Citation Nr: 18157031 Decision Date: 12/11/18 Archive Date: 12/11/18 DOCKET NO. 16-45 849 DATE: December 11, 2018 ORDER New and material evidence having not been received, the petition to reopen Veteran’s claim of service connection for posttraumatic stress disorder (PTSD) is denied. The reduction in rating from 30 percent to 10 percent for ischemic heart disease was not proper and a restoration of the 30 percent rating is granted. Entitlement to a compensable rating for fracture, proximal phalanx, right small finger is denied. Entitlement to a compensable rating for a chest scar, status post coronary artery bypass grafting, is denied. Entitlement to a compensable rating for graft scars, right lower extremity, status post coronary artery bypass grafting, is denied Entitlement to a higher initial rating for diabetes mellitus type 2, currently rated as 20 percent disabling is denied. Entitlement to an increased rating for major depressive disorder, currently rated as 50 percent disabling is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) is denied. FINDINGS OF FACT 1. In November 2011, the RO denied the Veteran’s application to reopen a claim for service connection for PTSD. The Veteran failed to file a timely notice of disagreement; and no new and material evidence was received within a year of the rating decision’s issuance 2. Evidence received since the November 2011 decision is either cumulative or redundant of the evidence of record at the time of the November 2011 denial and, by itself or in conjunction with the evidence previously assembled, does not relate to an unestablished fact necessary to substantiate the claim of service connection. 3. The 30 percent rating for the Veteran’s ischemic heart disease was in effect for fewer than five years at the time of the reduction. 4. The October 2013 VA examination report on which the reduction was based did not reflect a material improvement in the Veteran’s ischemic heart disease, nor is it reasonably certain that any improvement shown would be maintained under the ordinary conditions of life. 5. The Veteran’s fracture, proximal phalanx, right small finger is not manifested by x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups; ankylosis; or limitation of motion 6. The Veteran’s chest scar, status post coronary artery bypass grafting, is not deep and nonlinear in an area or areas of at least 6 square inches. It is not unstable or painful. 7. The Veteran’s graft scars, status post coronary artery bypass grafting, are not deep and nonlinear in an area or areas of at least 6 square inches. They are not unstable or painful. 8. The Veteran’s diabetes mellitus does not require insulin, a restricted diet, AND regulation of activities 9. Throughout the rating period on appeal, the Veteran’s major depressive disorder is manifested by occupational and social impairment with reduced reliability and productivity. It is not manifested by occupational and social impairment, with deficiencies in most area, such as work, school, family relations, judgment, thinking or mood and an inability to establish and maintain effective relationships. 10. The Veteran’s service-connected disabilities do not preclude substantially gainful employment. CONCLUSIONS OF LAW 1. The November 2011 RO rating decision, which denied the Veteran’s application to reopen a service connection claim for PTSD, is final. 38 U.S.C. § 7105. 2. Evidence received since the November 2011 RO rating decision is not new and material; accordingly, the claim for service connection for PTSD is not reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. The criteria for restoration of a 30 percent rating for ischemic heart disease, from November 1, 2014, have been met. 38 U.S.C. §§ 1155, 5107, 5112; 38 C.F.R. §§ 3.105(e), 3.344, 4.71a, Diagnostic Code 7005. 4. The criteria for a compensable rating for fracture, proximal phalanx, right small finger grafting have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including § 4.7 and Codes 5003-5230. 5. The criteria for a compensable rating for a chest scar, status post coronary artery bypass grafting, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including § 4.7 and Codes 7801-7805. 6. The criteria for a compensable rating for graft scars, status post coronary artery bypass grafting have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including § 4.7 and Codes 7801-7805. 7. The criteria for a rating in excess of 20 percent for diabetes mellitus have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including § 4.7 and Code 7913. 8. The criteria for entitlement to a disability evaluation in excess of 50 percent for the Veteran’s service-connected major depressive disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including § 4.7 and Code 9434. 9. The criteria for entitlement to a total disability rating due to service-connected disabilities have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16, 4.18, 4.25. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board notes that the Veteran requested to testify at a Board hearing. He was scheduled for a Board hearing that was to take place in October 2018. In September 2018, the RO attempted to contact the Veteran and confirm the details of the hearing; but the RO was unable to contact him via phone because the number called was a non-working phone. Also in September 2018, the Veteran’s representative contacted the RO to inform it that he had made numerous attempts to contact the Veteran, but without success. He was unsure if the veteran would appear at the hearing. The representative stated that he (the representative) would not be present. The Veteran failed to report for the hearing or provide good cause for his failure to report. The Board therefore considers his hearing request to have been withdrawn. New and Material Evidence Following notification of an initial review and adverse determination by the Regional Office (RO), a notice of disagreement must be filed within one year from the date of notification thereof; otherwise, the determination becomes final and is not subject to revision except on the receipt of new and material evidence. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156. Following receipt of a notice of a timely disagreement, the RO is to issue a statement of the case. 38 C.F.R. § 19.26. A substantive appeal must be filed within 60 days from the date that the agency of original jurisdiction mails the statement of the case to the appellant, or within the remainder of the 1-year period from the date of mailing of the notification of the determination being appealed, whichever period ends later. 38 C.F.R. § 20.302(b). Otherwise, the determination becomes final and is not subject to revision except on the receipt of new and material evidence. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156. When a claim to reopen is presented, a two-step analysis is performed. The first step of which is a determination of whether the evidence presented or secured since the last final disallowance of the claim is “new and material.” See Elkins v. West, 12 Vet. App. 209, 218-19 (1999) (en banc); see also 38 U.S.C. § 5108; Hodge v. West, 155 F.3d 1356, 1359-60 (Fed. Cir. 1998). The provisions of 38 C.F.R. § 3.156 (which define “new and material evidence”) provides as follows: New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means 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. § 3.156(a). Second, if VA determines that the evidence is new and material, the VA may then proceed to evaluate the merits of the claim on the basis of all evidence of record, but only after ensuring that the duty to assist has been fulfilled. See Winters v. West, 12 Vet. App. 203, 206 (1999) (en banc) (discussing the analysis set forth in Elkins), overruled on other grounds sub nom. Winters v. Gober, 219 F.3d 1375, 1378 (Fed. Cir. 2000); Elkins, supra. The second step becomes applicable only when the preceding step is satisfied. See Vargas-Gonzalez v. West, 12 Vet. App. 321, 325 (1999). In order for evidence to be sufficient to reopen a previously disallowed claim, it must be both new and material. If the evidence is not material, the inquiry ends and the claim cannot be reopened. See Smith v. West, 12 Vet. App. 312, 314 (1999). In Evans v. Brown, 9 Vet. App. 273 (1996), the Court held that to reopen a previously and finally disallowed claim, there must be new and material evidence presented or secured since the time that the claim was finally denied on any basis. Additionally, evidence considered to be new and material sufficient to reopen a claim should be evidence that tends to prove the merits of the claim that was the specified basis for the last final disallowance of the claim. In Justus v. Principi, 3 Vet. App. 510 (1992), the Court held that for new and material evidence purposes only, new evidence is presumed to be credible. The only exception would be where evidence presented is either (1) beyond the competence of the individual making the assertion or (2) inherently incredible. If new and material evidence has been received with respect to a claim that has become final, then the claim is reopened and decided on a de novo basis. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. The Veteran’s claim of service connection for PTSD was originally denied by way of a December 2001 rating decision. The Veteran failed to file a timely notice of disagreement, and no evidence was received within the appeal period after the decision. As such, the decision became final. In November 2011, the RO confirmed the previous denial. The Veteran failed to file a timely notice of disagreement, and no evidence was received within the appeal period after the decision. As such, the decision became final. 38 U.S.C. § 7105(c) (West 2014); 38 C.F.R. § 3.156(b) (2016) (new and material evidence received within the appeal period after a decision is considered as having been received in conjunction with the prior claim); Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011) (VA must determine whether evidence received during the appeal period after a decision contains new and material evidence per 3.156(b) and failure to readjudicate the appeal after receipt of such evidence renders the decision non-final). The evidence of record at the time of the November 2011 includes service treatment records; a report reflecting that the Veteran was hospitalized for depression in March 1983; and June 2011 VA examination report in which the examiner found that the Veteran had many (mild) symptoms of PTSD, but the psychometric scores were below the cutoffs for a diagnosis of PTSD. The basis for the denial was the fact that the Veteran did not have a diagnosis of PTSD and that no in-service stressor had been established. Evidence received since the November 2011 rating decision includes an October 2013 VA examination report in which the examiner found that the Veteran had one psychiatric disorder that conformed to DSM-IV criteria; and that diagnosis was major depressive disorder (not PTSD). The examiner was asked whether the Veteran has more than one mental disorder; and the examiner stated “no.” The Board notes that the Veteran was also scheduled to undergo a VA psychiatric examination in June 2016. He failed to report for the examination and he failed to provide good cause for his failure to report. Finally, the evidence includes psychiatric treatment records from December 2014 to July 2015. The reports reflect that the Veteran was treated for major depression. A December 2014 report reflects that the Veteran was focused on wanting PTSD added to his chart. The treating physicians failed to do so. The Board notes that the Court has interpreted the language of 38 C.F.R. § 3. 