Citation Nr: 1807710 Decision Date: 02/06/18 Archive Date: 02/14/18 DOCKET NO. 11-34 262 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUES 1. Entitlement to service connection for a respiratory disorder, claimed as chronic obstructive pulmonary disease (COPD), to include as secondary to non-Hodgkin's Lymphoma (NHL). 2. Entitlement to service connection for bilateral hand tremors, to include as secondary to NHL. 3. Entitlement to an initial compensable rating for NHL prior to August 26, 2015. 4. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C. Boyd Iwanowski, Counsel INTRODUCTION The Veteran served on active duty from June 1963 to May 1967, to include service in the Republic of Vietnam. These matters come before the Board of Veterans' Appeals (Board) from July 2010 and April 2012 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Pittsburgh, Pennsylvania. In August 2015, the Board remanded the claims for further development. The service connection claims and TDIU claim were remanded again in April 2017. In a July 2016 rating decision, a 100 percent rating was awarded for NHL from August 26, 2015. Because the maximum rating was not assigned for the entire appeal period, the issue of entitlement to an initial compensable rating for NHL remains in appellate status and the Board will address it in the decision below. AB v. Brown, 6 Vet. App. 35 (1993) (where a claimant has filed a notice of disagreement as to an RO decision assigning a particular rating, a subsequent RO decision assigning a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal). Regarding a TDIU, the Veteran was granted a 100 percent schedular rating for NHL effective August 26, 2015. The remaining question, therefore, is whether he is entitled to a TDIU prior to August 26, 2015. FINDINGS OF FACT 1. The probative evidence of record demonstrates that shortness of breath on all but mild exertion is a symptom of NHL when active; the evidence is against a finding that the Veteran has a separately diagnosed respiratory condition, to include COPD, which was caused or aggravated by NHL or chemotherapy treatment for NHL. 2. The probative evidence of record does not support a finding that the Veteran has a clinical diagnosis of disability in the bilateral upper extremities besides service-connected peripheral neuropathy. 3. Prior to August 26, 2015, the Veteran's NHL had not recurred nor metastasized since the conclusion of his cancer treatment in September 2008; residual disability for which the Veteran is not being compensated has not been demonstrated. 4. The evidence of record does not support a finding that at any time during the appeal period the Veteran's service-connected disabilities alone rendered him incapable of securing and following a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for service connection for a respiratory condition, to include COPD, are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.309, 3.310 (2017). 2. The criteria for service connection for bilateral hand tremors are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.309, 3.310 (2017). 3. The criteria for an initial compensable rating for NHL prior to August 26, 2015, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.117, Diagnostic Code 7715 (2017). 4. The criteria for a TDIU are not 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 Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the [appellant] fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). The Board has reviewed all the evidence in the record. Although there is an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). When there is an approximate balance of evidence for and against an issue, all reasonable doubt will be resolved in the appellant's favor. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a chronic condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F.3d 1331, 1340 (Fed. Cir. 2013) (holding that only conditions listed as chronic diseases in § 3.309(a) may be considered for service connection under 38 C.F.R. § 3.303(b) (2017). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Under 38 C.F.R. § 3.310, service connection may be granted for disability that is proximately due to or the result of a service-connected disease or injury, or for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). a. Respiratory Condition In statements in support of claim, the Veteran reports that he did not experience shortness of breath prior to his diagnosis of NHL in 2008 and he believes that his continued respiratory symptomatology is due to the chemotherapy he underwent for that service-connected disability. The Veteran's service treatment records (STRs) are silent for complaints of, treatment for, or diagnosis of a respiratory condition resulting in difficulty breathing. In a March 2008 VA treatment record, the Veteran presented with a 4 month history of gradual shortness of breath on exertion. He underwent a CT scan, which revealed moderate-sized left-sided pleural effusion with lung atelectasis and a large left retroperitoneal mass. It was noted he had smoked 2 packs of cigarettes per day prior to stopping 5 years previously. In April 2008, the Veteran was diagnosed with NHL. He underwent 6 cycles of chemotherapy ending in September 2008 and NHL was noted to be in remission at that time. A VA treatment record dated in October 2008 indicated the Veteran was feeling good, although he noted weight