Citation Nr: 20045352 Decision Date: 07/08/20 Archive Date: 07/08/20 DOCKET NO. 10-05 691 DATE: July 8, 2020 ORDER Entitlement to service connection for peripheral neuropathy of the right upper extremity, to include as due to herbicide agent exposure or as secondary to service-connected diabetes mellitus, type II, is denied. Entitlement to service connection for peripheral neuropathy of the left upper extremity, to include as due to herbicide agent exposure or as secondary to service-connected diabetes mellitus, type II, is denied. Entitlement to an evaluation in excess of 20 percent for residuals of a gunshot wound to the right elbow with ulnar nerve numbness is denied. Entitlement to an initial evaluation in excess of 20 percent for diabetes mellitus, type II, is denied. Entitlement to an initial evaluation in excess of 10 percent for peripheral neuropathy of the right lower extremity is denied. Entitlement to an initial evaluation in excess of 10 percent for peripheral neuropathy of the left lower extremity is denied. Entitlement to an initial evaluation in excess of 50 percent for posttraumatic stress disorder (PTSD) is denied. Entitlement to a total disability rating based upon individual unemployability (TDIU rating) is denied. FINDINGS OF FACT 1. The Veteran, without good cause, failed to report for VA examinations which were necessary to establish entitlement to the benefits sought in each of the claims on appeal herein. 2. The preponderance of the evidence of record is against finding that the Veteran has had peripheral neuropathy of the right upper extremity (separate from his service-connected gunshot wound to the right elbow with ulnar nerve numbness) during the period on appeal. 3. The preponderance of the evidence of record is against finding that the Veteran has had peripheral neuropathy of the left upper extremity during the period on appeal. 4. The Veteran’s diabetes mellitus, type II, has required metformin and a restricted diet during the period on appeal. 5. The Veteran’s peripheral neuropathy of the right lower extremity is manifest by no more than mild incomplete paralysis. 6. The Veteran’s peripheral neuropathy of the left lower extremity is manifest by no more than mild incomplete paralysis. 7. Throughout the appeal period, the Veteran’s PTSD symptoms have been productive of occupational and social impairment with reduced reliability and productivity; and the severity, frequency, and duration of the Veteran’s PTSD symptoms did not more closely approximate occupational and social impairment with deficiencies in most areas. 8. Throughout the appeal period, the Veteran was not precluded from obtaining and securing substantially gainful employment as a result of his service-connected disabilities at any time during the period on appeal. CONCLUSIONS OF LAW 1. The criteria for service connection for peripheral neuropathy of the right upper extremity, to include as due to herbicide agent exposure or as secondary to service-connected diabetes mellitus, type II, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for service connection for peripheral neuropathy of the left upper extremity, to include as due to herbicide agent exposure or as secondary to service-connected diabetes mellitus, type II, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 3. The criteria for an evaluation in excess of 20 percent for residuals of a gunshot wound to the right elbow with ulnar nerve numbness have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Codes 5307, 8512. 4. The criteria for an initial evaluation in excess of 20 percent for diabetes mellitus, type II, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.119, Diagnostic Code 7913. 5. The criteria for an initial evaluation in excess of 10 percent for peripheral neuropathy of the right lower extremity have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8520. 6. The criteria for an initial evaluation in excess of 10 percent for peripheral neuropathy of the left lower extremity have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8520. 7. The criteria for an initial evaluation in excess of 50 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 8. The criteria for entitlement to a TDIU rating have not been met. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. § §§ 3.340, 3.341, 4.15, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from December 1966 to August 1968 and September 1981 to September 1984. For his meritorious service, the Veteran was awarded (among other decorations) the Purple Heart, the Combat Infantryman Badge, and the Vietnam Service and Campaign Medals. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In March 2017, and again in July 2018, the Board remanded this matter for additional evidentiary development. Failure to Attend Examinations Pursuant to the Board’s July 2018 remand, the Veteran was scheduled for multiple VA examinations relating to each of the issues herein on October 8, 2019, and again on October 29, 2019. The Veteran cancelled these examinations on both occasions. In November 2019, the Veteran, acting through his fiduciary, indicated that he would have the necessary examination forms completed by a private physician. In January 2020, the RO mailed to the Veteran the disability benefit questionnaires (DBQs) necessary to adjudicate his service connection claims and also assess the severity of the Veteran’s PTSD, peripheral neuropathy, diabetes, and residuals of gunshot wound to the right elbow. The RO’s letter noted that these examinations were to be completed by the Veteran’s private physician and returned within 30 days. No subsequent response was received from the Veteran. In April 2020, the RO issued a supplemental