Citation Nr: 21070549 Decision Date: 11/24/21 Archive Date: 11/24/21 DOCKET NO. 10-40 754 DATE: November 24, 2021 ORDER A rating higher than 10 percent for tinea cruris/tinea pedis and lichen simplex chronicus is denied. Entitlement to special monthly compensation (SMC) based on the need for aid and attendance of another person or due to being housebound is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) is denied. FINDINGS OF FACT 1. At no time during the appeal period has the service-connected tinea cruris/tinea pedis and lichen simplex chronicus involved 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas, nor has it required systemic therapy or other immunosuppressive drugs for a total duration of six weeks or more, but not constantly, during the past 12-month period. 2. The Veteran does not have anatomical loss or loss of use of both feet, or one hand and one foot due to service connected disabilities, nor does he suffer from service-connected blindness in both eyes with visual acuity of 5/200 or less; he is not shown to be permanently bedridden or so helpless that he needs the regular aid and attendance of another person solely because of service-connected disabilities. 3. The Veteran does not have any service-connected disabilities evaluated as 100 percent disabling and entitlement to a TDIU has not been established. 4. The Veteran does not meet the schedular criteria for a TDIU based on his service-connected disabilities and the probative evidence of record does not reflect that he is unemployable because of his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for rating higher than 10 percent for tinea cruris/tinea pedis and lichen simplex chronicus have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.118, Diagnostic Code 7806. 2. The criteria for special monthly compensation based on the need for regular aid and attendance or being housebound have not been met. 38 U.S.C. § 1114(l) and (s); 38 C.F.R. § 3.350 (b) and (i). 3. The criteria for a TDIU due to service-connected disabilities have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from February 1980 to April 1986. These matters come before the Board of Veterans Appeals (Board) on appeal from rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in August 2009, December 2009, and January 2011. A transcript of the Veteran's testimony at a May 2014 hearing before the undersigned Veterans Law Judge is of record. The claims were last before the Board in July 2021. 1. Entitlement to a rating higher than 10 percent for tinea cruris/tinea pedis and lichen simplex chronicus Disability ratings are determined by applying the criteria set forth in the VA Schedule of Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. Service connection was originally established for tinea cruris/tinea pedis (also claimed as rash of the groin, bilateral thighs, and feet) in an October 2007 rating decision, which assigned a noncompensable rating under 38 C.F.R. § 4.118, Diagnostic Code 7806, effective May 23, 2007. The disability was recharacterized as tinea cruris/tinea pedis and lichen simplex chronicus, bilateral groin, in the August 2009 rating decision that is the subject of this appeal, which increased the rating assigned to 10 percent effective January 12, 2009. Despite this recharacterization, since the original disability was not limited to the Veteran's groin area, the Board will also consider manifestations of the skin disability that appear on his thighs and feet. The Board has also recharacterized the disability as tinea cruris/tinea pedis and lichen simplex chronicus. The rating criteria used to evaluate the skin were amended effective August 13, 2018. Since the amended criteria can only be applied for the period from the effective date of the regulatory change, the Board will consider the rating criteria in effect prior to the August 2018 amendments in addition to the amended criteria. Prior to August 13, 2018, Diagnostic Code 7806 provided the rating criteria for dermatitis or eczema. A 30 percent evaluation was provided for dermatitis or eczema that affected 20 to 40 percent of the entire body or exposed areas, or; required systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of six weeks or more, but not constantly, during the past 12-month period. A note under the diagnostic criteria indicated that the disability could be rated as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), depending upon the predominant disability. Since the Veteran's skin disability affects areas other than his head, face or neck, Diagnostic Code 7800 is not for application. Of the remaining diagnostic codes in effect prior to August 13, 2018, only diagnostic codes 7801 and 7804 provided ratings higher than 10 percent. Diagnostic Code 7801 provided a 20 percent rating for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are deep and nonlinear in an area or areas of at least 12 square inches (77 sq. cm.) but less than 72 square inches (465 sq. cm.). A deep scar is one associated with underlying soft tissue damage. Diagnostic Code 7807, Note 1. Diagnostic Code 7804 provided a 20 percent rating for three or four scars that are unstable or painful. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Diagnostic Code 7804, Note 1. If one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Id. at Note 2. For claims filed prior to August 13, 2018, the Court has held that a systematic therapy is one that that affects the entire body in its treatment of the condition at issue, and that the Board must determine (1) whether a topical treatment affects the body as a whole in treating a veteran's skin condition; and (2) whether the given treatment is "like" a corticosteroid or other immunosuppressive drug." Burton v. Wilkie, 30 Vet. App. 286 (2018). Effective August 13, 2018, Diagnostic Code 7806 continues to provide the criteria for dermatitis or eczema but stipulates those conditions are to be evaluated under the General Rating Formula for the Skin (General Rating Formula). Under the General Rating Formula, a 30 percent rating is assigned for characteristic lesions involving 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, over the past 12-month period. 38 C.F.R. § 4.118, General Rating Formula. Effective August 13, 2018, VA regulations explicitly state that systemic therapy is treatment that is administered through any route other than the skin, and topical therapy is treatment that is administered through the skin. 38 C.F.R. § 4.118(a). Ratings higher than 10 percent are also provided under the criteria effective August 13, 2018, for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are associated with underlying soft tissue damage in an area of at least 12 square inches (77 sq. cm.) but less than 72 square inches (465 sq. cm.) (Diagnostic Code 7801); and for three or four scars that are unstable or painful (Diagnostic Code 7804). The definition of an unstable scar remains the same as it was prior to August 13, 2018. The Veteran asserts that his skin disability has increased in severity. He testified in May 2014 that his skin condition was spreading from the groin area down his legs and up to his naval. In each of those areas he experienced itching and irritation. The Veteran testified to the embarrassment he felt scratching in certain areas and he also reported that he sometimes scratched in his sleep and will scratch the skin off. The Veteran indicated that he had been given several different creams and none appeared to be working. He reported that he was taking three medications at that time. No other arguments have been provided in support of the claim for increase. The preponderance of the evidence is against the assignment of a rating higher than 10 percent at any time during the appeal period for the tinea cruris/tinea pedis and lichen simplex chronicus pursuant to Diagnostic Code 7806 in effect both prior to and since August 13, 2018. To merit the assignment of the next highest (30 percent) rating under the diagnostic criteria in effect prior to August 13, 2018, the skin condition had to affect 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas, or it had to require systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of six weeks or more, but not constantly, during the past 12-month period. To merit the assignment of the next highest (30 percent) rating under the General Rating Formula in effect as of August 13, 2018, the skin condition must be manifested by characteristic lesions involving 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas, or it must require systemic therapy or other immunosuppressive drugs for a total duration of six weeks or more, but not constantly, over the past 12-month period. The evidence in this case does not show that the service-connected tinea cruris/tinea pedis and lichen simplex chronicus involved 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas at any time during the appeal. Rather, during VA examination in July 2009, the examiner reported that less than five percent of the Veteran's total body area and less than 20 percent of his exposed body area were affected; during a July 2011 VA examination, it was reported that less than 20 percent of the total body area was affected and none of his exposed area was; and VA examinations conducted in May 2015, March 2017, and May 2018 all found that none of the Veteran's exposed area was affected by the skin condition and that the condition affected less than five percent of the Veteran's total body area. The Board also notes that while tinea pedis and lichen simplex chronicus were present during the May 2015 examination, tinea cruris was not, and that while tinea cruris was present during the May 2018 examination, there were no references to tinea pedis, only onychomycosis of the left foot, which is not service connected. References to other skin conditions in the VA treatment records, such as xerosis and shingles, have not been considered in this decision since they are also not service connected. The evidence in this case also does not show that the service-connected tinea cruris/tinea pedis and lichen simplex chronicus requires systemic therapy or other immunosuppressive drugs for a total duration of six weeks or more, but not constantly, during the past 12-month period. The Board remanded the claim most recently in July 2021 in order for a VA examiner to specifically address the medications prescribed for the Veteran's skin condition since January 2008, which include triamcinolone; tacrolimus; Lubriderm; ketoconazole 2%; mupirocin 2%; hydrocortisone 2.5%; hydrophilic ointment; selenium sulfide 2.5%; capsaicin 0.025%; calamine