Citation Nr: 21002406 Decision Date: 01/13/21 Archive Date: 01/13/21 DOCKET NO. 20-12 495 DATE: January 13, 2021 ORDER Prior to November 12, 2019, a disability rating in excess of 10 percent for varicose veins of the left leg is denied. From November 12, 2019, a disability rating of 40 percent, but no more, for varicose veins of the left leg is granted. A disability rating in excess of 10 percent for a wound to the right hand and wrist (major), involving muscle group VIII, is denied. A compensable disability rating for a scar, shell fragment wound, of the right shoulder, is denied. An effective date prior to April 12, 2017 for the assignment of a 30 percent disability rating for a scar, laceration to scalp with disfigurement, is denied. An effective date prior to April 12, 2017 for the grant of service connection for a painful scar, laceration to forehead, is denied. New and material evidence having been received, the application to reopen a previously denied claim of entitlement to service connection for bilateral hearing loss is granted and the claim is reopened. New and material evidence having been received, the application to reopen a previously denied claim of entitlement to service connection for hypertension is granted and the claim is reopened. New and material evidence having been received, the application to reopen a previously denied claim of entitlement to service connection for erectile dysfunction is granted and the claim is reopened. New and material evidence having not been submitted, the application to reopen a previously denied claim of entitlement to service connection for basal cell carcinoma is denied and the claim is not reopened. New and material evidence having not been submitted, the application to reopen a previously denied claim of entitlement to service connection for rosacea of the face is denied and the claim is not reopened. New and material evidence having not been submitted, the application to reopen a previously denied claim of entitlement to service connection for dental disorder, claimed temporomandibular joint disorder, to include as secondary to posttraumatic-stress disorder (PTSD), is denied and the claim is not reopened. Service connection for a migraine headache disorder is granted. Service connection for a bilateral knee disorder is granted. Service connection for a traumatic brain injury (TBI) is granted. Service connection for a neck disorder is granted. Service connection for bilateral hearing loss is granted. Service connection for erectile dysfunction is granted. Service connection for hypertension is granted. Service connection for a respiratory disorder is denied. Service connection for a sinus/septum condition is denied. Service connection for a parotidectomy is denied. Service connection for sleep apnea is denied. A total disability rating based on individual unemployability (TDIU) is granted. FINDINGS OF FACT 1. Prior to November 12, 2019, the Veteran’s varicose veins of the left leg were characterized by aching in the left leg after prolonged walking and standing and the use of compression hosiery to relieve symptoms; persistent edema incompletely relieved by elevation of the left leg, with or without beginning stasis pigmentation or eczema was not shown. 2. Since November 12, 2019, the Veteran’s varicose veins of the left leg have been characterized by persistent edema and stasis pigmentation or eczema, with or without intermittent ulceration; persistent edema or subcutaneous induration, stasis pigmentation or eczema, and persistent ulceration has not been shown. 3. Throughout the period on appeal, the Veteran’s wound to the right hand and wrist (major), involving muscle group VIII has been manifested by symptoms consistent with moderate severity; symptoms consistent with a moderately severe level of severity have not been shown. 4. The Veteran’s scar, shell fragment wound, of the right shoulder was not shown to be painful, unstable, deep and nonlinear, covering an area of at least 6 sq. in. (39 sq. cm) but less than 12 sq. in., or superficial and nonlinear covering an area of 144 sq. in (929 sq. cm) or greater. 5. April 12, 2017 is the current and proper effective date for the assignment of a 30 percent disability rating for a scar, laceration to scalp with disfigurement, and for the grant of service connection for his painful scar, laceration to forehead because it is the later of the date entitlement arose and the date of the claim. 6. In a February 2009 rating decision, the claim of entitlement to service connection for bilateral hearing loss was denied on the ground that the evidence failed to show that bilateral hearing loss was incurred during active duty service or an etiological relationship between bilateral hearing loss and active duty service. 7. In a June 2011 rating decision, the claim of entitlement to service connection for hypertension was denied on the ground that the evidence failed to show that an etiological relationship between the Veteran’s hypertension and active duty service or his service-connected PTSD. 8. In a November 2013 rating decision, the claim of entitlement to service connection for erectile dysfunction was denied on the ground that the evidence failed to show that the Veteran’s erectile dysfunction occurred in or was caused by active duty service. 9. The evidence added to the record since the February 2009, June 2011, and November 2013 rating decisions relates to unestablished facts that are necessary to substantiate the claims of service connection for bilateral hearing loss, hypertension, and erectile dysfunction. 10. In a November 2013 rating decision, the claim of entitlement to service connection for basal cell carcinoma was denied because available scientific and medical evidence failed to support the conclusion that basal cell carcinoma was associated with herbicide exposure and on the ground that it was not incurred in, aggravated by, or caused by active duty service. 11. In a November 2013 rating decision, the claim of entitlement to service connection for rosacea of the face was denied because rosacea of the face was not a recognized disability under the Agent Orange Act and on the ground that it did not occur in and was not caused by active duty service. 12. In a November 2013 rating decision, the claim of entitlement to service connection for a dental disorder, claimed temporomandibular joint disorder, to include as secondary to PTSD, was denied on the ground that the evidence failed to show that a dental disorder had been clinically diagnosed. 13. The evidence added to the record since the November 2013 rating decision does not include information that was not previously considered and that relates to an unestablished fact necessary to substantiate the claims of entitlement to service connection for basal cell carcinoma, rosacea of the face, and a dental disorder. 14. Resolving reasonable doubt in the Veteran’s favor, it is at least as likely as not that his migraine headache disorder, bilateral knee disorder, TBI, neck disorder, bilateral hearing loss are etiologically related to his active duty service, and his erectile dysfunction and hypertension are proximately due to or the result of his service-connected varicose veins of the left leg. 15. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal a current diagnosis of a respiratory disorder, a sinus/septum condition, a parotidectomy, and sleep apnea for VA compensation purposes. 16. The Veteran’s service-connected disabilities have prevented him from obtaining and retaining substantially gainful employment. CONCLUSIONS OF LAW 1. Prior to November 12, 2019, the criteria for a disability rating in excess of 10 percent for varicose veins of the left leg have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.20, 4.56, 4.112, Diagnostic Code (DC) 5320. 