Citation Nr: 21002747 Decision Date: 01/14/21 Archive Date: 01/14/21 DOCKET NO. 10-10 173 DATE: January 14, 2021 ORDER The petition to reopen a previously denied claim for service connection for a gallbladder condition is denied. Entitlement to service connection for sleep apnea as secondary to service-connected disabilities is granted. Entitlement to service connection for gastroesophageal reflux disorder (GERD) is granted. Entitlement to service connection for a hiatal hernia is denied. Entitlement to service connection for hypertension is denied. Entitlement to service connection for type II diabetes mellitus is denied. Entitlement to a rating higher than 20 percent for a lumbar spine disability is denied. Prior to March 5, 2019, a separate 10 percent disability rating, but not higher, for right lumbar radiculopathy, is granted. Entitlement to a 70 percent rating, but not higher, for adjustment disorder with anxiety and depressed mood, is granted. Entitlement to a total rating based on individual employability due to service-connected disabilities (TDIU) is granted. FINDINGS OF FACT 1. In an unappealed October 1999 rating decision, the RO denied the Veteran’s original claims for service connection for a gallbladder condition. 2. Evidence received since the last final rating decision in October 1999 does not raise a reasonable possibility of substantiating the claim of service connection for a gallbladder condition. 3. Diagnosed sleep apnea was aggravated by service-connected disabilities. 4. The Veteran had symptoms of GERD during service and since service separation. 5. The weight of the evidence is against finding that the diagnosed hernia is related to service. 6. The weight of the evidence is against finding that the diagnosed hypertension is related to service or a service-connected disability. 7. The weight of the evidence is against finding that the diagnosed type II diabetes mellitus is related to service or a service-connected disability. 8. For the entire rating period on appeal, the lumbar spine disability does not more nearly approximate forward flexion of the thoracolumbar spine to 30 degrees, nor is there evidence of favorable ankylosis of the entire thoracolumbar spine. 9. A diagnosis of intervertebral disc syndrome (IVDS) is demonstrated beginning March 2019; however, any reports of having “incapacitating episodes” are not shown to result in prescribed bed rest by a physician. 10. Prior to March 5, 2019, the Veteran’s lumbar disability resulted in neurological impairment of the right and left lower extremities that was analogous to mild incomplete paralysis of the sciatic nerve. 11. Beginning March 5, 2019, the Veteran’s back disability resulted in neurological impairment of the right and left lower extremities that was analogous to moderate incomplete paralysis of the sciatic nerve. 12. Service-connected psychiatric disorder more nearly approximates occupational and social impairment with deficiencies in most areas. 13. The Veteran’s service-connected disabilities have rendered him unable to secure or maintain a substantially gainful occupation CONCLUSIONS OF LAW 1. The October 1999 rating decision denying service connection for a gallbladder condition is final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 3.105(a), 20.302, 20.1103. 2. The additional evidence received since the October 1999 rating decision is not new and material and the claim of service connection for a gallbladder condition is not reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. The criteria to establish service connection for sleep apnea are met. 38 U.S.C. §§ 1110, 1131, 5107, 38 C.F.R. §§ 3.102, 3.310. 4. The criteria to establish service connection for GERD are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria to establish service connection for hiatal hernia are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria to establish service connection for hypertension are not met. 38 U.S.C. §§ 1110, 1131; 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 7. The criteria to establish service connection for type II diabetes mellitus are not met. 38 U.S.C. §§ 1110, 1131; 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 8. The criteria for a rating higher than 20 percent for a lumbar spine disability are not met or approximated. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5243. 9. Prior to March 5, 2019, the criteria for a separate 10 percent rating for right lumbar radiculopathy are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.7, 4.123, 4.124, 4.124a; DC 8520. 10. For the entire rating period on appeal, the criteria for a 70 percent rating, but not higher, for adjustment disorder with anxiety and depressed mood are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.130, DC 9440. 11. The criteria for an award of a TDIU are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1978 to October 1998. In March 2015, the Board remanded the appeal for the Regional Office (RO) to issue statements of the case (SOCs) and supplemental statement of the case (SSOC). Subsequently, in January 2019, the Board remanded the above-mentioned issues for further development, to include obtaining outstanding records and providing the Veteran with new VA examinations. The Board notes that in 2019, the issue of entitlement to a rating higher than 30 percent for a left knee disability was also remanded. However, in an August 2020 rating decision, the RO increased the rating to 60 percent, the highest available rating for the entire rating period on appeal. In addition, in the April 2013 notice of disagreement (NOD), the Veteran limited the appeal to 60 percent. As such, this is considered a full grant of the benefits sought on appeal and this issue is no longer in appellate status. New and Material Evidence for a Gallbladder Condition Rating decisions are final and binding based on evidence on file at the time the claimant is notified of the decision and may not be revised on the same factual basis except by a duly constituted appellate authority. 38 C.F.R. § 3.104(a). The claimant has one year from notification of a RO decision to initiate an appeal by filing a NOD with the decision or submitting new and material evidence, and the decision becomes final if an appeal is not perfected within the allowed time period. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.160, 20.201, 20.302. An exception to the finality rule is found in 38 U.S.C. § 5108, which provides that, if new and material evidence is received with respect to a claim which has been disallowed, VA shall reopen the claim and review the former disposition of the claim. New evidence is defined as existing evidence not previously submitted to agency decision makers. Material evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence previously of record and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In determining whether evidence is new and material, the credibility of the evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510, 512-513 (1992). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held, however, that evidence that is merely cumulative of other evidence in the record cannot be new and material even if that evidence had not been previously presented. Anglin v. West, 203 F.3d 1343, 1347 (2000). In deciding whether new and material evidence has been received, the Board looks to the evidence submitted since the last final denial of the claim on any basis. Evans v. Brown, 9 Vet. App. 273, 285 (1996). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is “low.” Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). In the present case, in an October 1999 rating decision the RO denied the Veteran’s original claim for compensation, finding that although service treatment records showed probable diagnosis of gallbladder disease after complaints of right lower quadrant pain and fever, no actual diagnosis was rendered. In addition, a May 1999 post-service examination showed no evidence of a diagnosis of a gallbladder condition and the Veteran specifically denied having any problems related to the gallbladder. The evidence considered at the time included service treatment records, post-service treatment records, and a May 1999 VA examination report. The Veteran did not appeal this decision and new and material evidence was not received within one year of the decision. Thus, the October 1999 rating decision became final. See 38 U.S.C. § 7105 (d)(3); Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011); 38 C.F.R. §§ 3.104, 3.156(a)-(b), 20.302, 20.1103. The evidence received since the October 1999 rating decision includes the Veteran’s lay assertions and additional VA and private treatment records. However, despite the Veteran’s belief that he has a gallbladder condition, the medical evidence does not support this assertion. For example, Social Security Administration records dated in 2012 contained medical record in which the physician who treated the Veteran after a sleeve gastrectomy noted: “There was a question about his gallbladder report which I gave to his doctor to read. There is no evidence of any abnormality.” All other evidence failed to show a currently diagnosed gallbladder condition. This evidence, while new, is not material, as it fails to show a currently diagnosed gallbladder condition. The Board concludes that new and material evidence has not been received to reopen the previously denied service connection claim for a gallbladder condition, and therefore the petition to reopen is denied. Service Connection – Applicable Laws and Regulations Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). Service connection may alternatively be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a) (2018). Secondary service connection may also be established for a disorder which is aggravated by a service-connected disability. See 38 C.F.R. § 3.310(b) (2017); Allen v. Brown, 8 Vet. App. 374 (1995). Hypertension and diabetes mellitus are considered a “chronic” disease under 38 C.F.R. § 3.309(a). Therefore, the presumptive service connection provisions under 38 C.F.R. § 3.303(b) for service connection based on “chronic” symptoms in service and “continuous” symptoms since service are applicable. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). For the showing of chronic diseases in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). If not manifest during service, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and the ‘chronic’ disease became manifest to a degree of 10 percent within 1 year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307. The Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant. Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011). This includes weighing the credibility and probative value of lay evidence against the remaining evidence of record. See King v. Shinseki, 700 F.3d 1339 (Fed. Cir. 2012). A Veteran bears the evidentiary burden to establish all elements of a service connection claim, including the nexus requirement. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). In making its ultimate determination, the Board must give a veteran the benefit of the doubt on any issue material to the claim when there is an approximate balance of positive and negative evidence. Id. at 1287 (quoting 38 U.S.C. § 5107 (b)). Sleep Apnea The Veteran asserts that his diagnosed sleep apnea is caused and/or aggravated by his service-connected disabilities. The Veteran has a current diagnosis of sleep apnea. See e.g., August 2005 sleep study. As to the issue of a nexus, evidence against the claim includes January 2007 VA examination report that noted sleep apnea was due to obesity and April 2019 examination report and opinion that concluded that obesity was not due to the Veteran’s inactivity as a result of his service-connected disabilities but rather lifestyle choices. Nonetheless, the Veteran provided multiple statements from his treating physicians, which noted that the medications he took for treatment of his service-connected disabilities as well as lack of sleep at the very least aggravated the diagnosed sleep apnea. See e.g., September 2017 disability benefits questionnaire and opinion. In this regard, the Board notes that in Ward v. Wilkie, 31 Vet. App. 233, 239 (2019), the Court held that permanent worsening is not a requirement for secondary service connection of a non-service-connected injury or disease. Here, the Board finds that the evidence is at least in equipoise as to whether the diagnosed sleep apnea was aggravated by the service-connected disabilities. Resolving all doubt in the Veteran’s favor, the Board finds that service connection is warranted. GERD The Veteran asserts that the diagnosed GERD is related to his service-connected disabilities. The Veteran has a diagnosis of GERD. See e.g., VA treatment records beginning 2016. On review, the Board finds that service connection is warranted on direct basis. Notably, during the May 1999 VA examination, approximately six months after separation from active duty, the Veteran denied having problems associated with the liver, gallbladder, or pancreas; however, he had a substernal pain that was relieves by regurgitation. He reported these symptoms were present for many years. For example, in February 2012 correspondence, the Veteran indicated that he had heartburn, difficulty swallowing, and constant clearing of his throat in service. Due to these reported symptoms, a diagnosis of GERD was later rendered. In this case, the finding that the Veteran has had GERD symptoms, particularly to include reflux and regurgitation in service and since separation from service, is supportive of the claim overall, because it tends to show that the same symptoms that began in service were the basis for the later diagnosed GERD. See Horowitz v. Brown, 5 Vet. App. 217, 221-22 (1993) (lay statements are competent on in-service and post-service symptoms - dizziness, loss of balance, hearing trouble, stumble and fall, and tinnitus - that were later diagnosed as Meniere’s disease). Accordingly, based on the competent and credible lay and medical evidence on record, and resolving all reasonable doubt in favor of the Veteran, the Board finds that his GERD had its onset during active service. Hernia The Veteran asserts that he has a hiatal hernia that is related to service. The Veteran’s service treatment records are silent for any complaints, treatment, or diagnosis of a hernia. According to April 1999 treatment records, a radiologic examination report showed no evidence of a hernia. Private treatment records dated in August 2001 noted a lump in the abdominal wall and a provisional diagnosis of abdominal wall hernia. However, according to 2002 VA treatment records, the Veteran reported that he noticed a hernia for six or seven years, but it never bothered him. He indicated that he thought he had a ventral hernia. However, upon examination, the medical professional noted that the Veteran had diastasis recti but no true hernia. Additional 2002 treatment records showed no hernia on examination. In 2003, it was again noted that the Veteran had no hernias. According to December 2009 private radiology report, there was minimal GERD and small hiatal hernia. A barium swallow also showed small hiatal hernia. Nonetheless, even conceding a current diagnosis of a hernia, there is no lay or medical evidence to suggest a link between the diagnosis and the Veteran’s service. While the Veteran is competent to describe symptoms he experiences at any given time, he is not shown to possess the necessary medical knowledge or expertise to render a diagnosis of a hernia. In this regard, a confirmed diagnosis of hernia was not shown until December 2009, over a decade after separation from service. Moreover, no medical professional related the hernia to the Veteran’s active duty service and the Veteran is not competent to relate the diagnosed hernia to service. Upon review, the Board finds that under the facts of this case, a VA examination is not warranted for the claimed hernia. Under McLendon v. Nicholson, 20 Vet. App. 79 (2006), in initial service connection claims, the VA must provide a VA medical examination where there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing that an event, injury, or disease occurred in service; (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service; and (4) insufficient competent medical evidence on file for VA to make a decision on the claim. Here, the Veteran provided no explanation as to why he believed the hernia was related to service. Given that the service treatment records are silent for any complaints, treatment, or diagnosis of a hernia; the lack of any indication of an injury or theory of entitlement as to why the Veteran believed his hernia was related to service; and the fact that no medical professional suggested that the hernia was related to service, a VA examination is not necessary. The Board finds that the competent and credible evidence weighs against finding that the diagnosed hernia is related to active service; therefore, the appeal is denied, and the benefit-of-the-doubt doctrine does not apply. Hypertension and Diabetes Mellitus The Veteran asserts that his type II diagnosed diabetes mellitus and hypertension are secondary to his service-connected disabilities. Specifically, he believes that lack of physical activity due to his musculoskeletal disabilities resulted in obesity, which in turn developed into diabetes and hypertension. The Veteran has current diagnoses of type II diabetes mellitus and hypertension. See e.g., treatment records beginning in 2003 and 2004. The Veteran service treatment records are silent for any complaints, treatment, or diagnoses of hypertension or diabetes. All blood pressure readings and blood sugar testing were normal. In 2003, the Veteran was diagnosed with type II diabetes mellitus and in 2004 with hypertension. At the time it was also noted that he was morbidly obese. In a December 2005 letter, the Veteran’s treating physician indicated that due to his knee and back disabilities he had a sedentary lifestyle, which in turn led to an increase in his weight that “may have contributed” to the metabolic disorder of diabetes mellitus that then caused hypertension. In June 2007, the Veteran underwent VA examinations for diabetes mellitus and hypertension, at which time diagnosis of both conditions was confirmed. After review of the claims file and examination of the Veteran, the examiner opined that the diabetes mellitus was secondary to obesity with no connection to the back or knee conditions. In addition, the examiner opined that the hypertension was essential hypertension and not related to the diabetes mellitus since there was no renal involvement and that the back and knee conditions could not cause hypertension. According to February 2012 private treatment records, the Veteran had family history that was remarkable for hypertension and diabetes mellitus. In March 2012 correspondence, the Veteran indicated that he believed he was already diabetic in service because he had numbness in his leg and was constantly thirsty. He realized these were symptoms of diabetes mellitus after speaking with his brother who already had diabetes. In April 2019, the Veteran underwent additional VA diabetes and hypertension examinations. The examiner reviewed the claims file and cited to many entries dated from 1978 to the present. The examiner acknowledged all of the Veteran’s service-connected conditions. After extensive review of the record, the examiner opined that the Veteran’s level of obesity attributable to his service-connected disabilities was insignificant. The examiner supported this opinion by citing to specific weight changes during service and since separation from service. Regarding hypertension, the examiner noted that the Veteran was diagnosed in 2004, and that the hypertension improved to a point that his antihypertensive medications were at least temporarily stopped by his treating physician with weight reduction after his lap band procedure. In this regard, the examiner noted that weight could have been one of the factors that contributed to hypertension; however, as noted above, it was less likely than not that his obesity was caused by, the result of, or aggravated by his service-connected disabilities, and as such, it was less likely than not that his hypertension was related to his service connected disabilities. The examiner further explained that it was more likely than not that the Veteran’s failure to control his caloric intake was the cause for his obesity. In this regard, the examiner explained that lack of physical exercise does not cause obesity, which is evidence by many individuals who do not exercise at all and are still thin. Moreover, there was family history of obesity, diabetes, and hypertension. Similarly, regarding diabetes, the examiner noted that it was diagnosed in 2003 and improved to a point that the diagnosis was revised to metabolic syndrome after the Veteran’s lap band procedure. Here again, the examiner explained how obesity was a factor; however, in this specific Veteran’s case, there was no evidence that his weight gain as the result of any of his service-connected disabilities. The examiner concluded that due to the absence of a pathophysiological or temporal relationship between Veteran’s service connected musculoskeletal disabilities and obesity it was less likely than not (less than 50 percent probability) that the Veteran’s service-connected musculoskeletal disabilities caused weight gain (obesity) that contributed to the onset and worsening of hypertension or diabetes, and the level of obesity attributable to his service-connected disabilities was insignificant. The examiner further cited to a number of medical articles that supported the provided rationale. On review, service connection on a presumptive basis is not warranted. Notably, diabetes mellitus and hypertension were diagnosed approximately four and five years after separation from active duty and neither the Veteran nor the medical evidence suggest that either disability was present since separation from service. For these reasons and bases, service connection on a presumptive basis is not warranted. Service connection on a direct basis is also not warranted. In this regard, the Board assigns higher probative value to the VA examiners’ opinions as opposed to the Veteran’s private physician’s opinion. Specifically, the 2005 letter provided no rationale and used conditional language, namely, that the service-connected back and knee disabilities “may have contributed” to the Veteran’s obesity. A speculative opinion weighs neither for nor against the claim. Moreover, the private physician omitted the fact that the Veteran’s family history is remarkable for both diabetes mellitus and hypertension and that his obesity was present throughout the years and not only after he was limited by his service-connected conditions. To the extent that the private physician misstated the Veteran’s medical history, the opinion is of little to no probative value. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). On the contrary, the 2019 VA examiner thoroughly explained why this Veteran’s obesity could not be the cause of his hypertension and diabetes mellitus. The examiner supported the opinion by citing extensively to the Veteran’s medical history and also acknowledged his family history for both diseases. The opinion is therefore entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). As such, the VA examiner’s opinion outweighs the lay assertions in this case. While the Veteran is competent to describe certain observable symptoms, under the fact of this case, he is not shown to possess the necessary medical expertise to provide a nexus opinion showing a relationship between the diagnosed hypertension and diabetes mellitus and his service-connected disabilities. In this regard, the Board acknowledges the Veteran’s belief that he had symptoms of diabetes mellitus during service; however, the medical evidence during service and post-service do not show evidence of numbness that was related to the diagnosed diabetes and diabetes was not diagnosed until approximately five years after separation. Accordingly, the Board finds that the competent and credible evidence weighs against finding that the Veteran’s diabetes and hypertension are causally or etiologically related to service. Therefore, the claims are denied, and the benefit-of-the-doubt doctrine does not apply. Increased Rating – Applicable Laws and Regulations Disability evaluations are determined by comparing a veteran’s present symptoms with the criteria set forth in the VA Schedule for Rating Disabilities, which is based upon average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt is resolved in favor of the Veteran. 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in a veteran’s condition. Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. See 38 C.F.R. § 4.1. When a claimant is awarded service connection and assigned an initial disability rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found. Where the veteran is appealing the rating for an already established service-connected condition, her present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). 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. Hart v. Mansfield, 21 Vet. App. 505 (2007). Lumbar Spine Disability – Rating Criteria When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.”). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine (for Diagnostic Codes 5235 to 5243, unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes). Ratings under the General Rating Formula for Diseases and Injuries of the Spine are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. The General Rating Formula for Diseases and Injuries of the Spine provides a 10 percent rating for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. § 4.71a. A 20 percent rating is provided for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent disability rating is assigned for forward flexion of the thoracolumbar spine to 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent disability rating is assigned for unfavorable ankylosis of entire spine. Intervertebral disc syndrome can alternatively be rated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (IVDS Formula). Under the IVDS Formula, a 10 percent rating requires incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months. A rating of 20 percent is warranted for incapacitating episodes with a total duration of at least two weeks but less than four weeks during the past 12 months. A rating of 40 percent is warranted for incapacitating episodes with a total duration of at least four weeks but less than six weeks during the past 12 months. A maximum rating of 60 percent is warranted for incapacitating episodes with a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a, IVDS Formula. For these purposes, an incapacitating episode is defined as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Id. at Note (1). Lumbar Spine Disability – Rating Analysis According to February 2012 private treatment records, the Veteran’s physician noted that he could not exercise due to chronic back and knee pain. The pain was described as dull and worse with activity. The Veteran denied having redness or swelling. In February 2012 correspondence, the Veteran indicated that the back condition was incapacitating on constant basis. He added that he had pain in both lower extremities that he was told was the result of his back condition. He concluded that the back disability was “very crippling.” According to March 2012 private treatment records, the Veteran reported back pain but no muscle aches, muscle weakness, or swelling in the extremities. Thereafter, VA treatment records dated in October 2012 noted that the Veteran had back pain with slight tenderness to palpation of the mid-thoracic and lumbar area, range of motion was “fair” with pain and the end of range of motion, and there was no pain with heel walking and tip toe walking. The Veteran could not squat. According to private medical records furnished by the Social Security Administration, in April 2014, the Veteran complained that the back condition did not improve since his last procedure and that he had more pinched nerved that prevented him from moving. In December 2014, the Veteran underwent a back conditions compensation examination, at which time the examiner confirmed diagnoses of spondylosis and degenerative joint disease of the lumbar spine. The Veteran was very reluctant to give any information and indicated that all evidence should be within VA’s possession. He reported that the condition worsened despite temporary improvement after epidural injections. He was unable to sleep or have sexual intercourse. The Veteran stated that he had extensive treatment outside the VA but refused to share any of this information indicating that it would delay his claim processing. The examiner explained to the Veteran that this was important information that would assist the examiner in determining whether any changes occurred since the initial diagnosis. The Veteran reported having flare-ups, which he described as constant pain, taking hours to be mobile in the morning and hardly being able to walk, and any physical work caused pain. Flare-ups totally limited his back function and his ability to enjoy life. Upon physical examination, range of motion of the lumbar spine revealed forward flexion to 80 degrees with pain at 70 degrees; extension to 20 degrees with pain; lateral flexion to 20 degrees with pain at 15 degrees, bilaterally; and, lateral rotation to 20 degrees with pain at 15 degrees, bilaterally. There was no additional limitation in range of motion after repetitive use testing with three repetitions. The examiner indicated that during flare-ups and/or after repeated use, it was expected that the Veteran will experience additional 5 to 10-degree loss in range of motion. Functional loss/impairment was due to weakened movement, excess fatigability, and pain on movement. Guarding/muscle spasm were present but did not result in abnormal gait or spinal contour. The Veteran did not have a diagnosis of IVDS. The Veteran used no assistive devices. Muscle strength testing was normal (5/5) throughout with no evidence of muscle atrophy. Reflex examination was normal (2+) in both knees and hypoactive (1+) in both ankles. Sensory examination was normal throughout but deceased in the foot/toes, bilaterally. Straight leg raising test was negative, bilaterally. The examiner noted no radicular pain or any other signs or symptoms of radiculopathy. In May 2015, the Veteran underwent a decompression laminectomy followed by fusion due to spinal stenosis secondary to spondylolisthesis. The operating physician noted that the Veteran’s postoperative course was surprisingly well and that he was ambulatory without too much discomfort. The physician also rendered a preoperative diagnosis of radiculopathy and mechanical back pain. In March 2019, the Veteran underwent an additional back conditions compensation examination, at which time the examiner rendered diagnoses of degenerative arthritis of the spine, IVDS, and bilateral lumbar radiculopathy. The Veteran reported constant numbness, intermittent and sharp pain, and stiffness. He reported having flare-ups, which he described and inability to sit down or stand because it triggered a flare-up that prevented him from moving. These flare-ups occurred once a week and lasted 3 to 4 days, at which time pain severity increased to 10 out of 10. Functional loss/impairment was described as pain in the buddy, problems putting clothes on, and difficulty with prolonged sitting and standing. Upon physical examination, range of motion of the lumbar spine revealed forward flexion to 55 degrees; extension to 20 degrees; right lateral flexion to 20 degrees; left lateral flexion to 25 degrees; and, lateral rotation to 30 degrees, bilaterally. Range of motion itself contributed to functional loss with limitation on bending, stooping, pushing, pulling, carrying, and lifting moderate objects. Pain noted on examination and caused functional loss. There was no pain with weight bearing and no evidence of localized tenderness or pain on palpation. There was no additional loss of function or range of motion after repeated use testing with three repetitions. The examiner noted that the examination was neither medically consistent nor inconsistent with the Veteran’s statement describing functional loss after repeated use over time and/or during flare-ups. The examiner further noted that it was not possible to say without mere speculation whether pain, fatigability, or incoordination significantly limited functional ability during these conditions because the Veteran was not examined immediately after repeated use over time or during a flare-up. There was no evidence of guarding or muscle spasm. No other factors contributed to the disability. Muscle strength testing was normal (5/5) throughout with no evidence of muscle atrophy. Reflex examination was hypoactive (1+) in both knees and normal (2+) in both ankles. Sensory examination was normal throughout but deceased in the foot/toes, bilaterally. Straight leg raising test was positive, bilaterally. Signs and symptoms of radiculopathy included moderate intermittent pain, mild paresthesias, and moderate numbness, bilaterally. The examiner indicated that the radiculopathy was analogous to moderate incomplete paralysis of the sciatic nerve, bilaterally. There were no other neurological abnormalities. The Veteran had IVDS; however, there was no evidence of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician in the previous 12 months. The Veteran used no assistive devices. In an April 2020 addendum, the examiner indicated that while the examination report was neither consistent nor inconsistent with the Veteran’s statements describing functional loss with repetitive use over time, pain, weakness, fatigability, and incoordination did not significantly limit functional loss under these conditions. In addition, it was not possible to describe any additional loss in terms of range of motion. The examiner explained that after review of the reported history, subjective complaints, and relevant evidence of record, in addition to the examiner’s medical knowledge and expertise, there remained no basis to offer additional losses of function or motion due to repetitive use. Regarding flare-ups, the examiner indicated that pain significantly limited functional ability at the time of flare-ups. The examiner estimated that during flare-ups, range of motion will show forward flexion to 50 degrees; extension to 20 degrees; right lateral flexion to 20 degrees; left lateral flexion to 25 degrees; and, lateral rotation to 25 degrees, bilaterally. Upon review, the Board finds that the criteria for a rating higher than 20 percent for the service-connected lumbar spine disability are not met or approximated at any point during the pendency of the appeal. Specifically, even taking into consideration the Veteran’s competent and credible reports of flare-ups and functional loss after repetitive use over time, limitation of flexion to 30 degrees is still not met or approximated. Forward flexion was to 55 degrees at worst during the appeal period and only an additional 5-degree loss in range of motion after repetitive use/during flare-ups was estimated by the 2020 examiner, which results in 50 degrees flexion at worst. Even if the Board will accept the December 2014 examiner’s estimation of a 10-degree loss during flare-ups, forward flexion would be 45 degrees, which still does not approximate 30 degrees and required by the criteria for a higher rating. The Board concludes that the currently assigned 20 percent rating already contemplates the additional loss due to pain and other DeLuca factors after repetitive use and/or during flareups. See 38 C.F.R. §§ 4.40, 4.45. A higher rating under the General Rating Formula is not warranted. A rating higher than 20 percent is also warranted under the IVDS Formula. Initially, the first indication of a diagnosis of IVDS was not shown until the 2019 examination report. Additionally, while acknowledging the Veteran’s competent reports of flare ups of back pain, previous surgery, and incapacitating episodes, there is no evidence of him experiencing any incapacitating episodes of IVDS as defined by VA regulation. Indeed, incapacitating episodes are defined by VA as those episodes for which bedrest is prescribed by a physician. Here, there is no evidence of incapacitating episodes, let alone episodes of IVDS of at least four weeks but less than six weeks during the past 12 months to warrant a higher rating. In sum, there is no basis to support a rating higher than 20 percent for the Veteran’s lumbar spine disability at any point during the pendency of the appeal under either the General Rating Formula or the IVDS formula. Associated Neurological Impairment In addition to consideration of the orthopedic manifestations of the lumbar spine disability, VA regulations require that consideration be given to any associated objective neurologic abnormalities, which are to be evaluated separately under an appropriate diagnostic code. 38 C.F.R. § 4.71a, DCs 5235 to 5243, Note (1). Disability ratings of 10, 20, and 40 percent are warranted, respectively, for mild, moderate, and moderately severe incomplete paralysis of the sciatic nerve. 38 C.F.R. § 4.124a. A disability rating of 60 percent is warranted for severe incomplete paralysis with marked muscle atrophy. An 80 percent rating is warranted for complete paralysis of the sciatic nerve. 38 C.F.R. § 4.124a, DC 8520. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. Neither the Rating Schedule nor the regulations provide definitions for descriptive words such as “mild,” “moderate,” “moderately severe,” and “severe.” See Spellers v. Wilkie, 30 Vet. App. 157 (2018). Rather than applying a mechanical formula, the Board must instead evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. Here, the Veteran is in receipt of a 20 percent rating for right lower extremity radiculopathy beginning March 5, 2019. A 10 percent rating for left lumbar radiculopathy prior to March 5, 2019 and a 20 percent rating thereafter. On review, the Board does not find evidence to support the assignment of ratings higher than those already assigned above. However, the Board finds that for the entire rating period on appeal prior to March 5, 2019, a 10 percent disability rating for right lumbar radiculopathy is warranted. In so finding, the Board notes that the reported numbness and radicular pain was noted in both extremities for the entire rating period on appeal. However, prior to March 5, 2019, its severity was not discussed, or it was noted to only be mild. Beginning March 5, 2019, the medical evidence supported that the radiculopathy was analogous to moderate incomplete paralysis of the sciatic nerve. However, neither the medical nor lay evidence suggested that the lumbar radiculopathy was moderate prior to March 5, 2019 or moderately severe after this date. In sum, the Board assigns a separate 10 percent rating for a right lumbar radiculopathy prior to March 5, 2019. The Board further finds that the already assigned 10 percent rating for left lumbar radiculopathy prior to March 5, 2019, as well as the assigned 20 percent rating beginning March 5, 2019 for both right and left lumbar radiculopathy are proper. Acquired Psychiatric Disorder – Rating Criteria The criteria for rating psychiatric disabilities, other than eating disorders, are set forth in the General Rating Formula (General Rating Formula) for Mental Disorders. See 38 C.F.R. § 4.130. This appeal stems from a March 2015 rating decision that denied a rating in excess of 50 percent for adjustment disorder with anxiety and depression. Under the General Rating Formula, a 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted if the evidence establishes there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating (total occupational and social impairment) is warranted 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; memory loss for names of close relatives, own occupation, or own name. Id. When determining the appropriate disability evaluation to assign, the Board’s primary consideration is the Veteran’s symptoms, but it must also make findings as to how those symptoms impact a Veteran’s occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). The use of the term “such as” in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Thus, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Id. at 442. Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the Veteran’s impairment must be “due to” those symptoms; a Veteran may only qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. The Board recognizes that the Court in Mauerhan, 16 Vet. App. 436, stated that the symptoms listed in VA’s general Rating Formula for mental disorders is not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating; however, the Court further indicated that, without those examples, differentiating between rating evaluations would be extremely ambiguous. Acquired Psychiatric Disorder – Rating Analysis The Veteran asserts that the diagnosed acquired psychiatric disorder is worse than the currently assigned 50 percent disability rating. For the reasons expressed below, the Board finds that the criteria for a 70 percent rating are approximated. Turning to the evidence, the Board notes that in December 2014, the Veteran underwent a mental disorder compensation examination, at which time the examiner confirmed a diagnosis of adjustment disorder with mixed anxiety and depressed mood. The examiner noted that the claims file was reviewed, and that the Veteran’s spouse was present during the examination and elaborated on some answers. In terms of social impairment, it was noted that the Veteran was married to his current spouse since 1983 and had two daughters. He described his relationship with his spouse as “okay,” but it noted that he tended to “shut down” and did not talk to his spouse when he was upset. His relationship with his children was “good.” He had a distant relationship with his mother and most siblings. He communicated briefly with one of them on occasion. He spent most of his time with his spouse but described himself as “not very social.” He enjoyed traveling, fishing, and biking with his spouse. In terms of occupational impairment, it was note that the Veteran left his job in early 2014 due to poor management but also decided to retire due to his health conditions. The examiner identified psychiatric symptoms of depressed mood, anxiety, panic attacks that occurred weekly or less often, chronic sleep impairment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. On mental status examination, the Veteran was fully oriented with grooming and hygiene within normal limits. Speech was normal. No psychotic symptoms, delusions, or hallucinations were observed or reported. Insight and judgment were intact. His mood was anxious with mood-congruent affect. He denied any history of suicidal thoughts or attempts. Memory and concentration were intact. The examiner concluded that the Veteran’s psychiatric disorder resulted in occupational and social impairment with reduced reliability and productivity. According to VA treatment records dated from 2014 to 2017, the Veteran sought no treatment in relation to his psychiatric disorder. In October 2018, the Veteran’s attorney submitted a mental disorders disability benefits questionnaire authored by a private psychologist who confirmed a diagnosis of adjustment disorder with mixed anxiety and depressed mood. In terms of social impairment, the psychologist indicated that the Veteran was married to his second spouse for 35 years and had three adult children. He lived with his spouse but kept his struggles to himself. He was socially isolated and withdrawn. In terms of occupational impairment, it was noted that the Veteran did not work since 2014. The psychologist identified psychiatric symptoms of depressed mood; anxiety; suspiciousness; near-continuous panic or depression affecting the ability to functional independently, appropriately, and effectively; chronic sleep impairment; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a work like setting; and, inability to establish and maintain effective relationships. On mental status examination, the Veteran’s attention was normal and concentration variable. He complained of increased trouble with short-term memory. The Veteran’s speech flow was normal, but he was brief with information offered. Thought process was appropriate and there were no reports of hallucinations. Judgement was average. Mood was anxious and nervous with restricted affect. The Veteran reported feeling anxious and depressed. On the day of the interview, the Veteran endorsed symptomatology of adjustment disorder as he was vague with his responses, suspicious, and seemed rather paranoid talking to the psychologist. The psychologist concluded that the Veteran’s psychiatric disorder resulted in occupational and social impairment with deficiencies in most areas. In March 2019, the Veteran underwent an additional compensation examination, at which time the examiner confirmed a diagnosis of adjustment disorder with mixed anxiety and depressed mood. The Veteran was anxious and frustrated by his pain and physician dysfunction secondary to his pain. His insomnia, which he also attributed to his pain further exacerbated his anxiety, depression, and irritability. He reported and demonstrated continuing depression, anxiety, and agitation, but denied any formal mental health treatment since 2014. In terms of social impairment, the examiner noted that the Veteran remained married and described his relationship with his spouse as “good” overall. He noted that his spouse was loving and a good caretaker but endorsed periods when he “shuts down and gives her the cold shoulder” due to his irritability. His similarly reported frequent “friction” with his three adult children. He was close with two of his brothers and was not close to but also non-confrontational with his sisters. He had no close friends and avoided socialization. In terms of occupational impairment, the Veteran remained retired since 2014. He spent time doing yard work and other household maintenance projects and helped his spouse take care of their grandchildren. The examiner identified psychiatric symptoms of depressed mood, anxiety, panic attacks that occurred weekly or less often, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. On mental status examination, it was noted that the Veteran was casually dressed and groomed. Speech was clear, logical, and goal-directed, but often mildly pressured and loud in volume. He described recent and current moods as depressed, anxious, and angry, which he clearly and specifically attributed to his pain and insomnia. He exhibited an agitated affect with frequent life complaints. After review of all the evidence, lay and medical, the Board finds that the criteria for a 70 percent rating is approximated. Although the Board notes that the findings in the 2014 and 2019 examination reports showed symptoms that are contemplated by the assigned 50 percent rating, the Board agrees with the clinician who authored the private disability benefits questionnaire in finding that the Veteran’s psychiatric disorder resulted in an inability to establish and maintain effective relationships. In this regard, both the 2014 and 2019 examiners agreed that the Veteran was isolative and had no meaningful relationship outside his immediate family. As such, under the facts of this case, the Board finds that this does not indicate the Veteran was able to establish and maintain relationships. Significantly, throughout the pendency of the appeal it was noted that the Veteran had no relationships outside his immediate family, and even these relationships, at times were impacted by his withdrawing and isolation. These symptoms are contemplated by the criteria for a 70 percent rating. However, the Board finds that a rating higher than 70 percent for PTSD is not warranted. In terms of occupational impairment, the Board specifically considered evidence suggesting that the psychiatric disorder impacts the Veteran’s ability to work. In this regard, as discussed below, the Board grants entitlement to a TDIU, in part due to the service-connected psychiatric disorder. Nonetheless, the Veteran has not been totally socially and occupationally impaired due to the diagnosed adjustment disorder with anxiety and depressed mood. He was found capable of managing his own financial affairs and appeared fully oriented throughout the pendency of the appeal. In addition, although his psychiatric disorder resulted in social impairment, he was not totally socially impaired. As discussed above, although he had no friends, he had a good overall relationship with his immediate family. Total occupational and social impairment generally requires symptoms severe enough to severely distort the individual’s perception of reality, which is not shown by the record. Overall, the Veteran’s psychiatric symptoms do not equate in severity, frequency, or duration to total occupational and social impairment, nor have the symptoms demonstrated a level of severity in symptomatology to approximate or equate to that in the symptoms listed for a 100 percent rating. Additionally, the identified psychiatric symptoms of depressed mood; anxiety; suspiciousness; near-continuous panic or depression affecting his ability to function independently, appropriately, and effectively; chronic sleep impairment; mild memory loss; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a worklike setting; and, inability to establish and maintain effective relationships are properly contemplated by the criteria for a 70 percent disability rating. Entitlement to a TDIU The Court has held that a request for TDIU is part and parcel of a higher rating when raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). Here, the medical evidence suggests that he was unable to maintain gainful occupation as a result of his service connection disabilities. A total disability rating for compensation purposes may be assigned where the schedular rating is less than total, where it is found that the disabled person is unable to secure or follow substantially gainful occupation as a result of a service-connected disability ratable at 60 percent or more or as a result of two or more disabilities, providing at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 4.16(a). Unlike the regular disability rating schedule, which is based on the average work-related impairment caused by a disability, “entitlement to a TDIU is based on an individual’s particular circumstances.” Rice, 22 Vet. App. at 452. Therefore, in adjudicating a TDIU claim, VA must take into account the individual Veteran’s education, training, and work history. The ultimate issue of whether TDIU should be awarded is not a medical issue, but rather is a determination for the VA adjudicator. See Moore v. Nicholson, 21 Vet. App. 211, 218 (2007) (ultimate question of whether a veteran is capable of substantial gainful employment is not a medical one; that determination is for the adjudicator), rev’d on other grounds sub nom, Moore v. Shinseki, 555 F.3d 1369 (Fed. Cir. 2009). Neither nonservice-connected disabilities nor advancing age may be considered in the determination. 38 C.F.R. §§ 3.341, 4.19; Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The Veteran met the schedular criteria for a TDIU for the entire rating period on appeal, as the record shows that the combined evaluation of all of his service-connected disabilities has been at least 70 percent. 38 C.F.R. §§ 4.16(a), 4.25. The question remains, however, whether the Veteran has been precluded from obtaining or maintaining a substantially gainful occupation as a result of the service-connected disabilities. For the reasons expressed below, the Board finds that the evidence is at least in equipoise as to whether the Veteran’s is unable to maintain gainful employment due to his service-connected disabilities. Notably, all VA examiners who examined the Veteran in connection with his service-connected disabilities agreed that those impacted his ability to work. In addition, the Veteran provided private opinions, which also supported the notion that he was unable to work due to his service-connected disabilities. See e.g. M.B, M.D. report dated October 2018. Moreover, the Veteran’s employer specifically noted that he retired “due to health.” After careful consideration of the record, to include both the lay and medical evidence, the Board resolves all doubt in the Veteran’s favor, finding that he is unemployable by reason of his service-connected disabilities. In this regard, the Board notes that in a recent precedent decision, in Ray v. Wilkie, the Court defined the term “unable to secure and follow a substantially gainful occupation” to have two components: one economic and one noneconomic. The economic component means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. The non-economic component includes consideration of: the Veteran’s history, education, skill, and training; whether the veteran has the physical ability to perform the type of activities required by the occupation at issue; and whether the veteran has the mental ability to perform the activities required by the occupation at issue. Ray v. Wilkie, 31 Vet. App. 58, 72-73 (2019). Here, the Veteran’s longest work history post-service was a program director at a university for fifteen years until 2014. He left the job due to his physical and mental health conditions, which prevented prolonged sitting, standing, walking, and interfered with interaction with others. Accordingly, the Board finds that the evidence is at least in equipoise regarding whether the Veteran’s service-connected disabilities impact his ability to obtain and maintain gainful employment. Finally, neither the Veteran nor his attorney has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). L. Chu Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Yaffe, 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.