Citation Nr: 19192383 Decision Date: 12/10/19 Archive Date: 12/09/19 DOCKET NO. 16-26 023 DATE: December 10, 2019 ORDER Entitlement to service connection for hepatitis C is granted. Entitlement to service connection for diabetes mellitus, type II is denied. Entitlement to service connection for a cervical spine disorder, to include as secondary to service-connected degenerative disc disease of the lumbar spine is denied. Entitlement to service connection for the cause of the Veteran's death is granted. Entitlement to an increased rating greater than 20 percent for degenerative disc disease of the lumbar spine is denied. Entitlement to a total disability rating for compensation based upon unemployability due to service-connected disabilities (TDIU) is granted. FINDINGS OF FACT 1. The weight of the probative evidence of record shows that the Veteran’s hepatitis C was aggravated by his service-connected degenerative disc disease of the lumbar spine. 2. Diabetes mellitus, type II, was first demonstrated years after service, and is not etiologically related to any incident of active military service. 3. Degenerative disc disease of the cervical spine was first demonstrated many years after service, is not etiologically related to any incident of active military service, and is not caused or aggravated by a service-connected disability. 4. A May 2015 certificate of death shows that the Veteran died on March [REDACTED], 2015. The certificate of death lists the immediate cause of death as malignant neoplasm of the liver. 5. The weight of the probative medical evidence shows that hepatitis C caused cirrhosis of the liver, which resulted in hepatocellular carcinoma. 6. As of the time of his death, service connection has been established for hepatitis C. 7. The Veteran’s degenerative disc disease of the lumbar spine manifested orthopedic impairment with pain and limitation of motion most nearly approximating forward flexion to 45 degrees or better and a combined range of motion of 170 degrees or better without ankylosis or incapacitating episodes requiring bed rest prescribed by a physician having a total duration of at least four weeks. 8. The Veteran’s service-connected disabilities precluded him from securing or following substantially gainful employment for which his education and occupational experience otherwise qualified him. CONCLUSIONS OF LAW 1. Hepatitis C was aggravated by a service-connected disability. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. 2. Diabetes mellitus, type II, was not incurred in or aggravated by active service. 38 U.S.C. § 1110, 1131, 5107; 38 C.F.R. § 3.303. 3. Degenerative disc disease of the cervical spine was not incurred in or aggravated by active service, is not proximately due to or the result of a service-connected disability, nor may its incurrence or aggravation be presumed. 38 U.S.C. §§ 1110, 1112, 1131; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 4. The criteria for entitlement to service connection for the cause of the Veteran’s death have been met. 38 U.S.C. §§ 1110, 1131, 1310, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.312. 5. The criteria for entitlement to an increased rating greater than 20 percent for degenerative disc disease of the lumbar spine are not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.14, 4.45, 4.71a, Diagnostic Codes 5003-5243. 6. The criteria for an award of a TDIU are met. 38 U.S.C. §§ 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from July 1981 to July 1984. The Veteran passed away in May 2015, and the appellant is his surviving spouse. The appellant’s request for substitution of the Veteran’s pending claims was granted by the RO in May 2018. In its January 2019 Remand, the Board requested that the RO provide the Veteran with a new VA lumbar spine examination in order to comply with Correia v. McDonald, 28 Vet. App. 158 (2016). However, as the Veteran passed away in March 2015, a new VA examination could not be provided. Accordingly, the Board finds that the RO substantially complied with its prior Remand directives. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where there was substantial compliance with Board’s remand instructions). The Board has considered the appellant’s claims and decided entitlement based on the evidence or record. Neither the appellant nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record, with respect to the claims. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Service Connection Service connection may be established for a disability resulting from disease or injury which was clearly present in service or for a disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection may be established on a secondary basis for a disability which is shown to be proximately due to, the result of, or chronically aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc) (additional disability resulting from aggravation of a nonservice-connected disorder by a service-connected disorder is also compensable under 38 C.F.R. § 3.310). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). 1. Entitlement to service connection for hepatitis C After thorough consideration of the evidence of record, the Board concludes that service connection for hepatitis C is warranted. The medical evidence of record prior to the Veteran’s death reflects diagnosis of and treatment for hepatitis C. Degmetich v. Brown, 104 F.3d 1328, 1333 (Fed. Cir. 1997) (holding that the existence of a current disability is the cornerstone of a claim for VA disability compensation). In addition, the weight of the medical evidence of record reflects that the Veteran’s hepatitis C was aggravated by his service-connected degenerative disc disease of the lumbar spine. 38 U.S.C. § 1113(b); 38 C.F.R. §§ 3.303; see Allen, 7 Vet. App. 439 (holding that secondary service connection requires that evidence is sufficient to show that the current disability was either caused or aggravated by a service-connected disability). In a March 2015 medical opinion, H.S., M.D., opined that the medications used to treat the Veteran’s service-connected degenerative disc disease of the lumbar spine aggravated his hepatitis C. Dr. H.S. noted that the medications prescribed over the prior 30 years, including Tylenol #3 and regular Tylenol, were “hepatoxic” and damaged the Veteran’s liver. Dr. H.S. further explained that the Veteran’s use of the hepatoxic medications was very frequent and that, when combined with hepatitis, the medications “aggravated his liver problem which was already compromised due to the hepatitis.” While a July 2015 VA examiner opined that the Veteran’s hepatitis C did not have its onset during active duty service, the examiner did not provide any opinion as to whether the Veteran’s hepatitis C was caused or aggravated by his service-connected degenerative disc disease of the lumbar spine. Also, although a March 2019 VA examiner concluded that the Veteran’s hepatitis C was not caused or aggravated by a service-connected disability, the examiner’s only rationale was that he was “unaware of any evidence based medical literature” or “supporting evidence in the medical records” to support the conclusion that the Veteran’s hepatitis C was “related to or aggravated by any of the Veteran’s service-connected disabilities.” The law is clear. Pursuant to the “benefit-of-the-doubt” rule, where there is “an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter,” the Veteran shall prevail upon the issue. 38 U.S.C. § 5107(b). Although there is evidence against the claim insofar as the July 2015 VA examiner concluded that the Veteran’s hepatitis C was not directly related to service, because the examiner did not consider the implication of any service-connected disability such as degenerative disc disease of the lumbar spine in determining the etiology of the Veteran’s hepatitis C, the Board finds that evidence ultimately is of limited probative value. Similarly, the Board affords the March 2019 VA opinion very little probative weight, as the rationale provided by the examiner was conclusory and did not address the evidence in favor of the Veteran’s claim, particularly the March 2015 opinion from Dr. H.S. Moreover, the March 2019 VA examiner failed to consider the effects of the medications used to treat the Veteran’s service-connected lumbar spine disorder on the Veteran’s hepatitis C. Upon weighing the evidence of record, the Board finds that the evidence is at least in equipoise as to whether the Veteran’s hepatitis C was caused or aggravated by his service-connected degenerative disc disease of the lumbar spine. The Board therefore concludes that, with the benefit of the doubt resolved in the appellant’s favor, a grant of service connection for hepatitis C is warranted. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990) (“[T]he ‘benefit of the doubt’ standard is similar to the rule deeply embedded in sandlot baseball folklore that ‘the tie goes to the runner’.... [I]f... the play is close, i.e., ‘there is an approximate balance of positive and negative evidence,’ the veteran prevails by operation of [statute].”). 2. Entitlement to service connection for diabetes mellitus, type II The appellant contends that service connection is warranted for diabetes mellitus, type II. The record establishes current diagnoses of diabetes mellitus, type II. VA treatment records dated as early as February 2011 document diagnoses of and treatment for diabetes, although the Veteran reported that he was initially diagnosed with diabetes in 2004. The record therefore clearly establishes the presence of diabetes mellitus, type II. However, the Veteran’s service treatment records are negative for any findings of elevated blood sugar or diabetes, and his separation examination reflects that there was no sugar or albumin in his urine at that time. Further, the medical evidence does not show the existence of diabetes mellitus until at least 2004. Additionally, a March 2019 VA examiner opined that it was less likely than not that the Veteran’s diabetes was caused by or incurred during his active duty service. The examiner explained that the Veteran’s service treatment records were negative for any evidence of diabetes, and there was no evidence of diabetes within one year of discharge from service. There is no probative evidence attributing the Veteran’s diabetes to any incident of service, and there is no probative evidence in support of a claim for service connection. The Board is grateful for the Veteran’s honorable service. However, given the record before it, the Board finds that the evidence in this case does not reach the level of equipoise. See 38 U.S.C. § 5107(a) (“[A] claimant has the responsibility to present and support a claim for benefits....”); Fagan v. Shinseki, 573 F.3d 1282, 1286 (Fed. Cir. 2009) (stating that the claimant has the burden to “present and support a claim for benefits” and noting that the benefit of the doubt standard in section 5107(b) is not applicable based on pure speculation or remote possibility); Skoczen v. Shinseki, 564 F.3d 1319, 1323-29 (Fed. Cir. 2009) (interpreting section 5107(a) to obligate a claimant to provide an evidentiary basis for his or her benefits claim, consistent with VA’s duty to assist, and recognizing that “[w]hether submitted by the claimant or VA... the evidence must rise to the requisite level set forth in section 5107(b),” requiring an approximate balance of positive and negative evidence regarding any issue material to the determination). As the probative evidence of record does not relate the Veteran’s diabetes mellitus, type II, to service, entitlement to service connection is not warranted. 3. Entitlement to service connection for a cervical spine disorder, to include as secondary to service-connected degenerative disc disease of the lumbar spine The record establishes a current diagnosis of degenerative disc disease of the cervical spine. VA treatment records as early as February 2011 document radiographic findings of mild to moderate degenerative spondylosis of the cervical spine. A current disability of degenerative arthritis of the cervical spine is therefore demonstrated. However, the weight of the probative evidence of record does not show that the Veteran’s cervical spine arthritis was caused or aggravated by his service-connected degenerative arthritis of the lumbar spine. The Veteran underwent a VA examination in October 2013. At that time, he reported that his lumbar spine pain “traveled up to the cervical spine area.” After reviewing the claims file and performing a physical examination, the examiner opined that the Veteran’s cervical spine disorder was not caused or aggravated by his service-connected lumbar spine disorder. The examiner explained that there was insufficient medical evidence in the claims file to support a relationship between the two disabilities. Additionally, a March 2019 VA examiner opined that it was less likely than not that the Veteran’s neck disorder was caused or aggravated by his service-connected lumbar spine disorder. The examiner explained that the Veteran’s lumbar spine arthritis would not predispose him to the development of arthritis in the cervical spine. The examiner noted that the medical literature did not support such a conclusion. The Board finds the October 2013 and March 2019 VA examinations to be probative, as they were based upon consideration of the pertinent evidence in the claims file and provide supporting rationale for their conclusions. Although a September 2010 private medical record notes that the Veteran experienced neck pain which “radiates down both arms and may be due to arthritis,” the opinion is speculative and does not provide a conclusive opinion with supporting rationale. Medical opinions that are speculative, general, or inconclusive in nature cannot support a claim. See Morris v. West, 13 Vet. App. 94, 97 (1999) (diagnosis that appellant was “possibly” suffering from schizophrenia deemed speculative); Hogan v. Peake, 544 F.3d 1295, 1298 (Fed. Cir. 2008) (the Board may discount the value of competent medical evidence based on factors including the lack of a definitive statement as to etiology); Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (the Board has authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (stating that a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two). Accordingly, the September 2010 private opinion is not afforded significant probative value. Ultimately, the weight of the probative evidence of record does not show that the Veteran’s cervical spine disorder was caused or aggravated by his service-connected lumbar spine disability. The Board has also considered whether service connection is warranted for degenerative disc disease of the cervical spine on a direct basis. However, the record does not establish in-service incurrence. Service treatment records are negative for any complaints of or treatment for neck pain. Additionally, an April 1984 separation examination reports that the Veteran’s spine was normal. In a report of medical history, completed at that time, the Veteran denied a history of recurrent back pain. Further, a March 2019 VA examiner opined that the Veteran’s cervical spine disorder was not caused by or incurred during his active duty service. The examiner noted that the service treatment records did not reflect complaints of neck pain during service or within one year of service, and that there was no other evidence in the medical records supporting a relationship between the Veteran’s neck disorder and his active duty service. The Veteran did not provide any lay statements suggesting that he experienced neck pain during service or continuously since service discharge. In fact, he did not provide any statements whatsoever linking his neck disorder to active duty service. Additionally, there is no competent and credible evidence linking the Veteran’s cervical spine disorder to any incident of service or to a service-connected disability. Therefore, in-service incurrence of arthritis of the cervical spine is not established and the claim for service connection is denied. 38 U.S.C. § 5107(b). Service connection is possible for arthritis on a presumptive basis as a chronic disease under 38 C.F.R. §§ 3.307 and 3.309, but the condition must manifest to a compensable degree within one year of separation. The absence of any clinical evidence for many years after service weighs the evidence against a finding that the Veteran’s cervical spine arthritis was present in service or the year immediately after. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). The Veteran also did not contend that his cervical spine arthritis was present in service or in the year immediately after his discharge. Therefore, service connection on a presumptive basis is not warranted for degenerative disc disease of the cervical spine. Finally, service connection is possible for arthritis under 38 C.F.R. § 3.303(b) based on a continuity of symptomatology. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). However, as noted above, the Veteran did not report experiencing continuous symptoms of neck pain since service. In light of the evidence described above, the Board concludes that the preponderance of the evidence is against the claim for entitlement to service connection for a cervical spine disorder. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application, and the claim must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Entitlement to service connection for the cause of the Veteran’s death The Veteran died on May 16, 2015. The death certificate lists the immediate cause of death as malignant neoplasm of the liver. The death of a veteran is considered due to a service-connected disability where the evidence establishes that such disability was either the principal or contributory cause of death. 38 C.F.R. § 3.312(a). A principal cause of death is one which, singularly or jointly with some other condition, was the immediate or underlying cause of death, or was etiologically related thereto. 38 C.F.R. § 3.312(b). A contributory cause of death is one which contributes substantially or materially to death, or aided or lent assistance to the production of death. 38 C.F.R. § 3.312(c). After review evidence of record, the Board resolves reasonable doubt in favor of the appellant and finds that service connection is warranted for the cause of the Veteran’s death. The evidence establishes that the immediate cause of death was malignant neoplasm of the liver. In a March 2019 VA opinion, the VA examiner explained that hepatocellular carcinoma “develops exclusively in a cirrhotic liver” and that the Veteran’s hepatitis C “remained quiescent for many years and progressed to cirrhosis.” Although the March 2019 VA examiner ultimately concluded that the cause of the Veteran’s death was not related to a service-connected disability, the examiner only considered the service-connected disabilities of degenerative disc disease of the lumbar spine, sciatica, erectile dysfunction, and depression. As discussed above, the Board grants service connection for hepatitis C herein. As the March 2019 VA examiner’s opinion clearly links the Veteran’s hepatitis C to the development of cirrhosis of the liver and then to the malignant neoplasm of the liver which resulted in his death, entitlement to service connection for the cause of the Veteran’s death is warranted. Increased Rating Disability ratings are determined by the application of the VA’s Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). Where the Rating Schedule does not provide for a noncompensable evaluation for a diagnostic code, a noncompensable evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. The primary concern in a claim for an increased evaluation for service-connected disability is the present level of disability. Although the overall history of the disability is to be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). VA has a duty to consider the possibility of assigning staged ratings in all claims for increase. See Hart v. Mansfield, 21 Vet. App. 505 (2007). 5. Entitlement to an increased rating greater than 20 percent for degenerative disc disease of the lumbar spine Service connection for degenerative disc disease of the lumbar spine was granted in a December 2010 rating decision, and a 20 percent disability rating was assigned, effective June 18, 2010, under 38 C.F.R. § 4.71a, Diagnostic Codes 5003-5243. In an October 2012 rating decision, the RO denied an increased rating greater than 20 percent for degenerative disc disease of the lumbar spine. The appellant contends that an increased rating greater than 20 percent is warranted for the Veteran’s lumbar spine disability. Numerous lay statements submitted in support of the claim document the Veteran’s symptoms including poor mobility, inability to stand or walk for more than 10 minutes, inability to lay down flat, poor sleep, inability to lift or carry more than 10 pounds, difficulty putting on shoes and socks, and inability to mow the lawn and participate in household chores. The Veteran’s service-connected low back disability is rated under the general rating formula for diseases and injuries of the spine under Diagnostic Code 5003-5243 for degenerative arthritis and intervertebral disc syndrome. 38 C.F.R. § 4.71a, Diagnostic Codes 5003-5242. Intervertebral disc syndrome is evaluated under the general formula for diseases and injuries of the spine or under the formula for rating intervertebral disc syndrome based on incapacitating episodes in Diagnostic Code 5243, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a, Diagnostic Code 5243. Under the general rating formula, a 20 percent evaluation is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees, but not greater than 60 degrees; the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or if there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation is warranted if forward flexion of the thoracolumbar spine is to 30 degrees or less or if there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is warranted if there is unfavorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. The Board finds that the current 20 percent evaluation is the appropriate rating for orthopedic impairment associated with the service-connected low back disability throughout the applicable claims period. With respect to limitation of motion of the spine, the Board finds that a rating in excess of 20 percent is not warranted. The Veteran’s ability to move his thoracolumbar spine was most restricted at a March 2013 VA examination. At that time, forward flexion was measured to 45 degrees with a combined range of motion of 170 degrees. These findings are contemplated by the current 20 percent evaluation. The Veteran experienced pain during motion testing, but there was no additional loss of motion upon repetitive testing. At no time during the claims period did the Veteran demonstrate forward flexion limited to 30 degrees or ankylosis of the spine as required for an increased 40 percent evaluation under the general rating formula. Rather, the Veteran’s flexion and combined range of motion was similar or better at examinations conducted throughout the claims period, to include the April 2012 VA examination. The Veteran also had no additional loss of motion after repetitive testing at the April 2012 VA examination. The medical evidence therefore establishes that the Veteran has manifested symptoms and impairment that most nearly approximate the current 20 percent rating. The Board has also considered the lay statements that the Veteran experienced symptoms and flare-ups that limited his ability to function. However, as noted above, the objective evidence, including the results of repetitive motion testing, does not indicate a loss of motion consistent with a higher evaluation under the general rating formula. The Board concludes that the Veteran’s reported impairments were contemplated by the current 20 percent evaluation assigned to the back. Thus, even with consideration of all relevant functional factors, the Board finds that a rating more than 20 percent for orthopedic impairment of the lumbar spine is not warranted at any time during the claims period. The Board must now determine whether an increased rating is appropriate under the criteria pertaining to intervertebral disc syndrome. 38 C.F.R. § 4.71a, Diagnostic Code 5243, provides for a 40 percent evaluation with incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past twelve months. A maximum 60 percent evaluation is warranted for incapacitating episodes having a total duration of at least six weeks during the past twelve months. An “incapacitating episode” is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bedrest prescribed by a physician and treatment by a physician. Associated objective neurological abnormalities (e.g., bladder and bowel impairment) are to be evaluated separately. The evidence does not show that the Veteran experienced incapacitating episodes requiring bedrest prescribed by a physician having a total duration of at least four weeks during the claims period. None of the VA examiners found that the Veteran experienced incapacitating episodes and none of the Veteran’s treating physicians prescribed bedrest in response to exacerbations of back pain. The Board finds that the low back disability did not manifest incapacitating episodes having a total duration of at least four weeks. Therefore, an increased rating is also not warranted under the criteria pertaining to intervertebral disc syndrome. In sum, the Veteran’s orthopedic impairment of the service-connected lumbar spine disability is appropriately rated as 20 percent throughout the claims period. The Board acknowledges that the Veteran experienced impairment of the sciatic nerves in both lower extremities; however, the Veteran was in receipt of separate disability ratings for those symptoms, and the ratings for those disabilities are not issues currently before the Board. The Board has considered whether there is any other schedular basis for granting a higher rating for the orthopedic impairment resulting from the Veteran’s low back disability, but has found none. In addition, the Board has considered the doctrine of reasonable doubt but has determined that it is not applicable because the preponderance of the evidence is against the grant of a higher schedular rating. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.7, 4.21. 6. Entitlement to a total disability rating for compensation based upon unemployability due to service-connected disabilities (TDIU) The appellant contends that the Veteran was unemployable due to his service-connected disabilities. VA will grant a TDIU when the evidence shows that the Veteran is precluded by reason of service-connected disabilities from obtaining or maintaining “substantially gainful employment” consistent with his education and occupational experience. 38 C.F.R. § 4.16. The Veteran meets the schedular criteria for an award of TDIU, even without consideration of hepatitis C granted herein, as he was service-connected for depression, rated as 70 percent disabling; intervertebral disc syndrome (IVDS) involving the right sciatic nerve, rated as 20 percent disabling; IVDS involving the left sciatic nerve, rated as 20 percent disabling, and erectile dysfunction, rated as noncompensable. His total combined disability evaluation was 80 percent. 38 C.F.R. § 4.16(a) (providing that the schedular criteria are met if there are two or more service-connected disabilities with one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more); 38 C.F.R. § 4.25, Table I (Combined Ratings Table). The record establishes that the Veteran was unemployable due to his physical and psychiatric service-connected disabilities. The Veteran last worked full-time in August 2011 when he was employed as a janitor. Information received from the Veteran and his employer shows that he worked as a janitor since 2009 with no other applicable job training. He graduated high school, but did not attend college. He explained that he stopped working in August 2011 due to his constant lower back pain and sciatica as well as his “constant appointments at the hospital for [his] liver disease.” Additionally, the March 2013 VA examiner noted that the Veteran’s lumbar spine disability impacted his ability to work due to pain, stiffness, limited range of motion, and difficulty with heavy lifting, bending, prolonged sitting, standing, walking, and climbing stairs. Further, in July 2019, M.B., M.D., opined that the Veteran was unable to maintain substantially gainful employment due to the combined effects caused by his service-connected depression, IVDS involving the right and left sciatic nerves, degenerative disc disease of the lumbar spine, and the side effects caused by medications used to treat his service-connected disabilities. Although the Veteran stopped working in December 2013 due to a nonservice-connected elbow and hip injury, the record contains several medical opinions from private and VA physicians weighing in favor of the claim. In August 2015, July 2016, August 2016, and June 2017, the Veteran’s VA and private doctors concluded that he was unable to drive trucks or perform non-sedentary work due to physical and mental impairments, to include back pain, knee pain, concentration problems, and multiple medications. Based on the severity of the impairment associated with his service-connected disabilities and his limited education and work experience, the Board finds that the evidence weighs in favor of a finding that the Veteran’s service-connected disabilities rendered him unemployable. The Board therefore finds that the criteria for a TDIU are met and the claim is granted. ANTHONY C. SCIRÉ, JR Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Katz, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.