2. Since November 12, 2019, the criteria for a 40 percent disability rating, but no more, for varicose veins of the left leg have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.20, 4.56, 4.112, DC 5320. 3. The criteria for a disability rating in excess of 10 percent for a wound to the right hand and wrist (major), involving muscle group VIII, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.20, 4.56, 4.73, DC 5308. 4. The criteria for a compensable disability rating for a scar, shell fragment wound, of the right shoulder, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.14, 4.118, DC 7805. 5. The criteria for an effective date prior to April 12, 2017 for the assignment of a 30 percent disability rating for a scar, laceration to scalp with disfigurement, have not been met. 38 U.S.C. § 7104; 38 C.F.R. §§ 3.400. 6. The criteria for an effective date prior to April 12, 2017 for the grant of service connection for a painful scar, laceration to forehead, have not been met. 38 U.S.C. § 7104; 38 C.F.R. §§ 3.400. 7. The February 2009, June 2011, and November 2013 rating decisions that denied the Veteran’s claims of entitlement to service connection for bilateral hearing loss, hypertension, and erectile dysfunction are final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 8. Because the evidence received after the February 2009, June 2011, and November 2013 rating decisions is new and material, the requirements to reopen the Veteran’s claims of entitlement to service connection for bilateral hearing loss, hypertension, and erectile dysfunction have been met. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.102, 3.156. 9. The November 2013 rating decision that denied the Veteran’s claims of entitlement to service connection for basal cell carcinoma, rosacea of the face, and a dental disorder is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 10. Because the evidence received after the November 2013 rating decision is not new and material, the requirements to reopen the claims of entitlement to service connection for basal cell carcinoma, rosacea of the face, and a dental disorder have not been met. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.102, 3.156. 11. The criteria for service connection for a migraine headache disorder have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.304, 3.307, 3.309. 12. The criteria for service connection for a bilateral knee disorder have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.304, 3.307, 3.309. 13. The criteria for service connection for a TBI have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.304, 3.307, 3.309. 14. The criteria for service connection for a neck disorder have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.304, 3.307, 3.309. 15. The criteria for service connection for bilateral hearing loss have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.304, 3.307, 3.309. 16. The criteria for service connection for erectile dysfunction have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.304, 3.307, 3.309, 3.310. 17. The criteria for service connection for hypertension have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.304, 3.307, 3.309, 3.310. 18. The criteria for service connection for a respiratory disorder have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.304, 3.307, 3.309. 19. The criteria for service connection for a sinus/septum condition have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.304, 3.307, 3.309. 20. The criteria for service connection for a parotidectomy have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.304, 3.307, 3.309. 21. The criteria for service connection for sleep apnea have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.304, 3.307, 3.309. 22. The criteria for TDIU have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1967 to January 1970, with service in the Republic of Vietnam. As a result of his exemplary service, the Veteran received multiple awards, including the Purple Heart and the Vietnam Service Medal with four Bronze Stars. Increased Ratings The Veteran is seeking increased disability ratings for his service-connected varicose veins of the left leg, wound to the right wrist and hand with moderate injury to muscle group VIII, and scar as a result of a shell fragment wound of the right shoulder. Disability evaluations are determined by the application of a schedule of ratings that is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. See 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two separate evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that particular rating. 38 C.F.R. § 4.7. When a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective enervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45; see also DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.14 (avoidance of pyramiding) do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including during flareups. 1. Entitlement to a disability rating in excess of 10 percent for varicose veins of the left leg The Veteran contends that a disability rating in excess of 10 percent is warranted for his varicose veins of the left leg for the period on appeal. Prior to November 12, 2019 The Veteran’s varicose veins of the left leg have been assigned a 10 percent disability rating pursuant to 38 C.F.R. § 4.112, DC 7120. In order to warrant a disability rating in excess of 10 percent, the evidence must show persistent edema, incompletely relieved by elevation of the extremity, with or without beginning stasis pigmentation or eczema (20 percent). 38 C.F.R. § 4.112, DC 7120. After a review of the evidence of record, the Board concludes that a disability rating in excess of 10 percent for the Veteran’s service-connected varicose veins of the left leg is not warranted prior to November 12, 2019 because the evidence fails to show that his varicose veins of the left leg were manifested by persistent edema, incompletely relieved by elevation of his left leg. Specifically, the report from the July 2017 VA examination reflects that the examiner determined that the Veteran’s by symptoms of aching in the leg after prolonged standing, aching in the leg after prolonged walking, and asymptomatic visible varicose veins. The examiner also noted that the Veteran wore pressure stockings as a result of varicose veins. Importantly, the examiner did not observe that his varicose veins of the left leg were manifested by persistent edema of the left leg that are incompletely relieved by elevation of the left leg. Thus, the report from the July 2017 VA examination fails to establish that a disability rating in excess of 10 percent is warranted for his varicose veins of the left leg prior to November 12, 2019. Moreover, the Veteran’s treatment records do not reflect that the Veteran’s service-connected varicose veins of the left leg were manifested by peristent edema that was incompletely relieved by elevation prior to November 12, 2019. Therefore, his treatment records also fail to establish that a disability rating in excess of 10 percent is warranted for his varicose veins of the left leg prior to November 12, 2019. By virtue of the foregoing, the Board concludes that a disability rating in excess of 10 percent is not warranted for the Veteran’s service-connected varicose veins of the left leg prior to November 12, 2019. From November 12, 2019 Initially, the Board assigns a 40 percent disability rating to the Veteran’s service-connected varicose veins of the left leg from November 12, 2019. The Board finds that a 40 percent disability rating is warranted from November 12, 2019 for his service-connected varicose veins of the left leg because the evidence, including a disability benefits questionnaire (DBQ) completed by a private physician, shows that his varicose veins of the left leg have been manifested by symptoms including aching and fatigue in the left leg after prolonged standing or walking, persistent stasis pigmentation or eczema, persistent edema that is incompletely relieved by elevation of the left leg, persistent edema, and constant pain at rest. Next, the Board finds that a disability rating in excess of 40 percent from November 12, 2019 for the Veteran’s service-connected varicose veins of the left leg is not warranted. In order for a disability rating in excess of 40 percent to be warranted for varicose veins, the evidence must show persistent edema or subcutaneous induration, stasis pigmentation or eczema, and persistent ulceration. 38 C.F.R. § 4.112, DC 7120. After a review of the evidence of record, the Board concludes that a disability rating in excess of 40 percent from November 12, 2019 is not warranted. Specifically, the November 2019 DBQ reflects that although the Veteran’s varicose veins of the left leg has been manifested by peristent edema and persistent stasis pigmentation or eczema, his varicose veins of the left leg have not been manifested by intermittent or persistent ulceration. Moreover, the treatment records do not reflect that his varicose veins of the left leg have been manifested by persistent ulceration. Given that neither the evidence, including the November 2019 DBQ and the treatment records, fail to show persistent ulceration, the Board concludes that a disability rating in excess of 40 percent from November 12, 2019 is not warranted for his varicose veins of the left leg. By virtue of the foregoing the Board concludes that a disability rating in excess of 10 percent is not warranted prior to November 12, 2019, and that a 40 percent disability rating, but no more, is warranted from November 12, 2019 for the Veteran’s service-connected varicose veins of the left leg. 2. Entitlement to a disability rating in excess of 10 percent for a wound to the right hand and wrist (major), involving muscle group VIII The Veteran contends that he is entitled to a disability rating in excess of 10 percent for his service-connected wound to the right hand and wrist (major), involving muscle group VIII. When considering the combined ratings for muscle injuries, the skeletal muscles of the body are divided into 23 muscle groups in 5 anatomical regions. There are 3 muscle groups for the anatomical region of the forearm and hand (DCs 5307, 5308, and 5309). For compensable muscle group injuries which are in the same anatomical region but do not act on the same joint, the evaluation for the most severely injured muscle group will be increased by one level and used as the combined evaluation for the affected muscle groups. 38 C.F.R. § 4.55. Muscle group VIII refers to extension of the wrist, fingers, and thumb and abduction of thumb. 38 C.F.R. § 4.72, DC 5308. The August 2017 VA examiner determined that the Veteran had injured muscle group VIII when he was struck by a fragment during his active duty service. Muscle injuries under DC 5308 are rated based on a scale characterized by “slight” (noncompensable), “moderate” (10 percent), “moderately severe” (20 percent), and “severe” (30 percent), and each of these terms is defined by a specific set of characteristics categorized by (i) type of injury, (ii) history and complaint, and (iii) objective findings. 38 C.F.R. § 4.56(d). For moderately severe injuries, the level of severity for a 20 percent disability rating, the type of injury is described as a through and through or deep penetrating wound by small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. Id. The history and complaint are described as a service department record or other evidence showing hospitalization for a prolonged period for treatment of wound, a record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, and, if present, evidence of inability to keep up with work requirements. Id. Objective findings are described as entrance and (if present) exit scars indicating track of missile through one or more muscle groups, indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side, tests of strength and endurance compared with sound side demonstrate positive evidence of impairment. Initially, the Board notes that the Veteran’s disability was properly rated under DC 5308 because the examiner determined that muscle group VIII was the muscle group impacted by the Veteran’s fragment wound, and because the examiner’s determination is consistent with the Veteran’s descriptions of right wrist pain and discomfort and numbness in his fingers. Next, after a review of the evidence of record, the Board concludes that a disability rating in excess of 10 percent for the Veteran’s wound to the right hand and wrist, involving muscle group VIII, is not warranted. Here, the report from the July 2017 VA muscle injuries examination reflects that the injury to muscle group VIII occurred when he was struck by a fragment during his active duty service. The examiner determined that the only cardinal sign of the Veteran’s muscle group VIII disability was occasional impairment of coordination. The examiner also noted that the wound resulted in the Veteran having a scar on his right wrist that measured 9 cm x .25 cm. Finally, the examination report reflects that his muscle injury did not affect muscle substance or function, did not cause symptoms of weakness, lowered threshold of fatigue, fatigue-pain, or uncertainty of movement, that muscle strength testing showed that wrist flexion and extension were normal, and that his muscle group VIII disability caused no functional impact. The report from the July 2017 wrist conditions VA exam similarly reflects that he had a normal range of motion in his right wrist, that there was no additional loss of function range of motion after repetitive use testing, that pain, weakness, fatigability, or incoordination do not significantly limit functional ability with a flareup, and that muscle strength testing was normal. The report also reflects that his right wrist disability did not cause functional impact, that there was no evidence of pain on non-weight bearing, and that his passive range of motion was the same as his active range of motion. The report from the July 2017 scars and disfigurement VA examination also reflects that the Veteran has a 9 cm x .25 cm scar on his wrist. The examiner did not determine that the scar was painful or unstable. The reports from the muscle injuries, wrist condition, and scars VA examinations fail to show that a disability rating in excess of 10 percent is warranted because they do not show that the Veteran’s muscle group VIII disability is moderately severe. With respect to the type of injury, they show that his injury was caused by a fragment, not a through and through or deep penetrating wound by a small high velocity missile or large low-velocity missile. With respect to history and complaint, the examination reports do not indicate, and his service treatment records do not show, hospitalization for a prolonged period of time. With respect objective findings, although a scar is present, there are not indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscle compared with the sound side, particularly given that the scar was not found to be painful or unstable and because muscle strength testing was normal. Thus, the reports from the July 2017 muscle injuries, wrist conditions, and scars and disfigurement VA examinations fail to show that a disability rating in excess of 10 percent is warranted for his muscle group VIII disability. Additionally, the Veteran’s treatment records do not reflect that his muscle group VIII disability was caused by anything other than a fragment, that he consistently complained of cardinal signs or symptoms of a muscle group VIII disability, or that there was any loss of muscle strength or range of motion. Thus, the treatment records also fail to show that a disability rating in excess of 10 percent for his muscle group VIII disability is warranted. By virtue of the foregoing, the Board concludes that a disability rating for the Veteran’s service-connected wound to the right hand and wrist (major), involving muscle group VIII, is not warranted for the period on appeal. 3. Entitlement to a compensable disability rating for a scar, shell fragment wound, of the right shoulder The Veteran contends that he is entitled to a compensable disability rating for his right shoulder scar, resulting from a shell fragment wound. The Veteran is currently assigned a noncompensable disability rating for his service-connected scar of the right shoulder, resulting from a shell fragment wound under 38 C.F.R. § 4.118, DC 7805. In order to warrant a compensable disability rating for that scar, the evidence must show that the scar is: • Deep and nonlinear, covering an area or areas of at least 6 square inches (39 cm sq.) but less than 12 square inches (77 sq. cm) (10 percent under DC 7801); • Superficial and nonlinear, covering an area or areas of 144 sq. inches (929 sq. cm.) or greater; • One or two in number that are unstable or painful (10 percent under DC 7804); or, • One or two in number that are unstable and painful (20 percent under DC 7804, Note (2)). 38 C.F.R. § 4.118. After a review of the evidence of record, the Board concludes that a compensable disability rating is not warranted for the Veteran’s service-connected scar of the right shoulder, resulting from a shell fragment wound. Here, the report from the July 2017 VA examination reflects that the Veteran has one linear scar located on his deltoid that measures 1 cm x .25 cm. The report reflects that the scar is not unstable or painful. The Veteran’s treatment records fail to show a larger scar or that the scar is painful or unstable. Thus, because the examination report and the treatment records fail to show that the scar is deep and nonlinear, covering an area or areas of at least 6 square inches, superficial and nonlinear, covering an area or areas of 144 square inches, painful, or unstable, the July 2017 VA examination report fails to show that a compensable disability rating is warranted for the Veteran’s service-connected scar of the right shoulder, resulting from a shell fragment wound. The Board has also considered whether a higher rating is warranted for his service-connected scar of the right shoulder, resulting from a shell fragment wound, based on limitation of function of the part affected under DC 7805. Here, the July 2017 VA examiner noted that the Veteran had no other pertinent physical findings, complications, signs, or symptoms. Moreover, there is no evidence that these scars cause any other disabling effects that would warrant a compensable rating. Therefore, a rating under DC 7805, or any other relevant DC is not for application. In considering the appropriate disability ratings for the Veteran’s varicose veins of the left leg, wound to the right hand and wrist (major), involving muscle group VIII, and right shoulder scar, resulting from a shell fragment wound, the Board has also considered the statements from the Veteran that these disabilities are worse than the ratings he currently receives. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Although the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses, he is not competent to identify a specific level of disability of his scars according to the appropriate DCs. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (“although interest may affect the credibility of testimony, it does not affect competency to testify”). On the other hand, such competent evidence concerning the nature and extent of the Veteran’s disabilities has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with their evaluations. The medical findings of the July 2017 VA examiners (as provided in the examination reports) directly address the criteria under which his varicose veins of the left leg, wound to the right hand and wrist (major), involving muscle group VIII, and right shoulder scar, resulting from a shell fragment wound are evaluated. Specifically, although he has asserted that the symptoms of these disabilities warrant higher ratings, the impacts of these disabilities were discussed and addressed by the July 2017 VA examiners, and the Board finds the examiners assessments of greater probative weight. By virtue of the foregoing, the Board concludes that a disability rating in excess of 10 percent for the Veteran’s varicose veins of the left leg is not warranted prior to November 12, 2019, a disability rating of 40 percent, but no more, is warranted for his varicose veins of the left leg from November 12, 2019, a disability rating in excess of 10 percent for his wound to the right hand and wrist (major), involving muscle group VIII, is not warranted for the period on appeal, and a compensable disability rating for his right shoulder scar, resulting from a shell fragment wound, is not warranted for the period on appeal. Effective Date 4. Entitlement to an effective date prior to April 12, 2017 for the assignment of a 30 percent disability rating for a scar, laceration to scalp with disfigurement 5. Entitlement to an effective date prior to April 12, 2017 for the grant of service connection for a painful scar, laceration to forehead The Veteran contends that he is entitled to an effective date prior to April 12, 2017 for the assignment of a 30 percent disability rating for his service-connected scar, laceration to scalp with disfigurement, and for the grant of service connection for his painful scar, laceration to forehead. The assignment of an effective date for an increased disability rating for an already service-connected disability that is based on an original claim, or a claim for increase, will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400. However, the effective date may also be the earliest date as of which it is “factually ascertainable” that an increase in disability occurred if the claim is received within one year from the date of the increase, based on a review of the entire evidence of record. 38 C.F.R. § 3.400(o)(2); see also Hazan v. Gober, 10 Vet. App. 511 (1997); Swanson v. West, 12 Vet. App. 442 (1999). In determining whether an effective date assigned for an increased disability rating is correct or proper, the law requires (1) a determination of the date of the receipt of the claim for the increased rating as well as (2) a review of all the evidence of record to determine when an increase in disability was “ascertainable.” See Hazan, 10 Vet. App. at 521. With respect to the effective date of service connection, in general, the effective date for the grant of service connection based upon an original claim or a claim reopened after final disallowance is either the day following separation from active service or the date entitlement arose if the claim is received within one year after separation from service; otherwise it will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 C.F.R. §§ 3.400(b)(2)(i), (ii). A claim is a formal or informal communication, in writing, requesting a determination of entitlement or evidencing a belief in entitlement, to a benefit. 38 C.F.R. § 3.1(p). After a review of the evidence of record, the Board concludes that an effective date prior to April 12, 2017 is not warranted for the assignment of a 30 percent disability rating for the Veteran’s service-connected scar, laceration to scalp with disfigurement, or for the grant of service connection for his painful scar, laceration to forehead. As an initial matter, the date of the formal claim for an increased disability rating for the Veteran’s service-connected scar, laceration to scalp with disfigurement, is April 12, 2017, the date that VA received his claim. This is also the date of the claim for the grant of service connection for his painful scar, laceration to forehead, because the RO granted a separate evaluation for this scar as a result of the increased rating claimed in it. Moreover, the record does not reflect that he filed subsequent claims for an increased rating for his service-connected scars, including the scar, laceration to scalp with disfigurement, prior to April 12, 2017, where the AOJ could consider whether a separate rating was warranted for his painful scar, laceration to forehead. Next, with respect to the Veteran’s service-connected scar, laceration to scalp with disfigurement, it is not factually ascertainable that an increased disability rating is warranted prior to April 12, 2017. Specifically, no treatment records document any symptoms showing that an increased disability rating would be warranted in the year prior to April 12, 2017. With respect to the Veteran’s painful scar, laceration to forehead, the Board has also reviewed whether there is any evidence of an intent to file a claim for benefits prior to April 12, 2017. In this regard, a review of the record fails to show that the RO received a claim or informal written communication indicative of the Veteran’s desire to seek to file a claim seeking an increase of the disability rating assigned to his service-connected scalp folliculitis with keloid scarring or service connection for scars from head to toe, linear scars from head toe, or scars of the anterior trunk due to a cholecystectomy. The Board has also considered whether the Veteran’s painful scar, laceration to forehead, was factually ascertainable in the year prior to April 12, 2017. In this case, the first evidence of the Veteran’s entitlement to service connection for the painful scar, laceration to forehead, is documented by the July 2017 VA examination. Therefore, given that 38 C.F.R. § 3.400 provides that the effective date for an increased disability rating for an already service-connected disability is the date of receipt of the claim or the date entitlement arose, whichever is later, and that the effective date for the grant of service connection is the date of receipt of the claim or the date entitlement arose, whichever is the later, the Board finds that there is no legal basis for the grant of an earlier effective prior to April 12, 2017 for assignment of the 30 percent disability rating for his service-connected scar, laceration to scalp with disfigurement, and service connection his painful scar, laceration to forehead. Indeed, the Board finds that the currently assigned effective date of April 12, 2017 is the earliest effective date possible because it is the date of the date of his claim for an increased rating for his scar, laceration to forehead and because there is no indication of an intent to file a claim prior to that date, or evidence that entitlement arose prior to that date. New and Material Evidence The Veteran contends that his claims of entitlement to service connection for bilateral hearing loss, erectile dysfunction, hypertension, basal cell carcinoma, rosacea of the face, and a dental disorder should be reopened because the record now contains new evidence, which shows that he has diagnoses of these disorders and that these disorders are etiologically related to active duty service. In order for evidence to be sufficient to reopen a previously disallowed claim, it must be both new and material. If the evidence is new, but not material, the inquiry ends, and the claim cannot be reopened. See Smith v. West, 12 Vet. App. 312, 314 (1999); Manio v. Derwinski, 1 Vet. App. 140 (1991). Under the relevant regulations, “new” evidence is defined as evidence not previously submitted to agency decision-makers. 38 C.F.R. § 3.156(a). “Material” evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. Id. If it finds that the submitted evidence is new and material, VA may then proceed to evaluate the merits of the claim on the basis of all evidence of record, but only after ensuring that the duty to assist the veteran in developing the facts necessary for the claim has been satisfied. See Elkins v. West, 12 Vet. App. 209 (1999). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low, and consideration is not limited to whether the newly submitted evidence relates specifically to the reason the claim was last denied. Rather, consideration should include whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the Secretary’s duty to assist or through consideration of an alternative theory of entitlement. See Shade v. Shinseki, 24 Vet. App. 110, 117-18 (2010). Moreover, when determining whether the claim should be reopened, the credibility of the newly submitted evidence is presumed. Justus v. Principi, 3 Vet. App. 510 (1992). 6. Whether new and material evidence has been submitted to reopen the claim of entitlement to service connection for bilateral hearing loss 7. Whether new and material evidence has been submitted to reopen the claim of entitlement to service connection for hypertension 8. Whether new and material evidence has been submitted to reopen the claim of entitlement to service connection for erectile dysfunction The Veteran contends that his claims of service connection for bilateral hearing loss, erectile dysfunction, and hypertension should be reopened because the record contains new evidence establishing etiological relationships between these disorders and his active duty service. The Veteran’s claim of entitlement to service connection for bilateral hearing loss was denied by a February 2009 rating decision on the ground that the evidence failed to show that bilateral hearing loss was incurred during active duty service or an etiological relationship between his bilateral hearing loss and active duty service. His claim of entitlement to service connection for hypertension was denied by a June 2011 rating decision on the ground that the evidence failed to show that an etiological relationship between his hypertension and active duty service or his service-connected PTSD. His claim of entitlement to service connection for erectile dysfunction was denied by a November 2013 rating decision on the ground that the evidence failed to show that his erectile dysfunction occurred in or was caused by active duty service. The Veteran did not appeal the denial of these claims in the February 2009, June 2011, and November 2013 rating decisions, nor did he submit any new and material evidence within a year of receiving them. Thus, the February 2009, June 2011, and November 2013 rating decisions represent the last final denials of his claims seeking service connection for bilateral hearing loss, hypertension, and erectile dysfunction. See Buie v. Shinseki, 24 Vet. App. 242, 252 (2011). After a review of the evidence submitted since the February 2009, June 2011, and November 2013 rating decisions became final, the Board determines that the Veteran’s claims of entitlement to service connection for bilateral hearing loss, hypertension, and erectile dysfunction should be reopened. The record now includes new evidence, including treatment records and private opinions from January 2018 and November 2019, which raise the possibility that he has current diagnoses of bilateral hearing loss, hypertension, and erectile function that are etiologically related to his active duty service, or, with respect to hypertension and erectile dysfunction, are secondary to his service-connected varicose veins of the left leg. Not only is this evidence “new” because it was not of record prior to the last final denial of the claims, it is also “material” because it relates to unestablished facts necessary to support the claims. Therefore, his claims seeking service connection for bilateral hearing loss, hypertension, and erectile dysfunction should be reopened. Shade, 24 Vet. App. at 118-21; see also 38 C.F.R. § 3.156(a). 9. Whether new and material evidence has been submitted to reopen the claim of entitlement to service connection for basal cell carcinoma 10. Whether new and material evidence has been submitted to reopen the claim of entitlement to service connection for rosacea of the face 11. Whether new and material evidence has been submitted to reopen the claim of entitlement to service connection for a dental disorder, claimed temporomandibular joint disorder, to include as secondary to PTSD The Veteran contends that his claims of service connection for basal cell carcinoma, rosacea of the face, and a dental disorder should be reopened. The Veteran’s claim of entitlement to service connection for basal cell carcinoma, rosacea of the face, and a dental disorder were denied by a November 2013 rating decision. His claim of entitlement to service connection for basal cell carcinoma was denied on the grounds that available scientific and medical evidence failed to support the conclusion that basal cell carcinoma was associated with herbicide exposure and ground that it was not incurred in, aggravated by, or caused by active duty service. His claim of entitlement to service connection for rosacea of the face was denied on the grounds that it was not a recognized disability under the Agent Orange Act and that it did not occur in and was not caused by active duty service. His claim of entitlement to service connection was denied on the ground that the evidence failed to show that a dental disorder had been clinically diagnosed. The Veteran did not appeal that November 2013 rating decision within one year, nor did he submit any new and material evidence within a year of receiving it. Therefore, the November 2013 rating decision represents the last final denial of his claims seeking service connection for basal cell carcinoma, rosacea of the face, and a dental disorder. See Buie, 24 Vet. App. at 252. After a review of the evidence submitted since the November 2013 rating decision became final, the Board concludes that new and material evidence has not been added to the record to reopen the Veteran’s claims of service connection for basal cell carcinoma. Since the last final denial of the Veteran’s claims of service connection for basal cell carcinoma, rosacea of the face, and a dental disorder, new treatment records have been added to the record. However, after a thorough review of the treatment records, the Board finds that although this evidence is new, it is not material because it does not relate to whether his basal cell carcinoma and rosacea of the face were incurred in, caused by, or permanently aggravated by his active duty service. This evidence also fails to show that he has been diagnosed with a dental disorder. Therefore, because this evidence could not reasonably substantiate his claims of service connection for basal cell carcinoma, rosacea of the face, and a dental disorder, the Board concludes that reopening these claims is not warranted. Service Connection The Veteran contends that service connection is warranted for a migraine headache disorder, a bilateral knee disorder, a TBI, a neck disorder, bilateral hearing loss, erectile dysfunction, hypertension, a respiratory disorder, a sinus/septum condition, parotidectomy, and sleep apnea. Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110. Generally, the evidence must show: (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, 1166-67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). Certain chronic diseases may be presumed to have been incurred during service if they become manifested to a compensable degree within one year from separation from service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). This presumption is rebuttable by affirmative evidence to the contrary. Id. Moreover, evidence of continuous symptoms since active duty is a factor for consideration as to whether a causal relationship exists between an in-service injury or incident and the current disorder as is contemplated under 38 C.F.R. § 3.303(a). Moreover, service connection is warranted for a disability that is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether the additional impairment is itself a separate disease or injury caused by the service-connected condition, should also be compensated. Allen v. Brown, 7 Vet. App. 439 (1995). Accordingly, when service connection is established for a secondary condition, the secondary condition shall be considered a part of the original condition. Id. Additionally, in cases where a Veteran asserts service connection for injuries or disease incurred or aggravated in combat, 38 U.S.C. § 1154(b) and its implementing regulation, 38 C.F.R. § 3.304(d), are applicable. This statute and regulation ease the evidentiary burden of a combat Veteran by permitting the use, under certain circumstances, of lay evidence. If the Veteran was engaged in combat with the enemy, VA shall accept as sufficient proof of service connection satisfactory lay or other evidence of in-service incurrence, if the lay or other evidence is consistent with the circumstances, conditions, or hardships of such service. 38 U.S.C. § 1154(b); 38 C.F.R. § 3.304(d). To establish service connection, however, there must be evidence of a nexus between the current disability and the combat injury. See Dalton v. Nicholson, 21 Vet. App. 23, 36-37 (2007); Libertine v. Brown, 9 Vet. App. 521, 523-24 (1996); Reeves v Shinseki, 682 F.3d 988 (Fed. Cir. 2012). 12. Entitlement to service connection for a migraine headache disorder 13. Entitlement to service connection for a bilateral knee disorder 14. Entitlement to service connection for a TBI 15. Entitlement to service connection for a neck disorder 16. Entitlement to service connection for bilateral hearing loss 17. Entitlement to service connection for erectile dysfunction 18. Entitlement to service connection for hypertension The Veteran contends that service connection is warranted for his migraine headache disorder, bilateral knee disorder, TBI, neck disorder, and bilateral hearing loss because they are etiologically related to his active duty service. He contends that service connection is warranted for erectile dysfunction and hypertension because they are proximately due to, have been caused by, or have been permanently aggravated by his service-connected varicose veins of the left leg. Based upon the evidence of record, and resolving all reasonable doubt in favor of the Veteran, the Board determines that service connection is warranted for migraine headache disorder, bilateral knee disorder, TBI, neck disorder, bilateral hearing loss, erectile dysfunction, and hypertension. 38 U.S.C. §§ 1110, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. §§ 3.303(a), (d), 3.304, 3.307, 3.309, 3.310. With respect to the Veteran’s migraine headache disorder, bilateral knee disorder, TBI, neck disorder, and bilateral hearing loss, the Board finds that the evidence is at least in equipoise that these disorders are etiologically related to active duty service. A January 2018 private opinion supports the conclusion that the evidence is at least in equipoise that his migraine headache disorder, bilateral knee disorder, and neck disorder are etiologically related to his active duty service, and his erectile dysfunction and hypertension are proximately due to his service-connected varicose veins of the left leg. Specifically, the private physician opined that it was more likely than not that the Veteran’s migraine headache disorder, bilateral knee disorder, and neck disorder were caused by and began during his active duty service. The physician also opined that it was more likely than not that the Veteran’s erectile dysfunction and hypertension were secondary to and caused by his service-connected varicose veins of the left leg. In support of those opinions, the physician provided several extensive rationales. With respect to the Veteran’s migraine headache disorder, the physician explained that the service treatment records reflected that the Veteran sustained a significant head injury during his active duty service, began experiencing headaches thereafter, and that his current headaches were a continuation of the headaches he began experiencing during active duty service. With respect to his bilateral knee disorder, the physician explained that his current bilateral knee disorder was related to the extensive amount of knee injuries that he suffered during his active duty service. With respect to his neck disorder, the physician reiterated that the service treatment records reflected that the Veteran sustained a significant head and neck injury during his active duty service and noted that he was assigned to the US Army Ranger unit, which because of its physical demands made him more susceptible to degenerative changes, which were the causes of his current neck disorder. With respect to erectile dysfunction, the physician explained that the compromised blood flow from the varicose veins of the Veteran’s left leg likely caused his erectile dysfunction. With respect to hypertension, the physician explained that the Veteran’s hypertension was likely caused by his varicose veins of the left leg because his left leg varicose veins have resulted in the breaking down of his veins, causing hypertension. A November 2019 private opinion by a separate physician similarly reflects that the physician opined that it was as likely as not that the Veteran’s migraine headache disorder, bilateral knee disorder, and neck disorder were caused by his active duty service, and his erectile dysfunction was secondary to and caused by his varicose veins of the left leg. In support of his opinions that the Veteran’s migraine headache disorder, bilateral knee disorder, and neck disorder were caused his active duty service, the physician explained that the service treatment records repeatedly demonstrated treatment for head and neck injuries and headaches and that he suffered injuries to both knees during combat and while in training as an Airborne Ranger. In support of his opinion that the Veteran’s erectile dysfunction was caused by his varicose veins of the left leg, the physician explained that medical literature supports finding that varicose veins cause erectile dysfunction, particularly in patients, like the Veteran, with vein stripping. Given the January 2018 and November 2019 physicians’ thorough rationales, expertise, reliance on medical literature, review of the medical evidence, and in-person examinations of the Veteran, the Board finds that the physicians’ opinions are entitled to significant probative weight and establish that the evidence is at least in equipoise that his migraine headache disorder, bilateral knee disorder, and neck disorder are etiologically related to his active duty service, and his erectile dysfunction and hypertension are proximately due to or caused by his service-connected varicose veins of the left leg. Additionally, the Board again finds that after resolving all reasonable doubt in favor of the Veteran, the evidence is at least in equipoise that his bilateral hearing loss and TBI are etiologically related to his active duty service. Here, the report from the October 2008 VA examination reflects that the Veteran has a diagnosis of bilateral hearing loss for VA compensation purposes because the auditory threshold in his left ear at 4000 Hertz was 40 decibels and the auditory threshold in his right ear at 4000 Hertz was 55 decibels. See 38 C.F.R. § 3.385. With respect to a TBI, the report from the January 2018 private examination reflects that the physician diagnosed the Veteran with a TBI because a November 1967 and January 1968 service treatment records reflected that he sustained head injuries during active duty service and other treatment records reflected that he experienced headaches during active duty service. Next, the Board finds that the Veteran’s statements regarding in-service acoustic trauma are competent and credible given the nature of his service as an armor reconnaissance specialist. Indeed, the Veteran explained that he suffered significant noise exposure as an armored tank gunner. With respect to a TBI, the Board finds that the in-service head injuries documented by the November 1967 and January 1968 service treatment records establish an in-service event. Finally, the Board finds that after resolving all reasonable doubt in favor of the Veteran, the evidence is at least in equipoise that his bilateral hearing loss and TBI are etiologically related to his active duty service because his statements concerning acoustic trauma as an armor reconnaissance specialist and a TBI given the head injuries documented by the November 1967 and January 1968 service treatment records are competent and credible. Indeed, his statements concerning his bilateral hearing loss and TBI are consistent with the circumstances, conditions, and hardships of his combat service and his claim for service. By virtue of the foregoing, and resolving all reasonable doubt in the Veteran’s favor, the Board concludes that the evidence is at least in equipoise that his current migraine headache disorder, bilateral knee disorder, neck disorder, bilateral hearing loss and TBI are etiologically related to his active duty service, and his hypertension and erectile dysfunction are proximately due to or the result of his varicose veins of the left leg. Accordingly, service connection is granted. 19. Entitlement to service connection for a respiratory disorder 20. Entitlement to service connection for a sinus/septum condition 21. Entitlement to service connection for a parotidectomy 22. Entitlement to service connection for sleep apnea The Veteran contends that service connection is warranted for a respiratory disorder a sinus/septum condition a parotidectomy, and sleep apnea. After a thorough review of the evidence of record, the Board finds that the evidence of record does not reflect that the Veteran has a current diagnosis of a respiratory disorder, a sinus/septum condition, a parotidectomy, or sleep apnea, or that he has had any of these disorders at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). Here, no service treatment records reflect that the Veteran ever sought treatment for, reported signs or symptoms of, or was been diagnosed with a respiratory disorder, a sinus/septum condition, a parotidectomy, or sleep apnea. In fact the report from his November 1969 separation examination does not reflect any issues or concerns related to these disorders, and in his November 1969 report of medical history, he denied shortness of breath, and did not report any issues related to a sinus/septum condition, a parotidectomy, or sleep apnea. The post-service treatment records similarly do not reflect that he sought treatment for, reported signs or symptoms of, or has been diagnosed with a respiratory condition or sleep apnea. In fact, numerous treatment records, including an April 2006 treatment record, reflect that his respiratory condition was normal. With respect to a parotidectomy and a sinus/septum condition, the Board acknowledges that treatment records note those conditions as resolved in his medical history. Indeed, a May 2017 treatment record reflects that his parotids and septum were normal. Thus, the evidence fails to show that he has a current diagnosis of a respiratory disorder, a sinus/septum condition, a parotidectomy, or sleep apnea. The Board acknowledges the Veteran’s assertions and belief that he has these disorders, however, he is not competent to provide a diagnosis in this case. These issues are medically complex and require specialized medical education and knowledge of the interaction between multiple systems in the body, as well as the ability to interpret complicated diagnostic medical testing. Jandreau, 492 F.3d at 1377, 1377 n.4; Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Accordingly, the preponderance of the evidence is against finding that the Veteran has had of a respiratory disorder, a sinus/septum condition, a parotidectomy, or sleep apnea at any point during the period on appeal. See 38 U.S.C. § 1110, 1131; Rabideau v. Derwinski, 2 Vet. App. 141 (1992). TDIU 23. Entitlement to TDIU When a veteran submits a claim for an increased rating for a service-connected disability, it is a claim for the highest rating available, to include entitlement to TDIU, if raised by the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). Here, the Veteran’s service-connected disabilities have caused functional impact. For example, the report from a private physician’s examination of the Veteran reflects that his service-connected peripheral neuropathy of the left lower extremity and varicose veins of the left leg prevent him from participating in physical activities, making any type of labor untenable and his PTSD symptoms prevent him from working with others. Accordingly, the issue of entitlement to TDIU has been raised by the record and, under Rice, the Board will consider the Veteran’s entitlement to TDIU. Total disability is considered to exist when there is any impairment that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340(a)(1). The Board must consider if the Veteran can obtain employment with more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce to be the poverty threshold for one person. See Ray v. Wilkie, 31 Vet. App. 58 (2019). A total disability rating for compensation purposes may be assigned on the basis of “individual unemployability,” or 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. In such an instance, if there is only one such disability, it must be rated at 60 percent or more; if there are two or more disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). If a veteran fails to meet the threshold minimum percentage standards enunciated in 38 C.F.R. § 4.16(a), rating boards should refer to the Director of Compensation and Pension Service for extra-schedular consideration all cases where the veteran is unable to secure or follow a substantially gainful occupation by reason of service-connected disability. 38 C.F.R. § 4.16(b); see also Fanning v. Brown, 4 Vet. App. 225 (1993). Additionally, the Board must evaluate whether there are circumstances in the Veteran’s case, apart from any non-service-connected conditions and advancing age, which would justify TDIU. 38 C.F.R. §§ 3.341(a), 4.19; see also Van Hoose v. Brown, 4 Vet. App. 361 (1993); see also Hodges v. Brown, 5 Vet. App. 375 (1993); Blackburn v. Brown, 4 Vet. App. 395 (1993). The Veteran’s service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed. 38 C.F.R. § 4.16(b). The veteran’s service-connected disabilities, alone, must be sufficiently severe to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). After a review of the evidence of record, the Board determines that TDIU should be granted. As an initial matter, the Board notes that the Veteran met the schedular requirements for TDIU since at least November 12, 2019. Based upon the ratings assigned above and previously assigned, he is currently service connected for varicose veins of the left leg (40 percent effective November 2019), PTSD (30 percent effective June 2008), a scar, laceration to scalp with disfigurement (30 percent effective April 2017), a wound to the right hand and wrist (major), involving muscle group VIII (10 percent effective January 1970), tinnitus (10 percent effective June 2008), peripheral neuropathy of the left lower extremity (10 percent effective January 2013), a painful scar, laceration to forehead (10 percent effective April 2017), a scar, shell fragment wound, right shoulder (noncompensable effective January 1970), and scars of the left knee and ankle (noncompensable effective January 1970). Thus, since November 12, 2019, he has met the schedular requirements for TDIU because he has a combined disability rating of 80 percent, with one disability rated at 40 percent disabling. Next the evidence demonstrates that the Veteran has been unable to obtain or retain substantially gainful employment due to his service-connected disabilities. In making this determination, the Board places significant probative weight on the October 2017 psychosocial assessment and employability evaluation performed by a private psychologist and the January 2018 medical opinion, which contains an employability assessment, performed by a private physician. The October 2017 psychosocial assessment and employability evaluation reflects that the Veteran last worked in 2010, and that he worked for approximately 38 years as an electrician, during which time he had difficulty with figures of authority and supervisors. The private psychologist noted that the Veteran did not possess any transferable skills to sedentary work without significant vocational adjustment in terms of the work setting, process, and industry. The private psychologist opined that based on the Veteran’s education, training, past work experience, and current level of symptoms related to his PTSD alone, he was not a viable rehabilitation candidate and was not capable of sustaining substantial, gainful work activity, and was unemployable. The employability assessment set forth in the report from the January 2018 examination performed by the private physician similarly demonstrates that the Veteran has been unable to obtain or retain substantially gainful employment due to his service-connected disabilities. The employability assessment reflects that the examining physician opined that his migraine headaches alone would render him unemployable because they are debilitating in nature, requiring bed rest, preventing him from looking at a computer monitor, and preventing him from speaking on the phone because the pain prevents him from concentrating. The private physician further stated that the Veteran’s peripheral neuropathy of the left lower extremity and varicose veins of the left leg prevent him from participating in normal physical activities, making any type of labor untenable and preventing him from performing the duties of an electrician, which he performed from 1972 until he stopped working in 2010. Finally, the private physician indicated that his PTSD would prevent the Veteran from maintaining gainful employment because of his symptoms of anxiety, anger, and an inability to work with others. In conclusion, the question in this case is whether the Veteran could secure or follow substantially gainful employment, not whether he was totally precluded from work. The Board finds that TDIU should be granted because the opinions of private psychologist in the October 2017 psychosocial assessment and employability evaluation and the employability assessment set forth in the report from the January 2018 private examination performed by the private physician, in conjunction with the credible statements by the Veteran, place the question of substantially gainful employment in great doubt and the Board has resolved all doubt in the Veteran’s favor. See Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). 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. B.T. KNOPE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Crosnicker, Associate Counsel