Citation Nr: 18153094 Decision Date: 11/28/18 Archive Date: 11/27/18 DOCKET NO. 15-02 356 DATE: November 28, 2018 ORDER Entitlement to a rating in excess of 20 percent for low back strain prior to September 19, 2017 is denied. Entitlement to a rating in excess of 40 percent from September 19, 2017 is denied. Entitlement to a total disability rating for individual unemployability (TDIU) due to a service-connected disability is denied. FINDINGS OF FACT 1. Prior to September 19, 2017, the Veteran’s low back strain was manifested by pain, limitation of motion, and forward flexion of the thoracolumbar spine greater than 30 degrees; neither favorable nor unfavorable ankylosis of the thoracolumbar spine was shown. 2. From September 19, 2017, the Veteran’s low back strain is manifested by pain and limitation of forward flexion to less than 30 degrees; unfavorable ankylosis of the thoracolumbar spine is not shown. 3. The Veteran’s service-connected disabilities do not preclude her from securing and following all forms of substantially gainful employment because of her service-connected disabilities. CONCLUSIONS OF LAW 1. Prior to September 19, 2017, the criteria for a rating in excess of 20 percent for low back strain are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237. 2. From September 19, 2017, the criteria for a rating in excess of 40 percent for low back strain are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237. 3. The criteria for entitlement to a TDIU are not met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1979 to May 1981, and from June 1986 to August 1992. Disability Ratings Disability evaluations are determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule). 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 service and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Separate ratings may be assigned for separate periods of time based on the facts found. This practice is known as staged ratings, and as explained in more detail below are warranted herein. Hart v. Mansfield, 21 Vet. App. 505 (2007). If the evidence for and against a claim is in equipoise, the claim will be granted. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When evaluating disabilities of the musculoskeletal system, functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements must be considered. See 38 C.F.R. § 4.40; DeLuca v. Brown, 8 Vet. App. 202 (1995). Consideration must also be given to weakened movement, excess fatigability and incoordination. 38 C.F.R. § 4.45. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The Veteran contends she is entitled to an increased rating for her service-connected low back strain. The Veteran’s lumbosacral strain is rated at 20 percent disabling prior to September 19, 2017, and 40 percent disabling thereafter, under 38 C.F.R. § 4.71a, Diagnostic Code 5237, lumbosacral strain. Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine (General Formula) (for DCs 5235 to 5243, unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes). The General Formula contemplates pain, whether or not it radiates. Under the General Rating Formula for Diseases and Injuries of the Spine, a 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is assigned for unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine; and 100 percent for unfavorable ankylosis of the entire spine. Note 1 to the rating formula specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. Note 2 states that, for VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Intervertebral disc syndrome (preoperatively or postoperatively) is to be evaluated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under § 4.25. Diagnostic Code 5243 provides for rating intervertebral disc syndrome (IVDS) under the General Rating Formula for Diseases and Injuries of the Spine, or under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.71a, Diagnostic Code 5243. The Veteran does not contend, and the evidence does not reflect that the Veteran has IVDS, therefore this DC is not applicable. 1. Entitlement to a Rating in Excess of 20 Percent for Low Back Strain prior to September 19, 2017 The Veteran filed a claim for an increased rating for her service connected low back strain in April 2011. Throughout the period of the appeal, the Veteran has also been rated as 40 percent disabling for fibromyalgia. The Veteran was afforded a VA examination in July 2011. The examiner noted the Veteran has reported a long history of ongoing back pain. She reported experiencing stiffness, fatigue, spasms, decreased motion, paresthesia, and numbness. The Veteran did not report weakness or bowel/bladder problems. She reported at times the pain is severe. The Veteran reported that her pain could be exacerbated by physical activity. During a flare-up, she experienced neither functional impairment nor any limitation of motion of the joint. She reported that she was not receiving any treatment for her back disability and did not experience any overall functional impairment because of this disability. The Veteran had a normal gait. There was no clinical evidence of radiating pain or muscle spasms. Tenderness was noted on palpation. Muscle tone was normal. The bilateral straight leg test was negative, and there was no ankylosis of the thoracolumbar spine. Range of motion testing was within normal limits. Repetitive use testing noted no additional loss of motion. On repetitive use testing the Veteran was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. Sensory and neurological examination of the lower extremities was normal. Intervertebral Disc Syndrome (IVDS) was not present. Diagnostic testing revealed mild degenerative changes at L4-L5 and L5-S1. May 2014 private treatment records reveal that the Veteran’s spine was normal. October 2014 VA treatment records reflect that the Veteran denied back pain. January 2015 correspondence reflects that the Veteran reported wearing a back brace. See January 2015 VA Form-9. September 2015 private treatment records reflect that the Veteran walked with a normal gait, but did complain of back pain. The Veteran was afforded an additional VA examination in October 2016. The examiner noted a low back strain. The Veteran reported that her condition had gotten worse. She told the examiner that during flare-ups her back disability caused pain and stiffness. The Veteran did not report having any functional loss or functional impairment because of her back. On range of motion testing forward flexion was to 50 degrees, extension to 15 degrees, right and left lateral flexion to 15 degrees and right and left lateral rotation to 15 degrees. The combined range of motion was 125 degrees. No pain was noted on the examination. The Veteran stated that she was unable to move due to anterior chest pain with movement from nonservice-connected heart transplant surgery. Pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time. There was no evidence of localized tenderness, guarding, muscle spasms or atrophy was noted. Muscle strength testing was 5/5. Reflex and sensory examinations were normal. Bilateral straight leg raising test was negative. The Veteran did not exhibit radicular pain or any other signs or symptoms due to radiculopathy. No ankylosis of the spine was noted. The examiner did not find any neurological abnormalities or findings, or IVDS of the thoracolumbar spine. The examiner concluded that the Veteran’s low back disability did not impact her ability to work. The Veteran attended another VA examination in April 2017. The examiner noted a low back strain. The Veteran reported that her condition had gotten worse. She reported pain with bending, lifting and squatting. She stated that she used a walker for her back and knee conditions. The Veteran denied experiencing flare-ups. On range of motion testing forward flexion was to 55 degrees, extension to 10 degrees, right and left lateral flexion to 20 degrees and right and left lateral rotation to 15 degrees. The combined range of motion was 135 degrees. Pain was noted on the examination, which was determined to cause functional loss. Pain, weakness, fatigability or incoordination did significantly limit functional ability with repeated use over a period of time. Localized tenderness resulted in an abnormal gait. There was evidence of pain with weight bearing. There was no evidence of guarding, muscle spasms or atrophy. Muscle strength testing was 5/5. Bilateral straight leg raising test was negative. The Veteran did not exhibit radicular pain or any other signs or symptoms due to radiculopathy. No ankylosis of the spine was noted. The examiner did not find any neurological abnormalities or findings, or IVDS of the thoracolumbar spine. The examiner concluded that the Veteran’s low back disability caused pain with walking, bending, squatting, and lifting. The examiner noted that the Veteran’s range of motion appeared to better when she was removing her knee brace, compared to the results of her examination. Private and VA treatment records reflect periodic complaints of back pain. Although the record reflects that the Veteran has complained of low back pain during this time period, to warrant a 40 percent disability rating under the General Rating Formula for Diseases and Injuries of the Spine, the evidence must show that the Veteran’s back disability results in forward flexion of the thoracolumbar spine 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. Moreover, a 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. The Board reiterates that the Veteran’s complaints are consistent with the VA examination findings as to range of motion and there are no range of motion findings to the contrary. The Board also notes that the medical evidence does not indicate that the Veteran has been prescribed bed rest by a physician based on incapacitating episodes totally at least four weeks but less than six weeks during any twelve-month period. Therefore, the Veteran’s service-connected low back strain does not warrant an increased disability rating alternatively under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes at any time during the course of this appeal. In evaluating the Veteran’s increased rating claim, the Board must also address the provisions of 38 C.F.R. §§ 4.40, 4.45, and 4.59. See DeLuca, supra. The Board recognizes the Veteran’s complaints of pain, flare-ups, and functional loss as a result of her low back strain, notably her difficulty with prolonged walking and bending. However, the Board places greater probative value on the objective clinical findings which do not support an increased disability rating. In this regard, the probative evidence of record does not indicate significant functional loss attributed to the Veteran’s low back complaints which warrant an increased disability rating. While the Board acknowledges the Veteran’s reports of pain during range of motion testing during some of the VA examinations, range of motion with pain was still greater than 30 degrees forward flexion. The Board is therefore unable to identify any clinical findings that would warrant an increased evaluation under 38 C.F.R. § 4.40 and 4.45. The Board further finds that the current 20 percent rating adequately compensates the Veteran for any functional impairment attributable to her low back strain. See 38 C.F.R. §§ 4.41, 4.10. During this time period, the Veteran’s low back symptomatology does not approach a 40 percent disability rating. The evidence prior to September 19, 2017, does not demonstrate that the Veteran has maintained forward flexion 30 degrees or below including consideration of pain and functional loss. See DeLuca, supra. The Board places greatest probative value on the objective clinical findings which do not support an increased disability rating. Accordingly, a 40 percent disability rating of the Veteran’s lumbar spine is not warranted prior to September 19, 2017. Entitlement to a TDIU is addressed below. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (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 a Rating in Excess of 40 percent for Low Back Strain from September 19, 2017 Upon VA examination in September 2017, the Veteran reported 10/10 pain, which was worse with movement and walking and better with rest and opiod therapy. She denied radiating pain, tingling and numbness. Range of motion testing revealed forward flexion to 20 degrees extension to 10 degrees, right and left lateral flexion to 5 degrees and right and left lateral rotation to 15 degrees. She explained that her range of motion was limited because of pain and hardware in place from a mammectomy secondary to breast cancer. There was no evidence of pain with weight bearing. The Veteran reported muscle spasms that did not result in an abnormal gait. Muscle strength testing was 4/5. There was no atrophy or guarding. Reflex and sensory examinations were normal. Bilateral straight leg raising test was negative. The Veteran did not exhibit radicular pain or any other signs or symptoms due to radiculopathy. No ankylosis of the spine was noted. The examiner did not find any neurological abnormalities or findings, or IVDS of the thoracolumbar spine. The Veteran did not use any assistive devices. The examiner concluded that the Veteran’s low back disability did not impact her ability to work. March 2018 private treatment records reflect that the Veteran reported that her back pain and spasms had improved due to the use of a back brace, and she reported feeling better overall. The Veteran underwent an additional VA examination in May 2018. The Veteran reported flare-ups causing aching pain and stiffness. She reported that her back disability caused limited range of motion, difficulty lifting heavy objects, difficulty with bending, and impairments with prolonged walking and climbing stairs. Range of motion testing revealed forward flexion to 55 degrees extension to 20 degrees, right and left lateral flexion to 20 degrees and right and left lateral rotation to 20 degrees. Range of motion did not contribute to functional loss. There was pain noted which caused functional loss. There was no evidence of pain with testing while weight bearing. There was additional loss of function after three repetitions, reflecting forward flexion to 50 degrees extension to 15 degrees, right and left lateral flexion to 15 degrees and right and left lateral rotation to 15 degrees. Additional limitations on range of motion following repeated use over time would reveal forward flexion to 45 degrees extension to 10 degrees, right and left lateral flexion to 10 degrees and right and left lateral rotation to 10 degrees. During a flare up, the Veteran’s forward flexion would be to 40 degrees extension to 5 degrees, right and left lateral flexion to 10 degrees and right and left lateral rotation to 10 degrees. Guarding, muscle spasms, and atrophy were not evident. Reflex and sensory examinations were normal. Bilateral straight leg raising test was negative. The Veteran did not exhibit radicular pain or any other signs or symptoms due to radiculopathy. No ankylosis of the spine was noted. The examiner did not find any neurological abnormalities or findings, or IVDS of the thoracolumbar spine. The Veteran reported using a back brace and walker constantly. The examiner concluded that the Veteran’s low back disability caused difficulty with walking, standing, and bending for prolonged time period. He determined that there were no restrictions on sedentary occupational tasks. Private and VA treatment records reflect periodic complaints of back pain. The Board finds that from September 19, 2017, a disability rating in excess of 40 percent for the Veteran’s low back strain is not warranted. The current evaluation contemplates pain on motion and limitation of motion to less than 30 degrees. In fact, the evaluation would contemplate no remaining functional flexion of the lumbar spine due to any factor other than unfavorable ankylosis. The Veteran is at the maximum evaluation for limited motion and functional impairment. Furthermore, she does not have unfavorable ankylosis. Regardless of her complaints of flare-ups, such reports would not warrant a higher evaluation. During this time period, the Veteran’s low back symptomatology does not approach a 50 percent disability rating. The evidence from September 19, 2017, does not demonstrate that the Veteran has experienced unfavorable ankylosis including consideration of pain and functional loss. See DeLuca, supra. The Board places greatest probative value on the objective clinical findings which do not support an increased disability rating. Accordingly, a rating in excess of 40 percent for the Veteran’s low back strain is not warranted at any time during the period on appeal. Entitlement to a TDIU is addressed below. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (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). 3. Entitlement to a TDIU due to Service-Connected Disabilities It is the established policy of VA that all Veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. See 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.” See 38 C.F.R. §§ 3.340(a)(1), 4.15. A TDIU may be assigned where the schedular rating is less than total and it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of either (1) a single service-connected disability ratable at 60 percent or more, or (2) two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there are sufficient additional service-connected disabilities to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). For the purposes of determining rating level, disabilities resulting from a common etiology or affecting a single body system are considered a single disability. 38 C.F.R. § 4.16(a). From April 2, 2004 to September 19, 2017, the Veteran was service connected for fibromyalgia, rated at 40 percent; a low back strain, rated at 20 percent; and left knee tendonitis with arthritis, rated at 10 percent. Her combined disability rating was 60 percent. From September 19, 2017, the Veteran’s low back strain was increased to 40 percent disabling, increasing her combined disability rating to 70 percent. Therefore, the Veteran’s service-connected disabilities do not meet the percentage rating standards for TDIU prior to September 19, 2017, and do meet the percentage rating standards for TDIU from that date. 38 C.F.R. § 4.16(a). For a Veteran to prevail on a claim for entitlement to TDIU, 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; the ultimate question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). When determining whether a TDIU is warranted, consideration may be given to the Veteran’s level of education, special training and previous work experience in arriving at a conclusion, but not to his or her age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 4.16, 4.19; see also Van Hoose v. Brown, 4 Vet. App. 361 (1993). The Veteran served in the United States Army as an administrative specialist. See Form DD-214. Private treatment records reflect that the Veteran completed graduate school. See September 2015 private treatment records. SSA records show that the Veteran had experience as an administrator in a school and for a federal agency, the latter using computers and data bases. She reported some education above the high school level in the Army and at a college. TDIU Evaluation prior to September 19, 2017 At no time prior to September 19, 2017, did the Veteran meet the scheduler TDIU requirements. When the schedular TDIU requirements are not met, as in this case, entitlement to a TDIU on an extraschedular basis may still be granted. See 38 C.F.R. § 4.16(b). In this regard, the Board notes that neither the Agency of Original Jurisdiction (AOJ) nor the Board is authorized to assign an extraschedular TDIU in the first instance under 38 C.F.R. § 4.16(b). See Wages v. McDonald, 27 Vet. App. 233 (2015). 38 C.F.R. § 4.16(b) states that “rating boards should submit to the Director, Compensation Service, for extra-schedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the” schedular TDIU requirements. Accordingly, the issue before the Board is more specifically whether referral to the Director of Compensation Service for consideration of an extraschedular TDIU is warranted prior to September 19, 2017. The Veteran reported that she stopped working in February 2009 because she was diagnosed with breast cancer. See July 2012 Notice of Disagreement. As noted above, the Veteran’s combined disability rating was 60 percent from April 2, 2004 to September 19, 2017. Her knee, back and fibromyalgia disabilities did not prevent her from working full time prior to her cancer diagnosis and treatment. Social Security Administration (SSA) records reflect that the Veteran filed for disability once she stopped working in February 2009. When asked why she stopped working, the Veteran reported that she was unable to return to work because she was actively receiving chemotherapy to treat her nonservice-connected breast cancer. She explained that her past and present employment required the ability to think and react in a timely manner. She stated that the chemotherapy treatment caused memory issues, anxiety attacks, exhaustion, and body aches, and prevented her from accomplishing her job responsibilities. SSA records ultimately reflect that the Veteran was awarded disability due to status post breast cancer, congestive heart failure with pulmonary embolism and neuropathy secondary to chemotherapy. The Board notes that none of these conditions are service-connected. A July 2011 VA examination report reflects that the Veteran denied any overall functional impairment due to her fibromyalgia, back, and knee disabilities. On her January 2015 VA Form-9, the Veteran reported that her fibromyalgia caused constant pain. She also stated that her back and knee pain inhibited her ability to work. In February 2015 correspondence, the Veteran reported that the Office of Personnel Management (OPM) determined she was disabled due to breast cancer. She attached a corresponding letter from OPM which stated, “[i]n reviewing your medical records we have found you to be disabled for your position as an Investigative Assistant due to cancer.” A July 2016 social worker’s report reflects the Veteran reported that the multitude of medications she was prescribed caused extreme fatigue and her numerous medical conditions limited her ability to be around people. She was required to wear a mask when in public to prevent potential illness or infection that would jeopardize her heart. Because the social worker had no medical