Citation Nr: 18158913 Decision Date: 12/18/18 Archive Date: 12/18/18 DOCKET NO. 17-34 678 DATE: December 18, 2018 ORDER 1. The petition to reopen a claim of entitlement to service connection for gout is denied. 2. The petition to reopen a claim of entitlement to service connection for diabetes mellitus is granted. 3. Entitlement to an increased disability rating in excess of 10 percent for postoperative status, colles fracture, distal left radius is denied. 4. Entitlement to an increased disability rating in excess of 10 percent for healed nondisplaced fracture, right distal fibula with degenerative changes is denied. 5. Entitlement to an increased disability rating in excess of 70 percent for posttraumatic stress disorder (PTSD) is denied. 6. Entitlement to a total disability rating for compensation based upon individual unemployability due to service-connected disabilities (TDIU) is denied. REMANDED 7. The reopened claim of entitlement to service connection for diabetes mellitus, to include as secondary to service-connected hypertension, is remanded. FINDINGS OF FACT 1. A December 2008 rating decision denied the Veteran’s claim of entitlement to service connection for gout. The Veteran was subsequently notified of this determination within a December 2008 notification letter, which included his appeal rights; however, the Veteran did not appeal that decision or submit new and material evidence within the one-year appeal period. 2. Evidence received since the December 2008 rating decision is either previously of record, cumulative or redundant of evidence already of record, or does not relate to an unestablished fact necessary to substantiate the Veteran’s claim of entitlement to service connection for gout, and does not raise a reasonable possibility of substantiating the claim. 3. A December 2002 rating decision denied the Veteran’s claim of entitlement to service connection for diabetes mellitus. The Veteran was subsequently notified of this determination within a January 2003 notification letter, which included his appeal rights; however, the Veteran did not appeal that decision or submit new and material evidence within the one-year appeal period. 4. Evidence received since the December 2002 rating decision was not previously of record and relates to a previously unestablished fact necessary to substantiate the claim of entitlement to service connection for diabetes mellitus, namely an indication that the Veteran’s diabetes mellitus may be associated with his active service, and thus, raises a reasonable possibility of substantiating the claim. 5. For the entire period on appeal, the Veteran’s postoperative status, colles fracture, distal left radius has been manifested by no worse than painful limitation of motion without any favorable or unfavorable ankylosis. 6. For the entire period on appeal, the Veteran’s healed nondisplaced fracture, right distal fibula with degenerative changes has been manifested by no worse than slight right ankle disability without ankylosis. 7. For the entire period on appeal, the Veteran’s posttraumatic stress disorder (PTSD) has not been manifested by total occupational and social impairment. 8. The Veteran has not been precluded from securing or following a substantially gainful occupation due to service-connected disabilities for any period on appeal. CONCLUSIONS OF LAW 1. The December 2008 rating decision that denied the Veteran’s claim of entitlement to service connection for gout is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 20.302, 20.1103 (2017). 2. New and material evidence sufficient to reopen the Veteran’s claim of entitlement to service connection for gout has not been added to the record. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156(a) (2017). 3. The December 2002 rating decision that denied the Veteran’s claim of entitlement to service connection for diabetes mellitus is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 20.302, 20.1103 (2017). 4. New and material evidence sufficient to reopen the Veteran’s claim of entitlement to service connection for diabetes mellitus has been added to the record. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156(a) (2017). 5. The criteria for an increased disability rating in excess of 10 percent for postoperative status, colles fracture, distal left radius have not been met for any period on appeal. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DCs) 5010, 5215 (2017). 6. The criteria for an increased disability rating in excess of 10 percent for healed nondisplaced fracture, right distal fibula with degenerative changes have not been met for any period on appeal. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DCs) 5010, 5262 (2017). 7. The criteria for an increased disability rating in excess of 70 percent for PTSD have not been met for any period on appeal. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.126, 4.130, Diagnostic Code (DC) 9411 (2017). 8. The criteria for a TDIU rating have not been met for any period on appeal. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service June 1974 to October 1974 and from June 1979 to July 1986, with additional Reserves service. The Veteran’s claim to reopen service connection for gout, claims for increased ratings for his distal left radius, right distal fibula, and PTSD, and TDIU claim were remanded by the Board in September 2014 for issuance of a statement of the case (SOC). This requested development was completed, and the Veteran subsequently perfected appeals regarding the claims; as such, the matters are now properly before the Board for adjudication. New and Material Evidence Generally, when a claim is disallowed, it may not be reopened and allowed, and a claim based on the same factual basis may not be considered. However, a claim on there is a final decision may be reopened if new and material evidence is submitted. New evidence is defined as existing evidence not previously submitted to agency decisionmakers, while material evidence is defined as existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low. Moreover, in determining whether this low threshold is met, consideration need not be limited to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but also whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the VA’s duty to assist or through consideration of an alternative theory of entitlement. For purposes of reopening a claim, the credibility of newly submitted evidence is generally presumed. 1. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for gout. A December 2008 rating decision denied the Veteran’s claim of entitlement to service connection for gout as the evidence of record did not document that gout had its onset during active service or that it was otherwise caused by active service. The Veteran was subsequently notified of this determination within a December 2008 notification letter, which included his appeal rights; however, the Veteran did not appeal that decision or submit new and material evidence within the one-year appeal period. As such, the December 2008 rating decision is final. Since the prior final December 2008 rating decision, relevant evidence added to the record includes VA treatment records, which document the Veteran’s ongoing complaints of gout with related treatment. While such evidence is new, in that it was not of record at the time of the prior final rating decision, it is not material evidence because it does not relate to an unestablished fact necessary to substantiate the Veteran’s claim of entitlement to service connection for gout, namely that gout had its onset during active service or that it is otherwise related to active service. To the extent that the Veteran’s lay statements continue to assert that his gout is related to active service, such statements are cumulative of his previous contentions at the time of the December 2008 final denial of the claim; therefore, such statements are not new and material evidence. Similarly, while the VA treatment records documenting his ongoing complaints of gout are new evidence, they do not identify a nexus between gout and his active service. In other words, the evidence of record still lacks competent evidence of a nexus between the Veteran’s post-service gout and his active service. Accordingly, as the evidence submitted is not both new and material, reopening of the Veteran’s claim of entitlement to service connection for gout is not warranted, and the application to reopen the claim is denied. 2. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for diabetes mellitus. The Veteran’s claim of entitlement to service connection for diabetes mellitus was previously denied within a December 2002 rating decision, as the evidence of record did not show that diabetes mellitus had its onset during active service, within one year of service discharge, or that it was otherwise related to active service. The Veteran was subsequently notified of this determination within a January 2003 notification letter, which included his appeal rights; however, the Veteran did not appeal that decision or submit new and material evidence within the one-year appeal period. As such, the December 2002 rating decision is final. Since the prior final December 2002 rating decision, evidence added to the record includes the Veteran’s April 2004 testimony at a decision review officer (DRO) hearing that he had been told by a civilian doctor that the service-connected hypertension might have brought on his diabetes mellitus. Additionally, in April 2006, the Veteran’s private physician stated that the Veteran’s exposure to chemical and nuclear weapons during active service could have contributed to his diabetes mellitus. Finally, in December 2010, the same private physician opined that there is a high probability that the Veteran’s service-connected hypertension contributed to his development of diabetes mellitus. Significantly, such evidence is new and material evidence sufficient to warrant reopening of the Veteran’s claim, as it was not of record at the time of the prior final December 2002 rating decision, and it relates to a material element of the Veteran’s claim, namely whether the Veteran’s current diabetes mellitus is related to his active service, to include as secondary to his