Citation Nr: 1815355 Decision Date: 03/14/18 Archive Date: 03/23/18 DOCKET NO. 13-04 559 DATE Advanced on the Docket THE ISSUES 1. Entitlement to a disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a compensable disability rating prior to April 15, 2016 and in excess of 60 percent thereafter for coronary artery disease (CAD). 3. Entitlement to a disability rating in excess of 20 percent for peripheral neuropathy of the right upper extremity. 4. Entitlement to a disability rating in excess of 20 percent for peripheral neuropathy of the left upper extremity. 5. Entitlement to a disability rating in excess of 20 percent for diabetes mellitus type II with diabetic retinopathy. 6. Entitlement to a total disability rating for individual unemployability due to service-connected disabilities (TDIU). ORDER Entitlement to a disability rating in excess of 30 percent for PTSD is denied. Entitlement to a 60 percent disability rating for CAD throughout the entire period on appeal is granted. Entitlement to a disability rating in excess of 20 percent for peripheral neuropathy of the right upper extremity is denied. Entitlement to a disability rating in excess of 20 percent for peripheral neuropathy of the left upper extremity is denied. Entitlement to a disability rating in excess of 20 percent for diabetes mellitus type II with diabetic retinopathy is denied. Entitlement to TDIU is granted. FINDINGS OF FACT 1. The Veteran's PTSD manifested with occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation, but without occupational and social impairment, with reduced reliability and productivity. 2. The Veteran's CAD manifested with an ejection fraction between 30 and 50 percent throughout the entire period on appeal, but did not manifest with chronic congestive heart failure, 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. 3. The Veteran's right upper extremity peripheral neuropathy manifested with mild or moderate incomplete paralysis of the external popliteal nerve, but without severe incomplete paralysis. 4. The Veteran's left upper extremity peripheral neuropathy manifested with mild or moderate incomplete paralysis of the external popliteal nerve, but without severe incomplete paralysis. 5. The Veteran's diabetes mellitus was controlled with regulated diet and oral hypoglycemic agents, but without restriction of activities. 6. The Veteran's service-connected disabilities have rendered him unable to maintain substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 30 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.130, Diagnostic Code 9411 (2017). 2. The criteria for a disability rating of 60 percent, but no greater, for CAD have been met throughout the period on appeal. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.104, Diagnostic Code 7005 (2017). 3. The criteria for a disability rating in excess of 20 percent for right upper extremity peripheral neuropathy have not been met. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.124a, Diagnostic Code 8521 (2017). 4. The criteria for a disability rating in excess of 20 percent for left upper extremity peripheral neuropathy have not been met. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.124a, Diagnostic Code 8521 (2017). 5. The criteria for a disability rating in excess of 20 percent for diabetes mellitus with diabetic retinopathy have not been met. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.119, Diagnostic Code 7913 (2017). 6. The criteria for a TDIU have been met. 38 U.S.C.A. §§ 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from April 1963 to April 1966 in the United States Army. This matter comes before the Board of Veterans' Appeals (Board) on appeal from August 2010, February 2011, and July 2012 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2016). 38 U.S.C.A. § 7107(a)(2) (West 2014). VA has a duty to notify and assist a claimant in the development of a claim. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2016). VA is required to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2017). Compliant VCAA notice was provided in June 2010 and June 2012. In addition, the Board finds that the duty to assist a claimant has been satisfied. The Veteran's service treatment records are on file, as are various post-service medical records. VA examinations have been conducted and any necessary opinions obtained. After a careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Increased Rating Laws and Regulations Disability ratings are determined by applying the criteria set forth in the VA Schedule of Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. 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 questions as to which of two evaluations apply, assigning a higher of the two where the disability pictures 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 disability upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 1. Entitlement to a disability rating in excess of 10 percent prior to May 20, 2010 and in excess of 30 percent thereafter for PTSD. Considerations in evaluating a mental disorder include the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The evaluation must be based on all evidence of record that bears on occupational and social impairment rather than solely on an examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). When determining the appropriate disability evaluation to assign, the Board's "primary consideration" is the Veteran's symptoms. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). The Veteran's service-connected PTSD has been rated under the provisions of 38 C.F.R. § 4.130, Diagnostic Code 9411, which provides, in part as follows: A 30 percent disability rating is warranted when the Veteran experiences occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent disability rating is warranted when the Veteran experiences occupational and social impairment, with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent disability rating is warranted when the Veteran experiences occupational and social impairment, with deficiencies in most area, such as work, school, family relations, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or work like setting); inability to establish and maintain effective relationships. A 100 percent disability rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of closest relatives, own occupation, or own name. 38 C.F.R. § 4.130. In Mittleider v. West, 11 Vet. App. 181 (1998), the United States Court of Appeals for Veterans Claims (Court) held that VA regulations require that when the symptoms and/or degree of impairment due to a Veteran's service-connected psychiatric disability cannot be distinguished from any other diagnosed psychiatric disorders, VA must consider all psychiatric symptoms in the adjudication of the claim. The Veteran's PTSD was rated at 30 percent disabling. To receive a higher disability rating during that period, the evidence must show occupational and social impairment, with reduced reliability and productivity. The Veteran attended a VA examination in July 2010. The examiner diagnosed PTSD and depression. The Veteran was on anti-depressants. The Veteran lived with his wife and his 9 year old granddaughter. He described his marriage as good. He stated that his three adult children were doing well and he got along with them. He enjoyed time with his grandchildren. He had friends from church. He had no history of suicide attempts and no history of violence and assaultiveness. The Veteran was mildly impaired with respect to his psychosocial functioning. The Veteran was neatly groomed, appropriately and casually dressed. His speech and psychomotor activity were unremarkable. His attitude was cooperative, friendly, and attentive. The affect was appropriate. His mood was dysphoric. He had no attention disturbance. He was oriented. His thought process and thought content were unremarkable. He had no delusions and understood the outcome of his behavior. He had a sleep impairment, to include difficulty with sleep onset and maintenance. He had no hallucinations and no inappropriate behavior. The Veteran had obsessive and ritualistic behavior. He had no panic attacks, homicidal thoughts, suicidal thoughts, or episodes of violence. He had good impulse control. His remote memory was normal, but his recent and immediate memory was mildly impaired. The Veteran's PTSD symptoms included recurrent and intrusive distressing recollections, persistent avoidance, difficulty falling or staying asleep, irritability or outbursts of anger, and difficulty concentrating. The Veteran's wife noted increased irritability and anger and decreased motivation or interest in previous hobbies. The examiner noted PTSD signs and symptoms that were transient or mild and decreased work efficiency and the ability to perform occupational tasks only during periods of significant stress. The Veteran reported ongoing re-experiencing, avoidant, and hyperarousal symptoms of PTSD that were mild in intensity and have mildly impaired his psychosocial functioning. The Veteran was afforded another VA examination in April 2016. The examiner diagnosed chronic PTSD. The examiner found occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The Veteran was married for 54 years. The Veteran had three adult children, with whom he maintained contact. The Veteran lived with his wife and 15 year old granddaughter. The Veteran maintained contact with his surviving brother. He also saw friends at church. He retired in 1998 as a supervisor with no formal disciplinary action reported. The Veteran had no psychiatric hospitalizations. The Veteran reported recurrent, involuntary, or intrusive distressing memories or dreams. He experienced avoidance, markedly diminished interest or participation in significant activities, feelings of detachment or estrangement from others, problems with concentration, sleep disturbance, and depressed mood. The Veteran had fair grooming and hygiene. His speech was within normal limits. He had good eye contact. His thoughts were logical and goal-directed. His memory was intact and he was oriented. The Veteran's attention was within normal limits. His affect and mood were congruent. The examiner noted no suicidal ideation, intent, or plan and no suicide attempts. The Veteran was able to control his anger and had no physical altercations, homicidal ideation, intent, or plan. He denied problems with anxiety. He had no panic attacks or hallucinations. The Board finds that a preponderance of the evidence shows that the Veteran's PTSD did not manifest to the level of a 50 percent disability