training, she was unable to render an opinion on the impact of the Veteran’s service-connected disabilities on her employability. A VA medical opinion was obtained in October 2016. Following a review of the claims file, a VA examiner determined that, “[t]he veteran’s medical records reviewed do not show a basis from social and industrial impairment due to her service connected conditions of fibromyalgia, low back strain and left knee tendonitis.” She went on to opine that the Veteran’s, “current diagnosis of breast cancer treatment and heart transplant surgery are her primary disability concerns which are not service connected.” An October 2016 VA examination report reflects that the Veteran’s fibromyalgia, knee disability, and back disability did not impact her ability to perform any type of occupational task. A May 2017 VA examination report reflect that the Veteran reported that her back and knee disabilities caused difficulty with walking, squatting, prolonged sitting and standing. The Board acknowledges that the Veteran’s service-connected disabilities have some effect on her occupational impairment. However, the 60 percent schedular rating prior to September 19, 2017 recognizes the industrial or commercial impairment resulting from her disorders. The Board has considered the Veteran’s lay statements, however affords greater probative weight to the VA examiners’ opinions, which did not find that the Veteran’s service-connected disabilities hindered her ability to work consistent with her education, experience and skills. Nevertheless, it is adjudicator’s responsibility to determine whether the service-connected disabilities preclude all forms of substantially gainful employment. During this period, the Veteran was significantly limited in lifting, carrying, extended walking and standing and did experience joint pain. However, the Veteran did not report cognitive deficits that would prevent use of administrative tools such as a computer or telephone or keeping track of and completing administrative assignments because of her back, knee, and fibromyalgia. The Veteran reported and examiner’s confirmed that she is also significantly disabled from residuals of cancer and heart disease. The medical evidence on file does not suggest that the Veteran’s fibromyalgia, knee disability, and back disability demonstrated referral to the Director of Compensation Service for consideration of an extraschedular TDIU. The preponderance of the evidence does not support the Veteran’s contentions that her service-connected disabilities have precluded her participation in sustainably gainful employment. Instead, the evidence overwhelmingly reflects that the Veteran ended her employment due to nonservice-connected disabilities. TDIU Evaluation from September 19, 2017 From September 19, 2017 the Veteran meets the threshold requirements for TDIU for the period on appeal. A September 2017 VA examination concluded that the Veteran’s back disability would have no impact on her ability to work. A November 2017 VA examination concluded that the Veteran’s knee disability would have no impact on her ability to work. On December 2017 correspondence, the Veteran again stated that she was entitled to a TDIU rating, in part because of her cancer and heart conditions. See December 2017 Notice of Disagreement. April 2018 correspondence reflects that the Veteran again attributed her cancer and corresponding chemotherapy and radiation treatment as the reason she stopped working in February 2009. See April 2018 Application for Increased Compensations based on Unemployability. A May 2018 VA examination report reflects that the Veteran’s back and knee disabilities caused difficulty standing and walking for prolonged periods of time but that there were no restrictions on sedentary employment. In October 2018 correspondence, the Veteran stated that she would be unable to work in sedentary employment because the medication that she was prescribed for her heart and cancer conditions caused “memory loss, tiredness, and the inability to function as a normal employee.” She also stated that left sided weakness (caused by nonservice-connected disabilities) prevented her from standing, walking, bending, and holding items. The Veteran also reported back and knee pain. The Board finds that the Veteran’s nonservice-connected disabilities impact the Veteran’s ability to work in both a physical as well as in an administrative position requiring cognition and use of general administrative tool such as a telephone and computer, and her service-connected disabilities are not the reason for her unemployment. The Board is unable to consider nonservice-connected disabilities in determining whether a TDIU is warranted. The Veteran’s service-connected disabilities resulted in a combined 60 percent disability rating prior to September 19, 2017, and a combined 70 percent disability rating thereafter. In this regard, 38 C.F.R. § 4.1 provides that “the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses.” The Board concludes that the assigned disability ratings contemplates and compensates the Veteran for the resulting occupational impairment from her service-connected disabilities during the periods in question. For the reasons and bases set forth above, the preponderance of the evidence is against finding her service-connected disabilities (singly or in combination) are of such severity so as to preclude her participation in any form of substantially gainful employment. As such, the benefit of the doubt doctrine is inapplicable, and the claim must be denied. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Fitzgerald, Associate Counsel