service-connected hypertension. As the information submitted since the December 2002 rating decision constitutes new and material evidence, the claim of entitlement to service connection for diabetes mellitus is reopened. The reopened claim of entitlement to service connection for diabetes mellitus is being remanded for additional development, and is addressed in the Remand section of the decision. Increased Rating Disability evaluations are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. Whether the issue is one of an initial rating or an increased rating, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as “staged” ratings. With respect to the Veteran’s increased rating claims on appeal, the Board has considered his claim from one year prior to his May 2013 increased rating claim, as well whether any staged ratings periods are warranted. 3. Entitlement to an increased disability rating in excess of 10 percent for postoperative status, colles fracture, distal left radius. The Veteran’s left wrist disability is currently rated as 10 percent disabling from September 30, 2002 under a hyphenated Diagnostic Code (DC) 5010-5215, which indicates traumatic arthritis rated as limitation of motion of the wrist. 38 C.F.R. § 4.71a, DCs 5010, 5215 (2017). Under DC 5215, a maximum schedular 10 percent disability rating is warranted for palmar flexion limited in line with the forearm or dorsiflexion to less than 15 degrees, on both the major and minor side. Higher disability ratings are possible under DC 5214 when there is favorable or unfavorable ankylosis of the wrist. Id., DC 5214. Upon VA examination in March 2014, the Veteran complained of left wrist and hand pain, which required the use of a soft brace and analgesic balm, but no prescription medication. Initial range of motion findings included palmar flexion to 65 degrees and dorsiflexion to 60 degrees, each with pain, but without any additional loss of range of motion upon repetition. The examiner noted functional loss/impairment including weakened movement and pain on movement, but was unable to opine whether pain, weakness, fatigability, or incoordination significantly limited functional ability either during flare-ups or when the joint is used repeatedly over a period of time without resort ing to mere speculation, because there is no conceptual or empirical basis for making such a determination without directly observing function under such conditions. There was localized tenderness or pain on palpation of the left wrist, and slightly diminished muscle strength (active movement against some resistance), but no resulting ankylosis. The examiner noted the Veteran’s prior left wrist surgery with residual pain and a scar that was not painful, unstable, or greater than 39 square centimeters in surface area. Diagnostic imaging documented degenerative or traumatic arthritis of the left wrist. Finally, the examiner opined that the Veteran’s left wrist disability did not result in any functional impact upon his ability to work, as his left wrist condition permitted sedentary and physical employment despite the Veteran’s efforts to avoid prolonged activity due to left wrist pain. VA treatment records from October 2015 document the Veteran’s mildly limited range of motion due to left wrist pain, which continued to require the use of a soft brace. Upon subsequent VA examination in March 2017, the Veteran reported increased pain in his left wrist, which required regular use of a wrist brace and daily use of Tylenol for pain. He reported limitation with physical activities that required lifting with the left wrist and flare ups of sharp and throbbing pain up and down his left arm that resulted in an inability to hold objects in his left hand for long periods of time. Upon physical examination, initial range of motion findings included palmar flexion to 60 degrees and dorsiflexion to 50 degrees. The examination was neither medically consistent or inconsistent with the Veteran’s statements describing functional loss with repetitive use over time or during flare ups. Pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time or during flare ups. Muscle strength testing was normal, without atrophy or ankylosis. The examiner concluded that the Veteran’s left wrist disability did not impact his ability to perform any type of occupational task. Upon review of the evidence of record, including as discussed above, the Board finds that the preponderance of evidence weighs against the Veteran’s claim of entitlement to an increased disability rating in excess of 10 percent for postoperative status, colles fracture, of the distal left radius for the entire period on appeal. The Veteran’s left wrist disability results in functional limitation including pain with range of motion and flare ups of pain resulting in difficulty holding objects in his left hand. Significantly, a disability rating in excess of 10 percent is not available based upon limitation of motion and the functional limitations experienced by the Veteran, as he is already in receipt of the maximum schedular rating available based upon limitation of motion of the wrist; therefore, a higher schedular rating cannot be assigned under DC 5215. Additionally, a higher rating is not warranted under DC 5214 without evidence of favorable or unfavorable ankylosis of the wrist. As the probative evidence of record documents that the Veteran retains some ability for manipulation of his left wrist, the Board finds that a higher disability rating is not warranted under DC 5214. Also, a separate or increased disability rating is not warranted based upon DC 5003, under which a higher 20 percent disability rating is warranted only when there is evidence of involvement of arthritis of two or more major joints or two or more minor joint groups, with occasional incapacitating episodes. 38 C.F.R. § 4.71a, DC 5003. Here, the Veteran’s left wrist consists of one major joint, see 38 C.F.R. § 4.45(f), and the evidence does not indicate the Veteran’s left wrist condition has resulted in incapacitating episodes for any period on appeal. Accordingly, a higher disability rating of 20 percent is not warranted under DC 5003. Further, a separate rating would not be warranted, as the current rating under DC 5215 contemplates limitation of motion. Accordingly, as the preponderance of evidence weighs against the Veteran’s claim, there is no reasonable doubt to be resolved, and the claim must be denied. 4. Entitlement to an increased disability rating in excess of 10 percent for healed nondisplaced fracture, right distal fibula with degenerative changes. The Veteran’s healed nondisplaced fracture, right distal fibula with degenerative changes, is currently rated as 10 percent disabling from September 22, 2008 under a hyphenated DC 5010-5262, which indicates traumatic arthritis rated as impairment of the tibia and fibula. 38 C.F.R. § 4.71a, DCs 5010, 5262 (2017). Under DC 5262, a 10 percent disability rating is warranted for malunion of the tibia and fibula with slight knee or ankle disability. A 20 percent disability rating is warranted for malunion of the tibia and fibula with moderate knee or ankle disability. A 30 percent disability rating is warranted for malunion of the tibia and fibula with marked knee or ankle disability. A 40 percent disability rating is warranted for nonunion of the tibia and fibula, with loose motion requiring a brace. Normal ranges of motion of the ankle are dorsiflexion to 20 degrees and plantar flexion to 45 degrees. 38 C.F.R. § 4.71, Plate II. Words such as “slight,” “moderate,” and “marked” are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6 (2017). Although the use of similar terminology by medical professionals should be considered, is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2017). Upon VA ankle examination in March 2014, the Veteran reported daily right ankle pain with flare ups of increased pain from walking or standing more than 10-15 minutes. He denied use of any assistive devices, surgeries, injections, or prescribed pain medication. Upon physical examination, initial range of motion findings included plantar flexion to 40 degrees and dorsiflexion to15 degrees, with no additional loss of range of motion upon repetition. The examiner noted functional loss/impairment including: pain on movement, interference with sitting, standing, and weight-bearing. The examiner was unable to opine whether pain, weakness, fatigability, or incoordination significantly limited functional ability either during flare-ups or when the joint is used repeatedly over a period of time without resort ing to mere speculation, because there is no conceptual or empirical basis for making such a determination without directly observing function under such conditions. There was localized tenderness or pain on palpation of the right ankle. Muscle strength and joint stability tests were normal, without any ankylosis. Diagnostic imaging documented degenerative or traumatic arthritis of the right ankle. The examiner noted that the Veteran’s current functional status permitted sedentary and physical employment but was obviated by his efforts to avoid prolonged activity due to ankle pain. Upon subsequent VA ankle examination in March 2017, the Veteran reported increased right ankle swelling and gout, with flare ups including stiffness in the morning that required waiting about an hour before walking without severe pain and limited ability to stand for long periods of time. Upon physical examination, initial range of motion findings included right ankle dorsiflexion to 20 degrees and plantar flexion to 35 degrees, with noted pain that did not result in or cause functional loss. There was no pain with weight-bearing, and although there was objective evidence of localized tenderness or pain on palpation of the joint, there was no objective evidence of crepitus. The examiner noted that the examination was neither medically consistent or inconsistent with the Veteran’s statements describing functional loss with repetitive use over time or during flare ups; moreover, pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time or during flare ups. Muscle strength testing was normal, without atrophy, ankylosis, or instability. Diagnostic x-rays documented a stable right ankle with continued appearance of a tiny spur on the lateral malleolus, without change from prior x-ray. The examiner concluded that the Veteran’s right ankle disability did not impact his ability to perform any type of occupational task. Upon review of the evidence of record, including as discussed above, the Board finds that the preponderance of evidence weighs against the Veteran’s claim of entitlement to an increased disability rating in excess of 10 percent for his healed nondisplaced fracture, right distal fibula with degenerative changes, for the entire period on appeal. The Board concludes that the Veteran’s right ankle disability results in no worse than slightly limited range of motion with contemplated pain, based upon the objective range of motion findings, as documented above. The Board has also considered the Veteran’s reports of increased pain during flare ups; however, it is significant that the March 2014 examiner was unable to opine regarding the functional impact during flare ups without resorting to mere speculation given the inability to directly observe a flare up, and the March 2017 examiner concluded that pain, weakness, fatigability, and incoordination did not significantly limit the Veteran’s functional ability with repeated use over a period of time or during flare ups. Without symptomatology that more closely approximates moderate ankle disability or worse, including ankylosis, an increased disability rating is not warranted under DCs 5262 or 5270. Additionally, a separate or increased disability rating is not warranted based upon DC 5003, under which a higher 20 percent disability rating is only warranted when there is evidence of involvement of arthritis of two or more major joints or two or more minor joint groups, with occasional incapacitating episodes. 38 C.F.R. § 4.71a, DC 5003. Here, the Veteran’s right ankle consists of one major joint and the evidence does not indicate the Veteran’s right ankle condition has resulted in incapacitating episodes for any period on appeal. Accordingly, a higher disability rating of 20 percent is not warranted under DC 5003. Further, a separate rating would not be warranted, as the current rating under DC 5215 contemplates limitation of motion. Accordingly, as the preponderance of evidence weighs against the Veteran’s claim, there is no reasonable doubt to be resolved, and the claim must be denied. 5. Entitlement to an increased disability rating in excess of 70 percent for posttraumatic stress disorder (PTSD). The Veteran’s service-connected PTSD is currently rated as 70 percent disabling from August 6, 2010 under Diagnostic Code (DC) 9411 of the General Rating Formula for Mental Disorders. Under the applicable rating criteria, a 70 percent disability rating is warranted for 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); inability to establish and maintain effective relationships. A 100 percent disability rating is warranted when there is 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 inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. When determining the appropriate disability evaluation to assign, the Board’s primary consideration is a veteran’s symptoms, but it must also make findings as to how those symptoms impact a veteran’s occupational and social impairment. The use of the term “such as” in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Thus, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the Veteran’s impairment must be “due to” those symptoms; a Veteran may only qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. In Golden v. Shulkin, 29 Vet. App. 221 (2017), the Court of Appeals for Veterans Claims held that, given that the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5) abandoned the Global Assessment of Functioning (GAF) scale and that VA has formally adopted the DSM-5, GAF scores are inapplicable to assign a psychiatric rating in cases where the DSM-5 applies when the appeal was certified after August 4, 2014. Because the current appeal was certified to the Board in March 2018, the Board will not rely on GAF scores when analyzing the merits of the Veteran’s increased PTSD rating claim on appeal. As discussed below, following a review of the evidence of record, the Board finds that the preponderance of the evidence is against the Veteran’s claim of entitlement to an increased disability rating for PTSD in excess of 70 percent for the entire period on appeal. Upon VA examination in January 2013, the VA examiner concluded that the Veteran’s PTSD symptoms, including depressed mood, anxiety, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances (including work or worklike setting), resulted in occupational and social impairment with deficiencies in most areas. Upon VA examination in September 2013, the examiner concluded that the Veteran’s PTSD symptoms, including anxiety, chronic sleep impairment, mild memory loss, flattened affect, and disturbances of motivation and mood, resulted in occupational and social impairment with reduced reliability and productivity. In May 2014, a VA psychologist concluded that the Veteran’s PTSD symptoms of decreased concentration, decreased memory, and decreased emotional control all impacted his ability to function in an employment setting. VA treatment records from December 2015, July 2016, and January 2017 document that upon mental status examination, the Veteran consistently appeared alert and oriented, with normal speech, cognition, and thought processes and content, and good judgment and insight. Upon private psychiatric evaluation in February 2017, the Veteran appeared alert and oriented, with intact reality testing and no evidence of hallucinations or delusions. The psychiatrist opined that the Veteran is unemployable and incapable of substantial gainful employment as a result of his service-connected PTSD. To the extent that the psychiatrist supported his opinion by reference to GAF scores, which he concluded would be incompatible with competitive employment, the Board affords his opinion less probative value, as GAF scores are inapplicable in determining the proper rating for the Veteran’s PTSD. See Golden, 29 Vet. App. 221. Upon VA PTSD examination in March 2017, the examiner concluded that the Veteran’s PTSD symptoms, including depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances (including work or a worklike setting), impaired impulse control (such as unprovoked irritability with periods of violence), neglect of personal appearance and hygiene, and intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. Notably, in each of the VA examination reports discussed above, the examiners concluded that the Veteran’s PTSD symptoms were best summarized by no worse than occupational and social impairment with deficiencies in most areas, which is the specific rating criteria for a 70 percent rating. While the adjudicator makes the determination of what evaluation is warranted for the Veteran’s service-connected PTSD, the examiners’ conclusions that the Veteran’s psychiatric disorder was best summarized by the criteria described under the 70 percent disability rating is evidence against a finding that the Veteran’s PTSD causes total occupational and social impairment. Moreover, VA treatment records support that the Veteran consistently appeared alert and oriented, with normal thought processes, which weighs against a finding that his PTSD symptoms resulted in gross impairment in thought processes or communication, delusions or hallucinations, or disorientation to time or place. While the Veteran does not have close friends, he is married and is raising two teenage grandchildren. This is evidence against total social impairment. Indeed, the Board finds that for the entire period on appeal, the Veteran’s PTSD has not been manifested by symptoms of similar severity, frequency, and duration to those contemplated by the criteria for a 100 percent disability rating. Given the above, the Board finds that the preponderance of evidence weighs against an increased disability rating in excess of 70 percent for PTSD, as the Veteran’s PTSD symptomatology does not more closely approximate total occupational and social impairment. As the preponderance of the evidence is against the Veteran’s claim, there is no reasonable doubt to be resolved, and the claim must be denied. 6. Entitlement to a TDIU rating. A TDIU rating may be granted upon a showing that the Veteran is unable to secure or follow a substantially gainful occupation due solely to impairment resulting from his service-connected disabilities. There are minimum disability rating percentages that must be shown for the service-connected disabilities, alone or in combination, to even qualify for consideration for a TDIU award under the schedular criteria. Indeed, if there is only one such disability, it must be rated at 60 percent or more; if instead there are two or more disabilities, at least one disability must be rated at 40 percent or more, with sufficient additional disability to bring the combined rating to 70 percent or more. In determining whether a veteran is unemployable for VA purposes, consideration may be given to the veteran’s level of education, special training, and previous work experience, but not to age or any impairment caused by nonservice-connected disabilities. The central inquiry in determining whether a Veteran is entitled to a TDIU rating is whether service-connected disabilities alone are of sufficient severity to produce unemployability. The sole fact that a Veteran is unemployed or has difficulty obtaining employment is not enough; a high disability rating itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question, however, is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. The ultimate question of whether a Veteran is capable of substantial gainful employment is not a medical one; rather, it is a determination for the adjudicator. The Veteran is currently service connected for PTSD (rated as 70 percent disabling from August 6, 2010), cardiomyopathy with left ventricular hypertrophy (rated as 60 percent disabling from September 30, 2002), ulnar neuropathy associated with distal left radius colles fracture (rated as 20 percent disabling from August 6, 2010), left radius colles fracture (rated as noncompensable from January 6, 1992 and as 10 percent disabling from September 30, 2002), right distal fibula fracture with degenerative changes (rated as noncompensable from January 6, 1992 and as 10 percent disabling from September 22, 2008), and hypertension (rated as noncompensable from September 30, 2002). Based upon the above, the Veteran’s combined disability rating of 0 percent from January 6, 1992, 60 percent from September 30, 2002, 70 percent from September 22, 2008, and 90 percent from August 6, 2010, meets the schedular criteria for a TDIU rating from September 30, 2002, but no sooner; although the Board is mindful that the failure to meet the schedular percentage requirements prior to that time does not preclude the availability of a TDIU rating on an extraschedular basis. In any event, following a review of the evidence of record, and, as discussed below, the Board finds that the preponderance of evidence weighs against the Veteran’s claim of entitlement to a TDIU rating for the entire period on appeal. The Veteran’s September 2011 TDIU application asserted that his PTSD, left right, and right ankle disabilities prevented him from securing or following any substantially gainful occupation. He stated that he last worked full time in June 2002 as a truck driver and reported an educational history including four years of high school, without further education or training. Regarding his service-connected cardiomyopathy with left ventricular hypertrophy, the Board finds it highly probative that upon VA heart examination in March 2017, the VA examiner concluded that the Veteran’s heart disability did not result in functional impact upon his ability to work. As discussed above, the Veteran’s service-connected left radius colles fracture and right distal fibula fracture have been found upon multiple VA examinations to have no objective functional impact upon his ability to work, though the Veteran’s efforts to avoid prolonged physical activity due to left wrist and right ankle pain were noted to affect his employability. Regarding his most severe service-connected disability, PTSD, the Board acknowledges that the objective findings from multiple VA examinations throughout the appeal period document functional impairment due to the Veteran’s PTSD, including occupational impairment. However, while multiple VA examiners have concluded that the Veteran’s PTSD results in occupational and social impairment with deficiencies in most areas, the examiners did not conclude that the Veteran’s PTSD symptoms preclude substantially gainful employment. Indeed, the Board is mindful that the high disability rating already assigned for the Veteran’s PTSD contemplates his level of occupational impairment due to his PTSD. The Veteran has the skills to drive vehicles based on his past work experience as a truck driver. Driving a taxi, driving for Uber or Lyft, being a chauffeur, being a limousine driver, and being a courier would be occupations that he could perform. The Board has also considered the February 2017 private psychiatric evaluation discussed above, after which the private psychiatrist concluded that the Veteran was unemployable and incapable of substantial gainful employment as a result of his service-connected PTSD. Specifically, the psychiatrist stated that given his symptoms, the Veteran would be unable to sustain focus, concentration, and task persistence secondary to reduced motivation and impaired concentration/focus; would not be able to relate predictably to others in a work situation given his paranoia, hypervigilance, episodic rage, irritability, and anger; sustain normal productivity levels or maintain regular work attendance; or tolerate normal work-related stress/pressure. The psychiatrist opined that the Veteran’s date of unemployability was approximated in January 2011 when he underwent initial psychiatric consultation. Notably, the psychiatrist supported his opinion regarding unemployability by reference to the Veteran’s GAF scores of 55 in 2011 and 52 in 2013. To the extent that the psychiatrist found such GAF scores would be incompatible with competitive employment, the Board affords his opinion less probative value, as GAF scores are inapplicable in the context of the Veteran’s appeal. See Golden, supra. Additionally, the private psychiatrist’s opinion failed to consider the VA examinations of record, which do not document total occupational impairment for any period on appeal, which also renders the opinion of lesser probative value than the findings of multiple VA examiners discussed above. In sum, while the evidence discussed herein documents some functional impact upon the Veteran’s ability to work based upon his service-connected disabilities, primarily his service-connected PTSD, the Board concludes that the preponderance of evidence weighs against the Veteran’s claim for entitlement to a TDIU rating for the entire period on appeal. As such, there is no reasonable doubt to be resolved, and the TDIU claim is denied. REASONS FOR REMAND 7. Entitlement to service connection for diabetes mellitus is remanded. As discussed above, the Board has herein reopened the Veteran’s claim of entitlement to service connection for diabetes mellitus. Notably, the Veteran has not been afforded a VA examination regarding this newly reopened claim. The Veteran’s April 2004 DRO hearing testimony and the April 2006 and December 2010 private nexus opinions discussed above are probative evidence, which are at least some indication that the Veteran’s diabetes mellitus is related to his active service, including his service-connected hypertension. As such, the Veteran should be afforded a VA examination upon remand, which addresses the etiology of his diabetes mellitus, including whether it is directly related to his active service, including exposure to chemical and nuclear weapons, or whether it is secondary to his service-connected hypertension. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination regarding his reopened claim of entitlement to service connection for diabetes mellitus, to include as secondary to the service-connected hypertension. The claims file must be made available to the examiner for review. The examiner is informed of the following facts: • The Veteran served on active duty from June 1974 to October 1974 and from June 1979 to July 1986. • The Veteran had elevated blood pressure readings while in service, but was not diagnosed with hypertension at that time. See VBMS entries with document type, “STR – Medical,” receipt dates 02/29/1988 and 12/02/2008. • A June 2002 private medical record indicates that the Veteran reported he had been diagnosed with hypertension “about 12 years ago,” which would place the diagnosis in approximately 1990. See VBMS entry with document type, “Medical Treatment Record – Non-Government Facility,” receipt date 10/29/2002, on page 1. • Private medical records show that the Veteran was diagnosed with diabetes mellitus in July 2002. See VBMS entry with document type, “Medical Treatment Record – Non-Government Facility,” receipt date 10/29/2002, on page 7. • In April 2004, the Veteran provided testimony before VA as to the onset of his high blood pressure. See VBMS entry with document type, “Hearing Testimony,” receipt date 04/06/2004. • In an April 2006 letter, a private physician, Dr. WLM, wrote that the Veteran was under his care and was a nuclear weapons specialist while in service, where he was responsible for handling chemical weapons and was exposed to nuclear weapons. He wrote, “This exposure could have contributed to his acquiring diabetes.” See VBMS entry with document type, “Medical Treatment Record – Non-Government Facility,” receipt date 04/21/2006. • In a December 2010 letter, Dr. WLM wrote that the Veteran had a long history of high blood pressure, which Dr. WLM wrote the Veteran had had since 1981. He also noted that the Veteran had a diagnosis of diabetes mellitus and that high blood pressure and diabetes “can be part of the metabolic syndrome.” He wrote, “There is a high probability that the [Veteran]’s service connected development of [high blood pressure” contributed to the development of the [Veteran]’s Type I Diabetes Mellitus.” • The Board notes that Dr. WLM’s statement that the Veteran was diagnosed with high blood pressure (assuming he meant hypertension) in 1981 does not appear to be accurate, as the Veteran was in service at that time, and he was not diagnosed with hypertension while in service. The Board finds that the Veteran’s June 2002 report of being diagnosed with hypertension 12 years prior is the most accurate history of when he was diagnosed with hypertension, which would have been in approximately 1990. • While the Board has laid out some of the relevant facts in the record, it asks that you review the file. The examiner is asked to provide the following opinions: a) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s diabetes mellitus is related to his period of active duty. b) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s diabetes mellitus is caused by his service-connected hypertension. c) If the answer to b) is negative, is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s diabetes mellitus is permanently aggravated by his service-connected hypertension. d.) If the examiner finds that the Veteran’s service-connected hypertension permanently aggravates the type I diabetes mellitus, the examiner is asked to state whether there is medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for the diabetes mellitus prior to aggravation. If the examiner is unable to establish a baseline for diabetes mellitus prior to the aggravation, he or she should state such and explain why a baseline cannot be determined. In rendering these opinions, the examiner is asked specifically consider and discuss relevant evidence of record, including the April 2006 private nexus opinion that the Veteran’s exposure to chemical and nuclear weapons during active service could have contributed to his diabetes mellitus, as well as the Veteran’s April 2004 testimony and the December 2010 private nexus opinion that the Veteran’s service-connected hypertension contributed to his development of diabetes mellitus.   A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D. Chad Johnson, Counsel