Citation Nr: 18152878 Decision Date: 11/27/18 Archive Date: 11/26/18 DOCKET NO. 11-21 266A DATE: November 27, 2018 ORDER New and material evidence having been received, the reopening of the claim of entitlement to service connection for melanoma is granted. Entitlement to service connection for melanoma is denied. Entitlement to a rating in excess of 20% for diabetes mellitus is denied. Entitlement to a separate compensable rating for peripheral vascular disease (PVD) is denied. Entitlement to an increased rating for nephropathy with hypertension is denied. Entitlement to a total disability evaluation based on individual unemployability (TDIU) is denied. FINDINGS OF FACT 1. A February 2008 rating decision denied service connection for melanoma that the condition was not incurred in or aggravated by service. A March 2010 rating decision continued the denial. The Veteran did not appeal that decision, or submit new and material evidence within the relevant appeal period. 2. Evidence submitted since the March 2010 decision relates to an unestablished fact necessary to substantiate the claim. 3. The Veteran’s melanoma did not manifest during service or to a compensable degree within a year thereafter, has not been continuous since service separation, and was not caused by any in-service event, including herbicide exposure, during service. 4. The Veteran’s service-connected diabetes mellitus required the use of an oral hypoglycemic agent and a restricted diet, but regulation of activities was not required. 5. The Veteran does not have a current diagnosis of PVD. 6. The Veteran’s nephropathy with hypertension manifested without persistent edema or albuminuria and normal levels of BUN and creatinine and no generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. 7. The most probative evidence of record indicates that the Veteran’s service connected disabilities have not precluded him from obtaining and maintaining substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for reopening the claim of entitlement to service connection for melanoma have been met. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017). 2. The Veteran’s melanoma was not incurred in service, nor may it be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1110, 1112, 1113 (2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2017). 3. The criteria for a rating in excess of 20 percent for diabetes mellitus have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.119, Diagnostic Code 7913 (2017). 4. The criteria for a rating in excess of 60 percent for diabetic nephropathy with hypertension have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.115b, Diagnostic Code 7502 (2017). 5. The criteria for a separate disability rating for PVD have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.104, Diagnostic Code 7114 (2017). 6. 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, 4.3, 4.16, 4.19 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from December 1966 to November 1968. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of March 2010 and August 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously before the Board in June 2015, at which time the Board remanded the issues currently on appeal for additional development. The case has now been returned to the Board for further appellate action. In connection with this appeal, the Veteran testified at a travel board hearing before the undersigned Veterans Law Judge in February 2015. A transcript of that hearing has been associated with the claims file and has been considered in support of the Veteran’s claim. A review of the record further shows that the Veteran filed a Notice of Disagreement (NOD) with an April 2017 rating decision that denied entitlement to service connection for depression and a heart condition. The filing of a NOD normally places a matter into appellate status, requiring the Board to remand for issuance of a Statement of the Case (SOC). See Manlincon v. West, 12 Vet. App. 238 (1999). However, the Agency of Original Jurisdiction (AOJ) has since responded to the Veteran’s NOD by inquiring as to the process by which the Veteran wished to resolve his appeal. The Board thereby declines to take appellate jurisdiction over these issues at this time as it is clear the AOJ is processing the appeal and will issue an SOC, thereby allowing the Veteran the opportunity to perfect the appeal if he so desires. See 38 C.F.R. §§ 3.103 (f), 20.200 (2017). The matter is referred to the AOJ for appropriate action. 38 C.F.R. § 19.9 (b) (2017). 1. New and material evidence has been submitted to reopen a claim for service connection for melanoma Generally, a final rating decision or Board decision may not be reopened, and a claim based on the same factual analysis may not be considered. 38 U.S.C. §§ 7104, 7105. Under 38 U.S.C. § 5108, however, “[i]f new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim.” New evidence is defined as existing evidence not previously submitted to VA, and material evidence is defined as existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.15(a). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is “low.” See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Consideration is not limited to whether the newly submitted evidence relates specifically to the reason the claim was last denied, but instead should include whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the Secretary’s duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. However, a new theory of entitlement does not automatically reopen a previously denied claim. See Bingham v. Nicholson, 421 F.3d 1346, 1348-49 (2005); see also Boggs v. Peake, 520 F.3d 1330, 1336 (Fed. Cir. 2008) (A new theory of causation for the same disease or injury that was the subject of a previously denied claim cannot be the basis of a new claim). In a February 2008 rating decision, the RO denied service connection for melanoma as there was no evidence of a relationship between the Veteran’s melanoma and his service. The Veteran did not file a notice of disagreement with the February 2008 rating decision, nor did the Veteran submit new and material evidence relating to either claim within one year of the February 2008 rating decision. 38 C.F.R. § 3.156. As such, the February 2008 rating decision is final. In March 2010, the RO issued a decision denying the Veteran’s claim to reopen the claim for service connection for melanoma as no new and material evidence had been submitted. As the Veteran did not appeal the March 2010 decision, that decision also became final. Evidence of record at the time of the March 2010 rating decision included the Veteran’s service medical records and post-service outpatient medical records from August 2007. Pertinent evidence received subsequent to the March 2010 rating decision includes additional post-service medical records. The evidence received since the March 2010 rating decision is new and material. This medical evidence is not cumulative or redundant of the evidence previously of record. Moreover, it raises a reasonable possibility of substantiating the claim as it includes additional treatment records. Accordingly, reopening of the claim of entitlement to service connection for melanoma is warranted. 2. Entitlement to service connection for melanoma Having reopened the claim, the Board notes that the RO reopened the claim and considered it on the merits in the October 2012 rating decision. Thus, there is no prejudice in the Board’s consideration of this claim on the merits. See Hickson v. Shinseki, 24 Vet. App. 394 (2010) (the Board is prohibited from considering a claim on the merits which has not yet been considered on the same basis by the RO). The Veteran contends that that his melanoma is the result of his service, including exposure to and herbicide agens. To prevail on a direct service connection claim, there must be competent evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a nexus between the in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). If a Veteran was exposed to an “herbicide agent,” such as Agent Orange, used in support of the United States and allied military operations in the Republic of Vietnam from January 9, 1962, to May 7, 1975, then, absent affirmative evidence to the contrary, certain diseases will be presumptively service connected even if there is no record of the disease in service. 38 U.S.C. §§ 1110, 1116, 1131; 38 C.F.R. §§ 3.307 (a)(6), (d), 3.309(e). Here, the Veteran has been diagnosed with melanoma, which is not on the list of chronic diseases associated with exposure to herbicide agents. See 38 C.F.R. §§ 3.307 (a)(6), 3.309(e). Thus, even if the Veteran was exposed to an herbicide agent during active service, presumptive service connection could not be established for this disability; however, a claimant is not precluded from establishing service connection with proof of actual causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). The question for the Board is whether any current skin disability either began during active service, or is otherwise etiologically related to service. The Board finds that competent, credible, and probative evidence establishes that the Veteran’s diagnoses of melanoma is not etiologically related to the Veteran’s active service, to include exposure to herbicide agents. Service treatment records (STRs) indicate that in an October 1966 service enlistment examination, the Veteran’s denied having any skin disorders. In a November 1968 separation examination, the Veteran’s skin and lymphatics were found to be clinically normal. The Veteran’s STRs indicate that he visited the dermatology clinic once in March 1967 but there is no record of any additional care related to the Veteran’s skin. The Veteran’s STRs did not otherwise show a complaint of a skin condition. There is no medical evidence that the Veteran had melanoma during service, or within one year of service. Although the Veteran’s medical records indicate that he was treated once during service for a skin condition, there is no competent evidence that the condition he sought treatment for is related to his current diagnosis. Lay testimony on skin diagnoses and etiology is not competent in the present case because the Veteran has not been shown to possess the knowledge of the complexities of dermatology, the various causes of skin disorders, and the results of exposure to various chemicals that is required to diagnose skin disorders, or to opine on their etiology. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (“sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer”). The Board also finds that there is no competent and credible evidence establishing that the current skin diagnosis is medically related to active service. The Board acknowledges that private medical records from Gwinnett Medical Center in February 2018 indicate that the Veteran has “melanoma from agent orange exposure,” but those indications appear to be recitations of history from the Veteran. There is no indication that there have been any clinic findings of a relationship between the Veteran’s melanoma and herbicide agent exposure. Also, there is a letter from Dr. R.L. of Georgia Cancer Specialists stating that “recent medical studies have shown a direct link between agent orange exposure and malignant melanoma.” Here, the physician has made a general statement about studies connecting herbicide agent exposure and melanoma, but has not opined that it is more likely than not that the Veteran’s melanoma was related to his herbicide agent exposure. The Veteran has made an assertion that his skin diagnoses are related to service. The Board, however, cannot rely on the Veteran’s general assertions as to medical nexus to service because, as discussed above, although he is competent to report observable skin symptoms, he is not shown to possess the type of medical expertise that would be necessary to opine regarding the etiology of skin disorders. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). The question of causation in this case involves a complex medical issue, requiring knowledge of the types and presentation of skin disorders, and the Veteran has not been shown to have the medical expertise required to address such an issue. Moreover, there is no competent medical opinion supporting a nexus between the Veteran’s melanoma and his herbicide agent exposure. Thus, there is no competent evidence to establish a nexus between the current skin diagnoses and any documented event or incident of service. There can be no doubt that the Veteran rendered honorable and faithful service for which the Board is grateful, and he is sincere in his belief that his skin diagnoses are related to his service. While the Board has carefully reviewed the record in depth, it has been unable to identify a basis upon which service connection may be granted for melanoma. The Board has weighed the evidence of record, and finds that the preponderance of the evidence is against a finding that the Veteran’s melanoma is related to service. As such, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Increased Rating Disability evaluations are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2017). However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14 (2017). 3. Entitlement to an increased evaluation for diabetes mellitus The Veteran’s service connected diabetes mellitus is currently rated as 20 percent disabling. The Veteran claims that his service-connected diabetes mellitus is worse than it is rated. The Veteran’s diabetes mellitus has been rated according to the provisions provided in 38 C.F.R. §4.119, Diagnostic Code 7913. Under Diagnostic Code 7913, a 20 percent rating is assigned when insulin and a restricted diet, or oral hypoglycemic agent and restricted diet are required. A 40 percent rating is warranted when the disease requires the taking of insulin, a restricted diet, and regulation of activities. “Regulation of activities” is defined by Diagnostic Code 7913 as the “avoidance of strenuous occupational and recreational activities.” Competent medical evidence is required to establish “regulation of activities,” namely, avoidance of strenuous occupational and recreational activities, for a 40 percent rating under Diagnostic Code 7913. Camacho v. Nicholson, 21 Vet. App. 360, 364 (2007). A 60 percent rating requires the taking of 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 total schedular (100 percent) rating for diabetes mellitus requires more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least 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. 38 C.F.R. §4.119, Diagnostic Code 7913. Note (1) to Diagnostic Code 7913 provides that compensable complications of diabetes 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. Because of the successive nature of the rating criteria for diabetes, e.g., the evaluation for each higher disability rating includes the criteria of each lower disability rating, each of the three criteria listed in the 40 percent rating must be met in order to warrant such a rating. See Tatum v. Shinseki, 23 Vet. App. 152, 156 (2009). Stated another way, if a component is not met at any one level, a veteran can only be rated at the level that did not require the missing component. Id. The Veteran was afforded a VA examination in February 2010. He denied any episodes of diabetic ketoacidosis which required hospitalization and also denied hospitalization for hypoglycemia. He described tingling and numbness of the feet but no progressive weight loss or loss of strength. He did not report urinary incontinence. He treated with medication. He did not experience any overall functional impairment from this condition. The Veteran’s last VA examination was in February 2016. The VA examiner noted that the Veteran was treated with a prescribed an oral hypoglycemic agent. The VA examiner opined that the Veteran did not require