statement of the case which noted this procedural history, including the Veteran’s failure to report for his VA examinations and notice that evidence expected from these examinations might have been material to the outcome of his claims. Still no response was received from the Veteran. Having cancelled the required examinations on two occasions, the Board finds the Veteran has failed to attend examinations without good cause. Moreover, attempts to assist the Veteran on gathering the required factual information on his own have also failed. VA's duty to assist is not always "a one-way street." See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). If a claimant wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining relevant evidence. Id. When entitlement to a benefit cannot be established without a current VA examination or reexamination and a claimant, without good cause, fails to report for such examination or reexamination, action shall be taken in accordance with 38 C.F.R. § 3.655(b) or (c) as appropriate. 38 C.F.R. § 3.655(a). When a claimant fails to report for a necessary medical examination in conjunction with an original compensation claim, the claim shall be rated based on the evidence of record. 38 C.F.R. § 3.655(b). Thus, the Board’s decision herein will address the issues of service connection for peripheral neuropathy of the bilateral upper extremities based upon the evidence of record. When a claimant fails to report for an examination scheduled in conjunction with a claim for increase, the claim shall be denied. Id. As such, the Board’s decision below denies the Veteran’s claim for an increased evaluation for his residuals of a gunshot wound to the right elbow with ulnar nerve numbness. In an initial rating claim, when the veteran fails to report for an examination, the case shall be rated on the evidence of record rather than denied, because an initial rating claim is an original compensation claim under 38 C.F.R. § 3.655 (b). See Turk v. Peake, 21 Vet. App. 565 (2008). Thus, the Board’s decision below addressing the initial evaluations assigned to Veteran’s service-connected PTSD, peripheral neuropathy of the right and left lower extremities, and diabetes mellitus, type II, shall be addressed adjudicated based upon the evidence currently of record. Service Connection Claims Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Certain chronic diseases, including organic diseases of the nervous system, are presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). VA regulations also provide for presumptive service connection for specific diseases associated with exposure to certain herbicide agents. See 38 C.F.R. § 3.307 (a)(6)(iii). Those diseases which are listed at 38 C.F.R. § 3.309(e), including early-onset peripheral neuropathy, shall be presumptively service-connected if there are circumstances establishing herbicide agent exposure during active military service, even though there is no record of such disease during service. Generally, the regulation applies where an enumerated disease becomes manifest to a degree of 10 percent or more at any time after service. However, in the case of early-onset peripheral neuropathy, it must have manifested to a degree of 10 percent or more within a year after the last date on which the Veteran was exposed to an herbicide agent during service. 38 C.F.R. § 3.307(a)(6)(ii). VA has determined that there is no positive association between exposure to herbicide agents and any other condition for which it has not specifically determined a presumption of service connection is warranted. 61 Fed. Reg. 41,446 (1996); 59 Fed. Reg. 341-46 (1994). Despite this, the Veteran is not precluded from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039, 1041-42 (Fed. Cir. 1994). Service connection may also be established for disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). Further, a disability that is aggravated by a service-connected disability may be service connected to the degree that the aggravation is shown. 38 C.F.R. § 3.310 (2017); Allen v. Brown, 7 Vet. App. 439 (1995). However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310. 1. Entitlement to service connection for peripheral neuropathy of the right upper extremity, to include as due to herbicide agent exposure or as secondary to service-connected diabetes mellitus, type II. 2. Entitlement to service connection for peripheral neuropathy of the left upper extremity, to include as due to herbicide agent exposure or as secondary to service-connected diabetes mellitus, type II. The Veteran asserts that he has peripheral neuropathy of the upper extremities as a result of his inservice exposure to herbicide agent. Alternatively, he contends these conditions developed secondary to his service-connected diabetes mellitus, type II. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. Based upon a longitudinal review of the evidence of record, the Board concludes that the Veteran does not have a current diagnosis of peripheral neuropathy of the right or left upper extremity and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The February 2008 VA examiner evaluated the Veteran and determined that his left upper extremity was normal upon examination. The VA examiner also noted that the Veteran’s right upper extremity was normal upon examination, with the exception of the right upper extremity neuropathy relating to his service-connected residuals of a gunshot wound to the right elbow with ulnar nerve numbness. In addition to the negative examination findings, no objective findings relating to right and left upper extremity peripheral neuropathy were noted in the Veteran’s post service treatment records. Finally, the Veteran failed to report for an additional examination which may have been helpful in establishing service connection for these disabilities. While the Veteran believes he has peripheral neuropathy of the right and left upper extremity, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires a specialized medical education and the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Physical examination of the Veteran in February 2008 failed to reveal any objective findings to support a diagnosis or current disability in this matter. Consequently, the Board gives more probative weight to the competent medical evidence. Despite the duty to assist, it remains a claimant’s general evidentiary burden to establish all elements of his or her claim. Fagan v. Shinseki, 572 F.3d 1282, 1286 (Fed. Cir. 2009). Accordingly, the preponderance of the evidence is against the Veteran's claims for service connection for peripheral neuropathy of the right and left upper extremities. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claims, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Evaluation Claims Disability ratings are determined by applying the criteria set forth in the VA Schedule of Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating many accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a questions as to which of two evaluations apply, assigning a higher of the two where the disability pictures more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person’s ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 3. Entitlement to an evaluation in excess of 20 percent for residuals of a gunshot wound to the right elbow with ulnar nerve numbness. The Veteran was granted service connection for residuals of a gunshot wound to the right elbow with ulnar nerve numbness in a September 1969 rating decision. He filed his present claim seeking, in pertinent part, an increased evaluation for residuals of a gunshot wound to the right elbow with ulnar nerve numbness in January 2008. In October 2018, the Veteran failed to report without good cause for a necessary examination scheduled in conjunction with his increased rating claim that did not stem from an original claim for compensation. Therefore, the Veteran's claim for an increased evaluation for residuals of a gunshot wound to the right elbow with ulnar nerve numbness is denied. 38 C.F.R. § 3.655(b). 4. Entitlement to an initial evaluation in excess of 20 percent for diabetes mellitus, type II, The Veteran is seeking an increased initial evaluation for his service-connected diabetes mellitus, type II. Diagnostic Code 7913 provides a structured scheme of specific, successive, cumulative criteria. Each higher rating includes the same criteria as the lower rating plus distinct new criteria. Middleton v. Shinseki, 727 F.3d 1172, 1178 (Fed. Cir. 2013). A 10 percent rating is warranted when diabetes is manageable by restricted diet only. A 20 percent rating is warranted when diabetes requires one or more daily injection of insulin and restricted diet, or an oral hypoglycemic agent and restricted diet. A 40 percent rating is warranted when it requires one or more daily injection of insulin, restricted diet, and regulation of activities. A 60 percent rating is warranted when diabetes requires one or more daily injection of insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating is warranted when diabetes requires more than one daily injection of insulin, restricted diet, and regulation of activities, with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. Compensable complications of diabetes are evaluated separately unless they are part of the criteria used to support a 100-percent evaluation. Noncompensable complications of diabetes are considered part of the diabetic process. 38 C.F.R. § 4.119, Diagnostic Code 7913 (Note 1). Because Diagnostic Code 7913 contains successive criteria, the criteria for the lower rating must be met before a higher disability rating may be awarded. A higher rating cannot be granted based on a finding that the Veteran’s disability picture more nearly approximates the criteria for the next higher rating. However, reasonable doubt regarding the presence of a criterion may be resolved in the Veteran’ favor. Johnson v. Wilkie, 30 Vet. App. 245 (2018). The question in this appeal is whether the Veteran’s diabetes mellitus, type II, required one or more daily injections of insulin, restricted diet, and regulation of activities. Based upon a longitudinal review of the evidence of record, the Board finds that the Veteran’s diabetes mellitus, type II, requires only metformin and a restricted diet. Such were the results noted in a February 2008 VA examination; and the results of that examination are consistent with the other evidence of record. There is no indication that his diabetes mellitus requires one or more daily injections of insulin. The Veteran has not alleged such treatment having been prescribed, and the treatment evidence of record does not suggest otherwise. The Board notes that the Veteran is separately service connected for hypertension and diabetic neuropathy of the right and left lower extremities. This Board decision also separately addresses his claims seeking service connection for peripheral neuropathy of the right and left upper extremities. No other complications warranting a separate compensable rating are shown. See 38 C.F.R. § 4.119, Diagnostic Code 7913 (Note 1). Accordingly, the preponderance of the evidence is against assigning an initial evaluation in excess of 20 percent at any point during the period on appeal. 5. Entitlement to an initial evaluation in excess of 10 percent for peripheral neuropathy of the right lower extremity. 