Citation Nr: 18143681 Decision Date: 10/19/18 Archive Date: 10/19/18 DOCKET NO. 14-00 865 34448DATE: October 19, 2018 ORDER An initial rating in excess of 60 percent for ischemic heart disease (IHD) is denied. From March 17, 2010 to October 8, 2010, an initial rating in excess of 10 percent for diabetes mellitus is denied. From October 8, 2010 to October 18, 2010, a rating of 20 percent, but no higher, for diabetes is granted. From October 18, 2010, forward, a rating in excess of 20 percent for diabetes is denied. From March 17, 2010 to November 30, 2011, a separate rating of 20 percent for right upper extremity peripheral neuropathy, secondary to service-connected diabetes, is granted. From March 17, 2010 to November 30, 2011, a separate rating of 20 percent for left upper extremity peripheral neuropathy, secondary to service-connected diabetes, is granted. For the entire period on appeal from March 17, 2010, a total disability rating based on individual unemployability (TDIU) is granted. REMANDED Entitlement to special monthly compensation (SMC) based on the need for regular aid and attendance is remanded. FINDINGS OF FACT 1. For the entire initial rating period on appeal, the IHD was characterized by left ventricular dysfunction with an ejection fraction greater than 30 percent, without chronic congestive heart failure. 2. For the period prior to October 8, 2010, the diabetes was manageable by restricted diet only. 3. For the period from October 8, 2010, forward, the diabetes has required oral hypoglycemic agent and a restricted diet, but not a regulation of activities. 4. From October 3, 2010 to November 30, 2011, the Veteran had bilateral upper extremity peripheral neuropathy, secondary to service-connected diabetes, that was no more than mild in severity. 5. For the entire period on appeal from March 17, 2010, the service-connected disabilities precluded maintaining substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 60 percent for IHD have not been met for any period. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102. 4.3, 4.7, 4.10, 4.104, Diagnostic Code (DC) 7005 (2017). 2. From March 17, 2010 to October 8, 2010, the criteria for an initial rating in excess of 10 percent for diabetes have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.10, 4.119, DC 7913 (2017). 3. From October 8, 2010 to October 17, 2010, the criteria for a rating of 20 percent, but no higher, for diabetes have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.10, 4.119, DC 7913 (2017). 4. From October 18, 2010, forward, the criteria for an initial rating in excess of 20 percent for diabetes have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.10, 4.119, DC 7913 (2017). 5. From March 3, 2010 to November 30, 2011, the criteria for an initial rating of 20 percent, but no higher, for right upper extremity peripheral neuropathy, secondary to diabetes, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.124a, DC 8513 (2017). 6. From March 3, 2010 to November 30, 2011, the criteria for an initial rating of 20 percent, but no higher, for left upper extremity peripheral neuropathy, secondary to diabetes, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.124a, DC 8513 (2017). 7. For the rating period on appeal from March 17, 2010, the criteria for a TDIU have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.1, 4.3, 4.16, 4.25 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant in this case, served on active duty from February 1965 to February 1968. He also appears to have had periods of unverified service. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from multiple rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. In an October 2010 rating decision, the RO, in pertinent part, awarded service connection for diabetes with peripheral neuropathy of the upper and lower extremities, secondary to herbicide exposure, and assigned a 10 percent initial rating, effective March 17, 2010. In a November 2010 rating decision, the RO, in pertinent part, awarded service connection for IHD and assigned a 60 percent initial rating, effective March 17, 2010. The RO also denied entitlement to a TDIU. In an August 2011 rating decision, the RO increased the rating for diabetes from 10 percent to 20 percent, effective October 18, 2010. Because less than the maximum available benefit for a schedular rating was awarded and to the extent that the increase was not awarded for the entirety of the claims period, the claim remains before the Board. See Fenderson v. West, 12 Vet. App. 119, 126 (1999); AB v. Brown, 6 Vet. App. 35 (1993). In a December 2013 rating decision, the RO, in pertinent part, awarded separate 20 percent ratings for bilateral upper extremity diabetic peripheral neuropathy and separate 10 percent ratings for bilateral lower extremity diabetic peripheral neuropathy, all effective December 1, 2011. The RO also awarded a separate 10 percent rating for diabetic gastroparesis, effective March 12, 2013. The Veteran did not appeal this decision; therefore, the Board does not have jurisdiction over these issues, and will not address them herein. The RO also denied entitlement to SMC based on the need for aid and attendance. In a June 2017 rating decision, the RO award service connection for erectile dysfunction and assigned a noncompensable rating, effective December 1, 2011. The RO also awarded special monthly compensation based on loss of use of a creative organ, effective December 1, 2011. The Veteran did not appeal this decision; therefore, the Board does not have jurisdiction over these issues and will not address them herein. The Veteran has another appeal before the Board. Because that appeal involves issues dependent on different law and facts, it is the subject of a separate decision. See BVA Memorandum No. 01-18-04; VA Purplebook 01-18-v1.0.0. The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Disability Rating Criteria 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 percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. A veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1 (2017); Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate for any initial rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). If two disability ratings are potentially applicable, the higher rating 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 reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. 1. Entitlement to an initial rating in excess of 60 percent for IHD The Veteran is in receipt of a 60 percent initial disability rating for IHD under 38 C.F.R. § 4.104, DC 7099-7005, applicable to arteriosclerotic heart disease. The Veteran contends generally that his IHD is worse than contemplated by the disability rating assigned for the entire period on appeal. The Veteran has been diagnosed with coronary artery disease (CAD). See September 2010 VA examination report. The Veteran’s IHD is rated under DC 7005, applicable to arteriosclerotic heart disease (CAD). As DC 7005 applies to the Veteran’s exact diagnosis, the diagnosis is listed in the rating schedule and a hyphenated diagnostic code is not warranted. As the Veteran’s IHD will continue to be rated under DC 7005, there is no prejudice to the Veteran in removing the hyphenated diagnostic code. See Butts v. Brown, 5 Vet. App. 532 (1993). Under Diagnostic Code 7005, a 60 percent rating is warranted where there is more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A rating of 100 percent requires chronic congestive heart failure, or; a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. The provisions of 38 C.F.R. § 4.104 Note (2) define one MET is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104. After a review of all the evidence, lay and medical, the Board finds that, for the entire initial rating period on appeal, the criteria for an initial rating in excess of 60 percent for IHD have not been met for any period. 38 C.F.R. § 4.104, DC 7005. For the entire initial rating period, the IHD was characterized by left ventricular dysfunction with an ejection fraction greater than 30 percent, without chronic congestive heart failure. A June 2005 private treatment note indicated that the left ventricular ejection fraction (LVEF) was 42 percent. A May 2010 private treatment note indicated that the LVEF was 35 percent. At a VA examination in September 2010, the Veteran had dyspnea on exertion with activity daily, METs level was 5, and there was no evidence of congestive heart failure. A December 2010 letter from the Veteran’s treating physician indicated that the LVEF was 35 percent. The Veteran had symptoms of shortness of breath and fatigue, activity level was diminished, and the Veteran reported that he was unable to walk 100 feet without needing to stop. An October 2011 echocardiogram report indicated that the LVEF was 40 to 45 percent. A December 2012 private treatment record indicated that the LVEF was 40 to 45 percent. In August 2013, the Veteran was afforded a VA IHD examination. No exercise METs testing was completed; however, the VA examiner stated that the Veteran reported symptoms at an estimated level of greater than three to five METs, which was consistent with activities such as light yard work (weeding), mowing lawn (power mower), and brisk walking (four miles per hour). LVEF was 45 to 50 percent. The Veteran got dyspnea, angina, and dizziness with increased activities. A June 2017 VA heart conditions examination shows METs level, based on an interview, was 1-3 METs with dyspnea and fatigue. The VA examiner opined that the limitation in METs level was due to multiple medical conditions including the heart conditions; it was not possible to accurately estimate the percent of METs limitation attributable to each medical condition. The VA examiner stated that the LVEF would be a better indicator of the current cardiac status than METs level because METs, by definition, incorporates co-morbidities. While the LVEF has a margin of error, it is only measuring the amount of blood that the left ventricle ejects with each beat. The LVEF is a much less inclusive, and, therefore, a more accurate, measure of cardiac function in isolation from other organ systems. The veteran’s co-morbidities that influence METs level are: COPD requiring home O2, prior bilateral knee replacements, chronic back pain, and diabetic neuropathy. The examiner indicated that co-morbidities cannot be separated to evaluate individually. A June 2017 VA echocardiogram report indicated that the LVEF was 40 to 45 percent. Based on a review of the evidence, lay and medical, the Board finds that an initial rating in excess of 60 percent is not warranted for the entire period on appeal. The evidence consistently reflected that the LVEF was at least 35 percent, which is consistent with the criteria for a 60 percent rating. While the June 2017 VA examination report indicated that the workload was 1-3 METs with dyspnea and fatigue, the VA examiner opined that the LVEF was a better indicator of the current cardiac status because it was reflective solely of the cardiac function, unlike the METs level, which was influenced by the numerous non-cardiac co-morbidities. The Board finds the June 2017 VA examiner’s opinion to be highly probative, as it supported by a highly detailed rationale. As such, the Board finds that the LVEF is the most accurate indicator of his current cardiac function and will only consider LVEF in determining the proper rating for the IHD. For these reasons, the preponderance of the evidence is against the appeal for a higher rating than 60 percent for IHD. Finally, the Board notes that neither the Veteran nor the representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 2. Entitlement to an initial rating in excess of 10 percent for diabetes from March 17, 2010 to October 18, 2010, and in excess of 20 percent thereafter. The Veteran is in receipt of a 10 percent initial rating for diabetes from March 17, 2010 to October 18, 2010, and a 20 percent rating thereafter. The Veteran contends generally that the diabetes warrants a higher rating. Diabetes is rated under 38 C.F.R. § 4.119, DC 7913, applicable to diabetes mellitus. DC 7913 provides that diabetes mellitus manageable by restricted diet only is assigned a 10 percent rating. Diabetes mellitus requiring insulin and restricted diet, or; oral hypoglycemic agent and restricted diet is assigned a 20 percent rating. Diabetes mellitus requiring insulin, restricted diet, and regulation of activities is assigned a 40 percent rating. A rating of 60 percent is assigned when diabetes mellitus requires insulin, 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. Diabetes mellitus requiring more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated, is assigned a 100 percent rating. The term “regulation of activities” is defined in the rating criteria for a 100 percent disability rating under DC 7913 as “avoidance of strenuous occupational and recreational activities.” Although not specified in the rating criteria, the Board finds that this definition also applies to the “regulation of activities” discussed in the 40 percent and 60 percent disability ratings under DC 7913. Additionally, medical evidence is required to show that occupational and recreational activities have been restricted. See Camacho v. Nicholson, 21 Vet. App. 360, 363-64 (2007). Further, in light of the conjunctive “and” in the criteria for a 40 percent disability rating under DC 7913, all criteria must be met to establish entitlement to a 40 percent rating. See, e.g., Heuer v. Brown, 7 Vet. App. 379, 385 (1995) (holding that criteria expressed in the conjunctive are connected by “and”); Malone v. Gober, 10 Vet. App. 539 (1997) (construing “and” as conjunctive in a statute); cf. Johnson v. Brown, 7 Vet. App. 95, 97 (1994) (holding that “or” in the rating criteria shows that each is an independent basis for granting that rating). Turning to the evidence, in July 2010, the Veteran stated that diabetes was controlled by diet. He did not suffer from weight loss or see a diabetic care specialist. In September 2010, the Veteran was afforded a VA examination. The Veteran reported that he had never been hospitalized for hypoglycemia and had never had an episode of ketoacidosis. Weight had remained stable within the same 10-pound range over the past year. There were no restrictions in activities due to diabetes. There was no evidence of diabetic retinopathy or diabetes-related skin problems. There were no diabetes-related bowel or bladder functional impairments. The Veteran had had paresthesias to the upper extremities for five to six years, getting progressively worse. He denied paresthesias to the lower extremities. The Veteran reported that flare-ups to the upper extremities occurred daily and lasted five minutes with a severity of 9/10, and that flare-ups usually occurred after prolonged positions and consisted of numbness, pain, and no functional loss. The Veteran was able to accomplish his daily activities. On examination of the hands in September 2010, sensation testing, deep tendon reflexes, and muscle strength were normal, and there was no tenderness to palpation in the joint areas of the hands. In the feet, vibration sensation was decreased, deep tendon reflexes were decreased, muscle strength was normal, and there was no muscle atrophy. The Veteran is right-hand dominant. The diagnosis was bilateral upper extremity paresthesias. In an October 2010 addendum medical opinion, the VA examiner opined that the Veteran’s peripheral neuropathy is at least as likely as not related to the diabetes. In November 2011, the Veteran reported that he started taking medication on October 8, 2010 because the diabetes was no longer controlled by diet. In August 2013, the Veteran was afforded a VA examination. The Veteran reported that he visited a diabetic care provider for episodes of ketoacidosis or hypoglycemic reactions less than two times per month, had not experienced any episodes of ketoacidosis or hypoglycemic reactions requiring hospitalization over the past 12 months, and had not had progressive unintentional weight loss or progressive loss of strength attributable to the diabetes. The VA examiner noted a diagnosis of diabetic peripheral neuropathy, with a 2010 date of diagnosis. In June 2017, the Veteran was afforded a VA examination where diabetes was treated by a restricted diet, prescribed oral hypoglycemic agent(s), and more than one insulin injection per day. The diabetes did not require regulation of activities as part of the medical management. The Veteran had not had any episodes of ketoacidosis or hypoglycemic reactions requiring hospitalization over the past 12 months. Based on a review of the evidence, lay and medical, the Veteran met the criteria for a 20 percent rating for diabetes under DC 7913 on October 8, 2010, the date he was prescribed medications to treat the diabetes. Prior to October 8, 2010, the diabetes was manageable by restricted diet only; therefore, the criteria for a rating in excess of 10 percent under DC 7813 were not met for this period. From October 8, 2010, forward, the Veteran has not met all the criteria for a 40 percent rating under DC 7913, as the evidence does not show regulation of activities due to diabetes is required. In addition, as the weight of the evidence indicates that the Veteran does not have any complications of diabetes that are not currently service-connected, no further discussion of separate compensable ratings for complications of diabetes is warranted subsequent to the respective effective dates for the awards of service connection for those disabilities. However, the Board will consider herein whether separate compensable ratings are warranted for any complications of diabetes prior to the effective dates of the existing awards. In that respect, the Board finds separate 20 percent ratings are warranted from March 17, 2010 to November 30, 2011 for mild bilateral upper extremity peripheral neuropathy under DC 8513, applicable to paralysis of all radicular groups. This is based on the September 2010 VA examination report indicating that the Veteran had had paresthesias to the upper extremities for five to six years, which were progressively worsening. This rating takes into account the Veteran’s reported daily flare-ups, lack of functional impairment, and normal sensation, reflex, and strength testing. Based on this evidence, ratings in excess of 20 percent for bilateral upper extremity peripheral neuropathy are not warranted under DC 8513 because the upper extremity peripheral neuropathy symptoms were mild and did not result in any functional impairment. As the evidence of record does not reflect any complaints of or treatment for bilateral lower extremity peripheral neuropathy, erectile dysfunction, and gastroparesis prior the effective dates currently assigned for the awards of service connection for these disabilities, no further discussion of these disabilities is warranted. In summary, the Board finds that an initial rating in excess of 10 percent for diabetes is not warranted for the rating period from March 17, 2010 to October 8, 2010, and a rating of 20 percent, but no higher, is warranted from October 8, 2010, forward. The Board also finds that separate ratings of 20 percent, but no higher, are warranted for bilateral upper extremity peripheral neuropathy from March 17, 2010 to November 30, 2011. Finally, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. 3. Entitlement to a TDIU It is the established policy of VA that all veterans who are unable to secure and maintain substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16. A finding of total disability is appropriate “when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation.” 38 C.F.R. §§ 3.340(a)(1), 4.15. A TDIU may be assigned when a veteran has one service-connected disability rated at 60 percent or more, or two or more service-connected disabilities where at least one disability is rated at 40 percent or more and the combined rating is at least 70 percent. 38 C.F.R. § 4.16(a). The record must also show that the service-connected disabilities alone result in such impairment of mind or body that the average person would be precluded from securing or maintaining a substantially gainful occupation. Id. The service-connected disabilities in this case met the schedular percentage requirements for a TDIU, as of March 17, 2010, as the Veteran was in receipt of service connection for IHD, rated 60 percent disabling from March 17, 2010; diabetes, rated 10 percent disabling from March 17, 2010, and 20 percent disabling from October 18, 2010; and residuals scars, status-post coronary artery bypass graft, rated 10 percent from March 17, 2010. Service connection for posttraumatic stress disorder (PTSD), bilateral upper and lower extremity peripheral neuropathy, gastroparesis, and erectile dysfunction has since been granted. The remaining question is whether these service-connected disabilities preclude the Veteran from securing or following a substantially gainful occupation. See 38 C.F.R. § 4.16(a). The fact that a veteran is unemployed or has difficulty finding employment does not alone warrant assignment of a TDIU, as a high rating itself establishes that his disability makes it difficult for him to obtain and maintain employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Rather, the evidence must show that the veteran is incapable “of performing the physical and mental acts required” to be employed. Id. at 363. Thus, the central question is whether a veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability, and not whether a veteran could find employment. Id. Consideration may be given to a veteran’s education, training, and special work experience, but not to his age or to impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19 (2017). In Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013), the Federal Circuit held that, when a veteran is claiming TDIU based upon the combined effects of multiple service-connected disabilities, VA’s duty to assist “does not require obtaining a single medical opinion regarding the combined impact of all service-connected disabilities.” See also Smith v. Shinseki, 647 F.3d 1380, 1385-86 (Fed. Cir. 2011) (VA is not required to obtain an industrial survey from a vocational expert before making a TDIU determination but may choose to do so in an appropriate case). Although VA must give full consideration, per 38 C.F.R. § 4.15, to “the effect of combinations of disability,” VA regulations place responsibility for the ultimate TDIU determination on VA adjudicators, not a medical examiner’s opinion. Geib, 733 F.3d at 1354; see also 38 C.F.R. § 4.16(a). The ultimate issue of whether TDIU should be awarded is not a medical issue, but rather is a determination for the VA adjudicator. See Moore v. Nicholson, 21 Vet. App. 211, 218 (2007) (ultimate question of whether a veteran is capable of substantial gainful employment is not a medical one; that determination is for the adjudicator), rev’d on other grounds sub nom, Moore v. Shinseki, 555 F.3d 1369 (Fed. Cir. 2009). There is no regulatory definition of “substantially gainful employment.” 38 C.F.R. § 4.16(a) provides guidance in that it states: “Marginal employment shall not be considered gainful employment.” It also says definitively that marginal employment exists when a veteran’s earned annual income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. 38 C.F.R. § 4.16(a). There is not always sufficient evidence in the claims folder to determine earned annual income. However, in case there is appropriate evidence of earned annual income, the most recent poverty threshold may be found at: http://www.census.gov/hhes/www/poverty/data/threshld/ (last visited July 18, 2018). Even if the income exceeds the poverty threshold, marginal employment may still exist on a facts-found basis. One example given is employment in a protected environment like a family business or a sheltered workshop. 38 C.F.R. § 4.16(a). VA must consider the nature of employment. Id. The Veteran’s DD Form 214 indicates that he served on active duty for three years. The military occupational specialty was cook. SSA records indicated that the Veteran had been disabled since May 2006. The primary diagnosis was chronic pulmonary insufficiency (chronic obstructive pulmonary disease (COPD)) and IHD. The Veteran had worked as a cook foreman at a VA hospital from 1969 to 1994, worked at an inn as a groundskeeper from 1996 to 2003, and lso worked as an elected township trustee from 1998 to 2002. The September 2010 VA examination report indicated that the Veteran was retired. He had previously worked as a groundskeeper. In an October 2010 VA addendum medical opinion, the September 2010 VA examiner opined that the Veteran did not exhibit symptoms from diabetes that would interfere with employment at that time. With regard to IHD, the assessment was that the Veteran would have a hard time maintaining physical employment, but could maintain sedentary employment. The examiner assessed that METs level of 5 with dyspnea on exertion would interfere with physical labor. With regard to the bilateral upper extremity peripheral neuropathy, the VA examiner assessed that the frequent paresthesias would impair the ability to work physically, but the Veteran could work in a sedentary environment with opportunities to rest or move the extremities. In January 2011, the Veteran stated that the ability to work had deteriorated since a heart attack in January 2002, that he forced himself to work part-time from 2002 to 2006, though his job performance during this time was not sufficient, and he had to quit the job in 2006 because he was unable to perform the work. The Veteran stated that his heart condition caused him multiple problems, including severe fatigue, stopping to rest every 100 feet because of exhaustion, inability to be in extreme hot or cold weather, hot flashes and cold sweats, nausea, high blood pressure, motion sickness due to medication, and heart palpitations. The Veteran reported that he had to take several naps during the day because of severe fatigue, could not sit or stand for more than 30 minutes because of numbness in the legs, that it was a struggle for him to get up in the morning and complete the daily personal hygiene tasks, he required assistance to perform personal hygiene tasks due to fatigue, could not perform any household chores, and that he had to urinate every 40 to 45 minutes due to diabetes. An October 2011 VA Form 21-4192, Request for Employment Information in Connection with Claim for Disability Benefits, indicated that the Veteran worked as a groundskeeper at an inn from January 2000 to December 2003, where he worked 10 to 20 hours each week. The August 2013 VA examiner opined that, due to the IHD, the Veteran would have a hard time maintaining gainful employment in a physical setting, but could possibly work in a more sedentary environment. This was based on the fact that the Veteran got dyspnea, angina, and dizziness with increased activities, which would interfere with prolonged periods of physical activity. However, the Veteran could work in a more sedentary environment that allowed adequate rest periods. The VA examiner also opined that the diabetes would not interfere with work requirements because it was under good control. As to the peripheral neuropathy, the VA examiner opined that the Veteran would have a hard time maintaining gainful employment in a physical setting, but could work in a sedentary environment. The Veteran could walk 200 feet, stand for 15 minutes, climb four steps at a time, and dropped objects frequently. The VA examiner opined that these functional limitations would interfere with the ability to do prolonged positions and repetitive movements, but the Veteran could possibly work in a slower paced sedentary environment with frequent rest periods. In June 2015, the Veteran’s treating psychiatrist wrote that the Veteran was currently unable to work. The psychiatrist indicated that the Veteran was socially isolated and unlikely to significantly improve. A January 2016 VA psychiatry treatment note indicated that the Veteran had at one time done auto detailing and worked mixing dough in a frozen food factory. The Veteran earned his GED and later got his high school diploma. A February 2016 VA mental health treatment note indicated that the Veteran worked at a VA hospital for 29 years as the supervisor of cooking and had to retire early due to health issues. A March 2017 VA peripheral nerves examination report indicated that the Veteran had difficulty holding things without dropping them. He had difficulty standing for long periods, driving, and doing anything that required precision with his hands. The June 2017 VA examiner opined that the Veteran’s ability to obtain and maintain employment was impacted by his service-connected disabilities. Due to service-connected disabilities, the Veteran was unable to lift/carry, push/pull, bend/twist, kneel/squat, climb, grasp/grip, and use a keyboard. In addition, the ability to walk and stand was limited to 10-minute intervals due to service-connected IHD and peripheral neuropathies. After a review of all the evidence of record, lay and medical, the Board finds that the evidence is at least in equipoise on the question of whether the Veteran has been unable to secure or maintain substantially gainful employment due to the service-connected disabilities for the entire period on appeal. Throughout the period on appeal, the evidence reflects that the IHD caused dyspnea, angina, and dizziness with increased activities, which would preclude him from any type of physical labor. See August 2013 VA examination report. In addition, the bilateral upper extremity peripheral neuropathy would significantly impair the ability to perform any type of non-physical or desk work because this would require frequent rests because the Veteran could not sustain prolonged hand positions. See October 2010 addendum medical opinion, August 2013 VA examination report, March 2017 VA peripheral nerves examination report, and June 2017 VA examination report. Resolving reasonable doubt in the Veteran’s favor, the Board finds that the functional impact of the Veteran’s service-connected disabilities rendered him unable to maintain substantially gainful employment. Given the significant impact of the service-connected disabilities on the ability to work and perform routine tasks that would likely be required for employment, the evidence supports a finding that the service-connected disabilities precluded the Veteran from maintaining substantially gainful employment. For these reasons, the criteria for a TDIU are met for the entire period on appeal from March 17, 2010. REASONS FOR REMAND 1. Entitlement to SMC based on the need for aid and attendance is remanded. In a December 2013 rating decision, the RO, in pertinent part, denied SMC based on the need for aid and attendance and housebound status. In February 2014, the Veteran filed a notice of disagreement (NOD) with the RO’s denial of these claims. While the Veteran only explicitly stated that he disagreed with the RO’s denial of his claim of SMC based on housebound status, his subsequent statements make it clear that he was also in disagreement with the Board’s denial of SMC based on the need for aid and attendance. As VA has not issued a SOC on this matter, the Board must remand for issuance of a SOC. 38 C.F.R. § 19.9 (c) (2017); see Manlincon v. West, 12 Vet. App. 238 (1999). The Board notes that a statement of the case was issued in June 2017 as to the issue of entitlement to SMC based on housebound status. The Veteran did not perfect this appeal, and it became final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.160(d), 20.200, 20.302, 20.1103. The Board also notes that a February 2016 VA treatment note indicates that the Veteran reported retiring from the military after 23 years. The Veteran stated that most of his service was in the Air Force. However, the only DD-214 of record indicates that the Veteran served in the Army for three years. On remand, the AOJ should verify the dates of the Veteran’s service, to include any service in the National Guard, Reserves, or United States Air Force. The matters are REMANDED for the following action: 1. Verify the dates of the Veteran’s service, to include any service in the National Guard, Reserves, or United States Air Force. 2. Issue a SOC on the issue of entitlement to SMC based on the need for A&A. The Veteran and his representative should be advised of the time limit for perfecting an appeal, and afforded such period of time to do so. If he timely perfects an appeal in the matter, it should be returned to the Board. J. PARKER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Thomas, Associate Counsel