Citation Nr: 21000532 Decision Date: 01/05/21 Archive Date: 01/05/21 DOCKET NO. 13-30 806 DATE: January 5, 2021 ORDER Entitlement to a disability rating in excess of 30 percent from November 4, 2009 to December 9, 2010 for Parkinson's disease, now rated as separate disabilities is denied. Entitlement to an initial disability rating in excess of 40 percent for stooped posture associated with Parkinson's disease is denied. Entitlement to an initial disability rating in excess of 30 percent for right upper extremity (major) tremors associated with Parkinson's disease is denied. Entitlement to an initial disability rating in excess of 20 percent for right lower extremity tremors associated with Parkinson's disease is denied. Entitlement to an initial disability rating in excess of 10 percent for sleep disturbance and sexual dysfunction associated with Parkinson’s disease is denied. Entitlement to an effective date prior to December 9, 2010 for the award of a separate disability rating for right lower extremity tremors associated with Parkinson's disease is denied. Entitlement to an effective date prior to August 8, 2013 for the award of a separate disability rating for stooped posture associated with Parkinson's disease is denied. Entitlement to an effective date prior to December 9, 2010 for the award of a separate disability rating for right (major) upper extremity tremors associated with Parkinson's disease is denied. Entitlement to an effective date prior to August 8, 2013 for the award of a separate disability rating for sleep disturbance and sexual dysfunction associated with Parkinson's disease is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) prior to August 8, 2013 is denied. FINDINGS OF FACT 1. For the period of November 4, 2009 to December 9, 2010, the symptoms owing to the Veteran's service-connected Parkinson's disease are most appropriately evaluated collectively, at 30 percent disabling, under Diagnostic Code 8004. 2. At all times relevant to the appeal, the Veteran's stooped posture associated with Parkinson's disease has been mild to moderate in severity but has not resulted in any unfavorable ankylosis of the entire thoracolumbar spine or unfavorable ankylosis of the entire spine. 3. At all times relevant to the appeal, the Veteran’s right (major) upper extremity tremors associated with Parkinson's disease has been no worse than moderate in severity. 4. At all times relevant to the appeal, the Veteran’s right lower extremity tremors associated with Parkinson's disease has been no worse than moderate in severity. 5. At all times relevant to the appeal, the Veteran’s sleep disturbance and sexual dysfunction associated with Parkinson’s' disease has been no worse than intermittent and mild in severity. 6. The criteria for entitlement to an effective date prior to December 9, 2010 for the award of a separate disability rating for right lower extremity tremors associated with Parkinson's disease have not been met. 7. The criteria for entitlement to an effective date prior to August 8, 2013 for the award of a separate disability rating for stooped posture associated with Parkinson's disease have not been met. 8. The criteria for entitlement to an effective date prior to December 9, 2010 for the award of a separate disability rating for right (major) upper extremity tremors associated with Parkinson's disease have not been met. 9. The criteria for entitlement to an effective date prior to August 8, 2013 for the award of a separate disability rating for sleep disturbance and sexual dysfunction associated with Parkinson's disease have not been met. 10. The evidence of record does not support a finding that the Veteran's ischemic heart disease, Parkinson’s disease, right upper extremity tremor and right lower extremity tremor rendered him unemployable prior to August 8, 2013. CONCLUSIONS OF LAW 1. The criteria for entitlement to a disability rating in excess of 30 percent from November 4, 2009 to December 9, 2010 for Parkinson's disease, now rated as separate disabilities have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8004. 2. The criteria for entitlement to an initial disability rating in excess of 40 percent for stooped posture associated with Parkinson's disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5299-5237. 3. The criteria for entitlement to an initial disability rating in excess of 30 percent for right (major) upper extremity tremors associated with Parkinson's disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8515. 4. The criteria for entitlement to an initial disability rating in excess of 20 percent for right lower extremity tremors associated with Parkinson's disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8520. 5. The criteria for entitlement to an initial disability rating in excess of 10 percent for sleep disturbance and sexual dysfunction associated with Parkinson’s disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.115b, 4.130, Diagnostic Codes 7522-9434. 6. The criteria for entitlement to an effective date prior to December 9, 2010 for the award of a separate disability rating for right lower extremity tremors associated with Parkinson's disease have not been met. 38 U.S.C. §§ 1155, 5110, 5107; 38 C.F.R. §§ 3.400, 4.124a, Diagnostic Code 8520. 7. The criteria for entitlement to an effective date prior to August 8, 2013 for the award of a separate disability rating for stooped posture associated with Parkinson's disease have not been met. 38 U.S.C. §§ 1155, 5110, 5107; 38 C.F.R. §§ 3.400, 4.71a, Diagnostic Code 5299-5237. 8. The criteria for entitlement to an effective date prior to December 9, 2010 for the award of a separate disability rating for right (major) upper extremity tremors associated with Parkinson's disease have not been met. 38 U.S.C. §§ 1155, 5110, 5107; 38 C.F.R. §§ 3.400, 4.124a, Diagnostic Code 8515. 9. The criteria for entitlement to an effective date prior to August 8, 2013 for the award of a separate disability rating for sleep disturbance and sexual dysfunction associated with Parkinson's disease have not been met. 38 U.S.C. §§ 1155, 5110, 5107; 38 C.F.R. §§ 3.400, 4.115b, 4.130, Diagnostic Code 7522-9434. 10. The criteria for TDIU or referral to the Director of Compensation and Pension for consideration of a TDIU under 38 C.F.R. § 4.16(b) have not been met as a matter of law. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.18, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from September 1967 to April 1969. These matters come before the Board of Veterans’ Appeals (Board) on appeal from November 2010 and September 2013 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California. In a September 2019 Joint Motion for Remand (JMR), the United States Court of Appeals for Veteran Claims (Court) vacated a September 2018 Board decision and remanded the matters back to the Board. These matters were last before the Board in March 2020, at which time they were remanded for further development. The Board finds that there has been substantial compliance and that it may now proceed with a decision. Stegall v. West, 11 Vet. App. 268, 271 (1998). Increased Rating 1. Entitlement to a disability rating in excess of 30 percent from November 4, 2009 to December 9, 2010 for Parkinson's disease, now rated as separate disabilities. The Veteran contends that he is entitled to a disability rating in excess of 30 percent from November 4, 2009 to December 9, 2010 for Parkinson’s disease, now rated as separate disabilities. In a November 2010 rating decision, service connection was granted for Parkinson’s disease, effective November 4, 2009. The Veteran's Parkinson's disease was rated at 30 percent under Diagnostic Code (DC) 8004. DC 8004 provides for a minimum rating of 30 percent for paralysis agitans. 38 C.F.R. § 4.124a. Paralysis agitans is also known as Parkinson's disease. Dorland's Illustrated Medical Dictionary, 972 (26th ed. 1990). The minimum rating is the only rating provided for under Diagnostic Code 8004. If, however, there are identifiable residuals that can be rated under a separate diagnostic code or codes and the combined disability rating resulting from these residuals exceeds 30 percent, the separate ratings will be assigned in place of the minimum rating assigned under Diagnostic Code 8004. VA must also analyze individual symptoms under the appropriate diagnostic code for that bodily system. See 38 C.F.R. § 4.124a. In a September 2013 rating decision, service connection was granted for right upper extremity tremors (30 percent, effective December 9, 2010), right lower extremity tremors (20 percent, effective December 9, 2010), sleep disturbance and sexual dysfunction (10 percent, effective August 8, 2013) and stooped posture (40 percent, effective August 8, 2013). As such, the Veteran’s Parkinson’s disease rating only covers the period of November 4, 2009 to December 9, 2010. The separately rated residuals will be evaluated separately. A November 2, 2009 private treatment record from Dr. R. S. Pathak notes the Veteran had been under his care since February 11, 2004 and having seen him last on October 7, 2009. A diagnosis of Parkinson's Disease was noted with three current medications being taken. A November 11, 2009 letter from Dr. R. S. Pathak notes the Veteran reported that his tremor was better, but ongoing. A November 12, 2009 private treatment record from Marshall Medical Center notes the Veteran reported some constipation. In a December 5, 2009 Social Security Administration (SSA) Function Report, the Veteran stated that he exercises three times per week at the gym, dresses himself, shaves, showers, runs errands, including grocery shopping and performs household and yard chores. He then stated that due to his Parkinson's he "can't grip anything well" and that he wakes up in the middle of the night and is unable to get back to sleep. He reported hobbies of kayaking, golfing and photography, stating that he was no longer able to do the latter as the pictures turn out poor. He reported pain from lifting and stated that performing tasks takes longer due to his shaking hands. A December 31, 2009 private treatment record from Dr. K. R. Desai notes the Veteran's Parkinson's disease is "active and asymptomatic." The Veteran was afforded a VA examination in January 2010. A diagnosis of Parkinson's disease was noted. He reported developing tremors in his right hand 2000/2001 and that he could not continue working as a meat cutter due to the increasing tremor of his right hand. He further reported experiencing right arm and right leg tremors, with no tremor to his left side. He denied difficulty with walking and denied using an assistive device. Rigidity was not noted. A January 19, 2010 SSA physical residual functional capacity report notes the Veteran has Parkinson's disease with some left cogwheel rigidity, non-ataxic gait, decreased right arm swing, and resting tremor of the hands. A September 16, 2010 letter from Dr. R. S. Pathak, notes the Veteran still has tremors but also has good balance and stable gait with equal arm swing and good stride. On November 4, 2010, VA received a letter from S. M., the Veteran's daughter, who stated that over the prior year his leg tremor affects his driving, limiting him to a 20-mile radius of his house. She then stated that he rarely writes due to his right-hand tremor and using a computer is now a challenge. She stated that his tremor limits his ability to take pictures. A December 9, 2010 letter from Dr. R. S. Pathak notes the Veteran has right leg weakness and "having more shaking". including continuous shaking of his right arm and right leg. It was also noted that he "sweats a lot", has "marked difficulty playing golf" and can only drive locally. It was then noted that he does not have sleepiness, dizziness, nausea, vomiting or weight loss. Speech was noted as normal. The doctor stated that the Veteran has Parkinson's disease which is a progressive neurodegenerative disease and that his "disability may worsen in [the] future, with time." The Board finds that for the entire appeal period, the symptoms related to the Veteran's service-connected Parkinson's disease are most appropriately rated collectively under Diagnostic Code 8004. The Board acknowledges the Veteran’s reported symptoms, however, the record does not support that the Veteran’s symptoms were of such a severity to warrant separate ratings in excess of 30 percent. Specifically, with regard to his right upper and lower extremities, there is no competent or credible evidence that the Veteran had symptoms which were of such severity that the 30 percent did not adequately compensate him. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102; 4.3. Neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record. See, Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017). 2. Entitlement to an initial disability rating in excess of 40 percent for stooped posture associated with Parkinson's disease. The Veteran contends that he is entitled to an initial disability rating in excess of 40 percent for stooped posture associated with Parkinson’s disease. The Veteran’s stooped posture is rated 40 percent disabling by analogy under 38 C.F.R. § 4.71a, Hyphenated Diagnostic Code 5299-5237 (addressing the lumbar or cervical spine). Based upon the nature of the Veteran’s symptoms, the Board agrees that this is the most appropriate diagnostic code. A rating in excess of 40 percent is warranted for a lumbar or cervical spine disability when the evidence shows unfavorable ankylosis of the entire thoracolumbar spine (60 percent) or unfavorable ankylosis of the entire spine (100 percent). 38 C.F.R. § 4.71a, Diagnostic Code 5237. An April 11, 2013 VA treatment record notes the Veteran's speech was fluent. Bilateral, postural hand tremors were noted, as was right hand resting tremor. Stooped posture was noted. An August 5, 2013 letter from Dr. R. S. Pathak notes that the Veteran reported feeing "that his symptoms are under excellent control" and now has minimal shaking. His balance was noted as good and it was further noted that he plays golf, goes fishing and can drive. The doctor stated that the Veteran "is able to do everything that he likes." VA obtained a Parkinson's disease disability benefits questionnaire (DBQ) in August 2013. A diagnosis of Parkinson's disease was noted. The Veteran was noted as being right-handed, having moderate drooped posture, mild gait impairment, mild bradykinesia and no loss of automatic movements or speech changes. In a September 19, 2013 Parkinson's disease DBQ, Dr, R, S, Pathak notes the Veteran's Parkinson's disease was manifested by, among others, mild stooped posture. VA obtained a Parkinson's disease DBQ in May 2020. Mild stooped posture was noted a symptom of the Veteran’s Parkinson's disease. Here, the evidence of record shows that at all times relevant to the appeal, the Veteran’s stooped posture associated with Parkinson’s disease has been no worse than mild to moderate, as described by both Dr R. S. Pathak and VA examiners. The evidence of record does not contain any findings of ankylosis, favorable or unfavorable, or symptoms more closely resembling such. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102; 4.3. Neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record. See, Doucette. 3. Entitlement to an initial disability rating in excess of 30 percent for right (major) upper extremity tremors associated with Parkinson's disease. The Veteran contends that he is entitled to an initial disability rating in excess of 30 percent for right (major) upper extremity tremors associated with Parkinson’s disease. The Veteran’s right (major) upper extremity tremors associated with Parkinson's disease is rated 30 percent disabling by analogy under 38 C.F.R. § 4.124a, Diagnostic Code 8515 (addressing paralysis of the median nerve). Based upon the nature of the Veteran’s symptoms, the Board agrees that this is the most appropriate diagnostic code. Under DC 8515, for incomplete paralysis, as is the case here, a 10 percent disability rating is warranted if the condition is "mild" regardless of whether the afflicted hand is the dominant or non-dominant side. If the disability is considered "moderate," a 30 percent disability rating is warranted for the dominant hand, while a 20 percent disability rating is warranted for the non-dominant hand. If the disability is considered "severe," the regulation provides for a 50 percent disability rating for the dominant hand and a 40 percent rating for the non-dominant hand. 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). 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. See 38 C.F.R. § 4.69. The Veteran is right-handed. A December 9, 2010 letter from Dt. R. S. Pathak notes the Veteran was "having more shaking", including continuous shaking of his right arm. On December 21, 2010, VA received a letter from V. J. M., the Veteran's wife, who stated that what started as a small tremor in his right hand "has since claimed the right side of his body and has continued to get more severe." She then stated that his writing is now "unreadable scribble" and that ice packs have to be applied to his right wrist every evening due to "disfiguring swelling and pain." A June 7, 2011 letter from Dr. R. S. Pathak notes the Veteran expressed feeling "that his symptoms are under excellent control." It was noted that he does not have shaking, has good balance and "is able to do everything that he likes." It was also noted that he golfs, goes fishing and can drive. An August 7, 2012 letter from Dr. R. S. Pathak notes the Veteran expressed feeling "that his symptoms are under excellent control." It was noted that he has "minimal shaking", has good balance and "is able to do everything that he likes." It was also noted that he golfs and goes fishing. An August 7, 2012 letter from Dr. R. S. Pathak notes the Veteran expressed feeling "that his symptoms are under excellent control." It was noted that he has "minimal shaking", has good balance and "is able to do everything that he likes." It was also noted that he golfs and goes fishing. A February 4, 2013 letter from Dr. R. S. Pathak notes the Veteran expressed feeling "that his symptoms are under excellent control." It was noted that he has "minimal shaking", has good balance and "is able to do everything that he likes." It was also noted that he golfs and goes fishing. An August 5, 2013 letter from Dr. R. S. Pathak notes that the Veteran reported feeing "that his symptoms are under excellent control" and now has minimal shaking. It was further noted that he plays golf, goes fishing and can drive. The doctor stated that the Veteran "is able to do everything that he likes." VA obtained a Parkinson's disease DBQ in August 2013. A diagnosis of Parkinson's disease was noted. The Veteran was noted as being right-handed and having moderate right upper extremity tremors and rigidity. He reported working as a meat cutter until 2009 when he could not continue due to tremors causing difficulties holding the knife or saw. He further reported that is learning to use his left hand for daily activities and cannot drive longer than 12 miles. In a September 19, 2013 Parkinson's disease DBQ, Dr, R, S, Pathak notes the Veteran's Parkinson's disease was manifested by moderate right upper extremity tremor and rigidity were noted. VA obtained a Parkinson's disease DBQ in May 2020. A diagnosis of Parkinson's disease was noted with moderate right upper extremity tremor and rigidity. The examiner noted that the evidence of record is "silent for any chronic report follow up, or treatment for any ongoing [Parkinson's]." Here, the evidence of record shows that at all times relevant to the appeal, the Veteran’s right (major) upper extremity tremors associated with Parkinson’s disease has been no worse than moderate, as described by VA examiners. The Board acknowledges the lay statement from the Veteran’s wife that his right sided tremors have become more severe and note that she is certainly competent to report observable symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). However, the Board cannot ignore the numerous letters from Dr. Pathak subsequent to this statement that note the Veteran expressed feeling "that his symptoms are under excellent control", that he does not have shaking, has good balance and "is able to do everything that he likes", including golfing and fishing. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102; 4.3. Neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record. See, Doucette. 4. Entitlement to an initial disability rating in excess of 20 percent for right lower extremity tremors associated with Parkinson's disease. The Veteran contends that he is entitled to an initial disability rating in excess of 20 percent for right lower extremity tremors associated with Parkinson’s disease. The Veteran’s right lower extremity tremors associated with Parkinson’s disease are rated by analogy under 38 C.F.R. § 4.124a, Diagnostic Code 8520, paralysis of the sciatic nerve. 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. On November 4, 2010, VA received a letter from S. M., the Veteran's daughter, who stated that over the prior year his leg tremor affects his driving, limiting him to a 20-mile radius of his house. A December 9, 2010 letter from Dt. R. S. Pathak notes the Veteran has right leg weakness and "having more shaking", including continuous shaking of his right arm and right leg. It was also noted that he has "marked difficulty playing golf" and can only drive locally. On December 21, 2010, VA received a letter from V. J. M., the Veteran's wife, who stated that the Veteran’s right leg tremor has limited him to only driving short distances. A June 7, 2011 letter from Dr. R. S. Pathak notes the Veteran expressed feeling "that his symptoms are under excellent control." It was noted that he does not have shaking, has good balance and "is able to do everything that he likes." It was also noted that he golfs, goes fishing and can drive. An August 7, 2012 letter from Dr. R. S. Pathak notes the Veteran expressed feeling "that his symptoms are under excellent control." It was noted that he has "minimal shaking", has good balance and "is able to do everything that he likes." It was also noted that he golfs and goes fishing. An August 7, 2012 letter from Dr. R. S. Pathak notes the Veteran expressed feeling "that his symptoms are under excellent control." It was noted that he has "minimal shaking", has good balance and "is able to do everything that he likes." It was also noted that he golfs and goes fishing. A February 4, 2013 letter from Dr. R. S. Pathak notes the Veteran expressed feeling "that his symptoms are under excellent control." It was noted that he has "minimal shaking", has good balance and "is able to do everything that he likes." It was also noted that he golfs and goes fishing. An August 5, 2013 letter from Dr. R. S. Pathak notes that the Veteran reported feeing "that his symptoms are under excellent control" and now has minimal shaking. His balance was noted as good, and it was further noted that he plays golf, goes fishing and can drive. The doctor stated that the Veteran "is able to do everything that he likes." VA obtained a Parkinson's DBQ in August 2013. A diagnosis of Parkinson's disease was noted. The Veteran was noted as having mild gait impairment and mild bradykinesia. Moderate right lower extremity tremors and rigidity were noted. He further reported that he cannot drive longer than 12 miles. In a September 19, 2013 Parkinson's disease DBQ, Dr, R, S, Pathak notes the Veteran's Parkinson's disease was manifested by, among other symptoms, mild right lower extremity tremor and rigidity. VA obtained a Parkinson's disease DBQ in May 2020. A diagnosis of Parkinson's disease was noted with mild right lower extremity tremor and rigidity. The examiner noted that the evidence of record is "silent for any chronic report follow up, or treatment for any ongoing [Parkinson's]." Here, the evidence of record shows that at all times relevant to the appeal, the Veteran’s right lower extremity tremors associated with Parkinson’s disease have more closely resembled that contemplated by the 20 percent “moderate” rating. The Board acknowledges the lay statement from the Veteran’s wife that his right sided tremors have become more severe and note that she is certainly competent to report observable symptoms. Layno. However, the Board cannot ignore the numerous letters from Dr. Pathak subsequent to this statement that note the Veteran expressed feeling "that his symptoms are under excellent control", that he does not have shaking or that the shaking is minimal, has good balance and "is able to do everything that he likes", including golfing and fishing. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102; 4.3. Neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record. See, Doucette. 