156(a) as creating a low threshold and viewed the phrase “raises a reasonable possibility of substantiating the claim” as enabling rather than precluding the reopening of a claim. The Court emphasized that the regulation is designed to be consistent with 38 C.F.R. § 3.159(c)(4), which does not require new and material evidence as to each previously unproven element of a claim. It was indicated that it would be illogical to require that a claimant submit medical nexus evidence when he has provided new and material evidence as to another missing element, as it would force the Veteran to provide medical nexus evidence to reopen his claim so that he could be provided with a medical nexus examination by VA. Shade v. Shinseki, No. 08-3548 (U.S. Vet. App. Nov. 2, 2010). In determining whether the submitted evidence is new and material, VA must consider whether the new evidence could, if the claim were reopened, reasonably result in substantiation of the claim. Shade v. Shinseki, 24 Vet. App. 110, 118 (2010). Thus, pursuant to Shade, evidence is new if it has not been previously submitted to agency decisionmakers and is material if, when considered with the evidence of record, would at least trigger VA’s duty to assist by providing a medical opinion, which might raise a reasonable possibility of substantiating the claim. Id. The Board finds that new evidence does not meet the meet the threshold of 38 C.F.R. § 3.156(a). It is not new and material because it does not address the basis for the previous denial. In November 2011, the RO noted that the Veteran had PTSD symptoms. The claim for PTSD was denied because the psychometric scores were below the cutoffs to support a DSM-V diagnosis of PTSD. The new evidence does not reflect a current diagnosis of PTSD. To the contrary, the October 2013 VA examiner failed to diagnose PTSD, and the outpatient treatment reports failed to include a diagnosis of PTSD. Finally, the Veteran failed to report for a June 2016 VA examination. The Veteran is hereby notified that the duty to assist is a two-way-street. Wood v. Derwinski, 1 Vet. App 190, 193 (1991). If the Veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the relevant evidence. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Whether it was proper to reduce the Veteran’s rating for ischemic heart disease from 30 percent to 10 percent effective November 1, 2014 Rating Reductions In any case involving a rating reduction, the fact-finder must ascertain, based upon a review of the entire record, whether the evidence reflects an actual change in the disability and whether the examination reports reflecting such change are based upon a thorough examination. The provisions of 38 C.F.R. § 3.344(a) require a review of the entire record of examinations and the medical-industrial history to ascertain whether the recent examination was full and complete. Examinations less full and complete than those on which payments were authorized or continued will not be used as a basis of reduction. Ratings will not be reduced on any one examination, except where all the evidence of record clearly warrants the conclusion that sustained improvement has been demonstrated, and it is reasonably certain that any material improvement will be maintained under the ordinary conditions of life. 38 C.F.R. § 3.344. If doubt remains, after according due consideration to all the evidence developed by the several items discussed in 38 C.F.R. § 3.344(a), the rating agency will continue the rating in effect, citing the former diagnosis with the new diagnosis in parentheses. 38 C.F.R. § 3.344 (b). The provisions of paragraphs 3.344(a) and 3.344(b) apply to ratings which have continued for long periods at the same level (5 years or more). They do not apply to disabilities which have not become stabilized and are likely to improve. The 30 percent rating assigned for the Veteran’s ischemic heart disease was granted by way of a March 2011 rating decision. It had been in effect for less than 5 years at the time of the reduction in August 2014. Thus, 38 C.F.R. § 3.344 (a) and (b) are not for application. Nevertheless, in any case, to warrant a reduction, it must be determined not only that an improvement in the disability level has actually occurred, but also that such improvement actually reflects an improvement in the ability to function under the ordinary conditions of life and work. Brown v. Brown, 5 Vet. App. 413, 420-21 (1993) (citing 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.13). The reduction of a rating generally must have been supported by the evidence on file at the time of the reduction, but pertinent post-reduction evidence favorable to restoring the rating must also be considered. Dofflemeyer v. Derwinski, 2 Vet. App. 277 (1992). If there is an approximate balance of positive and negative evidence regarding any material issue, all reasonable doubt shall be resolved in favor of the Veteran. In other words, a rating reduction must be supported by a preponderance of the evidence. 38 U.S.C. § 5107(a); see also Brown, 5 Vet. App. at 421. In this case, the reduction was based on VA examination reports dated in April 2011 and October 2013. The October 2013 examiner estimated the Veteran’s METs to be greater than 5 but less than 7 (which would warrant a 30 percent rating pursuant to Diagnostic Code 7005). However, the examiner also stated that the ejection fraction (of 60-65 percent) was a better indicator of his current cardiac status than his METs level because his METs level was also affected by co-morbidities including obesity and degenerative disc disease of his low back. The Board notes that in order for the Veteran’s rating to be properly reduced, it must be determined not only that an improvement in the disability level has actually occurred, but also that such improvement actually reflects an improvement in the ability to function under the ordinary conditions of life and work. Brown v. Brown, 5 Vet. App. 413, 420-21 (1993) (citing 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.13). The Board notes that the October 2013 VA examination report does not reflect an improvement in the Veteran’s ability to function. To the contrary, an April 2011 VA examination showed the exact same METs levels and ejection fraction was 55%. An earlier September 2010 treatment report reflects that the Veteran had a maximum workload of 7 METs and an ejection fraction of 66 percent. The October 2013 examination report reflects METs to be greater than 5 but less than 7; and an ejection fraction of 60-65 percent. The October 2013 examination report does not reflect any meaningful improvement in the heart disability as compared to the prior test results. Indeed, the METs reading in 2013 was identical to the prior test and the ejection fraction was nearly-identical to that shown in 2010. Some improvement was shown regarding the ejection fraction but it is not clear that this truly represents sustained improvement under the ordinary conditions of life and work. Indeed, VA examination in June 2016 showed an ejection fraction of 51, a worse result than at the last examination. In sum, there is insufficient evidence to determine that not only an improvement in the disability level has actually occurred, but also that such improvement actually reflects an improvement in the ability to function under the ordinary conditions of life and work. Consequently, the Board finds that the reduction was improper and that the 30 percent rating should be restored effective November 1, 2014. Increased Rating Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. 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. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran’s condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Where, in the case of the Veteran’s diabetes mellitus, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). Entitlement to an increased rating for fracture, proximal phalanx, right small finger, currently rated as 0 percent disabling The Veteran’s right small finger was originally rated under Diagnostic Code 5227. Under this Diagnostic Code, a noncompensable rating is warranted for ankylosis (favorable or unfavorable) of the ring or little finger. Additionally, under Diagnostic Code 5230, a noncompensable rating is warranted for any limitation of motion of the ring or little finger (on either the major or minor hand). The noncompensable rating is the only rating under these Diagnostic Codes. Effective November 14, 2014, the Veteran’s right small finger disability has been rated under Diagnostic Code 5003. Under this Diagnostic Code, a 10 percent rating is warranted for x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. A 20 percent rating is warranted for x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups with occasional incapacitating episodes. The Veteran underwent a VA examination in July 2015. The examiner noted that the diagnosis was fracture, proximal phalanx, right small finger. The Veteran reported that the finger locks sometimes. There was no pain. The Veteran is right hand dominant. He did not report flare-ups of the hand, finger, or thumb joints. He did not report having functional loss or functional impairment of the joint. Upon examination, the Veteran had normal range of motion. There was no gap between the pad of the thumb and the fingers. There was no gap between the finger and proximal transverse crease of the hand on maximal finger flexion. There was no evidence of pain with use of the hand. There was no objective evidence of localized tenderness or pain on palpation. The Veteran was able to perform repetitive testing without limitation of motion. Hand grip strength was normal (5/5), with no atrophy. There was no ankylosis. In the absence of x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, ankylosis, or limitation of motion, the Board finds that the criteria for a compensable rating have not been met. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply, and the claim for a compensable rating for fracture, proximal phalanx, right small finger must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). Entitlement to an increased rating for chest scar status post coronary artery bypass grafting, currently rated as 0 percent disabling; Entitlement to an increased rating for graft scars, right lower extremity status post coronary artery bypass grafting, currently rated as 0 percent disabling. With regard to scars, Diagnostic Codes 7800-7805 were amended, effective October 23, 2008. The RO granted service connection for the chest scar and right lower extremity scars in an April 2011 rating decision. The amended regulations are applicable to claims received on or after October 23, 2008, (the current claim was treated by the RO as received in November 2014 ), or where a claimant requests readjudication under the new criteria. Per the revised criteria, Diagnostic Code 7800 pertains to scars of the head, face and neck and is not applicable in this case. Pursuant to Diagnostic Code 7801, burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are deep and nonlinear in an area or areas of at least 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.) warrants a 10 percent rating. A 20 percent rating requires an area or areas of at least 12 square inches (77 sq. cm.) but less than 72 square inches (465 sq. cm.). A 30 percent rating requires an area or areas of at least 72 square inches (465 sq. cm.) but less than 144 square inches (929 sq. cm.). A 40 percent rating requires an area or areas of 144 square inches (929 sq. cm.) or greater. A qualifying scar is one that is nonlinear and deep, and is not located on the head, face, or neck. Note (1) to Diagnostic Code 7801 provides that a deep scar is one associated with underlying tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7801. Diagnostic Code 7802 provides that a 10 percent rating is assignable for burn scars or scars due to other causes, not of the head, face or neck, that are superficial and nonlinear and have an area or areas of 144 square inches (929 sq. cm.) or greater. 38 C.F.R. § 4.118, Diagnostic Code 7801. According to Diagnostic Code 7804, a 10 percent rating is assignable for one or two scars that are unstable or painful. A 20 percent rating is assignable for three or four scars that are unstable or painful. A 30 percent rating is assignable for five or more scars that are unstable and painful. Note (1) 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. The revised version of Diagnostic Code 7805 pertains to other scars (including linear scars) and other effects of scars evaluated under diagnostic codes 7800, 7801, 7802 and 7804. Any disabling effect(s) not considered in a rating provided under diagnostic codes 7800-7804 are to be evaluated under an appropriate diagnostic code. The Veteran underwent a VA examination in July 2015. He had an 18 cm., vertical, linear scar on his sternum. He had two scars on his right lower extremity. The first was a 2.0 cm. scar of the medial aspect of the distal third of the right lower leg. The other was a 3.5 cm. scar of the medial aspect the proximal third of the right lower leg. None of the Veteran’s scars were painful. None of the scars were unstable, with frequent loss of covering of skin. None of the scars were both painful and unstable. The examination report is consistent with an April 2011 VA examination report, which also noted three superficial scars that were not painful or deep. In the absence of evidence that the Veteran’s scars are deep and nonlinear in an area or areas of at least 6 square inches; or are unstable or painful, the Board finds that the criteria for a compensable rating have not been met. As the preponderance of the evidence is against these claims, the benefit-of-the-doubt doctrine does not apply, and the claims for compensable ratings for a chest scar and scars of the right lower extremity must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). Entitlement to a higher initial rating for diabetes mellitus, currently rated as 20 percent disabling The Veteran’s service-connected diabetes mellitus has been rated by the RO under the provisions of Diagnostic Code 7913. Under this regulatory provision, a 10 percent rating is warranted for diabetes mellitus which is manageable by restricted diet only. A 20 percent rating is warranted for diabetes requiring insulin and restricted diet; or oral hypoglycemic agent and restricted diet. A 40 percent rating is warranted for diabetes requiring insulin, restricted diet, and regulation of activities. A 60 percent rating requires the use 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 rating of 100 percent is warranted when the disability requires more than one daily injection of insulin, a 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 from diabetes mellitus are to be evaluated separately unless they are part of the criteria used to support a 100 percent evaluation; however, noncompensable complications are considered part of the diabetic process under Diagnostic Code 7913. The Veteran underwent VA examinations in October 2013 and June 2016. At his October 2013 VA examination, it was noted that the Veteran treated his diabetes with a restricted diet and prescribed oral hypoglycemic agents. Diabetes did not require regulation of activities. The Veteran visited his diabetic care provider for episodes of ketoacidosis or hypoglycemic reactions fewer that two times per month. He had no such episodes that required hospitalization within the past year. The Veteran had no progressive, unintentional weight loss or progressive loss of strength attributable to diabetes. He had no complications as a result of diabetes and it did not impact his ability to work. The June 2016 examination report was consistent with the October 2013 findings. The only difference was that the June 2016 report noted that the only treatment was prescribed oral hypoglycemic. There was no indication that a restricted diet was necessary for treatment. Both examination reports noted that the Veteran did not require a regulation of activities, and that there were no episodes of ketoacidosis or hypoglycemic requiring hospitalization. To warrant a rating in excess of 20 percent, the Veteran’s diabetes would have to require insulin, a restricted diet, AND regulation of activities. In the absence of evidence that the Veteran’s diabetes requires a regulation of activities, the criteria for a rating in excess of 20 percent are not met. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply, and the claim for a rating in excess of 20 percent for diabetes mellitus must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990).   Entitlement to an increased rating for major depressive disorder, currently rated as 50 percent disabling The Veteran’s service-connected major depressive disorder has been rated by the RO under the provisions of Diagnostic Code 9434. Under this regulatory provision: a 50 percent is warranted if the Veteran experiences occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect, circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. a 70 percent is warranted when the Veteran experiences occupational and social impairment, with deficiencies in most area, 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 work like setting); inability to establish and maintain effective relationships. a 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closest relatives, own occupation, or own name. Considerations in evaluating a mental disorder include the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remission. The evaluation must be based on all evidence of record that bears on occupational and social impairment rather than solely on an examiner’s assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). Although the extent of social impairment is a consideration in determining the level of disability, the rating may not be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Finally, the Board notes that the American Psychiatric Association’s Diagnostic and Statistical Manual for Mental Disorders (DSM)-V no longer utilizes Global Assessment of Functioning (GAF) scores. DSM-V is applicable for cases certified to the Board on or after August 4, 2014, as here. Accordingly, GAF scores will not be considered in evaluating the claim. The Veteran underwent a VA examination in October 2013. He reported that he has three living sisters and one living brother. He stated that he gets along well with one sibling, but hasn’t talked to the others in 4-5 years (which the examiner noted is not a change since the previous examination). He has three grown children from his marriage. He hasn’t talked to two of them since he and his wife divorced in 2004. He communicates with his son but the Veteran believed that it was just because he (the son) developed a substance abuse problem and he needed his the Veteran’s help. The Veteran communicated and got along well with his daughter, although he hasn’t seen her in three years because she lives in Arkansas. He stated that he has not dated since 2005; he had been dating someone who passed away from breast cancer. Since his most recent examination his sister passed away and he retired because he felt that his heart disease was catching up with him. He endorsed some anger issues. He got along well with some coworkers but not with others. There were no physical altercations at the job but he thought that there could have been if he stayed. He stated that he has been fired from jobs in the past due to his temper. The Veteran stated that for recreation, he goes to the shooting range. He also sees some acquaintances, but nothing is ever planned. He also stated that he spends time with his son and son’s family. The examiner noted that although he has had several jobs since leaving the military, he was working for an airline at the time of his most recent VA examination in 2010, and he continued to work there until he retired in 2012. He was concerned about possible altercations at work but there were no such altercations while he was there. The Veteran reported that he was considering some short-term retraining because he would like to go back to work in a less physically strenuous field. He stated that he tried college courses but couldn’t handle them. He was considering retraining for the medical field. The Veteran stated that he admitted himself to the VA for depression in 1983 because he was afraid he would hurt himself. He soon checked himself out because “all they did was dope me up.” He stated that he has not received any treatment since. The Veteran stated that he has not had any substance abuse since his divorce in 2004. At the time of his 2010 VA examination, he was drinking 2-3 times per week. He stated that substance use is less of an issue now than it was in 2010. The examiner found that the Veteran was capable of managing his financial affairs. The examiner stated that the Veteran is mildly depressed and that his mental health symptoms would likely cause mild to moderate discomfort when interacting with other people, and mildly to moderately reduced communication effectiveness. His ability to maintain a logical thinking process appeared adequate and would likely not impact