Citation Nr: 21062030 Decision Date: 10/06/21 Archive Date: 10/06/21 DOCKET NO. 17-31 829 DATE: October 6, 2021 ORDER For the initial rating period from August 29, 2014 to November 13, 2019, a 20 percent disability rating for cervical spine strain is granted. For the entire initial rating period on appeal from August 29, 2014, a rating in excess of 20 percent for cervical spine strain is denied. For the initial rating period from August 29, 2014 to November 13, 2019, a 20 percent disability rating for degenerative joint disease (DJD) of the lumbar spine is granted. For the entire initial rating period on appeal from August 29, 2014, a rating in excess of 20 percent for DJD of the lumbar spine is denied. For the initial rating period from August 29, 2014 to December 15, 2014, a 30 percent disability rating for a psychiatric disorder is granted. For the initial rating period from August 29, 2014 to November 13, 2019, a rating in excess of 30 percent a psychiatric disorder is denied. For the initial rating period on appeal from November 13, 2019, a rating in excess of 50 percent for a psychiatric disorder is denied. For the initial rating period on appeal from August 29, 2014, a rating in excess of 20 percent for status-post removal of nonseminoma germ cell tumor of the left testicle, in remission with residuals of voiding dysfunction, fatigue, and transient leukocytosis, is denied. For the initial rating period from August 29, 2014, a 10 percent disability rating, and no higher, for right knee arthritis is granted. For the entire initial rating period on appeal from August 29, 2014, a rating in excess of 10 percent for left knee arthritis is denied. For the initial rating period from August 29, 2014, a 20 percent disability rating for painful scars of the abdomen and inner left thigh, status post lymph node dissection is granted. For the initial rating period on appeal from August 29, 2014, a disability rating in excess of zero percent for a linear scar of the abdomen is denied. For the period from August 29, 2014 to November 13, 2019, a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is granted. For the period from November 13, 2019, a TDIU, having been rendered moot, is dismissed. FINDINGS OF FACT 1. For the initial rating period on appeal from August 29, 2014 to November 13, 2019, the cervical spine disability has more nearly approximated forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees. 2. For the entire initial rating period on appeal from August 29, 2014, the cervical spine disability has not more nearly approximated forward flexion of the cervical spine 15 degrees or less or favorable ankylosis of the entire cervical spine. 3. For the initial rating period on appeal from August 29, 2014 to November 13, 2019, the lumbar spine disability has been manifested by objective evidence of painful motion, interference with standing and weight-bearing, and forward flexion limited to 45 degrees. 4. For the entire initial rating period on appeal from August 29, 2014, the lumbar spine disability has not been manifested by ankylosis, limitation of flexion to 30 degrees or less, or incapacitating episodes requiring physician ordered bed rest having a total duration of at least 4 weeks during a 12-month period. 5. For the initial rating period on appeal from August 29, 2014 to December 15, 2014, the psychiatric disorder has been manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 6. For the initial rating period on appeal from August 29, 2014 to November 13, 2019, the psychiatric disorder has not been manifested by occupational and social impairment with reduced reliability and productivity. 7. For the initial rating period on appeal from November 13, 2019, the psychiatric disorder has not been manifested by occupational and social impairment with deficiencies in most areas. 8. For the initial rating period on appeal from August 29, 2014, testicular cancer residuals have not been manifested by urinary leakage requiring the use of absorbent material that must be changed two to four times per day, daytime voiding interval less than one hour, awakening to void five or more times per night, or urinary retention requiring intermittent or continuous catheterization. 9. For the initial rating period on appeal from August 29, 2014, right knee arthritis has been manifested by symptoms of painful motion, flare-ups, and interference with standing and weight-bearing, that are productive of noncompensable limitation of motion. 10. For the entire initial rating period on appeal from August 29, 2014, the right and left knee disabilities have not been manifested by limitation of flexion to 30 degrees or limitation of extension to 15 degrees including on the basis of functional loss due to pain, fatigability, or incoordination, instability, dislocation of the semilunar cartilage with frequent episodes of joint "locking," pain, and effusion, malunion or nonunion of the tibia and fibula, or genu recurvatum. 11. For the initial rating period on appeal from August 29, 2014, the residual scar disability, which includes a linear abdominal scar, has been manifested by three to four scars that painful. 12. A separate compensable rating under Diagnostic Code 7805 (in addition to the 20 percent rating for three painful scars under Diagnostic Code 7804) for the linear abdominal scar would compensate the Veteran twice for the same scar symptoms including pain. 13. The 20 percent rating assigned under Diagnostic Code 7804 is the most favorable disability rating for the Veteran's service-connected scar disability; alternative use of Diagnostic Code 7804 or any other rating criteria to rate the scar disability would not produce a higher rating percentage than 20 percent. 14. For the period on appeal from August 29, 2014 to November 13, 2019, the service-connected disabilities prevented the Veteran from retaining (maintaining) substantially gainful employment. 15. For the period from November 13, 2019, the Veteran is in receipt of a 100 percent schedular rating for all the service-connected disabilities. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in favor of the Veteran, for the initial rating period on appeal from August 29, 2014 to November 13, 2019, the criteria for a 20 percent rating for cervical spine strain have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237. 2. For the entire initial rating period on appeal from August 29, 2014, the criteria for a disability rating in excess of 20 percent for cervical spine strain have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237. 3. Resolving reasonable doubt in favor of the Veteran, for the initial rating period on appeal from August 29, 2014 to November 13, 2019, the criteria for a 20 percent rating for lumbar spine DJD have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5242-5237. 4. For the entire initial rating period on appeal from August 29, 2014, the criteria for a disability rating in excess of 20 percent for lumbar spine DJD have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5242-5237. 5. Resolving reasonable doubt in favor of the Veteran, for the initial rating period on appeal from August 29, 2014 to December 15, 2014, the criteria for a 30 percent disability rating for a psychiatric disorder have been met. 38 C.F.R. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9413. 6. For the initial rating period on appeal from August 29, 2014 to November 13, 2019, the criteria for a disability rating in excess of 30 percent for a psychiatric disorder have not been met. 38 C.F.R. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9413. 7. For the initial rating period on appeal from November 13, 2019, the criteria for a disability rating in excess of 50 percent for a psychiatric disorder have not been met. 38 C.F.R. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9413. 8. For the entire initial rating period on appeal from August 29, 2014, the criteria for a disability rating in excess of 20 percent for the residuals of testicular cancer have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.115a, 4.115b, Diagnostic Code 7528. 9. Resolving reasonable doubt in favor of the Veteran, for the initial rating period on appeal from August 29, 2014, the criteria for a 10 percent rating for right knee arthritis have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.71a, Diagnostic Code 5003. 10. For the entire initial rating period on appeal from August 29, 2014, the criteria for a disability rating in excess of 10 percent for right knee arthritis have not been met or more nearly approximated. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003. 11. For the entire initial rating period on appeal from August 29, 2014, the criteria for a disability rating in excess of 10 percent for the left knee disability have not been met or more nearly approximated. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003. 12. Resolving reasonable doubt in favor of the Veteran, for the initial rating period on appeal from August 29, 2014, the criteria for a 20 percent disability rating, but not higher, for scars of the abdomen and inner left thigh, status post lymph node dissection, have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.118, Diagnostic Code 7804. 13. A separate compensable rating for the abdomen scar disability under Diagnostic Code 7805 (in addition to the 20 percent rating under Diagnostic Code 7804) is precluded because it would constitute prohibited pyramiding of compensation. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.14, 4.40, 4.45, 4.59, 4.118, Diagnostic Codes 7804, 7805. 14. Resolving reasonable doubt in favor of the Veteran, for the period on appeal from August 29, 2014 to November 13, 2019, the criteria for a TDIU have been met. 38 U.S.C.§§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.15, 4.16, 4.18, 4.19. 15. For the period on appeal from November 13, 2019, the claim for a TDIU has been rendered moot. 38 U.S.C. § 7105; 38 C.F.R. § 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant, had active service from April 2010 to August 2014. In March 2019, the Board, in pertinent part, remanded the issues on appeal to the Agency of Original Jurisdiction (AOJ) for additional development. VA examination reports and VA medical opinions have been associated with the record, fulfilling the remand order. See Stegall v. West, 11 Vet. App. 268 (1998) 1. Rating Cervical Spine Strain from August 29, 2014 to November 13, 2019 Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the rating of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran's service-connected disabilities. 38 C.F.R. § 4.14. It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; however, 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 conditions is duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits compensating a veteran twice for the same symptoms or functional impairment Under Diagnostic Code 5237, the Veteran is in receipt of a 10 percent disability rating for the cervical spine disability from August 29, 2014 to November 13, 2019, and a 20 percent disability rating from November 13, 2019. Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine (Diagnostic Codes 5235 to 5243). Ratings under the General Rating Formula 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. Under the General Rating Formula for Diseases and Injuries of the Spine, a 20 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees, but not greater than 60 degrees; forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; combined range of motion of the thoracolumbar spine not greater than 120 degrees; combined range of motion of the cervical spine not greater than 170 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 30 percent rating is assigned for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent rating is assigned for forward flexion of the thoracolumbar spine at 30 degrees or less; favorable ankylosis of the entire thoracolumbar spine; or unfavorable ankylosis of the entire cervical spine. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assigned for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees; extension is zero to 30 degrees; left and right lateral flexion are zero to 30 degrees; and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The combined normal range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of the spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. For VA compensation purposes, normal forward flexion of the cervical spine is 0 to 45 degrees; extension is 0 to 45 degrees; left and right lateral flexion are 0 to 45 degrees; and left and right lateral rotation are 0 to 80 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note 2. Any associated objective neurologic abnormalities, including, but not limited to bowel or bladder impairment, should be evaluated separately under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note 1. Under Diagnostic Code 5243 (Intervertebral Disc Syndrome), a 20 percent disability rating is assigned with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months; a 40 percent disability rating is assigned with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a maximum 60 percent disability rating is assigned with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. After a review of all the evidence, lay and medical, the Board finds that, for the initial rating period on appeal from August 29, 2014 to November 13, 2019, the criteria under Diagnostic Code 5242 for a 20 percent rating for the cervical spine disability have been more nearly approximated. Throughout the rating on appeal, considering all functional limitations including due to pain, the cervical spine disability has more nearly approximated forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees. The November 2019 VA examination report reflects forward flexion to 25 degrees, to include pain. Similarly, the October 2013 VA examination report reflects the VA examiner assessed that the Veteran had functional loss after repetitive use testing, to include less movement than normal. Such symptoms and findings more nearly approximate the criteria for a 20 percent disability rating under Diagnostic Code 5242. 38 C.F.R. §§ 4.3, 4.7, 4.71a. 2. Rating Cervical Spine Strain from August 29, 2014 After a review of all the evidence, lay and medical, the Board finds that, for the period on appeal from August 29, 2014, the criteria for a disability rating in excess of 20 percent for the cervical spine disability have not been more or more nearly approximated under Diagnostic Code 5242. For the initial rating period on appeal from August 29, 2014 to November 13, 2019, the cervical spine disability has more nearly approximated forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees. Throughout the entire initial rating period from August 29, 2014, the cervical spine disability has not more nearly approximated forward flexion of the cervical spine 15 degrees or less or favorable ankylosis of the entire cervical spine. Specifically, findings from the November 2019 and October 2013 VA examinations, and history and findings in the numerous VA and private treatment records reflecting treatment for neck pain, as well as the Veteran's self-reported symptoms, are consistent with a 20 percent rating under the General Rating Formula for Diseases and Injuries of the Spine for the symptoms and level of impairment actually demonstrated by the neck disability. Diagnostic Code 5242 warrants a 30 percent rating for forward flexion of the cervical spine 15 degrees or less or, favorable ankylosis of the entire cervical spine. In this case, as noted at the November 2019 VA examination, the Veteran was noted to have, at worst, flexion to 25 degrees. At the October 2013 VA examination, forward flexion was measured to 45 degrees, to include pain. In addition, no examiner has assessed favorable ankylosis of the entire cervical spine. As such, the November 2019 and October 2013 VA examination reports reflect forward flexion to, at worst, 25 degrees, which is greater than 15 degrees. See 38 C.F.R. § 4.71a, General Rating Formula for Disease and Injuries of the Spine (Diagnostic Codes 5235 to 5243) (assigning a 30 percent rating, in pertinent part, for forward flexion of the cervical spine 15 degrees or less). For these reasons, the Board finds that the Veteran's disability picture more nearly approximates the criteria described for a 20 percent rating for the period from August 29, 2014 and does not warrant a higher rating for the entire initial rating period on appeal. See 38 C.F.R. §§ 4.3, 4.7, 4.71a. 3. Rating Lumbar Spine DJD from August 29, 2014 to November 13, 2019 For the rating period on appeal from August 29, 2014 to November 13, 2019, the Veteran is in receipt of a 10 percent disability rating for the back disability under Diagnostic Code 5242, and a 20 percent disability rating from November 13, 2019. After a review of all the evidence, lay and medical, the Board finds that from August 29, 2014 to November 13, 2019, the criteria for a disability rating of 20 percent have been met because the back disability has been manifested by objective evidence of painful motion, interference with standing and weight-bearing, and forward flexion to 45 degrees. Findings from the November 2019 and October 2013 VA examinations are consistent with a 20 percent rating under the General Rating Formula for Diseases and Injuries of the Spine for the symptoms and level of impairment actually demonstrated by the thoracolumbar spine disability, especially as noted at the November 2019 examination. Diagnostic Code 5242 warrants a 20 percent rating for forward flexion greater than 30 degrees, but not greater than 60 degrees. In this case, as noted at the November 2019 examination, the lumbar spine disability manifested as flexion to 45 degrees with pain, to include painful flare-ups, which is greater than 30 degrees, but not greater than 60 degrees. See 38 C.F.R. § 4.71a, General Rating Formula for Disease and Injuries of the Spine (Diagnostic Codes 5235 to 5243) (assigning a 20 percent rating, in pertinent part, for forward flexion of the lumbar spine greater than 30 degrees but not greater than 60 degrees). The Board also recognizes that the October 2013 VA examiner noted objective functional loss after repetitive use testing, to include less movement than normal. See Diagnostic Code 5242. Such symptoms and findings more nearly approximate the criteria for a 20 percent disability rating under Diagnostic Code 5242. 38 C.F.R. §§ 4.3, 4.7, 4.71a. 4. Rating Lumbar Spine DJD from August 29, 2014 After a review of all the evidence, lay and medical, the Board finds that for the entire period on appeal from August 29, 2014, the back disability has not been manifested by ankylosis, limitation of flexion to 30 degrees or less, or incapacitating episodes requiring physician ordered bed rest having a total duration of at least 4 weeks during a 12-month period. The most relevant evidence is the November 2019 VA examination report and various VA treatment records, which reflect the back disability manifested as objective evidence of painful motion. Specifically, findings from the November 2019 VA examination, and history and findings in the numerous VA treatment records reflecting treatment for back pain, as well as the Veteran's self-reported symptoms, are consistent with a 20 percent rating under the General Rating Formula for Diseases and Injuries of the Spine for the symptoms and level of impairment actually demonstrated by the back disability. Diagnostic Code 5242 warrants a 20 percent rating for forward flexion greater than 30 degrees, but not greater than 60 degrees. In this case, as noted at the November 2019 VA examination, the Veteran was noted to have, at worst, flexion to 45 degrees, to include pain, fatigability, and incoordination during flare-ups. No examiner has assessed unfavorable ankylosis of the entire thoracolumbar spine. As such, the November 2019 VA examination report reflecting forward flexion to, at worst, 45 degrees when considering flare-ups of pain, which is greater than 30 degrees. See 38 C.F.R. § 4.71a, General Rating Formula for Disease and Injuries of the Spine (Diagnostic Codes 5235 to 5243) (assigning a 20 percent rating, in pertinent part, for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees). A higher disability rating of 40 percent or higher for the back disability would only be warranted for forward flexion more closely approximating 30 degrees or less, favorable or unfavorable ankylosis of the entire thoracolumbar spine, and/or incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during a 12-month period, none of which is present here. See November 2019 VA examination report; VA treatment records. Next, the evidence of record during the appeal period does not show the Veteran had any incapacitating episodes for at least 4 weeks during a 12-month period for any period. Additionally, the Board has considered whether there is additional functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40, 4.45, and 4.59. See also DeLuca. Evidence including the VA examination reports and VA and private treatment records indicate, at worst, forward flexion to 45 degrees, which does not warrant a higher rating based on limitation of motion. For these reasons, the Board finds that the Veteran's disability picture more nearly approximates the criteria described for a 20 percent rating for the period from August 29, 2014 and does not warrant a higher rating for the entire initial rating period on appeal. See 38 C.F.R. §§ 4.3, 4.7, 4.71a. 5. Rating Psychiatric Disorder from August 29, 2014 to December 15, 2014 The psychiatric disorder is rated under 38 C.F.R. § 4.130, Diagnostic Code 9413. Pertinent in this case, the General Rating Formula provides that a 30 percent rating is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130. A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped, speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130. A 70 percent rating will be assigned for 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); and inability to establish and maintain effective relationships. The criteria for a 70 percent rating are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). A 100 percent schedular rating contemplates total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130. The use of the term "such as" in the General Rating Formula for Mental Disorders in 38 C.F.R. § 4.130 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 symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). It is not required to find the presence of all, most, or even some, of the enumerated symptoms recited for particular ratings. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of the symptoms contemplated for each rating, in addition to permitting consideration of other symptoms particular to each veteran and disability, and the effect of those symptoms on his/her social and work situation. In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (2013), the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) held that VA "intended the General Rating Formula to provide a regulatory framework for placing veterans on a disability spectrum based upon their objectively observable symptoms." The Federal Circuit stated that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." It was further noted that "§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." The Veteran contends generally that the service-connected psychiatric disorder has been manifested by more severe symptoms and impairment than contemplated by the 10 percent disability rating assigned for the period from August 29, 2014 to December 15, 2014, the 30 percent disability rating assigned for the period from December 15, 2014 to November 13, 2019, and the 50 percent disability rating assigned for the period from November 13, 2019. See December 2015 notice of disagreement. After a review of the lay and medical evidence, for the initial rating period on appeal from August 29, 2014 to December 15, 2014, the Board finds that the frequency, severity, and duration of the psychiatric symptoms has caused occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks more nearly approximate the criteria for a 30 percent rating under Diagnostic Code 9413. During the initial rating period from August 29, 2014 to December 15, 2014, the psychiatric disorder has more nearly approximated occupational and social impairment occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to such symptoms as depressed mood, chronic sleep impairment, and flattened affect. The evidence of record includes an October 2013 VA examination report reflecting depressed mood, chronic sleep impairment, and flattened affect. The December 2015 notice of disagreement reflects the Veteran wrote that the psychiatric symptoms impaired the ability to fall and stay asleep, which impacted judgment and the ability to be close to others. For these reasons, and after resolving all reasonable doubt in favor of the Veteran, the Board finds that, for the rating period from August 29, 2014 to December 15, 2014, a 30 percent disability rating is warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. 6. Rating Psychiatric Disorder from August 29, 2014 to November 13, 2019 For the rating period on appeal from August 29, 2014 to November 13, 2019, the Board also finds that the level of occupational and social impairment due to psychiatric disorder symptoms did not meet or more nearly approximate the criteria for a higher 30 percent disability rating. See 38 C.F.R. § 4.130. For the rating period on appeal, the record does not show that the frequency, severity, and duration of the psychiatric symptoms has caused occupational and social impairment with reduced reliability and productivity required for a 50 percent disability rating under Diagnostic Code 9413. A review of the relevant lay and medical evidence, including VA treatment records, the November 2019 VA examination report, and lay statements, does not reveal that the Veteran has experienced occupational and social impairment with reduced reliability and productivity due to the service-connected psychiatric disorder, and the Veteran has not alleged otherwise. It is only with application of reasonable doubt that the criteria for a 30 percent rating are met for the rating period on appeal from August 29, 2014 to December 15, 2014. See November 2019 VA examination report, VA treatment records. For these reasons, the weight of the competent and probative lay and medical evidence of record is against a rating in excess of 30 for the service-connected psychiatric disorder for the period from August 29, 2014 to November 13, 2019. See 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 7. Rating Psychiatric Disorder from November 13, 2019 After a review of the evidence, both lay and medical, the Board finds that, for the rating period on appeal from November 13, 2019, the frequency, severity, and duration of the psychiatric symptoms have not caused occupational and social impairment with deficiencies in most areas as to more nearly approximate the criteria for a 70 percent rating under Diagnostic Code 9413. During the rating period on appeal, the psychiatric disorder has more nearly approximated occupational and social impairment with reduced reliability and productivity due to such symptoms as depressed mood, anxiety, sleep impairment, flattened affect, and disturbances of motivation and mood. The evidence of record includes the November 2019 VA examination report reflecting that the VA examiner specifically opined that the psychiatric disorder manifested as occupational and social impairment with reduced reliability and productivity. The November 2019 VA examiner specifically assessed depressed mood, anxiety, sleep impairment, flattened affect, and disturbances of motivation and mood. The November 2019 VA examination report also reflects the Veteran reported that symptoms and impairment of the psychiatric disorder had worsened since 2017, that he had been married for three years, and that he had good relationships with a twin brother and three other siblings. For these reasons, the weight of the competent and probative lay and medical evidence of record is against a rating in excess of 50 for the service-connected psychiatric disorder for the period from November 13, 2019. See 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 8. Initial Rating for Testicular Cancer Residuals For the initial rating period on appeal, the residuals of testicular cancer have been rated as 20 percent disabling under 38 C.F.R. § 4.115b, Diagnostic Code 7528. Under Diagnostic Code 7528, following the cessation of surgical, X-ray, antineoplastic chemotherapy, or another therapeutic procedure, a rating of 100 percent shall be assigned and shall continue with a mandatory VA examination at the expiration of six months. Any change in rating based upon that or any subsequent examination shall be subject to the provisions of 38 C.F.R. § 3.105(e). If there has been no local recurrence or metastasis, the evaluation is to be based upon residuals as voiding dysfunction or renal dysfunction, whichever is predominant. 38 C.F.R. § 4.115. Only the predominant area of dysfunction is to be considered for rating purposes to avoid violating the rule against the pyramiding of disabilities. 38 C.F.R. §§ 4.14, 4.115a. As an initial matter, the Board finds that the Veteran was treated for testicular cancer in approximately 2012. See December 2019 VA examination report. The Veteran does not assert, and the evidence does not otherwise show, that there has been a local reoccurrence or metastasis; therefore, there is no basis for a 100 percent disability rating under Diagnostic Code 7528. 38 C.F.R. § 4.115b. Similarly, the evidence of record in this case does not reflect that renal dysfunction is the predominant residual symptom; therefore, a rating based on renal dysfunction is not warranted because the weight of the evidence is against finding that renal dysfunction is the predominant residual symptom of the Veteran's testicular cancer. Specifically, the December 2019 and April 2017 VA examiners each assessed that the Veteran did not have renal dysfunction. See December 2019 VA examination report; see also April 2017 VA examination report. Voiding dysfunction is to be rated as urine leakage, urinary frequency, or obstructed voiding. 38 C.F.R. § 4.115a. For continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence, a 20 percent rating is assigned when the wearing of absorbent materials that must be changed less than two times per day is required; a 40 percent rating is assigned when the wearing of absorbent materials that must be changed two to four times per day is required; and a 60 percent rating is assigned when the use of an appliance or the wearing of absorbent materials that must be changed more than four times per day is required. Urinary frequency is rated at 10 percent disabling with daytime voiding interval between two and three hours, or; awakening to void two times per night. A 20 percent rating is assigned for a daytime voiding interval between one and two hours, or; awakening to void three to four times per night. A 40 percent rating is assigned for a daytime voiding interval less than one hour, or; awakening to void five or more times per night. Obstructed voiding warrants a maximum schedular rating of 30 percent for urinary retention requiring intermittent or continuous catheterization. A 10 percent rating is assigned for less severe symptoms. 38 C.F.R. § 4.115a. In addition to the rating criteria for voiding dysfunction discussed above, Diagnostic Code 7527 - for prostate gland injuries, infections, hypertrophy, and postoperative residuals - allows for a rating based on urinary tract infections, if those symptoms predominate. In this case, however, there is no indication that the service-connected testicular cancer residuals have manifested a predominant symptom of urinary tract infections; therefore, there is no basis for assigning a disability rating for residuals of prostate cancer under Diagnostic Code 7527. 38 C.F.R. § 4.115b. After reviewing all the evidence, lay and medical, the Board finds that testicular cancer residuals have not been manifested by urinary leakage requiring the use of absorbent material that must be changed two to four times per day, daytime voiding interval less than one hour, awakening to void five or more times per night, or urinary retention requiring intermittent or continuous catheterization. The December 2019 VA examination report indicates daytime voiding interval between one to two hours and awakening to void two times. The December 2019 VA examination report also reflects that the VA examiner assessed that voiding dysfunction did not cause urine leakage and/or obstructed voiding. The Veteran does not assert, and the record does not otherwise indicate, that the testicular cancer residuals have been manifested by urinary leakage requiring the use of absorbent material that must be changed two to four times per day, daytime voiding interval less than one hour, awakening to void five or more times per night, or urinary retention requiring intermittent or continuous catheterization. As such, the appeal for a disability rating in excess of 20 percent for testicular cancer residuals must be denied. 9. Initial Rating for Right Knee Arthritis For initial period on appeal, the Veteran is in receipt of a zero percent disability rating for the right knee disability and a 10 percent disability rating for the left knee disability under the rating criteria of Diagnostic Code 5003 (even though the AOJ incorrectly assigned Diagnostic Code 5260). Diagnostic Code 5003 provides that as degenerative arthritis established by X-ray findings will be rated based on limitation of motion under the appropriate diagnostic code(s) for the specific joint(s) involved. When, however, the limitation of motion of the specific joint(s) involved is noncompensable under the appropriate diagnostic code(s), a 10 percent rating is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent rating is warranted if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and a 20 percent rating is authorized if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. Id., Diagnostic Code 5003. Notes (1) and (2) under Diagnostic Code 5003 provides the following: Note (1) provides that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion. Note (2) provides that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be utilized in rating conditions listed under Diagnostic Codes 5013 to 5024, inclusive. Id., Diagnostic Code 5003, Notes (1) and (2). The appropriate diagnostic codes for rating limitation of motion of the knees are Diagnostic Codes 5260 and 5261. 38 C.F.R. § 4.71a. Normal range of motion of the knee is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. In VAOPGCPREC 9-2004, the VA General Counsel interpreted that, when considering Diagnostic Codes 5260 and 5261 together with 38 C.F.R. § 4.71, a veteran may receive a rating for limitation in flexion only, limitation of extension only, or, if the 10 percent criteria are met for both limitations of flexion and extension, separate 10 percent ratings for limitations in both flexion and extension under Diagnostic Code 5260 (leg, limitation of flexion) and Diagnostic Code 5261 (leg, limitation of extension). Under Diagnostic Code 5260, limitation of knee flexion is rated 30 percent disabling where flexion is limited to 15 degrees; 20 percent disabling where flexion is limited to 30 degrees; 10 percent disabling where flexion is limited to 45 degrees; and noncompensable where flexion is limited to 60 degrees. 38 C.F.R. § 4.71a. Under Diagnostic Code 5261, limitation of knee extension is rated 50 percent disabling where extension is limited to 45 degrees; 40 percent disabling where extension is limited to 30 degrees; 30 percent disabling where extension is limited to 20 degrees; 20 percent disabling where extension is limited to 15 degrees; 10 percent disabling where extension is limited to 10 degrees; and noncompensable where extension is limited to 5 degrees. Diagnostic Code 5257 contemplates "other impairment" of the knee including recurrent subluxation or lateral instability. Under Diagnostic Code 5257, where impairment is severe, moderate or slight, disability evaluations of 30, 20, and 10 percent are assigned, respectively. Diagnostic Code 5262 contemplates impairment of the tibia and fibula, assigning a 40 percent rating for nonunion of the tibia and fibula, and 10, 20, and 30 percent ratings for slight, moderate or marked knee or ankle disabilities. See 38 C.F.R. § 4.71a. The words "slight," "moderate," "severe," and "marked" as used in the various diagnostic codes are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence for "equitable and just" decisions. 38 C.F.R. § 4.6. After a review of all the evidence, lay and medical, the Board finds that, for the entire initial rating period on appeal from August 29, 2014, the criteria for a disability rating of 10 percent have been met for the right knee disability as the right knee has been manifested by symptoms of painful motion, swelling, weakened movement, flare-ups, and interference with standing and weight-bearing. The December 2014 notice of disagreement reflects the Veteran indicated that the right knee disability manifested as painful motion. The October 2013 VA examination report also reflects the right knee manifested as painful motion. For these reasons, and after resolving all reasonable doubt in favor of the Veteran, the Board finds that a 10 percent disability rating is warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. 10. Rating Right Knee Disability (whether in excess of 10 percent) 11. Rating Left Knee Disability (whether in excess of 10 percent) After a review of all the evidence, both lay and medical, the Board finds that the criteria for a disability rating in excess of 10 percent have not been met or more nearly approximated for the right or left knee. The right and left knee disabilities have not been manifested by limitation of flexion to 45 degrees or limitation of extension to 10 degrees including on the basis of functional loss due to pain, fatigability, or incoordination, instability, dislocation of the semilunar cartilage with frequent episodes of joint "locking," pain, and effusion, malunion or nonunion of the tibia and fibula, or genu recurvatum. Specifically, the VA and private treatment records, including the December 2019 and April 2017 VA examination reports, reflect that the right and left knee disabilities have been manifested by symptoms of pain and painful noncompensable limitation of motion, which is consistent with the 10 percent ratings assigned under Diagnostic Code 5003. At the December 2019 VA examination, the right and left knee were noted to have, at worst, flexion to 140 degrees and extension to zero degrees, to include pain, fatigability, and incoordination. The Board has considered whether a higher disability rating is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement. See 38 C.F.R. §§ 4.40, 4.45, and 4.59; DeLuca. Here, there is no question that the right and left knee disabilities have caused pain, which has restricted overall motion; however, as noted above, even taking into account the additional functional limitation due to pain, the right and left knee disabilities do not more nearly approximate limitation of flexion or extension for the 20 percent rating, or the separate 10 percent criteria for compensable limitation of flexion with compensable limitation of extension. To the extent that the Veteran had painful motion of the knee and flare-ups, such painful motion and flare-ups were specifically considered in the grant of the 10 percent disability ratings for the right and left knee under Diagnostic Code 5003. See DeLuca at 206-07. To alternatively consider the above evidence as pain throughout left knee range of motion still does not warrant a rating in excess of 10 percent, or the separate 10 percent criteria for compensable limitation of flexion with compensable limitation of extension but would only raise an assertion of complete ankylosis due to pain with no movement whatsoever. See 38 C.F.R. § 4.59. The Court of Appeals for Veterans Claims (Court) rejected such assertion in Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (rejecting veteran's contention that pain, even if experienced throughout the range of motion on examination, warrants a higher rating under the diagnostic codes providing ratings for limitation of motion). Rather, it is the functional limitation, i.e., the additional limitation of motion, caused by pain or the other DeLuca factors, that must be considered in determining whether a higher rating is warranted. See Mitchell, 25 Vet. App. at 38-43 (explaining that, although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded). In this case, the December 2019 VA examiner made specific findings of no right or left knee ankylosis, and noted that no change in range of motion was anticipated due to pain, weakness, fatigability, or incoordination with repetitive use of the right and left knee over time. Although the Veteran has reported episodes of flare-ups, the December 2019 VA examiner nonetheless did not assess that any change in range of motion in the right or left knee was anticipated due to pain and swelling during such episodes. Additionally, the Board finds that no other separate rating is warranted under any of the other diagnostic codes pertaining to the knee. As the lay and medical evidence for the entire rating period on appeal does not show ankylosis in the right or left knee, the Board finds that Diagnostic Code 5256 does not apply. Additionally, as the evidence of record does not demonstrate genu recurvatum, the Veteran is not entitled to a rating under Diagnostic Code 5263. The Board further finds that the Veteran is not entitled to a rating under Diagnostic Code 5055 for a knee replacement, as the evidence of record does not demonstrate the Veteran has had a knee replacement. Under Diagnostic Code 5259, a maximum 10 percent rating is assigned for removal of semilunar cartilage which is symptomatic. 38 C.F.R. § 4.71a, Diagnostic Code 5259. In this case, the evidence of record does not demonstrate that the semilunar cartilage or meniscus has been removed in the right or left knee. A separate rating from arthritis and limitation of motion is provided for knee instability or subluxation. See VAOPGCPREC 23-97, 09-98. Diagnostic Code 5257 contemplates "other impairment" of the knee including recurrent subluxation or lateral instability. Under Diagnostic Code 5257, where impairment is severe, moderate or slight, disability evaluations of 30, 20, and 10 percent are assigned, respectively. 38 C.F.R. § 4.71a. In this case, the evidence does not show right or left knee instability or subluxation to warrant a separate rating. Joint stability tests performed during the appeal period were also normal with no instability associated with the left knee joint noted. See December 2019 VA examination reports. For these reasons, the Board finds that the right and left knee disability pictures more nearly approximate the criteria described for a 10 percent rating and do not warrant a higher rating for the initial rating period on appeal. See 38 C.F.R. §§ 4.3, 4.7, 4.71a. 12. Rating Scar Residuals of Testicular Cancer For the initial rating period on appeal, the testicular cancer treatment scars have been rated as 10 percent disabling under Diagnostic Code 7804. Under Diagnostic Code 7801, scars other than on the head, face, or neck that are deep or cause limited motion are rated as 10 percent disabling for areas exceeding 6 square inches (39 square centimeters), 20 percent disabling for areas exceeding 12 square inches (77 square centimeters), 30 percent disabling for areas exceeding 72 square inches (465 square centimeters), and 40 percent disabling for areas exceeding 144 square inches (929 square centimeters). Note (2) under Diagnostic Code 7802 provides that a deep scar is defined as one associated with underlying soft tissue damage. Under Diagnostic Code 7802, a 10 percent rating is warranted for superficial scars that do not cause limited motion, in an area or areas of 144 square inches (929 square centimeters) or greater. Note (2) under Diagnostic Code 7802 provides that a superficial scar is defined as one not associated with underlying soft tissue damage. Under Diagnostic Code 7803, a 10 percent rating is warranted for superficial and unstable scars. Note (1) under Diagnostic Code 7803 provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Under Diagnostic Code 7804, a 10 percent rating is warranted for 1 or 2 scars that are unstable or painful. A 20 percent rating is warranted for 3 to 4 scars that are unstable or painful. A 30 percent disability rating is warranted for 5 or more scars that are unstable or painful. Note (1) states that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provides that if one or more scars are both unstable and painful, add 10 percent to the rating that is based on the total number of unstable or painful scars. 38 C.F.R. § 4.118. Any disabling effects of other scars (including linear scars), and other effects of scars rated under Diagnostic Codes 7800, 7801, 7802, and 7804 not considered in a rating provided under Diagnostic Codes 7800 through 7804 are to be rated under an appropriate diagnostic code. 38 C.F.R. § 4.118, Diagnostic Code 7805. After a review of all the evidence, lay and medical, the Board finds that, for the entire rating period on appeal from August 29, 2014, the cancer treatment scar disability has manifested as three or more scars that unstable or painful. Findings from the December 2019 VA examination report reveals three scars that are painful as required for a higher 20 percent rating under Diagnostic Code 7804. For these reasons, the Board finds the scar disability has been manifested as three or more painful scars. Resolving reasonable doubt in favor of the Veteran, the criteria for a rating of 20 percent under Diagnostic Code 7804 for three or more painful scars is warranted. 38 C.F.R. §§ 4.3, 4.7. The Board also finds that the scar disability has not been characterized by five or more scars that are unstable or painful, and the Veteran has not alleged otherwise. As discussed above, the December 2019 VA examination report reflects three painful residual scars. See December 2019 VA examination report. The Board also finds that no other higher or separate rating is warranted under any of the other diagnostic codes pertaining to scars. Here, the scars at issue are not located on the head, face, or neck; therefore, Diagnostic Code 7800 is not for application. The evidence of record also does not reflect that the Veteran has superficial, nonlinear scars in an area of 929 square centimeters or greater; and/or deep, nonlinear scars in an area of 39 square centimeters or greater; therefore, Diagnostic Code 7801 and Diagnostic Code 7802 are not for application. 13. Initial Rating for Linear Abdominal Scar The Board finds that a separate compensable rating under Diagnostic Code 7805 for the single abdominal scar as related to testicular cancer treatment (in addition to the 20 percent rating under Diagnostic Code 7804 for three painful scars, to include the abdominal scar) would compensate the Veteran twice for the same scar symptoms including pain. A separate compensable rating for abdominal scar disability under Diagnostic Code 7805 (in addition to the 20 percent rating under Diagnostic Code 7804) is precluded because it would constitute prohibited pyramiding of compensation. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.14, 4.40, 4.45, 4.59, 4.118, Diagnostic Codes 7804, 7805. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the rating of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran's service-connected disabilities. 38 C.F.R. § 4.14. None of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Such overlapping symptoms or impairment constitute pyramiding if a veteran is "compensated" twice for the same symptom or impairment. See Lyles. In this case, the Veteran is in receipt of a 20 percent schedular disability rating for three painful scars, to include the abdominal scar under Diagnostic Code 7805 for the entire period from August 29, 2014. 38 C.F.R. § 4.71a. For these reasons, a separate compensable rating under Diagnostic Code 7805 for a painful abdominal scar is not appropriate because it would compensate the same symptoms pain twice, violating the anti-pyramiding provisions of 38 C.F.R. § 4.14. See 38 C.F.R. §§ 4.14, 4.118, Diagnostic Codes 7804, 7805. 14. TDIU for the period from August 29, 2014 to November 13, 2019 VA will grant a TDIU when the evidence shows that a veteran is precluded, by reason of service-connected disabilities, from obtaining or maintaining "substantially gainful employment" consistent with the veteran's education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16; VAOPGCPREC 75-91. The central inquiry is, "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to a veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to age or the impairment caused by any non-service-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). TDIU may be assigned when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. The service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue will be addressed in both instances. 38 C.F.R. § 4.16(a), (b). If there is only one such disability, it must be rated at 60 percent or more; if there are two or more disabilities, at least one disability must be rated at 40 percent or more, with sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). For the above purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric, (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. Id. The ultimate issue of whether a TDIU should be awarded is not a medical issue, but rather is a determination for the 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). Although VA must give full consideration, per 38 C.F.R. § 4.15, to "the effect of combinations of disability," VA regulations place responsibility for the ultimate TDIU determination on VA, not a medical examiner's opinion. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013); 38 C.F.R. § 4.16(a); see also Smith v. Shinseki, 647 F.3d 1380, 1385-86 (Fed. Cir. 2011) (VA is not required to obtain an industrial survey from a vocational expert before making a TDIU determination but may choose to do so in an appropriate case). The Veteran contends that he is prevented from obtaining and maintaining substantially gainful employment from October 2014 due to service-connected disabilities. An VA Form 21-8940 reflects the Veteran wrote that the service-connected acquired psychiatric disorder impacted the ability to obtain and maintain employment. The Veteran is in receipt of at least a 70 percent combined schedular rating for the service-connected disabilities from August 29, 2014 to November 13, 2019, and a 100 percent combined disability rating from November 13, 2019. After reviewing all the evidence of record, the Board finds that the evidence is at least in equipoise on the question of whether the Veteran's service connected disabilities prevented maintaining substantially gainful employment from August 29, 2014. November 2019 VA examination reports reflect the VA examiner indicated that the service-connected back and neck disabilities impacted employability. A November 2019 VA mental health examination report reflects the VA examiner indicated that the service-connected psychiatric disorder manifested as occupational and social impairment with reduced reliability and productivity, to include difficulty in establishing and maintaining effective work and social relationships and difficulty in adapting to stressful circumstances, including work or a worklike setting. For these reasons, the Board finds that TDIU is warranted under 38 C.F.R. § 4.16(a) from August 29, 2014 to November 13, 2019. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 15. TDIU for the period from November 13, 2019 VA's duty to maximize benefits requires it to assess all of a claimant's service-connected disabilities to determine whether any combination of the disabilities establishes eligibility for special monthly compensation (SMC) under 38 U.S.C. § 1114(s). See Buie v. Shinseki, 24 Vet. App. 242, 250-51 (2010); Bradley v. Peake, 22 Vet. App. 280, 294 (2008). In Bradley, 22 Vet. App. 280, the Court held that 38 U.S.C. § 1114(s) permits a TDIU rating based on a single disability to satisfy the statutory requirement of a "total" rating. When a veteran is awarded TDIU based on a single disability and receives schedular disability ratings for other conditions, SMC based on the statutory housebound criteria may be awarded so long as the same disability is not counted twice, i.e., as a basis for TDIU and as a separate disability rated 60 percent or more disabling. See 75 Fed. Reg. 11,229, 11,230, Summary of Precedent Opinions of the VA General Counsel (March 10, 2010) (withdrawing VAOPGCPREC 6-1999 in light of Bradley, 22 Vet. App. at 280). A veteran with a 100 percent schedular disability rating for a single service-connected disability could also obtain a TDIU on a single separate disability (though not on multiple service-connected disabilities), in order to meet the SMC requirements (100 percent rating plus 60 percent rating). A TDIU could meet the SMC requirements by either: a) increasing a single disability rating of less than 60 percent to at least 60 percent (in a case where a separate 100 percent rating is already established), or b) increasing a single disability that is less than 100 percent to a "total" (100 percent) rating, in a case where there is already established a combination of other ratings that meet the separate 60 percent rating requirement for SMC. See Buie at 249-50. In this case, for the period from November 13, 2019, the Veteran is in receipt of a 100 percent schedular disability rating for all service-connected disabilities. As discussed above, because a 100 percent schedular disability rating has been assigned, a TDIU claim can only be raised if TDIU is alleged to be based on a single service-connected disability. See Buie at 249-50. In this case, the evidence of record does not reflect that the Veteran is unable to secure or follow a substantially gainful occupation by reason of any single service-connected disability, and such a contention has not even been raised. See VA examination reports, VA treatment records, private treatment records. As such, the Board finds that the assignment of a total (100 percent) schedular rating for the period from November 13, 2019 renders the TDIU claim moot. Sabonis v. Brown, 6 Vet. App. 426 (1994). J. PARKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Tenney, 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.