5. Entitlement to an initial disability rating in excess of 10 percent for sleep disturbance and sexual dysfunction associated with Parkinson’s disease. The Veteran contends that he is entitled to an initial disability rating in excess of 10 percent for sleep disturbance and sexual dysfunction associated with Parkinson’s disease. The Veteran’s sleep disturbance and sexual dysfunction associated with Parkinson’s disease has been rated at 10 percent disabling under 38 U.S.C. §§ 4.130, 4.115b, Hyphenated Diagnostic Code 7522-9434. As there is no specific disability rating for sexual dysfunction in the VA Rating Schedule, the Veteran's service-connected sexual dysfunction is rated by analogy under 38 C.F.R. § 4.115b, Diagnostic Code 7522, referring to deformity of the penis with loss of erectile power. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. See 38 C.F.R. § 4.31. Under Diagnostic Code 7522, the only schedular evaluation available is a 20 percent rating for a deformity of the penis with loss of erectile power. As "deformity" is not defined in the rating criteria, the term is given its ordinary meaning. See, Prokarym v. McDonald, 27 Vet. App. 307, 310 (2015). In medical terminology, a "deformity" is a "distortion of any part or general disfigurement of the body." See, Dorland's Illustrated Medical Dictionary 478 (32 ed. 2012). In this regard, the Board notes its reliance on a medical dictionary to define a term is appropriate. 38 C.F.R. § 20.903(b)(2) (while Board consideration of a medical treatise requires notice to the Veteran and his representative, such notice is not required if the Board uses the treatise or a medical dictionary for the limited purpose of defining a medical term and that definition is not material to the Board's disposition of the appeal). Furthermore, a "deformity" under Diagnostic Codes 7599-7522 means either an internal or external distortion of the penis. See, Williams v. Wilkie, 30 Vet. App. 134, 138 (2018). The actual criteria for rating psychiatric disabilities other than eating disorders are set forth in a General Rating Formula for Mental Disorders (General Rating Formula). See 38 C.F.R. § 4.130. Under the General Rating Formula, a 10 percent rating is assigned for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. A 30 percent rating is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. To warrant the next higher, 70 percent rating, the evidence must show occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and an inability to establish and maintain effective relationships. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. VA obtained a Parkinson's DBQ on August 8, 2013. A diagnosis of Parkinson's disease was noted. No changes in speech, depression or cognitive impairment were noted. Mild sleep impairment and sexual dysfunction were noted. He reported working as a meat cutter until 2009 when he could not continue due to tremors causing difficulties holding the knife or saw. He further reported that is learning to use his left hand for daily activities and cannot drive longer than 12 miles. In a September 19, 2013 Parkinson's disease DBQ, Dr, R, S, Pathak notes the Veteran's Parkinson's disease was manifested by, among other symptoms, mild sleep disturbance. VA obtained a Parkinson's disease DBQ in May 2020. A diagnosis of Parkinson's disease was noted, but not sexual dysfunction or sleep disturbance. Here, the evidence of record reflects that the Veteran’s sleep disturbance and sexual dysfunction are not chronic, but mild and intermittent at worst. There is no indication that the Veteran has penile deformity and he has not reported any penile deformity. Furthermore, the only evidence regarding functional impact deals with the Veteran’s tremors. No functional impact from his mild, intermittent sleep and sexual dysfunction has been noted in the evidence of record. As such, the Board finds that the Veteran’s symptoms of mild, intermittent sleep and sexual dysfunction more closely resemble that of the 10 percent level. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102; 4.3. Neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record. See, Doucette. Effective Date 6. Entitlement to an effective date prior to December 9, 2010 for the award of a separate disability rating for right lower extremity tremors associated with Parkinson's disease. The Veteran contends that he is entitled to an effective date prior to December 9, 2010 for the award of a separate disability rating for right lower extremity tremors associated with Parkinson’s disease. As noted above, in a November 2010 rating decision, service connection was granted for Parkinson’s disease, effective November 4, 2009, and was rated at 30 percent under DC 8004, which provides for a minimum rating of 30 percent for paralysis agitans. Further, if there are identifiable residuals that can be rated under a separate diagnostic code or codes and the combined disability rating resulting from these residuals exceeds 30 percent, the separate ratings will be assigned in place of the minimum rating assigned under Diagnostic Code 8004. VA must also analyze individual symptoms under the appropriate diagnostic code for that bodily system. See 38 C.F.R. § 4.124a. In general, the effective date of an award of compensation and rating based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400. When evidence demonstrates that a factually ascertainable increase in disability occurred within the one-year period preceding the date of receipt of a claim for increased compensation, the effective date of the award shall be the earliest date as of which it is ascertainable that an increase in disability had occurred, if application is received within one year from that date. 38 U.S.C. § 5110 (b)(2); 38 C.F.R. § 3.400 (o)(2); Harper v. Brown, 10 Vet. App. 125 (1997). A "claim" is defined broadly to include a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1 (p). Any communication indicating an intent to apply for a benefit under the laws administered by the VA may be considered an informal claim provided it identifies, but not necessarily with specificity, the benefit sought. See 38 C.F.R. § 3.155 (a). The reference above to "the date entitlement arose" is not defined in the current statute or regulation. The U.S. Court of Appeals for Veterans Claims (CAVC) has interpreted it as the date when the claimant met the requirements for the benefits sought; this is determined on a "facts found" basis. See 38 U.S.C. § 5110 (a); see also, McGrath v. Gober, 14 Vet. App. 28, 35 (2000). A November 2, 2009 private treatment record from Dr. R. S. Pathak notes the Veteran had been under his care since February 11, 2004 and having seen him last on October 7, 2009. A diagnosis of Parkinson's Disease was noted with 3 current medications being taken. A November 11, 2009 letter from Dr. R. S. Pathak notes the Veteran reported that his tremor was better, but ongoing. In a December 5, 2009 Social Security Administration (SSA) Function Report, the Veteran stated that he exercises 3 times per week at the gym, dresses himself, shaves, showers, runs errands, including grocery shopping and performs household and yard chores. He then stated that due to his Parkinson's he "can't grip anything well" and that he wakes up in the middle of the night and is unable to get back to sleep. He reported hobbies of kayaking, golfing and photography, stating that he was no longer able to do the latter as the pictures turn out poor. He reported pain from lifting and stated that performing tasks takes longer due to his shaking hands. A December 31, 2009 private treatment record from Dr. K. R. Desai notes the Veteran's Parkinson's disease is "active and asymptomatic." The Veteran was afforded a VA examination in January 2010. A diagnosis of Parkinson's disease was noted. He reported developing tremors in his right hand 2000/2001 and that he could not continue working as a meat cutter due to the increasing tremor of his right hand. He further reported experiencing right arm and right leg tremors, with no tremor to his left side. He denied difficulty with walking and denied using an assistive device. Rigidity was not noted. A January 19, 2010 SSA physical residual functional capacity report notes the Veteran has Parkinson's disease with some left cogwheel rigidity, non-ataxic gait, decreased right arm swing, and resting tremor of the hands. A September 16, 2010 letter from Dr. R. S. Pathak, notes the Veteran still has tremors but also has good balance and stable gait with equal arm swing and good stride. On November 4, 2010, VA received a letter from S. M., the Veteran's daughter, who stated that over the prior year his leg tremor affects his driving, limiting him to a 20-mile radius of his house. She then stated that he rarely writes due to his right-hand tremor and using a computer is now a challenge. She stated that his tremor limits his ability to take pictures. A December 9, 2010 letter from Dt. R. S. Pathak notes the Veteran has right leg weakness and "having more shaking", including continuous shaking of his right arm and right leg. It was also noted that he has "marked difficulty playing golf" and can only drive locally. Here, the evidence of record documents the presence of the Veteran's various Parkinson's disease residuals prior to December 9, 2010 and notes that there is no probative evidence that such residuals resulted in symptomatology that warranted the assignment of a combined disability rating in excess of the previously assigned minimum 30 percent disability rating which contemplates ascertainable residuals of Parkinson's disease. As such, an effective date prior to December 9, 2010 for right lower extremity tremors associated with Parkinson’s disease is not warranted as prior to this date it was appropriately contemplated by the assigned 30 percent disability rating for Parkinson's disease with ascertainable residuals. See 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 7. Entitlement to an effective date prior to August 8, 2013 for the award of a separate disability rating for stooped posture associated with Parkinson's disease. The Veteran contends that they are entitled to an effective date prior to August 8, 2013 for the award of a separate disability rating for stooped posture associated with Parkinson’s disease. An April 11, 2013 VA neurological consult treatment record notes the Veteran had stooped posture. An August 5, 2013 letter from Dr. R. S. Pathak notes that the Veteran reported feeing "that his symptoms are under excellent control" and now has minimal shaking. His balance was noted as good, as was his memory. It was further noted that he plays golf, goes fishing and can drive. The doctor stated that the Veteran "is able to do everything that he likes." It was noted that he had been "feeling more sleepy." Upon examination, paralysis agitans was assessed. No extrapyramidal findings were noted. VA obtained a Parkinson's disease DBQ on August 8, 2013 in which moderate drooped posture was noted. Here, the Board notes that a thorough search of the evidence of record reveals that the earliest evidence of stooped posture was the April 11, 2013 VA treatment record. However, the Board notes that that record does not contain any determination as to whether that stooped posture was associated with Parkinson’s disease. Further, the August 5, 2013 record from Dr. Pathak does not mention the Veteran’s posture at all. As such, the Board finds that the earliest effective date for the Veteran’s stooped posture associated with his Parkinson’s disease is August 8, 2013, which is the date on which such diagnosis was rendered. See 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3; Gilbert. 8. Entitlement to an effective date prior to December 9, 2010 for the award of a separate disability rating for right (major) upper extremity tremors associated with Parkinson's disease. The Veteran contends that he is entitled to an effective date prior to December 9, 2010 for the award of a separate disability rating for right (major) upper extremity tremors associated with Parkinson’s disease. Here, based on the evidence discussed above, the evidence of record documents the presence of the Veteran's various Parkinson's disease residuals prior to December 9, 2010 and notes that there is no probative evidence that such residuals resulted in symptomatology that warranted the assignment of a combined disability rating in excess of the previously assigned minimum 30 percent disability rating which contemplates ascertainable residuals of Parkinson's disease. As such, an effective date prior to December 9, 2010 for right (major) upper extremity tremors associated with Parkinson’s disease is not warranted as prior to this date it was appropriately contemplated by the assigned 30 percent disability rating for Parkinson's disease with ascertainable residuals. See 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3; Gilbert. 9. Entitlement to an effective date prior to August 8, 2013 for the award of a separate disability rating for sleep disturbance and sexual dysfunction associated with Parkinson's disease. The Veteran contends he is entitled to an effective date prior to August 8, 2013 for the award of a separate disability rating for sleep disturbance and sexual dysfunction associated with Parkinson’s disease. A February 20, 2007 letter from Dr. R. S. Pathak notes the Veteran has noticed decreased libido, but still has good balance and memory. A September 9, 2008 letter from Dr. R. S. Pathak notes the Veteran has bilateral hand tremor. He reported that he sometimes wakes up in the middle of the night had feels shaky. Erectile dysfunction that is part of his Parkinson's disease was noted. A December 31, 2009 private treatment record from Dr. K. R. Desai notes the Veteran's Parkinson's disease is "active and asymptomatic." A December 21, 2010, VA received a letter from V. J. M., the Veteran's wife, who stated that the Veteran wakes up once or twice per night, causing him to take more medication. A June 7, 2011 letter from Dr. R. S. Pathak notes the Veteran expressed feeling "that his symptoms are under excellent control." It was noted that he does not have shaking, has good balance and "is able to do everything that he likes." It was also noted that he golfs, goes fishing and can drive. An August 7, 2012 letter from Dr. R. S. Pathak notes the Veteran expressed feeling "that his symptoms are under excellent control." It was noted that he has "minimal shaking", has good balance and "is able to do everything that he likes." It was also noted that he golfs and goes fishing. An August 7, 2012 letter from Dr. R. S. Pathak notes the Veteran expressed feeling "that his symptoms are under excellent control." It was noted that he has "minimal shaking", has good balance and "is able to do everything that he likes." It was also noted that he golfs and goes fishing. A February 4, 2013 letter from Dr. R. S. Pathak notes the Veteran expressed feeling "that his symptoms are under excellent control." It was noted that he has "minimal shaking", has good balance and "is able to do everything that he likes." It was also noted that he golfs and goes fishing. A March 18, 2013 VA treatment record notes the Veteran's symptoms are "usually fairly well controlled." An August 5, 2013 letter from Dr. R. S. Pathak notes that the Veteran reported feeing "that his symptoms are under excellent control" and that he "is able to do everything that he likes." It was noted that he had been "feeling more sleepy." VA obtained a Parkinson's disease disability benefits questionnaire (DBQ) on August 8, 2013. A diagnosis of Parkinson's disease was noted, with associated mild sexual dysfunction and mild sleep disturbance. Here, the Board finds that prior to the August 8, 2013 VA DBQ, the evidence of indicated identified some sexual and sleep complaints but notes that these were at most sporadic and that the evidence reflected that the Veteran’s symptoms were mostly well-controlled, and at times asymptomatic. Here, the first evidence showing sleep and sexual dysfunction as measurable residuals of Parkinson’s disease was obtained with the August 8, 2013 VA DBQ and, as such, an earlier effective date is not warranted. See 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3; Gilbert. 10. Entitlement to a TDIU prior to August 8, 2013. It is the established policy of VA that all Veterans who are unable to secure and follow a substantially gainful occupation because of service-connected disabilities shall be rated totally disabled. 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 make it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. §§ 3.340(a)(1), 4.15. A TDIU may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In exceptional circumstances, where the Veteran does not meet those percentage requirements, a total rating may nonetheless be assigned upon a showing that the individual is unable to obtain or retain substantially gainful employment due to service-connected disability. 38 C.F.R. § 4.16(b). Under Chapter 51 of Title 38 of the United States Code, the effective date for an increased rating for disability compensation will be the date entitlement arose, the earliest date as of which it is factually ascertainable that an increase in disability occurred if a claim is received within one year from such date, or the date of receipt of the claim, whichever is later. 38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400(o); Gaston v. Shinseki, 605 F.3d 979, 984 (Fed. Cir. 2010). A TDIU claim is a claim for increased compensation; therefore, the effective date rules for increased compensation apply to a TDIU claim. See, Hurd v. West, 13 Vet. App. 449 (2000). In a February 2015 rating decision, the Veteran was granted TDIU as of August 8, 2013. As of that date, the Board notes that the Veteran had a combined disability evaluation of 70 percent, with his Parkinson’s disease being evaluated by itself at 40 percent. As such, TDIU was awarded as of August 8, 2013 on a schedular basis. Prior to August 8, 2013, the Veteran was service connected for ischemic heart disease at 10 percent from November 2009 forward, Parkinson’s disease at 30 percent from November 2009 to December 2010, and then with right upper extremity tremor at 30 percent and right lower extremity tremor at 20 percent, both from December 2010 forward. At no time prior to August 8, 2013 did the Veteran have at least one disability ratable at 40 percent or more nor was there sufficient additional service-connected disability to bring the combined rating to 70 percent or more. If a veteran fails to meet the rating enunciated in 38 C.F.R. § 4.16(a), an extraschedular rating is for consideration where a veteran is unemployable due to service-connected disability. 38 C.F.R. § 4.16(b). However, the Board is prohibited from assigning a TDIU on the basis of 38 C.F.R. § 4.16(b) in the first instance without ensuring that the claim was referred to VA's Director for Compensation and Pension (Director) for consideration of an extraschedular rating under 38 C.F.R. § 4.16(b). The Board has considered whether the Veteran’s service-connected ischemic heart disease, Parkinson’s disease and right-sided extremity tremors rendered him unable to work prior to August 8, 2013. Here, the evidence of record indicates that the Veteran worked as a meat cutter from June 1972 to June 2008 and has a high school education. In a Social Security Administration (SSA) Work History Report, the Veteran described his job duties as cleaning, cutting and trimming meat, putting it in containers and displays, using hand tools and power equipment, cleaning his work area, unloading delivery trucks and placing meat in a refrigerator, collecting money for sales, tracking ground meat logs, keeping sanitation reports and temperature checks. He further reported that supervising people was part of his job and that he spent “almost all day” supervising people. A November 2, 2009 private treatment record from Dr. R. S. Pathak notes the Veteran had been under his care since February 11, 2004 and having seen him last on October 7, 2009. A diagnosis of Parkinson's Disease was noted with 3 current medications being taken. A November 11, 2009 letter from Dr. R. S. Pathak notes the Veteran reported that his tremor was better, but ongoing. In a December 5, 2009 SSA Function Report, the Veteran stated that he exercises 3 times per week at the gym, dresses himself, shaves, showers, runs errands, including grocery shopping and performs household and yard chores. He then stated that due to his Parkinson's he "can't grip anything well" and that he wakes up in the middle of the night and is unable to get back to sleep. He reported hobbies of kayaking, golfing and photography, stating that he was no longer able to do the latter as the pictures turn out poor. He reported pain from lifting and stated that performing tasks takes longer due to his shaking hands. A December 31, 2009 private treatment record from Dr. K. R. Desai notes the Veteran's Parkinson's disease is "active and asymptomatic." The Veteran was afforded a VA examination in January 2010. A diagnosis of Parkinson's disease was noted. He reported developing tremors in his right hand 2000/2001 and that he could not continue working as a meat cutter due to the increasing tremor of his right hand. He further reported experiencing right arm and right leg tremors, with no tremor to his left side. He denied difficulty with walking and denied using an assistive device. Rigidity was not noted. A September 16, 2010 letter from Dr. R. S. Pathak, notes the Veteran still has tremors but also has good balance and stable gait with equal arm swing and good stride. On November 4, 2010, VA received a letter from S. M., the Veteran's daughter, who stated that over the prior year his leg tremor affects his driving, limiting him to a 20-mile radius of his house. She then stated that he rarely writes due to his right-hand tremor and using a computer is now a challenge. She stated that his tremor limits his ability to take pictures. A December 9, 2010 letter from Dt. R. S. Pathak notes the Veteran has right leg weakness and "having more shaking". including continuous shaking of his right arm and right leg. It was also noted that he "sweats a lot", has "marked difficulty playing golf" and can only drive locally. It was then noted that he does not have sleepiness, dizziness, nausea, vomiting or weight loss. Speech was noted as normal. The doctor stated that the Veteran has Parkinson's disease which is a progressive neurodegenerative disease and that his "disability may worsen in [the] future, with time." A December 21, 2010, VA received a letter from V. J. M., the Veteran's wife, who stated that what started as a small tremor in his right hand "has since claimed the right side of his body and has continued to get more severe." She then stated that his writing is now "unreadable scribble" and that ice packs have to be applied to his right wrist every evening due to "disfiguring swelling and pain." She further stated that he sweats profusely and wakes up once or twice per night, causing him to take more medication. She stated that his right leg tremor has limited him to only driving short distances. A series of letters from Dr. R. S. Pathak from June 2011 through February 2013 routinely note the Veteran expressed feeling "that his symptoms are under excellent control." It was also routinely noted that he has "minimal shaking", has good balance and "is able to do everything that he likes." It was also noted that he golfs and goes fishing. An August 5, 2013 letter from Dr. R. S. Pathak notes that the Veteran reported feeing "that his symptoms are under excellent control" and now has minimal shaking. His balance was noted as good, as was his memory. It was further noted that he plays golf, goes fishing and can drive. The doctor stated that the Veteran "is able to do everything that he likes." It was noted that he had been "feeling more sleepy." Upon examination, paralysis agitans was assessed. No extrapyramidal findings were noted. The Board finds that the evidence of record prior to August 8, 2013 weighs against a finding that the Veteran was precluded from obtaining and maintaining substantially gainful employment. While the Board acknowledges that his right hand tremors would interfere with continuing as a meat cutter, the Board notes that the Veteran described other job activities, such as cleaning his work area, keeping logs, producing reports, unloading trucks and supervising people which have not been shown to be impacted by his service-connected disabilities prior to August 8, 2013. The evidence from Dr. Pathak clearly shows the Veteran was able to golf, fish and “do everything that he likes." Based on the evidence of record, the Board finds that, prior to August 8, 2013, the criteria for TDIU or referral to the Director of Compensation and Pension for consideration of a TDIU under 38 C.F.R. § 4.16(b) have not been met as a matter of law. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.18, 4.19. D. SMART Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Brian P. Keeley 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.