his social or vocational functioning. Th examiner stated that his mood difficulties are similar in severity and frequency to those he was experiencing at the time of his 2010 VA examination. The examiner opined that the Veteran’s disability was manifested by occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. The Veteran sought treatment for depression on several occasions between December 2014 and July 2015. In July 2015, he stated that he has good days and bad days, and that he copes fairly well even on bad days. He reported that he takes walks and gets out of his apartment. He deals with loneliness but doesn’t want to do any volunteer work to increase socialization. He reported that he still hasn’t talked to one of his daughters since his 2004 divorce. He feels that the daughter caused the divorce. He stated that he has three children from that marriage but he only has contact with the oldest son. He also has contact with a daughter from before he was married. He stated that he enjoys reading, playing guitar, and occasionally does wood carving. He reported that his depression varies from a 2 to an 8 on a 1-10 scale. He reported mild anxiety and mild irritability since living alone. He reported that he sleeps fair, for about four hours per night. He complained of racing thoughts when he lies down. He thinks about the past, including time in Vietnam. He reported occasional nightmares (most recently a few months prior the treatment report). He reported that his energy levels were fair; his motivation was low; concentration was fair; and he had no trouble with memory. He denied suicidal ideation, though he stated that he has thought about it in the past when depressed. He then tells himself that it won’t solve his problems and he realizes that he wants to live. He never had any intent or plan. He denied homicidal ideation. He stated that he smells blood and decomposing bodies at times. Upon examination, the Veteran was alert and oriented times three. He was easily engaged, talkative, and made good eye contact. His mood was depressed; his affect was sad. His conversation was logical and organized. There was no evidence of psychosis. Concentration was good. He denied symptoms of obsessive compulsive and hypomania. He denied suicidal and homicidal ideation. His insight was present and his judgment was intact. The Veteran was taking sertraline and trazodone. The examiner’s assessment was that the Veteran had depression and anxiety, although the Veteran reported improvement in symptoms with medications. He was taking trazodone for sleep and it was working. He was participating in individual therapy. The examiner found that the Veteran did not pose an imminent threat to safety of self or others. The Veteran was scheduled to undergo another VA examination in June 2016. However, he failed to report for the examination or provide good cause for his failure to report. In order to warrant a rating in excess of 50 percent, the Veteran’s depression would have to be manifested by occupational and social impairment, with deficiencies in most area, 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 work like setting); inability to establish and maintain effective relationships. The Board notes that the Veteran has not exhibited any of the symptoms enumerated under the criteria for a rating in excess of 50 percent, or otherwise shown a basis for finding a higher level of social and occupational impairment. He worked without any altercations until he retired in 2012. He has stated that he would like to be trained so that he could return to some form of work that would be less physically strenuous. In terms of social ability, the Veteran stated that when he worked, he got along well with some coworkers, but not others. He stated that he spends time with his son and his son’s family; and that he communicates with his daughter and his grandchildren. Moreover, the Veteran was not seeking any treatment from 1983 to December 2014. The fact that the Veteran began seeking treatment could indicate that symptoms may have increased. However, this could not be confirmed as the Veteran failed to report for his June 2016 VA examination. Nevertheless, he maintained relationships with his son, a daughter, grandchildren, and other acquaintances. He also expressed interest in returning to some type of work. His symptoms were described as mild; and the October 2013 examiner found that his symptoms would cause only mild to moderate discomfort when interacting with other people, and would result in only mildly to moderately reduced communication effectiveness. His ability to maintain a logical thinking process appeared adequate and would likely not impact his social or vocational functioning. Further, he had hobbies that he engaged in. Finally, the October 2013 VA examiner concluded that the veteran’s disability was manifested by occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication (which the Board notes is exactly the criteria for a 10 percent rating). As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply, and the claim for a rating in excess of 50 percent for major depressive disorder must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). Entitlement to a TDIU In order to establish service connection for a total rating based upon individual unemployability due to service-connected disability, there must be an impairment so severe that it is impossible 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). For VA purposes, the term “unemployability” is synonymous with an inability to secure and follow a substantially gainful occupation. VAOPGPREC 75-91; 57 Fed. Reg. 2317 (1992). 