Citation Nr: 1807059 Decision Date: 02/02/18 Archive Date: 02/14/18 DOCKET NO. 12-03 675 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Buffalo, New York THE ISSUES 1. Entitlement to an increased rating for coronary heart disease with non-chronic congestive heart failure ("CAD"), evaluated as 30 percent disabling prior to May 3, 2016, and as 60 percent disabling thereafter. 2. Entitlement to an evaluation in excess of 20 percent for service-connected type II diabetes mellitus with erectile dysfunction. 3. Entitlement to an evaluation in excess of 10 percent for service-connected hypertension. 4. Entitlement to a total disability rating based on individual unemployability (TDIU), prior to May 3, 2016. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD R. Kipper, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1964 to October 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2011 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Buffalo, New York, which, in pertinent part, continued a 30 percent rating for CAD, continued a 20 percent rating for diabetes, continued a 10 percent rating for hypertension, and denied entitlement to a TDIU. In April 2016, the Board remanded this matter in order to obtain additional treatment records and to afford the Veteran updated VA examinations. In a November 2016 rating decision, the Appeal Management Center (AMC) increased the rating for CAD to 60 percent and granted entitlement to a TDIU, both effective from May 3, 2016. In December 2016, the Veteran filed a notice of disagreement with the effective dates assigned, and the AOJ issued a statement of the case in October 2017. In December 2017, the Veteran filed a substantive appeal. The Board acknowledges the Veteran's disagreement with the effective dates assigned for the increased rating and TDIU awarded by the November 2016 rating decision. However, the matter of the proper effective date for the increased rating and grant of TDIU is already on appeal, inasmuch as the Board is required to consider whether staged ratings are warranted and to consider the evaluation for the entire period on appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007); see also A.B. v. Brown, 6 Vet. App. 35 (1993). Consequently, even though the Veteran submitted a substantive appeal regarding the purported effective date claim, this does not result in new issues before the Board. The issues on appeal are more accurately reflected as an increased rating claim rather than as an effective date claim, and therefore will continue to be characterized as reflected on the title page. Moreover, as the Board is granting an increased rating for CAD and entitlement to a TDIU for the entire period on appeal, there is no prejudice to the Veteran from this characterization. FINDINGS OF FACT 1. For the entire rating period on appeal, the Veteran's CAD disability more nearly approximated more than one episode of acute congestive heart failure in the past year, but the evidence does not show chronic congestive heart failure, a workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular dysfunction with an ejection fraction of less than 30 percent. 2. Throughout the appeal period, the Veteran's diabetes mellitus has been managed by the use of oral hypoglycemic agents, insulin, and a restricted diet, but it has not medically required regulation of his activities. 3. For the entire period on appeal, the Veteran's hypertension was manifested by diastolic pressure predominantly less than 110 and systolic pressure predominantly less than 200. 4. Prior to May 3, 2016, the Veteran's service-connected disabilities precluded him from securing and following substantially gainful employment. CONCLUSIONS OF LAW 1. Prior to May 3, 2016, the criteria for a 60 percent rating, but no higher, for CAD were met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.104, Diagnostic Code 7005 (2017). 2. Since May 3, 2016, the criteria for a rating in excess of 60 percent for CAD have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.104, Diagnostic Code 7005 (2017). 3. The criteria for a rating in excess of 20 percent for diabetes mellitus with erectile dysfunction have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.119, Diagnostic Code 7913 (2017). 4. The criteria for a rating in excess of 10 percent for hypertension have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.104, Diagnostic Code 7101 (2017). 5. Prior to May 3, 2016, the criteria for a TDIU were met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist Under applicable law, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). In the present case, VA's duty to notify was satisfied by way of a September 2010 letter to the Veteran. VA also has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service treatment records (STRs) and pertinent treatment records and providing an examination when necessary. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. The record reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran. The Veteran has not identified any outstanding evidence, to include any other medical records, which could be obtained to substantiate his appeal. Additionally, the Board finds that there has been substantial compliance with its previous remand directives, to include obtaining outstanding records and providing the Veteran with updated VA examination. In light of the foregoing, the Board finds that there is no further action to be undertaken to comply with the provisions of 38 U.S.C. § 5103(a), § 5103A, or 38 C.F.R. § 3.159, and that all necessary development has been accomplished. Therefore, appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). II. Increased Ratings Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § Part 4. Ratings for service-connected disabilities are determined by comparing the Veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Here, the relevant evidentiary window begins one year before the Veteran filed his claim for an increased rating, and continues to the present time. The Board will also consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). In making all determinations, the Board must fully consider the lay assertions of record. A Veteran is competent to report on that of which he or she has personal knowledge. Layno v. Brown, 6 Vet. App. 465, 470 (1994). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Board has reviewed all of the evidence in the Veteran's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Court of Appeals for the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the Veteran's claims. A. CAD The Veteran is in receipt of a 30 percent disability rating for CAD under Diagnostic Code 7005 for the rating period prior to May 3, 2016, and a 60 percent rating thereafter. The Veteran's CAD has been rated under Diagnostic Code 7005, which provides that a 10 percent evaluation is assigned for a workload of greater than 7 METs but not greater than 10 METs, which results in dyspnea, fatigue, angina, dizziness, or syncope, or continuous medication required. A 30 percent evaluation is assigned for a workload of greater than 5 METs but not greater than 7 METs that results in dyspnea, fatigue, angina, dizziness, or syncope, or there is evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent evaluation is warranted when there is more than one episode of congestive heart failure in the past year, or a workload of greater than 3 METs but not greater than 5 METs that results in dyspnea, fatigue, angina, dizziness, or syncope, or there is left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating contemplates documented coronary artery disease resulting in chronic congestive heart failure; or workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104, DC 7005. One MET (metabolic equivalent) is defined as the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note (2). Turning to the evidence of record, a March 2009 cardiology consult shows that the Veteran reported increased exertional shortness of breath, including with walking up and down stairs or with trying to exercise. He denied any problems with chest discomfort or syncope. The Veteran reported that he tried to exercise on a treadmill about twice per week and that he can go for about 10 minutes at 2.5 miles per hour before he becomes short of breath and has to stop. An April 2009 VA echocardiogram report shows that the Veteran's systolic function appeared grossly normal with an estimated LVEF of 55 percent. There was also left atrial enlargement and aortic valve sclerosis. An April 2009 private hospital record shows that the Veteran was hospitalized for four days after complaining of a three-day history of worsening dyspnea. A chest x-ray showed cardiomegaly and congestive heart failure. The assessment at admission was acute decompensated congestive heart failure. A June 2009 private cardiology record shows that the Veteran reported increased shortness of breath and chest tightness. A chest x-ray showed cardiomegaly associated with a central pulmonary vascular engorgement and marginal congestive heart failure, and an angiogram showed normal left ventricular function with an overall ejection fraction of 58 percent. The Veteran was admitted for coronary angiography. A June 2010 private treatment record shows that the Veteran was admitted to the hospital for a cardiac workup after reporting shortness of breath and chest tightness after taking out the garbage. An echocardiogram revealed a left ventricular ejection fraction of 55 percent. A discharge summary dated two days later shows that the reason for hospitalization was unstable angina with congestive heart failure and shortness of breath. The Veteran was afforded a VA examination in October 2010. The examiner noted that there was no history of syncope or fatigue, but that there was a positive history for congestive heart failure, angina, dizziness, and dyspnea with moderate exertion. Regarding congestive heart failure, the examiner indicated that it was not chronic and that the Veteran had experienced one episode of congestive heart failure in the past 12 months. The examiner noted a diagnosis of CAD with congestive heart failure. The examiner indicated that a July 2010 stress test showed that the Veteran achieved a maximum of 7 METs. The heart size was normal as determined by echocardiogram, and the LVEF was greater than 50 percent. The examiner also opined that the Veteran's heart disability precluded physical work. A February 2012 private hospital record shows that the Veteran reported a one month history of increasing shortness of breath, dyspnea on exertion, and chest tightness and pain. He was admitted for symptomatic anemia with shortness of breath, dyspnea on exertion, and symptoms suggesting exertional angina. A chest x-ray showed mild to moderate cardiomegaly. A March 2012 private cardiology record shows that the Veteran underwent cardiac catheterization due to shortness of breath with minimal exertion suggestive of angina. His left ventricular ejection fraction was 55 percent. In August 2014, the Veteran was admitted to the hospital for two days after complaining of shortness of breath and chest pain. The differential diagnoses on admission were pneumonia, bronchitis, congestive heart failure, or COPD. A January 2015 private hospital record shows that the Veteran was admitted for one day after complaining of lightheadedness and near syncope. An echocardiogram showed a left ventricular ejection fraction of 55 percent with mildly dilated right ventricle and a new finding of pulmonary hypertension. A chest x-ray showed cardiomegaly. In February 2015, the Veteran underwent cardioversion for a recent onset of atrial fibrillation. A May 2015 private cardiology record shows that the Veteran reported feeling "fine" from a cardiac standpoint. He reported shortness of breath with exertion, but he denied chest pain, palpation, and syncope or near syncope symptoms. The Veteran's cardiologist noted that the Veteran was essentially asymptomatic at the present time with no symptoms suggestive of angina, heart failure, or arrhythmias. A July 2015 private primary care record shows that the Veteran reported chest pain and dyspnea with exertion. An assessment of congestive heart failure was noted. Private hospitalization records from August 2015 show that the Veteran was hospitalized for seven days after presenting to the emergency department with complaints of shortness of breath. A chest x-ray showed cardiomegaly with congestive heart failure. An echocardiogram showed mild systolic dysfunction of the right ventricle and a left ventricular ejection fraction of 60 percent. A nuclear stress test showed an ejection fraction of 69 percent. The impression at time of admission was acute congestive heart failure "as suggested by chest x-ray and clinical exam," COPD, and hypoxia. A May 2016 cardiac rehabilitation report shows a diagnosis of congestive heart failure. The Veteran was afforded a VA examination in August 2016. The examiner indicated that the Veteran had experienced one episode of acute congestive heart failure in the past year. The examiner also noted that a December 2015 echocardiogram showed evidence of cardiac dilatation and that a September 2015 echocardiogram showed a left ventricular ejection fraction of 60 percent. An interview-based METs test showed that the Veteran experienced dyspnea at a workload of greater than three but less than five METs. The examiner further indicated that the Veteran's estimated METs level was not due solely to the Veteran's cardiac condition. The examiner noted that the Veteran "has multiple comorbidities including CHF, CAD, and COPD. Ejection fraction is a better indicator of heart function." The examiner opined that the Veteran's heart condition did not impact his ability to work. The Veteran was afforded a VA examination in October 2016. The examiner noted that the Veteran had coronary artery disease and congestive heart failure. The examiner indicated that the Veteran's congestive heart failure was not chronic and that he had not had any episodes of acute congestive heart failure in the past year. An interview-based METs test showed that the Veteran experienced dyspnea at a workload of greater than three but less than five METs. The examiner noted that the limitation in METs level was due to multiple medical conditions, including CHF, CAD, and COPD, and that it was not possible to accurately estimate the percent of METs limitation attributable to each medical condition. Having carefully considered the Veteran's contentions in light of the evidence recorded and the applicable law, the Board finds that the criteria for a 60 percent rating were met for the entire appeal period. In this regard, the evidence discussed above reflects that from April 2009 to May 2016 (a period of 7 years), the Veteran was hospitalized eight times for episodes of acute congestive heart failure. Resolving doubt in the Veteran's favor, the Board finds that this more nearly approximates more than one episode of acute congestive heart failure per year such that the criteria for a rating of 60 percent were met for the entire increased rating period on appeal. The Board further finds, however, that a rating higher than 60 percent is not warranted at any time during the appeal period. In order to warrant a disability rating of 100 percent, the Veteran must manifest chronic congestive heart failure, a workload of three METs or less, or an ejection fraction of 30 percent or less. Here, although the Veteran had numerous episodes of acute congestive heart failure, multiple VA examiners specifically noted that the Veteran did not have chronic congestive heart failure. See October 2016 VA Examination Report; August 2016 VA Examination Report; October 2010 VA Examination Report. With regard to the workload at which the Veteran experienced dyspnea, fatigue, angina, dizziness, or syncope due to his service-connected CAD, the record reflects that the Veteran experienced dyspnea, angina, and syncope due, in part, to his service-connected heart disability. However, the evidence does not show a METs level of less than 3 due exclusively to the Veteran's CAD. METs testing in October 2010 revealed a METs level of 7, and the August 2016 and October 2016 VA examiners both found METs levels of greater than 3 but less than 5 METs. Moreover, the VA examiners specifically noted that the Veteran was additionally limited by COPD, and that, therefore, the Veteran's LVEF was a better representation of the Veteran's overall cardiac function. Similarly, private and VA treatment records reflect continuing complaints of dyspnea, angina, and fatigue, which were attributed, in part, to the Veteran's heart disability. However, the Veteran's clinicians also noted that the Veteran's symptoms could be due to multiple factors in addition to his heart disability. See, e.g., September 2015 Private Cardiology Record (indicating that the Veteran's August 2015 hospitalization sounded more like a COPD exacerbation than a cardiac event); September 2015 Private Primary Care Record (noting that the Veteran's dyspnea was "most likely all related to pulmonary disease"); July 2010 VA Treatment Record (indicating that the Veteran's dyspnea on exertion was "likely multifactorial, related to anemia, with possible cardiac and pulmonary components as well"); March 2009 VA Treatment Record (noting that the Veteran's exertional dyspnea improved with correction of iron deficiency anemia). Finally, an ejection fraction of 30 percent or less is not shown. As detailed above, the Veteran's LVEF measured, at worst, as 55 percent in April 2009, and, at best, as 69 percent in August 2015. Therefore, and resolving reasonable doubt in favor of the Veteran, the Board concludes that a rating of 60 percent, but not more, for the Veteran's service connected CAD is warranted for the entire appeal period. As the preponderance of the evidence is against an even higher rating, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107(b), 38 C.F.R. § 4.3. B. Diabetes Mellitus The Veteran contends that he is entitled to a higher rating for diabetes mellitus, which is currently assigned a 20 percent disability rating pursuant to Diagnostic Code 7913. Under Diagnostic Code 7913, a 20 percent evaluation is warranted for diabetes mellitus requiring insulin and restricted diet; or, an oral hypoglycemic agent and restricted diet. A 40 percent evaluation is warranted for diabetes mellitus requiring insulin, restricted diet, and regulation of activities. A 60 percent evaluation is warranted for diabetes mellitus requiring insulin, 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 100 percent evaluation is warranted for diabetes mellitus requiring more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. Compensable complications of diabetes are to be evaluated separately unless they are part of the criteria used to support a 100 percent evaluation. Noncompensable complications are considered part of the diabetic process under Diagnostic Code 7913. See Note (1) to 38 C.F.R. § 4.119, Diagnostic Code 7913. The Court has held that, in order to demonstrate a regulation of activities, "medical evidence" is required to show that both occupational and recreational activities have been restricted. Camacho v. Nicholson, 21 Vet. App. 360, 364 (2007). The phrase "regulation of activities" means "avoidance of strenuous occupational and recreational activities." Camacho, 21 Vet. App. at 362 (quoting 38 C.F.R. § 4.119, Diagnostic Code 7913 (defining the term within the criteria for a 100 percent rating)). "Successive" rating criteria in a diagnostic code is where the evaluation for each higher disability rating includes the criteria of each lower disability rating, such that if a component is not met at any one level, a veteran can only be rated at the level that does not require the missing component. Tatum v. Shinseki, 23 Vet. App. 152, 156 (2009). For example, Diagnostic Code 7913 is successive in nature because each higher evaluation requires the elements of the lower evaluation: the 10 percent evaluation requires a restricted diet; the 20 percent evaluation requires a restricted diet and insulin or oral hypoglycemic agent; the 40 percent evaluation requires insulin, restricted diet, and regulation of activities; and so forth. Camacho, 21 Vet. App. at 366. The Veteran was afforded a VA examination in October 2010. The examiner noted that the Veteran's diabetes was managed by insulin more than once daily and restricted diet, but that the Veteran did not require regulation of activities as part of his medical management of diabetes. The examiner also noted that the Veteran visited his diabetic care provider for episodes of ketoacidosis or hypoglycemic reactions once every three months and that the Veteran had no episodes of hospitalization for ketoacidosis or hypoglycemic reactions. The Veteran denied symptoms of peripheral neuropathy. The examiner indicated that the Veteran had erectile dysfunction secondary to diabetes mellitus. The examiner also noted that there was no history of urinary symptoms. An examination of the penis, testicles, and epididymis was normal. A July 2011 VA treatment record shows that the Veteran was advised to continue an exercise regimen and attempts at weight loss. A November 2011 VA diabetes education note shows that the Veteran reported going to the YMCA for exercise at the direction of his cardiologist. He was encouraged to continue weight loss and follow a low carbohydrate, low fat diet. A September 2012 private cardiology record shows that the Veteran was advised to increase his activity and reduce his weight. A February 2013 VA primary care note shows that the Veteran was encouraged to exercise to lose weight. A March 2013 private primary care record shows that the Veteran's diabetes was not under control. He was advised to improve his dietary and exercise compliance. An April 2013 VA treatment record shows that the Veteran was encouraged to continue exercise regimen and attempts at weight loss. An August 2013 VA primary care note shows that the Veteran's A1C was increased, and he was advised to increase his exercising to three times per week. A May 2014 VA primary care note shows that the Veteran stopped going to the gym because he could not take his oxygen with him. The Veteran's physician advised the Veteran to resume exercise but rest when he feels short of breath. A September 2014 VA weight management note shows that the Veteran reported difficulty doing physical activity at times due to his COPD. He was advised to walk on the treadmill for 15 to 30 minutes three times per week. An April 2015 private primary care record shows that the Veteran's A1C levels were high. He was advised to "be more aggressive in his management of his diabetes, get more physically active." A July 2015 private treatment record shows that the Veteran was encouraged to work on diet, exercise, and weight loss. A November 2015 private treatment record shows that the Veteran was encouraged to exercise and participate in cardiopulmonary rehabilitation. A May 2016 cardiac rehabilitation report shows that the Veteran planned to continue walking, and he was given some weight training exercises to supplement his walking program. A May 2016 VA primary care note shows that the Veteran was advised to resume walking "ASAP." A May 2016 VA kinesiotherapy note shows that the Veteran was found to be appropriate for participation at the VAMC fitness center. The Veteran was afforded a VA examination in October 2016. The examiner noted that the Veteran's diabetes was managed by more than one injection of insulin per day, but that the Veteran did not require regulation of activities as part of his medical management of diabetes. The examiner also noted that the Veteran visited his diabetic care provider for episodes of ketoacidosis or hypoglycemic reactions less than two times per months and that the Veteran had no episodes of hospitalization for ketoacidosis or hypoglycemic reactions in the past 12 months. The examiner indicated that the Veteran did not have progressive unintentional weight loss or loss of strength due to diabetes mellitus. Having carefully considered the Veteran's contentions in light of the evidence recorded and the applicable law, the Board finds that the criteria for a rating in excess of 20 percent were not met at any point during the rating period. In this regard, the Board notes that to warrant a higher rating under Diagnostic Code 7913 the evidence must show diabetes mellitus requiring insulin, a restricted diet, and regulation of activities. See Melson v. Derwinski, 1 Vet. App. 334 (1991) (use of the conjunctive "and" in a statutory provision meant that all of the conditions listed in the provision must be met); compare Johnson v. Brown, 7 Vet. App. 95 (1994) (only one disjunctive "or" requirement must be met in order for an increased rating to be assigned). Review of the evidence indicates that while the Veteran's diabetes mellitus is managed by oral medications, insulin, and a restricted diet, there is no medical evidence that the Veteran has had to regulate his activities as defined by Camacho. Rather, the evidence indicates that the Veteran has been continuously educated on the importance of exercise and that he has been encouraged to exercise to control his diabetes. In addition, the VA examiners who conducted the October 2010 and October 2016 examinations indicated that the Veteran did not require regulation of activities as part of the medical management of diabetes mellitus. The Board recognizes that the Veteran believes he is entitled to an evaluation in excess of 20 percent for his service-connected diabetes mellitus. In a November 2011 statement, the Veteran asserted that the large doses of insulin he requires results in "the need for careful control of physical activity." However, the rating criteria require that regulation of activities is necessary to manage diabetes mellitus. The record contains no evidence to suggest that this is the case. To the contrary, during almost every primary care visit, the Veteran was encouraged to exercise. Moreover, the regulation of activities criterion refers to regulation of activities medically necessary to control the Veteran's diabetes, rather than to regulation of activities for another purpose. Here, the Board notes that the Veteran has functional and occupational limitations due to his many service-connected and non-service connected disabilities; however, treatment records show that physical activity was generally advised or encouraged, and they do not otherwise show that regulation of activity was necessary to control the Veteran's diabetes. As such, the Veteran's assertions fail to demonstrate that a higher schedular evaluation is warranted. In the absence of medical evidence showing that the Veteran has been required to regulate his activities, as defined by Camacho, a rating in excess of 20 percent is not warranted for his service-connected type II diabetes mellitus. Pursuant to Note 1 under Diagnostic Code 7913, the Board must assign separate ratings for any compensable complications of the Veteran's service-connected diabetes mellitus, type II. All noncompensable complications are considered part of the diabetic process. 38 C.F.R. § 4.119; Diagnostic Code 7913, Note (1). Here, there is no evidence of any separate, compensable complications of diabetes, other than CAD and hypertension, which are discussed separately herein. The Board notes that the Veteran has erectile dysfunction associated with his type II diabetes mellitus, which the RO found to be noncompensable. In this case, a separate compensable rating is not warranted for the Veteran's erectile dysfunction associated with diabetes mellitus. In order to receive a compensable rating for erectile dysfunction, physical deformity of the penis with loss of erectile power is required. 38 C.F.R. § 4.115b, Diagnostic Code 7522. Upon review of the evidence, the Veteran does not meet the criteria for a compensable percent rating. It is not in dispute that the Veteran has loss of erectile power. See November 2011 Notice of Disagreement; October 2010 VA Examination Report. Regardless, in the present case, the Veteran has not alleged, nor does the evidence show, that he has penile deformity. See October 2010 VA Examination Report. As such, there is no lay or medical support for a compensable disability rating for the Veteran's erectile dysfunction under Diagnostic Code 7522. Moreover, the Board notes that he is already in receipt of special monthly compensation for loss of use of a creative organ. Therefore, a separate compensable rating for erectile dysfunction is not warranted. Based on the foregoing, the Veteran has not been shown to meet the criteria for an increased evaluation under the rating criteria. Although the Veteran has been shown to require insulin and a restricted diet, he does not require a regulation of activities, which is a necessary component for a higher evaluation. Nor does the evidence support any additional, separate compensable evaluations for complications of the service-connected diabetes mellitus. Accordingly, the Veteran is not entitled to an evaluation in excess of 20 percent for his diabetes mellitus. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. C. Hypertension The Veteran asserts that his hypertension is more disabling than reflected by his current 10 percent rating. The Veteran's hypertension is rated under diagnostic code 7101 for hypertensive vascular disease. 