regulation of activities for treatment of his diabetes mellitus, and that he suffered no loss of strength or unintentional weight loss due to his diabetes mellitus. The Veteran also testified at the hearing on this matter that he has been advised by a doctor to exercise and eat a healthy diet. He further testified that he has leg and calf pain after walking and standing for a period of time. He relives the pain by sitting and elevating his feet. Although the Veteran testified that he treats his pain by rest and elevation of his feet, a review of the Veteran’s private and VA medical evidence does not reflect that regulation of activities has been prescribed as part of the Veteran’s treatment. Here, the Board must emphasize a crucial distinction. An evaluation of 40 percent under DC 7913 does not merely require evidence that the Veteran experiences limitations in his activities as a result of his diabetes, but that it is medically necessary for him to avoid strenuous occupational and recreational activities. See Camacho v. Nicholson, 21 Vet. App. 360, 363 (2007); see also 38 C.F.R. § 4.119, DC 7913 (defining term within criteria for a 100 percent rating). For example, the Court in Camacho explained that an opinion from an employer that a Veteran should not drive was not based on an individualized assessment of the Veteran or constitute competent medical evidence that the diabetes actually made it unsafe to drive. Camacho at 365. The Court noted that VA’s intention in drafting the current version of the Diagnostic Code had been to ensure that the rating reflected how well diabetes had been controlled. Id. at 363. Further, the Court observed that the VA Clinician’s Guide instructed examiners to “[i]nclude any restrictions of diet or physical activities and any weight loss.” Id. at 364. Just as with restrictions in diet, the essential characteristic of regulation of activity under DC 7913 is medical instruction. The Board carefully considered the two private opinions. In this case, the evidence of record does not show that the Veteran has been instructed to avoid strenuous activities. The Board therefore does not find competent medical evidence that the Veteran’s diabetes treatment requires regulation of activities. Therefore, the Board finds that the Veteran does not meet the criteria for a rating in excess of 20 percent. As a preponderance of the evidence is against an increased rating, the benefit of the doubt doctrine does not apply, and the claim must be denied. 4. Entitlement to a rating in excess of 60 percent for nephropathy with hypertension The Veteran is currently service connected for nephropathy with hypertension associated with diabetes at 60 percent disabling. Diagnostic Code 7541, for renal involvement in diabetes mellitus, sickle cell anemia, systemic lupus erythematosus, vasculitis, or other systemic disease processes, directs that any such impairment is to be rated as renal dysfunction. 38 C.F.R. § 4.116, Diagnostic Code 7541. 38 C.F.R. § 4.115a provides for renal dysfunction to be rated as follows: Constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension at least 40 percent disabling under Diagnostic Code 7101 (diastolic pressure predominantly 120 or more) warrants a 60 percent evaluation. An 80 percent rating is warranted for persistent edema and albuminuria with BUN 40 to 80mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. Finally, a 100 (total) rating is warranted for renal dysfunction requiring regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80mg%; or, creatinine more than 8mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular. 38 C.F.R. § 4.115a. After considering the totality of the record, the Board finds the preponderance of the evidence to be against a disability rating in excess of 60 percent for the Veteran’s diabetic nephropathy at any time during the rating period. Nephropathy was identified as a complication of the Veteran’s service-connected diabetes mellitus The Veteran last underwent a VA examination for his nephropathy in March 2016. According to the examination report, the Veteran does not have persistent edema and albuminuria with elevated BUN or creatinine, or generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. The Veteran’s medical records indicate that in February 2016, he was diagnosed with microalbuminuria. According to the March 2016 examination report, the Veteran’s diabetic nephropathy did not require regular dialysis and he did not display any signs or symptoms of renal dysfunction, to include persistent edema and/or albuminuria. Urinalysis indicated BUN and creatinine levels as “normal,” well below the thresholds required for an 80 percent evaluation. The VA examiner opined that, while the Veteran reported a history of kidney stones, the Veteran suffers from microalbuminuria, and that, to diagnose the Veteran with nephropathy is “a little speculative.” Other VA and private medical records also do not demonstrate findings akin to a higher 80 percent rating. While the veteran has been seen for kidney stones, such symptoms did not result in the required renal involvement or generalized poor health. Hospital records in July 2016 noted a higher BUN of 31, which still falls below the 40 needed for a higher rating and creatinine was 0.91. An April 2016 record noted that the Veteran had underwent a cysto, attempted cystolitholopahy but the stones were not amenable to fragmentation and the decision was made to stop the procedure and plan for an open cystolithotomy. While hospital records in November 2016 reflect complaints of kidney stones, the radiological findings concluded that no calculi were noted. It did describe a right renal area that was obscured by fecal debris and a questionable tiny stone could not be excluded. Rather, for example, a November 2017 record noted a history of kidney stones, not having surgical treatment for the stones and indicating the symptoms resolved. Renal ultrasound was normal and showed no stones or obstruction. Similarly, a February 2018 hospitalization for abdominal symptoms ultimately was found to be related to his gallbladder and a cholecystectomy was performed. Laboratory findings during this hospitalization also do not reflect persistent edema, albuminuria, requisite BUN and creatinine findings. The Veteran further reported that he was diagnosed with hypertension in 2007, “around the same time” as being diagnosed with diabetes. A February 2010 VA examiner diagnosed the Veteran as having renal hypertension related to his diabetes because of renal involvement. Even at that time the BUN was 29 and BUN/creatinine ratio was 29. The Veteran reports taking medication to control his blood pressure, and attended a VA examination in March 2016 related to his hypertension. While hypertension is expressly considered by the 60 percent evaluation, the higher ratings do not include specific findings related to hypertension alone that would support the higher rating. Rather, the ratings are dependent upon persistent edema and albuminuria with BUN 40 to 80mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. As outlined above, the Board acknowledges the Veteran and his spouse’s report of frequent kidney stones, several requiring surgical intervention. To the extent to which these are attributable to the diabetic nephropathy, they have not resulted in persistent edema and albuminuria with the requisite BUN or creatinine levels nor has the evidence demonstrated that the Veteran is of such generalized poor health to warrant the higher rating. To the contrary, VA examinations reflect the BUN and creatinine levels were normal. More recent hospital records from February 2018 related to an unrelated condition include blood work that reflects a BUN of 22 and creatinine of 1.0 and one reported a BUN of 30 and creatinine of 1.1. Another record during that hospitalization reflected a BUN of 29 and creatinine of 1.2 and he was noted to have an acute kidney injury due to dehydration. A note on February 23, 2018 described the acute kidney injury as improved with fluid resuscitation. Additionally, the Board notes that the current rating is higher than that which would be provided under the diagnostic code for kidney stones (DC 7508) and in fact severe levels of kidney stones would be rated under the codes for renal dysfunction pursuant to 7508 and 7509. In conclusion, the Board finds the preponderance of the evidence is against the award of an initial rating in excess of 60 percent for diabetic nephropathy. As a preponderance of the evidence is against the award of an increased rating, the benefit of the doubt doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107 (b); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1991). 5. Entitlement to a separate compensable rating for PVD. The Veteran is also seeking a compensable rating for his claimed PVD. Under diagnostic code 7114, a 20 percent rating requires claudication on walking more than 100 yards, and; diminished peripheral pulses or ankle/brachial index of 0.9 or less; a 40 percent rating requires claudication on walking between 25 and 100 yards on a level grade at 2 miles per hour, and; trophic changes (thin skin, absence of hair, dystrophic nails) or ankle/brachial index of 0.7 or less; a 60 percent rating requires claudication on walking less than 25 yards on a level grade at 2 miles per hour, and; either persistent coldness of the extremity or ankle/brachial index of 0.5 or less; and a 100 percent rating requires ischemic limb pain at rest, and; either deep ischemic ulcers or ankle/brachial index of 0.4 or less. The Veteran underwent a VA examination in September 2008. The Veteran underwent ankle/brachial index (ABI) testing during the September 2008 examination. The right and left ABI test results were normal. The Veteran also underwent a VA examination in February 2010. Veteran’s February 2010 VA examination identified that the Veteran has bilateral mild PVD related to his diabetes. The Veteran underwent ABI testing in February 2010. The test results indicated a right ABI of 0.97 and a left ABI of 0.98. The Veteran underwent another VA examination in March 2016 related to this claim. The Veteran stated that he believes that he has always had a “circulation problem” and that his toes and feet are “always cold.” The Veteran stated that his feet feel “better” with walking. The Veteran has not had any ongoing treatment for PVD. The Veteran has not undergone an amputation of an extremity due to a vascular condition and does not use assistive devices in walking. The Veteran underwent ABI testing in March 2016. The right ABI test indicated a result of 1.31 on the right and 1.14 on the left. The VA examiner opined that the test results showed that the Veteran does not have PVD, and that the claimed condition does not have any functional impartments and does not interfere with physical or sedentary work. The Board recognizes that the Veteran reported pain in his feet, toe, and calves, that he has constant cold feet, and that he has to elevate his feet for “hours a day” to relieve the pain. However, as the medical evidence indicates that the Veteran does not currently have a PVD diagnosis, a separate compensable rating is not available. 6. Entitlement to a total disability evaluation based on individual unemployability (TDIU) VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that a veteran is precluded from obtaining or maintaining any gainful employment consistent with his education and occupational experience, by reason of his service connected disabilities. 38 C.F.R. §§ 3.340, 3.341, 4.16. A total rating for compensation purposes may be assigned on a schedular basis where the schedular rating is less than total, when, in the judgment of the rating agency, the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service connected disability ratable at 60 percent or more, or as a result of two or more service connected disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service connected disability to bring the combined rating to 70 percent or more. 38 U.S.C. §1155; 38 C.F.R. §§ 3.340, 3.341, 4.16(a). For the above purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable; disabilities resulting from common etiology or a single accident; disabilities affecting a single body system; multiple injuries incurred in action; or multiple disabilities incurred as a prisoner of war. 38 C.F.R. §4.16 (a). For a veteran to prevail on a claim for a TDIU rating, the record must reflect some factor which takes the case outside the norm. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is a recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether the Veteran can find employment. See 38 C.F.R. §4.16 (a); Van Hoose v. Brown, 4 Vet. App. 361 (1993). Age may not be considered as a factor when evaluating unemployability or intercurrent disability, and it may not be used as a basis for a total disability rating. 38 C.F.R. § 4.19. There must be a determination that the service connected disabilities are sufficient to produce unemployability without regard to advancing age or a non-service connected disability. 38 C.F.R. §§ 3.340, 3.341, 4.16. The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate each claim and what the evidence in the claims file shows, or fails to show, with respect to each claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. §5107; 38 C.F.R. §3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran filed this claim for a TDIU in December 2014, asserting that he was unable to work as a result of his service-connected disabilities. The Veteran is presently service connected for nephropathy with hypertension 60 percent and diabetes mellitus at 20 percent. As such, the Veteran meets the schedular criteria for a TDIU. The Veteran’s 2014 TDIU application indicates that has one year of college education. He reported on this application that he last worked full-time in January 1999 and that he became too disabled to work at the same time. The Veteran’s TDIU indicates that he worked for 30 years for United Parcel Service. Social Security Administration records reflect he was found to be disabled beginning July 2005 from malignant melanoma of the skin and other malignant neoplasms of the skin. Significantly, the Veteran’s application for SSA benefits reflects he indicated the cause of his inability to work was the melanoma, including his surgeries and continued care required for the condition. A VA examiner conducted an evaluation to determine if the aggregate effect of the Veteran’s service-connected disabilities precluded him from securing and following substantially gainful employment. The examination report indicates that the Veteran’s disabilities would not prevent the Veteran from obtaining or maintaining substantially gainful employment. Previous VA examination reports also indicate that the Veteran’s service connected disabilities would not preclude him from securing or maintaining substantially gainful employment. The Board further notes that the Veteran has applied for benefits from the Social Security Administration (SSA). In his SSA application, the Veteran indicated that he worked as a tractor trailer driver until May 2002 and at that time he stopped working because he retired. The Board finds the medical evidence addressing the Veteran’s level of disability to be more probative than the Veteran’s assertions. As noted above, the Veteran indicated that he retired from his job in May 2002. The Board finds that the Veteran’s service connected disabilities do not render him unable to obtain or maintain gainful employment consistent with his education, training, and work experience. Accordingly, the criteria for TDIU are not met, and the claim is denied. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. §5107 (b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). H. SEESEL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Boal, Associate Counsel