Citation Nr: 18153268 Decision Date: 11/27/18 Archive Date: 11/27/18 DOCKET NO. 16-22 720 DATE: November 27, 2018 ORDER Entitlement to service connection for rheumatoid arthritis is granted. The previously-denied claim of entitlement to service connection for pulmonary fibrosis is reopened on the basis of new and material evidence. Entitlement to service connection for pulmonary fibrosis is granted. Entitlement to an increased evaluation of right knee instability, currently evaluated as 10 percent disabling, is denied. Entitlement to an evaluation of 20 percent, but not higher, for status post right knee partial meniscectomy with degenerative arthritis is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to an increased evaluation for residual painful scar, right knee, currently evaluated as 0 percent disabling prior to February 26, 2012 and as 10 percent disabling thereafter, is denied. Entitlement to an increased evaluation for residual scar, right knee, currently evaluated as 0 percent disabling, is denied. Entitlement to an increased evaluation of diabetes mellitus type II, currently evaluated as 20 percent disabling, is denied. Entitlement to an increased evaluation of depressive disorder not otherwise specified, currently evaluated as 50 percent disabling, is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) is granted. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran’s favor, his rheumatoid arthritis began during active service. 2. A December 2009 rating decision denied service connection for interstitial lung disease, which encompasses pulmonary fibrosis; the Veteran did not perfect an appeal of that decision, and new and material evidence was not received within one year of notice of its issuance. 3. Evidence received more than one year after that December 2009 rating decision denying service connection for interstitial lung disease is neither cumulative nor redundant of the evidence that was already of record and considered in that decision, and this additional evidence raises a reasonable possibility of substantiating the Veteran’s claim. 4. Resolving reasonable doubt in the Veteran’s favor, his pulmonary fibrosis is proximately due to his service-connected rheumatoid arthritis. 5. The preponderance of the evidence weighs in favor of a finding that the Veteran’s right knee instability has not been any worse than slight during the period on appeal. 6. The preponderance of the evidence weighs in favor of a finding that the Veteran’s status post right knee partial meniscectomy with degenerative arthritis has been of a severity commensurate with that which can be characterized as dislocated semilunar cartilage with frequent episodes of “locking,” pain and effusion into the joint. 7. The preponderance of the evidence weighs in favor of a finding that during the period on appeal, the Veteran has had only one residual scar on his right knee that is painful, and that none of his service-connected scars were: located on his head, face or neck; covering an area of 6 square inches or more; or unstable. 8. The Veteran’s diabetes mellitus, type II, does not require the regulation of activities, and there are no separately ratable compensable complications. 9. The preponderance of the evidence weighs in favor of a finding that the severity of the Veteran’s service-connected depressive disorder not otherwise specified is best characterized as being productive of occupational and social impairment with reduced reliability and productivity. 10. The Veteran’s service-connected disabilities preclude him from securing or following a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for service connection for rheumatoid arthritis are met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 2. New and material evidence sufficient to reopen the claim of entitlement to service connection for interstitial lung disease/pulmonary fibrosis has been received since the final December 2009 rating decision. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156. 3. The criteria for service connection for pulmonary fibrosis are met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 4. The criteria for entitlement to a disability evaluation greater than 10 percent disabling for right knee instability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.14, 4.40, 4.71a, Diagnostic Code (DC) 5257. 5. The criteria for entitlement to a 20 percent disability evaluation for status post right knee partial meniscectomy with degenerative arthritis have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.14, 4.40, 4.71a, Diagnostic Codes (DCs) 5003, 5010, 5256-5263. 6. The criteria for entitlement to a disability evaluation greater than 0 percent disabling prior to February 26, 2012 and greater than 10 percent disabling thereafter for residual scar, right knee, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.14, 4.118, DC 7804. 7. The criteria for entitlement to a disability evaluation greater than 0 percent disabling for residual scar, right knee, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.14, 4.118, DC 7805. 8. The criteria for entitlement to a disability evaluation greater than 20 percent disabling for diabetes mellitus, type II, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.14, 4.119, DC 7913. 9. The criteria for entitlement to a disability evaluation greater than 50 percent disabling for depressive disorder not otherwise specified have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.14, 4.130, DC 9434. 