gain. He was walking his dog up to 2 miles a day, although shortness of breath made him stop for a minute before proceeding. In an August 2009 treatment record, it was noted the Veteran became tired and short of breath after doing a few hops on each leg in the treatment provider's office. The provider noted no sign of neurological weakness, sensory change, or significant reflex changes. The doctor recommended a more aggressive cardiopulmonary work-up to evaluate the Veteran's poor exercise tolerance. Pulmonary function testing (PFT) was performed in October 2009. Moderate COPD was diagnosed along with chronic left pleural thickening. It was noted that obesity likely contributed to dyspnea on exertion. Another October 2009 VA treatment record indicated that dyspnea was probably related to a combination of COPD and being overweight. In June 2010, the Veteran underwent a VA examination in connection with his claim for service connection for NHL filed in April 2010. Regarding his current symptoms, the Veteran reported symptomatology in his lower extremities and indicated he had chronic exertional dyspnea for many years, which presently was "not significantly changed compared with before." Upon VA examination in March 2012, the examiner identified issues with shortness of breath on exertion and decreased lung sounds. The examiner opined that it was less likely than not that COPD or another respiratory condition was secondary to NHL, given review of evidence from the Veteran's pulmonologist who attributed shortness of breath issues to his weight. In August 2015, the Board remanded the claim for a supplemental opinion to determine whether the Veteran's breathing difficulties were aggravated (chronically worsened) by his service-connected NHL. In April 2016, an addendum opinion was provided. Following review of the claims file, the examiner opined that it is less likely than not that the Veteran has a respiratory disability, including COPD, that was caused by his military service, or caused or aggravated by service-connected NHL. He explained that there was no evidence in the STRs that the Veteran had lung disease on active duty. The examiner noted a diagnosis of moderate COPD that was initially made in 2009. He opined that the likely cause was the Veteran's significant past smoking history (approximately 60 pack-years) as well as aging. It was noted that his exercise capacity had declined little since initial diagnosis, as per Pulmonologist's note, and there was no evidence that COPD had worsened beyond the natural course of the disease by his NHL or recurrence of the same (which occurred in 2015). In a May 2016 correspondence, the Veteran again argued that going through chemotherapy twice for his NHL caused side effects that were "everlasting" and he believed that his shortness of breath, specifically COPD, should be service-connected. Following an argument by the Veteran's representative that the April 2016 VA examination was provided by a physician's assistant and not necessarily someone with sufficient expertise to ascertain the nature and etiology of his disabilities, the Board remanded the claim in April 2017 for an additional VA examination. The examiner was asked to consider the August 2009 VA neurology consultation notes reflecting that the Veteran's shortness of breath is a representation of reduced exercise tolerance, the April 2016 VA examination noting that NHL symptoms include shortness of breath (dyspnea on all but mild exertion), and the April 2016 VA addendum reflecting that the Veteran's current COPD is likely due to significant smoking history. Following an extensive review of the record, in June 2017, the Chief of Occupational Medicine provided a supplemental opinion and noted that during treatment for NHL, the Veteran did not complain of shortness of breath. The examiner opined that the Veteran's COPD was "unmistakably" due to his history of cigarette smoking and there were no findings to indicate that he had early or late pulmonary involvement due to chemotherapy received. The examiner also stated he found no evidence of residuals from treatment for NHL, specifically chemotherapy, to include shortness of breath or decreased exercise tolerance. Specifically, he explained, there was no evidence of acute or chronic cardiac dysfunction which could be attributed to doxorubicin cardiotoxicity. He noted a July 2015 echocardiogram consistent with normal left ventricle size with an ejection fraction of 55% to 60%, a normal finding. Thereafter, the RO sought a VA examination as sought in the Board remand. In August 2017, the Veteran and his wife presented for an examination with the examiner who had provided the June 2017 opinion. The examiner recognized the Veteran's indication that he never had problems with respiration until diagnosis of NHL. He also indicated understanding that the Veteran's NHL is not cured and that he was now on oxygen to assist with his breathing. Regarding his smoking history, the Veteran reported he began at approximately 10 to 12 years old and smoked one to 1.5 packs per day until approximately 10 years previously. The examiner calculated this would constitute approximately 54-81 pack years. He indicated being unable to contribute the Veteran's current symptoms to NHL or chemotherapy. The only evidence in support of the claim consists of the Veteran's contentions. Although a layperson can provide evidence as to some questions of etiology, a question about the etiology of a respiratory condition such as COPD or a relationship between such condition and service, which would require more than direct observation to resolve, is not in the category of questions that lend themselves to resolution by lay observation. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Here, the evidence suggests that the Veteran began to experience shortness of breath approximately 5 months prior to diagnosis of NHL. He underwent 6 cycles of chemotherapy and NHL was then in remission; however, shortness of breath remained. About a year later, the Veteran underwent PFT and moderate COPD was assessed. It is uncontroverted that the Veteran was a heavy smoker beginning very early in his life. Medical opinions relate his COPD to smoking and obesity. The evidence reflects that the Veteran has shortness of breath caused by NHL, when active, and also by COPD which has remained stable throughout the period on appeal. Overall, there does not appear to be a medical basis for finding that chemotherapy for NHL or NHL itself caused or aggravated a separately diagnosable respiratory condition, specifically COPD. The competent evidence of record supports a finding that COPD is more likely than not caused by the Veteran's significant smoking history and it has remained stable throughout the appeal period. Given that the evidence is not in relative equipoise on this issue, the Board must find that the criteria for service connection for a respiratory condition, specifically COPD, 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 must be denied. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 55. b. Hand Tremors The Veteran's service treatment records (STRs) are negative for any complaints of, treatment for, or diagnosis of bilateral hand tremors. In an August 2009 VA treatment record, the Veteran complained of shakiness and numbness in his legs. He stated he did not have any problems with motor strength or sensation in the upper extremities. Hand tremors were not mentioned. In June 2010, the Veteran underwent a VA examination in connection with his claim for service connection for NHL. Regarding his current symptoms, the Veteran reported symptomatology in his lower extremities only. Hand tremors or upper extremity symptomatology was not mentioned. During VA examination in March 2012, the examiner indicated the Veteran had neuropathy in the upper extremities based on findings of decreased sensation, but there was no objective evidence of a hand tremor upon examination. Service connection was granted for peripheral neuropathy of the bilateral upper extremities in the April 2012 rating decision. The claim for bilateral hand tremors was denied because the evidence failed to show a diagnosis of an upper extremity condition other than peripheral neuropathy. In August 2015, the Board remanded the claim for a supplemental opinion to determine whether the Veteran had bilateral hand tremors, given his lay statements regarding their existence, and whether such tremors were aggravated (chronically worsened) by his service-connected NHL. In April 2016, the Veteran underwent a VA examination. The examiner stated it was unlikely that the Veteran had a disability manifested by tremors in the bilateral hands as there was no diagnosis of tremor on his problem list and no evidence in either inpatient or outpatient notes to indicate tremors in the hands. The examiner stated there was no significant rest and/or intention tremor on physical examination that day. In February 2017, the Veteran's representative challenged the adequacy of the April 2016 VA examination because it was performed by a physician's assistant. In April 2017, the Board remanded the claim again for an additional VA examination with an examiner with sufficient expertise to ascertain the nature and etiology of the Veteran's NHL, including his specifically claimed bilateral tremors of the hands In addition, the Board sought rationale on the question of aggravation and whether NHL or the treatment for NHL aggravated any bilateral hand tremors that were present. The examiner was asked to note the Veteran's competent reports of bilateral hand tremors and that the Veteran has been service-connected for bilateral upper extremity peripheral neuropathy as secondary to his NHL since April 2010. In June 2017, an examiner performed a detailed review of the evidence of record. As to hand tremors apart from peripheral neuropathy, the examiner indicated there were no records consistent with Vincristine neurotoxicity. He stated that any previous neurologic impairment should be considered to be temporary as there was no residual noted. Thereafter, the RO sought a VA examination as requested in the Board remand. In August 2017, the examiner who provided the June 2017 opinion met with the Veteran and his wife. The Veteran reported he could not stand in one spot without any tremor, shaking or lack of breath. Upon neurologic examination, there was no defined resting tremor. There was a mild intention tremor on the left on finger-to-nose testing after repeat episodes. Fine finger movements and rapid alternating movements were all normal. The examiner indicated that he could not state that the neuropathy was due to the chemotherapy because it was consistent with type II diabetes mellitus for which the Veteran is service-connected. It was also noted that there was a lack of medical evidence of neurologic toxicity from the chemotherapy that might explain upper extremity symptomatology. Overall, the Board finds the criteria for service connection for bilateral hand tremors have not been met. The record does not indicate diagnosis of a disability in the upper extremities other than peripheral neuropathy for which the Veteran has already been granted service connection. The existence of a current disability is the cornerstone of a claim for service connection and VA disability compensation. 38 U.S.C. § 1110, 1131; see Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (holding that interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). Evidence must show that the claimant currently has the disability for which benefits are being claimed. Here, there is no clinical diagnosis of neurologic disability in the upper extremities besides peripheral neuropathy, which is already service-connected. Lay statements are not considered competent evidence as to diagnosis of a disability causing tremor or the etiology of such. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply, and the claim for service connection must be denied. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 55. II. NHL Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history; reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where a Veteran appeals the initial rating assigned for a disability at the time that service connection for that disability is granted evidence contemporaneous with the claim and with the initial rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous . . . " Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Veteran's service-connected NHL is rated as noncompensable from April 13, 2010, and as 100 percent disabling effective August 26, 2015, under 38 C.F.R. § 4.117, Diagnostic Code 7715 (non-Hodgkin's lymphoma). A 100 percent rating is assigned under Diagnostic Code 7715 for NHL with active disease or during a treatment phase. A Note following Diagnostic Code 7715 provides: the 100 percent rating shall continue beyond the cessation of any surgical, radiation, antineoplastic chemotherapy or other therapeutic procedures. Six months after discontinuance of such treatment, the appropriate disability rating shall be [determined] by mandatory VA examination. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of [38 C.F.R.] § 3.105(e). The Note following Diagnostic Code 7715 finally provides that NHL should be rated on its residuals if there has been no local recurrence or metastasis of the disease. Id. Here, the Veteran was diagnosed with NHL in April 2008 and underwent 6 cycles of chemotherapy that concluded in September 2008. He filed his claim for service connection in April 2010. The evidence shows that the Veteran's NHL was in remission since September 2008, and there was no local recurrence or metastasis of the disease until 2015. The Veteran underwent a VA examination in June 2010. From September 2008, it was noted the Veteran had been in remission and was followed in Hematology/Oncology every six months with CT scan and PET scan. The last CT scan of the chest and abdomen done in April 2010 showed no adenopathy. The examiner noted there were no exacerbations of the disease and the Veteran's present state of health during remission was stable. It was noted the Veteran had no significant side effects during the chemotherapy except weakness and fatigue for several days after the treatment. Regarding his current symptoms, the Veteran reported symptomatology in his lower extremities and indicated he had chronic exertional dyspnea for many years, which presently was "not significantly changed compared with before." It was noted the Veteran could only walk approximately half a mile before needing to stop, mainly because of shortness of breath and sensation of his legs getting tired. The Veteran denied bleeding problems, fever, chills, or gastrointestinal problems. Examination findings revealed no evidence of lymphadenopathy, enlarged spleen or liver, or jaundice. Service connection was granted for NHL due to presumptive exposure to herbicide agents in Vietnam in a July 2010 rating decision. A noncompensable evaluation was assigned from the date of claim in the absence of active disease. In a January 2011 VA treatment record, it was noted the Veteran had a PET scan and reported with possible rectal polyps. The scan was negative for disease related to his lymphoma. The Veteran denied gastrointestinal symptoms, bleeding, weight loss, abdominal pain and fevers or chills. In a November 2011 follow-up for lymphoma, the Veteran did not report current symptomatology. In his December 2011 Form 9, the Veteran indicated his activity was limited as a direct result of treatment received for NHL. He indicated suffering from a number of chronic symptoms that he believed were related to the treatment undergone for his NHL, to include bilateral leg pain and tremors in his bilateral upper extremities. In March 2012, the Veteran underwent another VA examination. The examiner noted shortness of breath and that this was evaluated by neurology and pulmonary and was most likely attributable to the Veteran's weight. In addition, moderate COPD and chronic left pleural thickening were identified as causing shortness of the breath. It was noted NHL was in remission and the Veteran was not taking medications. He had completed treatment and was currently in a watchful waiting status. The Veteran did not have anemia or thrombocytopenia. The examiner did not note any findings or symptoms due to NHL, or due to treatment for that condition. In August 2015, the Board remanded the claim for a new examination to determine the current nature and severity of the Veteran's NHL and any residuals that may have surfaced since the March 2012 VA examination. VA treatment records indicated that a PET scan of August 26, 2015 showed recurrence of active NHL. In April 2016, the Veteran underwent another VA examination. It was indicated that he had a recurrence of NHL in 2015 and was treated with 4 cycles of chemotherapy. He had persistent hypermetabolic activity in the chest on last PET. It was noted his condition was active. The Veteran did not have anemia or thrombocytopenia. It was noted he had easy fatigability with mild exertion, shortness of breath on all but mild exertion and episodes where he felt like he was going to pass out and had to sit down fast. It was noted the Veteran had infections attributable to NHL at least once per year but less than once every 3 months. The Veteran did not have polycythemia vera or sickle cell anemia. Prior to August 26, 2015, the medical evidence of record demonstrates that the Veteran's NHL was in remission during the entirety of the appeal period. As such, under Diagnostic Code 7715 a compensable rating is not warranted at any time prior to August 26, 2015. The Board has considered whether a higher or separate disability evaluation is available under any other potentially applicable provision of the rating schedule. To the extent to which the Veteran has complained of bilateral hand and feet neuropathy, service connection has been established. The Veteran also complained of shortness of breath. While the Veteran is competent to report such symptom, he does not exhibit the qualifying medical knowledge to relate his described symptoms to his service-connected lymphoma. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). The record demonstrates that while shortness of breath is caused by NHL, when active, the Veteran also has COPD which is not at least as likely as not related to NHL and causes the Veteran's shortness of breath symptomatology during periods when NHL is in remission. Given the above, the Board finds that a compensable rating prior to August 26, 2015, for NHL is not warranted. The Board further finds that the Veteran been granted service connection for all residuals of his NHL. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). III. TDIU The Veteran contends that treatment for and residuals of his service-connected NHL have rendered him unemployable. A veteran may be awarded a TDIU upon a showing that he is unable to secure or follow a substantially gainful occupation due solely to impairment resulting from service-connected disabilities. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16 (2017). A total disability rating may be assigned where the schedular rating is less than total when the disabled person 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 is rated at 60 percent or more, or if there are two or more disabilities, there is at least one rated at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). Where a Veteran is unemployable by reason of his or her service-connected disabilities, but he or she fails to meet the percentage standards set forth in §4.16(a), TDIU claims are submitted to the Director of Compensation Service, for extraschedular consideration. 38 C.F.R. § 4.16(b). Entitlement to TDIU requires the presence of impairment so severe that it is impossible for the average person to follow a substantially gainful occupation. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). The fact that a claimant is unemployed or has difficulty obtaining employment is not enough. The question is whether or not the Veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. See Beaty v. Brown, 6 Vet. App. 532, 538 (1994). In arriving at a conclusion, consideration may be given to the veteran's level of education, special training, and previous work experience, but not to his/her age or the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19 (2017). From the date of claim in April 2010, service connected was in effect for NHL (0%), peripheral neuropathy of the right upper extremity (10%), peripheral neuropathy of the left upper extremity (10%), peripheral neuropathy of the right lower extremity (10%), and peripheral neuropathy of the left lower extremity (10%). His combined disability rating was 40 percent. Effective February 6, 2013, service connection was granted for diabetes mellitus, type II (20%), tinnitus (10%), and bilateral hearing loss (0%). The Veteran's combined rating increased to 60 percent. Effective August 26, 2015, the rating for NHL was increased to 100 percent. Prior to August 26, 2015, the Veteran does not meet the schedular criteria required for the grant of a TDIU under 38 C.F.R. § 4.16(a). Although the Board is precluded from assigning a TDIU on an extraschedular basis in the first instance; the Board must specifically adjudicate the issue of whether referral for a TDIU on an extraschedular basis pursuant to 38 C.F.R. § 4.16(b) is warranted. Bowling v. Principi, 15 Vet. App. 1, 8-10 (2001). In his Application for Increased Compensation Based on Unemployability, the Veteran