Citation Nr: 21002234 Decision Date: 01/13/21 Archive Date: 01/13/21 DOCKET NO. 10-33 219 DATE: January 13, 2021 ORDER Service connection for a liver disability, claimed as cirrhosis, is denied. Service connection for a disability manifested by weight gain is denied. Service connection for carcinoma of the abdominal cavity is denied. Service connection for kidney stones is denied. Service connection for psoriasis is denied. Service connection for a bilateral knee disability is denied. Service connection for erectile dysfunction is denied. Service connection for acid reflux is denied. Service connection for a hiatal hernia is denied. Service connection for a gastrointestinal disability is denied. An initial evaluation in excess of 50 percent for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD), is denied. A total disability rating based on individual unemployability as a result of service-connected disabilities (TDIU) is denied. FINDINGS OF FACT 1. The Veteran’s liver disability is not related to service, to service-connected disabilities, or to Gulf War exposures. 2. Obesity is not a disability for VA compensation purposes. 3. The Veteran’s carcinoma of the abdominal cavity was not related to service, to service-connected disabilities, or to Gulf War exposures. 4. The Veteran’s kidney stones are not related to service, to service-connected disabilities, or to Gulf War exposures. 5. The Veteran’s psoriasis is not related to service, to service-connected disabilities, or to Gulf War exposures. 6. The Veteran’s bilateral knee disability is not related to service, to service-connected disabilities, or to Gulf War exposures, and did not manifest within one year of separation from service. 7. The Veteran’s erectile dysfunction is not related to service or to service-connected disabilities. 8. The Veteran’s acid reflux is not related to service, to service-connected disabilities, or to Gulf War exposures. 9. The Veteran does not have a current hiatal hernia. 10. The Veteran does not have a current chronic gastrointestinal disability. 11. The Veteran’s acquired psychiatric disability is not productive of total occupational and social impairment or of occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, or mood. 12. The Veteran’s service-connected disabilities have not rendered him unemployable or unable to secure and follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for service connection for a liver disability, claimed as cirrhosis, are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310, 3.317 (2019). 2. The criteria for service connection for a disability manifested by weight gain are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). 3. The criteria for service connection for carcinoma of the abdominal cavity are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310, 3.317 (2019). 4. The criteria for service connection for kidney stones are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310, 3.317 (2019). 5. The criteria for service connection for psoriasis are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310, 3.317 (2019). 6. The criteria for service connection for a bilateral knee disability are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310, 3.317 (2019). 7. The criteria for service connection for erectile dysfunction are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2019). 8. The criteria for service connection for acid reflux are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310, 3.317 (2019). 9. The criteria for service connection for a hiatal hernia are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). 10. The criteria for service connection for a gastrointestinal disability are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). 11. The criteria for an initial evaluation in excess of 50 percent for an acquired psychiatric disability, to include PTSD, are not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2019). 12. The criteria for a TDIU are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.15, 4.16, 4.19 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1987 to December 1991. This appeal is before the Board of Veterans’ Appeals (Board) from an October 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri, and October 2015 and April 2017 rating decisions of the RO in Roanoke, Virginia. The Veteran’s appeals as to the issues of service connection for weight gain, carcinoma, knee disabilities, kidney stones, liver disability, and psoriasis (“initial issues”) were first before the Board in January 2015, at which time they were remanded with instruction to obtain complete service treatment records and provide VA examinations. The appropriate records were obtained, and the Veteran underwent VA examinations in May 2015. In September 2016, the Board denied the initial issues and remanded service connection for acid reflux, a hiatal hernia, a gastrointestinal disability, and erectile dysfunction (“second issues”) with instruction that a statement of the case be issued. A statement of the case was issues in November 2016, and the Veteran submitted a substantive appeal in December 2016. He appealed the denial of the initial issues to the United States Court of Appeals for Veterans Claims (Court), which vacated the denial in a January 2018 memorandum decision. In July 2018 the Board remanded the initial issues with instruction to confirm that all service treatment records were obtained and to obtain additional VA medical opinions. The appropriate records were obtained, and the Veteran underwent VA examinations in October 2018. In November 2018, the Board remanded the initial issues to ensure compliance with the July 2018 instructions and remanded the second issues with instruction to obtain VA medical opinions. The appropriate evidence was adjudicated, and the Veteran underwent additional VA examinations in August 2019. In April 2020, the Board remanded the initial issues and second issues with instruction to obtain additional VA medical opinions and to attempt to verify claimed mustard gas exposure. The Board further remanded the issues related to PTSD and TDIU with instruction to fully develop the issues in light of the earlier effective date granted therein. The Veteran underwent additional VA examinations in October 2020. The opinions provided ruled out mustard gas exposure as a potential etiology. The Board is therefore satisfied that the instructions in its remands of January 2015, September 2016, July 2018, November 2018, and April 2020 have been satisfactorily complied with. See Stegall v. West, 11 Vet. App. 268 (1998). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection 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 or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection is also warranted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(b). For certain chronic diseases, such as cirrhosis of the liver and arthritis, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within one year following discharge from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). When a chronic disease is not shown to have manifested to a compensable degree within one year after service, under 38 C.F.R. § 3.303(b) for the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. When the fact of chronicity in service is not adequately supported, a showing of continuity after discharge is required to support a claim for such diseases; however, such continuity of symptomatology may only support a claim for those chronic diseases listed under 38 C.F.R. § 3.309(a). 38 C.F.R. § 3.303(b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317. Unlike service connection on a direct basis, the provisions of 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 do not require competent medical nexus of a link between the qualifying chronic disability and military service. Service connection is presumed unless there is affirmative evidence to the contrary, where the criteria are met. See 38 C.F.R. § 3.317(c); Gutierrez v. Principi, 19 Vet. App. 1 (2004). The term “Persian Gulf Veteran” means a Veteran who, during the Persian Gulf War, served on active military, naval, or air service in the Southwest Asia theater of operations. The Southwest Asia theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317(e)(2). The term “qualifying chronic disability” means a chronic disability resulting from any of the following (or any combination of the following): (A) an undiagnosed illness; (B) a medically unexplained chronic multi-symptom illness that is defined by a cluster of signs or symptoms, such as: (1) chronic fatigue syndrome; (2) fibromyalgia; (3) functional gastrointestinal disorders (excluding structural gastrointestinal disorders). 38 C.F.R. § 3.317(a)(2)(i). A medically unexplained chronic multi-symptom illness means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. See 38 C.F.R. § 3.317(a)(2). “Objective indications of chronic disability” include both “signs,” in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Signs or symptoms that may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). For the purposes of 38 C.F.R. § 3.317, disabilities that have existed for six months or more or that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. 1. Entitlement to service connection for a liver disability, claimed as cirrhosis The Veteran claims service connection for a liver disability. Service treatment records do not reflect any symptoms of or treatment for any liver disability, and no such abnormality was noted at the Veteran’s September 1991 separation examination. Private treatment records reflect that elevated liver enzymes were noted in January 2003, though they had stabilized by April 2003. A November 2005 CT scan showed fatty infiltration of the liver. Fatty liver was noted on subsequent CT scans associated with diagnosis and followup for the Veteran’s carcinoid tumor, discussed below. In his February 2009 informal claim, the Veteran reported that he was told by his doctor that his liver looks like the beginning stages of cirrhosis. His wife stated the same thing in an April 2009 statement. She also reported that he drank while in service but had not drunk in many years. At his March 2011 hearing before the RO, the Veteran reported that he was diagnosed with cirrhosis of the liver when he had surgery to remove his tumor in August 2006. He stated that he did not drink. The Veteran underwent a VA examination in July 2012. He was diagnosed with fatty infiltration of the liver as diagnosed in CT scans in 2006. The examiner noted that liver function studies from January 2012 were normal. The examiner opined that the disability was less likely than not related to a specific exposure event experienced by the Veteran during service in Southwest Asia. This opinion was based on the rationale that fatty liver infiltration was a disease with clear and specific etiology and diagnosis. The examiner further referenced medical literature indicating that studies were inconclusive showing any association between Gulf War deployment and any metabolic disease, but in its January 2018 memorandum decision the Court concluded that reliance on this study rendered the opinion inadequate. In May 2015, a clarification opinion was obtained from the July 2012 VA examiner. The examiner opined that fatty liver was less likely than not related to service. This opinion was based on the rationale that the Veteran’s fatty liver was first noted in April 2003, more than 10 years after separation. The examiner explained that fatty liver is associated with alcohol intake and obesity. As the Veteran denies alcohol abuse, it is likely related to his obesity, which increased gradually after service. The Veteran underwent another VA examination in October 2018. The examiner found no evidence of a diagnosis of a liver condition except for fat infiltration of the liver. The examiner explained that this was caused by obesity and is not a particular medical condition. VA treatment records reflect that a May 2019 ultrasound showed sonographic evidence of hepatic steatosis. There was no cirrhotic morphology. The Veteran underwent another VA examination in September 2020. He was diagnosed with nonalcoholic fatty liver disease. The examiner further found no evidence of cirrhosis. The examiner opined that his liver disability was less likely than not related to service or to service in the Gulf War. This opinion was based on the rationale that the primary cause of the Veteran’s disability was his longstanding history of obesity. The examiner further opined that the liver disability was less likely than not related to PTSD or disabilities of the hands or elbows. This opinion as based on the rationale that there is no pathophysiological relationship between fatty liver and such disabilities. The Board finds that the evidence weighs against a finding that a current disability of fatty liver is related to service, to service-connected disabilities, or to Gulf War exposures. Despite the Veteran’s claims, multiple examiners have found no evidence of cirrhosis, and there is no medical evidence to contradict these findings. The examiners further opined that there is no relationship to service. These opinions are consistent with the record evidence, which shows no liver symptoms in service or for more than 10 years thereafter. The examiners explained that fatty liver is a symptom of known etiology, specifically the Veteran’s obesity. It is therefore neither an undiagnosed illness nor a medically unexplained chronic multi-symptom illness, and service connection under 38 C.F.R. § 3.317 is thus not available. The examiners noted that there is no understood relationship to Gulf War exposures, including any exposure to mustard gas. The examiners found no relationship between the Veteran’s fatty liver disability and any service-connected disability. There is no evidence apart from the Veteran’s baseless speculation to contradict the examiners’ opinions. For these reasons, the Board finds that the evidence weighs against a finding that a current disability of fatty liver is related to service, to service-connected disabilities, or to Gulf War exposures. Service connection is therefore denied. 2. Entitlement to service connection for a disability manifested by weight gain The Veteran claims service connection for weight gain. Obesity itself is not a disability eligible for service connection under VA regulations. VAOPGCPREC 1-2017 (Jan. 6, 2017); 38 C.F.R. § 20.105 (the Board is bound by OGC opinions); see 38 U.S.C. § 7104(c); see also Marcelino v. Shulkin, 29 Vet. App. 155, 158 (2018) (holding that the court does not have jurisdiction to review VA’s determination that obesity is not considered a disability under the rating schedule). Accordingly, as obesity or being overweight is not a disability for VA compensation purposes, the claim for service connection for obesity must be denied. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). While service connection is not available for obesity itself, obesity caused or aggravated by a service-connected disability may nevertheless be an “intermediate step” for secondary service connection for any compensable disabilities caused or aggravated by obesity. See Walsh v. Wilkie, 32 Vet. App. 300 (2020). Because the Veteran claims service connection for several disabilities that may be related to his obesity, the Board will engage in a service-connection analysis to determine whether his obesity was caused or aggravated by his service-connected disabilities. He is service-connected for sleep apnea, PTSD, elbow disabilities, hypertension, hand disabilities, tinnitus, and hearing loss. Service treatment records reflect that the Veteran weighed 168 pounds at his July 1987 enlistment examination. In August 1991 a diagnosis of hypertension was attributed in part to his recent weight gain of 10 pounds over the prior two months. No weight abnormality was noted at his September 1991 separation examination, at which time his weight was recorded at 186 pounds. In his February 2009 informal claim, the Veteran reported that he has had weight gain since discharge from service. He stated that he has tried several times but cannot lose the weight and keep it off. His wife stated the same thing in an April 2009 statement. At his March 2011 hearing before the RO, the Veteran reported that the first three years of his active duty he weighed about 168 pounds. He stated that he started putting on weight in January 1991 and weighed 210-211 at discharge. Since then he gained weight, reaching a high of 263. He reported that his doctors put him on diets and enrolled him in nutrition classes. He stated that sometimes his weight has gone down but then it would go back up. The Veteran underwent a VA examination in July 2012. He was diagnosed with obesity. The examiner opined that obesity was less likely than not related to a specific exposure event experienced by the Veteran during service in Southwest Asia. This opinion was based on the rationale that obesity is a disease with clear and specific etiology and diagnosis, and the Veteran’s obesity was most likely due to genetics and dietary behaviors. In May 2015, a clarification opinion was obtained from the July 2012 VA examiner. The examiner opined that obesity was less likely than not incurred in service. This opinion was based on the rationale that obesity is uncommon in combat ready Marines due to their intense training regimen, and the Veteran acknowledged that he did not reach his highest weight of 300 pounds until approximately 2009. The Veteran underwent another VA examination in October 2018. He reported that he noticed he began having weight gain while in Desert Storm in May 1991. He currently weighed 149 pounds. The examiner found no medical condition that would cause weight gain or prevent the Veteran from reducing the amount of food he eats to lose weight. The examiner noted that the Veteran gained approximately 22 pounds from entrance to separation but explained that weight gain is very common in young service members due to the physical exercise requirements which generally cause muscle mass gain and increased caloric intake. The examiner explained that obesity is near epidemic in this country and, in the Veteran’s case, is related to eating too many calories and being sedentary. The Veteran underwent another VA examination in September 2020. The examiner opined that weight gain was less likely than not related to service or to a service-connected disability. This opinion was based on the rationale that his current obesity was caused by his poor diet. The Board finds that the evidence weighs against a finding that the Veteran’s obesity is caused or aggravated by a service-connected disability. His examiners and treating physicians have unanimously found that his obesity was linked to his caloric intake and sedentary behavior, with no relationship to Gulf War exposure or any service-connected disability. There is no medical evidence to contradict these findings. For these reasons, the Board finds that the evidence weighs against a finding that the Veteran’s obesity is caused or aggravated by a service-connected disability, and service connection for any other disability secondary to obesity is therefore not available. Furthermore, as stated above, because obesity is not recognized as a disability for VA compensation purposes, service connection for obesity must be denied as a matter of law. 3. Entitlement to service connection for carcinoma of the abdominal cavity The Veteran claims service connection for carcinoma. Service treatment records do not reflect any symptoms of or treatment for any cancer disability, and no such abnormality was noted at the Veteran’s September 1991 separation examination. Private treatment records reflect that after the Veteran reported right flank pain, a December 2005 CT scan showed a non-obstructing ureterovesical stone and incidentally noted a mass on the base of the mesocolon and left transverse colon. A June 2006 CT guided biopsy showed a carcinoid tumor. VA treatment records reflect that in July 2006 the Veteran reported his belief that he had Gulf War syndrome which was responsible for his tumor. Private treatment records reflect that in August 2006 the Veteran underwent surgery, and the tumor was found to be located at the base of the pancreas. A distal pancreatectomy, removal of the tumor, and splenectomy was performed. A biopsy confirmed malignancy. Followups in March 2007, October 2007, and May 2008 showed recovery without recurrence or metastases. In his February 2009 informal claim, the Veteran reported that in 2005 a mass was discovered in his abdominal cavity. It was eventually diagnosed as a carcinoid tumor and removed in August 2006 along with his spleen and half of his pancreas. His wife stated the same thing in an April 2009 statement. In an April 2009 statement, a friend who served with the Veteran attributed his cancer, among other symptoms, to Gulf War syndrome. No rationale was provided beyond a statement that the Veteran’s doctors were unable to rule it out as a cause. At his March 2011 hearing before the RO, the Veteran described his diagnosis and surgery. He stated that he was never given an etiology for his cancer. The Veteran underwent a VA examination in April 2011. He described his August 2006 surgery with current residual stomach pain. He was diagnosed with status post pancreatectomy and splenectomy for carcinoid tumor with normal healed surgical scar. The Veteran underwent another VA examination in July 2012. He was diagnosed with residuals of a pancreatic neoplasm. Current residuals included frequent loose bowel movements and incisional hernia. The examiner opined that the disability was less likely than not related to a specific exposure event experienced by the Veteran during service in Southwest Asia. This opinion was based on the rationale that the carcinoid tumor was a disease with clear and specific etiology and diagnosis. The examiner further referenced medical literature indicating that studies were inconclusive showing any association between Gulf War deployment and any cancer, but in its January 2018 memorandum decision the Court concluded that reliance on this study rendered the opinion inadequate. In May 2015, a clarification opinion was obtained from the July 2012 VA examiner. The examiner opined that carcinoma of the pancreas was less likely than not related to service. This opinion was based on the rationale that it was diagnosed as an incidental finding nearly 15 years after separation. The cancer was considered well-differentiated and of low grade and thus was likely to be slow growing, but without a better understanding of the tumor’s history it cannot be predicted whether the tumor was present in 1991. The Veteran underwent another VA examination in October 2018. The examiner found no clinically accepted medical evidence that shows neuroendocrine tumors are caused by exposures during the Gulf War. The examiner explained that etiology of such tumors is varied and largely unknown, though some are associated with hereditary disease. The Veteran underwent another VA examination in September 2020. The examiner opined that his carcinoma was less likely than not related to service, to service in the Gulf War, or to exposure to mustard gas. This opinion was based on the rationale that there is no medical research to support a relationship between Gulf War exposure or exposure to mustard gas and such a tumor, which was not diagnosed until over a decade after separation from service. The Board finds that the evidence weighs against a finding that the Veteran’s pancreatic cancer was related to service, to service-connected disabilities, or to Gulf War exposures. Multiple VA examiners have opined that there is no relationship to service. These opinions are consistent with the record evidence, which shows no symptoms of such a tumor in service or for more than 10 years thereafter. The examiners explained that the Veteran’s tumor was a definitive condition with a partially understood etiology. It is therefore neither an undiagnosed illness nor a medically unexplained chronic multi-symptom illness, and service connection under 38 C.F.R. § 3.317 is thus not available. The examiners noted that there is no understood relationship to Gulf War exposures, including any exposure to mustard gas. The examiners found no relationship between the Veteran’s tumor and any service-connected disability. There is no evidence apart from the Veteran’s baseless speculation to contradict the examiners’ opinions. For these reasons, the Board finds that the evidence weighs against a finding that the Veteran’s pancreatic cancer was related to service, to service-connected disabilities, or to Gulf War exposures. Service connection is therefore denied. 4. Entitlement to service connection for kidney stones The Veteran claims service connection for kidney stones. Service treatment records do not reflect any symptoms of or treatment for any kidney disability, and no such abnormality was noted at the Veteran’s September 1991 separation examination. Private treatment records reflect that in November 2005 the Veteran underwent a CT scan for right flank pain showing a three-millimeter upper right ureter stone and a three-millimeter intrarenal stone in the left kidney. In January 2006 he reported pain in his back and left flank, stating that he thought it was his kidney stone again. In July 2006 he was noted to have a non-obstructing stone in the left ureterovesical junction. In August 2007 he reported right flank pain and nausea. He was diagnosed with a four-to-five-millimeter right proximal ureteral stone. He underwent ureteroscopy, laser lithotripsy, and stent placement. March 2008 x-rays showed no definite stones. In July 2008 he was diagnosed with a ureter stone on the right with no associated flank pain. In December 2008 x-rays were normal. In January 2009 he reported nocturia. Records reflect ongoing treatment thereafter for urolithiasis and a right renal cyst. In his February 2009 informal claim, the Veteran reported that he developed kidney stones in 2005. He reported that in total he has had five kidney stones; three were passed, one was addressed surgically, and one dissolved on its own. His wife stated the same thing in an April 2009 statement. At his March 2011 hearing before the RO, the Veteran described his history of kidney stones. The Veteran underwent a VA examination in April 2011. He described his history of kidney stones and urinary tract stones beginning in November 2005. He was diagnosed with urolithiasis. Private treatment records reflect that in June 2011 x-rays showed no current renal or ureteral stones. The Veteran underwent another VA examination in July 2012. The examiner noted a history of 5 ureteral stones, four of which were passed but one requiring laser lithotripsy. He was currently medicated to prevent stone formation. He was diagnosed with nephrolithiasis. The examiner opined that the disability was less likely than not related to a specific exposure event experienced by the Veteran during service in Southwest Asia. This opinion was based on the rationale that kidney stones were a disease with clear and specific etiology and diagnosis. The examiner further referenced medical literature indicating that studies were inconclusive showing any association between Gulf War deployment and any specific condition of the genitourinary system, but in its January 2018 memorandum decision the Court concluded that reliance on this study rendered the opinion inadequate. In May 2015, a clarification opinion was obtained from the July 2012 VA examiner. The examiner opined that kidney stones were less likely than not related to service. This opinion was based on the rationale that the Veteran’s kidney stones began in 2005, 14 years after separation. The Veteran underwent another VA examination in October 2018. He reported that he had a total of five kidney stones, one of which required surgery. The examiner opined that kidney stones were unrelated to service or exposures during the Gulf War. This opinion was based on the rationale that the stones were not incurred in service and there is no mention of kidney stones being a part of Gulf War illness in medical literature. The Veteran underwent another VA examination in September 2020. He was diagnosed with nephrolithiasis without current symptoms. The examiner noted that he had not had a recurrent kidney stone since 2006. The examiner opined that his kidney stones were less likely than not related to service, to service in the Gulf War, or to exposure to mustard gas. This opinion was based on the rationale that there is no medical research to support a relationship between Gulf War exposure or exposure to mustard gas and kidney stones. The Board finds that the evidence weighs against a finding that the Veteran’s kidney stones were related to service, to service-connected disabilities, or to Gulf War exposures. Multiple VA examiners have opined that there is no relationship to service. These opinions are consistent with the record evidence, which shows no symptoms of kidney stones in service or for more than 10 years thereafter. The examiners explained that kidney stones are a definitive condition with an etiology. It is therefore neither an undiagnosed illness nor a medically unexplained chronic multi-symptom illness, and service connection under 38 C.F.R. § 3.317 is thus not available. The examiners noted that there is no understood relationship to Gulf War exposures, including any exposure to mustard gas. The examiners found no relationship between kidney stones and any service-connected disability. There is no evidence apart from the Veteran’s baseless speculation to contradict the examiners’ opinions. For these reasons, the Board finds that the evidence weighs against a finding that the Veteran’s kidney stones were related to service, to service-connected disabilities, or to Gulf War exposures. Service connection is therefore denied. 5. Entitlement to service connection for psoriasis The Veteran claims service connection for psoriasis. Service treatment records do not reflect any symptoms of or treatment for any psoriasis disability, and no such abnormality was noted at the Veteran’s September 1991 separation examination. VA treatment records reflect that in January 1996 the Veteran was diagnosed with possible psoriasis of the left knee. Private treatment records reflect that in March 1999 the Veteran was diagnosed with psoriasis on his knee. In August 2001 he was treated for psoriasis in his knees and right elbow. In January 2003 he reported psoriasis on his hands, elbows, and left knee for years. He was diagnosed with psoriasis and prescribed medication. He reported improvement in March 2003 but reported that the medication no longer worked in September 2004. VA treatment records reflect that in July 2006 the Veteran reported his belief that he had Gulf War syndrome which was responsible for his rashes. In his February 2009 informal claim, the Veteran reported psoriasis on his knees, elbows, ears, and hands. His wife stated the same thing in an April 2009 statement. In a July 2009 statement, he reported that his psoriasis had spread to his left calf and low back. At his March 2011 hearing before the RO, the Veteran reported that his psoriasis began on his left knee around 1993. He stated that at the time he worked in a factory and squatted on his left knee, and this caused him to notice a patch of dry skin. He bought a knee pad, but it then spread to his right knee, which he did not squat on. It had since spread elsewhere, including his elbows, ears, and calf. The Veteran underwent a VA examination in April 2011. He reported his history of psoriasis beginning in 1993. Physical examination revealed psoriasis on the hands, ears, elbows, knees, left lateral tibia and fifth left toe. He was diagnosed with psoriasis. The Veteran underwent another VA examination in July 2012. Physical examination showed classic psoriatic rash involving the ear canals, elbows, hands, knees, and left ankle. He was diagnosed with psoriasis. The examiner opined that the disability was less likely than not related to a specific exposure event experienced by the Veteran during service in Southwest Asia. This opinion was based on the rationale that psoriasis was a disease with clear and specific etiology and diagnosis. The examiner further referenced medical literature indicating that studies were inconclusive showing any association between Gulf War deployment and specific skin diseases, but in its January 2018 memorandum decision the Court concluded that reliance on this study rendered the opinion inadequate. In May 2015, a clarification opinion was obtained from the July 2012 VA examiner. The examiner opined that psoriasis was less likely than not related to service. This opinion was based on the rationale that the Veteran reports that his psoriasis began in 1993, more than one year after separation. The examiner explained that psoriasis is more often than not caused by genetic predisposition. The Veteran underwent another VA examination in October 2018. He reported that his psoriasis began in approximately 1993 or 1994. He reported that he got it on his elbows, knees, hands, and ears. The examiner opined that the Veteran’s psoriasis was unrelated to military service. This opinion was based on the rationale that there was no evidence that he had a skin condition in service, and it has several possible etiologies and is not a multi-system disease. In a December 2019 statement, the Veteran’s representative raised the argument that his psoriasis was secondary to his PTSD. The Veteran underwent another VA examination in September 2020. He reported developing psoriatic plaques about six months after separation from service. Physical examination showed scaly, erythematous plaques on his elbows and left knee consistent with psoriasis. The examiner opined that psoriasis was less likely than not related to service. This opinion was based on the rationale that the Veteran had no symptoms suggestive of psoriasis at the time of separation or within one year. There was insufficient medical research evidence to demonstrate whether psoriasis is associated with Gulf War exposure. The examiner further opined that psoriasis was less likely than not related to PTSD. This opinion was based on the rationale that there is no pathophysiological link between psoriasis and PTSD. The Board finds that the evidence weighs against a finding that the Veteran’s psoriasis is related to service, to service-connected disabilities, or to Gulf War exposures. Multiple VA examiners have opined that there is no relationship to service. These opinions are consistent with the record evidence, which shows no symptoms of psoriasis in service or for more than a year thereafter. The examiners explained that psoriasis is a definitive condition with an etiology. It is therefore neither an undiagnosed illness nor a medically unexplained chronic multi-symptom illness, and service connection under 38 C.F.R. § 3.317 is thus not available. The examiners noted that there is no understood relationship to Gulf War exposures, including any exposure to mustard gas. The examiners found no relationship between psoriasis and any service-connected disability. There is no evidence apart from the Veteran’s baseless speculation to contradict the examiners’ opinions. For these reasons, the Board finds that the evidence weighs against a finding that the Veteran’s psoriasis is related to service, to service-connected disabilities, or to Gulf War exposures. Service connection is therefore denied. 6. Entitlement to service connection for a bilateral knee disability The Veteran claims service connection for knee pain. Service treatment records do not reflect any symptoms of or treatment for any knee disability, and no such abnormality was noted at the Veteran’s September 1991 separation examination. Private treatment records reflect that in May 2007 the Veteran reported sudden left calf pain while running. X-rays were normal and an MRI showed a mild muscle strain of the gastrocnemius muscle. In his February 2009 informal claim, the Veteran reported aching in his knees. At his March 2011 hearing before the RO, the Veteran reported pain in multiple joints, including knees, that started about a year after separation from service. He stated that he had not been given a diagnosis beyond unspecified pain. Private treatment records reflect that in September 2014 the Veteran broke his left leg falling out of a tree stand while hunting. There is no contention made that this injury is claimed as service-connected, and as such the Board will not further address evidence solely related to this injury. The Veteran underwent a VA examination in May 2015. He reported daily pain and generalized stiffness in his joints, including his knees. He stated that this had been a longstanding problem for years and was part of his original claim. He was diagnosed with bilateral degenerative arthritis. The examiner explained that the osteoarthritis is a disease with clear and specific etiology, a repetitive use, biomechanical wear and tear condition with genetic and biomechanical risk factors becoming more common with advancing age. The examiner opined that the disability was less likely than not related to service. This opinion was based on the rationale that the Veteran was not diagnosed with arthritis until years after separation from service. The Veteran underwent another VA examination in October 2018. He was diagnosed with osteoarthritis of the bilateral knees. The examiner opined that the disability was unrelated to service. This opinion was based on the rationale that there was no evidence of a knee disability in service, and the Veteran’s current arthritis was caused by aging and aggravated by obesity. The Veteran underwent another VA examination in September 2020. The examiner opined that his knee disabilities were less likely than not related to service, to a service-connected disability, or to Gulf War exposure to include exposure to mustard gas. This opinion was based on the rationale that there was no evidence of knee disabilities in his service treatment records, there was no pathophysiological relationship between his knee disabilities and his service-connected disabilities, and there is no indication that Gulf War environmental hazards, to include mustard gas, cause degenerative arthritis of the knees. The Board finds that the evidence weighs against a finding that the Veteran’s knee arthritis manifested within one year of separation from service or is related to service, to service-connected disabilities, or to Gulf War exposures. Multiple VA examiners have opined that there is no relationship to service. These opinions are consistent with the record evidence, which shows no symptoms of knee disabilities in service or for more than 10 years thereafter. The examiners explained that osteoarthritis is a definitive condition with an understood etiology. It is therefore neither an undiagnosed illness nor a medically unexplained chronic multi-symptom illness, and service connection under 38 C.F.R. § 3.317 is thus not available. The examiners noted that there is no understood relationship to Gulf War exposures, including any exposure to mustard gas. The examiners found no relationship between osteoarthritis and any service-connected disability. There is no evidence apart from the Veteran’s baseless speculation to contradict the examiners’ opinions. For these reasons, the Board finds that the evidence weighs against a finding that the Veteran’s bilateral knee arthritis manifested within one year of separation from service or is related to service, to service-connected disabilities, or to Gulf War exposures. Service connection is therefore denied. 7. Entitlement to service connection for erectile dysfunction The Veteran claims service connection for erectile dysfunction. In a statement accompanying his June 2015 claim, the Veteran alternatively claimed direct service connection, service connection secondary to PTSD, or service connection secondary to any medication for a service-connected disability. Service treatment records do not reflect any symptoms of or treatment for erectile dysfunction, and no such abnormality was noted at the Veteran’s September 1991 separation examination. In a March 2017 statement, the Veteran’s representative argued that he has stated that he has erectile dysfunction. In a November 2018 statement, the Veteran’s representative argued that his claimed erectile dysfunction was associated with his PTSD. The Veteran underwent a VA examination in August 2019. He was diagnosed with erectile dysfunction secondary to hypogonadism or testicular hypofunction. The examiner opined that erectile dysfunction was less likely than not secondary to his PTSD. This opinion was based on the rationale that the Veteran had been diagnosed in July 2019 with testicular hypofunction and that he had been getting testicular injection intramuscularly weekly. The examiner thus concluded that this was the major risk factor for his erectile dysfunction. The examiner further stated that according to medical literature, not enough study was done yet to support PTSD as a cause of erectile dysfunction. The Veteran underwent another VA examination in September 2020. He reported erectile dysfunction beginning three years prior. He was diagnosed with erectile dysfunction. The examiner opined that erectile dysfunction was less likely than not related to service or to PTSD. This opinion was based on the rationale that it did not develop until decades after service and that based on the onset date it was likely from physiological aging, not PTSD or the medication used to treat it. The Board finds that the evidence weighs against a finding that the Veteran’s erectile dysfunction is related to service or to a service-connected disability. There is no evidence that erectile dysfunction began in service or is otherwise directly related to service. As to relationships to service-connected disabilities (or to Gulf War exposures), two VA examiners have offered more likely etiologies, specifically physiological aging and hypogonadism with testicular dysfunction. There is no medical evidence in the record to contradict these opinions. For these reasons, the Board finds that the evidence weighs against a finding that the Veteran’s erectile dysfunction is related to service or to a service-connected disability. Service connection is therefore denied. 8. Entitlement to service connection for acid reflux 9. Entitlement to service connection for a hiatal hernia 10. Entitlement to service connection for a gastrointestinal disability The Veteran claims service connection for acid reflux, a hiatal hernia, and a gastrointestinal disability. Service treatment records reflect that in May 1991 the Veteran reported symptoms of vomiting and diarrhea. Two days later he reported that his symptoms had improved. He was diagnosed with resolving gastroenteritis. No such abnormality was noted at his September 1991 separation examination. VA treatment records reflect that in December 1994 the Veteran reported that after his discharge from active duty in 1991, he experienced a three-month period of daily nausea and vomiting in the morning. The symptoms disappeared but reestablished themselves a few months prior to his consultation. He was referred to gastroenterology, where a July 1995 x-ray showed a small sliding hiatal hernia and thickening of the mucosal folds of the stomach consistent with gastritis. His gastroenterologist noted that the hernia was asymptomatic and offered an esophagogastroduodenoscopy (EGD) to assess the possible gastritis. He declined. In a February 2009 statement, the Veteran reported that after discharge from service he was sick every morning for six months. His wife stated the same thing in an April 2009 statement. At his March 2011 hearing before the RO, the Veteran reported that he was sick every morning for six months after returning from deployment. He stated that his symptoms had since ceased. In a statement accompanying his June 2015 claim, the Veteran alternatively claimed direct service connection, service connection secondary to PTSD, service connection secondary to any medication for a service-connected disability, or service connection secondary to his pancreatic cancer. In a March 2017 statement, the Veteran’s representative argued that his stomach condition likely began in service, based on his longstanding history of stomach problems including a diagnosis of a sliding hiatal hernia in 1995 consistent with gastritis. In a November 2018 statement, the Veteran’s representative argued that his claimed gastrointestinal disabilities were associated with his PTSD. VA treatment records reflect that in July 2019 the Veteran reported diarrhea and was diagnosed with irritable bowel syndrome (IBS). The Veteran underwent a VA examination in August 2019. He reported longstanding acid reflux, indigestion, and heartburn. He was diagnosed with gastroesophageal reflux disease (GERD). The examiner opined that GERD was less likely than not secondary to PTSD. This opinion was based on the rationale that PTSD is not among the common risk factors of GERD. The Veteran underwent another VA examination in September 2020. He reported intermittent reflux beginning in 1993 or 1994. He was diagnosed with GERD and a resolved hiatal hernia. Based on the Veteran’s reported symptoms, the examiner found no intestinal disability such as IBS. The examiner opined that GERD was less likely than not related to his service in the Gulf War. This opinion was based on the rationale that there was no medical evidence to support that Gulf War exposure was associated with the development of GERD. The examiner further opined that GERD was less likely than not related to PTSD. This opinion was based on the rationale that there is no known relationship with PTSD and the development or aggravation of an anatomical condition such has GERD. Finally, the examiner opined that GERD was less likely than not directly related to service. This opinion was based on the rationale that there were no such symptoms on separation from service and it was not formally diagnosed until 2007. The Board finds that the evidence weighs against a finding that acid reflux or GERD is related to service, to a service-connected disability, or to Gulf War exposure. There was no evidence of reflux upon separation from service, and GERD was not diagnosed until more than 15 years later. Multiple VA examiners have opined that there is no relationship to service. The examiners explained that GERD is a definitive condition with an understood etiology. It is therefore neither an undiagnosed illness nor a medically unexplained chronic multi-symptom illness, and service connection under 38 C.F.R. § 3.317 is thus not available. The examiners noted that there is no understood relationship to Gulf War exposures, including any exposure to mustard gas. The examiners found no relationship between GERD and any service-connected disability, specifically noting that there is no evidence that PTSD has any effect on the development or aggravation of an anatomical condition such as GERD. There is no evidence apart from the Veteran’s baseless speculation to contradict the examiners’ opinions. For these reasons, the Board finds that the evidence weighs against a finding that acid reflux or GERD is related to service, to a service-connected disability, or to Gulf War exposure. Service connection is therefore denied. The Board further finds that the evidence weighs against a finding of a current hiatal hernia disability. While treatment records establish a diagnosis of hiatal hernia in 1995, there are no subsequent treatment or diagnoses during the appeal period. The September 2020 VA examiner found that the Veteran’s hiatal hernia had resolved, and there is no evidence in the record to contradict this finding. Where the evidence does not support a finding of current disability upon which to predicate a grant of service connection, there can be no valid claim for that benefit. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As such, the Board finds that the evidence weighs against a finding of a current disability and service connection must therefore be denied. Finally, the Board finds that the evidence weighs against a finding of a current gastrointestinal disability. The evidence does not establish the presence of a chronic disability. While the Veteran reported diarrhea in July 2019 and was given a diagnosis of IBS, his treatment records do not reflect any chronic symptoms, nor has he described any such symptoms in his statements to VA in pursuing his claim. Rather, at his VA examinations he has described symptoms associated with GERD. The examiners thus diagnosed GERD, and the September 2020 VA examiner explicitly found that there was no current gastrointestinal disability. This finding is more probative than the July 2019 diagnosis which does not appear to be based on reports of chronic symptoms. Where the evidence does not support a finding of current disability upon which to predicate a grant of service connection, there can be no valid claim for that benefit. See Gilpin, 155 F.3d at 1353; Brammer, 3 Vet. App. at 225. As such, the Board finds that the evidence weighs against a finding of a current disability and service connection must therefore be denied. 11. Entitlement to an initial evaluation in excess of 50 percent for an acquired psychiatric disability, to include PTSD The Veteran claims an increased rating for his PTSD. Disability evaluations are determined by application of the criteria set forth in the VA’s Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran’s ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Diagnostic Code 9411 of 38 C.F.R. § 4.130 specifically addresses PTSD; however, all psychiatric disabilities are evaluated under a general rating formula for mental disorders. Under the general rating formula, the Veteran’s current 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 effective work and social relationships. A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, 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 an 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 inability to establish and maintain effective relationships. A total schedular rating of 100 percent 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 mental and personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). If the evidence shows that the Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the criteria for a particular rating, the appropriate equivalent rating will be assigned. Id. at 443. Furthermore, the rating code requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment at a level consistent with the assigned rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). At his March 2011 hearing before the RO, he explained that he sometimes forgets conversations from a few weeks prior, or he will start talking and then forget and go do something else. He denied having any cognitive screening by his doctors. Private treatment records reflect that in June 2011 the Veteran reported to his urologist increased fatigue. In July 2011 he reported increased fatigue and irritability. His urologist discussed these symptoms in the context of his testosterone therapy. Symptoms continued to be monitored for years thereafter. The Veteran underwent a VA mental health examination in July 2012. He reported a very good relationship with his wife and children. He stated that he had a few friends and some activities he enjoyed, including hunting and shooting. He reported that his work a police officer isolated him to some degree, such that mostly the only friends police officers have are other police officers. He reported occasional intrusive thoughts but not very often, maybe a few times per year. He reported mild memory problems which the examiner stated did not appear to be outside the range of expected functioning. He was not diagnosed with any mental disability. Specifically, the examiner found that he did not report, endorse, or exhibit symptoms of a mental health disability, and healthy mental health functioning was indicated. Private treatment records reflect that in May 2013 the Veteran reported to his primary care provider that he was wondering if he had PTSD. He reported having difficulty with his daughter and damaging his study in anger. He was diagnosed with depressive disorder, likely situational. In July 2013 he reported to his primary care provider daily panic attacks with anxious and fearful thoughts, depressed mood, difficulty sleeping, and excessive worry. He reported a history of suicidal ideation but none in the prior year. He was diagnosed with panic attacks and prescribed medication. In August 2013 he again reported anxiety. In March 2014 he reported that he could not stop Zoloft for more than three days without having outbursts of anger. His physician was concerned that his rage episodes could be related to his prescribed testosterone. In July 2014 he reported that he needed to take Xanax for his panic attacks twice in the past year. The Veteran underwent another VA examination in June 2015. He reported a very good relationship with his wife and adult children. He reported having a few friends and some activities he enjoys, including hunting and shooting. He reported about five close friends with whom he goes out for dinner and hunting. He stated that he does not like large gatherings. He reported that he still worked full time as a police officer and handles job stress well. He reported taking daily medication for panic symptoms. He reported dreams of combat. He reported occasional depression. The examiner noted symptoms of anxiety and panic attacks occurring weekly or less often. A cognitive screen showed no current memory impairment. He was diagnosed with depression, productive of 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 of symptoms controlled by medication. Private treatment records reflect that in August 2015 the Veteran reported becoming emotional and shaky when thinking of his war experiences. He reported periods of crying and depression. He stated that he overreacts to things at work. He reported nightmares and poor sleep. He reported panic attacks with shortness of breath. He reported erratic episodes of anger and intense anxiety. He was diagnosed with PTSD and panic disorder. His medication was altered, and in September 2015 he reported improvement. In October 2015 he reported no more nightmares. He reported having to step out when encountering a dead body as a police officer. In November 2015 he was concerned about being placed on administrative leave at work. In February 2016 he continued to report work trouble, but he denied panic attacks or nightmares. In May 2016 he reported that work was going well again and that his mood had improved. He denied flashbacks and nightmares. In September 2016 he reported that he got a part-time job disassembling firearms so they can be augmented. He reported that he felt very close to his wife. In October 2016 he reported distress having discovered that his wife had had an affair over the prior year. In January 2017 he reported distress because he was being investigated at work after having a car accident. In February 2017 he reported that he left his job and was unable to find work as a police officer. The Veteran underwent another VA examination in February 2017. He reported that he left his job and was trying to find another. He reported difficulties in his marriage. He reported that he has five friends with whom he spends time target shooting. He reported infrequent panic attacks with medication. The examiner noted symptoms of depressed mood, anxiety, panic attacks occurring weekly or less often, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, and difficulty in adapting to stress. He was diagnosed with PTSD and recurrent moderate major depressive disorder, together productive of occupational and social impairment with reduced reliability and productivity. Private treatment records reflect that in April 2017 the Veteran reported that he and his wife were working well together as a team. He had decided to take early retirement from the police force and would begin to receive his pension in January. VA treatment records reflect that in May 2017 the Veteran reported anxiety, depression, insomnia, occasional nightmares, and memory loss. He was diagnosed with PTSD and primary insomnia. In July 2017 he reported a substantial reduction in stress since leaving his job as a police officer. He reported that he and his wife began teaching a concealed carry class in recent months. He reported occasional depressive episodes. Later in the month he reported improvement but stated that his memory was still bad. In August 2017 he reported an improved mood but difficulties in his marriage due to infidelity. In September 2017 he reported that he was doing okay. Private treatment records reflect that in August 2017 the Veteran reported that his medication helped him avoid nightmares and flashbacks. He stated that he was happy with his current control over his anxiety. He reported that he enjoyed teaching concealed carry classes, which involved teaching shooting. The Veteran underwent another VA examination in November 2017. He reported that he and his wife had worked through their marital problems and their marriage was stable. He maintained relationships with his adult children. He stated that he has a close friend with whom he target-shoots. He reported that he was looking for work, but his former police department was blackballing him elsewhere. He reported that he enjoys hunting with his son and some friends. He reported that he has been teaching firearms management. He stated that he intended to help his daughter with childcare when his grandchild is born. The examiner noted symptoms of depressed mood, anxiety, panic attacks occurring weekly or less often, chronic sleep impairment, mild memory loss, disturbances of motivation or mood, and difficulty in adapting to stress. He was diagnosed with PTSD and insomnia disorder, together productive of occupational and social impairment with reduced reliability and productivity. In terms of the impact on employment capacity, the examiner noted that his understanding, memory, sustained concentration, and social interaction were good. Adaptation was fair. Private treatment records reflect that in January 2018 the Veteran reported that he and his wife had worked hard on their marriage and he was pleased with the results. He reported that he was sleeping well and had no crying or sadness. VA treatment records reflect that in February 2018, the Veteran reported that he was spending a lot of time caring for his grandson while his daughter attended classes. He continued to facilitate concealed carry courses and anticipated a heavier load of students. He reported that he was getting along with his wife better than they had in quite some time. His psychologist noted that his depression symptoms were notably improved and that his PTSD symptoms were largely manageable. In March 2018 he reported that his mood was stable with occasional anxiety. He stated that sometimes he had nightmares and anxiety spells. Private treatment records reflect that in June 2018 the Veteran reported that he and his wife provide childcare for their grandson 3-4 days per week, though he provides more hours than his wife because she had a job. He was also teaching concealed carry classes. He had no sadness, crying, despair, or panic attacks. VA treatment records reflect that in September 2018 the Veteran reported that he was doing good. He reported no exacerbations of his PTSD. He stated that he was looking forward to an upcoming hunting trip and to his daughter’s wedding. Private treatment records reflect that in December 2018 the Veteran reported that he was planning to move and would shut down his gun instruction business, thought he stated that he may open it in his new location in the future. He reported that he had recently gone on a hunting trip for veterans. VA treatment records reflect that in April 2019 the Veteran reported he was doing well. He reported that he was doing a lot of home projects and was making a home office for his wife. Private treatment records reflect that in June 2019 the Veteran reported a recent 2-or 3-week period of low moods, but afterwards he had been good. VA treatment records reflect that in November 2019 the Veteran reported that he was doing pretty good. He stated that he was sleeping well and had no major flare-ups of his PTSD recently. Private treatment records reflect that in December 2019 the Veteran reported that he had recently been on a cruise with his wife. He reported that he enjoys spending time with his grandson. He reported nightmares twice weekly, often in which he gets killed. In June 2020 he reported continued nightmares and flashbacks. VA treatment records reflect that in May 2020 the Veteran reported that he was doing well and was stable. He stated that his medications were working and he was sleeping well. The Board finds that an initial evaluation in excess of 50 percent is not warranted for the Veteran’s acquired psychiatric disability. Higher ratings are available for total occupational and social impairment or for occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, or mood. The evidence weighs against symptoms of such severity. He has strong family relationships and remains social with friends, going out to dinner and going on hunting trips. He was fully employed as a police officer until 2017, at which time he took early retirement. He reported that he had difficulty with his supervisor, but afterwards he remained active teaching firearms classes and providing childcare for his grandson. He and his wife have travelled, and he has expressed satisfaction with time spent with his family. His symptoms have consisted of nightmares, flashbacks, depression, crying spells, irritability, mild memory loss, and panic attacks occurring relatively rarely. These are not the symptoms associated with the criteria for higher ratings. No VA examiner has found that his symptoms are productive of impairment at the higher rating levels, and his treatment records reflect that on most occasions he has reported that he is functioning well. For these reasons, the Board finds that an initial evaluation in excess of 50 percent is not warranted for the Veteran’s acquired psychiatric disability. 12. Entitlement to a TDIU The Veteran seeks a TDIU. He contends that his service-connected disabilities, when considered in combination, render him unemployable. Total disability means that there is present any impairment of mind or body sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. §§ 3.340, 4.15. A substantially gainful occupation has been 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 the Veteran actually works and without regard to the Veteran’s earned annual income.” Faust v. West, 13 Vet. App. 342 (2000). When jobs are not realistically within his physical and mental capabilities, a veteran is determined unable to engage in a substantially gainful occupation. Moore v. Derwinski, 1 Vet. App. 356 (1991) (citing Timmerman v. Weinberger, 510 F.2d 439 (8th Cir. 1975)). In making this determination, consideration may be given to factors such as the veteran’s level of education, special training, and previous work experience, but not to age or impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). A veteran is totally disabled if his service-connected disability or combination of service-connected disabilities is rated at 100 percent pursuant to the Schedule for Rating Disabilities. 38 C.F.R. § 3.340(a)(2). Even if a veteran is less than 100 percent disabled, he still is deemed totally disabled under the Schedule for Rating Disabilities if he satisfies two requirements. 38 C.F.R. § 4.16(a). First, the veteran must meet a minimum percent evaluation. If he has one service-connected disability, it must be evaluated at 60 percent or more. If he has two or more service-connected disabilities, at least one disability must be evaluated at 40 percent or more and the combined evaluation of all the disabilities must be 70 percent or more. The following will be considered as one disability with respect to the minimum percent evaluation: (1) disabilities of one or both upper extremities or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system (e.g., orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric), (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. Second, the veteran must be found to be unable to secure and follow a substantially gainful occupation as a result of his service-connected disability or disabilities. Id. Where a veteran does not meet the percentage evaluation requirements under 4.16(a), he still may be deemed totally disabled on an extraschedular basis under 38 C.F.R. § 4.16(b) when the evidence nonetheless indicates that the veteran is unemployable by reason of his service-connected disabilities. Under such circumstance the matter is referred to the Director of the Compensation and Pension Service (“Director”) for consideration. Id.; see also Bagwell v. Brown, 9 Vet. App. 337 (1996); Floyd v. Brown, 9 Vet. App. 88 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). Extraschedular TDIU consideration requires contemplation of the following factors: severity of the veteran’s service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue. 38 C.F.R. § 4.16(b). Although the Board does not have the authority to award an extraschedular TDIU prior to referral to the Director, the Board has jurisdiction to review and award extraschedular ratings in claims that have been denied by the Director. See Kuppamala v. McDonald, 27 Vet. App. 447 (2015). In determining whether a TDIU is warranted, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. For the entirety of the appeal period, the Veteran has been in receipt of a 50 percent rating for PTSD, a 50 percent rating for sleep apnea with memory loss, a 10 percent rating for hypertension, two 10 percent ratings for disabilities in each elbow, and two noncompensable ratings for disabilities in each hand. Additionally, effective in June 2015 he was awarded a noncompensable rating for right ear hearing loss, and effective in October 2017 he was awarded a 10 percent rating for tinnitus. His combined rating is thus 80 percent for the entirety of the appeal period, meeting the threshold for a schedular TDIU under 38 C.F.R. § 4.16(a). In his September 2017 application for a TDIU, the Veteran stated that his PTSD rendered him unemployable in January 2017, at which time he left his job as a police officer. In an accompanying statement, he reported that he has a high school degree and worked in various aspects of law enforcement for 20 years, beginning at a jail before becoming a police officer. He stated that the department he worked for began “hyperfocusing” on everything he did once they found out he had been diagnosed with PTSD. He stated that his disability prevented him from socializing with his fellow officers. He reported that his irritability compromised his ability to interact with his coworkers, supervisors, and the public. He stated that his disability caused sleep deprivation which impaired his focus, attention, concentration, memory, and judgment. He stated that since leaving the department he interviewed for two other departments but was rejected due to his diagnosis. In a December 2017 statement, the Veteran’s representative argued that he was unemployable because his private psychologist noted severe panic attacks and at least one dissociative episode, making it very difficult for him to continue working as a police officer. A June 2018 disability determination and transmittal from the Social Security Administration determined that the Veteran became fully disabled on January 23, 2017 with a primary diagnosis of other unspecified arthropathies and a secondary diagnosis of osteoarthritis and allied disorders. The associated documentation and medical examination noted that these disabilities referred to his problems with his left knee and right ankle. The June 2018 medical evaluation noted that the Veteran’s mental health medically determinable impairments were non-severe. The Board finds that the evidence weighs against a finding that the Veteran’s service-connected disabilities have rendered him unemployable or unable to secure and follow a substantially gainful occupation. He claims that he has been rendered unemployable by his PTSD alone. The Veteran does not contend, and the evidence does not suggest, that his other service-connected disabilities have rendered him unemployable. The evidence does not support his contention that PTSD has rendered him unemployable. It is unclear the exact incidents that led to his early retirement from the police force, though the Veteran alleges that his department learned of his PTSD diagnosis and targeted him and blackballed him from other police work. Even if this were fully established, the inability to perform police work is not the equivalent of being unemployable. Since his early retirement, the Veteran has reported that he began his own business teaching firearms classes with his wife. He spends several days a week providing childcare for his toddler grandson. Such tasks are not suggestive of someone who is closed out from earning a living by his mental health disability. Moreover, PTSD is rated based on occupational and social impairment, and, as discussed above, no VA examiner has found that the Veteran’s PTSD is productive of total occupational impairment. Finally, while the Veteran has been determined to be disabled by the Social Security Administration, this determination was based on non-service-connected disabilities of his left knee disability; a right hand disability for which the Veteran receives a 0 percent rating; and the medical examiner noted that PTSD presented non-severe impairment. For these reasons, the Board finds that the evidence weighs against a finding that the Veteran’s service-connected disabilities have rendered him unemployable or unable to secure and follow a substantially gainful occupation, and a TDIU is therefore denied. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Gallagher, 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.