Citation Nr: 21069786 Decision Date: 11/19/21 Archive Date: 11/19/21 DOCKET NO. 16-51 246 DATE: November 19, 2021 ORDER Prior to March 21, 2017, entitlement to a rating in excess of 50 percent for posttraumatic stress disorder is denied. From March 21, 2017, entitlement to a rating in excess of 70 percent for posttraumatic stress disorder is denied. Entitlement to a rating in excess of 10 percent for a lumbar strain is denied. Entitlement to a rating in excess of 30 percent for coronary artery disease is denied. Entitlement to a total disability rating based on individual unemployability is granted. FINDINGS OF FACT 1. Prior to March 21, 2017, the Veteran's PTSD was manifested by symptoms that more closely approximated the criteria for a rating of 50 percent. 2. From March 21, 2017, the Veteran's PTSD was manifested by symptoms that more closely approximated the criteria for a rating of 70 percent. 3. During the period of appeal, the Veteran's lumbar strain manifest by forward flexion of 90 degrees and overall range of motion of 180 degrees without evidence of ankylosis. 4. During the period of appeal, the Veteran's coronary artery disease (CAD) did not manifest with more than one episode of acute congestive heart failure in the past year, or a workload of greater than 3 METs but not greater than 5 METs that results in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. 5. During the period of appeal, the Veteran's service-connected disabilities precluded him from obtaining and maintaining substantially gainful employment consistent with his level of education, prior work history and training. CONCLUSIONS OF LAW 1. Prior to March 21, 2017, the criteria for entitlement to a rating in excess of 50 percent for PTSD are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.125, 4.130, Diagnostic Code 9411. 2. From March 21, 2017, the criteria for entitlement to a rating in excess of 70 percent for PTSD are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.125, 4.130, Diagnostic Code 9411. 3. The criteria for entitlement to a rating in excess of 10 percent for a lumbar strain are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5237. 4. The criteria for entitlement to a rating in excess of 30 percent for coronary artery disease (CAD) are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.104, Diagnostic Code 7005-7018. 5. The criteria for entitlement to a total disability rating based on individual unemployability (TDIU) are met. 38 U.S.C. §§ 1155, 5107 (2018); 38 C.F.R. §§ 3.102, 3.159, 3.340, 3.341, 4.15, 4.16, 4.18, 4.19 (2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from September 1963 to September 1967. This appeal comes before the Board of Veterans' Appeals (Board) from a May 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO), in New Orleans, Louisiana. In a December 2018 decision, the Board remand the claims for PTSD, coronary artery disease (CAD) and a lumbar strain for issuance of a supplemental statement of case (SSOC) and for review of the claim for a TDIU. In a January 2020 decision, the Board remanded the claim for PTSD for issuance of an SSOC after the Veteran underwent a new VA examination. The RO issued July 2020 and September 2020 SSOCs for PTSD, CAD, a lumbar strain and TDIU. The case was then returned to the Board. This appeal has been advanced on docket pursuant to 38 C.F.R. § 20.902(c). Increased Rating Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. See 38 U.S.C. § 1155; 38 C.F.R. Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted considering the entire recorded history, and each disability must be considered from the viewpoint of the Veteran working or seeking work. 38 C.F.R. § 4.2. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In all increased rating claims, staged ratings must be considered for the entire period on appeal. A staged rating is appropriate when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings under the applicable diagnostic code(s). Hart v. Mansfield, 21 Vet. App. 505, 509 (2007), Fenderson v. West, 12 Vet. App. 119 (1999). 1. Prior to March 21, 2017, entitlement to a rating in excess of 50 percent for posttraumatic stress disorder 2. From March 21, 2017, entitlement to a rating in excess of 70 percent for posttraumatic stress disorder Under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under that regulation. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-117 (Fed. Cir. 2013). The symptoms listed are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms, but also that those symptoms have caused occupational and social impairment in most of the referenced areas" - i.e., "the regulation...requires an ultimate factual conclusion as to the Veteran's level of impairment in most areas." Vazquez-Claudio, 713 F.3d at 117-118; 38 C.F.R. § 4.130. Further, when evaluating a mental disorder, the Board must consider the "frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission," and must also "assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination." 38 C.F.R. § 4.126(a). The Veteran's service-connected PTSD has been evaluated pursuant to 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411 throughout the appeal period. Under DC 9411, a 30 percent rating is assigned where there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted 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 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. A 70 percent rating is warranted where there is occupational and social impairment with deficiencies in most areas, including work, school, family relationships, judgment, thinking or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; 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. The highest rating of 100 percent is warranted where 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. a) Prior to March 21, 2017 The Veteran contends in his March 2016 notice of disagreement that he is entitled to a higher rating for PTSD. During a mental health consult in July 2010, the Veteran reported nightmares, irritability, difficulty with concentration, and hypervigilance. See November 2011 VA Medical Treatment Records. The Veteran denied suicidal or homicidal ideations. He was diagnosed with PTSD and major depression, however he refused medications for his condition. Id. During a September 2010 medical appointment, the Veteran reported nightmares, isolation at home, and anxiety. The physician noted he was struggling with his PTSD, depression, and anxiety but that he still refused to take medication to treat his symptoms. Id. During a December 2010 VA examination, the Veteran reported nightmares, anxiety, difficulty falling asleep, irritability, hypervigilance and difficulty concentrating. The examiner opined that the Veteran did not meet the criteria for a PTSD diagnosis. The examiner stated that a diagnosis could not be offered because the Veteran did not present an accurate portrayal of his symptoms during the evaluation. Id. In addition, the examination yielded inconsistent and unreliable results based on a structured assessment used to detect malingering. Id. During a September 2012 mental health evaluation, the Veteran reported insomnia, nightmares, flashbacks, anxiety, intense anger, and a startle response. See September 2012 Private Medical Treatment Records. He stated that his life was unbearable and that he had thoughts of suicide but would not act one them. The Veteran was diagnosed with PTSD and moderate to severe major depressive disorder. Id. During a January 2015 VA examination, after evaluating the Veteran for 1.75 hours, the examiner opined he did not meet the full criteria for PTSD. In addition, the examiner stated they left sections of the examination blank because the Veteran was not cooperative and therefore the examiner was unable to provide the information without resorting to mere speculation. Specifically, they stated the Veteran was administered two tests and the results from both tests indicated he was feigning symptoms. Further, one of the tests was specifically standardized on a sample of veterans applying for financial remuneration for a claim of disability resulting from PTSD. The examiner also noted the Veteran was administered a test during his December 2010 VA examination that indicated he was feigning psychological symptoms. Id. The January 2015 VA examiner was asked to provide an addendum medical opinion due to the conflicting medical evidence regarding the Veteran's PTSD diagnosis. See March 2015 VA Examination. The VA examiner explained the Veteran's private medical providers based their diagnostic opinion on an unstructured interview and failed to assess the veracity of the Veteran's reported symptoms. Id. In contrast, the VA examiner explained that they used a structured interview to assess the Veteran for PTSD, which research supported was significantly and statistically superior to the unstructured interview. Id. Further, it was possible for the Veteran to have PTSD related symptoms but to still not meet the criteria for a PTSD diagnosis. Id. In a January 2016 private mental health evaluation, the Veteran reported flashbacks, nightmares, hypervigilance, impaired memory, reckless behavior, aggressiveness, and sleep disturbance. See March 2016 Correspondence. Dr. D.M. (D.M., PsyD) diagnosed the Veteran with moderate to severe PTSD, memory loss, and depressive disorder. Id. Dr. D.M opined that the Veteran's symptoms caused a level of impairment that greatly interfered with his daily functioning and would prohibit working in any capacity. Id. The Board finds that prior to March 21, 2017 the Veteran's symptoms did not more closely approximate occupational and social impairment with deficiencies in most areas, including work, school, family relationships, judgment, thinking or mood. The Veteran reported symptoms of sleep impairment, nightmares, irritability, difficulty concentrating and hypervigilance. See March 2016 Correspondence and September 2012 Private Medical Treatment Records. However, he also reported being married for 48 years, having a good relationship with his adult daughter, and working full time until a back injury in 1995 forced him to retire. While there are multiple conflicting medical opinions regarding whether the Veteran currently has a diagnosis of PTSD, the Board finds the VA and private medical opinions to be in equipoise for the purposes of his diagnosis. Therefore, while the Board acknowledges the Veteran's symptoms caused some social impairment, the record in total reflects his symptoms are not productive of occupational and social impairment with deficiencies in most areas. A rating in excess of 50 percent for PTSD is not warranted. 38 C.F.R. § 4.130. For the foregoing reasons, the preponderance of the evidence is against the claim for a rating in excess of 50 percent for PTSD. The benefit of the doubt doctrine is therefore not for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. a) From March 21, 2017 During a March 2017 VA examination, the Veteran reported weekly panic attacks, distressing thoughts, angry outbursts, avoidance of public places and sleep impairment. He denied having many friends as most of his friends had died or were diagnosed with terminal illnesses. The examiner confirmed a diagnosis of PTSD and opined the Veteran had occupational and social impairment with reduced reliability and productivity. Id. The Veteran's symptoms included depressed mood, anxiety, suspiciousness, weekly panic attacks, chronic sleep impairment, mild memory loss, disturbance of mood, difficulty adapting to stressful circumstances and in establishing effective work and social relationships. Id. During an April 2018 VA examination, the examiner stated he concurred with the March 2015 VA opinion that the Veteran's symptoms did not meet the criteria for PTSD. Instead, the examiner opined the Veteran had a major neurocognitive disorder, that was not caused by a traumatic stressor, resulting in occupational and social impairment with deficiencies in most areas, including family relations, judgment, thinking and mood. Id. The Veteran's symptoms included anxiety, chronic sleep impairment, mild memory loss, and impairment of short- and long-term memory. Id. During an October 2019 VA examination, the examiner confirmed the Veteran's diagnosis of PTSD and opined this caused occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although he was generally functioning satisfactorily. The Veteran denied a history of hospitalizations, suicidal or homicidal ideations. The Veteran's symptoms included anxiety, suspiciousness, and chronic sleep impairment. Id. In a January 2020 statement, the Veteran reported symptoms of hypervigilance, irritability, nightmares, and flashbacks. See January 2020 Correspondence. He stated it was difficult for him to leave the house which made his depression worse. He stated that due to his condition, when he goes out in public he needs to sit with his back against the wall and at times sees shadowy figures in the room that are not actually present. Id. He stated that his memory has declined making it difficult to remember what people tell him and cause him to forget to complete simple tasks. Id. The Board finds that from March 21, 2017, the Veteran's symptoms did not more closely approximate 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 or intermittent inability to perform activities of daily living. The Veteran reported symptoms of depressed mood, anxiety, suspiciousness, weekly panic attacks, chronic sleep impairment, mild memory loss, disturbance of mood, difficulty adapting to stressful circumstances and in establishing effective work and social relationships. See March 2017 and April 2018 VA Examinations. However, the Veteran has maintained his familial relationships, goes out to dinner on occasion, is talkative, and maintains personal hygiene. See October 2019 VA Examination. There is no evidence of suicidal or homicidal ideations or of persistent delusions or hallucinations. Id. While the Board acknowledges the Veteran's PTSD caused some social impairment, the record in total reflects his symptoms are not productive of total occupational and social impairment. A rating in excess of 70 percent for PTSD is not warranted. 38 C.F.R. § 4.130. For the foregoing reasons, the preponderance of the evidence is against the claim for a rating in excess of 70 percent for PTSD. The benefit of the doubt doctrine is therefore not for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. 