Citation Nr: 21002361 Decision Date: 01/13/21 Archive Date: 01/13/21 DOCKET NO. 16-29 987 DATE: January 13, 2021 ORDER Entitlement to an increased rating in excess of 60 percent for ischemic heart disease (IHD) for the period before August 12, 2016, is denied. Entitlement to an increased rating of 60 percent, but no more, for IHD for the period from August 12, 2016 to September 21, 2019, is granted. Entitlement to an increased rating in excess of 60 percent for IHD for the period from September 21, 2019 to December 24, 2019, is denied. Entitlement to an increased rating of 70 percent, but no more, for PTSD for the period from October 16, 2012 to December 24, 2019, is denied. Entitlement to a rating in excess of 70 percent for PTSD for the period beginning December 24, 2019 is denied. Entitlement to a total disability evaluation based on individual unemployability (TDIU) from July 1, 2013 is granted. FINDINGS OF FACT 1. For the period prior to August 12, 2016, the Veteran’s IHD was manifested by a cardiac workload of greater than 5 and less than 7 metabolic equivalents (METs) resulting in fatigue and angina and left ventricular ejection fraction (LVEF) between 55 to 62 percent. 2. Affording the Veteran with the benefit of the doubt, for the period from August 12, 2016 to September 21, 2019, the Veteran’s IHD was manifested by a cardiac workload of greater than 5 and less than 7 METs resulting in fatigue and angina and LVEF of 49 percent at worst. 3. For the period from September 21, 2019 to December 24, 2019, the Veteran’s IHD was manifested by LVEF between 35 to 45 percent. 4. For the entire period on appeal from October 16, 2012, the Veteran’s reported psychiatric symptoms have included suicidal ideation. 5. The Veteran’s service-connected disabilities have been shown to be of such severity as to preclude him from securing and following substantially gainful employment July 1, 2013, the day after he ceased working. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 60 percent for IHD for the period prior to August 12, 2016, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.114, Diagnostic Code (DC) 7005. 2. The criteria for an evaluation of 60 percent, but no more, for IHD for the period from August 12, 2016 to September 21, 2019, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.114, DC 7005. 3. The criteria for an evaluation in excess of 60 percent for IHD for the period from September 21, 2019 to December 24, 2019, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.114, DC 7005. 4. The criteria for an evaluation of 70 percent, but no more, for PTSD for the period on appeal beginning October 16, 2012 until December 24, 2019, have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.3, 4.7, 4.130, DC 9411. 5. The criteria for an evaluation in excess of 70 percent for PTSD for the period beginning December 24, 2019 is denied. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.3, 4.7, 4.130, DC 9411. 6. The criteria for the award of TDIU from July 1, 2013, have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1968 to February 1972. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a November 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois. The Veteran testified at an August 2019 Board hearing before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing is associated with the Veteran’s claims file. This matter was previously before the Board in October 2019 when it was remanded for further development to include new VA examinations and furnish the Veteran a 38 C.F.R. § 3.159(b) notice letter addressing the claim of entitlement to TDIU. New examinations evaluating the current nature of the Veteran’s service connected IHD and PTSD were obtained, and the record includes a December 2019 development letter requesting employment information for the TDIU claim. The Board notes that VA complied with the remand instructions, and there exist no deficiencies in VA’s duties to notify and assist in that regard. See Stegall v. West, 11 Vet. App. 268 (1998). The matter has returned to the Board for further appellate review. During pendency of the appeal, a May 2016 rating decision granted an earlier effective date of October 16, 2011 for the award of service connection for IHD. A subsequent August 2020 rating decision increased the Veteran’s IHD disability rating to 60 percent, effective October 16, 2011; assigned a 30 percent disability rating for the period from August 12, 2016 to September 21, 2019; assigned a 60 percent disability rating for the period from September 21, 2019 to December 24, 2019; and assigned a 100 percent, total disability rating beginning December 24, 2019. The Board will not disturb the total disability rating. However, as the RO did not assign the maximum disability rating back to the effective date of the grant of service connection, the appeal for higher disability evaluations for each staged rating remains before the Board. See AB v. Brown, 6 Vet. App. 35 (1993). The August 2020 rating decision also increased the Veteran’s PTSD disability rating to 50 percent, effective March 29, 2017, and assigned a 70 percent disability rating for the period beginning December 24, 2019. Again, the appeal for higher disability evaluations for each staged rating remains before the Board. See AB v. Brown, supra. This case raises no further issues. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). Increased Rating Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate DCs. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In cases in which a claim for a higher initial evaluation stems from an initial grant of service connection for the disability at issue, multiple (“staged”) ratings may be assigned for different periods of time during the pendency of the appeal. See Fenderson v. West, 12 Vet. App. 119 (1999). Where entitlement to compensation has already been established, and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994); 38 C.F.R. § 4.2. Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. See generally Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 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). 1. Entitlement to an increased rating in excess of 60 percent for IHD for the period before August 12, 2016 The Veteran’s IHD is rated under DC 7005 for coronary artery disease (CAD). A 30 percent rating is warranted when a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; there is evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent disability rating is warranted when there is more than one episode of acute congestive heart failure in the past year, or; when a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; when there is left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent disability rating is warranted when there is chronic congestive heart failure, or; when a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104, DC 7005. The Board’s analysis will address each staged rating in turn. One MET (metabolic equivalent) is defined as the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note (2). The claims file includes an October 2012 IHD disability benefits questionnaire (DBQ) that the Veteran submitted with his October 2012 VA 21-526EZ Fully Developed Claim for Compensation. A private treatment provider noted the Veteran has a diagnosis of IHD and his treatment plan includes the use of continuous medication. Coronary bypass surgery was noted. The DBQ was negative for congestive heart failure (CHF) and cardiac hypertrophy or dilatation. Diagnostic testing noted in the DBQ included a January 2006 exercise test showing cardiac workload of 12.5 METs, a November 2010 chest X-RAY showing normal heart size, and an August 2012 echocardiogram showing LVEF of 50 percent. No functional impacts on the Veteran’s ability to work were noted. The claims file also includes an August 2013 VA IHD examination. Following an in-person examination and review of the claims file, the examiner confirmed an IHD diagnosis and coronary bypass from 2000. The examination report notes the Veteran’s treatment plan includes taking continuous medication. Congestive heart failure (CHF) was not noted. Cardiac workload was assessed at greater than 7 but less than 10 METs resulting in fatigue. Diagnostic testing showed no evidence of cardiac hypertrophy or dilatation. The examiner noted that the Veteran’s IHD does not impact his ability to work. Multiple private treatment records noting treatment for IHD were received by VA in October 2019. The Board notes these records are dated throughout the appeal and will be addressed in the appropriate time period in this analysis. A November 2011 private progress record cited a previous diagnosis of atrial fibrillation (A-fib) and noted the Veteran started medication to improve rate control. A March 2012 private radiology record noted echocardiogram results showing LVEF of 50 percent. An August 2012 echocardiogram result showed LVEF at 50 percent. In an October 2012 VA Agent Orange Program record, the Veteran denied chest pains but endorsed shortness of breath when tying his shoes or ascending stairs that resolved after several minutes of rest. Orthopnea and palpitations were denied. A March 2016 private cardiac report noted the Veteran has chronic, rate-controlled A-fib, that his symptoms are correlated with the A-fib; there was no evidence of rapid ventricular response. The Board notes that the examinations of record during the period before August 12, 2016, specifically, an October 2012 DBQ and an August 2013 VA examination, both establish the Veteran has a cardiac workload of greater than 7 METs which correlates to a 30 percent rating. However, the Board notes the private treatment records cited above establish that the Veteran’s IHD was manifested by LVEF of 50 based on multiple echocardiogram results. LVEF between 30 to 50 percent correlates to a 60 percent disability rating. Based on the evidence noted above, the Veteran’s IHD disability picture more nearly approximates the criteria required for at most a 60 percent disability rating for the period before August 12, 2016. The Board finds that an increased rating in excess of 60 percent is not warranted for this period as there is no showing of symptoms for a higher rating in excess of 60 percent during this period. The appeal to this extent is denied. 2. Entitlement to an increased rating of 60 percent, but no more, for IHD for the period from August 12, 2016 to September 21, 2019 The RO assigned a 30 percent rating for the period from August 12, 2016 to September 21, 2019. However, affording the Veteran the benefit of the doubt, the Board finds that his symptoms warranted a 60 percent rating during this period. The claims file includes an August 12, 2016 private echocardiogram with results showing LVEF at 55 percent, a September 2016 private myocardial perfusion test with LVEF noted at 56 percent, and a November 2016 private myocardial perfusion test with LVEF noted at 56 percent. A January 2018 private echocardiogram report notes LVEF at 60 percent and mild hypertrophy; a progress record dated the same day notes moderate left ventricular hypertrophy. A January 2018 private treatment discharge summary notes the Veteran had recently been treated for heart failure. An April 2018 private progress record notes that the Veteran continued to experience some dyspnea with exertion but denied chest pains, syncope/pre-syncope. The same record cited the January 2018 LVEF results above. November 2018 echocardiogram results note LVEF at 60 percent and evidence of hypertrophy. This suggests an improved LVEF during this period. Following a thorough review of the claims file, the Board has identified a second August 2016 echocardiogram showing LVEF at 50 percent. The claims file also includes an October 2017 private anesthesiology record that noted that the Veteran is status post (s/p) coronary artery bypass graft, has a history of CAD, a diagnosis of hypertension, and an exercise tolerance greater than 4 METs. Finally, a separate April 2018 private myocardial perfusion study noted LVEF at 49 percent. The claims file also includes an April 2018 IHD DBQ, wherein the private provider noted a diagnosis of CHF from 2018 but then indicated it was not chronic. The examiner also acknowledged the April 2018 results showing LVEF at 49%. Based on an interview based METs test, the examiner noted a cardiac workload greater than 5 and less than 7 METS, resulting in fatigue. The Board also reviewed a September 2018 IHD DBQ. The examiner noted that the Veteran had CHF from 2018, but noted it is not chronic and indicated that the Veteran had not experienced more than one episode of acute CHF in the past year. Diagnostic testing cited in the DBQ includes a January 2018 echocardiogram showing LVEF of 60 percent. The Board acknowledges the November 2018 echocardiogram showing LVEF at 60 percent and September and November 2016 myocardial perfusion results showing LVEF at 56 percent. However, based upon the foregoing medical records, the Board finds that the Veteran’s IHD manifested through symptomatology that warrants both a 30 percent and 60 percent rating, and further, that the symptomatology overlaps in a manner that makes separate stages unwarranted. Thus, affording the Veteran with the benefit of the doubt, the disability picture more nearly approximates the criteria required for a 60 percent rating based on LVEF between 30 to 50 percent. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102, 4.7. The appeal to this extent is granted. 3. Entitlement to an increased rating of 60 percent, but no more, for IHD for the period from September 21, 2019 to December 24, 2019 The RO assigned a 60 percent rating for the period from September 21, 2019 to December 24, 2019. Based on the evidence of record, the Board finds that a rating in excess of 60 percent is not warranted during this period based on the Veteran’s symptomatology. A June 2020 VA internal medicine record noted hospital admission in September 2019 for worsening shortness of breath and chest tightness. The record also noted that the Veteran underwent another echocardiogram at a private hospital with decreased LVEF at 35 percent. An electrocardiogram was noted to be unremarkable. The Veteran underwent a cardiac catheterization and was found to have patent bypass grafts and minimal diffuse disease in his native right coronary artery. A repeat echocardiogram showed LVEF at 45 percent. Finally, the same record notes that the cardiac catherization report mentioned a possible apical aneurysm that is likely an artifact as seen on echocardiogram. Medical records in the claims file relevant to this period includes a December 