Citation Nr: 21065493 Decision Date: 10/26/21 Archive Date: 10/26/21 DOCKET NO. 08-06 924A DATE: October 26, 2021 ORDER An initial rating in excess of 10 percent for service-connected degenerative arthritis of the cervical spine (previously evaluated as cervical spondylosis and cervical myositis) from June 15, 2006 to June 21, 2009 is denied. A disability rating in excess of 20 percent for service-connected degenerative arthritis of the cervical spine (previously evaluated as cervical spondylosis and cervical myositis) from June 22, 2009 to May 23, 2021 is denied. A disability rating of 30 percent for service-connected degenerative arthritis of the cervical spine (previously evaluated as cervical spondylosis and cervical myositis) from May 24, 2021 is granted. An initial rating of 50 percent for service-connected depression not otherwise specified from May 21, 2009 to June 5, 2013 is granted. A disability rating in excess of 50 percent for service-connected depression not otherwise specified from June 6, 2013 is denied. A total disability rating based on individual unemployability (TDIU) due to service-connected disabilities prior to November 24, 2017 is denied. A TDIU due to service-connected disabilities from November 24, 2017 is granted. FINDINGS OF FACT 1. From June 15, 2006 to June 21, 2009, the preponderance of the evidence shows that symptoms of the Veteran's service-connected degenerative arthritis of the cervical spine (previously evaluated as cervical spondylosis and cervical myositis) more nearly approximate forward flexion of the cervical spine greater than 30 degrees, to include consideration of pain on motion and any limitation of function on repetitive use; the combined range of motion of the cervical spine is greater than 170 degrees, was not manifested by favorable or unfavorable ankylosis of the entire cervical spine, and did not result in physician prescribed bed rest having a total duration of at least two weeks over a 12 month period. 2. The preponderance of the evidence shows that symptoms of the Veteran's service-connected degenerative arthritis of the cervical spine did not more nearly approximate forward flexion of 15 degrees or less from June 22, 2009 to May 23, 2021, to include consideration of pain on motion and any limitation of function on repetitive use, was not manifested by favorable or unfavorable ankylosis of the entire cervical spine, and did not result in physician prescribed bed rest having a total duration of at least four weeks over a 12 month period at any time during the appeal period. 3. From May 24, 2021, the evidence was at least evenly balanced as to whether the Veteran's service-connected degenerative arthritis of the cervical spine was manifested by forward flexion of 15 degrees or less or favorable ankylosis of the cervical spine on flare-ups; however, the preponderance of the evidence shows that it was not manifested by unfavorable ankylosis of the entire cervical spine, and did not result in physician prescribed bed rest having a total duration of at least four weeks over a 12 month period from May 24, 2021. 4. Since the effective date of service connection, the Veteran's depression not otherwise specified has been manifested by moderate occupational and social impairment with reduced reliability and productivity to include such symptoms as depressed mood, mood swings, anxiety, disturbances of motivation and mood, irritability, mild memory loss, chronic sleep impairment, difficulty adapting to stressful circumstance, and difficulty establishing and maintaining effective work and social relationships with no evidence of occupational and social impairment with deficiencies in most areas or total occupational and social impairment. 5. The preponderance of the evidence shows that the Veteran's service-connected disabilities did not preclude him from securing and following substantially gainful employment from May 21, 2009 to November 24, 2017. 6. The evidence is at least evenly balanced as to whether the Veteran is unable to secure or follow a substantially gainful occupation due the combined effects of his service-connected disabilities from November 25, 2017. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for service-connected degenerative arthritis of the cervical spine (previously evaluated as cervical spondylosis and cervical myositis) from June 15, 2006 to June 21, 2009 are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5237. 2. The criteria for a disability rating in excess of 20 percent for service-connected degenerative arthritis of the cervical spine (previously evaluated as cervical spondylosis and cervical myositis) from June 22, 2009 to May 23, 2021 are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5242. 3. The criteria for a disability rating of 30 percent, but not higher, for service-connected degenerative arthritis of the cervical spine (previously evaluated as cervical spondylosis and cervical myositis) from May 24, 2021 are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5242. 4. The criteria for an initial rating of 50 percent, but not higher, for service-connected depression not otherwise specified from May 21, 2009 to June 5, 2013 are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9400. 5. The criteria for a disability rating in excess of 50 percent for service-connected depression not otherwise specified from June 6, 2013 are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9400. 6. The criteria for a TDIU are not met from May 21, 2009 to November 24, 2017. 38 U.S.C. § 1155; 38 C.F.R. § 3.102, 3.340, 3.341, 4.16. 7. The criteria for a TDIU are met from November 25, 2017. 38 U.S.C. §§ 1155, 7104; 38C.F.R. §§3.159, 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the National Guard from 1989 to 2009 with active duty from July 1989 to December 1989, from March 2005 to June 2006, including service in Southwest Asia from May 2005 to May 2006. This case is before the Board of Veterans' Appeals (Board) on appeal from Regional Office (RO) rating decisions in January 2007, September 2009, and March 2012. In the January 2007 rating decision, the RO granted service connection for cervical spondylosis and cervical myositis, and assigned an initial 10 percent disability rating, effective from June 15, 2006. The Veteran's notice of disagreement (NOD) was received in April 2007. The RO issued a statement of the case (SOC) in February 2008. The Veteran's VA Form 9, substantive appeal to the Board, was received in March 2008. In September 2009 rating decision, the RO denied entitlement to a TDIU. The Veteran's NOD was received in June 2010. The RO issued a SOC in March 2012. The Veteran's VA Form 9, substantive appeal to the Board, was received in April 2012. In the March 2012 rating decision, the RO granted service connection for depression not otherwise specified, and assigned an initial 10 percent disability rating, effective from May 21, 2009. The Veteran's NOD was received in July 2012. The RO issued a SOC in October 2013. The Veteran's VA Form 9, substantive appeal to the Board, was received in December 2013. During the appeal, in a June 2013 rating decision, the RO granted an increased rating for depression not otherwise specified from10 percent to 50 percent, effective from June 6, 2013. Thereafter, in a June 2021 rating decision, the RO granted an increased rating for depression not otherwise specified from 10 percent to 30 percent from May 21, 2009 to June 5, 2013. In a September 2016 rating decision, the RO granted service connection for degenerative arthritis of the cervical spine (previously rated as cervical spondylosis and cervical myositis) and assigned a 20 percent rating from June 22, 2009. In May 2016 and January 2018, the Board remanded the case to the RO for further development and adjudicative action. Increased Rating Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. When the evidence is in relative equipoise, the veteran is accorded the benefit of the doubt. 38 U.S.C. § 5107(b). In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). 1. Entitlement to an initial rating in excess of 10 percent for service-connected degenerative arthritis of the cervical spine (previously evaluated as cervical spondylosis and cervical myositis) from June 15, 2006 to June 21, 2009. The Veteran contends that he is entitled to a higher rating for his cervical spine disability. The Veteran's cervical spondylosis and cervical myositis was rated under 38 C.F.R. § 4.71a, Diagnostic Code 5237, which evaluates cervical strain, from June 15, 2006 to June 21, 2009. Diagnostic Code 5257 is evaluated under the General Rating Formula for Diseases and Injuries of the Spine. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the 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 warranted for forward flexion of the cervical spine to 15 degrees or less; or favorable ankylosis of the entire cervical spine. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. Unfavorable ankylosis is defined as "a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching." Id. at Note 5. Additionally, fixation of a spinal segment in neutral position (zero degrees) is "always" considered favorable ankylosis. Id. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." The spine has no opposite joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The preponderance of the evidence is against the assignment of a disability rating in excess of 10 percent for cervical spondylosis and cervical myositis) from June 15, 2006 to June 21, 2009. The evidence includes the Veteran's lay reports of symptoms due to neck pain and stiffness. He noted that there was tight sensation of the neck since he was in Iraq. He reported frequent neck pain and he was constantly moving his neck and cracking neck. The Veteran used analgesics to decrease intensity of neck pain. He denied numbness, electricity, or burning sensation in the upper extremities. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements would not result in limitation of motion more nearly approximating forward flexion of 15 degrees but not greater than 30 degrees or the combined range of motion of the cervical spine not greater than 170 degrees. This is shown in the findings from an August 2006 cervical spine examination. Additionally, the Veteran did not have muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Forward flexion of the cervical spine was to 45 degrees with pain beginning at 45 degrees. Extension of the cervical spine was to 45 degrees with pain beginning at 45 degrees. Lateral bending right and left were to 45 degrees. Lateral rotation right and left were to 80 degrees. The examiner determined that range of motion was not additionally limited by pain, fatigue, weakness, lack of endurance or the neck. The examiner also noted that there was no additional limitation of motion or functional impairment during flare-ups. There were mild cervical spasms to palpation at C5 and C6, bilaterally. X-rays revealed degenerative changes of the cervical spine. The examiner observed that the Veteran was able to walk, despite neck pain discomfort. The examiner noted that the Veteran worked as a mechanic in the National Guard and he was able to work despite neck discomfort. There were no limitations to walking. Consideration has also been given to assigning a rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. However, the Veteran did not have IVDS and the evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating prior to June 22, 2009. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Regarding neurological impairment, the lay and medical evidence of record is against a finding that the Veteran had any other neurological abnormality associated with his cervical spine disability prior to June 22, 2009. Specifically, during the August 2006 VA examination, the Veteran denied numbness, electricity, and burning sensation of the upper extremity. The Veteran also had a normal neurological examination with intact pin prick and light touch of the bilateral upper extremity. Deep tendon reflexes of the biceps, triceps, and brachioradialis. The Veteran had normal muscle tone and normal muscle strength. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent for cervical spondylosis and cervical myositis from June 15, 2006 to June 22, 2009. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 2. Entitlement to a disability rating in excess of 20 percent for service-connected degenerative arthritis of the cervical spine (previously evaluated as cervical spondylosis and cervical myositis) from June 22, 2009 to May 23, 2021 As of June 22, 2009, the Veteran's degenerative arthritis of the cervical spine is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5242, which evaluates degenerative arthritis of the spine. Diagnostic Code 5242 is evaluated under the General Rating Formula for Diseases and Injuries of the Spine. The preponderance of the evidence is against the assignment of a rating in excess of 20 percent for degenerative arthritis of the cervical spine from June 22, 2009 to May 23, 2021. However, as noted below, the evidence is at least evenly balanced regarding whether a 30 percent disability rating is warranted for degenerative arthritis of the cervical spine from May 24, 2021. The Veteran reports symptoms resulting in functional loss due to pain in the cervical area that radiates upwards and that last three to five hours per day. The Veteran also report flare-ups in pain rated as 9 out of 10 that occur weekly lasting for several hours. His neck pain is aggravated by overhead activities and alleviated with medication. See June 2009 VA examination. In an April 2010 VA examination, the Veteran reported experiencing constant cervical pain and he has to crack his neck to partially relieve the pain. He also noted that the cervical pain radiated to the right arm with shoulder spasm and pain. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements would not result in limitation of motion more nearly approximating forward flexion of the cervical spine to 15 degrees or less; or favorable ankylosis of the entire cervical spine. Specifically, a June 2009 VA examination shows that forward flexion of the cervical spine was from zero to 30 degrees with pain in the last 10 degrees. The examiner noted that the Veteran had functional loss of 15 degrees due to pain. Extension of the cervical spine was from zero to 25 degrees with pain in the last 10 degrees. The examiner noted that the Veteran had functional loss of 20 degrees due to pain. Left and right lateral flexion was from zero to 30 degrees due to pain. Left and right lateral rotation was from zero to 40 degrees due to pain. The examiner noted that he asked the Veteran to repeatedly flex and extend the cervical area. Pain was elicited, but no weakness or fatigue. The examiner documented that spasms were palpated in the cervical area. An April 2010 VA examination shows that the Veteran had a history of fatigue, decreased motion, stiffness, weakness, spasms, and pain in the cervical area. The Veteran reported constant daily pain that was 6 out of 10 in severity. The Veteran reported severe flare-ups that occur upon washing the car or engaging in yard chores such as trimming the lawn. Flare-ups would usually last one to two days. During a flare-up that the Veteran reported that he had difficulty lifting or doing any kind of work. The examiner observes that the Veteran had bilateral spasms, guarding, pain with motion, tenderness, and weakness. Forward flexion of the cervical spine was from zero to 40 degrees. Extension was from zero to 30 degrees. Left and lateral flexion were from zero to 40 degrees. Left and right lateral rotation were from zero to 65 degrees. Forward flexion was from zero to 30 degrees after repetitive motion. Consideration has also been given to assigning a rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. However, the Veteran does not have IVDS and the medical evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Regarding neurological impairment, the Veteran reported in the June 2010 VA examination that he experienced cervical pain that radiated to the right arm. On examination, pinprick was one out of two and light touch was one out of two in both upper extremities. Reflex of the bilateral biceps, triceps and brachioradialis were normal. The examiner noted that the Veteran had diminished pinprick and smooth sensation not following any specific pattern in the bilateral extremity. The examiner concluded that it was non radicular. Furthermore, an EMG and NCS conducted as part of peripheral neve examination in September 2011 showed an abnormal NCS with evidence of mild distal sensory neuropathy, but no evidence of carpal tunnel syndrome. The EMG was normal with no evidence of cervical radiculopathy. The Veteran's lay statements indicate that the pain radiating into his right arm may be related to his service-connected cervical spine disability. While the Veteran is competent to report observable symptomatology that he experiences, such as the location of his pain, he has not shown that he has the medical experience or training to relate the arm pain to his cervical spine disability, which is a medically complex determination that cannot be based on lay observation alone. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Instead, such a determination must be made by a medical professional with appropriate expertise. Id. Accordingly, the Veteran's statements of experiencing pain in his arm is not competent evidence that the Veteran has radiculopathy associated with the cervical spine. Thus, the competent and credible evidence does not show that there were any neurological impairments associated with the Veteran's cervical spine disability prior to May 24, 2021. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim for a rating in excess of 20 percent for degenerative arthritis of the cervical spine from June 22, 2009 to May 23, 2021. In denying such a rating, the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 3. Entitlement to a disability rating in excess of 20 percent for service-connected degenerative arthritis of the cervical spine (previously evaluated as cervical spondylosis and cervical myositis) from May 24, 2021. The evidence is at least evenly balanced as to whether a 30 percent disability rating is warranted for the service-connected cervical spine arthritis from May 24, 2021. Specifically, a May 2021 VA examination reveals that the Veteran reported that he experiences severe pain at the cervical spine. Pain intensity was an eight out of ten, but could increase to more. He denied radicular symptoms. The Veteran reported flare-ups of the cervical spine. He experienced flare-ups with bending, driving, and he is unable to ride a bicycle. The Veteran reported difficultly with sudden movements of the neck. Active and passive forward flexion of the cervical spine was to 30 degrees. Active and passive extension was limited to 30 degrees. Active and passive right and left lateral flexion was to 30 degrees. Active and passive right and left lateral rotation was to 40 degrees. The examiner documented that active and passive range of motion exhibited pain. There was evidence of pain on weight-bearing, nonweight-bearing, active motion, and passive motion. There was no additional loss of function or range of motion after three repetitions. The examiner determined that there was change in range of motion after repetitive use over time. The examiner noted that this determination was based on the Veteran's lay statements. However, the examiner determined forward flexion, extension, right and left lateral flexion, and right and left lateral rotation was limited to zero degrees during flare-ups based on the Veteran's lay statements. The Veteran had cervical spasm and tenderness due to cervical condition. Thus, the medical evidence shows that with consideration of flare-ups the Veteran's range of motion was limited to less than 15 degrees of cervical flexion. In fact, although the examiner determined that the Veteran did not have ankylosis the spine, the examiner noted that the Veteran's flare-ups resulted in a range of motion that was limited to zero degrees. This suggests that during flare-ups, the Veteran's cervical spine more nearly approximates favorable ankylosis of the cervical spine as it would result in the neck being fixed at zero degrees. See 38 C.F.R. § 4.71a, Spine, Note (5) ("fixation of a spinal segment in neutral position (zero degrees) is always represents favorable ankylosis." Accordingly, the Veteran's degenerative arthritis of the cervical spine more closely approximates a 30 percent disability rating from May 24, 2021. In granting a 30 percent disability rating, the preponderance of the evidence is against a rating in excess of 30 percent for the cervical spine degenerative arthritis. The Veteran's lay reports of symptoms and functional loss due to pain on repetitive use over time and during flare-ups has been considered. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements would not result in symptoms more nearly approximating unfavorable ankylosis of the entire cervical spine. Specifically, the medical evidence does not show that the Veteran's cervical spine is fixed in flexion or extension and one of the additional symptoms set forth in Note 5. even with consideration of flare-ups or repetitive use over time. See May 2021 VA examination. Consideration has also been given to assigning a rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. However, the Veteran does not have IVDS of the cervical spine and evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Regarding neurological impairment, the lay and medical evidence of record is against a finding that the Veteran has any other neurological abnormality associated with his spine disability. For the foregoing reasons, the evidence is at least evenly balanced to whether the Veteran meets the criteria for a 30 percent disability rating for service-connected degenerative arthritis of the cervical spine as of May 24, 2021. Resolving any reasonable doubt in the Veteran's favor, a 30 percent disability rating is warranted from May 24, 2021. 4. Entitlement to an initial rating in excess of 30 percent for service-connected depression not otherwise specified from May 21, 2009 to June 5, 2013. 5. Entitlement to a disability rating in excess of 50 percent for service-connected depression not otherwise specified from June 6, 2013. The Veteran contends that he is entitled to a higher initial rating for his service-connected depression, initially rated at 10 percent, but increased to 30 percent from May 21, 2009 to June 5, 2013 and 50 percent from June 6, 2013 during the appeal period. When evaluating a mental disorder, VA shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126. The Veteran's service-connected depression is currently rated under 38 C.F.R. § 4.130, Diagnostic Code 9400 for generalized anxiety disorder. Generalized anxiety disorder is rated pursuant to the General Rating Formula for Mental Disorders. Id. Under the General Rating Formula for Mental Disorders, a 30 percent rating is warranted 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, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9400. A 50 percent rating is prescribed for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is prescribed 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); inability to establish and maintain effective relationships. Id. A 100 percent rating is prescribed for 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. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptomatology contemplated for each rating. The use of such terminology permits consideration of items listed as well as other symptoms and contemplates the effect of those symptoms on the Veteran's social and work situation. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In determining whether the Veteran meets the criteria for a 70 percent rating, the Board must consider whether the Veteran has deficiencies in most of the following areas: work, school, family relations, judgment, thinking, or mood. Bowling v. Principi, 15 Vet. App. 1, 11 (2001). Entitlement to a 70 percent disability rating requires sufficient symptoms of the kind listed in the 70 percent requirements, or others of similar severity, frequency or duration, that cause occupational and social impairment with deficiencies in most areas such as those enumerated in the regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). Further, VA must engage in a "holistic analysis" of the severity, frequency, and duration of the signs and symptoms of the veteran's mental disorder, determine the level of occupational and social impairment caused by those signs and symptoms, and assign an evaluation that most nearly approximates that level of occupational and social impairment. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017). The medical evidence of record consists of VA treatment records and VA examinations dated in November 2010, June 2013, October 2104, and May 2021. The Veteran also provided additional information about his symptoms in written lay statements. This evidence, the most pertinent of which is summarized below, shows that the Veteran's depression is manifested by an overall disability picture that more nearly approximates occupational and social impairment with reduced reliability and productivity for the entire appeal period, warranting a 50 percent disability rating throughout the relevant appeal period. The evidence does not support the assignment of a rating in excess of 50 percent at any point during the appeal. In this regard, the medical and lay evidence reflects that the Veteran's symptoms of depression include anhedonia, depressed mood, mood swings, anxiety, apprehension, nightmares, irritability, outbursts of anger, poor tolerance to crowds and noisy places, decreased or loss of energy, forgetfulness, difficulty focusing attention and learning new information, and lack of motivation prior to June 5, 2013. See VA treatment records dated in February 2011, September 2011, January 2012, August 2012, February 2013, and November 2010 VA examination report. The medical and lay evidence reflects that the Veteran's symptoms of depression resulted in him having difficulty in establishing and maintaining effective work and social relationships. The November 2010 VA examination report shows that the Veteran worked for the Army National Guard as a mechanic until September 2009 when he was medically discharged and then separated from work. In November 2010 he was attending a university studying Business Administration. The November 2010 VA examiner determined that the signs and symptoms of the Veteran's mental disorder are transient or mild and decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. However, a February 2011 VA treatment record reflected that although the Veteran was complying with academic demands, he had difficulties with focus, attention, and learning new information. An August 2012 VA treatment record documented that the Veteran ran out medication to treat his depression two weeks prior and he started experiencing anxiety, apprehension, mood swings, irritability, outbursts of anger, and reliving experiences in Iraq. Particularly, the Veteran's symptoms of decreased or loss of energy, lack of motivation, forgetfulness, difficulty focusing attention and learning new information, anxiety, mood swings, irritability, and outbursts of anger would most likely result in an overall impairment more nearly approximating occupational and social impairment with reduced reliability and productivity. Accordingly, the Veteran's symptoms of depression warrant a 50 percent disability rating from May 21, 2009 to June 5, 2013. Nonetheless, the overall evidence of record reflects that the Veteran's symptoms do not meet the requirements for a 70 percent or 100 percent disability rating at any time during the appeal. The evidence does not show that the Veteran's symptoms of depression include characteristics such as suicidal or homicidal ideation; persistent danger of hurting self or others, obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships; gross impairment in thought processes or communication; grossly in appropriate behavior; persistent delusions or hallucinations; spatial disorientation; disorientation to time and place; intermittent inability to perform activities of daily living, or memory loss for names of close relatives, own occupation, own name. In addition, the Veteran's depressive symptoms do not include characteristics of a similar nature or frequency to those listed above. Throughout the appeal period the Veteran's depressive symptoms included anhedonia, depressed mood, mood swings, anxiety, apprehension, nightmares, irritability, outbursts of anger, demanding, poor tolerance to crowds and noisy places, decreased or loss of energy, forgetfulness, difficulty focusing attention and learning new information, socially withdrawn, rumination, racing thoughts, chronic sleep impairment, flattened affect, problems with short term memory, and disturbances of motivation and mood. See VA treatment records dated in February 2011, September 2011, January 2012, August 2012, February 2013, and VA examinations dated in November 2010, June 2013, October 2014, and May 2021. The medical evidence shows that the Veteran was consistently oriented to person, place and time throughout the appeal period. See VA treatment records dated in September 2012, April 2013, and January 2015 and VA examinations dated in November 2010, June 2013, October 2014, and May 2021. Thought process was coherent, logical, goal-directed, and relevant. Id. Thought content was normal. Insight was adequate and fair. Judgement was good. His speech was described as spontaneous, loud, clear, and coherent throughout the appeal period. The Veteran was consistently described as neatly groomed and appropriately dressed in appearance in the medical records. Although the evidence shows that the Veteran's depression results in depressed mood, apprehension, and anxiety, it does not affect the Veteran's ability to function independently, appropriately, and effectively. His symptoms do not interfere with him engaging in activities of daily living. The evidence consistently reflects that the Veteran's depressive symptoms do not result in suicidal or homicidal ideation and persistent danger of hurting self or others. Throughout the appeal period the Veteran has denied experiencing suicidal ideation or homicidal ideation. Furthermore, while the Veteran has problems with irritability and difficulty controlling anger, there is no indication that he has impaired impulse control with periods of violence. The medical records consistently indicate that his anger is expressed verbally and does not result in physical altercations. The medical evidence reveals that the Veteran's symptoms result in some occupational impairment. In this regard, his depression manifests in depressed mood, anxiety, disturbances of motivation and mood, and difficulty establishing and maintaining effective work and social relationships resulting in occupational and social impairment with reduced reliability and productivity. During the appeal, the Veteran attended a University. The evidence reflects that the was working on a bachelor's degree in Business Administration from 2009 to 2014. He completed his bachelor's degree in May 2014. The Veteran reported that he obtained good grades. A February 2015 VA treatment record notes that the Veteran worked part-time for the post office since November 2014; however, he had difficulties adapting to the job routine. A May 2015 VA treatment record noted that the Veteran quit his job in March. The evidence also shows that the Veteran worked full-time for the Department of Veterans Affairs in clerical work from March 2014 to November 2017. During the May 2021 VA examination, the Veteran reported that he "couldn't deal with my multiple things and work." The evidence indicates that the Veteran left his job with VA due in part to his service-connected depression. The evidence reflects that the Veteran has been unemployed since November 2017. Accordingly, the Veteran's symptoms of depression do not result in significant or total occupational impairment. Regarding social impairment, the evidence indicates the Veteran's depression results in mild to moderate social impairment. The Veteran has been married twice, divorced once. He has been married to his current spouse for approximately 32 years. He has three adult children. He has described his relationship with his children as good. See VA examination dated in November 2010, October 2014, and May 2021. However, in the June 2013 VA examination, he described his family relationships as impaired since he returned from his deployment. The November 2010 VA examiner documented that the Veteran attended church, would visit family members, visit some friends, but he would mostly stay home helping with the house chores or studying. The Veteran also noted that he liked to cook barbeque, go to the mall with his wife, go to the beach, use the computer, studying, and going to church on Sunday. In June 2013, the Veteran noted that he avoids socializing. The May 2021 VA examination reveals that the Veteran reported no significant interpersonal relations difficulties. He enjoys watching television and he helps with household chores. The medical evidence indicates that he experiences anxiety regarding socializing with others. Finally, while the evidence suggests that the Veteran's symptoms are largely responsive to treatment, such ameliorative effects of the medication may be considered in determining the appropriate disability rating to assign. In this case, the criteria for rating mental disorders contemplates the ameliorative effects of medication. See 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders. Generally, when assigning a disability rating, that rating may not consider the ameliorative effects of medication where those effects are not explicitly contemplated by the rating criteria. See generally Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). "Thus, if [the applicable DC] does not specifically contemplate the effects of medication, the Board is required pursuant to Jones to discount the ameliorative effects of medication when evaluating [the disability]. Conversely, if [the applicable DC] does specifically contemplate the effects of medication, then Jones is inapplicable." McCarroll v. McDonald, 28 Vet. App. 267, 271 (2016) (en banc). Diagnostic Code 9411 provides for a noncompensable disability rating when symptoms of a mental disorder do not require continuous medication for control; a 10 percent disability rating when symptoms are controlled by continuous medication; and, by implication, higher disability ratings when psychiatric symptoms of greater severity are not controlled by continuous medication. Therefore, DC 9411 does contemplate the effects of medication. In conclusion, the Veteran's overall disability picture, including the frequency and severity of symptoms reported in VA treatment records, VA examinations, and lay statements from the Veteran, more nearly approximates the criteria for the assignment of a 50 percent rating throughout the appeal period. The preponderance of the evidence shows that the Veteran's symptoms of depression do not more nearly approximate the criteria for a 70 percent or 100 percent rating at any time during the appeal period. Thus, entitlement to a disability rating of 50 percent from May 21, 2009 to June 5, 2013 is warranted and entitlement to a disability rating in excess of 50 percent for service-connected depression not otherwise specified from June 6, 2013 is denied. 6. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities. The Veteran filed the claim for entitlement to a TDIU in May 2009. At that time, he asserted that his service-connected sleep apnea and cervical spondylosis prevented him from securing or following any substantially gainful employment. In May 2021, the Veteran claimed that his service-connected sleep apnea, depression, lumbar disability, and cervical disability prevented him from securing or following any substantially gainful employment. Total disability will be considered to exist when there is present any impairment of mind or body, which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. If the total rating is based on a disability or combination of disabilities for which the Schedule for Rating Disabilities provides an evaluation of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age. 38 C.F.R. § 3.341. In evaluating total disability, full consideration must be given to unusual physical or mental effects in individual cases, to peculiar effects of occupational activities, to defects in physical or mental endowment preventing the usual amount of success in overcoming the handicap of disability and to the effects of combinations of disability. 38 C.F.R. § 4.15. In order to establish an inability to maintain a substantially gainful occupation, as required for a TDIU award pursuant to 38 C.F.R. § 3.340(a), a veteran is not required to submit proof that he is 100 percent unemployable. See Roberson v. Principi, 251 F.3d 1378, 1385 (2001). Instead, the regulations contemplate more flexibility in the employability determination. Id. If the schedular rating is less than total, a total disability evaluation can be assigned based on individual unemployability if the veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disability, provided that he or she has one service-connected disability rated at 60 percent or higher; or two or more service-connected disabilities, with one disability rated at 40 percent or higher and the combined rating is 70 percent or higher. 38 C.F.R. § 4.16(a). It is provided further that the existence or degree of nonservice-connected disabilities or previous unemployability status will be disregarded where the percentages referred to in this paragraph for the service-connected disability or disabilities are met and in the judgment of the rating agency such service-connected disabilities render the Veteran unemployable. From June 2009, the Veteran's service-connected disabilities included the following: obstructive sleep apnea, evaluated as 50 percent disabling; depression, not otherwise specified, evaluated as 50 percent disabling; lumbar spondylosis, evaluated as 20 percent disabling prior to April 30, 2021 and 40 percent disabling from April 30, 2021; degenerative arthritis of the cervical spine, evaluated as 20 percent disabling from June 22, 2009 to April 24, 2021 and 30 percent disabling as of April 24, 2021; right shoulder degenerative joint disease, evaluated as 20 percent disabling from January 21, 2010; epicondylitis of the left upper extremity with carpal tunnel syndrome, evaluated as 10 percent disabling; epicondylitis of the right upper extremity with carpal tunnel syndrome, evaluated as 10 percent disabling; tinnitus, evaluated as 10 percent disabling from May 19, 2016; gastroesophageal reflux disease (GERD); evaluated as 10 percent disabling from May 19, 2016; hypertension, evaluated as noncompensable; sinusitis, evaluated as noncompensable; erectile dysfunction, evaluated as noncompensable; right ear hearing loss, evaluated as noncompensable, and tension headaches, evaluated as noncompensable from June 3, 2020. The combined rating for the Veteran's service-connected disabilities was 90 percent from May 21, 2009 to April 29, 2021 and 100 percent from April 30, 2021, with at least one disability rated at least 40 percent. Thus, the Veteran met the schedular percentage threshold requirement for consideration of a TDIU pursuant to the provisions of 38 C.F.R. § 4.16(a) throughout the entire appeal period. The crucial inquiry in determining whether the Veteran is entitled to TDIU is not whether the Veteran is able to pursue his profession of choice, or indeed any particular job. Instead, the Board must inquire as to whether the Veteran can secure and follow a substantially gainful occupation in a more general sense. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The fact that a veteran is unemployed is not enough. It must be determined that his service-connected disorders without regard to his advancing age make him incapable of performing the acts required by employment. Id. Consideration may be given to the veteran's education, special training, and previous work experience, but not to the veteran's age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16; see also Van Hoose v. Brown, 4 Vet. App. 361 (1993). In this case, the preponderance of the evidence shows that the Veteran's service-connected disabilities did not render him unable to follow or sustain a substantially gainful occupation prior to November 25, 2017. Specifically, the Veteran reported in the VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability received in January 2010 that he last worked full time in September 2009 and that he became too disabled to work in September 2009. The Veteran stated that he worked full-time as a mechanic for the Puerto Rico National Guard from August 2001 to September 2009. The Veteran noted that he completed two years of college. The Veteran indicated that he retired from the National guard due to medical conditions of sleep apnea and cervical spondylosis. Evidence subsequently received, however, shows that the Veteran attended university for a bachelor's degree in Business Administration from 2009 to May 2014. The Veteran asserted in the VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability received in May 2021 that his service-connected sleep apnea, depression, lumbar disability, and cervical disability prevented him from securing or following any substantially gainful employment. He reported that his disability affected full-time employment in April 2009, he last worked full time in November 2017, and he became too disabled to work in November 2017. He indicated that he worked full time doing clerical work at the Department of Veterans Affairs from March 2014 to November 2017. The Veteran stated that he left his last job because of his disability. The preponderance of the evidence shows that the Veteran's service-connected disabilities did not prevent the Veteran from obtaining or maintaining substantial gainful employment prior to November 25, 2017. Specifically, the evidence shows that while the Veteran was not employed full time between 2009 and May 2014, he was attending school. Thus, the Veteran was able to perform sedentary tasks such as attending class, learning new skills, and applying what he learned in the form of test taking. "Sedentary" is defined as "doing or involving a lot of siting: not doing or involving much physical activity" See "sedentary." Merriam-Webster.com. https://www.merriam-webster.com (21 October 2021). Sedentary employment is a job where the worker primarily sits down. Here, the Veteran was able to attend university and complete a bachelor's degree in business administration from 2009 to May 2014. The Veteran's service-connected disabilities did not prevent the Veteran from studying, completing homework, and attending classes full-time. The physical and mental demands of obtaining a bachelor's degree in business administration are similar to the type of work that would be expected in a typical office setting. Furthermore, the Veteran worked full-time from March 2014 to November 2017. The evidence reveals that his employment during that time period was not marginal in nature (i.e., that the Veteran's income did not exceed the relevant poverty threshold) or that the job was in a protected environment. While the Veteran was not working during the time that he was attending university, the evidence does not establish that he would have otherwise been unemployable during that time period, particularly given that he was admittedly gainfully employed following school until November 2017. Nonetheless, the collective evidence suggests that the Veteran's service-connected disabilities have rendered him unable to follow or sustain a substantially gainful occupation from November 25, 2017. Turning to the medical evidence of record, a May 2021 VA examination of the cervical spine reveals that the Veteran experienced severe pain at the cervical spine with an intensity of eight out of ten. The Veteran experiences flare-ups with bending and driving. He is unable to ride a bicycle. The examination revealed that the Veteran's cervical spine had reduced range of motion with forward flexion of the cervical spine limited to 30 degrees, extension limited to 30 degrees, right and left lateral flexion limited to 30 degrees, and right and left lateral rotation limited to 40 degrees. Significantly, the examiner determined that range of motion of the cervical spine was limited to zero degrees (i.e., unable to move his cervical spine) in forward flexion, extension, bilateral lateral flexion, and bilateral lateral rotation during flare-ups based on the Veteran's lay statements. The Veteran reported that he experienced flare-ups with prolonged walking. He is unable to run or bicycle and he has difficult with repetitive movements. Rane of motion of the thoracolumbar spine was reduced with forward flexion limited to 30 degrees, extension limited to 5 degrees, bilateral lateral flexion limited to 10 degrees, and bilateral lateral rotation limited to 10 degrees. Moreover, the examiner also determined that range of motion of the thoracolumbar spine was limited to zero degrees (i.e., unable to move his cervical spine) in forward flexion, extension, bilateral lateral flexion, and bilateral lateral rotation during flare-ups based on the Veteran's lay statements. A May 2021 VA examination of the lumber spine showed that the Veteran reported he experiences severe low back pain. The examiner determined that based on physical evaluation and history, the Veteran has some functional limitations in occupational environment. The Veteran has difficulty in prolonged standing position, prolonged walking, and climbing stairs. He is unable to perform heavy lifting and/or repetitive pulling, pushing, or twisting of the spine. There are no functional limitations if the occupational environment required sitting position or moderate walking most of the time. A May 2021 VA examiner determined that based on physical evaluation and history, the Veteran's bilateral carpal tunnel syndrome and bilateral lateral epicondylitis results in some functional limitations in occupational environment. The examiner explained that the Veteran has difficulty performing heavy lifting (no more than 20 pounds) and difficulty with repetitive activities with the upper extremities. He is unable to perform repetitive pushing, pulling, carrying, or lifting heavy weights. His bilateral carpal tunnel syndrome and bilateral lateral epicondylitis does not result in limitations regarding standing and walking. A May 2021 VA examiner determined that the Veteran is unable to do any type of overhead movements including lifting of the right upper extremity due to his service-connected right shoulder disability. The Veteran is limited in carrying, pulling, or pushing moderate to heavy objects with the right upper extremity. There are no functional limitations concerning the right shoulder joint below 90 degrees able or activities of standing and walking due to the right shoulder disability. A May 2021 VA examination for mental health disorders reveals that the Veteran's service-connected depression is manifested by anxiety, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, and difficulty adapting to stressful circumstance, including work or a work like setting. The examiner determined that the Veteran's level of occupational and social impairment regarding his depression is best summarized as occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routing behavior, self-care and conversation. The examiner provided the opinion that based on review of the claims file, medical records, taking a psychiatric history, and performing a mental status examination, the Veteran's mood instability can limit his capacity to interact effectively and on a sustained basis with other individuals. Social function at work environment that involve interaction with the public, responding appropriately to persons in authority or cooperative behaviors involving coworkers can be limited. Regarding obstructive sleep apnea, a May 2021 VA examiner determined that the Veteran has episodes of hypersomnolence. The Veteran reported episodes when he had fallen asleep while driving. He also feels weak during the day. A May 2021 VA examiner determined that the Veteran's sinusitis impacts his ability to work. The examiner explained that the Veteran has to clean his nose very frequently. The Veteran also reported episodes of respiratory difficulty accompany his episodes of sinusitis. With respect to the Veteran's hypertension, a May 2021 VA examiner determined that the Veteran's hypertension impacts the Veteran's ability to work in that his high blood pressure manifests with episodes, which affects his concentration levels. He also feels weak when having episodes of high blood pressure. A May 2021 VA examiner determined that the Veteran's erectile dysfunction and gastroesophageal reflux disease did not interfere with his ability to perform any type of activity of daily living or employment. A May 2021 VA examiner also concluded that the Veteran's right ear hearing loss and tinnitus did not impact ordinary conditions of daily life including ability to work. An August 2021 VA examiner determined that the Veteran's headache condition did not impact his ability to work. The ultimate question of whether a veteran is capable of substantially gainful employment is not a medical question, but rather a determination that must be made by an adjudicator. See 38 C.F.R. § 4.16 (a); Geib v. Shinseki, 733 F.3d 1350 (Fed. Cir. 2014) and Floore v. Shinseki, 26 Vet. App. 376, 381 (2013)). However, as a medical examiner is responsible for providing a full description of the functional effects of disability upon a person's ordinary activity (see 38 C.F.R. § 4.10), and has done so here. The findings, comments and opinions of the VA examiners have appropriately been considered as pertinent evidence, along with the Veteran's competent assertions, in determining whether he is able to perform the acts required for substantially gainful employment. Based on the foregoing, the overall evidence of record indicates that Veteran is unable to maintain employment in any occupation due to his service-connected disabilities from November 25, 2017. Specifically, the medical and lay evidence shows that the Veteran's service-connected lumbar spondylosis ,degenerative arthritis of the cervical spine, right shoulder degenerative joint disease, epicondylitis of the left upper extremity with carpal tunnel syndrome, and epicondylitis of the right upper extremity with carpal tunnel syndrome result in the Veteran being unable to work in physical employment. The combined effect of his service-connected musculoskeletal and neurological disabilities prevent the Veteran in engaging any employment that would require prolonged standing, prolonged walking, climbing stairs, heavy lifting, repetitive pulling, pushing, or twisting of the spine, repetitive use of the upper extremities to include pushing, pulling, carrying, or lifting moderate to heavy weights, or lifting of the right upper extremity. Furthermore, during flare-ups, it appears that the Veteran is unable to move his cervical spine, thoracolumbar spine, and right shoulder. With respect to the Veteran's ability to obtain and maintain sedentary employment (where the worker primarily sits down such as in an office setting), the Veteran's work experience is with physical and sedentary employment. Specifically, the Veteran worked as a mechanic from August 2001 to September 2009 and in clerical work from March 2014 to November 2017. Furthermore, the Veteran obtained a bachelor's degree in business administration in May 2014. However, the evidence shows that the Veteran's service-connected depression resulted in difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a worklike setting. He left his most recent job as he was unable to handle the stress due to his anxiety. Furthermore, the medical evidence shows that his mood instability can limit his capacity to interact effectively and on a sustained basis with other individuals. The Veteran's ability to interact in positions that deal with the public or respond appropriately to persons in authority or cooperative behaviors involving coworkers are limited. Furthermore, the Veteran's service-connected obstructive sleep apnea results in hypersomnolence resulting in him falling asleep while driving and causing him to feel week during the day. Thus, the combined effect of the Veteran's service-connected disabilities would allow only marginal employment at best, given the restrictions the disabilities would put on the Veteran finding adequate employment. See Friscia v. Brown, 7 Vet. App. 294 (1995), citing Beaty v. Brown, 6 Vet. App. 532, 537 (1994) (TDIU may not be denied without producing evidence, as distinguished from mere conjecture, that the Veteran's disability does not prevent him or her from performing work that would produce sufficient income to be other than marginal). In conclusion, the evidence is at least evenly balanced as to whether the Veteran is precluded by his service-connected disabilities from obtaining and maintaining substantially gainful employment in occupations related to his education, training, and work experience from November 25, 2017. Resolving any reasonable doubt in favor of the Veteran, a TDIU is warranted from November 25, 2017. L. B. CRYAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Berry, 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.