3. Entitlement to a rating in excess of 10 percent for lumbar strain The Veteran's service-connected spinal condition, diagnosed as a lumbar strain, is rated pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5237, which follows the General Rating Formula for Diseases and Injuries of the Spine. Although the portion of the rating schedule that addresses the musculoskeletal system was revised effective February 7, 2021, this diagnostic code was not changed. Under Diagnostic Code 5237, a 10 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent disability rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. When evaluating musculoskeletal disabilities, the Board must also consider whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45 under any applicable diagnostic code pertaining to limitation of motion. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The Veteran contends that he should be granted a higher rating for his lumbar strain due to the severity of his symptoms. The Veteran states that the condition causes him constant pain that has gotten worse over the last few years. The Veteran initially injured his back prior to service playing high school football where he fractured his L4-5 vertebrae. See October 2019 VA Examination and June 2015 Buddy Statement. The Veteran was diagnosed with the lumbar strain during service in 1967 and spondylolisthesis of the lumbosacral spine in 1996 that required surgery in 1996 and 1997. See December 2011 and October 2019 VA Examination and June 2015 Buddy Statement. During a December 2010 VA examination, the Veteran reported constant low back pain rated a 3-4/10 with flare-ups occurring 6-8 times per year he rated 10/10. He was diagnosed with a chronic lumbar strain and showed forward flexion of the thoracolumbar spine of 90 degrees, extension to 10 degrees, right lateral flexion to 10 degrees, left lateral flexion to 30 degrees, right lateral rotation to 10 degrees, and left lateral rotation to 30 degrees, for a total range of motion of 180 degrees. The Veteran was able to complete the repetitive use testing without additional limitations to his range of motion due to pain. The VA examiner opined that the Veteran's current spine condition was related to his back injury in service based on the Veteran's report that the more recent back injury in 1995 was a chronic injury. The examiner noted the absence of medical records in support of long-term treatment for back pain, however they stated the surgical scar was consistent with his back surgery and the Veteran reported consistent low back pain. Id. During a December 2011 VA examination, the Veteran reported constant low back pain with radiating pain into the lower extremities. He was diagnosed with a chronic lumbar strain and spondylolisthesis of the lumbosacral spine, status post L3-4 laminectomy and fusion. He showed forward flexion of the thoracolumbar spine of 50 degrees, extension to 5 degrees, right lateral flexion to 10 degrees, left lateral flexion to 10 degrees, right lateral rotation to 25 degrees, and left lateral rotation to 15 degrees for a total range of motion of 115 degrees with active motion. The Veteran was not able to complete the repetitive use testing due to pain. The examiner stated the Veteran had intervertebral disc syndrome (IVDS), however there were no incapacitating episodes within the past 12 months. The VA examiner opined that the Veteran's current spine condition would impact his ability to work because it limited his ability to sit, stand, lift or walk for extended periods of time. Id. In a February 2012 letter to VA, the Veteran reported that his back condition had gotten worse and that he had 3 to 4 episodes of debilitating back pain that each lasted 3 to 4 weeks at a time. See February 2012 Correspondence. In an October 2012 letter, Dr. V. S. (V.S., M.D.) stated that they had been treating the Veteran for low back pain for the last 15 years and that his most recent lumbar spinal surgery was a lumbar decompression and fusion in 1997. See October 2012 VA Medical Treatment Records. Dr. V.S. stated the Veteran's motion was limited by pain and he showed forward flexion to approximately 30 degrees and extension to 5 degrees. Id. No other range of motion values were provided and there is no indication whether a goniometer was used to measure the ROM. During a September 2013 VA examination, the examiner confirmed the Veteran's diagnoses of lumbar strain and spondylolisthesis of the lumbosacral spine, status post L3-4 laminectomy and fusion, in addition to degenerative disc disease (DDD) of the lumbar spine. However, the examiner stated that both the lumbar decompression and fusion and the DDD were unrelated to the Veteran's lumbar strain. The examiner stated the Veteran did not have IVDS, radicular pain, and his sensory exam and reflexes were normal. The examiner did not provide range of motion measurements due to unreliable and inconsistent results during the examination. Id. The examiner opined that the Veteran's subjective complaints during the examination were out of proportion to the objective findings and that the Veteran displayed poor effort during the examination. Id. The examiner explained that during the examination, the Veteran reacted to even slight movement with an over response of noise and vocal output indicating he was having very severe pain from almost no movement. He had a jerking movement whenever his body was touched or whenever he moved his body no more than 5 degrees in any of the six directions and was grunting and groaning throughout all of the maneuvers. There was no evidence of a serious muscle spasm noted throughout the lower back at any time. When not being examined, he was observed moving and bending to at least 55-60 degrees to untie his shoes with no apparent distress. During strength testing, he claimed could not move his legs or push against this examiner's hand, but he was able to move his legs in a figure-four cross and placed one ankle on top of the other leg's knee, with top leg's knee pointing sideways, to put his shoes and socks. Id. During a January 2015 VA examination, the examiner also stated the Veteran's lumbar decompression and fusion and the DDD were unrelated to the Veteran's lumbar strain. The Veteran reported increasing pain that he rated a 6/10 with flare-ups 4 to 5 times per year that last 3 to 4 weeks that he rated a 10/10 for pain. The examiner was unable to provide range of motion (ROM) values because testing was unreliable and inconsistent. Id. The examiner explained that during the ROM examination, the Veteran could only bend or move anywhere from 15-30 degrees, however he had no difficulty bending at least 60 degrees when sitting down and redressing himself. The Veteran also exhibited an exaggerated response to slight movement or touch during the physical exam. Id. The Veteran's April 2015 medical records from the Social Security Administration (SSA) contain a July 1998 letter from Dr. V.S. in support of his disability application to SSA. See April 2015 Medical Treatment Records, SSA. The letter indicates that the Veteran began treatment with Dr. V.S. in April 1996 after a work-related accident where he injured his low back. Id. Due to that injury, the Veteran had undergone two operations, a nerve root decompression followed by a lumbar decompression and fusion. Id. In a March 2016 statement, Mrs. M.S. stated that the Veteran had fractured his L4 vertebrae in high school, hurt his back again while in service, and hurt it a third time at work in 1995, at which time he was placed on Worker's Compensation and underwent two surgeries. See March 2016 Buddy Statement. During a March 2016 medical appointment, Dr. V.S. noted the Veteran appeared healthy and was not in distress but that his range of motion was limited with forward flexion to about 30 degrees and virtually no extension. See March 2016 VA Medical Treatment Records. Dr. V.S. stated that the Veteran will ultimately need surgery, however the Veteran opted to wait and try more conservative measures to treat his back pain. Id. During an April 2018 VA examination, the Veteran reported constant pain and that he needed additional surgery. He did not report functional loss or flare-ups. The examiner stated they were unable to complete ROM testing due to pain, however the Veteran showed bilateral rotation and lateral flexion to 25 degrees. The examiner opined the Veteran's symptoms were due to his non-service-connected degenerative disc disease of the lumbar spine and his lumbar surgeries and not due to the service-connected lumbar strain. Id. In support of their opinion, the examiner explained that a lumbar strain is considered myofascial and often due to a sprain or strain of the soft tissues of the back and the majority of patients diagnosed with this condition improve over time without a long-term disability. Further, a lumbar spine strain does not lead to, or cause, degenerative disc disease because a back strain relates to problems with the muscle and ligaments of the back, not the discs of the spine. The examiner opined that a lumbar spine strain would not preclude light duty or sedentary employment. Id. During an October 2019 VA examination, the Veteran reported low back pain but that he was still able to drive. The examiner noted the Veteran was diagnosed and service-connected for a lumbar strain but opined the condition had resolved. The examiner stated that the Veteran's current symptoms were due to his non-service-connected back conditions and not the lumbar strain. Id. The examiner stated that the Veteran's current functional loss was not due to the lumbar strain, and in support, noted he had worked full time, standing, seated, and walking around, and was able to spend his free time hunting, fishing, bowling, swimming, and restoring vehicles until his accident at work in 1995 resulting in a back injury. Id. The examiner was unable to test the Veteran's ROM due to his behavior. The examiner stated that the Veteran moved seamlessly when transitioning from sitting to standing, but when asked to move, would jerk his torso as if he was going to fall. He appeared to be very unsteady while telling the examiner he had frequent falls, but not when ambulating to and from examination room. Id. The Veteran refused to remove his socks, shoes, or bulky ankle braces for the examination, and admitted that the ill-fitting walker he was using was not his and had not been prescribed to him. The examiner opined the Veteran's lumbar strain did not cause any occupational or functional limitations. Id. While the evidence supports the Veteran was diagnosed with a lumbar strain during service, the record is silent for any treatment of a back condition after the Veteran's separation from service until his work-related back injury in 1995. There is no medical evidence of record in support that the Veteran's lumbar strain in service resulted in a chronic back condition. Although the Veteran contends he had back pain consistently since service, and that his symptoms have continued to worsen since that time, his lay statements are not credible as the Veteran provided inconsistent reports to multiple VA examiners. See January 2015, April 2018, and October 2019 VA Examinations. The Board finds that during the period of appeal the Veteran had forward flexion of the thoracolumbar spine of 90 degrees and a combined range of motion of 180 degrees, without evidence of ankylosis. Applying the most favorable rating criteria under diagnostic code 5237, a rating in excess of 10 percent for a lumbar strain is not warranted. 38 C.F.R. § 4.71a. For the foregoing reasons, the preponderance of the evidence is against the claim for a rating in excess of 10 percent for a lumbar strain. The benefit of the doubt doctrine is therefore not for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. 4. Entitlement to a rating in excess of 30 percent for coronary artery disease The Veteran contends that he should be granted a higher rating for his coronary artery disease (CAD) due to his current symptoms. The Veteran's service-connected heart condition, diagnosed as coronary artery disease (CAD), is rated pursuant to 38 C.F.R. § 4.104, Diagnostic Code 7005, for arteriosclerotic heart disease and DC 7018, for implantable cardiac pacemakers which is evaluated under 7011, ventricular arrhythmias. Under both DC 7005 and 7011, a 10 percent rating is assigned for a workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required. A 30 percent rating is assigned for a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent rating is assigned for more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. The Veteran was diagnosed with atrial fibrillation in 1992, which required the implantation of a pacemaker in 1999 and a second pacemaker in 2009. See October 2019 VA Examination. The Veteran reported that prior to the implantation of the pacemaker in 1999 that his physician had tried to control his heart rate with medication, but when that did not work, he needed ablation and a pacemaker. Id. The Veteran was also diagnosed with coronary artery disease (CAD) in 2009. See April 2011 VA Examination. During his April 2011 VA examination, the Veteran reported using daily medication to treat his heart condition but denied congestive heart failure. Diagnostic testing indicated the Veteran was able to perform a workload of 7.0 METs but reported symptoms of dyspnea. Id. His left ventricular ejection fraction was 69 percent. Id. During a January 2015 VA examination, the Veteran reported getting winded easily while climbing stairs. There was no evidence of myocardial infraction, congestive heart failure, or heart valve conditions. An interview based METs test indicated the Veteran was able to perform a workload of greater than 7.0 METs to 10.0 METs but reported symptoms of dyspnea. Id. The examiner opined the Veteran's heart condition would not impact his ability to work. Id. During an April 2018 VA examination, the examiner stated that there was no objective evidence of ischemic heart disease in the Veteran's medical records until the June 2015 entry of CAD after he had a cardiac stent placed in Mach 2015. Id. The examiner opined the Veteran's pacemaker was unrelated to his CAD and the diagnosis of atrial fibrillation that led to the pacemaker was not related to ischemic heart disease (IHD). Id. They stated the Veteran had a long history of hypertension, which was the primary etiology of atrial fibrillation which led to the pacemaker, and that the atrial fibrillation diagnosis preceded a diagnosis of IHD by more than 20 years and therefore the two conditions were unrelated. Id. There was no evidence of myocardial infraction, congestive heart failure, or heart valve conditions. An interview based METs test indicated the Veteran was able to perform a workload of greater than 7.0 METs to 10.0 METs but reported symptoms of dyspnea and fatigue. Id. The examiner opined the Veteran's heart condition would not impact his ability to work. Id. An October 2019 VA medical examiner provided a concurrent opinion that the Veteran's atrial fibrillation and pacemaker were not etiologically related to his CAD. The examiner noted there was no evidence of myocardial infraction, congestive heart failure, or heart valve conditions. An interview based METs test indicated the Veteran was able to perform a workload of greater than 7.0 METs to 10.0 METs but reported symptoms of dyspnea and fatigue. Id. The examiner opined the Veteran's heart condition would not impact his ability to work. Id. Although the Veteran is currently service connected for coronary artery disease status post implanted pacemaker, both the April 2018 and October 2019 VA examiners opined the Veteran's pacemaker is unrelated to his CAD. Therefore, the Board finds that DC 7005 is the more appropriate diagnostic code as the Veteran was granted service connection based on his diagnosis of CAD. Regardless, his rating would be the same under both DC 7005 and 7011, and therefore there is no prejudice to Veteran. The Board finds that the preponderance of the evidence demonstrates that the Veteran did not have more than one episode of acute congestive heart failure in the past year, a workload of greater than 3 METs but not greater than 5 METs that resulted in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular dysfunction with an ejection fraction of 30 to 50 percent during the period of appeal. Therefore, applying the most favorable rating criteria under diagnostic code 7005, a rating in excess of 30 percent for coronary artery disease is not warranted. 38 C.F.R. § 4.104. For the foregoing reasons, the preponderance of the evidence is against the claim for a rating in excess of 30 percent for coronary artery disease. The benefit of the doubt doctrine is therefore not for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. 5. Entitlement to a total disability rating based on individual unemployability The Veteran contends that his symptoms caused by his service-connected disabilities contribute to his inability to secure and follow substantially gainful employment. 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. 38 U.S.C. § 1155. Total disability is considered to exist when there is any impairment which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340(a)(1). Total disability may or may not be permanent. Id. Total ratings are authorized for any disability or combination of disabilities for which the Rating Schedule prescribes a 100 percent evaluation. 38 C.F.R. § 3.340(a)(2). 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 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. Id. 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. In reaching such a determination, the central inquiry is "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). For VA purposes, the term "unemployability" is synonymous with an inability to secure and follow a substantially gainful occupation. VAOPGPREC 75-91; 57 Fed. Reg. 2317 (1992). The term "unable to secure and follow a substantially gainful occupation" in § 4.16(b) has two components: one economic and one noneconomic. The economic component means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. The non-economic component includes consideration of the Veteran's history, education, skill, and training; whether the Veteran has the physical ability to perform the type of activities required by the occupation at issue; and whether the Veteran has the mental ability to perform the activities required by the occupation at issue. Ray v. Wilkie, 31 Vet. App. 58, 72-73 (2019). In a claim for TDIU, the ultimate question of whether a Veteran is capable of substantially gainful employment is not a medical one; that determination is for the adjudicator. See 38 C.F.R. § 4.16(a); see also Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013) (noting that "applicable regulations place responsibility for the ultimate TDIU determination on the adjudicator, not a medical examiner"). 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. As of March 15, 2018, the Veteran was service connected for posttraumatic stress disorder (PTSD), rated at 50 percent, effective October 3, 2011, coronary artery disease (CAD) rated at 30 percent, effective August 31, 2010, diabetes mellitus, type II rated at 20 percent, effective May 27, 2009, a chronic lumbar strain rated at 10 percent, effective May 27, 2009, right lower extremity neuropathy due to diabetes, rated at 10 percent, effective November 4, 2011, left lower extremity neuropathy due to diabetes, rated at 10 percent, effective November 4, 2011, and erectile dysfunction with a non-compensable rating, effective November 29, 2011, for a total disability rating of 80 percent effective November 4, 2011. 38 C.F.R. §§ 4.25, 4.26. As such, the Veteran had one disability 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). Therefore, for the period on appeal, the Veteran met the schedular TDIU requirements. Id. The Veteran has a high school diploma and completed 2 years of college with additional job-related training. See March 2018 Application for Increased Compensation based on Unemployability. The Veteran reported that he was employed until 1999 as a director at D.L.C. and left his employment due to his service-connected disabilities. Id. A January 2015 response from D.L.C. indicated the Veteran had been employed for 32 years and retired in 1999 with a pension benefit. See January 2015 Request for Employment Information. In addition, the Veteran has separately reported he took a medical retirement after he had a work-related accident resulting in two spinal surgeries. See July 2020 VA Examination. As discussed above, during VA examinations for the Veteran's coronary artery disease, the examiners opined the Veteran's heart condition did not impact his ability maintain employment. See April 2018 and October 2019 VA Examinations. During VA examinations for the Veteran's lumbar spine condition, the examiners opined the Veteran's lumbar strain did not impact his ability maintain employment, and further that his service-connected lumbar strain had resolved. See April 2018 and October 2019 VA Examinations. In a January 2016 private medical opinion, Dr. D.M. opined the Veteran's moderate to severe PTSD symptoms caused a level of impairment that greatly interfered with his daily functioning and would prohibit working in any capacity. See March 2016 Correspondence. However, the April 2018 VA examiner opined the Veteran did not have any PTSD symptoms that would cause functional impairment, but rather any impairment was cause by non-service-connected disabilities. See April 2018 VA Examination. The Veteran submitted a January 2020 vocational assessment from J.C. (J.C., ABDA, NRA), a vocational expert. In their extensive analysis, J.C. discussed the necessary abilities required to maintain substantially gainful employment and provided a comparison to the Veteran's current limitations due to his PTSD, CAD, diabetes, lumbar condition, and neuropathy of the lower extremities. See January 2020 Private Medical Treatment Records. After a complete review of the Veteran's medical records, lay statements and work history, J.C. opined that the Veteran was unable to obtain and maintain substantially gainful employment, including sedentary employment, since August 2010. Id. The Board is satisfied that the current evidence of record indicates the Veteran is prevented from securing and maintaining substantially gainful employment due to his service-connected disabilities. His service-connected disabilities caused depression, anxiety, panic attacks, sleep impairment, difficulty with concentration, disturbance of mood and motivation, impaired memory, fatigue, back, hip, leg, and foot pain. He was unable to sit, stand or walk for extended periods of time, and has difficultly completing simple tasks. Although there is evidence that suggests the Veteran might be able to complete sedentary work, the 2016 private psychological evaluation and the January 2020 vocational assessment indicate that his combined symptoms are severe enough to preclude even sedentary employment. Overall, his current symptoms caused by his disabilities prohibit him from obtaining and maintaining substantially gainful employment. Therefore, the Board finds there is an equal balance of evidence establishing he was unable to obtain or maintain substantially gainful employment as a result of his service-connected disabilities. 38 C.F.R. § 4.16(a). Accordingly, after resolving all doubt in favor of the Veteran, the Board concludes that entitlement to a schedular TDIU rating due to service-connected disabilities is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. J. B. FREEMAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Aubee, 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.