Citation Nr: 21068519 Decision Date: 11/10/21 Archive Date: 11/10/21 DOCKET NO. 17-48 158 DATE: November 10, 2021 ORDER Entitlement to service connection for tinnitus is denied. Entitlement to service connection for a sleep disorder is denied. The petition to reopen the previously denied service connection claim for a bilateral foot disorder (other than pes planus) is denied. The petition to reopen the previously denied service connection claim for ischemic heart disease (IHD) is denied. The petition to reopen the previously denied service connection claim for hypertension is denied. The petition to reopen the previously denied service connection claim for a respiratory disorder is denied. Entitlement to a rating in excess of 70 percent for posttraumatic stress disorder (PTSD) is denied. Entitlement to a rating in excess of 20 percent for diabetes mellitus, type 2, is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) is denied. FINDINGS OF FACT 1. The most probative evidence of record does not show that the Veteran's current tinnitus manifested during active service or to a compensable degree within one year of separation from active service, or that his bilateral tinnitus is etiologically related to his active service. 2. The Veteran's claimed sleep disorder did not originate in service and is not otherwise etiologically related to service. 3. The June 1998 rating decision denied the Veteran's claim of service connection for a bilateral foot disorder; the Veteran did not perfect an appeal with respect to the issue. 4. The evidence received since the June 1998 rating decision, by itself, or in conjunction with previously considered evidence, does not relate to an unestablished fact necessary to substantiate the underlying claim of entitlement to service connection for a bilateral foot disorder. 5. The June 2014 rating decision denied the Veteran's claim of service connection for IHD; the Veteran did not perfect an appeal with respect to the issue. 6. The evidence received since the June 2014 rating decision, by itself, or in conjunction with previously considered evidence, does not relate to an unestablished fact necessary to substantiate the underlying claim of entitlement to service connection for IHD. 7. The May 2010 rating decision denied the Veteran's claim of service connection for hypertension; the Veteran did not perfect an appeal with respect to the issue. 8. The evidence received since the May 2010 rating decision, by itself, or in conjunction with previously considered evidence, does not relate to an unestablished fact necessary to substantiate the underlying claim of entitlement to service connection for hypertension. 9. The June 1998 rating decision denied the Veteran's claim of service connection for a respiratory disorder; the Veteran did not perfect an appeal with respect to the issue. 10. The evidence received since the June 1998 rating decision, by itself, or in conjunction with previously considered evidence, does not relate to an unestablished fact necessary to substantiate the underlying claim of entitlement to service connection for a respiratory disorder. 11. The Veteran's PTSD manifested as symptoms no greater than occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. 12. The Veteran's service-connected diabetes has required treatment with an oral hypoglycemic agent but not daily injection of insulin, restricted diet, or regulation of activities. 13. The Veteran's service-connected disabilities were not of such severity that he was unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for tinnitus have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for entitlement to service connection for a sleep disorder have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 3. The June 1998 rating decision is final as to the Veteran's claim of entitlement to service connection for a bilateral foot disorder. 38 U.S.C. §§ 5108, 7105(c); 38 C.F.R. §§ 3.104, 20.200, 20.302, 20.1103. 4. New and material evidence sufficient to reopen the Veteran's claim of entitlement to service connection for a bilateral foot disorder has not been received; the claim is not reopened. 38 U.S.C. §§ 5108, 7105(c); 38 C.F.R. §§ 3.156, 20.1103. 5. The June 2014 rating decision is final as to the Veteran's claim of entitlement to service connection for IHD. 38 U.S.C. §§ 5108, 7105(c); 38 C.F.R. §§ 3.104, 20.200, 20.302, 20.1103. 6. New and material evidence sufficient to reopen the Veteran's claim of entitlement to service connection for IHD has not been received; the claim is not reopened. 38 U.S.C. §§ 5108, 7105(c); 38 C.F.R. §§ 3.156, 20.1103. 7. The May 2010 rating decision is final as to the Veteran's claim of entitlement to service connection for hypertension. 38 U.S.C. §§ 5108, 7105(c); 38 C.F.R. §§ 3.104, 20.200, 20.302, 20.1103. 8. New and material evidence sufficient to reopen the Veteran's claim of entitlement to service connection for hypertension has not been received; the claim is not reopened. 38 U.S.C. §§ 5108, 7105(c); 38 C.F.R. §§ 3.156, 20.1103. 9. The June 1998 rating decision is final as to the Veteran's claim of entitlement to service connection for a respiratory disorder. 38 U.S.C. §§ 5108, 7105(c); 38 C.F.R. §§ 3.104, 20.200, 20.302, 20.1103. 10. New and material evidence sufficient to reopen the Veteran's claim of entitlement to service connection for a respiratory disorder has not been received; the claim is not reopened. 38 U.S.C. §§ 5108, 7105(c); 38 C.F.R. §§ 3.156, 20.1103. 11. The criteria for a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.130, Diagnostic Code 9411. 12. The criteria for a rating in excess of 20 percent for diabetes mellitus, type 2, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.119, Diagnostic Code 7913. 13. The criteria for the grant of a TDIU are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from June 1968 to March 1970. This matter is before the Board of Veterans' Appeals (Board) on appeal from an April 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. Certain chronic diseases will be presumed related to service if they were noted as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if continuity of the same symptomatology has existed since service, with no intervening cause. 38 U.S.C. §§ 1101, 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2012); Fountain v. McDonald, 27 Vet. App. 258 (2015); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). The benefit of the doubt rule provides that a veteran will prevail in a case where the positive evidence is in a relative balance with the negative evidence. Therefore, the Veteran prevails in a claim when: (1) the weight of the evidence supports the claim, or (2) when the evidence is in equipoise. It is only when the weight of the evidence is against the claim that the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to service connection for tinnitus is denied. The Veteran contends that he has tinnitus that is related to in-service exposure to acoustic trauma. According to the Veteran's DD Form 214, he served as a light weapons infantryman during his active service from June 1968 to March 1970. A review of the Veteran's service treatment records does not reflect any diagnoses or treatment for tinnitus. The Veteran's March 1970 military separation medical examination did not report any complaints of tinnitus. A March 1970 report of medical history documented the Veteran's negative response to whether he had ever experienced hearing loss. At a February 1980 VA examination, the examiner reported that no hearing loss was noted. The examination report did not note any complaints of tinnitus. At a September 2012 VA PTSD examination, the Veteran reported that he worked for his father's yard service business during his teenage years. After his military service, the Veteran was a schoolteacher for 34 years and then retired. In October 2014, the Veteran filed a disability compensation claim for tinnitus. The Veteran received a VA tinnitus examination in March 2015. The Veteran reported that he experienced tinnitus that had an onset five to six year prior to the examination. The audiologist opined that the tinnitus was less likely than not caused by or a result of military noise exposure. As rationale, the examiner explained that the Veteran reported his tinnitus began approximately 5 to 6 years ago, which is approximately 40 years after separation from service, and there is nothing regarding tinnitus in the Veteran's service treatment records. Based on the evidence in this case, the Board finds that service connection for bilateral tinnitus is not warranted. The fact that the Veteran was exposed to some degree of noise during service does not by itself establish a basis for the grant of service connection. Rather, the noise exposure must cause the tinnitus. As noted above, a review of the Veteran's service treatment records does not reflect any complaints, findings, or treatment for tinnitus. The Veteran failed to report any problems with tinnitus at his separation medical examination conducted in March 1970, and there is a lengthy period between his active service and the first documented complaint of tinnitus in October 2014, when he claimed service connection for tinnitus. The Veteran's failure to report any complaints of tinnitus until more than forty years after discharge from active service is persuasive evidence that he was not experiencing tinnitus in the immediate years after service. The Board acknowledges that the Veteran believes his tinnitus is due to military noise exposure. To the extent the Veteran asserts that his tinnitus is etiologically related to service, such an assertion treads into the realm of medical expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n. 4 (Fed. Cir. 2007). For this purpose, the Board finds the Veteran's statements are not competent medical evidence. Consequently, the Board gives more probative weight to the March 2015 VA examination report. The audiologist opined that the Veteran's tinnitus was less likely than not caused by or a result of military noise exposure as there are no complaints of tinnitus in the Veteran's service treatment records and the Veteran first complained of tinnitus many years after discharge from service. Therefore, the Board finds that the criteria for service connection for tinnitus have not been met. Considering the foregoing, the preponderance of probative evidence of record is against the Veteran's claim for entitlement to service connection for tinnitus. Because the weight of the evidence is against the Veteran's claim, the benefit-of-the-doubt doctrine does not apply. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Service connection for bilateral tinnitus is therefore denied. 2. Entitlement to service connection for a sleep disorder is denied. The Veteran contends that he has a sleep disorder that is related to an in-service, event, illness, or injury. The Board notes that the Veteran was not afforded a VA examination for his service connection claim for a sleep disorder. In determining whether the duty to assist requires that a VA medical examination be provided, or medical opinion obtained with respect to a Veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumptive period; (3) whether there is an indication that the disability or symptoms may be associated with service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A(d) and 38 C.F.R. § 3.159 (c)(4). The third factor, in particular, is a low threshold. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this regard, the Board finds that the Veteran has not submitted sufficient evidence to indicate that he has a sleep disorder related to an event, injury, or disease that occurred in service. Accordingly, the Board finds that no further development of the claims for service connection for a sleep disorder is required. A review of the Veteran's service treatment records does not reflect any diagnoses or treatment for a sleep disorder. The Veteran's March 1970 military separation medical examination did not report any complaints of a sleep disorder. A March 1970 report of medical history documented the Veteran's negative response to whether he had ever experienced frequent trouble sleeping. A November 2012 VA administrative note reported the Veteran was having problems with sleep. A February 2014 VA primary care note reported the Veteran did not have any trouble falling or staying asleep. An October 2015 VA nursing note documented the Veteran's report of not experiencing sleep disturbances. During a March 2017 VA PTSD examination, the Veteran reported that he had moderate trouble falling or staying asleep. He reported that he woke up 2 to 3 times to "check my perimeter." He reported it was especially difficult to sleep in very windy conditions because he hears things blowing around and feels on guard. In October 2017, the Veteran submitted a statement in which he expressed that he still had problems sleeping. According to the Veteran, his wife has to wake him up because he gets very combative when dreaming. A February 2021 VA pre-operative medical evaluation reported the Veteran did not have a history of sleep apnea. As previously described, the Veteran's service treatment records do not reflect any diagnoses or treatment for a sleep disorder. The Veteran's March 1970 military separation medical examination did not report any complaints of a sleep disorder and a March 1970 report of medical history documented the Veteran's negative response to whether he had ever experienced frequent trouble sleeping. A February 2021 VA pre-operative medical evaluation reported the Veteran did not have a history of sleep apnea. Although the Veteran has chronic sleep impairment as a symptom of his PTSD, the evidence of record does not reflect that he has been diagnosed with sleep apnea or any other sleep disorder. As described above, the first prong of a service connection claim is a current disability. The evidence does not demonstrate that the Veteran had a sleep disorder during the pendency of the appeal. The U.S. Court of Appeals for Veterans Claims has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Based on a review of the foregoing evidence and the applicable laws and regulations, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for a sleep disorder. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against the claim, that doctrine is not helpful to this claimant. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Service connection has not been established and the Veteran's claim for a sleep disorder must be denied. New and Material Evidence Where a claim has been finally adjudicated, a claimant must present new and material evidence to reopen the previously denied claim. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). New evidence is evidence not previously submitted to agency decision makers. 38 C.F.R. § 3.156(a). Material evidence is evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. Id. New and material evidence cannot be either cumulative or redundant of the evidence of record at the time of the last prior final denial and must raise a reasonable possibility of substantiating the claim. Id. For the purposes of reopening a claim, newly submitted evidence is generally presumed to be credible. Justus v. Principi, 3 Vet. App. 510, 513 (1992). New and material evidence is not required as to each previously unproven element of a claim in order to reopen. Shade v. Shinseki, 24 Vet. App. 110, 120 (2010). There is a low threshold for determining whether evidence raises a reasonable possibility of substantiating a claim. Id. at 11718. 3. The petition to reopen the previously denied service connection claim for a bilateral foot disorder (other than pes planus) is denied. This matter is on appeal from an April 2015 rating decision, which included a denial of entitlement to service connection for a bilateral foot disorder as it was decided that the evidence submitted in support of the current claim did not constitute new and material evidence. The Veteran's claim for entitlement to service connection for a bilateral foot disability, other than pes planus, was previously denied on the merits in June 1998. The Veteran had claimed that he was hospitalized for two weeks during service for his feet swelling, cracking, and pulling away from the bone. The claim was denied as his service treatment records did not show treatment for or diagnosis of any chronic bilateral foot disorder other than flat feet, which had been previously considered and denied service connection. The Veteran did not submit any new and material evidence or any notice of disagreement to that determination within one year of the June 1998 decision. Therefore, the June 1998 decision became final. 38 U.S.C. §§ 7104, 7105; 38 C.F.R. §§ 3.104, 20.302, 20.1103. The pertinent evidence of record at the time of the June 1998 rating decision consisted of service dental records, private treatment records, a February 1980 VA examination, the Veteran's DD Form 214, and the Veteran's statements. Pertinent evidence received since the June 1998 rating decision consists of service treatment records, VA treatment records, private treatment records, a September 2017 VA foot conditions examination, and the Veteran's statements. A December 1968 service treatment record reported a complaint of pain in the Veteran's feet since he arrived in Vietnam. The Veteran reported he fractured his left first metatarsal two year ago, which was prior to his entry on active service. The diagnosis was flat feet and left foot sesamoiditis. A March 1980 rating decision denied service connection for pes planus, as it was found to pre-exist service but was not aggravated beyond its normal progression. In September 2017, the Veteran submitted a statement in which he reported that his feet and ankle are in pain every day. He stated that he was sent to a hospital in Vietnam and was given a profile. According to the Veteran, the condition was brought on from being in the rice fields of Vietnam. A September 2017 VA foot conditions examination report indicated that the Veteran was not determined to have a current foot diagnosis. A May 2018 VA podiatry outpatient note reported the Veteran had pain in "an area at the metatarsal heads plantarly and an area just distal to that, too." By itself or when considered with the evidence previously of record, none of the evidence submitted since the June 1998 denial relates to an unestablished fact necessary to substantiate the claim of entitlement to service connection for a bilateral foot disability and does not raise a reasonable possibility of substantiating the claim. Therefore, new and material evidence has not been received to reopen the claim of service connection for a bilateral foot disability. The requirements to reopen this claim have not been met, and the appeal must be denied. Until the appellant meets his threshold burden of submitting new and material evidence sufficient to reopen his claim, the benefit of the doubt doctrine does not apply. See Annoni v. Brown, 5 Vet. App. 463, 467 (1993). 4. The petition to reopen the previously denied service connection claim for ischemic heart disease (IHD) is denied. This matter is on appeal from an April 2015 rating decision, which included a denial of entitlement to service connection for ischemic heart disease as it was decided that the evidence submitted in support of the current claim does not constitute new and material evidence. The Veteran's claim for entitlement to service connection for IHD was previously denied on the merits in June 2014. The claim was denied because the medical evidence of record failed to show that IHD had been clinically diagnosed. The Veteran did not submit any new and material evidence or any notice of disagreement to that determination within one year of the June 2014 decision. Therefore, the June 2014 decision became final. 38 U.S.C. §§ 7104, 7105; 38 C.F.R. §§ 3.104, 20.302, 20.1103. The Veteran submitted a service connection claim for hypertension in October 2014. The RO interpreted this as a claim for reopening the claims for both hypertension and IHD. The Board recognizes that the Veteran's October 2014 claim was received within one year of the June 2014 rating decision. According to 38 C.F.R. § 3.156(b), new and material evidence received prior to the expiration of the appeal period, or prior the appellate decision if a timely appeal has been filed, will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. As will be discussed in greater detail below, new and material evidence has not been received in this case, to include within the one year period following the June 2014 rating decision. As the Veteran also did not file a notice of disagreement with the June 2014 decision, the decision is now final. 38 U.S.C. §§ 7104, 7105; 38 C.F.R. §§ 3.104, 20.302, 20.1103. The pertinent evidence of record at the time of the June 2014 rating decision consisted of service treatment records, VA treatment records, private treatment records, a February 1980 VA general examination report, an April 2014 VA ischemic heart conditions examination report, and the Veteran's statements. Pertinent evidence received since the June 2014 rating decision consists of VA treatment records, private treatment records, a September 2017 heart conditions disability benefits questionnaire, and the Veteran's statements. A September 1993 private medical record reported a heart catheterization found the Veteran's coronary arteries to be normal. A January 2011 VA medical record reported that the Veteran's heart exhibited no murmur or gallop. In April 2014, the Veteran was provided a VA ischemic heart disease examination. The examiner concluded that the Veteran did not have ischemic heart disease or congestive heart failure. The examiner remarked that the Veteran had a positive treadmill in August 1993 and then a heart catheter showed normal coronary arteries. The examiner found no documentation of any cardiac problems. The Veteran submitted a September 2017 heart conditions disability benefits questionnaire completed by a doctor. The doctor reported the Veteran did not have ischemic heart disease but had hypertension and hyperlipidemia. The doctor reported that an exercise stress test performed in July 2015 reported the Veteran's heart was normal. According to a July 2015 echocardiogram, the Veteran had a sinus arrhythmia. The doctor concluded that the Veteran's heart conditions did not impact his ability to work. By itself or when considered with the evidence previously of record, none of the evidence submitted since the June 2014 denial relates to an unestablished fact necessary to substantiate the claim of entitlement to service connection for a IHD and does not raise a reasonable possibility of substantiating the claim. Therefore, new and material evidence has not been received to reopen the claim of service connection for IHD. The requirements to reopen this claim have not been met, and the appeal must be denied. Until the appellant meets his threshold burden of submitting new and material evidence sufficient to reopen his claim, the benefit of the doubt doctrine does not apply. See Annoni v. Brown, 5 Vet. App. 463, 467 (1993). 5. The petition to reopen the previously denied service connection claim for hypertension is denied. This matter is on appeal from an April 2015 rating decision, which included a denial of entitlement to service connection for hypertension because it was decided that the Veteran did not submit new and material evidence. Here, the RO last denied service connection for hypertension in May 2010 on the basis that the evidence of record did not show that the Veteran's hypertension was incurred or caused by service. Although treatment records showed the Veteran was being treated for hypertension, there was no evidence showing that the hypertension began during or was caused by military service. In the year following the May 2010 decision, the Veteran did not submit any statements expressing disagreement with the decision nor did he submit any documents concerning the claim of service connection for congenital spinal deformity that could be considered new and material evidence. 38 C.F.R. §§ 3.156(b), 20.302. Therefore, the May 2010 decision became final. 38 U.S.C. §§ 7104, 7105; 38 C.F.R. §§ 3.104, 20.302, 20.1103. The pertinent evidence of record at the time of the May 2010 rating decision consisted of the Veteran's DD Form 214, VA treatment records, a February 1980 VA general examination report, and the Veteran's statements. Pertinent evidence received since the May 2010 rating decision consists of service treatment records, VA treatment records, private treatment records, a September 2017 heart conditions disability benefits questionnaire, and the Veteran's statements. A March 1970 report of medical history documented the Veteran's report that he did not have high blood pressure. At a February 1980 VA examination, the Veteran's blood pressure was 130/80 while sitting, and 120/80 while standing. An August 2002 VA primary care note reported that the Veteran denied any history of hypertension or heart disease. The Veteran submitted a September 2017 heart conditions disability benefits questionnaire completed by a doctor. The doctor reported the Veteran did not have ischemic heart disease but had hypertension and hyperlipidemia. The doctor reported that the results were normal for an exercise stress test performed in July 2015. The doctor reported that a July 2015 echocardiogram showed the Veteran had a sinus arrhythmia. The doctor concluded that the Veteran's heart conditions did not impact his ability to work. In consideration of the foregoing, new and material evidence has not been received to reopen a claim of service connection for hypertension. While new medical evidence has been received, the evidence is cumulative or redundant of the evidence of record at the time of the last final denial of the claim. By itself or when considered with the evidence previously of record, none of the evidence submitted since May 2010 relates to an unestablished fact necessary to substantiate the claim of entitlement to service connection for hypertension and does not raise a reasonable possibility of substantiating the claim. Therefore, new and material evidence has not been received to reopen the claim of service connection for hypertension. The requirements to reopen this claim have not been met, and the appeal must be denied. Until the appellant meets his threshold burden of submitting new and material evidence sufficient to reopen his claim, the benefit of the doubt doctrine does not apply. See Annoni v. Brown, 5 Vet. App. 463, 467 (1993). 6. The petition to reopen the previously denied service connection claim for a respiratory disorder is denied. This matter is on appeal from an April 2015 rating decision, which included a denial of entitlement to service connection for a respiratory disorder because it was decided that the Veteran did not submit new and material evidence. Here, the RO last denied service connection for a respiratory condition in June 1998 on the basis that the evidence of record did not show that the Veteran had a chronic respiratory condition that was incurred in or aggravated by service. The decision found that, although service treatment records show the Veteran was seen with complaints of sinus trouble, his separation examination showed the lungs and sinuses as normal and there was no diagnosis of a chronic respiratory condition. In the year following the June 1998 decision, the Veteran did not submit any statements expressing disagreement with the decision nor did he submit any documents concerning the claim of service connection for a respiratory disorder that could be considered new and material evidence. 38 C.F.R. §§ 3.156(b), 20.302. Therefore, the June 1998 decision became final. 38 U.S.C. §§ 7104, 7105; 38 C.F.R. §§ 3.104, 20.302, 20.1103. The pertinent evidence of record at the time of the June 1998 rating decision consisted of service dental records, private treatment records, a February 1980 VA examination, the Veteran's DD Form 214, and the Veteran's statements. Pertinent evidence received since the June 1998 rating decision consists of service treatment records, VA treatment records, private treatment records, and the Veteran's statements. A February 2014 VA annual review of chronic conditions reported that that Veteran had no breathing problems. A February 2015 VA annual review of chronic conditions reported that that Veteran had no breathing problems. VA primary care notes compiled in December 2017 and November 2018 reported that the Veteran had no breathing problems. In consideration of the foregoing, new and material evidence has not been received to reopen a claim of service connection for a respiratory disorder. While new medical evidence has been received, the evidence is cumulative or redundant of the evidence of record at the time of the last final denial of the claim. By itself or when considered with the evidence previously of record, none of the evidence submitted since June 1998 relates to an unestablished fact necessary to substantiate the claim of entitlement to service connection for a respiratory disorder and does not raise a reasonable possibility of substantiating the claim. Therefore, new and material evidence has not been received to reopen the claim of service connection for respiratory disorder. The requirements to reopen this claim have not been met, and the appeal must be denied. Until the appellant meets his threshold burden of submitting new and material evidence sufficient to reopen his claim, the benefit of the doubt doctrine does not apply. See Annoni v. Brown, 5 Vet. App. 463, 467 (1993). 7. Entitlement to a rating in excess of 70 percent for posttraumatic stress disorder (PTSD) is denied. An April 2015 rating decision granted denied an increased rating in excess of 70 percent for the Veteran's service-connected PTSD. The Veteran contends that the severity of his PTSD symptoms warrants a higher rating. The Veteran's PTSD has been rated under Diagnostic Code 9411, which is rated under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. 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. A 50 percent rating requires occupational and social impairment, but with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, 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 task); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted for even greater occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals that interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted if there is 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. When rating a mental disorder, VA must consider the frequency, severity, and duration of the Veteran's psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency must assign a rating 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. When rating the level of disability from a mental disorder, the rating agency must consider the extent of social impairment but cannot assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126. The Veteran's actual symptomatology, and resulting social and occupational impairment, will be the primary focus when assigning a disability rating for a mental disorder, and the Veteran may qualify for a particular rating by demonstrating the particular symptoms associated with that percentage, or other symptoms of similar severity, frequency, and duration. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). In deciding claims, it is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss each and every piece of evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Turning to the evidence, in May 2014, the Veteran was afforded a VA-contracted PTSD examination. Based on the clinical evaluation, the examiner diagnosed the Veteran with PTSD under DSM-5 criteria. The Veteran reported his marriage was going well and that he enjoyed fishing with a friend. He also lifts weights and works around the house. The Veteran attends a weekly PTSD group and denied ever being hospitalized or suicidal. The examiner reported the Veteran's speech was somewhat difficult to understand. He was cooperative with the examiner and would repeat himself when necessary. He is rigid and demanding of others, to the point that others tell him that he is harsh. He did credit working with his group for being able to control his anger, to some extent. He still gets angry easily, especially if he feels disrespected. He also holds on to his anger for days, which is interfering with his relationships. The examiner reported that the Veteran exhibited the following symptoms for VA rating purposes: depressed mood; anxiety; suspiciousness; panic attacks that occur weekly or less often; chronic sleep impairment; mild memory loss; disturbances of motivation and mood; and difficulty in adapting to stressful circumstances. The examiner opined that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood. In March 2017, the Veteran was afforded a VA PTSD examination. Based on the clinical evaluation, the examiner diagnosed the Veteran with PTSD under DSM-5 criteria. The Veteran reported he did not get along well with his wife. He reported having good relationships with his two daughters who both live near him. The Veteran reported feeling a connection to the guys in his PTSD group and says he never misses group therapy because it has been very helpful to him, especially in learning to control his anger. The Veteran also had some friends outside of the group. The examiner reported that testing conducted was suggestive of moderate depression and mild anxiety. The Veteran indicated he did not like being around a lot of people because he was always on guard. The Veteran was easily irritated and gets "depressed a little" over health issues. The Veteran reported he loved fishing, watching cowboy shows, and coming to his weekly PTSD therapy group. The Veteran denied suicidal and homicidal ideation. He did not display any evidence of delusional thinking or perceptual disturbances. His attention, concentration, and memory all appeared grossly intact. The Veteran exhibited the following symptoms for VA rating purposes: anxiety; suspiciousness; chronic sleep impairment; mild memory loss; and difficulty in adapting to stressful circumstances. The examiner opined that the Veteran had occupational and social impairment with reduced reliability and productivity. An August 2020 VA mental health note reported that the Veteran was doing "OK." He reported that he had been working on a deck in his backyard. As chronicled above, the Veteran clearly experienced psychiatric symptomatology during this period as a result of his PTSD with symptoms such as anxiety, suspiciousness, chronic sleep impairment, and difficulty in adapting to stressful circumstances. However, the preponderance of evidence weighs against finding that his level of occupational and social impairment was total during this period. In support of such finding, the Board assigns great probative value to the VA medical examination reports. The May 2014 examiner opined that the Veteran had symptoms resulting in occupational and social impairment with deficiencies in most areas. The March 2017 examiner opined that the Veteran had symptoms resulting in occupational and social impairment with reduced reliability and productivity. Additionally, the Board has taken into consideration the frequency, severity, and duration of the Veteran's symptoms of mental disorders during the appellate period, as well as his statements regarding his assessment of the severity of his symptoms. However, the symptoms presented here, and their resulting effects, do not rise to the level of the next higher rating for 100 percent. The Veteran had good relationships with his two daughters who both live near him. The Veteran reported feeling a connection to the guys in his PTSD group and says he never misses group therapy. He also had some friends outside of the group. The Veteran reported he loved fishing, watching cowboy shows, and coming to his weekly PTSD therapy group. In March 2017, the Veteran did not display any evidence of suicidal ideation or delusional thinking and his attention, concentration, and memory all appeared grossly intact. In August 2020, the Veteran expressed that he was doing "OK" and reported that he had been working on a deck in his backyard. Clearly, such findings are not consistent with a higher 100 percent rating, which is due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. 38 C.F.R. § 4.130. For these reasons, the Board finds that the Veteran's PTSD, has not manifested by symptomatology more nearly approximating the criteria for a 100 percent disability rating under 38 C.F.R. § 4.130, Diagnostic Code 9411. The benefit-of-the-doubt doctrine is not for application, and an increased rating under this code is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim must be denied. 8. Entitlement to a rating in excess of 20 percent for diabetes mellitus, type 2, is denied. An April 2015 rating decision granted denied an increased rating in excess of 20 percent for the Veteran's service-connected diabetes mellitus, type 2. The Veteran contends that the severity of his symptoms warrants a higher rating. The Veteran's diabetes mellitus, type 2, is rated as 20 percent disabling under Diagnostic Code 7913. 38 C.F.R. § 4.119, Diagnostic Code 7913. Diagnostic Code 7913 provides a structured scheme of specific, successive, cumulative criteria. Each higher rating includes the same criteria as the lower rating plus distinct new criteria. Middleton v. Shinseki, 727 F.3d 1172, 1178 (Fed. Cir. 2013). A 10 percent rating is warranted when diabetes is manageable by restricted diet only. A 20 percent rating is warranted when diabetes requires one or more daily injections of insulin and restricted diet, or an oral hypoglycemic agent and restricted diet. A 40 percent rating is warranted when it requires one or more daily injections of insulin, restricted diet, and regulation of activities. Regulation of activities is defined as avoidance of strenuous occupational and recreational activities. A 60 percent rating is warranted when diabetes requires one or more daily injections of insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating is warranted when diabetes requires more than one daily injection of insulin, restricted diet, and regulation of activities, with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. Compensable complications of diabetes are evaluated separately unless they are part of the criteria used to support a 100-percent evaluation. Noncompensable complications of diabetes are considered part of the diabetic process. 38 C.F.R. § 4.119, Diagnostic Code 7913 (Note 1). Turning to the evidence, a March 2015 VA examination report reflects that the Veteran's diabetes mellitus was managed by restricted diet and he had been prescribed an oral hypoglycemic agent. The examiner reported that regulation of activities was not required as part of medical management of his diabetes mellitus. He visited his diabetic care provider for episodes of ketoacidosis less than two times per month, and there were no episodes of ketoacidosis that required hospitalization over the past 12 months. He visited his diabetic care provider for episodes of hypoglycemia less than two times per month, and there were no episodes of hypoglycemia that required hospitalization over the past 12 months. A March 2017 VA examination report reflects that the Veteran's diabetes mellitus was managed by restricted diet and he had been prescribed an oral hypoglycemic agent. The examiner reported that regulation of activities was not required as part of medical management of his diabetes mellitus. He visited his diabetic care provider for episodes of ketoacidosis less than two times per month, and there were no episodes of ketoacidosis that required hospitalization over the past 12 months. He visited his diabetic care provider for episodes of hypoglycemia less than two times per month, and there were no episodes of hypoglycemia that required hospitalization over the past 12 months. The Veteran's VA and private treatment records do not show that the Veteran visited his diabetic care provider for episodes of ketoacidosis less than two times per month and there were no episodes of ketoacidosis or hypoglycemia that required hospitalization during the appeal period. The Veteran is competent to report that he has symptoms of diabetes mellitus. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, he does not assert, and medical treatment records do not show, that his diabetes mellitus required one or more daily injections of insulin, regulation of activities, or twice a month visits or one or more hospitalizations per year. Accordingly, the preponderance of the evidence is against assigning a rating in excess of 20 percent during the period on appeal. Consequently, the benefit-of-the-doubt rule does not apply and entitlement to an increased rating as described above, is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 9. Entitlement to a total disability rating based on individual unemployability (TDIU) is denied. The Veteran contends that he is entitled to a TDIU because his service-connected PTSD causes him to be unemployable. A TDIU may be assigned when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation because of service-connected disabilities. 38 C.F.R. § 4.16(a). If there is only one such disability, it must be rated at 60 percent or more; if there are two or more disabilities, at least one disability must be rated at 40 percent or more, with sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). For the above purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric, (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. 38 C.F.R. § 4.16(a). The Veteran was service connected for the following: PTSD, rated at 70 percent from April 11, 2012; right upper extremity diabetic peripheral neuropathy, rated at 40 percent from January 13, 2011; left upper extremity diabetic peripheral neuropathy, rated at 30 percent from January 13, 2011; diabetes mellitus, type 2, rated at 10 percent from December 6, 2012; right lower extremity diabetic peripheral neuropathy, rated at 20 percent from January 13, 2011; left lower extremity diabetic peripheral neuropathy, rated at 20 percent from January 13, 2011; and chronic bilateral tinea pedis, rated at 0 percent from February 5, 1980. The Veteran had a combined disability rating of 70 percent from April 11, 2012, 80 percent from December 5, 2013, and 100 percent from January 13, 2021. Thus, the schedular criteria for TDIU have been met from April 11, 2012. 38 C.F.R. § 4.16(a). Turning to the evidence, in August 2014, the Veteran submitted a VA Form 21-8940 (Veteran's Application for Increased Compensation Based on Unemployability) in which he reported that his high blood pressure and service-connected PTSD prevented him from securing or following any substantially gainful occupation. The Veteran reported that he last worked full-time as a teacher in 2008 and did not leave his last job because of his disability. The Veteran's education included completion of four years of college. The Veteran submitted another VA Form 21-8940 in August 2014 in which he reported that his high blood pressure, heart, and service-connected diabetes mellitus and PTSD prevented him from securing or following any substantially gainful occupation. According to a February 2015 VA Form 4192, Request for Employment Information in Connection with Claim for Disability, completed by Wichita Public Schools, the Veteran had been employed as an art teacher from August 1977 to July 2007. The Veteran was working 35 hours per week. The reason for termination was that the Veteran retired. It was reported that no concessions were made for disability. The examiner who conducted a May 2014 VA PTSD examination opined that the Veteran had symptoms resulting in occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood. The Veteran received VA diabetes mellitus examination in March 2015 and March 2017. The examiners opined that the Veteran's diabetes mellitus does not impact his ability to work. The examiner who conducted a March 2017 VA PTSD examination opined that the Veteran had symptoms resulting in occupational and social impairment with reduced reliability and productivity. An August 2020 VA mental health note reported that the Veteran was doing "OK." He reported that he had been working on a deck in his backyard. Following a review of the evidence of record, the Board finds that the collective impact of the Veteran's service-connected disabilities did not preclude him from obtaining or maintaining substantially gainful employment. In support of such finding, the Board assigns great probative value to the VA medical examination reports. The May 2014 examiner opined that the Veteran had symptoms resulting in occupational and social impairment with deficiencies in most areas. The March 2017 examiner opined that the Veteran had symptoms resulting in occupational and social impairment with reduced reliability and productivity. The examiners who assessed the Veteran's diabetes mellitus in March 2015 and March 2017 opined that the Veteran's diabetes mellitus does not impact his ability to work. Moreover, on the second VA Form 21-8940 submitted by the Veteran in August 2014, he reported that his high blood pressure, heart, and service-connected diabetes mellitus and PTSD prevented him from securing or following any substantially gainful occupation. However, as previously described, the Veteran's service connection claims for hypertension and ischemic heart disease are denied herein. The Veteran's former employer reported the Veteran retired after serving as a schoolteacher for 30 years. It was reported that no concessions were made for disability. (Continued on the next page) The preponderance of the evidence does not show that the severity of the Veteran's service-connected disabilities renders him unable to secure or follow a substantially gainful occupation. Accordingly, the Board finds that entitlement to TDIU is not warranted and the Veteran's claim is denied. As the preponderance of the evidence is against the claim for a TDIU, the benefit-of-the-doubt rule is inapplicable. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). KELLI A. KORDICH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Moore, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.