Citation Nr: 21068948 Decision Date: 11/17/21 Archive Date: 11/17/21 DOCKET NO. 20-23 747 DATE: November 17, 2021 ORDER Entitlement to service connection for peripheral vascular disease, claimed as peripheral artery disease, bilateral lower extremities is granted. Entitlement to an increased disability rating to 70 percent, but no higher, for PTSD from May 18, 2017, is granted. Entitlement to a finding of total disability based on individual unemployability (TDIU) from May 18, 2017 is granted. Entitlement to service connection for diabetes mellitus type II is dismissed. Entitlement to service connection for sleep apnea is dismissed. Entitlement to service connection for onychomycosis, bilateral toes is dismissed. Entitlement to service connection for degenerative arthritis, left knee is dismissed. Entitlement to service connection for degenerative arthritis, right knee is dismissed. Entitlement to service connection for degenerative arthritis, right hip is dismissed. Entitlement to service connection for cervical spine condition is dismissed. Entitlement to service connection for degenerative arthritis, right hand is dismissed. Entitlement to service connection for degenerative arthritis, left hip status post arthroplasty is dismissed. Entitlement to service connection for degenerative arthritis, lumbar and thoracic spine is dismissed. Entitlement to service connection for COPD is dismissed. Entitlement to an increased disability rating for hypertension is dismissed. Entitlement to an increased disability rating for bilateral hearing loss is dismissed. REMANDED Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected disabilities, is remanded. FINDINGS OF FACT 1. The Veteran has a current diagnosis of peripheral vascular disease in the bilateral lower extremities that is secondary to service-connected hypertension. 2. In a June 2011 rating decision, the RO denied entitlement to service connection for peripheral vascular disease. The Veteran did not perfect an appeal to that decision, and it became final. Evidence received since that decision is new and material as to the issue of peripheral vascular disease of the bilateral lower extremities. 3. The Veteran's overall record does not demonstrate that his PTSD symptoms manifest in gross impairment in thought processes or communication, grossly inappropriate behavior, disorientation to time and place, or memory loss for names of close relatives, own occupation, or own name. 4. The record documents that the Veteran's service-connected disabilities prevent him from securing or following a substantially gainful occupation consistent with his work and educational background. 5. At the April 2021 Board hearing, prior to the promulgation of a decision in the appeal, the Board received notification from the Veteran, through his authorized representative, to withdraw the appeal for entitlement to service connection for diabetes mellitus type II, sleep apnea, onychomycosis of the toes, degenerative arthritis of the knees, hips, right hand, and lumbar, thoracic, and cervical spine condition, and COPD; and entitlement to an increased rating for hypertension and bilateral hearing loss disability. CONCLUSIONS OF LAW 1. The June 2011 rating decision, which denied the claim for entitlement to service connection for peripheral vascular disease bilateral lower extremities, is final. 38 U.S.C. § 7105; 38 C.F.R. § 3.105. 2. The evidence received subsequent to the June 2011 rating decision is new and material, and the issue of service connection for peripheral vascular disease bilateral lower extremities is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. The criteria for entitlement to service connection for peripheral vascular disease of the bilateral lower extremities have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.310. 4. The criteria for entitlement to a disability rating of 70 percent, but no higher, for PTSD from May 18, 2017 have been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. § 4.126, 4.3, 4.7, 4.130, Diagnostic Code 9411. 5. The criteria for entitlement to TDIU have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.340, 3.341, 4.1, 4.3, 4.16, 4.19, 4.25, 4.26. 6. The criteria for withdrawal of the appeal for entitlement to service connection for diabetes mellitus type II, sleep apnea, onychomycosis of the toes, degenerative arthritis of the knees, hips, right hand, and lumbar, thoracic, and cervical spine condition, and COPD; and entitlement to an increased rating for hypertension and bilateral hearing loss disability have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from May 1958 to April 1961 and from July 1961 to August 1978. Service Connection 1. Entitlement to service connection for peripheral vascular disease, claimed as peripheral artery disease, bilateral lower extremities is granted. The Veteran contends that he has peripheral vascular disease of the bilateral lower extremities that is related to a service-connected disability. After a thorough review of the evidence, the Board finds that entitlement to service connection for peripheral vascular disease, claimed as peripheral artery disease, of the bilateral lower extremities is warranted. In a June 2011 rating decision, the AOJ denied entitlement to service connection for peripheral vascular disease. The Veteran did not perfect an appeal to this decision. The Veteran submitted a new claim in May 2017. The AOJ found the additional evidence submitted was not new and material and did not reopen the claim for entitlement to service connection for peripheral vascular disease of the bilateral lower extremities. The Veteran perfected a timely appeal in response to the March 2020 statement of the case. After a review of the evidence, the Board finds that new and material evidence was submitted to reopen the claim for entitlement to service connection for peripheral vascular disease of the bilateral lower extremities and the claim is reopened. In reviewing the November 2018 rating decision, the Board has determined that a new and material evidence analysis is proper for the peripheral vascular disease claim on appeal, as it was clearly adjudicated by the June 2011 rating decision. See Velez v. Shinseki, 23 Vet. App. 199, 204 (2009) (when determining whether a new and material evidence analysis is required, the focus of VA's analysis must be on whether the evidence presented truly amounts to a new claim "based upon distinctly diagnosed diseases or injuries," or whether it is evidence tending to substantiate an element of the previously adjudicated matter). Regardless of the RO's actions, the Board has jurisdictional responsibility to determine whether a claim previously denied by the RO is properly reopened. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001) (citing 38 U.S.C. §§ 5108, 7105(c)). See also Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996) and VAOPGCPREC 05-92 (March 4, 1992). Accordingly, the Board must initially determine whether there is new and material evidence to reopen the peripheral vascular disease issue before proceeding to adjudicate the underlying merits of the claim. If the Board finds that no new and material evidence has been provided, that is where the analysis must end. A claimant may reopen a finally adjudicated claim by submitting new and material evidence. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The question of whether new and material evidence has been received sufficient to reopen the matter is a threshold question in any case involving a previously denied claim. Wakeford v. Brown, 8 Vet. App. 237, 239-40 (1995). The United States Court of Appeals for Veterans Claims (Court) has interpreted the language of 38 C.F.R. § 3.156(a) as creating a low threshold and viewed the phrase "raises a reasonable possibility of substantiating the claim" as "enabling rather than precluding reopening." The Court emphasized that the regulation is designed to be consistent with 38 C.F.R. § 3.159(c)(4), which "does not require new and material evidence as to each previously unproven element of a claim." Shade v. Shinseki, 24 Vet. App. 110 (2010). See also Evans v. Brown, 9 Vet. App. 273, 284 (1996) (the newly presented evidence need not be probative of all the elements required to award the claim, but only need to be probative in regard to each element that was a specified basis for the last disallowance). That is, a finally decided claim must be reopened where the claimant submits new and material evidence relative to a fact that was unestablished at the time of the prior final decision on the claim. Shade, 24 Vet. App. at 119. For the purpose of reopening a claim, the credibility of evidence is presumed unless the evidence is inherently incredible or consists of statements that are beyond the competence of the person or persons making them. See Justus v. Principi, 3 Vet. App. 510, 513 (1992); Meyer v. Brown, 9 Vet. App. 425, 429 (1996); King v. Brown, 5 Vet. App. 19, 21 (1993). Here, the Board finds that new and material evidence within the meaning of 38 C.F.R. § 3.156(a) has been received since the final June 2011 rating decision. Specifically, the Veteran's claim was previously denied for a lack of evidence showing a nexus between a currently diagnosed condition and some injury or event during a period of eligible service. The Veteran has since submitted a medical examination dated January 2021 for hypertension that notes peripheral vascular disease of the bilateral lower extremities is related to service-connected hypertension. This new evidence was neither cumulative nor redundant, as the medical documentation relating to peripheral vascular disease relates to the reason for which the claim was originally denied. For purposes of reopening a claim, the credibility of newly submitted evidence is generally presumed. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). The Board finds that the additional evidence of record constitutes new and material evidence to reopen the claim for entitlement to service connection for peripheral vascular disease of the bilateral lower extremities. In short, this evidence, if presumed credible, relates to an unestablished fact necessary to substantiate the peripheral vascular disease claim, i.e. whether the Veteran has a condition that is proximately due to a service-connected disability, and raises a reasonable possibility of substantiating the claim. Accordingly, the Board finds that new and material evidence has been presented to reopen the Veteran's previously denied peripheral vascular disease claim. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. As to the underlying merits of the appeal for entitlement to service connection for peripheral vascular disease of the bilateral lower extremities, the Veteran's medical treatment records document a current diagnosis of peripheral vascular disease. Service connection may be granted for a disability, which is proximately due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either caused or aggravated by a service-connected disease or injury. The Veteran is currently service-connected for hypertension since 1982. The Veteran has since submitted a medical examination dated January 2021 for service-connected hypertension wherein the physician states that the Veteran's peripheral vascular disease of the bilateral lower extremities, diagnosed as mild bilateral lower extremity arterial disease, is related to hypertension. The remaining medical evidence of record does not contain contradictory medical findings to that of the April 2021 medical examiner. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current bilateral lower extremity peripheral vascular disease, diagnosed as mild bilateral lower extremity arterial disease is proximately due to or aggravated beyond its natural progression by his service-connected hypertension. In cases where the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1Vet. App.49, 53-54 (1990). Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for bilateral lower extremity peripheral vascular disease as secondary to service-connected hypertension is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102, 3.310. Increased Rating 2. Entitlement to an increased disability rating to 70 percent, but no higher, for PTSD from May 18, 2017 is granted. The Veteran contends that his PTSD is worse than contemplated by the currently assigned 50 percent rating in effect when he submitted the claim on May 18, 2017. In a January 2021 rating decision, the RO increased the disability evaluation for PTSD to 70 percent with an effective date of October 16, 2020. After a thorough review of the evidence, the Board finds that a 70 percent disability evaluation, but no higher, for PTSD is warranted for the period on appeal from May 18, 2017. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. If there is a question as to which evaluation to apply to the Veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings are sufficiently characteristic to identify the disease and the resulting disability and coordination of rating with impairment of function. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of his disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Mental disorders are evaluated under the general rating formula for mental disorders, a specific rating formula presented under 38 C.F.R. § 4.130. When evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126(a). In addition, the evaluation must be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). As provided by the General Rating Formula, a 50 percent rating is assigned when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130. A 70 percent rating is in order when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130. A 100 percent rating is in order when 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; and memory loss for names of close relatives, own occupation, or own name. Id. A veteran need not exhibit "all, most, or even some" of the symptoms enumerated in the General Rating Formula for Mental Disorders to warrant the assignment of a higher rating. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Rather, the use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptomatology contemplated for each rating. Id. In particular, use of such terminology permits consideration of items listed as well as other symptoms and contemplates the effect of those symptoms on the claimant's social and work situation. Mauerhan, 16 Vet. App. at 442. The Federal Circuit has clarified that the General Rating Formula for Mental Disorders requires not only (1) sufficient symptoms of the kind listed in the percentage requirements, or others of similar severity, frequency, or duration, but also (2) that those symptoms cause the level of occupational and social impairment specified in the regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). The Federal Circuit endorsed an approach whereby the Board would identify the symptoms associated with the service-connected mental health disability, determine whether they are of the kind enumerated in the regulation, and if so, assess whether they result in the level of occupational and social impairment specified by a particular rating. Id. The Veteran's service-connected PTSD is currently assigned a 50 percent evaluation pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411, prior to October 16, 2020 and 70 percent from that date. The Veteran filed the initial claim for increased disability rating for PTSD on May 18, 2017. The Veteran contends that the PTSD symptoms he experiences support a higher evaluation. In the April 2021 Board hearing, the Veteran, through his authorized representative requested that the Veteran's 70 percent rating for PTSD be effective as of the date of filing the claim in May 2017. The Veteran expressed that he wants to kill himself but does not have a plan to do so, categorizing himself as "too coward" to do so. The Veteran explained that sometimes he goes a week without showering. The Veteran stated that at the time of filing the claim he was also having suicidal ideations. The Veteran stated that he has anger issues and avoids people to avoid confrontation. The Veteran explained that he sometimes has hallucinations like seeing his deceased mother. At the July 2017 VA PTSD examination, the Veteran denied suicidal or homicidal ideations. The Veteran expressed being lonely sometimes but also intentionally isolating socially. The Veteran reported that he lived at a senior community, but generally did not interact with the other tenants. The Veteran reported sleep disturbances, nightmares, irritability, and intrusive thoughts or memories associated with the PTSD. The examiner recorded the symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The examiner noted, "there was no evidence of hallucinations or delusions." The examiner assigned an overall evaluation corresponding to the 30 percent rating evaluation for PTSD. At the December 2020 PTSD examination, the Veteran stated that he handles his chores, and showers and dresses independently. The Veteran denied suicidal or homicidal ideation. The Veteran reported that his daughter had started to handle his finances as he was becoming too forgetful. The Veteran reported ongoing sleep problems, anxiety, anger issues, and being forgetful. The examiner recorded the symptoms of anxiety, suspiciousness, chronic sleep impairment, mild memory loss, impairment of short- and long-term memory, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, and intermittent inability to perform activities of daily living including maintenance of minimal personal hygiene. The examiner assigned an overall evaluation corresponding to the 70 percent rating evaluation for PTSD. The Veteran submitted a private psychiatric evaluation performed in June 2021. The provider recorded that the Veteran experienced severe nightmares and intrusive thoughts or memories, depression, periodic suicidal ideation. The examiner noted that the Veteran was alert, well-oriented, and logical but the Veteran was socially isolated and distrusting. The examiner noted the Veteran had a past history of irritable behavior to include treatment in 2012 for possible hallucinations. The examiner recorded the symptoms of persistent danger of hurting self or others; persistent delusions/hallucinations (but noted "questionable" next to this category); intermittent inability to perform activities of daily living including maintenance of minimal personal hygiene; suicidal ideations; inability to establish and maintain effective work and social relationships; difficulty in adapting to stressful circumstances; unprovoked irritability with periods of violence; panic/depression affecting the ability to function independently. The examiner assigned an overall evaluation corresponding to the 70 percent rating evaluation for PTSD. The examiner noted that the Veteran's condition was overall the same since 2017 according to the medical records and the Veteran's reported experiences. The Board finds that based on the record including, but not limited to, VA examinations, lay statements, other medical provider letters and records, and health treatment records, that the Veteran's PTSD, when viewed in light most favorable to the Veteran, was not productive of total occupational and social impairment during the appeal period based on the rating criteria. In adjudicating this claim, the competence and credibility of lay statements must be considered by the Board. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). The Veteran contends that his PSTD symptoms warrant a higher rating. The Board acknowledges that the Veteran is competent to give evidence about what he observes or experiences. Layno v. Brown, 6 Vet. App. 465 (1994). The Board finds that the Veteran's statements about his PTSD symptoms are credible where they are consistent with the overall record. The Veteran's overall record does not demonstrate that his PTSD symptoms manifest in gross impairment in thought processes or communication, grossly inappropriate behavior, disorientation to time and place, or memory loss for names of close relatives, own occupation, or own name. Although more recently the Veteran was reporting suicidal ideation and the 2021 evaluator noted that the Veteran presented a danger to himself or others, the overall record reflects that the Veteran was not previously reporting suicidal ideations at prior examinations and stated at the hearing that although he does have suicidal thoughts, he would not actually attempt it. Accordingly, the Veteran's PTSD does not most nearly approximate the 100 percent disability level. The Board finds that the Veteran's symptoms during the period on appeal most closely approximate the 70 percent disability level, accordingly, as to the appeal for an increased rating to 70 percent during the relevant period, the Board grants the appeal. 38 C.F.R. § 4.7. TDIU 3. Entitlement to a finding of total disability based on individual unemployability (TDIU) from May 18, 2017 is granted. The Veteran contends that as a result of service-connected disabilities, he in unemployable. After a thorough review of the evidence, the Board finds that the Veteran is unemployable and a grant of favorable finding of TDIU from the date of claim on May 18, 2017 is warranted. 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 as a result of their service-connected disabilities. 38 C.F.R. §4.16(a). Where a claimant, or the record, raises the question of unemployability due to the disability for which an increased rating is sought, then part of the increased rating claim is an implied claim for TDIU. Rice v. Shinseki, 22 Vet. App. 447 (2009). The law provides that a total disability rating may be assigned where the schedular rating is less than total, when the Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, or if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. See 38 C.F.R. §4.16(a). For the purpose of one 60 percent disability or one 40 percent disability in combination, disabilities resulting from a common etiology will be considered as one disability. See 38 C.F.R. §4.16(a)(2). Entitlement to a total rating must be based solely on the impact of the Veteran's service-connected disabilities on his ability to keep and maintain substantially gainful employment. See 38 C.F.R. §§3.340, 3.341, 4.16. While the regulations do not provide a definition of "substantially gainful employment," the VA Adjudication Procedure Manual, M21-1, Part VI, paragraph 7.09(a)(7), defines the term as "that which is ordinarily followed by the nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the Veteran resides." Also, in Faust v. West, 13 Vet. App. 342 (2000), the Court of Appeals for Veterans Claims ("Court/CAVC") defined "substantially gainful employment" as an occupation "that provides an annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days that the Veteran actually works and without regard to the Veteran's earned annual income..." The ability to work sporadically or obtain marginal employment is not substantially gainful employment. 38 C.F.R. §4.16(a); Moore v. Derwinski, 1Vet. App. 356, 358 (1991). Marginal employment, i.e., earned annual income that does not exceed the poverty threshold for one person, is not considered substantially gainful employment. 38 C.F.R. §4.16(a). Marginal employment also may be held to exist on a facts-found basis when earned annual income exceeds the poverty threshold. Id. Such situations may include, but are not limited to, employment in a protected environment such as a family business or sheltered workshop. Id. Requiring a Veteran to prove that he is 100-percent, i.e., totally unemployable, is different than requiring he prove that he cannot maintain substantially gainful employment. The use of the word "substantially" suggests intent to impart flexibility into a determination of the Veteran's overall employability, whereas a requirement that a Veteran prove 100-percent unemployability leaves no flexibility. Roberson v. Principi, 251 F.3d 1378, 1385 (Fed. Cir. 2001). But that said, as already referenced, to receive a TDIU, the Veteran's service-connected disabilities, alone, must be sufficiently severe to cause unemployability. Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Furthermore, VA regulations provide that all Veterans who, in light of their individual circumstance, but without regard to age, are unable to secure and follow a substantially gainful occupation as a result of service-connected disability shall be rated totally disabled, without regard to whether an average person would be rendered unemployable under the circumstances. See VAOPGPREC 75-91;57 Fed. Reg. 2317 (1992). Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion. 38 C.F.R. §4.16(b). However, individual unemployability must be determined without regard to any nonservice-connected disabilities or the Veteran's advancing age. 38 C.F.R. §§3.341(a), 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose, 4 Vet. App. at 363. Thus, the Board must evaluate whether there are circumstances in the Veteran's case, apart from any non-service-connected conditions and advancing age, which would justify a TDIU rating. 38 C.F.R. §§3.341(a), 4.16(a), 4.19. See Van Hoose v. Brown, 4 Vet. App. 361 (1993); see also Hodges v. Brown, 5 Vet. App. 375 (1993); Blackburn v. Brown, 4 Vet. App. 395 (1993). When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. §4.3. In analyzing the evidence, the Board must determine, as a question of fact, both the weight and credibility of the evidence. Equal weight is not accorded to each piece of evidence contained in a record; every item does not have the same probative value. The Board must account for the evidence which it finds to be persuasive or unpersuasive, analyze the credibility and probative value of all material evidence submitted by and on behalf of a claimant, and provide the reasons for its rejection of any such evidence. See Struck v. Brown, 9 Vet. App. 145, 152 (1996); Caluza v. Brown, 7 Vet. App. 498, 506 (1995); Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994); Abernathy v. Principi, 3 Vet. App. 461, 465 (1992); Simon v. Derwinski, 2 Vet. App. 621, 622 (1992); Hatlestad v. Derwinski, 1Vet. App.164, 169 (1991). The effective date of an evaluation and award of compensation will be the date of receipt of the claim, or the date entitlement arose, whichever is the later. 38 C.F.R. §3.400. The Veteran submitted a VA Form 21-526EZ, Claim, on May 18, 2017, with a variety of issues included herein, but did not specifically list TDIU. On the VA Form 21-8940 TDIU form submitted in October 2020, the Veteran listed PTSD, hypertension, and hypertensive heart disease as the disabilities preventing him from obtaining and maintaining successfully gainful employment, with the date of last full-time employment in 2000, and the date when the disability affected full-time employment as 1992. With the decision herein, the Veteran is currently service-connected for posttraumatic stress disorder (PTSD) at 70 percent from May 18, 2017; hypertensive heart disease at 30 percent; hypertension at 10 percent; tinnitus at 10 percent; and bilateral hearing loss at noncompensable rate; with a total rating of at least 80 percent from May 18, 2017. Although the RO has yet to assign a rating for the bilateral lower extremity peripheral vascular disease discussed earlier in this decision, the Veteran already meets the schedular rating requirements for consideration of a TDIU award. 38 C.F.R. §4.16(a)(2). At the April 2021 Board hearing, the Veteran stated that he finished high school and last worked in security for a college in the year 2000. At the July 2017 VA PTSD examination, the examiner recorded that the Veteran last worked in 2007 in the field of security. The Veteran stated that due to PTSD, he is not able to concentrate to the extent required to perform work. The Veteran also stated that he is unable to get along with coworkers to a level required by work. The Veteran also mentioned that he has been "seeing things that aren't there" for about two to three years and thinks that would also impact negatively on his ability to perform work. At the December 2020 PTSD examination, the examiner commented that, "His anxiety, sleep issues, memory problems, concentration and focus / as well as irritability problems and difficulties building and maintaining effective relationships affects his ability to obtain and maintain gainful employment. This veteran has not worked in 13 + years. At times his severe symptoms keep him from being able to maintain his hygiene and this would also affect his ability to maintain professional presence in the workplace." The January 2021, December 2020, and July 2017 examiners noted that the Veteran's hypertension does not affect his ability to work. The December 2020 examiner noted that the Veteran's service-connected hypertensive heart disease does not impact the ability to work. The December 2020 examiner noted that the Veteran's service-connected hearing loss affects his ability to work as reported by the Veteran in that he has difficulty hearing "most of the time" and the tinnitus affects his sleep. The July 2017 examiner noted that the hearing loss disability and tinnitus do not affect the Veteran's ability to perform work. Overall, the Veteran's inability to obtain and maintain substantially gainful employment is based on factors related to and symptoms of his service-connected PTSD. Given the foregoing, the Board finds that the positive evidence is at least in a state of equipoise with the negative evidence regarding the Veteran's claim of entitlement to an award of TDIU and thus grants the award from May 18, 2017. 38 U.S.C. §5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Dismissed 4. Entitlement to service connection for diabetes mellitus type II is dismissed. 5. Entitlement to service connection for sleep apnea is dismissed. 6. Entitlement to service connection for onychomycosis, bilateral toes is dismissed. 7. Entitlement to service connection for degenerative arthritis, left knee is dismissed. 8. Entitlement to service connection for degenerative arthritis, right knee is dismissed. 9. Entitlement to service connection for degenerative arthritis, right hip is dismissed. 10. Entitlement to service connection for cervical spine condition is dismissed. 11. Entitlement to service connection for degenerative arthritis, right hand is dismissed. 12. Entitlement to service connection for degenerative arthritis, left hip status post arthroplasty is dismissed. 13. Entitlement to service connection for degenerative arthritis, lumbar and thoracic spine is dismissed. 14. Entitlement to service connection for COPD is dismissed. 15. Entitlement to an increased disability rating for hypertension is dismissed. 16. Entitlement to an increased disability rating for bilateral hearing loss is dismissed. At the April 2021 Board hearing, the Veteran, through his representative, requested to withdraw several issues. An oral withdrawal of an appeal, such as one made at a hearing, must be (1) explicit, (2) unambiguous, and (3) done with a full understanding of the consequences of such action on the part of the claimant. DeLisio v. Shinseki, 25 Vet. App. 45, 57 (2011); see Acree v. O'Rourke, 891 F.3d 1009, 1014 (Fed. Cir. 2018). As the Veteran's withdrawal of the issues specified below was done with the aid of an authorized representative, the Board finds that the withdrawal was explicit, ambiguous, and done with the full understanding of the consequences of such action on the part of the Veteran. The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 19.55. Withdrawal may be made by the appellant or by his or her authorized representative. Id. In the present case, the Veteran, through his authorized representative, has withdrawn the appeal for entitlement to service connection for diabetes mellitus type II, sleep apnea, onychomycosis of the toes, degenerative arthritis of the knees, hips, right hand, and lumbar, thoracic, and cervical spine condition, and COPD; and entitlement to an increased rating for hypertension and bilateral hearing loss disability, and, hence, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the appeal for those issues and it is dismissed. REASONS FOR REMAND 17. Entitlement to service connection for erectile dysfunction is remanded. The Veteran contends that he has erectile dysfunction as a result of another service-connected disability. The Veteran's records do not show a formal diagnosis of erectile dysfunction. Lay persons are competent to report information to which they have knowledge of facts or circumstances and matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Although the Veteran has not been diagnosed with erectile dysfunction, nor has the medical background to formally provide an etiology to this condition if it exists, the Veteran is competent to report symptoms that would correlate to a diagnosis of erectile dysfunction. As the Veteran has not had a formal examination for this condition, nor has a doctor opined on whether it might be related to a service-connected condition if it is diagnosed, the RO should schedule a VA examination. The matter is REMANDED for the following action: 1. Schedule the Veteran for a VA examination for erectile dysfunction. The examiner should respond to the following questions: (a.) Does the Veteran have a diagnosis of erectile dysfunction? (b.) Is the Veteran's erectile dysfunction at least as likely as not related to an injury or event during active service? (c.) Is the Veteran's erectile dysfunction proximately caused or aggravated by any service-connected disability? DAVID L. WIGHT Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Miller, 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.