rating. The VA examiner in July 2010 specifically noted that the Veteran's PTSD signs and symptoms were transient or mild and decreased work efficiency and the ability to perform occupational tasks only during periods of significant stress. The VA examiner in August 2016 found occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The evidence indicates that the Veteran's symptoms were mild in degree. Specifically, the Veteran did not have a flattened affect, circumstantial, circumlocutory, or stereotyped speech, panic attacks more than once a week, difficulty in understanding complex commands, impairment of short- and long-term memory, impaired judgment, impaired abstract thinking, disturbances of motivation and mood, or difficulty in establishing and maintaining effective work and social relationships. The Board has considered that the symptoms listed in Diagnostic Code 9411 are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Vazquez-Claudio; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). As such, the Board notes that the Veteran experiences other symptoms that are not listed in the criteria, but may reflect the severity of his PTSD. These include, but are not limited to recurrent and intrusive distressing recollections, persistent avoidance, difficulty falling or staying asleep, and difficulty concentrating. Specifically, the Board has also considered many of the Veteran's symptoms as "like or similar to" the schedular rating criteria of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, due to such symptoms as: depressed mood, anxiety, or suspiciousness. See Mauerhan, 16 Vet. App. 436. Based on the evidence of record, and after resolving all doubt in the Veteran's favor, the Board finds that the manifestations of the Veteran's PTSD do not more nearly approximate the criteria for a 50 percent disability rating. As such, the Board finds that the preponderance of the evidence is against the claim. 2. Entitlement to a compensable disability rating prior to April 15, 2016 and in excess of 60 percent thereafter for CAD. The Board acknowledges that the Veteran's representative has submitted a notice of disagreement with the effective date of the April 15, 2016 assignment of a 60 percent disability rating. The Board notes that the issue of entitlement to a higher disability rating for CAD prior and subsequent to the April 15, 2016 assignment is currently on appeal. As this appeal addresses the entitlement to a higher disability rating prior to April 15, 2016, the Board finds that the issue is already on appeal and a separate issue regarding the effective date of the April 15, 2016 increased rating is moot. Thus the staged rating will be addressed below. The Board also notes that the Veteran's CAD has been rated at times with and at times without subtracting the level of disability present prior to aggravation by the Veteran's diabetes mellitus. When rating based upon aggravation, the Veteran is entitled to a compensable rating only for the increase in severity of the symptoms caused by the aggravating factor. In this case, the Board notes that the Veteran served in Vietnam. Under 38 U.S.C.A. § 1116(a)(2) and 38 C.F.R. § 3.309(e), as to Veterans who served in Vietnam during a certain time period, selected diseases may be presumed to have resulted from exposure to herbicide agents such as Agent Orange. According to the Veteran's service records, he served in the Republic of Vietnam during the Vietnam Era, therefore, his exposure to toxic herbicides is presumed. See 38 U.S.C.A. §§ 1116, 1154. Regulations provide, in pertinent part, that if a veteran was exposed to an herbicide agent (such as Agent Orange) during active military, naval, or air service, the following diseases shall be service-connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied: AL amyloidosis, chloracne or other acneform disease consistent with chloracne, type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes), Hodgkin's disease, ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina), all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia), multiple myeloma, non-Hodgkin's lymphoma, Parkinson's disease, early-onset peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). I 38 C.F.R. § 3.309(e). Although the Veteran's CAD was originally granted on the basis of aggravation, due to the inconsistent application of the rating criteria for aggravation and the Veteran's service in Vietnam, which would have allowed direct service connection, the Board will rate the Veteran's CAD on a direct basis without consideration of aggravation of the disability by the diabetes mellitus. The Veteran's CAD is rated under the Diagnostic Code 7005 for arteriosclerotic heart disease. Under that regulation, CAD 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 warrants a 100 percent disability rating. CAD with more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent warrants a 60 percent disability rating. CAD with a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray warrants a 30 percent disability rating. CAD with a workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required warrants a 10 percent disability rating. 38 C.F.R. § 4.104. Prior to April 15, 2016, the Veteran's CAD is rated as noncompensable. To receive a higher disability rating during that time period, the evidence must show a workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or continuous medication required. The Veteran attended a VA examination in June 2010. The Veteran performed a stress test. The Veteran exercised for 7:07 minutes, achieving a work level of 8:70 METS. The maximal heart rate was 137 beats per minute (88 percent of maximal age-predicted heart rate). The exercise test was stopped due to fatigue and target heart rate. Ejection fraction was 35 to 45 percent. The Veteran was afforded another VA examination in August 2010. The examiner noted that the Veteran's ejection fraction decreased from 50 percent in 2007 to 35-45 percent in 2008. The examiner noted a new stenosis requiring a stent. The Board notes that the evidence showed an ejection fraction of 30 to 50 percent. Therefore, a 60 percent disability rating is warranted throughout the period on appeal. The Board must then determine whether a disability rating in excess of 60 percent is warranted throughout the entire period on appeal. To receive a higher disability rating, the evidence must show 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. The Veteran was afforded a VA examination in April 2016. The examiner diagnosed CAD. The Veteran had angioplasty, coronary artery bypass surgery, and an implanted cardiac pacemaker. Physical examination showed regular rhythm with a heart rate of 62. The point of maximal impact was not palpable. The heart sounds were normal and auscultation of the lungs was clear. The Veteran did not have jugular-venous distension. The examiner noted no lower extremity peripheral edema. His blood pressure was 135/78. The Veteran had an interview-based METs test. The METs level was >3-5, consistent with activities such as light yard work, mowing lawn, and brisk walking. The examiner noted dyspnea and fatigue. The evidence shows that the Veteran did not have chronic congestive heart failure. Examination revealed METs greater than 3. The record did not show ejection fraction of less than 30 percent. Therefore, the Board finds that a disability rating in excess of 60 percent is not warranted from April 15, 2016 forward. Based on the evidence of record, and after resolving all doubt in the Veteran's favor, the Board finds that the manifestations of the Veteran's CAD met the criteria for a 60 percent disability rating, but no greater, throughout the entire period on appeal. To that extent, the Veteran's claim is granted. 3-4. Entitlement to a disability rating in excess of 20 percent for peripheral neuropathy of the right and left upper extremities. The Board will address the claims for increased ratings for peripheral neuropathy of the right and left upper extremities together as they stem from the same factual background. The Veteran's right and left upper extremity peripheral neuropathy is rated at 20 percent each under Diagnostic Code 8521 for paralysis of the external popliteal nerve. Under that regulation, complete paralysis of the nerve with foot drop and slight droop of first phalanges of all toes, cannot dorsiflex the foot, extension (dorsal flexion) of proximal phalanges of toes lost; abduction of foot lost, adduction weakened; anesthesia covers entire dorsum of foot and toes, warrants a 40 percent disability rating. Severe incomplete paralysis warrants a 30 percent disability rating. Moderate incomplete paralysis warrants a 20 percent disability rating. Mild incomplete paralysis warrants a 10 percent disability rating. 38 C.F.R. § 4.124a. During the June 2010 VA examination for diabetes mellitus, the examiner diagnosed bilateral upper extremity neuropathy. Testing showed electrophysiological findings indicative of a moderate diffuse sensorimotor polyneuropathy. The Veteran attended a VA examination in July 2012. The examiner diagnosed diabetic peripheral neuropathy. The Veteran was left hand dominant. The examiner noted mild bilateral upper extremity numbness. The Veteran had normal strength for the upper extremities with no muscle atrophy. Reflex examination was normal. The sensory examination showed decreased results for sensation testing for light touch of the hands and fingers. The examiner noted no trophic changes. The examiner noted mild incomplete paralysis of the median nerve bilaterally. The Veteran was afforded a VA examination for peripheral neuropathy in April 2016. The examiner diagnosed bilateral upper peripheral neuropathy. The examiner noted mild intermittent pain and paresthesias or dysesthesias. The neurological examination showed normal strength and normal deep tendon reflexes in the upper extremities. Sensory examination also showed normal testing results of the upper extremities. The Veteran had no muscle atrophy or trophic changes. The examiner noted mild bilateral incomplete paralysis of the median nerve. To receive a higher disability rating, the evidence must show severe incomplete paralysis of the nerve. Throughout the period on appeal, the Veteran's peripheral neuropathy was described as mild or moderate. At no point did the treatment records or VA examinations show severe peripheral neuropathy of the right or left upper extremity. Based on the evidence of record, and after resolving all doubt in the Veteran's favor, the Board finds that the manifestations of the Veteran's right or left upper extremity peripheral neuropathy do not more nearly approximate the criteria for a disability rating in excess of 20 percent for either extremity. As such, the Board finds that the preponderance of the evidence is against the claims. 5. Entitlement to a disability rating in excess of 20 percent for diabetes mellitus type II with diabetic retinopathy. The Veteran's diabetes mellitus is rated at 20 percent under Diagnostic Code 7913. Diagnostic Code 7913 provides, in part as follows: 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, warrants a 100 percent disability rating. Diabetes mellitus requiring one or more daily injection of 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, warrants a 60 percent disability rating. Diabetes mellitus requiring one or more daily injection of insulin, restricted diet, and regulation of activities warrants a 40 percent disability rating. Diabetes mellitus requiring one or more daily injection of insulin and restricted diet, or; oral hypoglycemic agent and restricted diet warrants a 20 percent disability rating. 38 C.F.R. § 4.119. To receive a higher disability rating, the Veteran's diabetes mellitus must require one or more daily injection of insulin, restricted diet, and regulation of activities. The Veteran attended a VA examination in July 2012. The examiner diagnosed diabetes mellitus type II. The Veteran's diabetes is managed by restricted diet and prescribed oral hypoglycemic agents. The Veteran visited his diabetic care provider less than two times per month for ketoacidosis or hypoglycemic reactions. The Veteran did not require any hospitalizations and did not have any progressive unintentional weight loss. The Veteran also did not have progressive loss of strength. The Veteran was afforded a VA examination in April 2016. The examiner diagnosed diabetes mellitus type II. The Veteran's diabetes was managed by restricted diet and prescribed oral hypoglycemic agents. The Veteran did not require regulation of activities as part of medical management of diabetes mellitus. The Veteran visited his diabetic care provider for episodes of ketoacidosis or hypoglycemia less than two times per month with no hospitalizations. The Veteran has had no progressive unintentional weight loss or loss of strength. The Veteran's treatment records and VA examinations do not indicate any required restriction of activities. The Veteran's diabetes mellitus is managed with restricted diet and prescribed oral hypoglycemic agents. Therefore, the Veteran's symptoms do not more nearly approximate the criteria for a higher disability rating. The Board notes that Diagnostic Code 7913 Note (1) indicates that compensable complications of diabetes should 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. 38 C.F.R. § 4.119. Retinopathy is rated under Diagnostic Code 6006. To receive a separate compensable rating for retinopathy under that regulation, the evidence must show incapacitating episodes having a total duration of at least one week, but less than two weeks, during the prior 12 months, or vision correctable to a minimum of 20/40 in one eye and 20/50 in another eye. 38 C.F.R. § 4.79. The record shows that the Veteran's vision is correctable to 20/40 or better throughout the period on appeal. The record also does not indicate any incapacitating episodes. The Veteran was afforded a VA examination of the eyes in July 2012. The examiner diagnosed diabetic retinopathy status post laser treatment. The Veteran's vision was correctable to 20/40 or better bilaterally. The examiner noted no incapacitating episodes attributable to any eye conditions. Therefore, the Board finds that a separate compensable disability rating is not warranted for diabetic retinopathy. Based on the evidence of record, and after resolving all doubt in the Veteran's favor, the Board finds that the manifestations of the Veteran's diabetes mellitus with diabetic retinopathy do not more nearly approximate the criteria for a disability rating in excess of 20 percent. As such, the Board finds that the preponderance of the evidence is against the claim. 6. Entitlement to TDIU. The Board notes that the Veteran has requested unemployability due to his service-connected disabilities. Where a Veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability, the requirement in 38 C.F.R. § 3.155(a) that an informal claim "identify the benefit sought" has been satisfied and VA must consider whether the Veteran is entitled to a total rating for compensation purposes based on individual unemployability (TDIU). See Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001) (VA to "determine all potential claims raised by the evidence, applying all relevant laws and regulations"); See also Rice v. Shinseki, 22 Vet. App. 447 (2009) (holding that an appeal for higher rating includes a claim for TDIU, if reasonably raised by the record). In light of the Court's determination that evidence of unemployability in the context of a rating claim may include a TDIU claim as well as the submission of vocational evaluations, the Board finds that the issue of TDIU is currently on appeal as part of his increased rating claims. Therefore, the Board may address the issue without remanding it for the agency of original jurisdiction to address it in the first instance. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2014). Total disability is considered to exist when there is any impairment which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. Total disability may or may not be permanent. 38 C.F.R. § 3.340(a)(1). Total ratings are authorized for any disability or combination of disabilities for which the Rating Schedule prescribes a 100 percent evaluation. 38 C.F.R. § 3.340(a)(2). TDIU may be assigned when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. If there is only one such disability, it must be rated at 60 percent or more; if 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. 38 C.F.R. § 4.16(a). But for the above purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric, (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. 38 C.F.R. § 4.16(a). Individual unemployability must be determined without regard to any non-service connected disabilities or the Veteran's advancing age. 38 C.F.R. §§ 3.341(a), 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. All veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16(b) (2011). Factors such as employment history, as well as educational and vocational attainments, should be considered. Id. For VA purposes, the term unemployability is synonymous with an inability to secure and follow a substantially gainful occupation. VAOPGCPREC 75-91; 57 Fed. Reg. 2317 (1992). The word substantially suggests intent to impart flexibility into a determination of a veteran's overall employability, as opposed to requiring the appellant to prove that he is 100 percent unemployable. Roberson v. Principi, 251 F.3d 1378, 1385 (Fed. Cir. 2001). In this case, the Veteran contends that he is unable to secure employment due to his service-connected disabilities. The Veteran is service connected for CAD at 60 percent, PTSD at 30 percent, diabetes mellitus with diabetic retinopathy at 20 percent, peripheral neuropathy of the right lower extremity at 20 percent, peripheral neuropathy of the left lower extremity at 20 percent, peripheral neuropathy of the right upper extremity at 10 percent, peripheral neuropathy of the left upper extremity at 10 percent, tinnitus at 10 percent, atrial fibrillation at 10 percent, and residual scar at 0 percent. He currently has a total disability rating of 90 percent. Therefore, the percentage criteria for TDIU are met throughout the period on appeal and entitlement to TDIU is considered on a schedular basis. 38 C.F.R. § 4.16(a). In October 2017, a vocational consultant reviewed the Veteran's records and provided an opinion regarding his ability to obtain and maintain employment. The examiner specified the Veteran's service-connected disabilities. The examiner cited multiple medical records from the Veteran's files. The consultant cited studies and research regarding the ability of the Veteran to maintain employment. The consultant found that the Veteran would be expected to miss more than one day per month based on the reports of his physical and mental symptoms, the results of the evaluations, and his prior work history. More than five percent of time off-task for any reason would prevent sustaining competitive work. The Veteran would likely exceed that due to emotional and physical symptoms impacting his concentration and persistence at a work task. The consultant also noted that the Veteran had a combination of physical and emotional conditions that interact in terms of severity level. The consultant noted the opinion that found that his diabetes, heart condition, and peripheral neuropathy would not impact his ability to work. Another doctor, however, opined that the Veteran could not be a driver due to his eye disability. The Veteran had fatigue, chest pain, and shortness of breath, and due to his service-connected disabilities, he would be unable to maintain substantially gainful employment. The consultant found that due to the combination of the Veteran's fatigue, deficiencies in focus and concentration, and his inability to attend work in a predictable manner, the Veteran would not be able to sustain any level of work activity. The Board recognizes that the opinions of the VA examiners when considering the disabilities individually found that each individual disability did not prevent the Veteran from obtaining or maintaining substantially gainful employment. The VA examiners did not provide an opinion that considered the Veteran's mental and physical disabilities in combination. The private VA consultant reviewed the record and provided an opinion that cited studies as well as the Veteran's treatment records and VA examinations. The Board notes that all doubt is to be resolved in the Veteran's favor. 38 U.S.C.A. § 5107(b); also see generally Gilbert v. Derwinski, 1 Vet. App 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). Therefore, the Board finds that the Veteran was unable to obtain or sustain substantially gainful employment due to his service-connected disabilities. Therefore, the criteria for a TDIU have been met. 38 C.F.R. §§ 4.3, 4.7. ______________________________________________ B. MULLINS Veterans Law Judge, Board of Veterans' Appeals ATTORNEY FOR THE BOARD Patricia Veresink, Associate Counsel Copy mailed to: J. Michael Woods Department of Veterans Affairs