38 C.F.R. § 4.104, Diagnostic Code 7101. Under diagnostic code 7101, a 10 percent rating is warranted for diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is warranted for diastolic pressure predominantly 110 or more or; systolic pressure predominantly 200 or more. A 40 percent evaluation is warranted for diastolic pressure predominantly 120 or more. A 60 percent evaluation is warranted for diastolic pressure predominantly 130 or more. The Veteran was afforded a VA examination in October 2010. The examiner noted that the Veteran required continuous medication for control of his hypertension. The Veteran's blood pressure readings were: 175/72, 161/74, and 156/62. The examiner indicated that the Veteran's hypertension did not have an effect on the Veteran's occupational or usual daily activities. The Veteran was afforded a VA examination in October 2016. The examiner noted that the Veteran required continuous medication for control of his hypertension. The Veteran's blood pressure reading was 148/66. VA treatment records show blood pressure readings as follows: 172/72 (December 2009); 158/62 (April 2010); 156/70 (June 2010); 144/60 (July 2010); 131/61 (October 2010); 144/68 (May 2011); 126/61 (July 2011); 138/78 (November 2011); 164/72 (February 2012); 124/62 (March 2012); 140/78 (April 2012); 160/80 (September 2012); 144/80 (February 2013); 143/79 (April 2013); 142/66 (August 2013); 132/66 (November 2013); 152/66 (February 2014); 143/54 (April 2014); 140/72 (May 2014); 146/78 (August 2014); 124/54 (September 2014); 167/75 (March 2015); 148/74 (April 2015); 120/54 (July 2015); 150/68 (August 2015); 156/70 (November 2015); 138/64 (February 2016); 128/58 (March 2016); 147/64 (March 2016); 134/62 (May 2016); 138/60 (September 2016); 148/66 (October 2016). Private treatment records show blood pressure readings as follows: 188/84 (June 2010);158/71 (November 2011); 210/84 (February 2012); 131/68 (February 2012); 151/71 (March 2012); 140/88 (April 2012); 154/80 (May 2012); 130/80 (May 2012); 142/78 (August 2012); 194/77 (September 2012); 140/78 (March 2013); 128/78 (July 2013); 136/72 (October 2013); 152/80 (April 2014); 164/70 (August 2014);140/70 (December 2014); 140/76 (January 2015); 133/66 (January 2015); 154/70 (February 2015); 124/72 (April 2015); 152/70 (May 2015); 138/74 (July 2015); 165/74 (August 2015); 140/59 (September 2015); 110/70 (October 2015); 160/70 (November 2015); 151/65 (December 2015); 138/78 (February 2016); 144/80 (March 2016); 124/76 (April 2016); 122/74 (May 2016). Upon a careful review of the record, the Veteran's blood pressure readings during the appeal period do not show that the Veteran had diastolic pressure predominantly 110 or more, nor does the record show systolic pressure predominantly 200 or more as required for a 20 percent disability rating. In this regard, with the exception of a single blood pressure reading of 210/84 in February 2012, the Veteran's systolic pressure was never above 200, and the highest diastolic pressure recorded was 88 in April 2012. Moreover, the single systolic pressure over 200 does not provide a basis upon which to award a rating in excess of 10 percent, given the repeated blood pressure tests otherwise documented in the record showing systolic pressure consistently under 200. See McCarroll v. McDonald, 28 Vet. App. 267, 274 (2016) (holding that a single diastolic blood pressure reading of 100 does not demonstrate a history of diastolic pressure "predominantly" of 100 or more, as required by Diagnostic Code 7101). The Board further notes that the Veteran's diastolic pressure was never predominately 120 or 130 or more as required for a 40 percent and 60 percent disability rating, respectively. As noted above, the highest diastolic pressure was 88. Based on the foregoing, the Veteran has not been shown to meet the criteria for an increased evaluation under the rating criteria. Throughout the entire period on appeal, the Veteran's blood pressure readings never rose to the level of diastolic pressure predominantly 110 or more or systolic pressure predominantly 200 or more. In the absence of diastolic readings predominantly 110 or higher or systolic readings predominantly 200 or higher, the criteria for an increased rating are not met. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. III. TDIU Prior to May 3, 2016 The Veteran filed his claim for increased ratings for CAD, diabetes mellitus, and hypertension (his only service-connected disabilities) on September 7, 2010. During the pendency of the appeal, he has asserted that he is unemployable as a result of his service-connected disabilities. Accordingly, the claim for a TDIU is part and parcel of the claims for higher ratings, which have been pending since September 7, 2010. See Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). The Veteran contends, in essence, that his service-connected disabilities prevented him from securing or following any substantially gainful employment for the period prior to May 3, 2016. Where the schedular rating is less than total, a total disability rating for compensation purposes may be assigned when the Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, or if there are two or more disabilities, there shall be at least one ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). The term unemployability, as used in VA regulations governing total disability ratings, is synonymous with an inability to secure and follow a substantially gainful occupation. See VAOPGCPREC 75-91 (Dec. 17, 1991). The issue is whether the Veteran's service-connected disability or disabilities preclude him from engaging in substantially gainful employment (i.e., work which is more than marginal, that permits the individual to earn a living wage). See Moore v. Derwinski, 1 Vet. App. 356 (1991). In a claim for TDIU, the Board may not reject the claim without producing evidence, as distinguished from mere conjecture, that the Veteran's service-connected disability or disabilities do not prevent him from performing work that would produce sufficient income to be other than marginal. Friscia v. Brown, 7 Vet. App. 294 (1995). Consideration may be given to a Veteran's level of education, special training, and previous work experience in arriving at whether a TDIU rating is warranted, but the Veteran's age or the impairment caused by nonservice-connected disabilities may not be considered in such a determination. 38 C.F.R. §§ 3.341, 4.16, 4.19. In light of the increased rating granted above, for the entire period on appeal, the Veteran was service-connected for the following disabilities: (i) CAD, rated as 60 percent disabling; (ii) diabetes mellitus, rated as 20 percent disabling; and (iii) hypertension, rated as 10 percent disabling. These disabilities combine to a 70 percent rating, and the Veteran met the schedular criteria for a TDIU outlined above. 38 C.F.R. § 4.16 (a). In a November 2016 rating decision, the Veteran was awarded a TDIU from May 3, 2016. Thus, the remaining question concerns whether the Veteran was unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities prior to May 3, 2016. 38 C.F.R. § 4.16. The evidence shows that the Veteran last worked in April 2008 as an executive, a position which he purports to have left due to diabetes and heart disease. See September 2010 VA 21-8940; September 2010 Correspondence. He also worked as a scientist, and earned a Master's degree in Material Science in 1982. Id. After a careful review of the evidence of record, the Board finds that the Veteran was unable to secure or follow a substantially gainful occupation by reason of his service-connected disabilities prior to May 3, 2016. As the AOJ essentially conceded in its November 2016 rating decision granting entitlement to a TDIU from May 3, 2016, the Veteran's service-connected disabilities preclude the Veteran from securing and following substantially gainful employment. In that rating decision, the AOJ indicated that because the Veteran's CAD did not warrant an increased rating until May 3, 2016, the Veteran did not meet the schedular criteria for a TDIU rating until May 3, 2016, and therefore a TDIU was only warranted from that date. However, as discussed above, the Board finds that the Veteran's CAD warranted an increased rating for the entire appeal period, i.e. since September 2010, the date of the Veteran's increased rating and TDIU claims. In addition to the evidence cited above regarding the occupational impact of the Veteran's service-connected disabilities, the record contains a November 2011 letter from the Veteran's VA primary care physician, who indicated that the Veteran was no longer able to continue working due to his heart disease. The record also contains a February 2015 letter from the Veteran's private primary care provider, who opined that the Veteran's diabetes, heart disease, and non-service connected pulmonary disease have rendered him 100 percent medically disabled. Also of record is a March 2016 letter from the Veteran's VA primary physician, who indicated that the Veteran's hypertension, heart disease, and diabetes severely limit the Veteran's lifestyle and forced him to retire early at age 54. During the October 2016 VA heart conditions examination, the Veteran reported that he retired prematurely due to his medical problems and that he also has difficulty performing activities around the home, including yard work and general household work. After a careful review of the evidence of record, the Board finds that the evidence is at least in equipoise as to whether the Veteran's service-connected disabilities, alone, rendered him unable to secure or follow a substantially gainful occupation prior to May 3, 2016. Thus, the Board finds that entitlement to a TDIU is warranted prior to May 3, 2016. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. ORDER Prior to May 3, 2016, a 60 percent rating, but not higher, for CAD is granted, subject to the laws and regulations governing monetary awards. Since May 3, 2016, a rating in excess of 60 percent for CAD is denied. A rating in excess of 20 percent for diabetes mellitus with erectile dysfunction is denied. A rating in excess of 10 percent for hypertension is denied. Entitlement to a TDIU is granted prior to May 3, 2016, subject to regulations applicable to the payment of monetary benefits. ____________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs