Citation Nr: 21001493 Decision Date: 01/08/21 Archive Date: 01/08/21 DOCKET NO. 15-36 825 DATE: January 8, 2021 ORDER Entitlement to service connection for esophagus disorder, to include gastroesophageal reflux disease (GERD), as secondary to and/or aggravated by service-connected acquired psychiatric disorder, is denied. Entitlement to an increased disability evaluation in excess of 10 percent for left-inguinal hernioplasty is denied. Entitlement to an initial disability evaluation for epididymitis in excess of 10 percent prior to May 12, 2016, to an increased disability evaluation in excess of 10 percent in the periods from August 1, 2016 to March 1, 2017 and from June 1, 2017 to October 30, 2019, and in excess of 30 percent thereafter, is denied. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) prior to November 13, 2017 is denied. FINDINGS OF FACT 1. The objective medical evidence shows GERD is not proximately due to, the result of or made worse beyond its natural progression by service-connected acquired psychiatric disorder. 2. The objective medical evidence shows at no time during the appeal period did service-connected left-inguinal hernioplasty exhibit a small, postoperative recurrent hernia, or unoperated irremediable hernia that is not well-supported by truss or belt, or not readily reducible, or a large, postoperative recurrent hernia that is not well-supported under ordinary conditions and not readily reducible, when it is considered inoperable. 3. The objective medical evidence shows at no time during the appeal period prior to October 30, 2019 did service-connected epididymitis require long-term drug therapy, 1-2 hospitalizations per year and/or intermittent intensive management, it did not manifest recurrent symptomatic infection requiring drainage and/or frequent hospitalization (greater than two times/year) and/or requiring continuous intensive management, nor was there manifestation of poor renal function; and in the period from October 30, 2019 there was no manifestation of poor renal function. 4. The objective medical evidence in the period prior to November 13, 2017 shows the Veteran’s service-connected disabilities alone did not preclude him or an average person from securing and following a substantially gainful occupation, nor in the period prior to February 9, 2016 does the record reveal unusual or exceptional aspects associated with the Veteran’s disabilities to warrant referral to the Director of the Compensation Service for extraschedular consideration under 38 C.F.R. § 4.16 (b). CONCLUSIONS OF LAW 1. The criteria for service connection for GERD, as secondary to and/or aggravated by service-connected acquired psychiatric disorder, have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2019). 2. The criteria for an increased disability evaluation in excess of 10 percent for left-inguinal hernioplasty have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.114, Diagnostic Code 7338 (2019). 3. The criteria for an initial disability evaluation for epididymitis in excess of 10 percent prior to May 12, 2016, to an increased disability evaluation in excess of 10 percent in the periods from August 1, 2016 to March 1, 2017 and from June 1, 2017 to October 30, 2019, and in excess of 30 percent thereafter, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.115a, 4.115b, Diagnostic Code 7525 (2019). 4. The criteria for TDIU prior to November 13, 2017, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.16 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Army from September 1991 to May 1992. Additionally, from April 1975 to August 1975 he underwent active duty for training in the Army National Guard. In July 2018, the Veteran testified at a videoconference Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. These issues were previously remanded by the Board, and have now been returned for further appellate consideration. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from a disease or injury incurred in active service or that a preexisting injury or disease was aggravated by active service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (a) (2019). Establishing service connection generally requires: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Additionally, service connection may be granted on a secondary basis for a disability which is proximately due to, the result of or made worse beyond its natural progression by a service-connected disease or injury. 38 C.F.R. § 3.310. Moreover, service connection of a nonservice–connected disease or injury will be established if an increase in severity of the nonservice–connected disability is shown to be proximately due to or the result of a service-connected disease or injury and not due to the natural progress of the nonservice–connected disease or injury. 38 C.F.R. § 3.310 (b). The evidence must show (1) a current disability exists and (2) the current disability was the (a) proximately caused by or (b) proximately aggravated (worsened in severity beyond its natural progress) by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439, 448-49 (1995). 1. Entitlement to service connection for esophagus disability, to include GERD, as secondary to and/or aggravated by service-connected acquired psychiatric disorder. Although the Veteran initially filed a claim for GERD, the Veteran has also complained of chest pain, which he claims is caused by his anxiety due to his hernia disorder. To afford the Veteran the widest possible scope for his claim of entitlement, the Board in its March 2019 Remand recharacterized the issue as it appears above, thereby reflecting a broader disorder of the esophagus. As shown below, VA opinions address the disorder accordingly. Turning to the record, the service treatment records (STRs) show in the September 1991 enlistment examination the Veteran reported past or current “ear, nose or throat trouble.” A handwritten note by the examiner refers to a tonsillectomy the Veteran underwent at age 20. The STRs otherwise show no reports, complaints, treatment, or diagnosis of GERD or related pathology. The record overall does not offer evidence of direct causation by an event, injury, or illness during active service, nor has the Veteran asserted his claim on that basis. However, the post-service record contains a VA medical treatment note in January 2006 showing the Veteran had a complaint of “anxiety pain in the pit of his chest.” A June 2006 VA treatment note indicates that the Veteran reported a history of GERD, he was so diagnosed and the treatment provider prescribed Protonix. In a January 2015 VA esophagus study, the Veteran underwent an esophagram. The reported noted the Veteran had had a chest CT earlier in January. Multiple swallowing acts were observed fluoroscopically and the esophagram further revealed a small hiatal hernia, as well as mildly thickened distal esophageal mucosal folds which are slightly irregular posteriorly and most consistent with esophagitis, no definite mass lesion, nonspecific esophageal motility disorder, mild proximal escape and mild right carotid atherosclerosis. Biopsies taken at VA in March 2015 produced a diagnosis of reflux esophagitis/carditis, accompanied by columnar mucosal metaplasia of non-specialized-type. Pertinent negative findings included no specialized-type intestinal metaplasia, no intra-epithelial or invasive neoplasm, no viral cytopathic effect or invasive infection, no acute erosion/ulceration, and no marked eosinophilia. A June 2015 VA treatment note shows a treatment provider assessed the Veteran with esophagitis-likely due to GERD/hiatal hernia. A June 2015 gastrointestinal consult note states that the biopsies did not show changes classic for Barrett’s esophagus, but were suggestive of reflux. Additionally, a VA primary care physician note in November 2015 noted the Veteran underwent an upper endoscopy a few months prior because a CT scan showed some thickening in the distal esophagus, there were some pink tongues extending upward from the gastroesophageal junction but biopsies did not show changes classic for Barrett’s esophagus, but rather, changes suggestive of reflux. Diagnostic results from March 2016 VA esophagogastroduodenoscopy (EGD) results revealed Grade A esophagitis and possible Barrett’s esophagus. However, an August 2016 VA education discharge note states a diagnosis of GERD. In an October 2016 VA psychiatry note, the Veteran reported having episodes of increased anxiety attacks and esophageal spasm and tightness in his epigastric region. He had such episodes a few times per week and was evaluated at the emergency department and by the gastrointestinal clinic in October 2016. with the impression of panic attacks, hiatal hernia, and esophageal spasm due to erosive esophagitis. A December 2017 VA gastroenterological note shows the Veteran was being followed at the gastroenterological clinic for reflux esophagitis. The treatment provider noted the Veteran has a history of anxiety-induced “esophageal spasms” which are resolved since he was started on lorazepam for panic attacks. However he is endorsing new symptoms of feeling discomfort while swallowing food, “more to solids than liquids for last few weeks.” In August 2018, the Veteran presented at the VA emergency department reporting symptoms of chest tightness and palpitations, but also mentioned typical reflux-type symptoms and he felt that this was likely his esophagus. On further questioning by the treatment provider, the Veteran reported his history of GERD. The treatment provider concluded that the Veteran’s reports of symptoms “sound a bit atypical for cardiac chest pain.” Nonetheless, tests were made, but an electrocardiogram (EKG) indicated normal results. A VA primary care note December 2018 noted the Veteran presented for follow-up after a hospital stay for detoxification from alcohol use excess. The treatment provider further noted that most of the Veteran’s symptoms which he had while drinking have now resolved, with no more chest or abdominal pains, no GERD symptoms and no nausea. An April 2019 VA psychiatric note states, based on the Veteran’s report, he has GERD, panic attacks aggravate the symptoms and However, was prescribed lorazepam for panic attacks. The Veteran was afforded two VA examinations for esophageal conditions. In the February 2017 VA examination, the VA examiner diagnosed GERD, hiatal hernia and esophageal chest pain, each diagnosis based on diagnoses made between 1 and 4 years earlier. In response to the opinion question of whether GERD is at least as likely as not (50 percent or greater probability) proximately due to or the result of major depressive disorder or due to the medication taken to help control the Veteran’s psychiatric disorder, the February 2017 opined, “The condition claimed is at least as likely as not (50 [percent] or greater probability) proximately due to or the result of the Veteran’s service connected condition.” She explained in her rationale: Veteran has a long history of GERD and was recently diagnosed with a hiatal hernia. Veteran states both of these conditions had been well controlled on a PPI [proton pump inhibitor—a class of drugs for treating GERD]. However, veteran states he then began to experience chest pain especially when he would also suffer an anxiety attack. Veteran went to the ER [emergency room] multiple times for this and was told it was not cardiac but probably related to his underlying esophageal condition. Veteran was referred to GI [gastrointestinal] clinic and after hearing his history and the fact that symptom of chest pain occurs with his anxiety attack, suggested that the two are likely related. In fact, once veteran was prescribed Ativan and Zoloft to treat the anxiety attacks, the episodes of chest pain resolved as well. Therefore, it is likely that these 2 conditions are inter-related. Therefore, I feel it is at least as likely as not (>50%) that veteran’s symptom of esophageal chest pain is caused by his S/C [service-connected] anxiety attacks and depression. The condition of GERD or hiatal hernia are pre-existing and NOT caused by the anxiety or depression. In March 2019, the Board remanded the claim for another VA examination to ascertain any current diagnosis pertaining to the Veteran’s esophagus and the etiology of any such disorder. Since the Veteran claims secondary service connection, a medical opinion as to whether any esophagus disorder was aggravated beyond its natural progression by his service-connected acquired psychiatric disorder was required. As directed by the Board, the Veteran was afforded an October 2019 VA examination for esophageal conditions, in which the VA examiner diagnosed only esophagitis. He opined that the Veteran’s esophagus disorder is less likely than not (less than 50 percent probability) proximately due to or the result of his psychiatric disability. He explained: Rationale: The veteran has diagnosis of mental health issues including bipolar disorder [.] The veteran has diagnosis of esophagitis[.] Review literature including that from the Mayo Clinic does not list mental health issues as a likely cause for esophagitis therefore making it less likely that the veterans mental health issues a likely cause of this veterans esophagitis[.] Although this opinion addressed secondary causation, the Agency of Original Jurisdiction (AOJ) requested an addendum opinion for aggravation of the esophagus disorder by an acquired psychiatric disorder. A July 2020 VA examiner stated that opinion as follows: 1. The vet condition esophagitis doesn’t not to fit in [sic] (1) undiagnosed Illnesses or (2) diagnosable but medically unexplained chronic multisystem illness of unknown etiology due to there had not been adequate evaluation process. It has been had clear [sic] histopathological process identified from treating physician establish/ confirmed evident medical symptoms. The disease[] is with a clear and specific etiology and diagnosis which is not due to exposure during service in Southwest Asia if there was any exposure. 2. The clamed condition esophagitis is less likely than not (less than 50 percent probability) proximately due to or aggravated of the result of Veteran’s service connected mental condition/ anxiety/ bipolar disease. 3.The rationales are[:] 1) There is no adequate evident diagnosis/clear clinical symptoms description and treatment for condition (silent) in the STR available record reviewed. It is less likely than not (less than 50 percent probability) esophagitis has been due to service or aggravated beyond natural process related with mental condition including anxiety/bipolar of service connected disabilities. 2) It is also in medical literature the causes of esophagitis is NOT including [sic] the mental condition and bipolar disease or anxiety [.] please see medical literature link list down below. The July 2020 VA examiner appended to this opinion excerpts from the medical evidence of record and extensive excerpts from accepted medical literature in further support of her opinion. As indicated in the foregoing summary of the record, the overall medical evidence provides no competent clinical findings that GERD is caused or aggravated by the Veteran’s acquired psychiatric disorder. Moreover, the record does not contain competent medical findings, an adequate opinion, a supporting rationale, or competent lay evidence from the Veteran which establish facts contrary to the above. At the July 2018 Board hearing, the Veteran testified that GERD attacks occurred with panic attacks and the medications to relieve anxiety and panic attack helped to relieve his GERD. The Veteran explained that what he experienced was not really reflux, but rather a cramping in the esophagus like a muscular constriction, due to anxiety. The Board is well aware that lay persons are competent to report on matters observed or within their personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Therefore, the Veteran is competent to provide statements of symptoms which are observable to his senses and there is no reason to doubt his credibility. However, the lay evidence of the Veteran must in turn be weighed against other evidence, as all relevant evidence of varying kinds must be considered. The Veteran is competent to report the sensations in his esophagus he described. However, the inferences he has drawn from what was experienced and observed fall outside the realm of his competency. The record does not indicate he possesses the highly specialized education, training and clinical experience to be able to identify the origins, causes and distinctions in pathology relating to what he felt. In short, in a long history of GERD and esophagitis, the pronounced but occasional manifestations of those disorders at the same time as the manifestations of anxiety and panic attacks is not a basis on which to conclude cause and effect, but rather indicates for certain no more than the concurrence of events. Without clinical evidence found in the record or shown in accepted medical literature, what remains is only the suggestion that the claimed disorders are associated and the belief of the Veteran as a lay person that a certain legal conclusion should be reached. The October 2019 VA examiner established from the record that GERD or hiatal hernia pre-exist the Veteran’s complaints of anxiety and panic attacks. More pertinently, as a factual determination by the Board, the record shows that GERD and hiatal hernia exist independent of anxiety and panic attacks, as nothing in the medical evidence of record establishes that the appearance of the psychiatric symptoms exacerbates the gastroenterological symptoms. Although the Veteran in his November 2016 Statement in Support of Claim asserts that an October 2016 VA progress note states the Veteran presented after a sleepless night, “secondary to panic attacks causing GERD causing pain,” the treatment provider at that visit is simply restating what the Veteran reported to him, not what has been clinically established anywhere in the record. The July 2020 VA examiner concludes the same as to what accepted medical literature supports regarding the Veteran’s esophagus disorder. The Veteran’s inference of causation is therefore not competent evidence; rather, it is no more than surmise. For these reasons and based on the objective medical evidence, the Board finds the preponderance of the evidence is against the claim for service connection on any basis. 2. Entitlement to an increased disability evaluation in excess of 10 percent for left-inguinal hernioplasty. The Veteran’s postoperative residuals of left-inguinal hernia is rated in the appeal period at 10 percent under Diagnostic Code 7338, which provides a 10 percent evaluation if a hernia is postoperative recurrent, readily reducible and well-supported by truss or belt. A 30 percent evaluation is warranted for a small, postoperative recurrent hernia, or unoperated irremediable hernia that is not well-supported by truss, or not readily reducible. A maximum schedular evaluation of 60 percent is warranted for a large, postoperative recurrent hernia that is not well-supported under ordinary conditions and not readily reducible, when it is considered inoperable. 38 C.F.R. § 4.114. VA received the Veteran’s claim for an increased evaluation on March 5, 2013, thereby beginning the appeal period. The Board has considered evidence in the period preceding that date of approximately a year. Turning to the record, at a January 2012 VA surgery consult, the Veteran reported constant “uncomfortable” aching in the left groin and lower abdomen that radiating to the left testicle and exacerbated by heavy, causing “burning and sharp pain” at a 10/10 pain level. He added that during heavy lifting, he feels a “downward pressure” into the left testicle. On examination, the Veteran’s abdomen was non-distended, but with tenderness to deep palpation in the left-inguinal region and there was no guarding or rebound tenderness. The testicular examination indicated no incisional hernia over the left-inguinal scar, the treatment provider appreciated no bulge through the external inguinal ring, although he noted the Veteran was tender in the left-inguinal region and palpation of left testicle. There was no increased size in the spermatic cord, no testicular masses were appreciated and the testicles were smooth. The treatment provider assessed the Veteran with left-inguinal pain with a possible small inguinal hernia, but rule out orchitis or epididymitis. He ordered a CT scan. In February 2012, the Veteran underwent the CT scan of the pelvis, ordered the previous month, which revealed no evidence of inguinal hernia. In March 2013, the Veteran reported during his visit to the VA pain clinic a history of inguinal hernia repair was performed 25 years prior, left-sided inguinal pain began 10 years ago and for the last 2-3 years, the pain has become worse. The Veteran complained of localized pain present over his left-inguinal region which radiates inferiorly and medially to his left testicle. The Veteran also reported the pain becomes worse on heavy lifting, coughing or bearing down and his job involves all these activities; the pain is about 5-6/10, described as a pressure like, achy sensation above the inguinal ligament and radiates as a sharp, shooting, stabbing, electric shock-like pain into his left testicle; the pain comes as episodes of sharp pain with the above activities, and occasionally unprovoked, as well at night. The Veteran further reported that occasionally his left testicle gets pulled up. He added that he also notices swelling over his left testicle, especially after working for long hours. Examination of the Veteran’s abdomen showed it was soft, non-tender, with mild tenderness noted at the site of mid-inguinal ligament on superficial, as well as on deep palpation, no tenderness over the scrotal region, obvious swelling noted over the left scrotal region with no overlying skin changes, and the neurologic examination was indicated “intact.” After noting the results of the February 2012 CT scan and the ultrasound, above, the treatment provider assessed the Veteran with a history of inguinal hernia multiple years ago, with worsening of inguinal pain radiating to the left testicle, ongoing for the last 2 years. “He is referred to the pain clinic for the possibility of nerve block for diagnostic and therapeutic purposes.” After reviewing the imaging studies, as well as recommendations from general surgery and urology clinic, the treatment provider concluded there is a possibility of nerve damage to the genito-femoral nerve; “however, it seems not very likely, given the recurrence of symptoms 15 years after the surgery. However, with the scar tissue regrowth and mesh movement could account for the ongoing pain.” The Veteran declined the genito-femoral nerve block as an office-based procedure for diagnostic purpose. An August 2013 VA primary care note states the Veteran presented because left-inguinal pain is continuing to bother him and he is concerned that he may have a hernia. He reported he has persistent left-lower quadrant pain for which he was evaluated in February to follow. He added that, when seen in February 2012, he felt that he had a recurrent left-sided hernia. He had had surgery for this in 1977. He does a lot of lifting at work and has felt a left-sided discomfort that is similar to the pain that he had at the time he had the hernia. He is not aware of a bulging at any time. He was seen by the surgery department at that time and had a CT scan of the pelvis that did not reveal a hernia other than small umbilical hernia. He was then referred to urology who felt the ascending teste was likely due to exaggerated cremasteric reflex and the ultrasound results were within normal limits for the left teste. The VA urology treatment provider recommended the Veteran return to the clinic in one month; however he did not report. Later in August 2013 VA, an addendum to a surgery consult noted the Veteran’s reports similar to those above and found on physical examination of the groin no palpable hernia noted on coughing or straining at both the right and left external ring and the Veteran was tender overlying the pubic tubercle and external ring area on the left. The treatment provider concluded there was no recurrent hernia. “I explained to the patient that I cannot appreciate a hernia and this is not the cause of his chronic pain. There [m]ay be some element of chronic groin or inguinal strain. I am recommending that he consider a pain consult and he agreed.” Although the Veteran reported to his VA treatment provider in October 2013 that he had been informed that