6. Entitlement to an initial evaluation in excess of 10 percent for peripheral neuropathy of the left lower extremity. The Veteran contends that he is entitled to higher initial evaluations for his service-connected peripheral neuropathy of the right and left lower extremities. Paralysis of the sciatic nerve is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8520. Under these criteria, mild incomplete paralysis is rated as 10 percent disabling. Moderate incomplete paralysis is rated as 20 percent disabling. Moderately severe incomplete paralysis is rated as 40 percent disabling. Severe incomplete paralysis, with marked muscular atrophy is rated as 60 percent disabling. Complete paralysis, with the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost is rated as 80 percent disabling. 38 C.F.R. § 4.124a. The words “mild,” “moderate,” and “severe” as used in the various Diagnostic Codes are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at “Diseases of the Peripheral Nerves.” The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). The maximum rating which may be assigned for neuritis not characterized by organic changes will be moderately severe incomplete paralysis for sciatic nerve involvement. See 38 C.F.R. § 4.123. Regarding impairment of motor functions, the Veteran’s February 2008 VA examination for peripheral neuropathy noted that there was no motor loss. Physical examination at that time revealed a normal motor examination. Regarding trophic changes, the Veteran’s February 2008 VA examination noted findings of thin skin, absent hair, and dystrophic nails. There were no ulcers, and dorsalis pedis pulse and posterior tibial pulse were both normal. Regarding sensory disturbance, the Veteran’s February 2008 VA examination for peripheral neuropathy noted symptoms of numbness and paresthesias on his toes and feet up to the ankles. Vibration and pain were decreased to the ankle; and light touch and position sense were normal. Regarding loss of reflexes, the February 2008 VA examination for peripheral neuropathy noted that his bilateral knee and ankle reflexes were all 2+; and Babinski reflex on both sides were normal Regarding pain, it was noted to be decreased to the ankle. Regarding muscle atrophy, there was no muscle atrophy present and no abnormal muscle tone or bulk. The Veteran’s gait and balance were also noted to be normal. Regarding complete paralysis, the report noted peripheral neuropathy of the feet, bilaterally, with nerve dysfunction, and absent paralysis, neuritis, and neuralgia. Based on the above, the Board finds that the Veteran’s bilateral lower extremity neuropathies were primarily manifest by decreased vibration and pain to the ankle. The Board also finds that the most probative evidence of record is against a finding that his lower extremity disabilities are manifested by no more than symptoms of numbness and paresthesias on his toes and feet up to the ankles. The Board thus finds that the level of impairment in either the right or left lower extremity is most analogous to no more than mild incomplete paralysis. The Board has considered all other potentially applicable Diagnostic Codes, but there is no evidence showing the Veteran has neurological impairment associated with any other peripheral nerves that have not already been service-connected. Therefore, a separate or higher rating under a different Diagnostic Code is not warranted. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claims for increased initial evaluations in excess of 10 percent for his peripheral neuropathy of his right or left lower extremity. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 7. Entitlement to an initial evaluation in excess of 50 percent for PTSD. The Veteran contends that his PTSD warrants an initial evaluation in excess of 50 percent. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a “holistic analysis” that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). The issue in this appeal is whether the Veteran’s associated symptoms caused the level of impairment required for a disability rating of 70 percent or higher. The Board concludes that the Veteran’s symptoms did not cause the level of impairment required for a disability rating of 70 percent or higher. The Veteran’s symptoms more closely approximated the symptoms associated with a 50 percent rating, and resulted in a level of impairment that most closely approximated the level of impairment associated with a 50 percent rating. A 50 percent rating is assigned when symptoms such 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; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; 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 worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned when symptoms such 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; or memory loss for names of close relatives, own occupation or own name cause total occupational and social impairment. In this case, the Veteran’s VA medical records show that throughout the appeal period he has suffered from depression, anxiety, chronic sleep impairment, occasional panic attacks, mildly impaired recent memory, recurrent and intrusive distressing recollections, avoidance of thoughts and feelings associated with service, difficulty concentrating, hypervigilance, exaggerated startle response, social isolation, irritability and anger. He reported that people make him angry, he avoids going out and he gets angry over little things. See November 2008 VA Mental Health Record. His VA medical records further show that he has suffered from some paranoia. See March 2010 VA Mental Health Record. His VA mental health treatment records show that during the appeal period, he has become more depressed, anxious, irritable and withdrawn, and has very low energy and little motivation. See April 2010, August 2011, February 2012 and January 2013 VA Mental Health Records. More recently, it is noted that the Veteran also suffers from confusion and memory loss, leading to his inability to manage his own medication and leading to a finding of incompetency the handle his VA benefit payments. See October 2013 Examination for Housebound Status. The Board finds the severity, frequency, and duration of the Veteran’s unlisted symptoms more closely approximate the symptoms contemplated by a 50 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by a 70 percent rating. Accordingly, the preponderance of the evidence is against the Veteran's claim for an initial evaluation in excess of 50 percent for his PTSD. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 8. Entitlement to a TDIU rating. VA will grant TDIU when the evidence shows that a veteran is precluded by reason of a service-connected disability or disabilities from obtaining and maintaining substantially gainful employment consistent with his education and occupational experience. 38 C.F.R. § §§ 3.340, 3.341, 4.16. Advancing age, any impairment caused by conditions that are not service connected, and prior unemployability status must be disregarded when determining whether a Veteran is currently unemployable. 38 C.F.R. § §§ 4.16(a), 4.19. A total disability rating may be assigned when the schedular rating is less than total, where, if there is only one disability, the disability is rated at 60 percent or more, or where, if there are two or more disabilities, at least one disability is rated 40 percent or more and there is sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § § 4.16(a). Where the percentage requirements for TDIU are not met, a total disability rating may nevertheless be assigned on an extraschedular basis when the veteran is unable to secure or follow a substantially gainful occupation as a result of his or her service-connected disability or disabilities. 38 C.F.R. § § 4.16(b). The Board is precluded from assigning a TDIU rating on an extraschedular basis in the first instance. Instead, a claim that meets the criteria for referral for consideration of entitlement to a TDIU rating on an extraschedular basis must be referred to the Director of Compensation Service for consideration. See Bowling v. Principi, 15 Vet. App. 1, 10 (2001). For a veteran to prevail on a claim for a TDIU rating, the record must reflect some factor which takes the case outside the norm. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is a recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether the veteran can find employment. See 38 C.F.R. § 4.16(a). Van Hoose v. Brown, 4 Vet. App. 361 (1993). The Veteran’s claim for a TDIU rating arises from his claims filed in January 2008. Initially, the Board concludes that the Veteran meets the preliminary schedular criteria for entitlement to a TDIU rating. The Veteran was service-connected for the following: PTSD, evaluated as 50 percent disabling; residuals of gunshot wound to the right elbow with ulnar nerve, evaluated as 20 percent disabling; diabetes mellitus, type II, evaluated as 20 percent disabling; peripheral neuropathy, right lower extremity, evaluated as 10 percent disabling; peripheral neuropathy, left lower extremity, evaluated as 10 percent disabling; scar, gunshot wound to the right thigh and hypertension, each evaluated as noncompensable. These disabilities result in a combined evaluation of 80 percent, throughout the appeal period. Based upon a longitudinal review of the record, the Board concludes that the evidence does not show that the Veteran had been rendered unemployable by reason of his service-connected disabilities. Pursuant to the Board’s July 2018 remand, the RO requested that the Veteran complete a VA Form 21-8940, Application for Increased Compensation Based on Unemployability, in September 2019. No response to this request was received from the Veteran, and his failure to provide the requested information was noted in the RO’s April 2020 Supplemental Statement of the Case. Moreover, as noted above, the Veteran failed to attend examinations scheduled for him to ascertain the current severity of his service-connected disabilities. A review of the current evidence of record indicates that the Veteran retired from his usual occupation in construction in 2002. His February 2008 VA examination for PTSD noted that his retirement was due to a work-related injury to his thigh. A review of the remaining evidence of record does not suggest that he was precluded from obtaining and securing substantially gainful employment as a result of his service-connected disabilities at any time during the period on appeal. The Veteran’s failure to submit a VA Form 21-8940 has precluded potentially favorable evidence as a completed form could have allowed for verification of the Veteran's work status. See Wood, 1 Vet. App. at 193 (stating that the duty to assist is not always a one-way street, or a blind alley, and that a veteran must be prepared to cooperate with VA's efforts to provide an adequate medical examination and submit all the medical evidence supporting the claim). Moreover, evidence of unemployability due to his service-connected disabilities is not established in the remaining evidence of record. For these reasons, the Board finds that the weight of the evidence demonstrates that the criteria for TDIU rating have not been met at any point throughout the appeal period. Evan M. Deichert Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board W. Yates, 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.