Citation Nr: 1825075 Decision Date: 04/30/18 Archive Date: 05/07/18 DOCKET NO. 11-23 499 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana THE ISSUES 1. Entitlement to service connection for arthritis. 2. Entitlement to service connection for macular degeneration. 3. Entitlement to service connection for diabetes mellitus type II. 4. Entitlement to service connection for lower lumbar ruptured disc. 5. Entitlement to service connection for enlarged heart. 6. Entitlement to service connection for sleep apnea. 7. Entitlement to service connection for hypertension. 8. Entitlement to a higher initial disability rating for a left shoulder scar, in excess of 10 percent from July 15, 2009 to February 23, 2012, and a compensable rating from February 23, 2012. 9. Entitlement to a higher initial disability rating for degenerative joint disease of the left shoulder (left shoulder disability), in excess of 10 percent from February 13, 2008 to July 15, 2009, 20 percent from July 15, 2009 to August 31, 2011, 30 percent from August 31, 2011 to February 23, 2012, 20 percent from February 23, 2012 to April 9, 2014, and 30 percent from April 9, 2014. 10. Entitlement to a higher initial disability rating for depression, in excess of 10 percent from February 13, 2008 to March 7, 2012, and 30 percent from March 7, 2012. 11. Entitlement to a total disability rating for compensation purposes based on individual unemployability due to service-connected disabilities (TDIU) prior to March 14, 2017. REPRESENTATION Appellant represented by: Christopher L. Loiacono, Agent WITNESS AT HEARING ON APPEAL The Veteran (Appellant) ATTORNEY FOR THE BOARD E. Choi, Associate Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from April 1970 to May 1974, and from June 1974 to April 1977. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2009 rating decision of the RO in San Diego, California, and a June 2011 rating decision of the RO in Indianapolis, Indiana. Jurisdiction over this case is currently with the RO in Indianapolis, Indiana. In a July 2017 rating decision, the RO granted service connection for residuals of carcinoma, status post nephrectomy, and assigned an initial 100 percent disability rating from March 14, 2017. As the Veteran is already in receipt of a total (100 percent) disability rating starting from March 14, 2017, the Board need only consider entitlement to a TDIU for the period prior to March 14, 2017. See 38 C.F.R. § 4.16(a) (2017) (providing that a TDIU is only available where the combined schedular disability rating is "less than total"). In October 2017, the Veteran testified at a Travel Board hearing held at the RO in Indianapolis, Indiana, before the undersigned Veterans Law Judge (VLJ) sitting in Washington, D.C. A transcript of the hearing has been associated with the electronic file. The Board has reviewed the electronic file on "Virtual VA" and the Veterans Benefits Management System (VBMS) to ensure a complete review of the evidence in this case. FINDINGS OF FACT 1. Per the Veteran's October 2017 Board testimony, prior to the promulgation of a decision in the present appeal, the Veteran asked to withdraw the issues of service connection for arthritis, macular degeneration, diabetes mellitus type II, lower lumbar ruptured disc, enlarged heart, sleep apnea, and a higher initial rating for a left shoulder scar. 2. The Veteran is currently diagnosed with hypertension. 3. The Veteran had symptoms of hypertension during active service. 4. The Veteran's hypertension was incurred in service. 5. For the entire initial rating period on appeal from February 13, 2008 forward, the left shoulder disability has been manifested by symptoms of pain, weakened movement, and muscle atrophy that are productive of limitation of motion of the left arm that more closely approximates 25 degrees from the side. 6. For the entire initial rating period on appeal from February 13, 2008 forward, the left shoulder disability has not been manifested by ankylosis, loss of head, nonunion, or fibrous union of the humerus. 7. For the initial rating period on appeal from February 13, 2008 to March 7, 2012, the Veteran's depression has manifested in symptoms that more nearly approximate occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, due to symptoms such as depressed mood, anxiety, suspiciousness, chronic sleep impairment, and mild memory loss. 8. For the initial rating period on appeal from March 7, 2012 forward, the Veteran's depression has manifested in symptoms that more nearly approximate occupational and social impairment with reduced reliability and productivity due to symptoms such as flattened affect, impairment of short- and long-term memory, impaired judgment, disturbances of motivation and mood, difficulty establishing and maintaining effective work and social relationships. 9. The Veteran maintained substantially gainful employment through June 1, 2009. 10. For the period from June 1, 2009 to March 14, 2017, the Veteran has been unable to obtain (secure) or maintain (follow) substantially gainful employment as a result of service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for the withdrawal of a substantive appeal have been met regarding the appeals for service connection for arthritis, macular degeneration, diabetes mellitus type II, lower lumbar ruptured disc, enlarged heart, sleep apnea, and a higher initial rating for a left shoulder scar. 38 U.S.C. § 7105 (2012); 38 C.F.R. § 20.204 (2017). 2. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for hypertension have been met. 38 U.S.C. §§ 1110, 1131, 1154, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 3. Resolving reasonable doubt in favor of the Veteran, for the entire initial rating period on appeal from February 13, 2008 forward, the criteria for a higher initial disability rating of 30 percent, but no higher, for the left shoulder disability have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Code 5010-5201 (2017). 4. Resolving reasonable doubt in favor of the Veteran, for the initial rating period on appeal from February 13, 2008 to March 7, 2012, the criteria for a higher initial disability rating of 30 percent, but no higher, for depression have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9434 (2017). 