24, 2019 VA heart conditions (including IHD) examination. Following an in-person examination and review of the claims file and September 2019 echocardiogram results, the examiner confirmed diagnoses of CHF from 2012, s/p coronary artery bypass graft from 2000, IHD, and A-fib from 2012. The use of required continuous medication was noted. The examination report noted the Veteran had chronic CHF with more than 1 episodes of acute CHF in the past year with the most recent episode noted in October 2019. Intermittent A-fib was noted with 1-4 episodes in the past 12 months. The report is negative for a heart valve condition, an infectious cardiac condition, and pericardial adhesions. Diagnostic testing noted in this examination included a September 2019 echocardiogram showing LVEF at 35 percent and evidence of cardiac hypertrophy and dilatation. A December 2019 interview-based METs test assessed cardiac workload at greater than 3 but less than 5 METs resulting in dyspnea and dizziness. The examiner noted that the Veteran’s reported shortness of breath and dizziness would impact his ability to work or perform any activity. Based upon the foregoing medical records, the Board finds that the Veteran’s IHD manifested itself through symptomatology including a LVEF between 35 and 45 percent, warranting a 60 percent rating, but no more, for the period from September 21, 2019 to December 24, 2019. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102, 4.7. Thus, the appeal to this extent is denied. 4. Entitlement to an evaluation of 70 percent, but no more, for PTSD for the entire period on appeal beginning October 16, 2012 The Veteran contends that his service-connected PTSD is worse than contemplated by the initially assigned 30 percent disability rating. See December 2013 Notice of Disagreement (NOD). As noted above, an August 2020 rating decision increased the disability rating for the Veteran’s PTSD to 50 percent, effective March 29, 2017, and assigned a 70 percent disability rating for the period beginning December 24, 2019. However, the Board finds that a 70 percent rating is warranted for the entire period on appeal beginning October 16, 2012. The Veteran’s PTSD is rated under the General Rating Formula for mental disorders. 38 C.F.R. § 4.130. Under the General Rating Formula, a 70 percent disability rating is warranted when occupational and social impairment reflects deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; and an inability to establish and maintain effective relationships. Id. A 100 percent disability rating is assigned when there is total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. The claims file includes an August 2013 VA initial PTSD examination, wherein the examiner confirmed diagnoses of PTSD, alcohol abuse, and opiod dependence in sustained full remission. The examiner noted that the Veteran underwent treatment during service and had not used any opioids since. The report notes that the Veteran has multiple mental health diagnoses and indicates it is not possible to differentiate symptomatology attributable to each diagnosis. No traumatic brain injury (TBI) was noted. Occupational and social impairment was noted due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. The examiner discussed the Veteran’s social and occupational history in detail, noting an irregular work history up to 1979 could be the product of substance abuse or PTSD, or both. Further the examiner noted the Veteran has significantly reduced alcohol consumption over the past 10 years and has reported an increased social and occupational functioning since he started medication and psychotherapy. Symptomology included depressed mood, mild memory loss, and chronic sleep impairment. The examiner noted the Veteran’s PTSD has a very mild impact on his current social and occupational functioning. The claims file also includes a December 2019 PTSD examination wherein the examiner confirmed a diagnosis of PTSD. The examiner noted that all symptoms are attributable to the Veteran’s PTSD. No TBI was noted. Occupational and social impairment was noted with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The examiner noted the Veteran’s symptomatology included depressed mood; anxiety; suspiciousness; panic attacks that occur weekly or less often; and chronic sleep impairment; mild memory loss; motivation and mood disturbances; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a work like setting; an inability to establish and maintain effective relationships; and suicidal ideation. The examiner also noted that the severity of symptoms has slightly increased and the Veteran now has worse anxiety and experiences passive suicidal ideation with no intent or plan. After a thorough review of the record, the Board identified records indicating that the Veteran has reported multiple suicide attempts and/or suicidal ideation since his separation from active service. An August 2015 VA mental health record noted the Veteran acknowledged suicide attempts in 1971 and 1975, and a subsequent mental health hospitalization in 1975. A February 2013 VA mental health counseling record noted the Veteran endorsed thoughts of killing himself but indicated that he would not act on them and also noted the Veteran denied current suicidal intention or plan. A January 2017 VA social work consult record noted the Veteran reported a 2015 suicide attempt. The Board also notes a March 2017 VA mental health treatment plan record that indicated the Veteran’s symptoms appear to be worsening. The Veteran reported running out of medication and having difficulty sleeping, worrying all the time, feeling sad daily, decreased energy levels, yelling at others, shaking, nightmares, and short-term memory issues. In addition, the Veteran reported his anxiety increased to 7/10. The Veteran denied suicidal ideation in VA treatment records dated in March 2018. An April 2019 VA general medicine attending record noted that the Veteran has a history of PTSD, and symptoms are controlled at the present; the Veteran denied mood changes, suicidal and homicidal ideation, and hallucinations. The same record also noted that the Veteran is receiving treatment for mental health on a regular basis. A July 2019 VA mental health attending record noted that the Veteran reported feeling worried all the time but felt like he can control the worry. He reported anxiety at 5-7/10, irritability, and arguing with his wife. He denied violence. An August 2019 VA internal medicine attending record noted that he denied suicidal, homicidal ideation, and hallucinations. The Board considered the Veteran’s lay statements including his December 2013 NOD and June 2016 Form 9 formal appeal that both note suicide attempts and a psychiatric hospitalization following separation from active service, and the Veteran’s testimony during his August 2019 Board hearing wherein the Veteran reported that his PTSD had subsequently gotten worse and testified to previous suicide attempts and suicidal ideation. The Board finds that the Veteran is competent to observe his PTSD symptoms including suicidal ideation and suicide attempts. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Accordingly, his lay statements have probative value. In reviewing the above symptoms, the Board finds no basis for an evaluation in excess of 70 percent at any time during the period on appeal. The evidence of record in no way demonstrated total occupational and social impairment. Indeed, the December 2019 PTSD examination addresses the Veteran’s social isolation and increased anxiety in crowds. The remaining criteria listed for a 100 percent evaluation have not been demonstrated. The Board has considered the significant frequency, severity, and duration of psychiatric symptoms but finds that they are entirely contemplated by the assigned 70 percent evaluation. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013); 38 C.F.R. § 4.126(a). Therefore, the appeal is granted for the period prior to December 24, 2019 and denied for the period subsequent to that period. 5. Entitlement to TDIU for the period prior to December 24, 2019 The Board notes a claim for TDIU is part and parcel of an increased rating claim when such is raised by the Veteran or by the record. As such, a claim for entitlement to TDIU was added in the Board’s October 2019 remand order pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009). During this appeal, in the August 2020 rating decision the RO granted entitlement to TDIU, effective December 24, 2019. Nonetheless, the Board notes entitlement to for the period prior to December 24, 2019 remains before the Board at this time. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. The criteria require that in cases where there are two or more disabilities, as is the case in this here, at least one disability is rated at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. The existence or degree of nonservice-connected disabilities or previous unemployability status will be disregarded where the percentages referred to in this paragraph for the service-connected disability or disabilities are met, and, in the judgment of the rating agency, such service-connected disabilities render the Veteran unemployable. Marginal employment shall not be considered substantially gainful employment. Consideration shall be given in all claims to the nature of the employment and the reason for termination. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating is a recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether the Veteran can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). According to the rating results based on the order above, the Veteran has had a combined rating of at least 70 percent, with at least one disability rated 40 percent or more throughout the entirety of this appeal. Service-connected disabilities include IHD status post coronary artery bypass graft, rated at 60 percent from October 16, 2011; PTSD rated at 70 percent from October 16, 2012; and upper chest surgical scar associated with the IHD rated noncompensable. This is a combined rating of 88 percent rounded up to 90 percent. 38 C.F.R. § 4.25. Thus, he has met the threshold requirements and is entitled to consideration of TDIU under 38 C.F.R. § 4.16(a) throughout this appeal. Following the Board’s October 2019 remand, the Veteran filed a VA 21-8940 application for TDIU in February 2020, wherein he reported that he last worked in June 2013 and had to retire because his service-connected disabilities prevented him from performing job duties. The Veteran’s representative also submitted a VA Form 21-4192 Request for Employment Information, wherein it is noted that the Veteran retired effective July 1, 2013 but does not note the reason for or cause of his retirement. The Veteran testified during the August 2019 Board hearing that he cannot walk more than a block without gasping for air, and he retired in part based on his heart condition. The claims file includes an August 2019 independent medical evaluation submitted by the Veteran’s representative. Following a review of the record, and an in-person evaluation to include a mental status examination, the independent medical evaluator opined that the Veteran’s mental health symptoms cause total occupational and social impairment based on frequent panic attacks, ongoing paranoia, persistent hallucinations, and ongoing suicidal ideation. The examiner noted that the Veteran’s prognosis is poor due to the length of time symptoms have persisted and the relative lack of improvement despite treatment. The Veteran’s representative also submitted a separate October 2019 vocational assessment. The provider noted a review of the claims file to include mental health and medical records. At the time, the Veteran was rated at 30 percent for PTSD and 10 percent for IHD. Nonetheless, the provider opined that the Veteran would be unable to maintain substantial gainful employment in the competitive market based on the chronicity, permanency and severity of his mental health conditions, in combination with his IHD. The provider noted that vocationally relevant factors include (1) PTSD symptomology included lack of concentration, irritability, panic attacks and paranoia, rituals such as checking doors and windows, intrusive thoughts, short temper and alcohol abuse; and (2) assistance with activities of daily living due to symptoms of IHD. The claims file also includes a December 24, 2019 individual unemployability statement attached to the December 2019 Review PTSD examination wherein the VA contract examiner noted that the Veteran had difficulty maintaining concentration and focus on work over a period of time, tends to skip from one task to another without completing the prior task, has intrusive thoughts which interfere with the ability to stay focused on the task at hand, has significant difficulty functioning around other people, has difficulty functioning as a team member, and feels uncomfortable around others and cannot tolerate being around other people in any setting for more than a few minutes. The Veteran’s sleep is so disrupted that he is usually fatigued at work, making concentration and focus on work assignments difficult. A second unemployability statement associated with the December 2019 IHD examination notes that the Veteran is capable of sedentary work including exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull. The August 2013 VA IHD examiner noted the Veteran’s IHD did not impact his ability to work. The August 2013 VA PTSD examiner noted that the impact of the Veteran’s PTSD on social and occupational functioning is very mild. However, considering the findings from the December 2019 VA examinations, the employment evidence noted above, and the Veteran’s meeting the threshold requirements of TDIU under 38 C.F.R. § 4.16(a) throughout the entirety of this appeal, the Board finds that the evidence is at least in equipoise to show that the cumulative effect of the Veteran’s service-connected disabilities has prevented him from securing and following a substantially gainful occupation during the appeal. [Continued on next page] Accordingly, based on the totality of the evidence in this case, the Board will resolve reasonable doubt in the Veteran’s favor and find that his service-connected disabilities precluded him from securing and following substantially gainful employment consistent with his education and work experience from July 1, 2013, the date he last worked. See 38 U.S.C. § 5107(b). TDIU is thus granted effective July 1, 2013. A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Banks, 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.