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. VA regulations establish objective and subjective standards for an award of total rating based on unemployability. When the Veteran’s schedular rating is less than total (for a single or combination of disabilities), a total rating may nonetheless be assigned provided that if there is only one service-connected disability, this disability shall be rated at 60 percent or more. When there are two or more disabilities, at least one disability must be ratable at 40 percent or more, and any additional disabilities must result in a combined rating of 70 percent or more, and the disabled person must be unable to secure or follow a substantially gainful occupation. See 38 C.F.R. § 4.16(a). A total disability rating may also be assigned on an extra-schedular basis, pursuant to the procedures set forth in 38 C.F.R. § 4.16(b), for Veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in section 4.16(a). Thus, the Board must evaluate whether there are circumstances, apart from any non-service-connected conditions and advancing age, which would justify a total rating based on unemployability. A TDIU claim is an alternate way to obtain a total disability rating without recourse to a 100 percent evaluation under the rating schedule. See Parker v. Brown, 7 Vet. App. 116, 118 (1994). Consequently, the Board must determine whether the Veteran’s service-connected disabilities preclude him from engaging in substantially gainful employment (work that is more than marginal, which permits the individual to earn a “living wage”). Moore v. Derwinski, 1 Vet. App. 356 (1991). The fact that a Veteran may be unemployed or has difficulty obtaining employment is not determinative. The ultimate question is whether the Veteran, because of service-connected disability, is incapable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). An inability to work due to advancing age may not be considered. 38 C.F.R. §§ 3.341 (a), 4.19. In making its determination, VA considers such factors as the extent of the service-connected disability, and employment and educational background. See 38 C.F.R. §§ 3.340, 3.341, 4.16(b), 4.19. The Veteran is service connected for major depressive disorder, evaluated as 50 percent disabling; ischemic heart disease, evaluated as 30 percent disabling; diabetes mellitus, evaluated as 20 percent disabling; fracture, proximal phalanx, right small finger, evaluated as 0 percent disabling; chest scar post coronary artery bypass grafting, evaluated as 0 percent disabling; and graft scars, right lower extremity, status post coronary artery bypass grafting, evaluated as 0 percent disabling. His combined rating is therefore 70 percent. See 38 C.F.R. § 4.25. Thus, the Veteran meets the schedular requirements for a total disability rating based on individual unemployability due to service-connected disabilities under 38 C.F.R. § 4.16(a). However, the Board must still determine whether the Veteran’s service-connected disabilities result in impairment so severe that it is impossible to follow a substantially gainful occupation. The Board emphasizes that a total rating based on individual unemployability is limited to consideration of service-connected disabilities. Following a full and thorough review of the evidence of record, the Board concludes that the preponderance of the evidence is against the Veteran’s claim of entitlement to a TDIU for any portion of the rating period on appeal. The Board once again notes that the Veteran failed to report for a June 2016 psychiatric examination. In light of the Veteran’s failure to report for the examination as well as his Board hearing and in light of the fact that neither the RO nor the Veteran’s representative has been able to contact the Veteran, the Board finds that it must decide the claim on the evidence of record. The October 2013 VA psychiatric examiner opined that the Veteran’s psychiatric disability would cause mild to moderate discomfort when interacting with other people, and mildly to moderately reduced communication effectiveness. His ability to maintain a logical thinking process appeared adequate and would likely not impact his social functioning. At the time, he wanted short-term retraining so he could go back to work, albeit in a less physically strenuous job. He stated that he stopped working because his heart disease was catching up him. These findings are consistent with an October 2013 cardiology examination, which revealed that the Veteran’s coronary artery disease would prevent him from doing heavy physical labor, but not sedentary or light work. Finally, a June 2016 examination report reflects that his diabetes would not impact his ability to work. Consequently, it appears that the veteran’s greatest impediment to working is his ischemic heart disease, and that the ischemic heart disease only precludes heavy physical labor. The Veteran has not been shown to be precluded from performing sedentary or light work In sum, the weight of the evidence is against a finding that the Veteran’s service-connected disabilities alone render him unable to obtain and retain substantially gainful employment, nor is the evidence in a state of equipoise on that question. As such, the claim for a TDIU is denied. Eric S. Leboff Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Prem, Counsel