he has a recurrent hernia in the left-inguinal area and was therefore assessed with a history of chronic left groin and testicular pain and a possible recurrent hernia, when he presented to the VA emergency department in November 2013, a cursory examination revealed “no obstruction or hernia at that site.” A May 2014 urology consult note states the Veteran presented with the same complaints of persistent left-inguinal pain, which he believes is related to implanted mesh and wants it removed. The note adds that the Veteran has consulted an outside non-VA general surgeon who described the challenge of mesh removal at this time and the possibility of not offering any therapeutic benefit. At a June 2014 VA surgery consult, the Veteran presented for evaluation of chronic pain in the left-inguinal region. The Veteran reported two left-inguinal hernia repairs in 1970’s and again in 1993 for recurrence, which required implantation of a mesh patch. The Veteran also reported that, following the second repair, there were no issues for approximately 1.5 years, but pain has been increasing over last 5 years and is now intermittent, sharp and shooting across pelvis towards the bladder and there is a dull, aching pain in the left testicle. The Veteran further reported the inability to obtain an erection and he has dysejaculation. An August 2014 VA pharmacology note records the Veterans reports that he often experiences panic attacks if the hernia pain arises while he is out and the resulting health issues from the surgical mesh implantation has been a source of anxiety. The Veteran received some pain injections in 2016 from the VA pain clinic. In a VA urology note in May 2019, the treatment provider noted from the record the Veteran’s two hernia repairs in 1976 and 1996 and his report of chronic left-inguinal pain status post left-epididymal cyst excision in 2016 and right-epididymal cyst excision in 2017. In June 2019, a urology consult note showed that, in a general examination of the Veteran’s person, the Veteran’s abdomen was soft, not tender, there was no rebound or guarding, there was no palpable mass, and there was “no hernia.” An VA primary care physician note in August 2020 noted that a general examination of the Veteran’s person revealed no hernia found in his abdomen. The Veteran underwent three VA examinations for hernias in the appeal period. In January 2014, the VA examiner for hernias stated a 1976 diagnosis of inguinal hernia. She noted in relevant part the Veteran’s reported medical history of having surgeries, first in 1977, then in 1993 (as indicated above, the record shows this was in 1996), during which a mesh was placed. The Veteran reported chronic pain in this area since the surgery and is awaiting a nerve-block procedure for treatment of neurogenic pain from the mesh. The January 2014 VA examiner further noted his report that he has no recurrence of hernia at this time. On examination, the January 2014 VA examiner did not make a finding that the inguinal hernia was inoperable. She detected no hernia on left or right side and no indication for the need for a supporting belt. In a December 2014 VA examination for hernias, the VA examiner diagnosed inguinal hernia. She noted the Veteran’s reports of the history of his hernia repairs, the resulting effects and their inducement of panic attacks, as set forth above. He added that he was told by a physician that the mesh tended to fragment and migrate and could cause nerve damage and that the pain that he was feeling could be neuropathic. The Veteran stated he then came to VA to ask to see if the mesh could be removed but he was told that he could lose his testicle. The Veteran added that he was told to treat the pain with nerve blocks first and if that does not work, then removal of the mesh would be considered. The December 2014 VA examiner further noted in detail the Veteran’s treatment notes from his previous visits to VA in 2014. In her examination, she detected no hernia on the left or right side, with no indication for the need for a supporting belt. She further found the surgery status to be a left-“[r]ecurrent hernia following surgical repair…. Recurrent hernia appears operable and remediable.” The Board in its March 2019 Remand noted that the January 2014 and November 2014 VA examinations did not clarify any residuals of the left-inguinal hernioplasty or the current condition of the left-inguinal hernia and the Board directed that a new VA examination be conducted to produce findings of the current severity of this disorder. In a VA examination for hernias in October 2019, the VA examiner diagnosed inguinal hernia. He noted the Veteran’s medical history as having had 2 surgeries, including a mesh surgery, and as a result he has continued to have significant complications causing him to experience severe sharp pain requiring nerve-block shots every 3 months. On examination, he detected no hernia on the left or right sides. He further found no indication for the need for a supporting belt. The October 2019 VA examiner noted as related pertinent physical findings, complications, conditions, signs or symptoms that, as result of the hernia repair in the mesh placement the Veteran has significant complication, due to which he continues to have chronic pain requiring injections every 3 months and he has restrictions with lifting and bending. “The pain in the groin is significant, striking sharp pain. As this examiner attempted to perform a hernia exam he was extremely sensitive to any palpation.” As already set forth above, for an evaluation at a higher rate than 10 percent, Diagnostic Code 7338 requires findings showing a small, postoperative recurrent hernia, or unoperated irremediable hernia that is not well-supported by truss, or not readily reducible is necessary for 30 percent and a maximum schedular evaluation of 60 percent is warranted for a large, postoperative recurrent hernia that is not well-supported under ordinary conditions and not readily reducible, when it is considered inoperable. None of the foregoing examinations provides findings of a small, recurrent hernia or unoperated irremediable hernia that is not well-supported by a truss, or not readily reducible and, of course, nothing larger. Each of the VA examiners specifically found no hernia on the left or right side, with no indication for the need for a supporting belt. The January 2014 VA examiner made no finding of an inoperable hernia. The December 2014 VA examiner specifically stated the “[r]ecurrent hernia appears operable and remediable.” Although the October 2019 VA examiner noted the Veteran’s pain, the diagnostic code does not provide a higher rating for complications which may or may not be due to the application of a mesh patch to the hernia. The Veteran has asserted in a May 2013 statement that, with the implantation of mesh, his hernia in fact is now not “well supported” within the meaning of Diagnostic Code 7338, therefore it is recurrent and therefore it is not readily reducible. The diagnostic code specifically identifies “support” by a truss, not by mesh. Moreover, to repeat, each of the VA examiners on examination of the Veteran specifically found no signs of a hernia on the left or right side. For these reasons and based on the objective medical evidence, the Board finds the preponderance of the evidence does not support an increased disability evaluation in excess of 10 percent. 