Citation Nr: 21004813 Decision Date: 01/28/21 Archive Date: 01/28/21 DOCKET NO. 15-32 391 DATE: January 28, 2021 ORDER Service connection for a cervical spine disability, to include as secondary to service-connected degenerative disc disease of the lumbosacral spine, is denied. Service connection for a left upper extremity disability is denied. Service connection for a right upper extremity disability is denied. Service connection for a left lower extremity disability, to include as an undiagnosed illness or other qualifying, chronic disability pursuant to the provisions of 38 U.S.C. § 1117, is denied. Service connection for a right lower extremity disability, to include as an undiagnosed illness or other qualifying, chronic disability pursuant to the provisions of 38 U.S.C. § 1117, is denied. Service connection for a sleeping disability, to include as an undiagnosed illness or other qualifying, chronic disability pursuant to the provisions of 38 U.S.C. § 1117, is denied. Service connection for double vision, to include as secondary to medication taking for service-connected disability, is denied. Service connection for disability manifested by weight loss is denied. Entitlement to total disability rating for compensation based on individual unemployability (TDIU) is granted. FINDINGS OF FACT 1. The most probative evidence of record weighs against a conclusion that the Veteran has a cervical spine disability due to service. 2. The most probative evidence of record weighs against a conclusion that a cervical spine disability is proximately due to or a result of degenerative disc disease of the lumbosacral spine, to include with consideration of aggravation. 3. The bilateral cervical neuropathy in the left and right upper extremities is due to a cervical spine condition for which service connected is not warranted and there is otherwise not a left or right upper extremity disability of in-service origin. 4. The most probative evidence of record weighs against a conclusion that the Veteran has a left or right lower extremity disability or a sleeping disability that was due to service, to include as a result of an undiagnosed illness or other qualifying, chronic disability based on his presence in the Southwest Asia theater of operations. 5. The most probative evidence of record weighs against a conclusion that the Veteran has double vision due to service. 6. The most probative evidence of record weighs against a conclusion that double vision is proximately due to or a result of medication taking for service-connected disability, to include with consideration of aggravation. 7. A disability manifested by weight loss is not shown at any time proximate to or during the appeal period. 8. Service connection is in effect for a mood disorder, rated as 70 percent disabling; headaches, rated as 50 percent disabling; degenerative disc disease of the lumbosacral spine, rated as 40 percent disabling; tinnitus, rated as 10 percent disabling; and hearing loss in the right ear, rated noncompensable; the service connected disabilities combine to be 90 percent disabling. 9. The Veteran reports education through four years of high school and work experience as an assembly worker; he stated that he became too disabled to work in April 2008. 10. It is at least as likely as not that service-connected disability has precluded the Veteran from securing and following substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for service connection for a cervical spine disability, to include as secondary to service-connected degenerative disc disease of the lumbosacral spine, and a left and right upper extremity disability are not met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2020). 2. The criteria for service connection for a left and right lower extremity disability and a sleeping disability, to include as a result of an undiagnosed illness or other qualifying, chronic disability due to the Veteran's presence in the Southwest Asia theater of operations, are not met. 38 U.S.C. §§ 1110, 1117, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.317 (2020). 3. The criteria for service connection for double vision, to include as secondary to medication taking for service-connected disability, are not met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2020). 4. The criteria for service connection for disability manifested by weight loss are not met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2020). 5. Resolving all reasonable doubt in favor of the Veteran, the criteria for TDIU are met. 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 3.340, 4.16 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1987 to July 1992. The claims on appeal were remanded by the Board of Veterans’ Appeals (Board) for further development and processing in September 2018 and are now ready for appellate review. I. Service Connection Claims A. Legal Criteria It is the Board’s responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court of Appeals for Veterans Claims (Court) held that an appellant need only demonstrate that there is an “approximate balance of positive and negative evidence” in order to prevail. The Court has also stated, “It is clear that to deny a claim on its merits, the evidence must preponderate against the claim.” Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. Service connection will be granted for disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge from service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. §§ 3.303(d). A disability which is proximately due to or the result of a service-connected disease shall be service connected. 38 C.F.R. § 3.310(a). A claimant is also entitled to service connection on a secondary basis when it is shown that a service-connected disability has aggravated a nonservice-connected disability. 38 C.F.R. § 3.310(b). Service connection may also be granted for a disability due to a qualifying chronic disability of a Persian Gulf Veteran, provided that such disability became manifest during either active service in the Southwest Asia theater of operations or to a degree of 10 percent or more, under the appropriate diagnostic code of 38 C.F.R. Part 4 not later than December 31, 2016, and by history, physical examination, and laboratory tests, the disability cannot be attributed to any known clinical diagnosis. 38 U.S.C.§ 1117; 38 C.F.R. § 3.317(a)(1). The Veteran’s service department awards and decorations reflect that as he served in the Southwest Asia theater of operations; as such, he is presumed to be a Persian Gulf Veteran for the purposes of this decision. A chronic qualifying disability means a chronic disability resulting from an (A) undiagnosed illness; (B) the following medically unexplained chronic multisymptom illnesses that are defined by a cluster of signs or symptoms: (1) chronic fatigue syndrome; (2) fibromyalgia; (3) irritable bowel syndrome; or (4) any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multisymptom illness; or (C) any diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. 38 C.F.R. § 3.317(a)(2)(i). For the purposes of this section the term medically unexplained chronic multisymptom illness means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). “Objective indications of chronic disability” include both “signs,” in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). Signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic multi-symptom illness include, but are not limited to: (1) fatigue, (2) unexplained rashes or other dermatological signs or symptoms, (3) headache, (4) muscle pain, (5) joint pain, (6) neurological signs and symptoms, (7) neuropsychological signs or symptoms, (8) signs or symptoms involving the upper or lower respiratory system, (9) sleep disturbances, (10) gastrointestinal signs or symptoms, (11) cardiovascular signs or symptoms, (12) abnormal weight loss, and (13) menstrual disorders. 38 C.F.R. § 3.317(b). B. Analysis 1. Cervical Spine/Upper Extremities The service treatment reports (STRs), to include the reports from a November 1993 service department examination conducted after the Veteran’s July 1992 separation from service, are silent for a cervical spine or left or right upper extremity disorder. A medical history collected in conjunction with the November 1993 examination was silent for a cervical spine or left or right upper extremity disorder, and the Veteran specifically denied a history at that time of “[s]wollen or painful joints,” neuritis, or paralysis. After service, an August 1994 Persian Gulf War examination and an April 1998 VA general medical examination did not reflect any findings or complaints associated with a cervical spine or left or right upper extremity disorder. A February 2015 VA examination of the cervical spine, which included an X-ray that demonstrated cervical disc disease and diagnosed the Veteran with bilateral cervical radiculopathy, resulted in the opinion that it was less likely than not that the Veteran had a cervical spine disability that was caused by service. The rationale for the opinion was as follows: The [V]eteran relates an onset in service of his neck pain, which he relates to the rigors of military service, to include episodes in which his neck was jarred when his seat in a vehicle repeatedly gave way. The service records were reviewed. No mention of a neck condition was identified. The post-service records were reviewed. No mention of a neck condition was found in the records immediately following service. Abundant medical notes after 2010 describe the [V]eteran’s neck condition and surgery. The [V]eteran is diagnosed with degenerative disc disease with spondylosis and bilateral cervical radiculopathy. Since there is no in-service documentation of a neck condition, it is not possible to compare this diagnosis with signs or symptoms in service in order to establish causality. In the absence of medical records regarding a neck condition for many years after service, it is not possible to trace back signs, symptoms, test results, imaging studies, clinical impressions and diagnoses from the present back to service in order to establish continuity and causality. The evidence to date does not support a relationship to service. The September 2018 Board remand found the above opinion to be inadequate because it was said to have been based entirely on a lack of documentation of symptoms since service and because the examiner did not provide a sufficient explanation for his negative opinion. As such, the Board remand requested an opinion as follows: Schedule the Veteran for an appropriate examination for an opinion on whether it is as likely as not (50/50 probability or better) that any cervical spine diagnosis is related to the Veteran’s service. He has reported that his neck has been symptomatic since service, which he attributes to multiple incidents when riding in a howitzer and the seat that he was in suddenly dropped. He also reported that he does not recall seeking treatment in service because it was not that bad while in service. He reported that he began to experience numbness in his hands in or around 1995. In 2012, he was diagnosed with cervical radiculopathy, and he had fusion of vertebrae in the neck in 2013. The February 2015 VA examiner opined against a relationship between the Veteran’s service and his neck diagnoses based on a lack of documentation, which is insufficient on its own to deny service connection. The Veteran is competent to report his own history. Therefore, the examiner is asked to elicit from the Veteran a thorough history of his symptoms in and since service. The examiner is asked to conduct a search of the relevant literature prior to opining on whether the injuries in service, as reported by the Veteran, likely as not caused his current cervical spine diagnoses. The examiner is also asked to opine on whether it is as likely as not (50/50 probability or better) that any cervical spine diagnosis was caused or aggravated by the Veteran’s other service-connected disabilities, including his lumbar spine disability. (“Aggravated” means to cause any increase in the severity of a disability that is beyond the normal progression of the disability.) The examiner is asked to conduct a review of the relevant literature prior to opining on this possibility. The requested opinion was completed in October 2019, with the examiner again concluding that it was less likely than not that the Veteran had a cervical spine disability that was caused by service. The rationale for this opinion was follows: From a medical probability standpoint, a plausible mechanism of injury to have accounted for [the Veteran’s] later cervical spine degenerative disc disease (DDD) would have customarily been significant enough to have caused acute neck pain that would have led him to seek medical care. He received medical care for his back and there is no verbal report or other reported barrier that would have prevented him from ALSO seeking medical care for a neck condition, in the time period most closely associated with this claim of injury during his Gulf War deployment. However, he did not seek care for his neck until about 2012, which is a time period of approximately 20 years after his active duty discharge. In the interim, there is certainly the additional possibility that his occupational duties and genetic predisposition to DDD would have been causal to his development of DDD in the intervening 20 years. Although this Veteran is certainly competent to be able to report his lay symptoms of any type of neck pain closer to his Gulf War service, this is not corroborated by any additional medical evidence that would account for a causal medical event significant enough to have led to an acute onset of cervical DDD. Thus, it is not possible to attribute a 50% or greater medical probability that his military service alone was causal or proximately causal to the later development of his DDD. Another October 2019 opinion concluded that it was less likely than not that the Veteran had a cervical spine disability that was aggravated beyond its natural progression by his service-connected lumbar spine disability. The rationale for the opinion was as follows: There is no published medical evidence to suggest that a lumbar spine condition (lumbar DDD) is aggravating, (beyond its normal progression), to a cervical spine condition (cervical DDD/spondylosis with bilateral radiculopathy). Thus, in the absence of any type of published medical aggravating evidence, it is not possible to attribute a 50% or greater medical probability that his lumbar condition aggravated his cervical spine condition, beyond its normal progression. The undersigned finds the October 2019 opinions—which are not contradicted by any positive opinion to the contrary—to be definitive as to the claims for service connection for cervical spine and upper extremity disabilities as they are documented to be based on thorough review of the clinical history and history provided by the Veteran and are supported by detailed rationale. To the extent the assertions of the Veteran and his attorney are advanced in an attempt to establish that he has a cervical spine disability as a result of service or service connected lumbar spine disability, such complex medical matters are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-38 (1994). As neither the Veteran nor is attorney are shown to have the appropriate training and expertise, neither are competent to render a persuasive opinion as to such matters. Moreover, because the left and right upper extremity disability that is currently demonstrated, bilateral cervical radiculopathy, is clearly the result of the degenerative disc disease of the cervical spine, and there is otherwise no evidence of any other upper extremity that may be related to service, the denial of service connection for a cervical spine disability necessarily precludes a grant of service connection for left and right upper extremity disabilities. While the Veteran is competent to describe any lay observable symptoms associated with his neck and upper extremities since service, the undersigned finds the silent STRs for these conditions; the silent VA examinations for these conditions conducted in August 1994 and April 1998; the lack of a diagnosis for a cervical spine or left or right upper extremity disability for almost two decades after service; and the negative opinion with respect to direct service connection rendered by the VA cilician in October 2019 set forth above to be more probative than any lay assertions made in connection with the claim for service connection for cervical spine and left and right upper extremity disabilities, and that these facts weigh against a finding of continuity of relevant symptoms associated with these conditions since service. Given all of the above, the Board finds that the preponderance of the evidence is against the claims for service connection for cervical spine and left and right upper extremity disabilities. As such, these claims must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. 2. Left and Right Lower Extremity Disability/Sleeping Disability The STRs, to include the reports from the aforementioned November 1993 service department examination conducted after the Veteran’s July 1992 separation from service and a medical history collected at that time, are silent for a lower extremity or sleeping disability. After service, an August 1994 Persian Gulf War examination and an April 1998 VA general medical examination did not reflect any findings or complaints associated with a lower extremity or sleeping disability. While a February 2013 VA examination noted that the Veteran had lumbar radiculopathy, such was not found upon VA examination in February 2015. Clarification of this matter was sought, and following a thorough review of the clinical evidence, a September 2015 opinion by a VA clinician—who noted that the objective evidence including an MRI was negative for lumbar radiculopathy—concluded as follows: The current examiner therefore retains the 2015 C&P [VA examination] conclusion that [] radiculopathy was not present The September 2018 Board remand found fault as follows with respect to the above opinion: The VA examination reports each address the relationship between the lumbar spine and the lower extremities, with the September 2015 VA examiner opining against the Veteran having lumbar radiculopathy. It is not clear if there is another diagnosis that is causing his lower extremity symptoms, but if not, then this claim must be considered under 38 C.F.R. § 3.317, which pertains to undiagnosed disabilities occurring in Persian Gulf Veterans. As such, the Board remand directed that the Veteran be afforded a VA examination to address the claims for service connection for left and right lower extremity disabilities that reflected consideration of the provisions of 38 C.F.R. § 3.317. Such was accomplished in October 2019 as follows: As described in the previous 09/10/2015 [VA] Medical Opinion [] both a Neurosurgeon and Dr. [sic] [] did not diagnose the Veteran with any form of lower extremity radiculopathy. However, confirmatory neurodiagnostic testing was not performed at that time. In this examiner's duty to assist, confirmatory electrodiagnostic testing and evaluation by a subject matter expert Physiatrist was performed. However, both the examination results by the Physiatrist and the electrodiagnostic testing failed to show the presence of any lower extremity radiculopathy or polyneuropathy. His symptoms are NOT (less than 50% medical probability) attributable to an undiagnosed illness or a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms (such as chronic fatigue syndrome, fibromyalgia, or functional gastrointestinal disorders). With respect to a sleeping disability, the September 2018 Remand noted as follows: The record does show that impaired sleeping is a symptom of his mood disorder, but the record also shows that [t]he [Veteran] has a separate insomnia disorder diagnosis. A July 2017 sleep study did not diagnose sleep apnea. On remand, an opinion must be obtained as to whether this is a separate diagnosis, a symptom of some other diagnosis, or a symptom of an undiagnosed illness, and whether there is a relationship to service. The opinion with respect to a sleeping disorder requested by the September 2018 Remand were completed in October 2019 as follows: The Veteran’s claimed condition of a “sleeping disability” is less likely than not (less than 50 percent probability) proximately due to or the result of a “mood disorder.” The Veteran is currently diagnosed with “Unspecified Depressive Disorder, with anxious distress” and Opioid Use Disorder, in sustained remission and is NOT currently diagnosed with a sleep disorder or “sleeping disability” at the current time. The Veteran’s current report of sleep disturbances are a part of his currently diagnosed Unspecified Depressive Disorder, with anxious distress and NOT a separate disorder. The October 2019 opinion also concluded as follows: [The] Veteran's claimed “sleeping disability” was less likely than not (less than 50 percent probability) aggravated beyond its natural progression by his [] service-connected mood disorder. The Veteran is not currently diagnosed with a “sleeping disability” and thus there is no aggravation of the claimed condition. With respect to the provisions of 38 U.S.C. § 1117 as applied to a sleep disorder, the opinion in October 2019 was as follows: A GW [Gulf War and the presumptions related to thereto] statement cannot be provided as the Veteran is currently diagnosed with “Unspecified Depressive Disorder, with anxious distress” and “Opioid Use Disorder, in sustained remission” and [the Veteran] is NOT diagnosed with a sleep disorder or “sleeping disability” at the current time. The Veteran's current report of sleep disturbances are a part of his currently diagnosed Unspecified Depressive Disorder, with anxious distress and NOT a separate disorder. The undersigned finds the October 2019 opinions—which are not contradicted by any positive opinion to the contrary—to be definitive as to the claims for service connection for left and right lower extremity and sleeping disabilities as they are documented to be based on thorough review of the clinical history and history provided by the Veteran and are supported by detailed rationale. To the extent the assertions of the Veteran and his attorney are advanced in an attempt to establish that he has a left or right lower extremity or sleeping disability as a result of service, to include on a presumptive basis pursuant to the provisions of 38 U.S.C. § 1117, such complex medical matters are within the province of trained medical professionals. See Jones, supra. As neither the Veteran nor is attorney are shown to have the appropriate training and expertise, neither are competent to render a persuasive opinion as to such matters. While the Veteran is competent to describe any lay observable symptoms associated with left and right lower extremity and sleeping disabilities since service, the undersigned finds the silent STRs for these conditions; the silent VA examinations for these conditions conducted in August 1994 and April 1998; and the negative opinions rendered in October 2019 set forth above to be more probative than any lay assertions made in connection with the claims for service connection for left and right lower extremity and sleeping disabilities, and that these facts weigh against a finding of continuity of relevant symptoms associated with these conditions since service. Given all of the above, the Board finds that the preponderance of the evidence is against the claims for service connection for left and right lower extremity and sleeping disabilities. As such, these claims must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. 3. Double Vision The STRs, to include the reports from the aforementioned November 1993 service department examination, are silent for double vision. A medical history collected in conjunction with the November 1993 examination was silent for double vision, and the Veteran at that time specifically denied a history of “[e]ye trouble.” After service, an April 2013 VA examination attributed complaints of double vision to esophoria, a condition in which the eyes turn more inward than necessary. The examiner opined that the literature did not support that any of the medications the Veteran was taking at that time caused double vision. Notwithstanding this fact, the September 2018 Board remand set forth as follows: However, at the April 2013 VA ear examination, the Veteran attributed his double vision to prescription venlafaxine [used in the treatment of psychiatric disorders such as the service-connected mood disorder] which the Board notes was discontinued prior to the April 2013 VA examination. It is not clear whether the VA eye examiner considered whether venlafaxine caused or contributed to the Veteran’s double vision. Further, he did not provide an opinion as to whether esophoria is related to his service or other service-connected disabilities. The opinions to address the above concern were completed in September 2019, with the VA examiner concluding at that time that it was less likely as not that double vision or esophoria were caused or aggravated by venlafaxine. The rationale for the opinion was as follows: While the product information for venlafaxine does list diplopia as an “infrequent” side effect, there are no scholarly journal articles linking venlafaxine to diplopia or esophoria. A search of pubmed.gov (the US National Library of Medicine National Institutes of Health’s online site for medical journal articles) for “venlafaxine diplopia” returns 0 hits. A search for “selective serotonin and norepinephrine reuptake inhibitors diplopia” also returns 0 hits. A search for “venlafaxine esophoria” returns 0 hits. A search for “selective serotonin and norepinephrine reuptake inhibitors esophoria” also returns 0 hits. An article in Review of Optometry (Muchnick, BG. Which Side Effects are Lurking in the Shadows 2/15/13) bears no mention of diplopia or esophoria for venlafaxine or other psychogenic medications. An article from the American Orthoptic Journal (Smith, JL, Buncic, JR. Drugs which can affect near vision: A useful list. American Orthoptic Journal 1999; 49: 180-190.) does not list venlafaxine as a drug causing diplopia. Of note also is that the [V]eteran’s diplopia appears to have occurred after his use of venlafaxine was discontinued as in April of 2013[,] he stated the intermittent diplopia had been going on for 6 mo[nth]s and venlafaxine was discontinued in October of 2012. Esophoria is a term to describe how the eyes aim and work together as a team. When there is misalignment, it can be related to nerve, muscle, congenital or mechanical anomalies. The [V]eteran’s eye muscle alignment was not measured on entering the service, therefore it is impossible to tell if it was “aggravated” by any medications. However, chart review shows he was taking BUPRENORPHINE 8MG/NALOXONE, GABAPENTIN, LISINOPRIL, NICOTINE PATCH, OMEPRAZOL, and PRAZOSIN in late 2012 (approximately the time of the diplopia complaints) and none of the medications are listed as causing diplopia (the end result of aggravating an existing esophoria). See: Smith, JL, Buncic, JR. Drugs which can affect near vision: A useful list. American Orthoptic Journal 1999; 49: 180-190. The undersigned finds the above September 2019 opinions to be definitive as to the claim for service connection for double vision as they are documented to be based on thorough review of the clinical history and history provided by the Veteran and are supported by detailed rationale. To the extent the assertions of the Veteran and his attorney are advanced in an attempt to establish that he has double vision as a result of service or medications taken for service connected disability, such complex medical matters are within the province of trained medical professionals. See Jones, supra. As neither the Veteran nor is attorney are shown to have the appropriate training and expertise, neither are competent to render a persuasive opinion as to such matters. While the Veteran is competent to describe any lay observable symptoms associated with double vision since service, the undersigned finds the silent STRs for these conditions; the specific denial of “eye problems” upon the medical history collected in November 1993; and the lack of any objective clinical evidence linking double vision to service to be more probative than any lay assertions made in connection with the claim for service connection for double vision, and that these facts weigh against a finding of continuity of relevant symptoms associated with these condition since service. Given all of the above, the Board finds that the preponderance of the evidence is against the claim for service connection for double vision. As such, this claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. 4. Weight Loss The STRs do not document a weight loss disability, and these records reflect that the Veteran weighed 181 pounds at the aforementioned November 1993 service department examination and 142 pounds upon the service entrance examination conducted in February 1987. The post service evidence reflects that the Veteran has had problems with weight loss, and the September 2018 Board remand directed that the Veteran be afforded a VA examination to address the claim for service connection for a disability manifested by weight loss as follows: Obtain a medical opinion as to whether the Veteran has had a clinical diagnosis manifesting with weight loss during the appeal period, and if so, whether it is as likely as not (50/50 probability or better) that weight loss is related to his service. The record shows that he has been prescribed cyproheptadine (April 2013), mirtazapine (April 2016), and Remeron (June 2016) to increase his appetite, and to treat his mood disorder, which suggests a relationship to service secondarily to mood disorder. His weight has fluctuated during the appeal period from the 150’s to the 180’s, and he is 70 inches tall. The opinion with respect to weight loss requested in the September 2018 Board remand was completed in October 2019 as follows: Although this Veteran may not have the body weight that he desires that he claims as “weight loss,” he is not medically underweight. His actual body mass index (BMI) would be considered ideal. He has no medical evidence of any type of nutritional abnormality or malabsorption syndrome. Thus, there is no “weight loss” disability that is medically diagnosable as chronic disability, regardless of his claim of weight loss due to a mental health disorder. A VA Nutritional Deficiencies Disability Benefits Questionnaire completed in October 2019 found that the Veteran did not have a currently diagnosed nutritional deficiency, and the examiner noted as follows: [The Veteran’s] current body weight is 140.5 pounds, as per [measurement on] 08/13/2019. [] [F]rom a medical standpoint, this is considered an ideal body mass index, with his BMI being (20.2). Review of the remaining evidence does not reflect a diagnosis of a disability manifested by weight loss at any time proximate to or during the appeal period, and the undersigned finds the conclusions rendered above in October 2019 to be definitive as to his matter as they are documented to be based on thorough review of the clinical history during this period. To the extent the assertions of the Veteran and his attorney are advanced in an attempt to establish that he has a current disability manifested by weight loss for which service connection can be granted, such a complex medical matter is within the province of trained medical professionals. See Jones, supra. As neither the Veteran nor is attorney are shown to have the appropriate training and expertise, neither are competent to assert that the Veteran has a current disability manifested by weight loss. With respect to any argument based on continuity of symptoms, the lack of a diagnosed current disability associated with weight loss precludes a grant of serve connection on such basis. Given the above, the Board finds that the preponderance of the evidence is against the claim for service connection for a disability manifested by weight loss. As such, this claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. II. TDIU A. Legal Criteria TDIU may be assigned when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that the Veteran meets the schedular requirements. If there is only one service-connected disability, this disability should be rated at 60 percent or more, if there are two or more disabilities, at least one should be rated at 40 percent or more with sufficient additional service-connected disability to bring the combination to 70 percent or more. For the purpose of determining whether a Veteran meets the criteria for assigning a schedular TDIU, disabilities resulting from a common etiology and disabilities affecting a single body system are considered to be one disability. Marginal employment shall not be considered substantially gainful employment. 38 C.F.R. § 4.16(a). Where these percentage requirements are not met, entitlement to benefits on an extraschedular basis may be considered when the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities, and consideration is given to the Veteran’s background including her employment and educational history. 38 C.F.R. § 4.16(b). The Board does not have the authority to assign an extraschedular TDIU in the first instance. Bowling v. Principi, 15 Vet. App. 1 (2001). In determining whether Unemployability exists, consideration may be given to the Veteran’s level of education, special training, and previous work experience, but it may not be given to her age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. Substantially gainful employment is “that which is ordinarily followed by the non-disabled to earn their livelihood with earnings common to the particular occupation in the community where the Veteran resides.” Moore v. Derwinski, 1 Vet. App. 356 (1991) (quoting the VA Adjudication Procedure Manual M21-1, pt. VI, para. 50-55(8) [now para. 7.55b (7)]). It also suggests “a living wage.” Ferraro v. Derwinski, 1 Vet. App. 326 (1991). The Court further defined “substantially gainful employment” as “an occupation that provides an annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days that the Veteran actually works and without regard to the Veteran’s earned annual income.” Faust v. West, 13 Vet. App. 342 (2000). The ability to work sporadically or obtain marginal employment is not substantially gainful employment. See Moore, 1 Vet. App. at 358; 38 C.F.R. § 4.16(a) (“marginal employment shall not be considered substantially gainful employment”). Marginal employment may also be held to exist, on a facts-found basis, when earned annual income exceeds the poverty threshold. 38 C.F.R. § 4.16(a). The ultimate question of whether a Veteran is capable of substantial gainful employment is not a medical one; that determination is for the adjudicator. See Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013); Floore v. Shinseki, 26 Vet. App. 376, 381 (2013). As such, the focus of the examiner is not on whether the Veteran is unemployable due to her service-connected disabilities, but the functional impairment caused solely by service-connected disabilities. VBA Fast Letter 13-13 (June 17, 2013).   B. Analysis Service connection is in effect for a mood disorder, rated as 70 percent disabling; headaches, rated as 50 percent disabling; degenerative disc disease of the lumbosacral spine, rated as 40 percent disabling; tinnitus, rated as 10 percent disabling; and hearing loss in the right ear, rated noncompensable. The service-connected disabilities combine to be 90 percent disabling. As such, the schedular criteria for TDIU under 38 C.F.R. § 4.16(a) are met. On a VA Form 21-8940 “Veteran’s Application for Increased Compensation Based on Unemployability received in April 2015, the Veteran reported education through four years of high school and work experience as an assembly worker. He stated therein that he became too disabled to work in April 2008. An April 2017 assessment by a private physician resulted in the conclusion that the Veteran’s headaches preclude him from maintaining substantially gainful employment. Moreover, an August 2020 vocational assessment, based on a review of the claims file, concluded as follows: Based on the totality of the file for this Veteran, he is totally occupationally disabled from all competitive employment due to his service-connected degenerative disc disease with spondylosis; [] mood disorder; headaches; tinnitus; and hearing loss [in the] right ear. This has been true since the date of filing and is supported by the lack of any earnings reported since 2008. There is no negative opinion of record that directly contradicts the above conclusions with regard to the impact of the Veteran’s service-connected disabilities on employment. Therefore, the undersigned concludes that these conclusions represent sufficient evidence to find that the Veteran cannot secure and   follow substantially gainful employment due to his service connected disabilities, thereby warranting entitlement to TDIU. 38 C.F.R. § 4.16(a). All reasonable doubt in this regard has been resolved in favor of the Veteran. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. MARJORIE A. AUER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Andrew Ahlberg, 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.