and occasional abdominal pain. While the December 2011 examination report indicated that symptoms were near-constant and debilitating, the Veteran reported that his symptoms did not cause overall functional impairment, did not cause incapacitation, and were responsive to therapy or treatment. The Board finds that these symptoms more closely approximate a disability rating of 10 percent under DC 7345. The above evidence reflects, however, that the symptoms have not more nearly approximated the daily symptoms or number of incapacitating episodes that would warrant a 20 percent rating because the Veteran did not experience weight loss or hepatomegaly (enlarged liver), or incapacitating episodes with a duration of at least two weeks, but less than four weeks, for the past 12-month period. From September 21, 2015, however, the Veteran experienced daily fatigue and arthralgia with no incapacitating episodes during the past 12 months. Beginning in January 2018, the Veteran endorsed Veteran endorsed near-constant and debilitating fatigue, as well as daily malaise. However, he reported no incapacitating episodes during the past 12 months. Weight loss and hepatomegaly were not noted at any time during the appellate period. The January 2018 VA examiner noted that the Veteran’s hepatitis B impacted his employment due to increased fatigue which made completing tasks, doing heavy lifting, and carrying difficult. However, the Veteran was not considered a liver transplant candidate. Accordingly, the Board finds that the Veteran’s symptoms more closely approximate a disability rating of 20 percent. The above evidence reflects, however, that the symptoms have not more nearly approximated the daily symptoms or number of incapacitating episodes that would warrant higher ratings under DC 7345 because the Veteran did not experience minor weight loss and hepatomegaly, or incapacitating episodes with a duration of at least four weeks, but less than six weeks, for the past 12-month period. Further while the Veteran’s fatigue was noted as near-constant or debilitating in the January 2018 examination report, the totality of the evidence does not support a higher rating. As such, an initial disability rating prior to December 28, 2011, for hepatitis B is not warranted. From December 28, 2011, to September 20, 2015, a disability rating of 10 percent, but no higher, is warranted. Beginning September 21, 2015, a disability rating of 20 percent, but no higher, is warranted. 38 C.F.R. § 4.114; Diagnostic Code 7345. Service Connection Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection generally requires evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Service connection for specific diseases, including prostate cancer may be presumed if a veteran served on the land mass or on the inland waters of the Republic of Vietnam during the Vietnam War. 38 U.S.C. § 1116. Veterans who served on active duty on the land mass of the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(a)(6)(iii). Service connection is also warranted for disability proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(b). 4. Entitlement to service connection for liver failure, as secondary to hepatitis B. The Veteran claims entitlement to service connection for liver failure, as secondary to service-connected hepatitis B. The question for the Board is whether the Veteran has a current disability that is proximately due to or the result of, or is aggravated beyond its natural progress by his service-connected hepatitis B. The Board concludes that the Veteran does not have a current diagnosis of liver failure, and has not had one at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). The December 2011VA examiner evaluated the Veteran and determined that, while he experienced symptoms related to his Hepatitis B, there was no clinical or serologic evidence that the Veteran had liver failure. Further, private treatment records associated with the claims file do not contain a diagnosis of liver failure. While the Veteran believes he has a current diagnosis of liver failure, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education and the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. Thus, after careful review and consideration of all lay and medical evidence of record, the Board finds that the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for liver failure. As the preponderance of the evidence weighs against the claim, the benefit-of-the-doubt doctrine does not apply. See 38 U.S.C. § 5107(b). 5. Entitlement to service connection for prostate cancer. 6. Entitlement to service connection for right wrist carpal tunnel. The Veteran filed claims for entitlement to service connection for prostate cancer and right wrist carpal tunnel in March 2010. However, the Veteran has provided no lay or medical evidence to support his assertions that these disabilities are due to his active duty service. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has diagnoses of prostate cancer and right wrist carpal tunnel, the preponderance of the evidence is against finding that either began during active service, or are otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). The Veteran’s service treatment records are silent as to the diagnosis of, or treatment for, prostate cancer and/or right wrist carpal tunnel While the VA has not afforded the Veteran examinations with regard to his claims for entitlement to service connection for prostate cancer and right wrist carpal tunnel, the Board finds that examinations are not warranted. VA must provide a medical examination or opinion when a review of the information and evidence of record shows (1) there is competent evidence of a veteran’s current disability, (2) evidence establishing an event, injury or disease occurred in service, (3) an indication that the current disability may be associated with a veteran’s service, and (4) insufficient competent medical evidence to decide the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006); 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Regarding the second McLendon factor, the Veteran has not provided any evidence or lay testimony establishing an event, injury or disease that occurred in service that he asserts is related to his diagnosis of prostate cancer and/or right wrist carpal tunnel. Absent evidence establishing an event, injury or disease occurred in service, the Board finds that examinations or medical opinions are not warranted. Additionally, while the Veteran served during the Vietnam War era, he has stated that he underwent no combat deployments during his active service and has not asserted exposure to herbicide agents. See September 2018 VA Examination. Therefore, the herbicide agent presumption does not apply with regard to his prostate cancer. See 38 C.F.R. § 3.309(e); 38 C.F.R. § 3.307(a)(6). Significantly, the Board finds that there is no competent evidence of record to suggest that the Veteran’s prostate cancer and/or right wrist carpal tunnel are etiologically related to his active service. While the Veteran believes his prostate cancer and right wrist carpal tunnel are related to his active service, the Board reiterates that the preponderance of the evidence weighs against this finding. As the preponderance of the evidence weighs against the claims, the benefit-of-the-doubt doctrine does not apply. See 38 U.S.C. § 5107(b). TDIU 7. Entitlement to a TDIU. In its October 2016 remand, the Board found that entitlement to a TDIU had been reasonably raised by the record and should be considered a part of the Veteran’s increased rating claims. The evidence of record demonstrates that the Veteran stopped working full time as a night stocker at a home improvement store on November 21, 2011. See the Veteran’s December 2016 VA Form 8940. He has a high school education, and worked as a warehouse manager, custodian, and night stocker from January 1994 to November 2011. There is no indication that the Veteran has other work experience or specialized training. Total disability ratings for compensation may be assigned on a schedular basis, 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 if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more such 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. 38 C.F.R. § 4.16(a). The Veteran has met the minimum percentage requirements, set forth in 38 C.F.R. § 4.16(a), for award of a TDIU. With consideration of the awards outlined in the Board’s decision above, the Veteran is service-connected for right knee gout, rated at 60 percent disabling; hepatitis B, rated as 20 percent disabling; tinnitus, rated as 10 percent disabling; and hypertension, rated as 10 percent disabling. The Veteran’s combined disability evaluation is 70 percent disabling. In Hatlestad v. Derwinski, 5 Vet. App. 524, 529 (1993), the Court held that the central inquiry in determining whether a veteran is entitled to a TDIU is whether his or her service-connected disabilities, alone, are of sufficient severity to produce unemployability. Factors to be considered are the Veteran’s “education, employment history and vocational attainment.” See 38 C.F.R. § 4.16(b). The evidence of record indicates that the Veteran began receiving Social Security disability on November 11, 2011, primarily due to nonservice-connected discogenic and degenerative disorders of the back and a secondary diagnosis of gout. See February 2012 Disability Determination and Transmittal. However, during the September 2012 VA examination, the Veteran reported that he stopped working due to a work-related injury to his back and left leg (radiculopathy). That stated, the more recent findings of the January 2018 VA examiner show that it is at least as likely as not that the Veteran’s service-connected disabilities, specifically his gout and hepatitis prevent the Veteran from securing or following gainful employment. Indeed, the January 2018 examiner stated that Veteran’s right knee gout impacts his ability to be employed in an environment that entails standing, walking, lifting, climbing, or repetitive bending, as well as sitting for an extended period of time. The examiner opined that the Veteran was not precluded from sedentary work only if accommodations were made, and if he were allowed him to stand every one to two hours. Additionally, the examiner stated in the hepatitis examination report that the Veteran’s hepatitis B impacted employment on account of increased fatigue, which made completing tasks, doing heavy lifting, and carrying difficult. After reviewing all the evidence, and after considering the Veteran’s high school education and his 17 years of work experience performing exclusively physical labor, the Board finds that the Veteran’s service-connected right knee gout and hepatitis B are of sufficient severity to produce unemployability. The benefits sought on appeal is granted. An effective date for the award of TDIU will be assigned by the AOJ in the first instance. V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD L. Bristow Williams, Associate Counsel