lotion; Zeasorb powder; cellulose/talcum powder; clotrimazole 1%; and for the examiner to indicate whether those that are topical treatments affected the body as a whole and whether treatment is "like" a corticosteroid or other immunosuppressive drug. The requested review was conducted in August 2021, at which time the examiner reported that the topical medications only affect the localized area they are applied to, not the whole body. More specifically, the examiner reported that triamcinolone and hydrocortisone 2.5% are topical steroids with only local effects; that Lubriderm is a topical lubricant for dry skin; that hydrophilic ointment is an oil-in-water emulsion containing petrolatum and propylene glycol used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin; that ketoconazole 2% and clotrimazole 1% are topicals to treat fungal skin infections; that Zeasorb Powder (Miconazole Nitrate 2%) is also antifungal and used to relieve itching, burning and scaling in athlete's foot and jock itch; that selenium sulfide 2.5% is used to treat tinea versicolor, also a fungal infection of the skin; that capsaicin 0.025% is a topical local analgesic used to treat pain of joint osteoarthritis; that Calamine Lotion is a topical lotion used to relieve the itching, pain and discomfort of minor skin irritations caused by poison ivy or poison oak; that cellulose/talcum powder is generic and the examiner was not sure what that is used for by itself, but the components are used in many topical compounds; and that Mupirocin (Bactroban; GlaxoSmithKline, Research Triangle Park, North Carolina) is a topical antibiotic is used for the elimination of staphylococcus nasal carriage with a unique mechanism of action among antimicrobials, binding to isoleucyl tRNA synthetase, thereby preventing incorporation of isoleucine into proteins and arresting protein synthesis, showing no cross-resistance with other classes of antimicrobial agents. The examiner also indicated that Mupirocin is bactericidal at concentrations achieved by topical administration. The August 2021 examiner reported that the only systemic medication on the list is tacrolimus, which is an oral medication used for immunosuppression to prevent transplant rejection. The RO requested an addendum opinion to address the fact that the Veteran's treatment records indicated that he had been prescribed tacrolimus ointment, topical 0.1%, with clarification as to whether this medication is in fact systemic or topical. The addendum obtained in September 2021 indicated that the examiner was not aware that it was not oral tacrolimus the Veteran had been prescribed and that if it is topical, which the VA records make clear it is, there are no systemic effects, only local absorption. Given the opinion obtained in August 2021 with addendum in September 2021, it is clear that the Veteran has never been prescribed systemic therapy and that none of the topical medications have acted "like" a corticosteroid or other immunosuppressive drug since the examiner clearly stated that the topical medications only affected or were absorbed at the local area to which they were applied. See Burton, 30 Vet. App. at 293. The Board has considered whether to apply either Diagnostic Code 7801 or Diagnostic Code 7804 to the Veteran's service-connected disability; however, the Veteran's predominant disability is manifested by what has been reported during VA examination and treatment as bumps, discoloration/pink areas, plaques, exaggerated skin lines, rash, and flaking and dry skin, not scarring. Since scarring is not the predominant disability, those diagnostic codes are not for application to the instant case. In sum, the preponderance of the evidence supports the currently assigned 10 percent rating for tinea cruris/tinea pedis and lichen simplex chronicus under Diagnostic Code 7806. The evidence in this case is not so evenly balanced to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 2. Entitlement to SMC based on the need for aid and attendance of another person or due to being housebound SMC at the aid and attendance rate is payable to a Veteran for anatomical loss or loss of use of both feet or one hand and one foot, blindness in both eyes with visual acuity of 5/200 or less, or being permanently bedridden or so helpless as a result of service-connected disability that he or she is in need of the regular aid and attendance of another person. 38 U.S.C. § 1114(l); 38 C.F.R. § 3.350(b). Factors considered to determine whether regular aid and attendance is needed include: inability to dress or undress himself, or to keep himself ordinarily clean and presentable; frequent need to adjust special prosthetic or orthopedic appliances which by reason of the particular disability requires aid (this does not include adjustment of appliances that persons without any such disability would be unable to adjust without aid, such as supports, belts, lacing at the back, etc.); inability to feed himself through loss of coordination of upper extremities or through extreme weakness; inability to attend to wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect a claimant from the hazards or dangers incident to his daily environment. 38 C.F.R. § 3.352 (a). It is not required that all the disabling conditions enumerated in 38 C.F.R. § 3.352(a) be found to exist before a favorable decision is permissible. Particular personal functions which the Veteran is unable to perform should be considered in connection with his condition as a whole. It is only necessary that the evidence establish that he is so helpless as to need regular aid and attendance, not that there is a constant need. 38 C.F.R. § 3.352 (a); Turco v. Brown, 9 Vet. App. 222 (1996). It is logical to infer, however, a threshold requirement that "at least one of the enumerated factors be present." Id. at 224. "Bedridden" will be that condition which, by virtue of its essential character, actually requires that the claimant remain in bed. The fact that a claimant has voluntarily taken to bed or that a doctor has prescribed rest in bed for a greater or lesser part of the day to promote convalescence or cure is insufficient. 38 C.F.R. § 3.352 (a). To establish entitlement to SMC based on housebound status under 38 U.S.C. § 1114(s), the evidence must show that a veteran has a single service-connected disability evaluated as 100 percent disabling and an additional service-connected disability, or disabilities, evaluated as 60 percent or more disabling that is separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems; or, the veteran has a single service-connected disability evaluated as 100 percent disabling and due solely to service-connected disability or disabilities, the Veteran is permanently and substantially confined to his or her immediate premises. 38 C.F.R. § 3.350(i). The Court of Appeals for Veterans Claims (Court) has emphasized that a TDIU premised on a single disability may satisfy the requirements for entitlement to SMC under 38 U.S.C. § 1114(s). See Bradley v. Shinseki, 22 Vet. App. 280, 293 (2008); see also Buie v. Shinseki, 24 Vet. App. 242, 249-250 (2010). In this case, the Veteran does not have any service-connected disabilities evaluated as 100 percent disabling, and entitlement to TDIU has not been established. As such, the preponderance of the evidence is against the claim for SMC on the basis of being housebound. The Veteran is service connected for a foot disability, plantar fasciitis with bilateral pes cavus and calcaneal spurs, and a skin disability, tinea cruris/tinea pedis and lichen simplex chronicus. His combined rating has been 60 percent since May 30, 2009. Loss of use of any extremity has not been established, nor is such shown by the evidence. The Veteran is not service-connected for his psychiatric disability, any orthopedic disability other than his bilateral foot disability, or an eye disability. Impairment due to nonservice-connected conditions cannot be considered in determining entitlement to special monthly compensation. See 38 C.F.R. §§ 3.350, 4.114. The Veteran filed an informal claim for aid and attendance in August 2010. VA mailed him an aid and attendance/housebound form for a doctor to fill out, but it was not returned. He testified in May 2014 that he was dependent upon the care of family members for meals, home maintenance and financial support and that he stayed two days with one friend, two days with another friend, and three days with his mother, reporting that he found it difficult to stay alone because of nightmares and acting out in his sleep. In terms of how his service-connected conditions are impacting his activities of daily life, the Veteran reported that he could not walk without pain and that his groin rash was very uncomfortable and embarrassing. He also mentioned that he had to have someone looking out for him because of suicide attempts and wandering away without knowing how he got to where he ended up. One of the friends with whom he was living testified that after the Veteran started living with him a few days a week, the first thing the friend noticed was that the Veteran's nerves were shot a lot of times, that he was shaking all the time, and that he did not have closure on the situation. The friend also testified to having to get up at night to go around the apartment and make sure certain things like the stove were turned off. Upon review of the record, the preponderance of the evidence of record is against the claim for entitlement to SMC pursuant to 38 U.S.C. § 1114(l) and 38 C.F.R. § 3.350 (b) because the Board has determined that he is not in need of the regular aid and attendance of another person as a result of service-connected disability. The Veteran has not asserted, and none of the medical evidence of record suggests, that he has anatomical loss or loss of use of both feet, one hand and one foot, or service-connected blindness in both eyes with visual acuity of 5/200 or less. See VA treatment records; VA examination reports. Longitudinal review of the record reveals that the Veteran's bilateral foot disability has impacted his functioning. For example, during a July 2011 VA examination of his feet, it was noted that there were severe effects on several activities of daily living, to include chores, shopping, bathing, dressing, toileting, and grooming; it was also noted that the Veteran did not drive. A March 2018 VA social work note indicated that the Veteran had a motorized scooter, which he stated he used for long distance walking. At that time, he reported he was able to do all activities of daily living and walk shorter distances without the scooter. Although the Veteran has reported that he utilizes the scooter because of his service-connected foot disability, it appears that he also uses it because of his other orthopedic problems, to include his hips, knees, and back. Additional records indicate that the Veteran was quite independent. VA records dated in July 2018, August 2018, and April 2019 indicate that he was self-grooming, self-dressing, self-eating, self-transferring, and self-turning/positioning, though another August 2018 VA record documents that a functional screen revealed the Veteran was ambulatory and had partial weight bearing, but was chair bound and would need assistance with toileting and bathing. Although that assistance was noted, there is no indication it was due to either of the service-connected disabilities, and prior to an April 2021 VA mental health admission due to homicidal ideation, the Veteran had been living alone on the third floor of an apartment with an elevator and was independent with all activities of daily living. During the admission, an occupational therapy impression was that he had deficits in strength, endurance, and functional activities of daily living related to muscle weakness impacting function and independence with transfers. He was functional with mobility, bathing, toileting, and independent activities of daily living tasks. Another admission report documents that a functional assessment found the Veteran had full function and could perform his activities of daily living; he had no assistive devices and was able to self-administer medication. The May 2021 discharge summary indicated that the Veteran was independent in both activities of daily living and independent activities of daily living. The Board concedes that the Veteran's bilateral foot disability has impacted his functioning; however, the evidence as a whole does not support a conclusion that he is in need of aid and attendance as a result of his service-connected disabilities. The Veteran's advanced age cannot be a basis for a grant of SMC. 38 C.F.R. § 4.19. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the claim for SMC, that doctrine is not applicable. See 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). 3. Entitlement to TDIU VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that the Veteran is precluded from obtaining or maintaining any gainful employment consistent with his education and occupational experience by reason of his service-connected disabilities. 38 C.F.R. §§ 3.340, 3.341, 4.16. Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to the impairment caused by nonservice-connected disabilities. Id. 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). The law provides that a total disability rating may be assigned where the schedular rating is less than total when the person 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. As previously noted, the Veteran is service connected for plantar fasciitis with bilateral pes cavus and calcaneal spurs and tinea cruris/tinea pedis and lichen simplex chronicus; his combined rating has been 60 percent since May 30, 2009. As such, the schedular requirements set forth in 38 C.F.R. § 4.16(a)(2) for consideration of a TDIU have not been met at any point during the appeal period. In the case of a veteran who is unemployable by reason of a service-connected disability, but who fails to meet the schedular percentage standards, the case should be submitted to the Director of Compensation Service, for extraschedular consideration. See 38 C.F.R. § 4.16(b). For a veteran to prevail on a claim for a total compensation rating based on individual unemployability on an extraschedular basis, it is necessary that the record reflect some factor which places the case in a different category than other Veterans with equal rating of disability. The question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether the Veteran can find employment. This is so because a disability rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. See Van Hoose v. Brown, 4 Vet. App. 361 (1993). In the VA Form 21-8940 (Veteran's Application for Increased Compensation Based on Unemployability) received in November 2011, the Veteran reported that his service-connected flat feet and skin conditions were the disabilities that prevented him from securing or following any substantially gainful occupation. He indicated that January 1, 1980, was the date on which his disability affected full-time employment and that April 2005 was the date that he last worked full-time and the date on which he became too disabled to work. The Veteran listed two security firms as his last employers, noting he had worked for one from January 1, 1997, to January 1, 2003, and the other from January 1, 2003, to April 2005. He reported that he had left his last job because of his disability, that he had not tried to obtain employment since becoming too disabled to work, that he had completed one year of a college education, and that he had not had any education or training before or since becoming too disabled to work. The Veteran testified in May 2014 that his service-connected conditions keep him from having and maintaining a job because he was told at his last job that he was scratching too much and that exceptions had to be made for him because he could not stand very much, which caused other workers to feel he was getting special treatment and it got to the point he was forced to resign to get himself together. He denied currently working and indicated that he had not had any jobs over the last two years, with his last job ending in April 2005. He had tried compensated work therapy and was able to work in that capacity for up to three to six months, but he eventually had a panic attack and had to resign. He stated they then found out he had severe depression and he had to resign because his doctor said that he would never be able to work again. The Veteran also testified that there was nothing more VA's vocational rehabilitation could do for him. The Board acknowledges that the Veteran has not worked during the entire appeal period. The Board also acknowledges that a July 2011 VA examiner determined that the Veteran's skin condition may hinder his ability to secure and perform work duties related to heavy physical exertion, since sweat in the groin area is well known to increase the risk of tinea cruris and it can worsen lichen simplex chronicus. The examiner also determined, however, that the skin disability should not prevent the Veteran from obtaining a job where he works at a desk with minimal physical activity, and it was the same examiner's opinion that the Veteran's foot disability does not prevent him from sustaining physical and/or sedentary employment. In addition to the foregoing, a June 2015 VA examiner concluded that the Veteran's service-connected skin condition does not preclude gainful employment and does not present functional impairments that would impact physical or sedentary employment, while also noting that the condition is not visible and did not impede any movement. Moreover, review of the records associated with the Veteran's participation in VA's vocational rehabilitation program indicates that in August 2010, a vocational goal was considered infeasible at that time due to the extent of the Veteran's poor physical and mental health capacities resulting from both his service-connected (foot and skin) and nonservice-connected (lumbosacral or cervical strain, traumatic arthritis, and general muscle condition) disabilities, with specific reference to the physical limitations creating unfavorable conditions to attaining and maintaining employment; difficulties adapting effectively to his environment, which limits his ability to adapt to others and situations as well as maintain employment; difficulty retraining for future employment due to the severity of his arthritis conditions and lack of flexibility; frequent medical management appointments posing potential difficulties with scheduling training and subsequent employment since he would require an inordinate amount of sick days to continue medical treatment to care for physical health; and that physical limitations preclude him from obtaining or maintaining employment in fields that require more than sedentary physical activity and most sedentary positions require a customer service component, which he may not be capable of performing due to his chronic pain and his limitation in sitting and standing. Finally, the Board notes that in statements associated with the Veteran's medical treatment, rather than his claim for entitlement to a TDIU, he reported that he was forced to resign due to psychological distress, tantrums, no respect for authority, falling asleep on the job, and verbal altercations even following reprimand. During a January 2021 VA mental health examination, the Veteran reported that he was let go from his last job in 2004 due to physical and psychological conditions, indicating that he had difficulties because he would find himself falling asleep on the job. Records obtained from the Social Security Administration (SSA) indicate that in its June 2009 administrative decision, SSA determined that the Veteran had not engaged in substantial gainful activity since July 20, 2006, due to severe impairments from depression, bipolar disorder, and posttraumatic stress disorder. The Board finds this evidence more persuasive than the Veteran's testimony and affords greater probative weight to this evidence than to the Veteran's assertions that he cannot work as a result of his service-connected disabilities. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (VA cannot ignore a veteran's testimony simply because the veteran is an interested party; personal interest may, however, affect the credibility of the evidence) In sum, a TDIU may be assigned where the schedular rating is less than total when the person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16(a). Here, the probative and persuasive evidence does not establish that the Veteran is unable to secure or follow a substantially gainful occupation because of his service-connected disabilities. Rather, it appears his skin and foot disabilities only impact certain aspects of employment and that a bigger roadblock was due to mental health challenges and physical impairment caused by orthopedic and muscular problems beyond the bilateral foot condition. Accordingly, extraschedular referral under 38 C.F.R. § 4.16(b) is not warranted. K. A. BANFIELD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Van Wambeke, 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.