5. Resolving reasonable doubt in favor of the Veteran, for the initial rating period on appeal from March 7, 2012 forward, the criteria for a higher initial disability rating of 50 percent, but no higher, for depression have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9434 (2017). 6. Resolving reasonable doubt in favor of the Veteran, for the period from June 1, 2009 to March 14, 2017, the criteria for a TDIU have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.340, 3.341, 4.3, 4.15, 4.16, 4.18, 4.19, 4.25 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duties to notify and assist claimants in substantiating their claims 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). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim and of the relative duties of VA and the claimant for procuring that evidence. 38 U.S.C. § 5103(a); 38 C.F.R. § 3.159(b) (2017). Such notice should also address VA's practices in assigning disability ratings and effective dates for those ratings. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). Notice should be provided to a claimant before the Agency of Original Jurisdiction's initial unfavorable decision on a claim. 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). As the instant decision grants service connection for hypertension and a TDIU, no further discussion of VA's duties to notify and assist is necessary as to those issues. The Veteran is challenging the initial disability rating assigned following the grant of service connection for a left shoulder disability and depression. The United States Court of Appeals for the Federal Circuit (Federal Circuit) and the United States Court of Appeals for Veterans Claims (Court) have held that regarding the downstream element of the initial rating that, once service connection is granted the claim is substantiated, additional notice is not required, and any defect in notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007) (noting that, once an initial VA decision awarding service connection and assigning a disability rating and effective date has been made, 38 U.S.C. § 5103(a) notice is no longer required); 38 C.F.R. § 3.159(b)(3) (no VCAA notice required because of filing of a Notice of Disagreement). With respect to the issues of a higher initial disability rating for the left shoulder disability and depression, no additional notice is required regarding this downstream element of the service connection claim; thus, the Board concludes that VA satisfied its duty to notify the Veteran. VA has also satisfied its duty to assist the Veteran in the development of the claim by fulfilling its duty to seek and assist in the procurement of relevant records. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. Specifically, the information and evidence that have been associated with the claims file includes the military personnel records, service treatment records, VA treatment records, Social Security Administration (SSA) records, private treatment records, VA examination reports, and lay statements. The Veteran was afforded VA examinations in March 2009, July 2010, February 2012, March 2012, and April 2014, the examination reports for which are of record. To that end, when VA undertakes to either provide an examination or to obtain an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The March 2009, July 2010, February 2012, March 2012, and April 2014 VA examination reports reflect that the VA examiners reviewed the claims file, personally interviewed and examined the Veteran, including eliciting a history, conducted an in-person examination, and provided detailed findings supported by clinical testing. Based on the foregoing, the Board finds that all relevant documentation has been secured and all relevant facts have been developed. There remains no question as to the substantial completeness of the issue on appeal. 38 U.S.C. §§ 5103, 5103A, 5107; 38 C.F.R §§ 3.102, 3.159, 3.326(a). Service Connection for Hypertension Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Veteran is currently diagnosed with hypertension which is listed as a "chronic disease" under 38 C.F.R. § 3.309(a); therefore, the presumptive provisions of 38 C.F.R. § 3.303(b) for "chronic" in-service symptoms and "continuous" post-service symptoms apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where the evidence shows a "chronic disease" in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service. For the showing of "chronic" disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of "continuity of symptoms" after service is required for service connection. 38 C.F.R. § 3.303(b). Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases, such as hypertension, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. The Veteran generally contends that service connection for hypertension is warranted because symptoms of hypertension began to develop during active service. See October 2017 Board hearing transcript. Initially, the Board finds that the Veteran is currently diagnosed with hypertension. Numerous VA and private treatment records throughout the course of this appeal reflect a diagnosis of hypertension. See e.g. January 2008 private treatment record. After a review of all the evidence of record, both lay and medical, the Board finds that the evidence is at least in equipoise on the question of whether the Veteran had the onset of symptoms of hypertension in service and since service separation (i.e. whether hypertension was "incurred in" service). The evidence that weighs against an incurrence of hypertension in service includes service treatment records, which are absent for a diagnosis of hypertension during service. Favorable evidence supporting a finding that the Veteran had symptoms of hypertension in service and since service separation includes numerous service treatment records showing elevated blood pressure measurements. For example, an April 1976 service treatment record notes the Veteran's history of fluctuating blood pressure, which was measured at 150/100 and 142/94 that day. Additionally, the Veteran testified during the October 2017 Board hearing that since he worked in the emergency room during military service, the emergency room doctors he had come to know began informally treating the Veteran's high blood pressure, including with prescription medication. The Veteran also testified to seeking treatment for high blood pressure following service separation in the 2000s. Such symptoms of high blood pressure were subsequently diagnosed as hypertension in January 2008. For the above reasons, and resolving reasonable doubt in the Veteran's favor, the Board finds that the criteria for service connection for hypertension have been met. 38 U.S.C. §5107; 38 C.F.R. §3.102. As service connection is being granted on a direct basis, there is no need to discuss entitlement to service connection on a presumptive or any other basis, as other theories of service connection have been rendered moot, leaving no question of law or fact to decide. See 38 U.S.C. §7104 (2012). Disability Rating Laws and Regulations Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. Where there is a question as to which of two disability ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25 (2017). Pyramiding, the rating of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran's service-connected disabilities. 