10. The criteria for TDIU have been met. 38 C.F.R. § 4.16(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1983 to April 2007. In February 2018, the Veteran waived his right to have the Department of Veterans Affairs (VA) regional office (RO) review and consider additional evidence that he submitted that month. Service Connection The Veteran claims entitlement to service connection for rheumatoid arthritis and pulmonary fibrosis. 1. Entitlement to service connection for rheumatoid arthritis Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service, even if the disability was initially diagnosed after service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Certain chronic diseases will be presumed related to service if they were noted as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if continuity of the same symptomatology has existed since service, with no intervening cause. 38 U.S.C. §§ 1101, 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2012); Fountain v. McDonald, 27 Vet. App. 258 (2015); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). Rheumatoid arthritis (RA) is one such chronic disease. See id. The Veteran claims that he developed RA while serving on active duty. A letter from his private physician indicates that the Veteran had an initial presentation of carpal tunnel syndrome (CTS) in 2003, and that the physician was of the opinion that the initial presentation of CTS could have been a manifestation of RA. The Veteran was afforded a VA examination in February 2013 and the examiner opined that the Veteran’s RA was less likely than not incurred during, caused or aggravated by his active duty service. The examiner supported this opinion with a very brief rationale. The Veteran submitted a private medical opinion in February 2018, which indicates that the private physician is of the opinion that it is as likely as not that the Veteran developed rheumatoid arthritis during his time in service. This private opinion is much more lengthy and detailed than the aforementioned VA examination opinion is, and it is also accompanied by medical literature supporting the physician’s conclusion. Thus, the Board finds the private opinion to be worthy of at least as much probative value as the VA examination opinion is. The aforementioned letter and medical opinions are the most probative evidence related to this issue. Therefore, the Board finds that the evidence is in relative equipoise as to whether the Veteran incurred RA during the course of his active military service. Accordingly, the Veteran is entitled to service connection for rheumatoid arthritis, and the claim is granted. 2. Whether new and material evidence has been received to reopen a previously-denied claim of entitlement to service connection for pulmonary fibrosis Service connection for interstitial lung disease was denied in a December 2009 rating decision. The Veteran was notified of that determination and of his appellate rights, and he did not appeal or submit new and material evidence within the following year. Accordingly, that decision is a final and binding determination based on the evidence then of record. See 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104(a), 3.160(d), 20.200, 20.1103. Evidence received since that unappealed rating decision includes but is not limited to a July 2017 medical opinion authored by a private physician who opined that the Veteran’s pulmonary fibrosis, which is a form of interstitial lung disease, is secondary to his rheumatoid arthritis which was incurred during his active military service. See medical opinion dated in July 2017. This newly received evidence is new because it was not previously considered in the December 2009 rating decision, and it is material because it pertains to unestablished facts necessary to substantiate the claim of entitlement to service connection for migraine headaches, namely, the etiology of the claimed disability. As this additional evidence is new and material, this claim consequently is reopened. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). This action will not prejudice the Veteran, as the Agency of Original Jurisdiction (AOJ) previously reopened the claim in an April 2013 rating decision and an April 2016 Statement of the Case (SOC). See Hickson v. Shinseki, 23 Vet. App. 394, 398 (2010). The reopened claim will be addressed substantively below. 3. Entitlement to service connection for pulmonary fibrosis The elements of direct service connection are set forth above, but service connection may also be granted on a secondary basis for a disability if it is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was either proximately caused by or proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995). Here, the Veteran claims that he has incurred pulmonary fibrosis as the result of his RA. The Veteran’s private medical records contain comments by one of his physicians indicating that his interstitial lung disease is secondary to his RA. The Veteran was afforded a VA examination in relation to this claim of secondary service connection in February 2013, and the examiner indicated that the Veteran’s pulmonary fibrosis was a type of interstitial lung disease, but the examiner also indicated that he or she was unable to determine whether it was related to his rheumatoid arthritis without mere speculation. The examiner did, however, state that the Veteran’s pulmonologist did not think that his pulmonary fibrosis was secondary to his RA. The private medical opinion that the Veteran submitted in February 2018 also addressed the etiology of the Veteran’s pulmonary fibrosis. In that opinion, the private physician opined that it is as likely as not that the Veteran’s RA contributed substantially and materially to the development of his pulmonary fibrosis. As mentioned above, this opinion is accompanied by supporting rationale. The aforementioned evidence is the most probative evidence in the claims file as related to this issue. Thus, the Board finds, upon review of the claims file, that the preponderance of the evidence weighs in favor of a finding that the Veteran’s pulmonary fibrosis was caused or at least aggravated by his RA. Accordingly, the Veteran is entitled to service connection for pulmonary fibrosis, and the claim is granted. Increased Ratings The Veteran also claims entitlement to increased evaluations for his service-connected right knee disabilities and associated scars, diabetes mellitus type II, and depressive disorder not otherwise specified, and to TDIU. 4. Entitlement to an increased evaluation of status post right knee partial meniscectomy with degenerative arthritis and entitlement to an increased evaluation of right knee instability, both currently evaluated as 10 percent disabling Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities (Rating Schedule). Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. When a claimant is assigned an initial disability rating or when a higher disability rating is granted during the direct appeal of the decision below, separate disability ratings may be assigned for separate periods of time in accordance with the facts found. Such separate disability ratings are known as staged ratings. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. In determining the appropriate rating for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Factors of joint disability include increased or limited motion, weakened movement, excess fatigability, incoordination, and painful movement, including during flare-ups and after repeated use. DeLuca v. Brown, 8 Vet. App. 202, 206-08 (1995); 38 C.F.R. § 4.45. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. 38 C.F.R. § 4.40. Additionally, “pain itself does not rise to the level of functional loss as contemplated by the VA regulations applicable to the musculoskeletal system.” Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). Pain in a particular joint may result in functional loss, but only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance. Id.; 38 C.F.R. § 4.40. Under 38 C.F.R. § 4.59, painful joints are entitled to at least the minimum compensable rating for the joint. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. See generally Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, the Veteran’s service-connected status post right knee partial meniscectomy with degenerative arthritis is currently evaluated as 10 percent disabling under DCs 5010-5259. Hyphenated diagnostic codes, such as the ones utilized here, are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. Thus, in this case, the Veteran’s service-connected status post right knee partial meniscectomy with degenerative arthritis is rated under DC 5010 and DC 5259 is the diagnostic code identifying the basis for the evaluation. The Board will consider additional diagnostic codes pertinent to the evaluation of knee disabilities in order to determine the highest possible evaluation for the left knee disability during the period on appeal. However, in considering the applicability of those other diagnostic codes, the Board finds, at the outset, that Diagnostic Codes 5256 (ankylosis of the knee), 5262 (impairment of tibia and fibula) and 5263 (genu recurvatum) are not applicable in this instance, as the Veteran has not claimed to have suffered from those conditions during the period on appeal and the medical evidence does not show that he has any such conditions or symptoms or is troubled by any such effects. See 38 C.F.R. § 4.71a, DCs 5256, 5262, 5263; VA Form 21-4138, Statement in Support of Claim received March 8, 2012. Pursuant to DCs 5003 and 5010, degenerative arthritis established by X-ray findings and traumatic arthritis substantiated by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added, under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, DC 5003, 5010. Under DC 5257, which provides ratings for recurrent subluxation or lateral instability, a 10 percent rating is assigned when the impairment is slight, while a 20 percent rating is assigned for moderate impairment and a 30 percent rating is for severe impairment. 38 C.F.R. § 4.71a, DC 5257. DC 5258 provides that a 20 percent rating is warranted where a veteran has dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint. 38 C.F.R. § 4.71a, DC 5258. DC 5259 provides that a 10 percent rating is for application where a veteran suffers from the symptomatic removal of semilunar cartilage. 38 C.F.R. § 4.71a, DC 5259. Limitation of motion of the knee is rated under DC 5260, for limitation of flexion, and DC 5261, for limitation of extension. Under DC 5260, a noncompensable rating is assigned when flexion is limited to 60 degrees or more; a 10 percent rating is assigned when flexion is limited to 45 degrees; a 20 percent rating is assigned when flexion is limited to 30 degrees; and a 30 percent rating is assigned when flexion is limited to 15 degrees or less. 38 C.F.R. § 4.71a, DC 5260. Under DC 5261, a noncompensable rating is assigned when extension is limited to 5 degrees or less; a 10 percent rating is assigned when extension is limited to 10 degrees; a 20 percent rating is assigned when extension is limited to 15 degrees; a 30 percent rating is assigned when extension is limited to 20 degrees; a 40 percent rating is warranted for extension limited to 30 degrees; and a 50 percent rating is assigned when extension is limited to 45 degrees or more. 38 C.F.R. § 4.71a, DC 5261. The standardized description of joint measurements is provided in Plate II under 38 C.F.R. § 4.71a. For VA purposes, “normal” extension and flexion of the knee is from zero to 140 degrees, and references to normal motion below indicate that the Veteran, in fact, had motion from zero to 140 degrees. 38 C.F.R. § 4.71a, Plate II. 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 or overlapping with the symptomatology of the other. Esteban v. Brown, 6 Vet. App. 259, 262 (1994); 38 C.F.R. § 4.14. Considering the above, the question for the Board, with respect to this claim, is whether the Veteran’s service-connected status post right knee partial meniscectomy with degenerative arthritis and right knee instability are characterized by moderate or severe recurrent subluxation or lateral instability of the right knee, dislocated semilunar cartilage of the right knee with frequent episodes of “locking,” pain, and effusion into the joint, limitation of flexion of the right knee to 45 degrees or less, and/or limitation of extension of the right knee to 10 degrees or more. The Board finds that the most pertinent evidence related to this claim consists of the Veteran’s statements, his private and VA treatment records, and the reports of the relevant VA examinations in the record. The Veteran claims that his knee “gives out” on him and becomes very painful after he walks over about 100 feet, but he does not claim to have any limitation of motion of the knee. See letter received April 22, 2009; VA Form 21-4138, Statement in Support of Claim received March 8, 2012. The Veteran’s private and VA treatment records reflect that he has pain in his right knee but they do not show that he has ankylosis, limitation of motion to a compensable extent (e.g., limitation of flexion to 60 degrees or less or limitation of extension to 5 degrees or more), dislocated semilunar cartilage with frequent episodes of “locking,” impairment of the tibia and fibula, or genu recurvatum. The Veteran was afforded two relevant VA examinations during the period on appeal – one in January 2012 and the other in February 2013. Both examiners opined that the Veteran does not have ankylosis, dislocated semilunar cartilage, impairment of the tibia and fibula, genu recurvatum or a compensable extent of range of motion limitation in or related to his right knee. There is no evidence to the contrary in the claims file. And the Board notes that the Veteran has not contended that he suffers from any of the aforementioned conditions, symptoms or effects in relation to his right knee. Thus, as indicated above, the Veteran is not entitled to an increased evaluation of his service-connected status post right knee partial meniscectomy with degenerative arthritis under DCs 5256, 5260, 5261, 5262, or 5263. The Veteran has already been assigned a 10 percent disability rating under DC 5259, for the symptomatic removal of semilunar cartilage, and the Board finds that the reports from the two aforementioned VA examinations support that rating. However, the Board also takes note of the fact that those reports indicate that the Veteran has had frequent episodes of “locking,” pain and effusion into his right knee during the period on appeal. Thus, the Board finds that the Veteran’s post-meniscectomy symptomatology is commensurate with that which warrants a 20 percent disability rating under DC 5258. Accordingly, the Board finds that the Veteran is entitled to such a rating. However, in order to be avoid pyramiding, the Veteran may only be compensated once for said post-meniscectomy symptomatology. Thus, the Board finds that the Veteran should be awarded a 20 percent disability evaluation under DC 5258 in place of (and not in conjunction with) his current 10 percent disability evaluation under DC 5259. As indicated above, the Veteran is not entitled to an increased evaluation under any other DCs. And regarding the Veteran’s claim of entitlement to an increase of his evaluation for his right knee instability, which is currently evaluated as 10 percent disabling under DC 5257, the question for the Board is whether the Veteran’s right knee instability is best characterized as slight, moderate or severe. The January 2012 VA examiner noted, in his or her report of the Veteran’s relevant medical history, that the Veteran has suffered from increasing right knee instability since 2008. However, in his or her report of the January 2012 VA examination, that examiner indicated that joint stability testing resulted in normal findings. The February 2013 VA examination report indicates that joint stability testing performed during the February 2013 VA examination revealed anterior, posterior and medial-lateral instability were each 1+ as to the right knee. There is no other competent medical evidence in the claims file that indicates that the severity of the Veteran’s right knee instability is any worse. Thus, the Board finds that these examination reports are the most probative evidence on the issue. They indicate that the Veteran’s right knee instability is, at most, slight. Thus, the Veteran is not entitled to an increased evaluation of his service-connected right knee instability. In making this determination, the Board notes that neither the Veteran nor his 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 (2017). 5. Entitlement to increased evaluations for residual painful scar, right knee, currently evaluated as 0 percent disabling prior to February 26, 2012 and as 10 percent disabling thereafter, and for residual scar, right knee, currently evaluated as 0 percent disabling During the pendency of the appeal, as it pertains to the Veteran’s scars, the Schedule for Rating Disabilities that addresses DCs 7801, 7802, and 7805 has been amended, which went into effect on August 13, 2018. 83 Fed. Reg. 32592 (July 13, 2018). Accordingly, both versions of the ratings schedule are applicable to this claim. VA will consider the claim in light of both versions and whichever is most favorable to the Veteran will be applied. Scars and other disfigurement of the head, face or neck are evaluated under DC 7800. Under the former rating criteria, scars not of the head, face or neck that are deep and nonlinear are evaluated under DC 7801; and scars not of the head, face or neck that are superficial and nonlinear are evaluated under DC 7802. Under the new rating criteria, burn scars or scars due to other causes, not of the head, face or neck, that are associated with underlying soft tissue damage are evaluated under DC 7801; and burn scars or scars due to other causes, not of the head, face or neck, that are not associated with underlying soft tissue damage are evaluated under DC 7802. Unstable or painful scars are evaluated under DC 7804. The minimum 10 percent disability rating is warranted for one or two scars that are unstable or painful. A 20 percent disability rating is warranted for three or four scars that are unstable or painful. The maximum 30 percent disability rating is warranted for five or more scars that are unstable or painful. See 38 C.F.R. § 4.118, DC 7804. Note (1) under the DC provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provides that if one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Note (3) provides that scars evaluated under diagnostic codes 7800, 7801, 7802, or 7805 may also receive an evaluation under this diagnostic code, when applicable. Id. Other scars and other effects of scars evaluated under DCs 7800-7802 and 7804 are evaluated under DC 7805. According to that DC (under both the former and new rating criteria), any disabling effects of such scars not considered in a rating under DCs 7800-7804 are to be evaluated under an appropriate diagnostic code. In every instance where the Rating Schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. Here, the Veteran claims entitlement to increased evaluations of his service-connected residual painful scar on his right knee associated with status post right knee partial meniscectomy with degenerative arthritis and of his other service-connected residual scar on his right knee. The residual painful scar is currently evaluated as 10 percent disabling under DC 7804 from February 26, 2013. The other residual scar is currently evaluated as 0 percent disabling (i.e., noncompensable). The Board finds that the most pertinent evidence related to these claims is comprised of the reports of two VA examinations that were performed during the period on appeal. VA and private treatment records are also in the Veteran’s claims file but those records do not show how many scars the Veteran has had or whether they are or were painful or unstable during the period on appeal. The report from the first VA examination, which was performed in January 2012, indicates that the Veteran had scars on the medial and lateral side of his right knee measuring not more than 0.6 centimeters, but no scars or disfigurement of the head, face or neck, no scars covering an area of at least 6 square inches, and no unstable or painful scars. The report also does not indicate the existence of any other effects of the Veteran’s right knee scars that would otherwise be compensable under DC 7805. The report from the second VA examination, which was performed in February 2013, indicates that the Veteran has four scars on the periphery of his right patella, including two lateral and two medial, and that the medial one is occasionally tender/painful. The examiner indicated that each of the scars were linear and measured 0.6 square centimeters. Both examiners indicated that none of the Veteran’s scars were on his head, face or neck; covering an area of 6 square inches or more, or unstable. Neither examiner indicated that the Veteran had more than one painful scar. There is no evidence in the claims file that contradicts those findings. Thus, the preponderance of the evidence is against this claim, and the claim is denied. Considering the above-mentioned evidence, the Board finds that the Veteran is not entitled to an increased evaluation of his service-connected residual painful scar on his right knee associated with status post right knee partial meniscectomy with degenerative arthritis or of his residual scar on his right knee under both the former and new rating criteria. In making this determination, the Board notes that neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette, 28 Vet. App. 366. 6. Entitlement to an increased evaluation of diabetes mellitus type II, currently evaluated as 20 percent disabling Diabetes mellitus (DM) is evaluated under DC 7913. A 20 percent evaluation is warranted where insulin and restricted diet or an oral hypoglycemic agent and restricted diet is required. The next higher evaluation of 40 percent disabling is available for DM requiring insulin, restricted diet, and regulation of activities. Even higher ratings are warranted for greater degrees of symptomatology requiring regulation of activities. The regulations stipulate that compensable complications of diabetes should be evaluated separately, and noncompensable complications are considered as part of the diabetic process under DC 7913. See 38 C.F.R. § 4.119, DC 7913. The Board notes that “regulation of activities” is defined in DC 7913 as “avoidance of strenuous occupational and recreational activities.” Medical evidence is required to show that occupational and recreational activities have been restricted. Camacho v. Nicholson, 21 Vet. App. 360, 363-364 (2007). In this case, a review of the relevant medical records reveals that regulation of the Veteran’s activities is not required to treat his DM. The Veteran was afforded two VA examinations for the purpose of assessing the severity of his DM – one in January 2012 and another in February 2013. The reports from those VA examinations show that regulation of activities was not required to manage his DM. His private and VA medical records do not show otherwise. Moreover, the Veteran has not established during this appeal that he has been required to regulate his activities to manage his DM. Consequently, as a rating higher than 20 percent contemplates the regulation of activities, which has not been shown, the Board concludes that a rating in excess of 20 percent is not warranted. The Board also notes that neither the Veteran’s private or VA treatment records nor the reports from the aforementioned VA examinations reflect the existence of any abnormal or separately compensable complications of diabetes. Therefore, the Board finds that the preponderance of the evidence weighs in favor of a finding that there are no separate compensable complications of diabetes to be evaluated at this time and no other noncompensable complications to be considered as part of the diabetic process under DC 7913. In making this determination, the Board notes that neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette, 28 Vet. App. 366. 7. Entitlement to an increased evaluation of depressive disorder not otherwise specified (NOS), currently evaluated as 50 percent disabling Mental disorders are evaluated under the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130. Under the General Rating Formula for Mental Disorders, a 70 percent rating is assigned for a mental disorder manifested by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood due to such symptoms as suicidal ideation, obsessional rituals which interfere with routine activities, speech intermittently illogical, obscure, or irrelevant, near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively, impaired impulse control (such as unprovoked irritability with periods of violence), spatial disorientation, neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances (including work or a work-like setting), or an inability to establish and maintain effective relationships. See 38 C.F.R. § 4.130. A 100 percent rating is assigned for a mental disorder manifested by total occupational and social impairment due to such symptoms as gross impairment in thought process or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, and memory loss for names of close relatives, own occupation, or own name. Id. The Veteran’s service-connected depressive disorder NOS is currently evaluated under DC 9434 as 50 percent disabling, in accordance with the above-mentioned criteria set forth in the General Rating Formula for Mental Disorders. The Veteran claims that he is entitled to an increased evaluation of his service-connected depressive disorder NOS. His VA treatment records reflect that he has complained of depression-related symptoms such as a depressed mood, anger, sleep disturbances and fatigue during the period on appeal, but those records do not reflect that his depressive disorder causes occupational and social impairment and deficiencies in most areas. To the contrary, they indicate that the Veteran’s depressive disorder is significantly more mild. The Veteran was afforded a VA examination for the purpose of assessing the severity of his depressive disorder in February 2013. The examiner indicated that the Veteran reported that his depressive disorder symptoms worsened when his “physical health” worsened and he learned of his pulmonary fibrosis in 2008. The Veteran also reported that he experiences depressive symptoms, such as fatigue/low energy, lack of motivation, loss of interest in activities, some social withdrawal, difficulty concentrating, feelings of hopelessness, issues with falling asleep, difficulty arising in the morning, and increased sadness. After a review of the Veteran’s claims file, the examiner opined that his depressive disorder was causing occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. There is no other significant evidence in the claims file relating to the severity of the Veteran’s depressive disorder during the period on appeal. The Board finds, upon review of the Veteran’s claims file, that the Veteran is not entitled to an increased evaluation of his service-connected depressive disorder NOS. Neither his medical records nor the aforementioned VA examination opinion indicate that the Veteran’s depressive disorder is severe enough to warrant such an increased evaluation. The only evidence indicating that the Veteran is entitled to an increased evaluation are the Veteran’s own statements, including those made to his medical providers and the February 2013 VA examiner. However, regarding those statements, the Board finds that they are of relatively little probative value, since the Veteran, as a lay person, is likely unable to distinguish normal feelings of sadness and fatigue from the clinical symptoms of depression. Therefore, the Board finds that the probative value of the report from the February 2013 examination opinion outweighs that of the Veteran’s lay statements. Thus, the Board also finds, in turn, that the preponderance of the evidence weighs against the Veteran’s claim of entitlement to an increased evaluation of his service-connected depressive disorder NOS. The claim is denied. In making this determination, the Board notes that neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette, 28 Vet. App. 366. 8. Entitlement to a TDIU In order to establish TDIU, there must be impairment so severe that it is impossible for the average person to follow a substantially gainful occupation. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is “whether the Veteran’s service connected disabilities alone are of sufficient severity to produce unemployability.” Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). 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 age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). Under the applicable criteria, TDIU may be assigned where the schedular rating is less than total, when it is found that 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 that one of those disabilities is ratable at 40 percent or more (including combined disabilities affecting a single body system), and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Here, the Veteran has met the schedular criteria for TDIU since May 1, 2007. He specifically claims that he is entitled to TDIU based primarily on the limitations he experiences as a result of his depression, right knee disability and pulmonary fibrosis. More specifically, he claims that he has difficulty walking any significant distance because of his right knee, has greatly diminished lung capacity and consequent lack of stamina, and that his depression also inhibits his ability to work. See, e.g., VA Form 21-4138, Statement in Support of Claim received March 8, 2012. The Board finds that the most pertinent evidence related to this issue includes the aforementioned statements by the Veteran, his records from the Social Security Administration (SSA), the relevant reports of VA medical examinations in the record, and a vocational opinion received in February 2018. The Veteran’s SSA records reflect that he was determined by the SSA to be disabled from work as of October 19, 2011. January 2012 VA examination opinions indicate that the Veteran avoids doing heavy exertional labor due to his diabetes mellitus and has difficulty standing, climbing stairs and driving due to his right knee disability. February 2013 VA examination opinions indicate that the Veteran would: have difficulty with bending, squatting, stairs, and carrying heavy loads as a result of his right knee disability; not be able to work in a strenuous or cold environment or around dust, mold, mildew, humidity or livestock as a result of his pulmonary fibrosis; have difficulty performing fine motor skills as a result of RA-related wrist, hand and finger tenderness; and have difficulty retaining instructions, sustaining concentration, responding appropriately to others, and responding to changes in work settings as a result of his depression. The February 2013 VA examiner that examined the Veteran in connection with his depression opined that the Veteran is essentially limited to sedentary employment that does not involve much interaction with others and allows for a flexible schedule. The Veteran also has service-connected hypertension and sleep apnea, diabetes mellitus, right knee scars, and hemorrhoids, but the January 2012 and February 2013 examiners collectively determined that those conditions would not affect the Veteran’s ability to work. The record reflects that the Veteran served on active duty in the military for 24 years, and that after active duty, he worked as a property manager for the federal government. See, e.g., vocational opinion received February 27, 2018. His DD Form 214, Certificate of Release or Discharge from Active Duty reflects that the Veteran worked as a communication cable and antenna system craftsman and an aircraft armament system journeyman while serving on active duty. The Board finds, upon review and consideration of the evidence of record, including but not limited to that listed above, that the Veteran is entitled to TDIU. He has significant physical and mental disabilities as a result of his service-connected right knee disability, pulmonary fibrosis and depression, and furthermore, the record reflects that consequently, he is, at best, only able to perform work that is not physically strenuous (in other words, requires little to no standing, walking, or lifting), requires little interaction with others, and allows for a very flexible schedule. In the Board’s view, the Veteran is not equipped for any such work, considering his prior work experience, even if any such employment opportunities do exist. Thus, he is not practically able to obtain or maintain gainful employment, given his physical and mental condition and his prior work experience. Therefore, the Veteran’s claim of entitlement to TDIU is granted. L. BARSTOW Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Banks, Associate Counsel