3. Entitlement to an initial disability evaluation for epididymitis in excess of 10 percent prior to May 12, 2016, to an increased disability evaluation in excess of 10 percent in the periods from August 1, 2016 to March 1, 2017 and from June 1, 2017 to October 30, 2019, and in excess of 30 percent thereafter. The Veteran is currently evaluated at 30 percent for epididymitis under Diagnostic Code 7525. In the periods from May 12, 2016 to August 1, 2016 and from March 1, 2017 to June 1, 2017, he was granted a temporary total evaluations for the respective periods of convalescence after the surgical excisions of left and right epididymal head cysts. Those ratings for those periods are not herein at issue. Diagnostic Code 7525 provides that chronic epididymo-orchitis shall be rated under the criteria for urinary tract infection, or, for tubular infections, it should be rated according to 38 C.F.R. § 4.88b (infectious diseases, immune disorders, and nutritional deficiencies) or 38 C.F.R. § 4.89 (ratings for inactive non-pulmonary tuberculosis in effect on August 19, 1968), whichever is appropriate. See 38 C.F.R. § 4.115b, Diagnostic Code 7525. The rating criteria for urinary tract infection provides that a 10 percent rating is warranted if the condition requires long-term drug therapy, 1-2 hospitalizations per year, and/or intermittent intensive management. A 30 percent rating is assigned if the condition is manifested by recurrent symptomatic infection requiring drainage and/or frequent hospitalization (greater than two times/year), and/or requiring continuous intensive management. For any higher rating, there must be manifestation of “poor renal function” under the criteria for renal dysfunction, which in turn will provide evaluations at noncompensable, 30, 60, 80, and 100 percent. 38 C.F.R. § 4.115a. VA received the Veteran’s Notice of Disagreement (NOD) with the evaluation of epididymitis on April 25, 2014, thereby beginning the appeal period. The Board has considered evidence from the period of approximately a year before that date. The record shows a February 2012 VA urology consult, in which the Veteran reported a history of left epididymitis since childhood, but with no antibiotic treatment. He also reported left-inguinal hernia repair in the 1980’s and subsequent chronic left-testicular pain which waxes and wanes. The Veteran further reported the left-testicle becomes inflamed, sensitive and at times drawn up into the body. However, the treatment provider noted that the Veteran denied a history of urinary tract infection and treatment with antibiotics. The Veteran reported he has tried multiple pain medications in the past, all without relief. He added that pain at times is worse with activity and if he has not engaged in sexual activity in a while. The treatment provider noted the Veteran was not in pain at present and he has been seen by a general surgery treatment provider, who did not feel he had a recurrent hernia problem. A February 2012 ultrasound of the scrotum revealed bilateral varicoceles with a right hydrocele and a small internal septation, bilateral cysts within the epididymal heads, normal flow bilaterally, and a tiny intratesticular cyst on the left measuring 3 mm. In July 2015, the Veteran presented at the VA emergency department with a 3 day history of left-testicular pain and swelling reminiscent of previous epididymal exacerbations. Ultrasound results revealed no evidence of testicular torsion or epididymitis, there were bilateral epididymal head cysts or spermatoceles, the largest measuring up to 4.2 cm on the right, and there was cystic dilatation of the testis noted on the left. The discharge note states that the previous ultrasound “showed no evidence of epididymitis.” Based on the findings of a November 2015 VA CT scan, the Veteran was assessed with chronic left-testicular pain, with the option of surgical removal of an epididymal head cyst. A January 2016 VA urology note contains the Veteran’s reports that since he was in his 20s and in the military, he has had chronic bilateral testicular tenderness with flares of worsening pain only on the left side, sometimes associated to epididymitis. He has had multiple flares in the last year, documented ultrasound-episode of epididymitis in May 2015, recently seen in the ER again in December 2015 with worsening left testicular pain. He had a negative scrotal ultrasound, given pain medication and his pain improved. He wishes to pursue treatment on the left side only. In May 2016, the Veteran underwent a left-epididymal head cyst excision. A VA urology outpatient note in October 2016 noted chronic and/or recurrent epididymo-orchitis, mostly on the left, now status post left-epididymitis cyst excision, with a remaining risk factor of right-epididymal cyst. The Veteran underwent a right-epididymitis-head cyst excision in March 2017, consistent with benign epididymal cyst and no evidence of inflammation or neoplasia. A May 2018 ultrasound at VA revealed no epididymal cyst recurrence and resolution of cyst of left-testis. A December 2018 VA primary care note states under the Veteran’s problems list, “previous Epididymo-orchitis – resolved.” In March 2019, the Veteran presented at VA for a urology consult, reporting reoccurring episodes of epididymitis. every 4-6 months and usually rides it out but this particular infection is worse than normal, he requested to be seen by a urologist and be prescribed an antibiotic. The Veteran further reported previous surgeries for correction of recurring epididymitis which were unsuccessful. The Veteran underwent three VA examinations in the appeal period for male reproductive system conditions. The January 2014 VA examiner stated a 1976 diagnosis of epididymitis, as well as a diagnosis of erectile dysfunction. She referred to the Veteran’s reports from his hernia VA examination of localized pain present over his left inguinal region which radiates inferiorly and medially to his left testicle. The Veteran further reported that the pain gets worse when doing heavy lifting, coughing or bearing down and his job involves all these activities. The pain is about 5-6/10, described as a pressure-like, achy sensation above the inguinal ligament and radiates as a sharp, shooting, stabbing, electric shock-like pain into his left testicle. The pain comes as episodes of sharp pain with above activities, and occasionally unprovoked as well at night. The Veteran further reported that occasionally his left testicle gets pulled up and he also notices swelling over his left testicle, especially after working for long hours. On examination, the January 2014 VA examiner found the Veteran’s left epididymis was tender to palpation. She found his treatment plan did not include taking continuous medication for epididymitis. Under the heading, “Urinary tract/kidney infection,” she further made a finding of “Not Applicable,” nor did she note from the Veteran’s reports that he has a history of recurrent symptomatic urinary tract or kidney infections. However, she noted the Veteran’s treatment for epididymitis consisted of intermittent oral antibiotics at least once per year. As set forth above, the rating criteria for urinary tract infection provides that a 10 percent rating is warranted if the condition requires long-term drug therapy, 1-2 hospitalizations per year, and/or intermittent intensive management. A 30 percent rating is assigned if the condition is manifested by recurrent symptomatic infection requiring drainage and/or frequent hospitalization (greater than two times/year), and/or requiring continuous intensive management. For any higher rating, there must be manifestation of “poor renal function” under the criteria for renal dysfunction, which will provide evaluations at noncompensable, 30, 60, 80, and 100 percent. 38 C.F.R. § 4.115a. The January 2014 VA examiner found neither recurrent symptomatic urinary tract infection nor recurrent symptomatic kidney infections, requiring drainage and/or frequent hospitalization. Moreover, the Veteran’s disorder in this period did not require continuous intensive management, as indicated by the need of only intermittent oral antibiotics at least once per year. Consequently, without the findings required above, no evaluation higher than 10 percent is available in period prior to May 12, 2016. In a September 2017 VA examination for male reproductive system conditions, the VA examiner, diagnosed chronic epididymitis based on the in-service diagnosis. She noted the Veteran’s reports that since his in-service hernia surgery and repair of the left hydrocele, he has had chronic testicular pain and increase in testicular size due to the development of testicular cysts. The Veteran further reported he underwent a May 2016 left-epidydimal head cyst removal, then a March 2017 right-epidydimal head cyst removal, as they were possible causes of his pain and recurrent epididymitis. After these procedures, testicular pain has continued and worsened and he has continued to have episodes of epididymitis requiring antibiotics, most recently in August 2017. However, the September 2017 VA examiner noted from the Veteran’s medical history that his treatment plan did not include taking continuous medication for epididymitis. She further noted there is no renal dysfunction due to epididymitis and the treatment modality used for epididymitis is intermittent oral antibiotics. The Veteran requested that his testes and epididymis not be examined. Once again, the findings on examination show epididymitis required not continuous medication, but only intermittent oral antibiotics and there was no renal dysfunction. In rating this disorder under urinary tract infection criteria, no evaluation over 10 percent is available in the periods from August 1, 2016 to March 1, 2017 and from June 1, 2017 to October 30, 2019. In its March 2019 remand of this claim, the Board noted that, although the Veteran underwent the January 2014 VA examination for epididymitis, it did not provide findings of the current condition of epididymitis or of any residuals from the cyst-removal operations the Veteran underwent in 2016 and 2017 and a new VA examination therefore was necessary to produce findings of the current severity of this disorder. As directed in the Board’s remand, the Veteran was afforded an October 2019 VA examination for male reproductive system conditions, in which the VA examiner diagnosed epididymitis. He noted the medical history, as reported by the Veteran, of having had chronic infections then surgical intervention on the left and right side. He further noted epididymitis requires continuous medication for what is estimated to be 4 times a year when the Veteran will have an infection requiring antibiotic treatment. The October 2019 VA examiner specifically noted from the Veteran’s reported medical history there is no renal dysfunction at present. On examination, he found the Veteran’s left and right testes were tender to palpation. Based on these findings, a 30 percent evaluation was warranted and granted. However, without signs and symptoms of renal dysfunction showing constant albuminuria with some edema; or definite decrease in kidney function; or, hypertension at least 40 percent disabling under Diagnostic Code 7101, a next higher evaluation of 60 percent under the criteria for renal dysfunction is not available. There are no findings of even greater dysfunction, such as persistent edema or dialysis, warranting 80 percent and 100 percent evaluations. For these reasons and based on the objective medical evidence, the Board finds the preponderance of the evidence does not support an initial disability evaluation in excess of 10 percent prior to May 12, 2016, to an increased disability evaluation in excess of 10 percent in the periods from August 1, 2016 to March 1, 2017 and from June 1, 2017 to October 30, 2019, and in excess of 30 percent thereafter. 4. Entitlement to TDIU prior to November 13, 2017. A finding of TDIU is appropriate “when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation.” 38 C.F.R. §§ 3.340 (a)(1), 4.15. Consideration may be given to the Veteran’s level of education, special training and previous work experience in arriving at a conclusion, but not to age or to the impairment caused by non-service-connected disabilities. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19. In reaching such a determination, the central inquiry is “whether the Veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability.” Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). The record must reflect that circumstances, apart from non-service-connected conditions, place the claimant in a different position than other veterans having the same compensation rating. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in and of itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question is whether the veteran, in considering his or her service-connected disabilities, can perform the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). 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. § 4.16 (a) (2017). In addition, there must be evidence that the disabled person is unable to secure or follow a substantially gainful occupation. See 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Ferraro v. Derwinski, 1 Vet. App. 326, 331-332 (1991). The combined rating is achieved by “adding” the disability ratings together. However, this is not the conventional addition of numerical values. The efficiency of the individual for employment purposes is not reflected as a numerical value equivalent to the assigned disability rating; in terms of actual efficiency, the number will be lessened under the regulation. However, VA recognizes that earning capacity is affected exponentially as a less severe service-connected disability is added to the most severe service-connected disability, thereby reflecting the ever-diminishing efficiency of the individual. See 38 C.F.R. § 4.25. The United States Court of Appeals for the Federal Circuit has held that determination of whether a veteran is unable to secure or follow a substantially gainful occupation due to service-connected disabilities is a factual rather than a medical question and that it is an adjudicative determination properly made by the Board or the VA Regional Office. See Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). Additionally, “substantially gainful employment” is defined as an occupation that provides an annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days that a veteran actually works and without regard to the veterans earned annual income. See Faust v. West, 13 Vet. App. 342 (2000). The determination as to whether TDIU is appropriate should not be based solely upon demonstrated difficulty in obtaining employment in one particular field, which could also potentially be due to external bases such as economic factors, but rather to all reasonably available sources of employment under the circumstances. See Ferraro v. Derwinski, 1 Vet. App. 326, 331-332 (1991). As stated, consideration may be given to level of education, special training and previous work experience in arriving at a conclusion, but not to age or impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. Marginal employment is not considered substantially gainful employment and generally is deemed to exist when a veteran’s earned income does not exceed the amount established by the United States Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Marginal employment may also be held to exist in certain cases when earned annual income exceeds the poverty threshold on a facts-found basis. Marginal employment, odd-job employment and employment at half the usual remuneration is not incompatible with a determination of unemployability if the restriction to securing or retaining better employment is due to disability. See 38 C.F.R. § 4.17 (a). The Board has reviewed all the evidence in the Veteran’s claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. The Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. The Board first notes that the Veteran’s acquired psychiatric disorder was assigned a total rating (100 percent ), effective November 13, 2017. Therefore, the claim for TDIU is moot as of that date, as the remaining service-connected disorders would not combine to cause unemployability. Therefore, the appellate issue is for the period prior to November 13, 2017. In that period, the Veteran’s service-connected disorders were rated as follows: Acquired psychiatric disorder was rated at 50 percent from December 26, 2013 and at 70 percent from February 9, 2016. Left-inguinal hernioplasty has been rated at 10 percent throughout the appeal period. Epididymitis has been rated at 10 percent from March 5, 2013, at 100 percent from May 12, 2016, at 10 percent from August 1, 2016, at 100 percent from March 1, 2017, at 10 percent from June 1, 2017, and at 30 percent from October 30, 2019. Post-surgical scar and erectile dysfunction, both are rated at noncompensable evaluations. Combined, the Veteran’s service-connected disabilities are at variously at 20 percent from March 5, 2013, at 60 percent from December 26, 2013, at 80 percent from February 9, 2016, at 100 percent from May 12, 2016, from 80 percent from August 1, 2016, from 100 percent from March 1, 2017, from 80 percent from June 1, 2017, and at 100 percent from November 13, 2017. The foregoing shows the Veteran meets the schedular requirement for TDIU for the period from February 8, 2016 to November 13, 2017 even before the assignment of a total rating for his acquired psychiatric disorder, effective November 13, 2017. However, in the period prior to February 9, 2016, the combination of ratings does not satisfy the regulatory threshold of a combined rating of 70 percent. That notwithstanding, it is the policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of a service-connected disability shall be rated totally disabled. 38 C.F.R. § 4.16 (b). Therefore, although the schedular criteria for TDIU, as set out in 38 C.F.R. § 4.16 (a), are not met, a total rating on an extraschedular basis may nonetheless be granted in exceptional cases (and pursuant to specifically prescribed procedures) when a Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. 38 C.F.R. § 4.16 (b). To accord justice, therefore, in the exceptional case where the schedular ratings are found to be inadequate, the Director of the Compensation Service, upon field station submission, is authorized to approve an extraschedular rating commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. Neither the Regional Office (RO) nor the Board is permitted to assign an extraschedular rating in the first instance. Floyd v. Brown, 9 Vet. App. 88, 95 (1996)). However, the Board may review the later determinations of the Director of the Compensation Service. Anderson v. Shinseki, 22 Vet. App. 423, 427. The Veteran’s service-connected disabilities, employment history, education, vocational attainment, and all other factors bearing on the issue will be considered. 38 C.F.R. §§ 3.341, 4.16 (b), 4.19. Therefore, for the period prior to February 9, 2016, the Board will consider the evidence of record on an extraschedular basis for possible referral to the Director of the Compensation Service. Turning to the record, the Veteran submitted a November 2017 Application for Increased Compensation Based on Unemployability (VA Form 21-8940), in which he states full-time employment was affected in August 2012, but he last worked full-time and became too disabled to work in August 2017. He further states the service-connected disability preventing him from securing or following substantially gainful employment is PTSD. PTSD in fact is not service-connected. However, a July 2013 Form 21-8940 (associated with the record in October 2014) states work was affected and prevented in September 2012 due to “[r]ecurrent hernias[,] hernia mesh pain.” The medical evidence of record for service-connected left-inguinal hernioplasty and epididymitis has been summarized and set forth in the preceding sections of this decision. As stated above, service-connected post-surgical scar and erectile dysfunction are both rated at noncompensable evaluations, thereby indicating no disabling effects of these disorders. Looking to the Veteran’s service-connected acquired psychiatric disorder, the record shows at the commencement of the appeal period to at least August 2020, the Veteran complained of both depressed mood and anxious mood and medications were prescribed. The Veteran’s problems were listed as major depressive disorder and also bipolar disorder, mixed, as well as a history of heavy alcohol abuse. He admitted to symptoms affecting mood, interest, concentration, sleep, appetite, fatigue, work, and interacting with other persons. Prominent symptoms, as shown in his reports to treatment providers and in his Board hearing testimony, are panic attacks, mostly controlled by medication. Nonetheless, mental status examination findings in this period generally show normal thought processes, thought content, speech patterns, orientation to all spheres, no delusions or hallucinations, and no evidence of psychosis. Overall, the Veteran consistently denied current suicidal ideation, but has made a few references to such thoughts at prior times. In the November 2014 VA examination, the VA examiner diagnosed major depressive disorder, single episode, moderate, adjustment disorder with anxious mood and obsessive-compulsive disorder. She found occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. Associated symptoms included depressed mood, anxiety, suspiciousness, panic attacks more weekly or less often, chronic sleep impairment, mild memory loss, such as forgetting names, directions or recent events, difficulty in understanding complex commands, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a worklike setting. The November 2014 VA examiner’s remarks were as follows: Regarding judgment, Veteran denied any physical violence towards others, CLIN DOC: drinking and driving, excessive speeding, or other risky situations. Panic attacks without diagnosis of panic disorder: Experiences expected panic attacks specifically related to sharp pain from hernia surgery/mesh. Panic attack symptoms include: pounding heart, sweating, shortness of breath, chest discomfort, dizziness, lightheadedness, feelings of derealization, fear of losing control. Onset occurred just over a year ago in a restaurant related to groin pain, unable to get out of seat due to pain. Mental health symptoms do not interfere with ability to complete tasks at home. Veteran spends his day watching TV, on computer, cleaning, working around the house, playing guitar, reading, online learning. Showers daily. Veteran leaves the house two times per week, grocery shopping with wife, visits mother. Otherwise prefers to stay home. Goes out because of wife. “Left to myself I would probably just be a recluse right now.” “Basically, what I am telling you is not who I normally am. I always considered myself an optimist, probably to a fault actually.” It is the opinion of this examiner that the Veteran’s symptoms of major depressive disorder, adjustment disorder with anxious mood, and obsessive-compulsive disorder, which are secondary to the Veteran’[s] chronic pain subsequent to left hernioplasty cause the Veteran to experience a moderate level of social impairment with the Veteran reporting that while he has two friends he has not had recent contact with them. As the Veteran is not currently employed, it is not possible to determine his current occupational functioning based upon current job performance. However, if the Veteran were to attempt to return to work at this time, it is expected that the Veteran would experience at least a moderate level of occupational impairment due to moderate symptoms of major depressive disorder, adjustment disorder with anxious mood, and obsessive-compulsive disorder. The Veteran is generally functioning satisfactorily with normal routine behavior, self care, and conversation. Veteran stated that he does not have difficulty completing tasks at home due to mental health symptoms. Based on the findings of this examination, service connection was granted for major depressive disorder with adjustment disorder and obsessive-compulsive disorder at a 50 percent evaluation, effective December 26, 2013. In a March 2016 VA examination for mental disorders, the VA examiner diagnosed the Veteran with unspecified depressive disorder and adjustment disorder with anxiety, noting further that both diagnoses appear to have worsened. However, he discontinued the previous diagnosis for obsessive-compulsive disorder. He found occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. He found associated symptoms of depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, mild memory loss, such as forgetting names, directions or recent events, difficulty in understanding complex commands, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a worklike setting. The March 2016 VA examiner identified other symptoms related to depression such as crying spells, guilt, hopelessness, loss of usual interests, low self-esteem, and diminished sense of pleasure. These coupled with low mood and low motivation indicate a moderately depressed episode. Since the last exam the symptoms have varied in their intensity but never fully remitted. There is no history of mania. Regarding anxiety, he noted the impact of hernia and problems with sexual function continue to contribute to the experience of anxiety by the Veteran. Based on the findings of this examination, the evaluation for the Veteran’s acquired psychiatric disorder was increased to 70 percent, effective February 9, 2016. With respect to the impact of the hernia disorder on the Veteran’s ability to work, the January 2014 VA examiner found there should be “no heavy lifting or tight clothing.” The December 2014 VA examiner found the impact of the hernia disorder to be “the Veteran has not worked regularly for the last 5 years. Veteran does home improvements. Veteran states he is limited by not being able to do any lifting, difficulty with bending, carrying anything heavy, any type of twisting movements cause severe pain.” Regarding epididymitis, the January 2014 VA examiner found there is no impact on the Veteran’s ability to work. The September 2017 VA examiner for epididymitis found the impact on the Veteran’s ability to work to be, as reported by the Veteran, he is unable to do any heavy lifting, twisting and bending due to his chronic testicular pain. Looking to the Veteran’s work experience, training and education, the November 2014 VA examiner for mental disorders noted the Veteran’s reports of his educational and occupational history as follows: Relevant Occupational and Educational history (pre-military, military, and post-military): Educational History: Prior to entering the military, the Veteran attended school through 12th grade. The Veteran received a GED prior to entering the military. Since his discharge from the military, the Veteran has completed some training courses, basic electrical, air conditioning, basic stationary engineering. His grades were good. The Veteran made many friends when he returned to school. “I always made friends. I never had any problem making friends. Occupational History: The Veteran reported full-time employment as a pipe fitter prior to entering the military. Since his discharge from the military 39 years ago in 1975 the Veteran has had approximately 12 jobs with the longest being for 2 years. He has worked [] in maintenance. He is not currently employed having retired in 2012 due to physical health problems with difficulty lifting. The Veteran reported no experience of occupational problems due to mental health symptoms when he was employed. Veteran reported that when he was employed he did not [have] difficulty completing tasks at work due to mental health symptoms. Military personnel records and the Veteran’s Board hearing testimony show the Veteran’s military occupation specialty (MOS) in service was as a ground surveillance radar technician, as well as an indirect fire infantryman, under which specialty he was tasked with neutralizing mines, ground navigation and operating and maintaining communications equipment. He was also a CBT Signaler, which also required him to operate and maintain communication systems. The Veteran’s July 2013 Form 21-8940 states his former employment as a warehouse worker and performing maintenance at Carrier Coach, which in his Board hearing testimony, the Veteran described as maintenance on the company’s fleet of buses. In the November 2017 Form 21-8940, the Veteran states hs last employment as “self-employed,” which in his testimony the Veteran described as home-improvement work. In a December 2017 Statement in Support of Claim, the Veteran states the name of his business was Real Property Improvements. In his reports to treatment providers at various times, for example, in a December 2014 a VA psychiatric admission assessment and in March 2014 mental health treatment notes, the Veteran refers to having been employed in “construction business,” which appears to refer to home-improvement contracting. He also mentions carpentry, also related to home-improvement work, but to some pre-service work as well. The Board further notes from the record that, although the Veteran submitted a claim for vocational rehabilitation under chapter 31 in May 2014, a June 2014 letter informed the Veteran that VA was suspending his claim for Vocational Rehabilitation and Employment services because he had not completed his evaluation. In effect, the Veteran applied for vocational rehabilitation, but almost immediately failed to pursue this opportunity. The foregoing summary shows no findings in the record for the Veteran’s acquired psychiatric disorder satisfy the criteria for a higher rating at a total disability evaluation, prior to when it was assigned. While some elements of the Veteran’s reports indicate social isolation, they also suggest the Veteran maintains something more than just limited social interaction. For example, earlier in the appeal period, the Veteran reported to the November 2014 VA examiner he will occasionally go to restaurants with his wife, he shops with his wife and he routinely visits his mother. He carries on with normal activities of daily living in his home and the November 2014 VA examiner concluded mental health symptoms do not interfere with the ability to complete tasks at home. Regarding occupational impairment, the November 2014 VA examiner found only a decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily. She further observed that, if returning to work, the Veteran would experience only a moderate level of occupational impairment. She repeated that the Veteran was generally functioning satisfactorily with normal routine behavior, self-care and conversation. The March 2016 VA examiner found occupational and social impairment, with deficiencies in most, but not all areas. However, this finding does not confirm total impairment of mental function so as to preclude work. Moreover, prior to February 2016, mental status examinations show no indication of impaired thought processes and content or impaired communication ability, as well as no delusions or hallucinations or other evidence of psychosis. Therefore, the record in this period provides no findings of total impairment, nor does it point to unusual or exceptional aspects which would warrant referral for extraschedular consideration. Lastly, the Veteran’s prior employment experience, to include in-service experience and training in sophisticated electronic equipment and post-service experience in mechanical maintenance, suggest plausible prospects of suitable employment, which does not necessarily demand physical maneuvers of bending, twisting and lifting. From his experience, the Veteran would appear to be able to interpret technical plans and schematics and, based on that ability, he hs the capacity to instruct others and assign tasks. The Veteran’s limitations due to pain have been identified by the VA examiner for hernia and epididymitis. The November 2014 VA examiner for mental disorders suggested there would be moderate impairment of work abilities due to psychiatric symptoms. However, as the record shows, no VA examiner or treatment provider in the period prior to November 13, 2017 has concluded the Veteran cannot work. Additionally, although throughout the record the Veteran voiced the need to be employed, that need apparently was not compelling enough to take advantage of VA’s vocational rehabilitation program. After considering the totality of the record, the Board finds the preponderance of the evidence in the period prior to November 13, 2017 shows the Veteran’s service-connected disabilities alone did not preclude him or an average person from securing and following a substantially gainful occupation, nor in the period prior to February 9, 2016 does the record reveal unusual or exceptional aspects associated with the Veteran’s disabilities to warrant referral to the Director of the Compensation Service for extraschedular consideration under 38 C.F.R. § 4.16 (b). The Board has considered the benefit-of-the-doubt doctrine; however, the Board does not perceive an approximate balance of positive and negative evidence. As the preponderance of the evidence is against the claims, the doctrine is not applicable and the claims must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. MICHAEL D. LYON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P. Franke, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.