38 C.F.R. § 4.14 (2017). It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). When a claimant is awarded service connection and assigned an initial disability rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found. Such separate disability ratings are known as staged ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999) (noting that staged ratings are assigned at the time an initial disability rating is assigned). In this case, the RO has already assigned staged ratings for the left shoulder disability and depression as discussed below. When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. Nor will ratings assigned to organic diseases and injuries be assigned by analogy to conditions of functional origin. 38 C.F.R. § 4.20. Initial Rating for the Left Shoulder Disability The Veteran is in receipt of an initial disability rating of 10 percent for the service-connected left (minor) shoulder disability from February 13, 2008 to July 15, 2009, 20 percent from July 15, 2009 to August 31, 2011, 30 percent from August 31, 2011 to February 23, 2012, 20 percent from February 23, 2012 to April 9, 2014, and 30 percent from April 9, 2014 under Diagnostic Code (DC) 5010-5201. 38 C.F.R. § 4.71a (2017). Hyphenated Diagnostic Codes are used when a rating under one Code requires use of an additional Diagnostic Code to identify the basis for the rating assigned. 38 C.F.R. § 4.27 (2017). The additional Code, shown after the hyphen, represents the basis for the rating, while the primary Code indicates the underlying source of the disability. Diagnostic Code 5010 represents arthritis due to trauma, substantiated by X-ray findings, which in turn is to be rated under Diagnostic Code 5003 as degenerative arthritis (hypertrophic or osteoarthritis). 38 C.F.R. § 4.71a. Degenerative arthritis established by X-ray findings will be rated based on limitation of motion under the appropriate diagnostic code(s) for the specific joint(s) involved. When, however, the limitation of motion of the specific joint(s) involved is noncompensable under the appropriate diagnostic code(s), a 10 percent rating is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent rating is warranted if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and a 20 percent rating is authorized if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. Id., Diagnostic Code 5003. Notes (1) and (2) under Diagnostic Code 5003 provides the following: Note (1) provides that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion. Note (2) provides that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be utilized in rating conditions listed under Diagnostic Codes 5013 to 5024, inclusive. Id., Diagnostic Code 5003, Notes (1) and (2). In this case, the Veteran's left shoulder disability affects the non-dominant (minor) upper extremity as the Veteran is right-handed. See October 2017 Board hearing transcript. Under Diagnostic Code 5201, limitation of motion of an arm at the shoulder level warrants a 20 percent rating whether it is the major or minor extremity. When motion is limited to midway between the side and shoulder level, a 30 percent rating is warranted for the major extremity and 20 percent for the minor extremity. When motion is limited to 25 degrees from the side, a 40 percent rating is warranted for the major extremity and 30 percent for the minor extremity. 38 C.F.R. § 4.71a. Normal ranges of shoulder flexion and abduction are from 0 to 180 degrees, and external and internal rotations are from 0 to 90 degrees. See 38 C.F.R. § 4.71, Plate I (2017). In determining whether a veteran has limitation of motion to shoulder level, it is necessary to consider forward flexion and abduction. See Mariano v. Principi, 17 Vet. App. 305, 314-316 (2003). When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995); Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Further, 38 C.F.R. § 4.45 provides that consideration also be given to decreased movement, weakened movement, excess fatigability, incoordination, and pain on movement, swelling, and deformity or atrophy of disuse. Painful motion is considered limited motion at the point that pain actually sets in. See VAOPGCPREC 9-98. With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. Muscle spasm will greatly assist the identification. Sciatic neuritis is not uncommonly caused by arthritis of the spine. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. After a review of all the evidence, lay and medical, the Board finds that the criteria for an initial 30 percent rating under DC 5201 for the left shoulder disability have been more nearly approximated for the entire initial rating period on appeal from February 13, 2008. 38 C.F.R. §§ 4.3, 4.7. VA treatment records from July 2007 and January 2009 show limited motion in the left shoulder with shortening across the left shoulder and a larger suprascapular muscle due to either muscle spasms or to the shoulder shortening. The Veteran underwent a VA examination in March 2009, during which the Veteran reported being unable to lift items with the left shoulder due to excruciating pain. The March 2009 VA examiner noted symptoms of weakness, stiffness, swelling, instability, giving way, locking, fatigability, lack of endurance, and flare-ups. Range of motion in the left shoulder was measured to 110 degrees forward flexion, 110 degrees abduction, 80 degrees external rotation, and 70 degrees internal rotation. The VA examiner assessed additional functional loss of the left shoulder with recurrent used due to painful motion, tenderness, and guarding of movement. The March 2009 VA examination report also shows additional findings of significant crepitus and muscular hypertrophy over the left trapezius, and remarks that the Veteran appeared to be moderately affected in his occupation and daily activities caused by to difficulty with left shoulder abduction and flexion due to pain. A subsequent July 2009 VA treatment record reflects the left shoulder had very limited abduction to 30 degrees and very limited internal and external rotation as well. A March 2010 VA treatment record shows findings of left shoulder muscle spasm, tenderness, and limited range of motion. An August 2011 VA treatment record reflects an examination of the left shoulder revealed complete atrophy of the left deltoid compared to the right. The August 2011 VA provider noted that range of motion in the left shoulder was "completely missing" as the Veteran was only able to achieve abduction to 23 degrees, forward flexion to 70 degrees, and extension to 40 degrees, with weakness in all fields of motion tested. Similarly, an April 2014 VA examination report reflects range of motion in the left shoulder was limited to 15 degrees forward flexion with pain beginning at 0 degrees and abduction to 10 degrees with pain beginning at 0 degrees. The April 2014 VA examiner assessed the functional impact of the left shoulder disability was very limited motion due to constant pain. A subsequent July 2017 VA treatment record also reflects range of motion in the left shoulder was limited to 20 degrees forward flexion and 20 degrees abduction. Based on the above, for the entire initial rating period from February 13, 2008 forward, the evidence shows that the left shoulder disability has been manifested by symptoms of painful motion that more nearly approximates limitation of motion of the arm to 25 degrees from the side. Resolving reasonable doubt in favor of the Veteran, for the entire initial rating period from February 13, 2008, the Board finds that an initial rating of 30 percent under Diagnostic Code 5201 have met. 38 C.F.R. §§ 4.3, 4.7. The Board further finds that, for the entire initial rating period from February 13, 2008, a higher initial rating in excess of 30 percent for the left shoulder disability under any of the other diagnostic codes pertaining to the shoulder is not warranted. Initially, with respect to Diagnostic Code 5201, the Veteran is only entitled to a single disability rating for the left arm for limited motion at the shoulder joint. In Yonek v. Shinseki, 722 F.3d 1355, 1358 (Fed. Cir. 2013), the Federal Circuit held that 38 C.F.R. § 4.71a, Diagnostic Code 5201 does not provide separate ratings for limitation of motion in the flexion and abduction planes for a single arm, but rather a single rating based on "limitation of motion of" the arm. As such, even though the Veteran has limitation of motion both in flexion and abduction in this case, only a single rating, based on the greatest type of limitation of motion, is warranted. Further, the Board's instant decision grants a higher 30 percent initial disability rating under DC 5201, which is the maximum rating available for left arm limitation of motion in a minor extremity. Finally, the evidence of record does not demonstrate that the left shoulder disability has manifested in ankylosis of the scapulohumeral articulation, fibrous union, nonunion, or loss of head of the humerus, or that the Veteran underwent a total shoulder joint replacement; thus, the Board finds that a higher initial rating in excess of 30 percent under Diagnostic Codes 5200, 5202, and 5051 is not warranted. See March 2009 VA examination report; February 2012 VA examination report; April 2014 VA examination report. Initial Rating for Depression For the initial rating period on appeal from February 13, 2008 to March 7, 2012, the service-connected depression has been assigned a 10 percent disability rating under Diagnostic Code 9434, and a 30 percent rating from March 7, 2012 forward. 38 C.F.R. § 4.130. In Golden v. Shulkin, No. 16-1208 (U.S. Vet. App. April 19. 2017), the Court recently held that, given that the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5) abandoned the Global Assessment of Functioning (GAF) scale and that VA has formally adopted the DSM-5, GAF scores are inapplicable to assign a psychiatric rating in cases where the DSM-5 applies when the appeal was certified after August 4, 2014. As the instant appeal was certified after August 4, 2014 (certified in October 2016), the Board will not rely on GAF scores in assigning the rating in this case. Pertinent in this case, the General Rating Formula for Mental Disorders provides that a 10 percent rating is assigned for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders. A 30 percent rating is assigned for 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 conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is provided when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is provided when there is evidence that the psychiatric disability more closely approximates occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating requires evidence of total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. The use of the term "such as" in the General Rating Formula for Mental Disorders in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). It is not required to find the presence of all, most, or even some, of the enumerated symptoms recited for particular ratings. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of the symptoms contemplated for each rating, in addition to permitting consideration of other symptoms particular to each veteran and disorder, and the effect of those symptoms on his/her social and work situation. Id. In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (2013), the Federal Circuit held that VA "intended the General Rating Formula to provide a regulatory framework for placing veterans on a disability spectrum based upon their objectively observable symptoms." The Federal Circuit stated that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." It was further noted that "§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." Initial Rating from February 13, 2008 to March 7, 2012 After a review of all the evidence, the Board finds that, for the initial rating period from February 13, 2008 to March 7, 2012, the service-connected depression has manifested in symptoms that more nearly approximate occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, due to symptoms such as depressed mood, anxiety, suspiciousness, chronic sleep impairment, and mild memory loss to warrant a higher rating of 30 percent for this period. A March 2008 VA treatment record reflects the Veteran reported symptoms of nightmares, avoidance, hyperarousal, decreased sleep, lack of interest, feelings of worthlessness, poor energy, and poor concentration, but denied any suicidal or homicidal ideation or plan. The VA provider noted the Veteran's thought process was logical and sequential and that he was cognitively oriented. A December 2009 private treatment record shows the Veteran appeared depressed and guarded but demonstrated normal speech that was informative and goal-directed. The Veteran's thought processes were logical and sequential and he was in good contact with reality and denied suicidal or homicidal ideation. Although the Veteran was noted to be alert and oriented with good concentration, his short-term memory was found to be very impaired. Similarly, an August 2010 private treatment record also notes findings of memory loss, in addition to symptoms such as intermittent inability to perform activities of daily living, difficulty adapting to stressful situations, deficiencies in work or school, disorientation to time or place, and that depression was affecting his ability to function independently and appropriately. The August 2010 private treatment record also reflects the Veteran denied suicidal ideation. The Board also finds that, for the initial rating period on appeal from February 13, 2008 to March 7, 2012, the lay and medical evidence of record does not demonstrate that the service-connected depression had manifested in occupational and social impairment with reduced reliability and productivity to warrant a 50 percent disability rating under Diagnostic Code 9434. The VA and private treatment records discussed above show that although the Veteran's concentration and memory had been impaired by depression, his thought process remained logical and sequential and judgement remained intact. Further, the Veteran underwent a VA examination in July 2010, the examination report for which reflects normal affect, attention, orientation, and thought process were intact and unremarkable, impulse control was good, and that the Veteran did not have panic attacks, suicidal or homicidal ideation, or any problems maintaining activities of daily living. Although the August 2010 private treatment record above shows findings such as deficiencies in work or school, disorientation to time or place, and that depression was affecting the Veteran's ability to function independently and appropriately, such findings are inconsistent with the findings contained in the July 2010 VA examination report from one month prior, and are also inconsistent with the findings in a subsequent May 2011 VA treatment record. The May 2011 VA treatment record shows the Veteran was noted to be neatly and appropriately dressed with good hygiene. The Veteran reported feelings of hopelessness regarding his financial circumstances and being bitter that he can no longer work due to his physical disabilities. The Veteran relayed the desire to find more work but that his physical disabilities prevented him from obtaining new employment. The Veteran reported low energy and poor memory but denied suicidal or homicidal ideation. Further, the Veteran also conveyed the desire to care for his grandchildren and concern for them, even though they do tend to cause him some stress. Based on the foregoing, the Board finds that for the initial rating period on appeal from February 13, 2008 to March 7, 2012, the evidence does not demonstrate that the Veteran's overall disability picture more nearly approximated symptoms required for a 50 percent disability rating under Diagnostic Code 9434 such as flattened affect, panic attacks more than once a week, difficulty in understanding complex commands, and impaired judgment or abstract thinking. For these reasons, the weight of the competent and probative lay and medical evidence of record is against a rating in excess of 30 percent for the service-connected depression for the period from February 13, 2008 to March 7, 2012. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Initial Rating from March 7, 2012 Forward For the initial rating period on appeal from March 7, 2012 forward, the Board finds that the service-connected depression has manifested in symptoms that more nearly approximate occupational and social impairment with reduced reliability and productivity due to symptoms such as flattened affect, impairment of short- and long-term memory, impaired judgment, disturbances of motivation and mood, difficulty establishing and maintaining effective work and social relationships to warrant a 50 percent rating for this period. The Veteran underwent another VA examination in March 2012, the report for which reflects the VA examiner's assessment that the service-connected depression resulted in occupation and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The March 2012 VA examination report shows positive findings for depressed mood, chronic sleep impairment, and some visual and auditory hallucinations. Further, the Veteran admitted to suicidal ideation, but denied suicidal plans or homicidal ideation. Subsequent private treatment records also show the Veteran admitting to suicidal ideation with symptoms of intermittent visual and auditory hallucinations. See August 2012 private treatment record; October 2017 private treatment record. For these reasons, and resolving reasonable doubt in favor of the Veteran, the Board finds that for the initial rating period from March 7, 2012, the criteria for a higher initial disability rating of 50 percent under Diagnostic Code 9434 have been met. 38 C.F.R. §§ 4.3, 4.7. The Board further finds that, for the initial rating period from March 7, 2012 forward, the lay and medical evidence of record does not demonstrate that the service-connected depression has manifested in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood to warrant a 70 percent disability rating under Diagnostic Code 9434. Although the Veteran started exhibiting symptoms of suicidal ideation starting from March 7, 2012 forward, the evidence does not show that the service-connected depression had manifested in obsessive 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. See April 2014 VA examination report. Instead, the evidence of record demonstrates that although the Veteran experienced a worsening of depression symptoms, he remained alert and oriented, appropriate in appearance and behavior, and his thought process remained logical and sequential. See April 2014 VA examination report; October 2017 VA treatment record; October 2017 private treatment record. Based on the foregoing, the Board finds that for the initial rating period on appeal from March 7, 2012, the evidence does not demonstrate that the Veteran's overall disability picture more nearly approximated symptoms required for a 70 percent disability rating under Diagnostic Code 9434, and that the weight of the competent and probative lay and medical evidence of record is against a rating in excess of 50 percent for the service-connected depression for the period from March 7, 2012 forward. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Extraschedular Referral Consideration The Board has considered whether referral for extraschedular consideration is warranted for the service-connected left shoulder disability and the service-connected depression. Ratings shall be based as far as practicable upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular ratings are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extraschedular rating commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2017). The Court has clarified that there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. Thun v. Peake, 22 Vet. App. 111, 115 (2008). Initially, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability are inadequate. See Yancy v. McDonald, 27 Vet. App. 484 (2016); Doucette v. Shulkin, 28 Vet. App. 366 (2017) (holding that either the veteran must assert that a schedular rating is inadequate or the evidence must present exceptional or unusual circumstances); Sowers v. McDonald, 27 Vet. App. 472, 478 (2016) ("[t]he rating schedule must be deemed inadequate before extraschedular consideration is warranted"). Second, if the schedular rating does not contemplate the veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the veteran's disability picture exhibits other related factors such as marked interference with employment and frequent periods of hospitalization. Thun, 22 Vet. App. at 116. Third, if the first two Thun elements have been satisfied, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. Thun at 116. In other words, the first element of Thun compares a veteran's symptoms to the rating criteria, while the second element considers the resulting effects of those symptoms; if either prong is not met, then referral for extraschedular consideration is not appropriate. Yancy, 27 Vet. App. at 494-95. Turning to the first step of the Thun extraschedular analysis, the Board finds that all the symptomatology and impairment caused by the Veteran's left shoulder disability are specifically contemplated by the schedular rating criteria, such that no referral for extraschedular consideration is required. The Board finds that the schedular rating criteria contemplate the Veteran's left shoulder disability and the symptoms associated with such disability including pain, weakness, limitation of motion, excess fatigability, and functional impairment causing difficulty carrying or lifting items with the left upper extremity. The schedular rating criteria pertaining to the Veteran's left shoulder disability provide for ratings based on limitation of motion, including due to pain and other orthopedic DeLuca and 38 C.F.R. §§ 4.40, 4.45, 4.59 factors such as weakness, incoordination, and fatigability. See Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991) (read together with schedular rating criteria, 38 C.F.R. §§ 4.40 and 4.45 recognize functional loss due to pain); Deluca v. Brown, 8 Vet. App. 202, 206-07 (1995) (functional limitations are applied to the schedular rating criteria to ascertain whether a higher schedular rating can be assigned based on limitation of motion due to pain and during flare-ups, and should be expressed in schedular rating terms of degree of range-of-motion loss); Burton v. Shinseki, 25 Vet. App. 1, 4 (2011) (the majority of 38 C.F.R. § 4.59, which is a schedular consideration rather than an extraschedular consideration, provides guidance for noting, evaluating, and rating joint pain); Sowers v. McDonald, 27 Vet. App. 472 (2016) (38 C.F.R. § 4.59 is limited by the diagnostic code applicable to the claimant's disability, and is read in conjunction with, and subject to, the relevant diagnostic code); Mitchell v. Shinseki, 25 Vet. App. 32, 33-36 (2011) (pain alone does not constitute functional impairment under VA regulations, and the rating schedule contains several provisions, such as 38 C.F.R. §§ 4.40, 4.45, 4.59, that address functional loss in the musculoskeletal system as a result of pain and other orthopedic factors when applied to schedular rating criteria); see also Mitchell, 25 Vet. App. at 45 (Footnote 2) and Vogan v. Shinseki, 24 Vet. App. 159, 161 (2010) (when a condition is not listed in the VA disability schedule, VA may undertake rating by analogy where the disability in question is analogous in terms of the functions affected, the anatomical localization, and the symptomatology of the ailments). With respect to the service-connected depression, the evidence in this instant appeal does not establish such an exceptional disability picture as to render the schedular rating inadequate. A comparison between the level of severity and symptomatology of the service-connected depression with the established criteria found in 38 C.F.R. § 4.130, Diagnostic Code 9434, reflects that the diagnostic criteria reasonably describe all the Veteran's disability level and degree of symptomatology. The diagnostic criteria convey that compensable ratings will be assigned for service-connected psychiatric disorders that manifest by various levels of occupational and social impairment. The Veteran's disability picture has been shown to encompass occupational and social impairment symptoms that fall within the diagnostic criteria for a 30 percent rating from February 12, 2008 to March 7, 2012, and for a 50 percent rating from March 7, 2012 forward. For the period from February 12, 2008 to March 7, 2012, the service-connected depression was productive of no more than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to symptoms including depressed mood, nightmares, and mild memory loss. Similarly, for the period from March 7, 2012 forward, the service-connected depression was productive of no more than occupational and social impairment with reduced reliability and productivity due to symptoms such as impairment of short- and long-term memory, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. All the impairment and symptoms are either explicitly part of the schedular rating criteria or are "like or similar to" examples or symptoms in the schedular rating criteria. Mauerhan, 16 Vet. App. at 443. For these reasons, the service-connected depression has not been shown to be productive of an exceptional disability picture; therefore, the Board determines that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. § 3.21(b)(1) is not required. Comparing the Veteran's disability level and symptomatology of the left shoulder disability and depression to the rating schedule, the degree of disability throughout the entire period under consideration is contemplated by the rating schedule and the assigned ratings are, therefore, adequate. There are no additional expressly or reasonably raised issues presented on the record. Absent any exceptional factors associated with the left shoulder disability and depression, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). TDIU Prior to March 14, 2017 Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. 38 U.S.C. § 1155. 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). A 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. The service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue will be addressed in both instances. 38 C.F.R. § 4.16(a), (b). 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). 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). If a veteran's disabilities do not meet the objective combined rating percentage criteria of 38 C.F.R. § 4.16(a), it then becomes necessary to consider whether the criteria for referral for extraschedular consideration are met under § 4.16(b) criteria. It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. Submission to the Director, Compensation and Pension Service, for extraschedular consideration is warranted in all cases of veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in § 4.16(a). 38 C.F.R. § 4.16(b). See Wages v. McDonald, 27 Vet. App. 233 (2015) (holding that a decision of TDIU under 38 C.F.R. § 4.16(b) by the Director of C&P is not evidence, and is not a policy decision, but is simply a decision or adjudication that is adopted by the RO and reviewed de novo by the Board). Cf. Kuppamala v. McDonald, 27 Vet. App. 447 (2015) (applying principles announced in Wages to 38 C.F.R. § 3.321(b) extraschedular adjudication, namely, Director of C&P decision is not evidence, and is not a policy decision, but is simply a decision or adjudication that is adopted by the RO and reviewed de novo by the Board). Individual unemployability must be determined without regard to any non-service-connected disabilities or a veteran's advancing age. 38 C.F.R. §§ 3.341(a), 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). The sole fact that a veteran is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether a veteran is capable of performing the physical and mental acts required by employment, not whether a veteran can find employment. Id. at 361. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in a veteran's favor. 38 C.F.R. § 4.3. In Faust v. West, 13 Vet. App. 342 (2000), the Court defined "substantially gainful employment" as an occupation that provides an annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days that a veteran actually works and without regard to a veteran's earned annual income. In Hatlestad v. Derwinski, 5 Vet. App. 524, 529 (1993), the Court held that the central inquiry in determining whether a veteran is entitled to a TDIU is whether a veteran's service-connected disabilities alone are of sufficient severity to produce unemployability. The determination as to whether a total disability is appropriate should not be based solely upon demonstrated difficulty in obtaining employment in one particular field, which could also potentially be due to external bases such as economic factors, but rather to all reasonably available sources of employment under the circumstances. See Ferraro v. Derwinski, 1 Vet. App. 326, 331-332 (1991). In evaluating a veteran's employability, consideration may be given to the level of education, special training, and previous work experience in arriving at a conclusion, but not to age or impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. Marginal employment is not considered substantially gainful employment and generally is deemed to exist when a veteran's earned income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Marginal employment may also be held to exist in certain cases when earned annual income exceeds the poverty threshold on a facts-found basis. Consideration shall be given in all claims to the nature of the employment and the reason for termination. 38 C.F.R. § 4.16(a). Marginal employment, odd-job employment, and employment at half the usual remuneration is not incompatible with a determination of unemployability if the restriction to securing or retaining better employment is due to disability. 38 C.F.R. § 4.17(a) (2017). The ultimate issue of whether a TDIU should be awarded is not a medical issue, but rather is a determination for the adjudicator. See Moore v. Nicholson, 21 Vet. App. 211, 218 (2007) (ultimate question of whether a veteran is capable of substantial gainful employment is not a medical one; that determination is for the adjudicator), rev'd on other grounds sub nom, Moore v. Shinseki, 555 F.3d 1369 (Fed. Cir. 2009). Although VA must give full consideration, per 38 C.F.R. § 4.15, to "the effect of combinations of disability," VA regulations place responsibility for the ultimate TDIU determination on VA, not a medical examiner's opinion. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013); 38 C.F.R. § 4.16(a); see also Smith v. Shinseki, 647 F.3d 1380, 1385-86 (Fed. Cir. 2011) (VA is not required to obtain an industrial survey from a vocational expert before making a TDIU determination but may choose to do so in an appropriate case). A June 2010 Application for Increased Compensation Based on Unemployability (TDIU claim) reflects the Veteran has not worked full time since June 1, 2009 due to the service-connected left shoulder disability. At the time the Veteran last worked on June 1, 2009, the combined ratings for the service-connected disabilities have met the schedular disability rating eligibility criteria for a TDIU under 38 C.F.R. § 4.16(a) by virtue of the Board's instant decision above. Prior to the Board's instant decision, the Veteran's service-connected disabilities did not meet the schedular disability rating eligibility criteria at the time the Veteran last worked in June 2009; regardless, in May 2016, the Acting Director of Compensation and Pension Service adjudicated and denied a TDIU under 38 C.F.R. § 4.16(b). Because the appeal for a TDIU under § 4.16(b) has already been reviewed and denied by the Acting Director of Compensation and Pension Service, the Board may consider, de novo, whether a TDIU is warranted under the provisions of 38 C.F.R. § 4.16(b), which provides that a veteran who is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. See Wages v. McDonald, 27 Vet. App. 233 (2015) (holding that a decision of TDIU under 38 C.F.R. § 4.16(b) by the Director of Compensation and Pension Service is not evidence, and is not a policy decision, but is simply a decision or adjudication that is adopted by the RO and reviewed de novo by the Board); Kuppamala v. McDonald, 27 Vet. App. 447 (2015) (the Board reviews the Director of Compensation and Pension Service's extraschedular decision de novo, and may assign an extraschedular rating when appropriate). After a review of all the evidence, lay and medical, the Board finds that the evidence is at lease in relative equipoise on the question of whether the service-connected disabilities prevented the Veteran from maintaining substantially gainful employment to warrant a TDIU for the period from June 1, 2009 to March 14, 2017. The June 2010 TDIU claim shows the Veteran had worked in a packing factory since July 1981 until June 2009, and that he had submitted numerous job applications to all different types of employment without success. During the October 2017 Board hearing, the Veteran testified that he worked at the packing factory for over 25 years until the factory closed in 2009. The Veteran testified that, prior to the factory closing, he had difficulty performing his job duties that involved lifting items due to the service-connected left shoulder disability. The Veteran further testified that the service-connected left shoulder disability and the service-connected depression have prevented obtaining substantially gainful employment. As discussed above, the March 2009 VA examination report reflects the VA examiner's assessment that the left shoulder disability had moderately affected the Veteran's usual occupation and daily activities as he had difficulty with left shoulder abduction and flexion due to pain. The February 2012 VA examination report reflects the functional impact of the left shoulder disability was that the Veteran was no longer able to lift items due to shoulder pain and limited motion. The April 2014 VA examination report contains the VA examiner's opinion that it is at least as likely as not that the Veteran is severely handicapped in performing any type of gainful employment due to the restrictions imposed by the limited range of motion and pain in the left shoulder. Moreover, the VA and private treatment records discussed above in regards to the service-connected depression demonstrate the Veteran began experiencing symptoms of memory impairment in December 2009, and that symptoms of depression now include suicidal ideation and occasional auditory and visual hallucinations. Based on the above, the Board finds that the evidence is at least in equipoise as to whether the service-connected disabilities preclude the type of employment for which the Veteran is trained and has experience. The ultimate issue of whether a TDIU should be awarded is not a medical issue, but rather is a determination for the adjudicator. See Geib, 733 F.3d at 1354; Moore, 21 Vet. App. at 218, rev'd on other grounds sub nom, Moore, 555 F.3d 1369; see also 38 C.F.R. § 4.16. The test is not whether the Veteran would have been precluded from all types of employment, such as sedentary employment, but whether such employment was realistically within the physical and mental capabilities of the claimant. For these reasons, and resolving all reasonable doubt in the Veteran's favor, the Board finds that the service-connected disabilities rendered the Veteran unemployable for the period from June 1, 2009 to March 17, 2017. 38 C.F.R. §§ 3.340, 3.341, 4.15, and 4.16. ORDER The appeal for service connection for arthritis is dismissed. The appeal for service connection for macular degeneration is dismissed. The appeal for service connection for diabetes mellitus type II is dismissed. The appeal for service connection for lower lumbar ruptured disc is dismissed. The appeal for service connection for an enlarged heart is dismissed. The appeal for service connection for sleep apnea is dismissed. The appeal for a higher initial rating for a left shoulder scar is dismissed. February 13, 2008, a higher initial rating of 30 percent, but no higher, for the left shoulder disability is granted. For the initial rating period from February 13, 2008 to to August 31, 2011, and from from February 23, 2012 to April 9, 2014, a 30 percent rating for left shoulder disability is granted; a disability rating in excess of 30 percent for any period is denied. For the initial rating period from February 13, 2008 to March 7, 2012, a higher initial rating of 30 percent, but no higher, for depression is granted; for the initial rating period from March 7, 2012 forward, a higher initial rating of 50 percent, but no higher, is granted. A TDIU for the period from June 1, 2009 to March 14, 2017 is granted. ____________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs