Citation Nr: 20030187 Decision Date: 04/29/20 Archive Date: 04/29/20 DOCKET NO. 14-23 679 DATE: April 29, 2020 ORDER Entitlement to an initial rating of 70 percent, but not greater, for major depressive disorder is granted, subject to the law and regulations governing the payment of monetary benefits. Entitlement to a rating in excess of 20 percent, prior to June 21, 2013, and from October 1, 2013 to September 19, 2018, for severe AC joint osteoarthritis of the right shoulder, is denied. Entitlement to a rating of 30 percent, as of December 1, 2018, for severe AC joint osteoarthritis of the right shoulder is granted, subject to the law and regulations governing the payment of monetary benefits. Entitlement to service connection for degenerative disc disease of the cervical spine is denied. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU), from April 30, 2013 to June 20, 2013, from October 1, 2013 to September 19, 2018, and as of December 1, 2018 is granted, subject to the law and regulations governing the payment of monetary benefits. FINDINGS OF FACT 1. For the entire period on appeal, the Veteran’s psychiatric symptoms have been manifested by occupational and social impairment with deficiencies in most areas, such as with work, school, family relations, judgment, thinking, or mood, but without total occupational and social impairment. 2. From October 30, 2012 to June 21, 2013, and from October 1, 2013 to September 19, 2018, the Veteran's right shoulder disability is characterized by limitation of the arm at shoulder level but not limitation of the arm midway between side and shoulder level. 3. As of December 1, 2018, the Veteran's right shoulder disability is characterized by limitation of the arm midway between side and shoulder level but not limitation of motion to 25 degrees from the side. 4. The Veteran's cervical spine disability was not manifest during service or within one year of separation. The disability was not caused or aggravated by a service-connected right shoulder disability. 5. As of April 30, 2013, the Veteran's service-connected disorders alone preclude substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for an initial rating of 70 percent, but not greater, for major depressive disorder, as of April 30, 2013, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9434. 2. The criteria for a disability rating in excess of 20 percent for severe AC joint osteoarthritis of the right shoulder, from October 30, 2012 to June 21, 2013, and from October 1, 2013 to September 19, 2018, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1-4.14, 4.71a, Diagnostic Code 5201. 3. The criteria for a disability rating of 30 percent for severe AC joint osteoarthritis of the right shoulder, as of December 1, 2018, have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1-4.14, 4.71a, Diagnostic Code 5201. 4. The Veteran’s cervical spine disability was not incurred in service and is not proximately due to or aggravated by a service-connected disease or injury. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 5. The schedular criteria for a TDIU rating are met and a TDIU rating is warranted from April 30, 2013 to June 20, 2013, from October 1, 2013 to September 19, 2018, and as of December 1, 2018. 38 U.S.C. § 1155; 38 C.F.R. § 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from October 1980 to September 1984. This matter comes to the Board of Veterans' Appeals (Board) from June 2013 and June 2014 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia; however, jurisdiction over these claims is now before the RO in San Diego, California. In March 2018, the Board remanded these claims for additional development. During the course of the appeal, a February 2020 rating decision increased the rating for the Veteran’s major depressive disorder to 70 percent, effective January 23, 2019, and granted TDIU as of the same date. However, as such did not constitute a full grant of the benefit sought on appeal, the issue remains in appellate status. See AB v. Brown, 6 Vet. App. 35 (1993). Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R. Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA has a duty to consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. The percentage ratings in the Rating Schedule represent the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. The percentage ratings are generally adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the disability. Diagnostic Codes (DCs) are assigned by the rating officials to individual disabilities. DCs provide rating criteria specific to a particular disability. If two DCs are applicable to the same disability, the DC that allows for the higher disability rating applies. 38 C.F.R. § 4.7. When a question arises as to which of two ratings apply under a particular DC, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of a veteran. 38 C.F.R. § 4.3. In disability rating cases, VA assesses the level of disability from the initial grant of service connection or a year prior to the date of application for an increased rating and determines whether the level of disability warrants the assignment of different disability ratings at different times over the course of the veteran’s claim, a practice known as "staged ratings." Fenderson v. West, 12 Vet. App. 119, 126 (1999); Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007) (holding that staged ratings may be warranted in increased rating claims). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to an initial rating in excess of 30 percent, from April 30, 2013 to January 22, 2019, and in excess of 70 percent, as of January 23, 2019, for major depressive disorder. The Veteran seeks a higher rating for his psychiatric disorder, which is currently rated 30 percent disabling from April 30, 2013 to January 22, 2019, and 70 percent disabling thereafter under 38 C.F.R. § 4.130, Diagnostic Code 9434. Under 38 C.F.R. § 4.130, Diagnostic Code 9434, a 30 percent rating is warranted 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, mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation is warranted 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; the Veteran's difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent disability rating requires 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); or inability to establish and maintain effective relationships. Id. A 100 percent disability rating requires 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 as to time or place; or demonstrated memory loss for names of close relatives, own occupation, or own name. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptomatology contemplated for each rating. The use of such terminology permits consideration of items listed and other symptoms and contemplates the effect of those symptoms on the Veteran's social and work situation. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Board acknowledges that symptoms recited in the criteria in the rating schedule for evaluating mental disorders are "not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating." Id., at 442. In adjudicating a claim for a higher rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Id., at 443. The Veteran was afforded a VA examination for his psychiatric symptoms in March 2014. The examiner diagnosed the Veteran with posttraumatic stress disorder (PTSD), major depressive disorder, a panic disorder, and a generalized anxiety disorder. The examiner opined that the Veteran’s psychiatric disorder resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The examiner explained that the Veteran's psychiatric disorders are co-occurring and negatively impact each other, worsening the Veteran's ability to cope with life stresses; that there is significant symptom overlap and multi-directional interactions between the disorders; and without resorting to speculation, it is impossible to delineate the impact of each specific disorder on the Veteran's social and occupational functioning. The examiner noted that the Veteran exhibits avoidance symptoms, specifically avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s); and avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). The examiner also noted that the Veteran had symptoms related to negative alterations in cognitions and mood, specifically persistent and exaggerated negative beliefs or expectations about oneself, others, or the world; and markedly diminished interest or participation in significant activities. The examiner also addressed the Veteran’s marked alterations in arousal and reactivity, noting symptoms of irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects; hypervigilance; exaggerated startle response; and sleep disturbance. The Veteran endorsed symptoms such as depressed mood; anxiety; suspiciousness; panic attacks more than once a week; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; disturbances of motivation and mood; and difficulty in establishing and maintaining effective and social relationships. The Veteran submitted a private psychiatric assessment dated December 2014. In this assessment, the physician diagnosed the Veteran with a major depressive disorder, PTSD, and Alcohol dependence. The physician opined that the Veteran’s psychiatric disorder resulted in occupational and social impairment with reduced reliability and productivity. The Veteran endorsed symptoms such as depressed mood; anxiety; mild memory loss, such as forgetting names, directions or recent events; flattened affect; and inability to establish and maintain effective relationships. The Veteran was afforded a second VA examination for his psychiatric symptoms in February 2015. The examiner diagnosed the Veteran with PTSD and an adjustment disorder with depression and anxiety. The examiner explained that it is not possible to differentiate symptoms related to each diagnosis, as there is substantial overlap in symptoms. The examiner opined that the Veteran’s psychiatric disorder resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The examiner noted that the Veteran exhibits persistent avoidance symptoms, specifically avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s); and avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). The examiner also noted that the Veteran had symptoms related to negative alterations in cognitions and mood, specifically a persistent negative emotional state; and markedly diminished interest or participation in significant activities. The examiner also addressed the Veteran’s marked alterations in arousal and reactivity, noting symptoms of irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects; hypervigilance; exaggerated startle response; problems with concentration; and sleep disturbance. The Veteran endorsed symptoms such as depressed mood; anxiety; panic attacks more than once a week; chronic sleep impairment; and disturbances of motivation and mood. The Veteran was afforded a third VA examination for his psychiatric symptoms in April 2017. The examiner diagnosed the Veteran with major depressive disorder with anxious distress and panic attacks and PTSD. The examiner explained that the Veteran’s mental disorder are mutually aggravating, which results in being unable to differentiate the Veteran’s psychiatric symptoms without resorting to mere speculation. The examiner opined that the Veteran’s psychiatric disorder resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The examiner noted that the Veteran currently exhibits symptoms of feeling fatigued; increased memory loss (e.g. forgetting he put something on the stove, or forgetting why he went to a certain room); avoidance of people and noise; irritability; hypervigilance; increase in being nervous around bridges and heights. The Veteran also endorsed having a range of trauma-related mental health problems including intrusion symptoms, avoidance symptoms, negative alterations in cognitions and mood, and a marked alteration in arousal and reactivity secondary to his traumatic stressors. The Veteran also described experiencing a range of depressive and anxious symptoms including depressed mood much of the time; feeling empty, hopeless, and worthless "just about all the time... every day;" frequent crying, irritability/agitation (perhaps beyond that secondary to his past traumas), difficulty sleeping, and panic attacks. Regarding the latter of these symptoms, the Veteran reported panic attacks "about once every two weeks or something like that." He characterized a panic attack as "just getting jittery and start sweating, my stomach gets real irritated like I have to go to the bathroom, real nervous..." The experiences last 5-10 minutes and come about without an identified stressor. The Veteran denied recurrent thoughts of death, passing/active suicidal ideations, or suicidal intentions. The Veteran endorsed symptoms such as depressed mood; anxiety; panic attacks that occur weekly or less often; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; and disturbances of motivation and mood. The Veteran’s private treating physician conducted an assessment of the Veteran’s psychiatric symptoms, and found that the Veteran exhibited depressed mood; anxiety; suspiciousness; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; flattened affect; disturbances of motivation and mood; difficulty in establishing and maintaining effective social relationships; difficulty in adapting to stressful circumstances, including work or a worklike setting; and inability to establish and maintain effective relationships. Based on this assessment, the Veteran was rated at 70 percent, as of January 23, 2019. The Board finds that the examinations and private evaluations in the record are probative and should be considered competent evidence of record. The Board finds that throughout the appeal, the Veteran’s psychiatric symptoms have been characterized by depressed mood; anxiety; suspiciousness; panic attacks that occur weekly or less often; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; flattened affect; disturbances of motivation and mood; impaired impulse control (such as unprovoked irritability with periods of violence); difficulty in adapting to stressful circumstances, including work or a worklike setting; and inability to establish and maintain effective relationships. While every symptom was not noted in the Veteran’s psychiatric evaluations with endorsed symptoms, the examinations and private assessments explained the Veteran’s avoidance, irritability, and inability to establish and maintain effective social and occupational relationships. Despite the March 2014, February 2015, and April 2017 opinions that the Veteran’s psychiatric disorder resulted in occupational and social occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation, the Board finds that the Veteran’s symptoms are suggestive of occupational and social impairment with deficiencies in most areas. Mainly due to his difficulties and inability to maintain effective social and occupational relationships and his noted irritable behavior with angry outbursts. After resolving any doubt in the Veteran’s favor, the Board finds that his major depressive disorder resulted in occupational and social impairment with deficiencies in most areas. Accordingly, as of April 30, 2013, an initial 70 percent rating for major depressive disorder is warranted. Despite the Veteran’s serious symptoms, the Board finds that his symptoms were not so severe or frequent so as to result in total social and occupational impairment. First, there is no evidence of record that the Veteran suffered from symptoms such as 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; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130. Moreover, the Veteran has not contended on appeal that he suffers from such symptoms. As such, the Board finds that the preponderance of the evidence is against total social and occupational impairment; there is no doubt to be resolved; and a rating in excess of 70 percent is not warranted. 2. Entitlement to a rating in excess of 20 percent for severe AC joint osteoarthritis of the right shoulder The Veteran contends he is entitled to an evaluation in excess of 20 percent for his right shoulder AC joint osteoarthritis, which is currently rated by 38 C.F.R. § 4.71a, Diagnostic Code 5201. In determining the appropriate evaluation for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Where functional loss is alleged due to pain upon motion, the provisions of 38 C.F.R. § 4.40 and § 4.45 must be considered. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995). Within this context, a finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant on motion. 38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Pain itself does not rise to the level of functional loss as contemplated by § 4.40 and § 4.45, but it may result in functional loss only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, coordination, or endurance. 38 C.F.R. §§ 4.40, 4.45; Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). Factors of joint disability include increased or limited motion, weakness, fatigability, or painful movement, swelling, deformity or disuse atrophy. 38 C.F.R. § 4.45. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Under 38 C.F.R. § 4.59, painful motion is an important factor of joint disability and actually painful joints are entitled to at least the minimum compensable rating for the joint. Handedness for the purpose of a dominant rating will be determined by the evidence of record or by testing on VA examination. Only one hand shall be considered dominant. Here, the Veteran is right hand dominant. Thus, when evaluating the right shoulder disability, major extremity disability ratings (as opposed to minor) will be applicable. 38 C.F.R. § 4.69. The standard ranges of motion of the shoulder are 180 degrees for forward elevation (flexion) and 180 degrees for abduction. The standard range of motion for internal and external rotation is 90 degrees. 38 C.F.R. § 4.71, Plate I. Diagnostic Code 5200 concerns ankylosis of the scapulohumeral articulation (the scapula and humerus move as one piece). Ankylosis is defined as stiffening or fixation of a joint as the result of a disease process with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). DC 5200 provides that ankylosis of the scapulohumeral articulation of the major upper extremity is assigned an evaluation of 30 percent when it is favorable with abduction to 60 degrees and able to reach mouth and head. An evaluation of 40 percent is assigned with intermediate ankylosis (between favorable and unfavorable); and an evaluation of 50 percent is assigned when it is unfavorable with abduction limited to 25 degrees from side. Minor arm evaluations for each of those criteria are 10 percent less than the major arm evaluations. 38 C.F.R. § 4.71a, Diagnostic Code 5200 and Note. Under Diagnostic Code 5201, a 20 percent disability evaluation is warranted for limitation of motion of the major or minor arm at shoulder level, or for a minor arm with limitation of motion to midway between the side and shoulder level. A 30 percent evaluation is warranted for a major arm with limitation of motion to midway between the side and shoulder level, or for a minor arm with limitation of motion to 25 degrees from the side. A 40 percent evaluation is warranted for a major arm with limitation of motion to 25 degrees from the side. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Under Diagnostic Code 5202, a 20 percent evaluation is assigned for malunion of the major humerus with a moderate deformity, and a 30 percent evaluation is assigned with a marked deformity. Malunion of the minor humerus with either a moderate or a marked deformity warrants a 20 percent evaluation. A 20 percent evaluation is also warranted for recurrent dislocation of the major humerus at the scapulohumeral joint with infrequent episodes and guarding of movement only at the shoulder level, and a 30 percent rating is warranted for frequent episodes and guarding of all arm movements; a minor arm with either of those symptoms is evaluated as 20 percent disabling. Impairment of the major humerus is rated at 50 percent if there is a fibrous union, 60 percent if there is nonunion or false flail joint, and 80 percent if there is loss the head of humerus with flail shoulder. Again, the minor arm with those symptoms is evaluated as 10 percent less than the major arm evaluations. 38 C.F.R. § 4.71a, Diagnostic Code 5202. Finally, Diagnostic Code 5203 provides a 10 percent evaluation for malunion of the clavicle or scapula or nonunion without loose movement. A 20 percent evaluation is warranted for nonunion of the clavicle or scapula with loose movement or dislocation of the clavicle or scapula. Major and minor arms are not evaluated differently under this diagnostic code. 38 C.F.R. § 4.71a, Diagnostic Code 5203. As background for this case, the Veteran has been service-connected for this disability since he exited service in September 1984. In October 2012, the Veteran filed a request to increase the rating for his service-connected right shoulder AC joint osteoarthritis, which was denied by the RO in a June 2013 rating decision. Throughout the course of this appeal, excluding periods during which a temporary total convalescent rating has been assigned, the Veteran’s service-connected right shoulder disability has been assigned a 20 percent disability evaluation under Diagnostic Code 5201. 38 C.F.R. § 4.71a, DC 5201. The Veteran was afforded VA examinations for his right shoulder disability in March 2013, February 2017, and June 2019. The March 2013 VA examiner found that the Veteran's right shoulder flexion range of motion (ROM) ended at 85 degrees, with painful motion. His right shoulder abduction ended at 90 degrees with painful motion. The Veteran's right shoulder external rotation and right shoulder internal rotation ended at 120 and 125 degrees, with painful motion. The Veteran was not able to perform repetitive use testing due to severe pain, but there is noted additional imitation of ROM. There is functional loss indicated by less movement than normal, weakened movement, excess fatigability, and pain on movement. The Veteran has pain on palpation and guarding of the right shoulder. The Veteran's muscle strength was decreased (4/5), and there were no signs of ankylosis. The Veteran reported flare-ups, specifically noting that it hurts to lift his arm overhead. The examiner found the Veteran positive for the Hawkins Impingement Test. The February 2017 VA examiner found that the Veteran's right shoulder flexion ROM ended at 90 degrees, with painful motion. His right shoulder abduction ended at 80 degrees with painful motion. The Veteran's right shoulder external rotation ROM ended at 60 degrees, with painful motion. The Veteran's right shoulder internal rotation ROM ended at 75 degrees, with painful motion. After repetitive use testing, the Veteran's ROM remained the same as initially evaluated. The Veteran's muscle strength was normal, there was no muscle atrophy, and there were no signs of ankylosis. The Veteran did not report flare-ups, however he did allege to experience functional loss due to right shoulder stiffness. The examiner noted a past surgery in June 2013, and that the Veteran experiences pain on passive and non-weight bearing testing. The June 2019 VA examiner found that the Veteran's right shoulder flexion ROM ended at 70 degrees, with painful motion. His right shoulder abduction ended at 65 degrees, with painful motion. The Veteran's right shoulder external rotation ROM ended at 60 degrees, with painful motion. The Veteran's right shoulder internal rotation ROM ended at 90 degrees, with painful motion. After repetitive use testing, the Veteran's ROM was unchanged, and no additional functional loss was noted. However, the examiner explained that pain, fatigue, weakness, and lack of endurance cause functional loss. The Veteran reported experiencing flare-ups due to pain, and decreased ROM. During flare-ups, the Veteran’s right shoulder flexion ROM ended at 60 degrees, his right shoulder abduction ended at 50 degrees, his right shoulder external rotation ROM ended at 60 degrees, and his right shoulder internal rotation ROM ended at 90 degrees. The Veteran's muscle strength was decreased (4/5), there was no muscle atrophy, and there were no signs of ankylosis. The examiner noted that the Veteran has had prior surgeries on his right shoulder in June 2013 and September 2018. The Board finds that the examinations in the record are probative and should be considered competent evidence of record. Additionally, according to private treatment records from June 2013, August 2013, September 2013, and June 2014, the Veteran’s disability was characterized as having limitation of the right arm at shoulder level. A. Prior to June 21, 2013, and from October 1, 2013 to September 19, 2018 Considering all the evidence as described above, prior to September 19, 2018, the Board finds that that the Veteran's right shoulder ROM has been limited to at or near shoulder level. As such, the Veteran's right shoulder disability most closely approximates the criteria for the currently-assigned 20 percent disability rating under DC 5201. A disability rating in excess of 20 percent under DC 5201 is not warranted because the Veteran has not exhibited the symptoms required for a higher rating, such as ROM limited to midway between his side and shoulder level or ROM limited to 25 degrees from his side. 38 C.F.R. § 4.71a, DC 5201. The Board has considered whether an increased evaluation would be warranted under the other relevant diagnostic codes pertaining to the shoulder or arm, but the Board finds that the criteria for a rating in excess of 20 percent under those diagnostic codes have not been met. The medical evidence of record also does not show scapulohumeral articulation ankylosis, which is required for a rating under DC 5200. The Board acknowledges the Veteran's assertion that his right shoulder disability warrants a higher disability rating. However, the Veteran lacks the adequate medical expertise in this case to render an opinion as to the nature or severity of his disability or as to whether his disabilities have worsened enough to warrant a higher disability evaluation. As such, the Veteran's assertions in this regard are not competent or probative evidence to decide this appeal. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Based on the above, the preponderance of the evidence is against the assignment of a rating in excess of 20 percent for the Veteran's right shoulder disability. Therefore, the Veteran's claim of entitlement to an evaluation in excess of 20 percent for a right shoulder disability must be denied. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). B. As of December 1, 2018 Considering all the evidence as described above, as of December 1, 2018, the Board finds that that the Veteran's right shoulder ROM has been limited to midway between his side and shoulder level or ROM limited to 25 degrees from his side. As such, the Veteran's right shoulder disability most closely approximates the criteria for a 30 percent disability rating under DC 5201. Following a right shoulder surgery in September 2018, and a period convalescence due to the surgery, the only VA examination of record is June 2019, which demonstrates a right shoulder disability characterized by being limited to midway between his side and shoulder level or ROM limited to 25 degrees from his side. Based on the above, the preponderance of the evidence is in favor of assigning a rating of 30 percent for the Veteran's right shoulder disability. Therefore, the Veteran's service-connected right should AC joint osteoarthritis is increased to a disability rating of 30 percent, as of December 1, 2018. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service or for aggravation of a preexisting injury suffered or disease contracted in line of duty. 38 U.S.C. § 1110, 1131. Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service or for aggravation of a preexisting injury suffered or disease contracted in line of duty. 38 U.S.C. § 1110, 1131. Establishing 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 present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection is warranted on a secondary basis for a disability which is proximately due to, aggravated by or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310 (b). For secondary service connection to be granted, generally there must be (1) evidence of a current disability; (2) evidence of a service-connected disease or injury; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). 3. Entitlement to service connection for degenerative disc disease of the cervical spine The Veteran contends that his cervical spine disability, diagnosed as degenerative disc disease of the cervical spine, is related to his service. Specifically, he claims his cervical spine disability is due to his service-connected right shoulder. The Board has carefully evaluated the evidence and finds that service connection for the Veteran's cervical spine disability is not warranted on either a direct basis or as secondary to his service-connected right shoulder disability. The Veteran was afforded a VA examination for his cervical spine in March 2013. The examiner diagnosed him with multilevel degenerative disc disease of the cervical spine. The VA examiner concluded that while a cervical disc disease may exacerbate the veteran’s right shoulder disability, “the reverse is not likely true.” The examiner concluded that the Veteran’s cervical spine disability is likely due to genetic and environmental factors. Pursuant to the March 2018 Board remand, addendum nexus opinions were obtained. The Board also noted that service treatment records confirm that the Veteran complained of back pain in August 1983, therefore a direct service connection nexus opinion was also needed. Regarding direct service connection, in November 2018 the examiner concluded that the Veteran's cervical spine disability was likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury. The examiner stated that the Veteran’s service treatment records are silent to the Veteran ever being evaluated for and/or treated for the claimed condition in service. The veteran's neck condition is degenerative, the result of chronic wear and tear, and/or genetic predisposition, and the loss of fluid in the disc spaces. In October 2019, the examiner amended the nexus opinion to address whether the August 1983 service treatment records noting back pain could be related to the Veteran’s current cervical spine disability. He concluded that there is no biomechanical relationship between to lumbar and cervical spine, and that the Veteran was treated for an acute low back muscle strain in service, which does not cause degenerative disease of the cervical spine. Regarding secondary service connection, in November 2018 the examiner concluded that the cervical spine disability was less likely than not proximately due to or the result of the service-connected right shoulder disability. The examiner explained the right shoulder and cervical spine conditions are comorbid, separated and independent of each other. They may be present alone or together, and there is no nexus or link between them. The examiner noted that contentions and opinions to the contrary are based on mere speculation. The examiner also concluded that the claimed cervical spine disability is not aggravated beyond its natural progression by the service-connected right shoulder disability. The examiner noted that the contention that one joint of the body having arthritis pain causes a person to favor or "unload" on another and therefore causes arthritis in the other joint is often cited, however, it is biomechanically incorrect and has been disproven in the orthopedic and occupational medicine literature. The examiner explained that the formation of arthritis would require increase speed and increase sheer forces across the joint. As above, the conditions are comorbid, separated and independent of each other, they may be present alone or together, but there is no nexus or link between them. For a medical opinion (i.e., medical evidence) to be given weight, it must be: (1) based upon sufficient facts or data; (2) the product of reliable principles and methods; and (3) the result of principles and methods reliably applied to the facts. Nieves-Rodriquez v. Peake, 22 Vet. App. 295, 302 (2008). The probative value of a medical opinion comes primarily from its reasoning; threshold considerations are whether a person opining is suitably qualified and sufficiently informed. In this case, the Board accepts the November 2018 and October 2019 opinions as highly probative medical evidence. Each opinion was based upon a full review of the claims file. The examiner considered the Veteran's statements in full regarding his medical history and symptoms and provided a reasoned analysis of the case. The Board has considered the Veteran's lay statements of record. Regarding direct service connection, the Veteran has not, during the period on appeal, claimed that his current cervical spine disability was incurred during service, even though he was treated for back pain during his service. Rather, throughout the period on appeal he has maintained that his cervical spine disability is related to his service-connected right shoulder disability. The Veteran has provided no probative evidence that his current cervical spine disability resulted from or was aggravated by an injury suffered or disease contracted during service. Regarding service connection as secondary to his service-connected right shoulder disability, the Veteran has provided no evidence beyond his statement that he believes the problems with his neck are related to his right shoulder injury. To the extent that the Veteran's statements indicated that his neck disability is directly related to his active service or is secondary to any service-connected disabilities, the Board finds that the Veteran is not competent to address these etiological issues, as they are complex medical question beyond the competence of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Veteran has not been shown to possess the requisite medical expertise or knowledge to offer such opinions. Therefore, his statements are not probative. The Board concludes that the objective medical findings, the lack of medical evidence showing a nexus between the Veteran's cervical spine disability and his service or a service-connected disability are more probative and credible than the lay evidence submitted in support of his claim. The only evidence submitted in support of his claim are his own lay statements. The Board must find that the Veteran's statements to be of minimal probative value and outweighed by the VA opinion prepared by a skilled neutral professional and the remainder of the record. In summary, the more probative evidence establishes that the Veteran did not have a cervical spine disability during service or within one year of separation, and that his current cervical spine disability is not the result of and was not aggravated by his service-connected right shoulder disability. The Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for his cervical spine disability on a direct basis and as secondary to his service-connected right shoulder disability. The claim must be denied. TDIU 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. 38 U.S.C. § 1155; 38 C.F.R. § 4.16. A finding of total disability is appropriate "when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation." 38 C.F.R. §§ 3.340(a)(1), 4.15. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability, such disability shall be ratable as 60 percent or more and if there are two or more disabilities, there shall be at least 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. § 4.16(a). Consideration may be given to the veteran's level of education, special training and previous work experience, but not to his age or to any impairment caused by non- service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. VA's General Counsel has concluded that the controlling VA regulations generally provide that veterans who, in light of their individual circumstances, but without regard to age, are unable to secure and follow a substantially gainful occupation as the result of service-connected disability shall be rated totally disabled, without regard to whether an average person would be rendered unemployable by the circumstances. Thus, the criteria include a subjective standard. As further observed by General Counsel, "unemployability" is synonymous with inability to secure and follow a substantially gainful occupation. VAOPGCPREC 75-91. 4. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) The Veteran contends that he has been unable to maintain substantially gainful employment since he was forced to stop working due to his right shoulder disability, as stated in a February 2013 letter from his employer, and was forced to retire on December 2013 due to his service-connected disabilities. In February 2020, the RO granted entitlement to TDIU from January 23, 2019. As the Board has herein granted an earlier effective date of April 30, 2013 for the award of a 70 percent rating for the Veteran's psychiatric disability, the schedular rating requirement for a TDIU rating under 38 C.F.R. § 4.16(a) is met from that date. Consequently, the critical question remaining is whether due to the Veteran’s service-connected disabilities he was unable to engage in a substantially gainful occupation prior to January 2019 (and from April 2013). The Board again notes that SSA records reflect that the Veteran was granted disability benefits as of April 2012 primarily based on his right shoulder disability and his psychiatric impairment, along with other nonservice-connected disabilities. The Board further notes that the Veteran was unable to work since at least February 2013 and was subsequently forced to retire from his employment on December 2013 due to his right shoulder disability. During the Veteran’s March 2013 VA examination for his right shoulder disability, the examiner concluded that the Veteran's right shoulder disability impacts his employment, as he is unable to secure and maintain gainful employment in the type of employment for which he is trained. The examiner added that based on his high school education and training his chances of finding employment would be difficult. The VA examiner for his February 2017 right shoulder examination noted that the Veteran is limited to lifting, pushing, or pulling no more than 15 pounds with his right arm, and that he cannot work over his head with his right arm. The Board finds that based on the VA examiners’ opinions regarding the impact of the Veteran’s right shoulder disability, the Veteran would not be able to secure and follow substantially gainful employment since, at least, April 2013. In summary, the Board finds that the evidence of record reasonably demonstrates that the Veteran's service-connected disabilities have been of such nature and severity as to have precluded him maintenance of employment in any occupation consistent with his education and occupational experience since April 30, 2013. Consequently, a TDIU rating is warranted from April 30, 2013, excluding periods during which a temporary total convalescent rating has been assigned. M.J. Colicelli Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. R. Montalvo, Associate 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.