related doing factory work for 12 years between 1972 and 1990 and working for a logging company from 1990 until he retired in 2008. He had a high school education. In a December 2010 statement, the Veteran indicated that although his NHL was in remission, his "health ailments at their current state which [are] side effects of the herbicide exposure direct or indirect would prohibit [him] from gainfully seeking employment" to help supplement his current retirement income. In a December 2011 statement in support of claim, the Veteran's son indicated his father was not physically able to work part time or full time and that his health ailments were directly related to the treatments he received. In March 2012, the Veteran underwent a VA examination related to his NHL. It was noted he had been diagnosed in 2008 and his NHL was currently in remission. As to employability, the examiner indicated the Veteran was unable to walk more than 10 feet without experiencing shortness of breath and he had pain in his legs and hands constantly and trouble with fine motor skills in his hands. He had difficulty getting up from a chair and was unable to climb stairs without shortness of breath. It was noted he could not use a keyboard. His last job was working at a saw mill cutting wood and the examiner opined that the Veteran would not be able to seek either physical or sedentary gainful employment based on his current medical history and symptoms. In August 2015 and April 2017 remands by the Board, TDIU was determined to be inextricably intertwined with the other remanded claims regarding service connection for COPD and bilateral hand tremors and the initial rating for NHL. At an April 2016 VA examination, it was noted that the Veteran had a recurrence of NHL that was active at a low level. The examiner stated that NHL was causing leg weakness, fatigability and a history of near syncopal episodes. The examiner stated that the Veteran was not a candidate for virtually any physical employment at that time and would be confined to sedentary, seated work only. The Veteran was considered immunocompromised and subject to recurrent infections, as evidenced by his 4 episodes of community acquired pneumonia over the past 2 years. The examiner reported he would be further challenged to maintain gainful employment due to the necessity of required frequent medical appointments. In a May 2016 correspondence, the Veteran argued that between April 2010 and September 2015, he had health ailments which would have prohibited him from performing the duties of a job in the trade in which he was skilled no matter what his overall evaluation indicated. Overall, although the Veteran's service-connected disabilities do impact his employability; the evidence demonstrates that his nonservice-connected COPD which causes difficulty breathing has had a significant impact on his employability throughout the appeal period. Herein, the Board has determined that it is not at least as likely as not that COPD is related to service or to the Veteran's NHL. The opinions in favor of the TDIU claim either include the COPD symptomatology or address the period when the Veteran is already rated at 100 percent. The service-connected disabilities during the period at issue - NHL, peripheral neuropathy of the extremities, diabetes mellitus, tinnitus, and hearing loss - are not shown to cause the Veteran to be unable to obtain and maintain gainful employment. As noted above, NHL was in remission during this period and would not have affected employability. At the Veteran's VA audiological examination in February 2016 functional limitation was described as difficulty hearing conversations in the presence of background noise; tinnitus was noted to not cause any functional impairment. During a 2013 VA audiological examination the Veteran reported difficulty making out certain words and that sometimes the ringing in his ears bothers his sleep. After a November 2013 VA diabetes examination it was noted that the disability caused no functional impairment. A 2012 VA examiner noted the Veteran's reports of pain in his hands and feet, trouble walking, and trouble with fine motor skills. Given the Veteran's high school education and long history of employment, to include at a factory and in logging, the Board finds the limitations described above would not preclude all forms of employment for which he was qualified. The limitations would not preclude a light work position such as factory work where extensive walking and fine motor skills would not be required. While it is recognized that the Veteran has pain, such is not shown to be debilitating to a degree where he could not function in a light work environment. Likewise, any communication problems that could occur appear to be limited especially in light of the Veteran having hearing aids. Given the above, the evidence is against a finding that the Veteran is unemployable due solely to his service-connected disabilities and, therefore, referral for extraschedular consideration is not warranted in this case. ORDER Service connection for a respiratory condition, to include COPD, is denied. Service connection for bilateral hand tremors is denied. An initial compensable rating for NHL prior to August 26, 2015 is denied. Entitlement to a TDIU is denied. ____________________________________________ Nathan Kroes Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs