Citation Nr: 21066832 Decision Date: 11/02/21 Archive Date: 11/02/21 DOCKET NO. 15-06 731 DATE: November 2, 2021 ORDER Entitlement to an initial rating in excess of 50 percent for depressive disorder is denied. Entitlement to a total disability based on individual unemployability (TDIU) from March 13, 2012 is denied. Entitlement to service connection for right ear hearing loss is denied. Entitlement to service connection for fibromyalgia is denied. REMANDED Entitlement to service connection for uterine fibroids is remanded. FINDINGS OF FACT 1. The Veteran's depressive disorder manifested in symptoms which most closely approximate cause occupational and social impairment with reduced reliability and productivity. 2. The Veteran has been gainfully employed during the appeal period. 3. The preponderance of the evidence is against finding that the Veteran's right ear hearing loss began during active service, within one year of separation, or is otherwise related to an in-service injury or disease. 4. The preponderance of the evidence is against finding that the Veteran's fibromyalgia began during active service, or is otherwise related to an in-service injury or disease, to include as secondary to a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 50 percent for depressive disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9434. 2. The criteria for a TDIU from March 13, 2012, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § § 3.340, 3.341, 4.16, 4.19. 3. The criteria for service connection for right ear hearing loss have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for fibromyalgia have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303,3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1991 to March 1991, and from April 1991 to April 1995. These matters come to the Board of Veterans' Appeals (Board) on appeal from August 2015, May 2016, and July 2018 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded several of the issues adjudicated herein for additional development in June 2018 and in December 2019. In March 2021, the Board remanded those same issues, for further development, as well as entitlement to a higher rating for the service-connected depressive disorder. Increased Ratings 1. Entitlement to an initial rating in excess of 50 percent for depressive disorder is denied. The Veteran seeks a higher initial rating for her depressive disorder NOS. The Veteran reported that her mental disorder involves depression, outbursts, mood swings, numbness, anhedonia, panic attacks, fear or danger that she is going to hurt herself or others, discomfort around others, detachment, social isolation, sleep problems, reduced concentration, memory problems, suicidal feelings and thoughts, inability to establishing friendships, and difficulty dealing with stress. See March 2009 VA Form 21-4138; June 2013 mental health symptoms checklist. In support of her claim, the Veteran also submitted the June 2009 statement of her friend, R.S., who indicated that the Veteran suffers from depression, social isolation, aversion to crowds, and crying spells. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). A noncompensable rating is assigned when a mental condition has been formally diagnosed, but symptoms are not severe enough to either require continuous medication, or to interfere with occupational and social functioning. A 10 percent rating is assigned when mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of occasional stress, or symptoms controlled by medication cause occupational and social impairment. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause 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 normal conversation). A 50 percent rating is assigned when symptoms such 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; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; 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 worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned 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; or memory loss for names of close relatives, own occupation or own name. The appeal period before the Board begins with the effective date of service connection and consideration of the appropriateness of a staged rating are required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). In a July 2018 rating decision, the RO effectuated the Board's grant of service connection for depressive disorder, not otherwise specified (NOS) with an evaluation of 30 percent, effective October 31, 2008. In a March 2021 remand, the Board granted a rating of 50 percent for the entire appeal period. The issue in this appeal is whether the Veteran's associated symptoms caused the level of impairment required for a disability rating of 70 percent or higher. For the reasons that follow, the Board finds that a higher rating is not warranted. In this case, the Veteran has consistently been treated by VA clinicians for her depressive disorder NOS. In the course of treatment, the Veteran has reported symptoms of irritability, depressed mood, agitation, panic attacks, lack of motivation, apathy, and social isolation. See e.g. October 2008, May 2011, and June 2015 VA treatment records. The Veteran also reported intermittent episodes where she spent days lying in bed. See October 2020 and May 2011 VA treatment records. The Veteran has rarely reported thoughts of potential harm and generally related to workplace conflicts. See July 2009 VA treatment records. In August 2017 VA treatment records, the Veteran also reported occasional passive suicidal ideation. However, in October 2018, the Veteran reported thoughts of death as frequently as every day and described it as a feeling that she is living another person's life. At that time, the Veteran also reported a suicide attempt two years prior without hospitalization. See also February 2019 VA treatment record (reporting a suicide attempt where she took pills and drank alcohol with an apathetic attitude as to whether she woke up). Conversely, the Veteran often reported no thoughts or plans of suicide. See e.g. August 2010, May 2011, January 2015, June 2016, May 2017, April 2018, and May 2020 VA treatment records. Rather, in the majority of mental status examinations and observations made by the VA clinician, the Veteran had dysthymic mood, appropriate affect, normal speech, cooperative behavior, linear thought process, no psychotic features, full orientation, and fair insight and judgment. These clinicians observed that she was almost always well-groomed and alert. As to social and occupational impairment, the Veteran reported a consistently good relationship with her daughter. See October 2010 VA treatment records. The Veteran also reported cordial relationships with co-workers, friendships with individuals outside of her family, a romantic relationship, and contact with other family members. See June 2010, August 2014 ,July 2016, August 2017, and March 2018 VA treatment records. During the appeal period, the Veteran was employed full-time in property management and subsequently in the health care industry. See May 2013 VA treatment records. Although the Veteran reported that she was terminated from the property management company, the Veteran indicate that this was caused by false allegations from her new supervisor and not as due to her own actions. See August 2010 VA treatment record. In May 2013, the Veteran was subject to an in-depth neuro-psychological evaluation related to her complaints of short-term memory loss. At the time, the Veteran reported decreased focus and attention, inability to be happy, sleep difficulties, and decreased energy. The Veteran also reported suicidal ideation and an incident in 2012 where she binged on alcohol and prescription medication. The clinician observed that the Veteran was neatly groomed, alert, and oriented, with normal speech, logical speech content, and restricted range of affect. Based upon the results of the neuropsychological evaluation, the clinician concluded that the Veteran demonstrated generally intact cognitive functioning in the majority of areas assessed. She demonstrated mild slowing in her speed of cognitive processing and in her cognitive flexibility. However, her level of functioning was generally in the average range and consistent with expectations; it was not suggestive of significant memory problems. After another neuropsychological consultation in March 2016, the clinician also concluded that the Veteran does not demonstrate objective evidence of memory impairment. The Veteran underwent a more involved psychological interview for purposes of bariatric surgery in February 2019. The Veteran reported symptoms of depression including feeling sad or down nearly every day, panic attacks, decreased concentration, loss of interest in previously enjoyed activities, daily thoughts of death, feelings of helplessness and hopelessness, sleep disturbance, and increased irritability. In describing daily thoughts of death, the Veteran reported that every day is like someone else's life and that she previously took pills and drank alcohol with an apathetic attitude regarding whether she woke up. The Veteran reported that her current depression is severe. The Veteran currently lives with her daughter and reported a close relationship with her oldest and youngest children. She also reported that she has worked as a telehealth technician since 2011. After testing, the clinician noted that the Veteran's profile is still considered valid, but her scores on the cognitive scales and somatic scales were elevated at such a level that they should be interpreted with extreme caution. Other tests suggested that there may have been some areas where the Veteran likely attempted to present her symptoms in a more exaggerated manner. Otherwise, the Veteran's profile suggests she is withdrawn, pessimistic, and has interpersonal difficulties. In relation to the original claim for service connection, the Veteran was examined in June 2010. The Veteran reported having friends and hobbies. The examiner observed that the Veteran had full orientation, appropriate affect, normal mood, relevant speech, no evidence of psychosis or thought disorder, and intact memory, attention, and concentration. There was no suicidal or homicidal thinking. The clinician concluded that the Veteran's depressive symptoms did not interfere with her ability to maintain employment, or ability to socialize. In August 2012, the Veteran was again afforded a VA examination for mental disorders. The examiner noted a diagnosis of depressive disorder NOS, alcohol abuse, and maladaptive personality features. Although the examiner noted the maladaptive personality features involved symptoms of inadequacy, low self-esteem, critical, blaming, brooding, and given to worry, negativity, and pessimism, the examiner also noted that it was not possible to differentiate which symptoms were attributable to each diagnosis, or to differentiate what portion of the impairment is caused by each mental disorder. The Veteran reported feeling depressed most days, hopeless, occasional worries, helplessness, and anhedonia, without recent panic attacks, problems maintaining hygiene, or problems with activities of daily living. The examiner endorsed symptoms of depressed mood, anxiety, chronic sleep impairment, mild memory loss. The examiner observed the Veteran had full orientation, good grooming and hygiene, clear and coherent speech, congruent affect, "empty" mood, unremarkable thought process, average judgement, fair insight, negative and pre-occupied thought content, and difficulty with impulse control. The examiner noted that impaired impulse control included verbal outbursts, excessive shopping, and gambling when a voice tells her to go. The examiner further noted passive suicidal ideation, but there was no plan. In describing the Veteran's alcohol use, the examiner noted that the Veteran took one extra bupropion when drinking and could not get out of bed in April 2012. The examiner also denied delusions or hallucinations. As to social relationships, the Veteran lives with her daughter. The Veteran occasionally talks to her father and brother. She also has friends at work and online, and engages in hobbies. The Veteran was employed and working towards completion of her bachelor's degree. Based on the Veteran's present level of social and occupational functioning, the examiner concluded that she has occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation. In support of her claim, the Veteran submitted an August 2017 private psychological evaluation completed by Dr. Moyerman. The clinician noted a diagnosis of major depressive disorder severe with psychotic features and alcohol use disorder in early remission. The Veteran reported living with her daughter, having the same employment for the previous five years, and obtaining a bachelor's degree in human resource management. The Veteran also reported numbness, crying, feeling lifeless, that she is being plotted against, and hearing things when asleep. The Veteran indicated that she attempted suicide in 2011 or 2012 with pills and alcohol, where she passed out in her bedroom and told the social worker several months later. The Veteran reported another overdose with some alcohol in December 2016. The clinician noted that the Veteran harbors a plan to wash down her pills with alcohol, but also that the Veteran has abstained from alcohol the past seven months. The clinician noted a history of passive suicidal ideation and homicidal ideation. The clinician observed that the Veteran had dysphoric mood, congruent affect, recurrent thoughts of hopelessness, vigilance, and poor critical judgment. There were no gross deficits, but the clinician noted slowed thought production, impaired attention and concentration, evidence of hypnopompic hallucinations, and delusions of persecution and interpersonal alienation. In the report, the clinician also noted that the Veteran's response style may indicate a broad tendency to magnify the level of experienced illness or characterological inclination to complaint or self-pitying, or extreme vulnerability with acute turmoil. In this way, Dr. Moyerman noted that the scale scores may be somewhat exaggerated. The clinician further noted that the Veteran does not need to be at the workplace while she is actively psychotic and ruminating about a homicide-suicide scenario. He indicated a poor prognosis due to the severity of psychosis and the risk for sporadic episodic violence. Conversely, the clinician concluded that the Veteran did not met a commitment criteria. Pursuant to the Board's Remand, the Veteran was afforded another examination in June 2021. The Veteran reported continued irritability, low self-esteem, social discomfort, limited motivation, chronic sadness, anxiety, sleep difficulty, chronic pain, and poor appetite. Comparatively, the examiner endorsed symptoms of depressed mood, anxiety, chronic sleep impairment, flattened affect, disturbances of motivation and mood, and difficulty adapting to stressful circumstances including work or a work like setting. The examiner noted a diagnosis of major depressive disorder recurrent moderate with anxious distress, and somatic symptom disorder predominant pain. It was not possible to differentiate symptoms between the varying mental disorders. The clinician noted an additional relevant diagnosis of fibromyalgia with pain having impact on the Veteran's sleep, motivation, mood and the ability to engage in previously enjoyed and potentially stress reducing activities. The examiner concluded that the Veteran suffers occupational and social impairment with reduced reliability and productivity. In support of this conclusion, the examiner indicated that this is the level most consistent with the Veteran's current psychosocial and marital functioning. Namely, the Veteran stays with daughter, who is her support system, and has friends from high school. In addition, she attends a car club and is independent in her activities of daily living. Occupationally, she has worked as a health technician since 2011. Her current duties include training providers and administrative work. Although the Veteran complained of being easily frustrated at work and being asked to do too much, she did not indicate a poor performance history or other detrimental impact due to her psychiatric symptoms. Upon review of the VA treatment records, the private and VA examinations, and the lay statements, the evidence shows that the Veteran's depressive disorder was predominantly manifested by symptoms associated with a 50 percent or lower rating. Her symptomatology associated with a 50 percent or lower rating included depressed mood, anxiety, suspiciousness, chronic sleep impairment, flattened affect, panic attacks, disturbances in motivation and mood, impairment of short and long-term memory, and impaired judgment. The Veteran also had occasional symptoms associated with a 70 percent rating including suicidal ideation, impaired impulse control, and difficulty in adapting to stressful circumstances. However, the vast majority of the Veteran's symptoms are accounted for in the criteria for a 50 percent or lower rating. In addition, the Veteran exhibited a level of social and occupational functioning which did not rise to the level of impairment with deficiencies in most areas. In this regard, the Veteran reported that she was gainfully employed for almost the entire period. Although the Veteran was terminated from her position as a property manager, the Veteran reported that this was due to false allegations of her new supervisor. The Veteran did not report any adverse employment related to her own symptoms. Furthermore, the Veteran completed her bachelor's degree during the course of this appeal. She also had a close relationship with at least one of her children, regular contact with other family members, friendships with co-workers and others, hobbies, and at least one romantic relationship. Neither the August 2012 and the June 2021 VA examiners endorsed a level of occupation and social impairment with deficiencies in most areas. Although the August 2017 private examination noted a far greater level of social and occupation impairment, the clinician did not explain how this is consistent with the above record of the Veteran's actual ability to perform in most areas of her life, including at work, social relationships, school, judgment and thinking. Moreover, the clinician noted psychiatric symptoms which are not consistent with the Veteran's own statements and the observation in VA psychiatric treatment records. Of note, the clinician noted delusions related to the Veteran believing that other people are out to get her and appearing to hear voices when she is asleep. However, the described symptomatology appears to involve the Veteran's suspiciousness as to her co-workers and the report does not appear to involve gross impairment or psychotic features. Moreover, no psychotic features were found in the mental status observations of the VA clinicians who treated the Veteran on a consistent basis for over a decade. Finally, the August 2017 private examination noted testing that appears to call into question the accuracy of the Veteran's own report of symptomatology. Nonetheless, the report appears to rely primarily on her report. As such, the Board accords less probative weight to this August 2017 private examination compared with the VA treatment records and examinations. As to the suicidal attempts, the Veteran reported two incidents involving alcohol and medication in approximately 2012 and 2016. In at least one description, the Veteran reported the incident as taking extra medication and feeling apathy towards whether she woke up. The Board notes that her reports did not indicate a clear or meaningful intent to harm herself. In each incident, the Veteran did not report this at her VA psychology appointments for many months and the Veteran was not hospitalized at the time. At other times, including in the February 2019 VA treatment records, the Veteran hesitated to classify the 2016 incident as a suicide attempt. Moreover, the private August 2017 evaluation noted that test results show a tendency to magnify the level of experienced illness and the February 2019 VA neuropsychological evaluation test results show that the Veteran likely attempted to present her symptoms in a more exaggerated manner. Given the Veteran's description of the incidents and her inconsistent characterizations, as well as the potentially unreliable nature of the Veteran's statements, the Board has reason to question the veracity of these self-described 'suicide attempts.' Comparatively, the Board notes that the Veteran has consistently reported passive suicide ideations, hopelessness, and apathy towards her life. In addition, her representative argues that the Veteran's suicidal thoughts and attempted overdose in December 2016 warrant at minimum, a 70 percent rating. See May 2020 and October 2021 correspondence. Further, the Board is cognizant of the Court's decision in Bankhead v. Shulkin, 29 Vet. App. 10 (2017), holding that "the presence of suicidal ideation alone, that is, a veteran's thoughts of his or her own death or thoughts of engaging in suicide-related behavior, may cause occupational and social impairment with deficiencies in most areas" correlating with a 70 percent evaluation under the rating criteria. Id. at 19 (emphasis added). However, the language used in the Bankhead decision, in particular the usage of "may," indicates that this is merely suggestive. Thus, the Court declined to hold that the presence of suicidal ideations automatically entitles a veteran to a 70 percent evaluation under the rating criteria in every situation. In the present matter, the Veteran's suicidal ideation, along with her other symptoms, did not result in social and occupational impairment with deficiencies in most areas. Rather, the VA examiners tasked with assessing the Veteran's psychiatric symptoms-all of whom are qualified mental health professionals- ultimately decided the totality of the Veteran's psychiatric symptoms did not amount to occupational and social impairment with deficiencies in most areas. In addition, and as noted above, the Veteran has demonstrated an ability to function in most areas. Ultimately, the Board finds the severity, frequency, and duration of the Veteran's symptoms more closely approximate those contemplated by a 50 percent rating. See 38 C.F.R. § 4.126. The Board also finds the level of impairment caused by the Veteran's symptoms more closely approximates the level associated with a 50 percent rating. While the Veteran did experience symptoms contemplated by a 70 percent rating, the evidence overall does not demonstrate the level of impairment associated with a 70 percent rating. As such, the preponderance of the evidence is against the Veteran's claim for an initial rating in excess of 50 percent for depressive disorder at any time during the period on appeal; the benefit of the doubt doctrine is not applicable as a result. 38 U.S.C. § 5107;38 C.F.R. §§ 4.3, 4.7. There are no additional expressly or reasonably raised issues presented on the record. 2. Entitlement to a TDIU from March 13, 2012 is denied. In March 2021, the Board found that the Veteran's March 2012 written correspondence satisfied the requirements for withdrawal for the claim of TDIU pending before the AOJ on March 13, 2012. However, the Board took jurisdiction of the issue of TDIU after March 13, 2012 as part of the Veteran's appeal for an increased rating for depressive disorder. The Board explained that despite her withdrawal of this matter, the Veteran has continued to pursue an increased rating for depressive disorder and also asserted that her service-connected disabilities interfere with her employment. Hence, the issue of TDIU is part of the Veteran's appeal for an increased rating for depressive disorder. See Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). In a June 2021 rating decision, the AOJ indicated that the issue of entitlement to a TDIU after March 13, 2012, is moot because the Veteran's service-connected disabilities have a combined 100 percent evaluation since May 12, 2011. However, the combined 100 percent rating does not necessarily moot the Veteran's TDIU claim. Rather, in Bradley v. Peake, 22 Vet. App. 280, 294 (2008), the Court determined that a separate TDIU rating predicated on one disability (although perhaps not ratable at the schedular 100 percent level) when considered together with another disability or disabilities separately rated at 60 percent or more could warrant special monthly compensation (SMC) under 38 U.S.C. § 1114 (s). Thus, the Court reasoned, it might benefit the Veteran to retain the TDIU rating, even where a 100 percent schedular rating has also been granted. See Buie v. Shinseki, 24 Vet. App. 242, 248 (2010). Thus, the Veteran's claim for entitlement to TDIU from March 13, 2012, remains pending. The Veteran asserts that she is precluded from substantially gainful employment due primarily to her depressive disorder. See June 2013 correspondence. It is the established policy of VA that all Veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. See 38C.F.R. §4.16. A finding of total disability is appropriate "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." See 38C.F.R. §§3.340 (a)(1), 4.15. The United States Court of Appeals for Veterans Claims (Court), in Ray v. Wilkie, 31 Vet. App. 58 (2019), interpreted the phrase "unable to secure and follow a substantially gainful occupation" to have two components: one economic and one noneconomic. The economic component means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. The non-economic component includes consideration of: the Veteran's history, education, skill, and training; whether the veteran has the physical ability to perform the type of activities required by the occupation at issue; and whether the veteran has the mental ability to perform the activities required by the occupation at issue. TDIU may be assigned where the schedular rating is less than total and it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of either (1) a single service-connected disability ratable at 60 percent or more, or (2) two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there are sufficient additional service-connected disabilities to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16 (a). For the purposes of determining rating level, disabilities resulting from a common etiology or affecting a single body system are considered a single disability. 38 C.F.R. § 4.16(a). Where these percentage requirements are not met, entitlement to the benefits on an extraschedular basis may be considered when the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. See 38 C.F.R. § 4.16(b). The Veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed. 38 C.F.R. § 4.16(b). In this case, the Veteran is service-connected for: migraine headaches rated 50 percent disabling from May 26, 2000; depressive disorder NOS rated 50 percent disabling from October 31, 2008; obstructive sleep apnea with bronchial asthma rated 50 percent disabling from May 12, 2011; lumbar strain rated 10 percent disabling from May 26, 2000, 20 percent disabling from July 20, 2007, and 40 percent disabling from October 3, 2012; bronchial asthma rated 10 percent disabling from May 26, 2000 and 30 percent disabling from October 31, 2008, to May 12, 2011; irritable bowel syndrome with gastroesophageal reflux disease (GERD) rated 30 percent disabling from May 12, 2011; carpal tunnel syndrome of the right wrist rate noncompensable from May 26, 2000, and 30 percent disabling from May 12, 2011; limitation of motion of the arm rate noncompensable from May 26, 2000, 20 percent disabling from January 26, 2015; and 30 percent disabling from March 27, 2019; left carpal tunnel syndrome rated noncompensable from July 13, 2000, 10 percent disabling from March 17, 2008, and 20 percent disabling from May 12, 2011; GERD rated 10 percent disabling from October 31, 2008 to May 12, 2011; right knee instability rated 10 percent disabling from July 24, 2013; right knee patellofemoral pain syndrome rated 10 percent disabling from July 24, 2013; tinnitus rated 10 percent disabling from July 24, 2013; left lower extremity radiculopathy rated 10 percent disabling from July 24, 2013; right lower extremity radiculopathy rated 10 percent disabling from July 24, 2013; scars rated 10 percent disabling from May 16, 2015; and pelvic inflammatory disease rated 10 percent disabling from June 26, 2015. The Veteran is also in receipt of noncompensable evaluations for bilateral hammer toes from October 31, 2008; allergic rhinitis from May 12, 2011; right foot bunion and hallux valgus from May 17, 2015; and left foot bunion and hallux valgus from May 17, 2015. The Veteran is in receipt of a combined evaluation of 90 percent from October 31, 2008; and 100 percent from May 12, 2011. For the following reasons, the Board finds the evidence does not support a TDIU at any time during the appeal period. In the March 2015 VA treatment records, the Veteran reported that she has been employed in the telehealth department of a local VA facility since 2011. At an April 2015 VA examination for migraine headaches, the Veteran reported that she worked full time as a medical technician. As recently as April 2021, the Veteran remained employed at that job, and that she was in line for a promotion. Given the evidence of record, the Board finds that the Veteran has been in full-time, or substantially gainful employment throughout the appeal period. There is no indication in the record that such employment is marginal, at the poverty threshold, or in a protected environment. The Board is cognizant that the Veteran had some difficulties due to her service-connected disabilities. As detailed above, the Veteran's psychiatric symptoms include difficulty dealing with stressful situations, disturbances of motivation and mood, depressed mood, anxiety, decreased attention and concentration, and memory difficulty. Of note, the Veteran also reported that she has difficulty coping with work stressors, irritability towards co-workers, and lack of motivation. See e.g., April 2021 VA treatment records. A June 2012 VA examination noted that the Veteran has lost two weeks of work in the last 12 months due to service-connected headaches and asthma. However, the examiner indicated that this did not preclude obtaining or maintaining gainful employment. In a November 2016 VA examination for gynecological conditions, the Veteran was noted to have functional impact due to her service-connected pelvic inflammatory disease, with the need for frequent breaks, and change clothes and personal items. See also March 2019 VA examination. Further, in a March 2019 VA examination for muscle injuries, the examiner noted functional impact with approximate lost time of up to one week in the prior 12 months, and impact on the Veteran's ability to hold her arm up for very long, mop or carrying groceries. Ultimately, the record reflects that the Veteran has been substantially gainfully employed in a full-time position or nearly full-time position throughout the appeal period, despite any impact of his service-connected disabilities. Thus, the inability to maintain gainful employment has not been demonstrated and entitlement to a TDIU is denied. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Certain chronic diseases, such as hearing loss, will be presumed related to service absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. 3. Entitlement to service connection for right ear hearing loss is denied. In her initial claim, the Veteran sought service connection for bilateral hearing loss, as due to noise exposure in service, including exposure to weapons and trucks during field exercises. See March 2016 VA 21-526b. After the claim for bilateral hearing loss was denied in May 2016, the Veteran disagreed only with "hearing loss, right ear" in her July 2016 notice of disagreement. An appellant may limit the scope of an appeal by clearly expressing an intent to exclude certain issues from appellate consideration. See AB v. Brown, 6 Vet. App. 35, 39 (1993). Accordingly, the Board will proceed with the appeal as shown above. For the reasons that follow, the Board finds that service connection is not warranted. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the following frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies at the above thresholds are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The Veteran's personnel record show that she worked as a food service specialist during her active service. See DD 214. In an April 2014 VA examination, the Veteran reported noise exposure in service when she was crawling near a bunker which exploded. The Veteran reported that her hearing "got sucked out" for approximately one week with subsequent return to normal hearing. The Veteran also reported that she was exposed to loud noises caused by pots and pans from working in food services. However, service treatment records are silent for complaints, diagnosis, or treatment for hearing loss. Audiograms at entrance in June 1990 and at separation in March 1991 did not show hearing loss for VA purposes. Further, in the March 1991 report of medical history, the Veteran checked "no" to having had hearing loss. However, in the April 1991 audiogram, the Veteran was noted to be routinely exposed to hazardous noise. Nonetheless, the Veteran was noted to have normal hearing at that time and a hearing loss profile of H1, indicating a high level of fitness. At the Veteran's February 1995 separation examination, the Veteran again had hearing within normal range. On the authorized audiological evaluation, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 0 0 10 10 LEFT 10 5 0 0 10 In the February 1995 report of medical history, the Veteran again indicated that she did not have hearing loss. After her separation from service, the Veteran underwent an audiological evaluation in November 1998. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 0 0 10 15 LEFT 10 0 0 25 25 In the November 1998 report of medical history, the Veteran checked yes to having had hearing loss. In March 2002, the Veteran reported an anxiety attack with physical symptoms including hearing loss to the right side, pain, tingling, and sensitivity. In a January 2016 VA audiological evaluation, the Veteran was noted to have bilateral sensorineural hearing loss. The clinician notes that pure tone thresholds on air and bone conduction testing, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 35 25 25 45 35 LEFT 30 30 20 35 35 Tympanometry results were normal and suggestive of normal middle ear function. In January 2018 private treatment records, the Veteran was seen for decreased hearing. At that time, she reported that she had ear pressure and ringing that began after an explosion in service. Although testing showed mild sensorineural hearing loss in the right ear, the physical examination showed normal anatomical landmarks and tympanogram. In relation to this claim, the Veteran underwent a VA examination in April 2014, March 2019, and November 2020. Hearing loss was shown for VA purposes in the right ear. Test results and use of the speech discrimination score was appropriate. As to the etiology of the Veteran's hearing loss, the April 2014, March 2019, and November 2020 VA examiners negatively opined as to whether the Veteran's right ear hearing loss was related to service. In the April 2014 VA examination report, the examiner noted that in-service audiograms showed exposure to hazardous noise. However, the April 2014, March 2019, and November 2020 VA examiners indicated that comparison of service treatment records did not show a significant threshold shift. Moreover, the examiners noted that the November 1998 audiological evaluation after service showed normal hearing. Of note, the March 2019 VA examiner concluded that the in-service and the post-service audiological evaluation was objective evidence that no permanent auditory damage occurred from in-service noise exposure. Although the March 2019 examiner noted that there is some relationship between early noise exposure and acceleration of age-related hearing loss due to early noise exposure, there is no auditory damage and hearing loss shown in this case. The examiner went on to note that the Veteran has a significant history of ear-related medical conditions that could cause or contribute to tinnitus. In the June 2018, December 2019, and March 2021 Remand, the Board noted numerous articles submitted by the Veteran, which had not been considered by the April 2014, March 2019 and November 2020 VA examiner. Of note, the Veteran submitted an article titled, "Acceleration of Age-Related Hearing Loss by Early Noise Exposure." This article detailed an animal study showing that age-noise interaction exacerbated age-related hearing loss in previously noise-damaged ears. Among the findings, the study showed substantial ongoing deterioration of cochlear neural responses, perineural responses, and primary neural degeneration throughout the cochlea of these animals and suggested that early noise exposure renders the inner ear significantly more vulnerable to aging. The Veteran also submitted an article on the possible neural correlation between tinnitus with delayed onset after noise exposure and the effects of intense sound exposure on the dorsal cochlear nucleus. In the December 2019 Remand, the Board also noted that the March 2019 VA examiner's rationale relating the Veteran's right ear hearing loss to the other significant ear-related conditions was inadequate. The Board indicated that this rationale was unclear as to whether it only pertained to the tinnitus claim and it did not adequately identify the nature of those conditions. In October 2021, the Veteran submitted additional treatise evidence, including an article from the Journal of Neuroscience titled, "Acceleration of Age-Related Hearing Loss by Early Noise Exposure: Evidence of a Misspent Youth." The study results suggested that previous noise exposure has significant deleterious effects on the nature and progression of an age related hearing loss in young-exposed (mouse) subjects. The article also noted that addressing the question in human studies is difficulty due to high variability in actual noise exposure and other factors. Most recently, VA obtained an April 2021 addendum opinion. The examiner noted that in comparison of entrance to separation, there was no significant permanent shift in hearing thresholds beyond test variability in the right ear. This finding suggests that there is no objective evidence of permanent auditory damage during active duty from noise exposure. Further, the examiner noted that there is no complaint or treatment for hearing decreases in treatment records or at separation. The examiner went on to consider the medical literature relevant to this case, including those submitted by the Veteran. Of note, the examiner indicated that the 2006 Institute of Medicine study found that there are no studies on humans which support delayed onset hearing loss from noise exposure. There have been several attempts to dispute the IOM finding by showing that damage to inner ear structures at the time of nose exposure may lead to later onset hearing loss. However, the examiner distinguished these studies and their applicability to this case. Notably, the studies themselves had numerous shortfalls including exclusive use of animal models and the limitations of using that model on the ability to predict human responses. The examiner noted that these studies have reported that hearing losses in humans are multifactorial with numerous variables. More importantly, unlike the subjects in these studies, the Veteran was not shown to have auditory damage during service. The objective medical testing showed no auditory damage or hearing loss in service. Her medical history after service did not include treatment for hearing loss and a 1998 audiogram was normal. Thus, the evidence does not support hearing loss until many years after service. Upon review of the above evidence, the claims file does not contain evidence indicating the Veteran's right ear hearing loss onset during service or to a degree of 10 percent or more within a year of discharge from service. In-service audiometric testing and testing three years after separation showed hearing within normal limits without threshold shift. At separation, the Veteran marked "no" to having had hearing loss. Thus, the contemporaneous clinical findings, and the Veteran's contemporaneous lay assertion weigh against the claimed right ear hearing loss having had onset in service or within one year of separation. As to a nexus between service and the Veteran's current hearing loss, the Board finds the April 2021 VA opinion highly probative on its own. The examiner had the appropriate training, expertise, and knowledge to evaluate the claimed disability. The opinion was supported by a thorough and cogent rationale. The examiner considered the medical literature on the issue, including the studies submitted by the Veteran and the general contentions raised in those articles. The opinion also included consideration of the Veteran's reported symptoms both during and after service, and the post-service clinical history. The opinion provided the Board with a clear description of all relevant data points necessary to evaluate this claim. Although the Veteran's representative urges that VA failed to consider in-service noise exposure leading to late onset hearing loss, that specific contention was considered by the April 2021 VA examination report. See October 2021 correspondence. Thus, the April 2021 opinion is highly probative evidence against the claim. Furthermore, the other April 2014, March 2019, and November 2020 nexus opinions support the conclusion of the April 2021 VA examiner. Although the Board previously noted that they did not consider the articles submitted by the Veteran, the opinions are entitled to some probative weight because the examiners considered the entire medical history of the disability and the Veteran's relevant lay statements. The examiners' conclusions were based on the comparison of the entrance audiogram, the separation audiogram, and post-service November 1998 audiogram which showed hearing within normal limits and no threshold shift. The VA examiners considered the history of the disability. The Board notes that a medical article or treatise can be probative evidence when combined with an opinion of a medical professional if the medical article or treatise deals with generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least "plausible causality" based upon objective facts rather than on an unsubstantiated lay medical opinion. Mattern v. West, 12 Vet. App. 222, 228 (1999). Here, the articles cited are not sufficient to support a causal nexus. They are not combined with an opinion of a medical professional and do not pertain specifically to the Veteran's circumstances and clinical history. Furthermore, the Veteran is not competent to diagnose hearing loss or discern its etiology. While the Veteran is competent to report having experienced symptoms of hearing loss since service, the issue is medically complex, as it requires knowledge of an entirely internal organ systems in the body and interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Furthermore, the Veteran made statements denying hearing loss at the time of separation from service. As such, she is not competent to provide an opinion in this case and her statements as to onset in service are not probative. In sum, the Veteran's right ear hearing loss was not noted during service and it did not manifest to a degree of 10 percent or more within a year of discharge from service. 38 C.F.R. §§ 3.303 (b), 3.307(a)(3), 3.309(a). The April 2021 VA opinion weigh heavily against a nexus between the current right ear hearing loss and active service. In addition, the April 2014, March 2019, and November 2020 VA examination report are also probative evidence against the claim. Accordingly, the competent and probative evidence weighs against a nexus between the current disability and active service. There is no reasonable doubt to be resolved in this instance. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Service connection for right ear hearing loss is not warranted. 4. Entitlement to service connection for fibromyalgia is denied. The Veteran contends that her fibromyalgia had onset during service and manifested as musculoskeletal complaints in service. See December 2015 notice of disagreement. Alternatively, she asserts that her fibromyalgia is secondary to her service-connected disabilities. Initially, the Board notes that military personnel records does not show that the Veteran had foreign service. Thus, the provisions of 38 C.F.R. § 3.317 applicable to Persian Gulf Veteran are not applicable in this case. In the June 1990 enlistment examination, no abnormalities were noted. In September 1990, during ACDUTRA service, the Veteran complained of muscle aches lasting two weeks. The Veteran was assessed as having musculoskeletal pain. In the March 1991 separation examination, the Veteran was only noted to have chest wall tenderness. The Veteran checked yes to having had recurrent back pain and pain or pressure in the chest in the March 1991 report of medical history. The notes indicated pulled chest wall muscles, improved. During service, the Veteran also complained of pain in the head, left foot, calf muscles, low back, and right knee. In the February 1995 separation examination, the Veteran was noted to have abnormalities of the upper extremities, and spine, other musculoskeletal. The clinician noted tenderness and lumbar spasm with decreased strength of left pectoralis muscle. In the February 1995 report of medical history, the Veteran checked yes to having had swollen or painful joints, recurrent back pain, and foot trouble. After service, the Veteran checked "no" to having had swollen or painful joints, and arthritis, rheumatism, or bursitis in November 1998. The Veteran checked "yes" to having had recurrent back pain or back injury, and foot trouble. In February 2008 VA treatment records, the Veteran was seen for flu like symptoms and an impression of myalgia/arthritis was noted. The clinician noted myalgia of unclear etiology in February 2011, but that the symptoms appeared to be muscle strain with activity. The Veteran complained of a need for a checkup in relation to fibromyalgia in September 2014. In a women's health examination in December 2014, the clinician noted an assessment of fibromyalgia. However, in April 2016, the clinician noted that the Veteran has multiple joint pain, but the rheumatologist who have evaluated the Veteran does not believe the wrist and joint pain was an autoimmune problem. In March 2019, the Veteran underwent a VA examination for fibromyalgia. The examiner noted a diagnosis of fibromyalgia. The Veteran reported generalized body pain from 1990 to present, constant fatigue, and weather affected muscle knots. As to etiology, the examiner offered a negative opinion as to whether fibromyalgia was due to service. The examiner reasoned that the Veteran was not diagnosed with fibromyalgia in service and for many years after service. The examiner further noted that there is no evidence that fibromyalgia was diagnosed by a specialist or rheumatologist. In the March 2019 opinion, the examiner further indicated that it was not possible to confirm a current chronic diagnosis. Therefore, the examiner indicated that there was no nexus or plausible secondary relationship, and that fibromyalgia did not manifest in service. In addition, a review of the medical literature does not support a causal relationship. The examiner indicated that the Veteran's service-connected conditions are not known to cause fibromyalgia. As to whether the Veteran's fibromyalgia was aggravated by one or more of her service-connected disabilities, the examiner opined that there was no aggravation. In support, the examiner explained that the diagnosed fibromyalgia is a separate condition from all of the Veteran's service connected conditions. Pursuant to the Board's December 2019 remand, the Veteran was afforded another VA examination in November 2020 . The Veteran reported generalized muscle pain and weakness, which began in 1990 (during the Veteran's ACDUTRA service). In providing a negative etiological opinion, the examiner indicated that the diagnosis of fibromyalgia occurred after service. Furthermore, due to the nature of fibromyalgia, it is unclear whether the September 1990 complaint of muscle aches or the February 1995 complaints of swollen and painful joints were related to the diagnosis of fibromyalgia or other joint conditions. The examiner went on to opine that the diagnosed fibromyalgia is at least as likely as not aggravated beyond its natural progression by active duty service. The examiner reasoned that the physical demands of service place increased stress and pain on joints which may increase degeneration over time. The overuse of the joints can lead to osteoarthritis, which can worsen or aggravate a fibromyalgia condition. The March 2021 remand found this opinion inadequate to make a determination because the examiner did not provide further explanation or context for this conclusion. See Stefl v. Nicholson, 21 Vet. App. 120 (2007). In addition, the examiner indicated that it was not possible to diagnose fibromyalgia based on the in-service complaints of generalized muscle pain. However, the examiner went on to indicate that service aggravated this condition due to overuse. The two conclusions are inconsistent as to whether the Veteran's fibromyalgia existed at the time of service. Thus, VA obtained an addendum opinion in May 2021. The examiner negatively opined as to whether fibromyalgia had onset in service or is otherwise related to service. The examiner noted that there is no medical diagnosis of fibromyalgia during service. The examiner explained that the criteria for a diagnosis of fibromyalgia includes higher pain index score, symptoms present for multiple months, and the absence of another disorder that would otherwise explain the pain. Ultimately, fibromyalgia is a diagnosis of exclusion. Although there were complaints of pain in service, they were non-specific and does not otherwise meet the criteria. The examiner indicated that ultimately, the nature of the complaints does not support a diagnosis of fibromyalgia. The Board finds the opinion of the March 2019 and May 2021 opinions probative. Each examiner has the appropriate training, expertise, and knowledge to evaluate the claimed disability. Collectively, the examiners provided a thorough and cogent rationale, which included consideration of the Veteran's reported symptoms, the entire clinical history, and the medical literature on the etiology of fibromyalgia. The examination reports and opinions provided the Board with a clear description of all relevant data points necessary to evaluate this claim. There are no competent opinions to the contrary. Although the Veteran and her representative opined that the in-service complaints of pain represented the manifestations of fibromyalgia, neither are shown to be competent to diagnosis the symptoms as fibromyalgia or medically related her current symptoms to service. See October 2021 correspondence (where the representative argued that the February 1995 report of swollen and painful joints was evidence of the disability manifesting in service). The issue is medically complex, as it requires knowledge of the pathology of fibromyalgia and the workings of the musculoskeletal, neurological, and the immune system. Therefore, it is outside the competence of lay persons. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the objective medical evidence, including the March 2019 and May 2021 VA opinions. In sum, the preponderance of the evidence weighs against a nexus between the Veteran's fibromyalgia and active service. The preponderance of the evidence does not support proximate cause or aggravation of fibromyalgia by a service-connected disability. Accordingly, the benefit of the doubt doctrine is not applicable and the claim for entitlement to service connection for fibromyalgia must be denied. REASONS FOR REMAND 1. Entitlement to service connection for uterine fibroids is remanded. In an October 2021 correspondence, the Veteran's representative raised a new contention in relation to whether the Veteran's uterine fibroids is secondary to her service-connected disabilities. The representative argued that VA failed to obtain an adequate opinion which considered whether the prescribed medication for the Veteran's service-connected disabilities caused or aggravated her uterine fibroids. As such, an addendum opinion should be obtained that considers this contention. The matters are REMANDED for the following action: Obtain an addendum opinion from an appropriate clinician to determine the nature and etiology of the Veteran's uterine fibroids. The examiner must opine whether fibromyalgia is at least as likely as not (1) proximately due to service-connected disability, or (2) aggravated beyond its natural progression by service-connected disability. The examiner should consider any effect of medications used to treat the Veteran's service-connected disabilities. In this regard, the examiner should also consider whether the medications caused her to become obese; whether such obesity was a substantial factor in causing the claimed uterine fibroids; and whether the uterine fibroids would not have occurred but for the medication caused obesity. A fully-explained rationale for the requested opinions should be provided. In providing the requested opinion, the examiner should consider the Veteran's lay statements and clinical history. The examiner should note whether the reports about the Veteran's contentions align with how the currently diagnosed disability is known to develop or if the Veteran's contentions are inconsistent with the medical knowledge or otherwise implausible. If the requested opinions cannot be rendered without resorting to speculation, the examiner must explain why this is so. D. JOHNSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Vuong, 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.