Citation Nr: 21072905 Decision Date: 12/06/21 Archive Date: 12/06/21 DOCKET NO. 13-34 804 DATE: December 6, 2021 ORDER 1. Entitlement to initial ratings in excess of 30 percent prior to December 31, 2019, in excess of 20 percent prior to May 20, 2021, and in excess of 30 percent from May 20, 2021 for peripheral neuropathy of the left upper extremity with scalene anticus syndrome (peripheral neuropathy of the left upper extremity) are denied. 2. Entitlement to a total disability rating for compensation based on individual unemployability due to service-connected disabilities (TDIU) is denied. REMANDED 3. Entitlement to service connection for peripheral artery disease (PAD) is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that peripheral neuropathy of the left upper extremity, which is the minor extremity, manifested in severe incomplete paralysis of the minor upper radicular group from April 6, 2011 to December 30, 2019; moderate incomplete paralysis of the minor upper radicular group from December 31, 2019 to May 19, 2021; and severe incomplete paralysis of the minor upper radicular group from May 20, 2021. 2. The preponderance of the evidence is against a finding that the Veteran has been unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities for the period on appeal. CONCLUSIONS OF LAW 1. The criteria for entitlement to initial ratings in excess of 30 percent prior to December 31, 2019, in excess of 20 percent prior to May 20, 2021, and in excess of 30 percent from May 20, 2021 for peripheral neuropathy of the left upper extremity have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code (DC) 8513. 2. The criteria for entitlement to a TDIU rating have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.3, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1971 to January 1975. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2013 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO), which denied the Veteran service connection for peripheral artery disease. The rating decision also denied a compensable rating for the Veteran's service-connected left upper extremity peripheral neuropathy. A May 2015 statement of the case, also on appeal here, denied the Veteran entitlement to a TDIU rating. The Veteran's increased rating and TDIU claims were remanded in an August 2020 Board decision, in order to obtain a medical opinion as to whether symptoms relating to the Veteran's peripheral neuropathy of the left upper extremity can be distinguished from symptoms associated with the Veteran's nonservice-connected scaleus anticus syndrome. This opinion was provided in May 2021. Thereafter, in a June 2021 rating decision, the Veteran was granted a 30 percent disability rating for peripheral neuropathy of the left upper extremity from April 6, 2011, a 20 percent disability rating from December 31, 2019, and a 30 percent disability rating effective May 20, 2021 and recharacterized the service-connected disability as peripheral neuropathy of the left upper extremity with scalene anticus syndrome. The Veteran's increased rating and TDIU claims have been returned to the Board for further appellate review. Within the August 2020 Board decision, it denied the claim for service connection for peripheral artery disease. The Veteran appealed that part of the Board decisions to the United States Court of Appeals for Veterans Claims (Court). In May 2021, the Veteran and the Secretary of VA (parties) entered a Joint Motion for Partial Remand (Joint Motion). The parties agreed that vacatur and remand of this issue was required because the Board erred by failing to ensure compliance with VA's duty to assist and a prior Board remand directive. The Joint Motion was granted by the Court the following month. As such, the Veteran's service connection claim has been returned to the Board for further development. This issue is addressed in the remand portion of the decision. Increased Rating Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher rating 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. Reasonable doubt as to the degree of the disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. The evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, which is called pyramiding, is to be avoided when evaluating a veteran's service-connected disability. 38 C.F.R. § 4.14. However, it is possible for a veteran to have separate and distinct manifestations from the same injury, which would permit rating under several diagnostic codes. The critical element in permitting the assignment of several evaluations under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Paralysis of all radicular groups is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8513. Evaluations of 20, 30, and 60 percent, respectively are assigned for mild, moderate, and severe, incomplete paralysis of the minor extremity. An 80 percent rating is warranted for complete paralysis of the minor extremity. 38 C.F.R. § 4.124a, DC 8513. It is noted that the Veteran is right-hand dominant. Accordingly, ratings associated with the Veteran's left upper extremity will be based on ratings under the minor extremity designation. The words "mild," "moderate," and "severe" as used in the various Diagnostic Codes are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. When the involvement is wholly sensory, the rating should be for the mild, or, at most, the moderate degree. The term "incomplete" paralysis indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis give with each nerve, whether due to varied level of the nerve lesion or partial regeneration. 38 C.F.R. § 4.124a. Following a review of the evidence of record, including as discussed below, the Board finds that the preponderance of evidence weighs against the Veteran's claim of entitlement to initial ratings in excess of 30 percent prior to December 31, 2019, in excess of 20 percent prior to May 20, 2021, and in excess of 30 percent from May 20, 2021 for peripheral neuropathy of the left upper extremity. From April 6, 2011 to December 30, 2019 The Veteran filed a service connection claim for peripheral neuropathy of the left upper extremity in April 2011; however, the record at that time and in the immediate years to follow did not show the Veteran received recurrent treatment relating thereto or to have significant functional limitations. In a November 2013 statement, the Veteran reported that his peripheral neuropathy makes him unable to use his hands and arms effectively and that it continues to get worse. The Veteran reported that, during this period, he worked as a cab driver, a truck driver, and as a deli supervisor with responsibilities that included cutting meats and training new employees. The Veteran underwent a VA examination for his diabetes mellitus and associated peripheral neuropathy in March 2015. The Veteran was noted to have no constant or intermittent pain, no paresthesias and/or dysesthesias, and no numbness in the left upper extremity. The Veteran recorded full strength and normal sensation with no muscle atrophy. The report included a finding that the Veteran did not have any upper extremity diabetic peripheral neuropathy. The examiner indicated that the Veteran's diabetes mellitus and complications of diabetes mellitus, to include peripheral neuropathy, did not impact the Veteran's ability to work. In a May 2015 Notice of Disagreement, the Veteran reported that his peripheral neuropathy prevents him from lifting his arm over his head and that he experiences pain when lifting or holding items. Treatment records in 2018 indicate that the Veteran began going to the gym for one hour, three times per week, riding a bike and lifting weights. In November 2018, the Veteran underwent another VA examination for assessment of his diabetes mellitus and peripheral neuropathy. The Veteran reported a long history of numbness, tingling, and pain in the hands. The Veteran was found to have mild constant and intermittent pain, moderate paresthesias and or dysesthesias, and moderate numbness in the left upper extremity. The Veteran recorded full strength with normal reflexes. Light touch and position sense testing were normal, as was vibration and cold sensation testing. The Veteran was found to have moderate incomplete paralysis of the left upper extremity. The examiner found that the functional impact of the Veteran's disability was that the Veteran could not perform "physical work." The Veteran continued to report aches and pain in his extremities in 2019. The Veteran was able to participate in a kinesiotherapy exercise program through VA, working out at the gym twice per week in order to lose weight. The Veteran reported in 2019 that this program allowed him to participate in physical activity. In November 2019, the Veteran stated that he signed up for a fitness membership at Allen Force and that he was excited about starting to engage in physical activity on a regular basis. He noted recent weight loss, crediting his exercise program. The weight of the evidence is against an award of increased rating in excess of 30 percent during this period. While the Veteran reported mild pain and moderate numbness, the Veteran's strength, sensation, and reflexes were normal. Additionally, the Veteran reported the ability to engage in an exercise routine with physical activity on regular basis and he held multiple jobs during this period requiring the use of his left arm. Examination findings show the Veteran's incomplete paralysis of the radial and median nerves to be moderate. Treatment for this condition has been conservative and the Veteran did not require urgent or inpatient treatment to indicate increased severity. The Board finds that the preponderance of the evidence is against the symptoms being indicative of severe, incomplete paralysis, and a rating in excess of 30 percent rating for peripheral neuropathy of the left upper extremity is denied for this portion of the appeal period. From December 31, 2019 to May 19, 2021 The Veteran underwent another VA examination for his diabetes mellitus and peripheral neuropathy in late December 2019. The Veteran was again found to have only mild pain in the left upper extremity with moderate paresthesias and/or dysesthesias and numbness. The Veteran had normal strength and reflexes, no muscle atrophy, and normal sensation testing. The Veteran was found to have mild incomplete paralysis of the radial and median nerves in the left upper extremity. The functional impact of the Veteran's condition was described as requiring sedentary work with no prolonged walking, climbing, or weightbearing, or which required lifting his left arm above his head. Records in 2019 and 2020 stated that the Veteran continued to work as a cab driver, despite his reports that he had difficulty manipulating the wheel. The Veteran underwent another VA examination for peripheral neuropathy in April 2020 with findings very similar to those documented within the December 2019 examination report. In this instance, the Veteran reported moderate constant pain with no intermittent pain. The Veteran recorded full strength in the left upper extremity with elbow flexion and extension, wrist flexion and extension, and grip strength. He had 4/5 strength on pinch testing. Deep tendon reflexes were normal for the biceps, triceps, and brachioradialis. The Veteran had some decreased sensation of the inner and outer forearm and hand/fingers, but position sense, vibration, and cold sensation were all normal in the left upper extremity. The left upper extremity also had no atrophy or trophic changes. The examiner indicated the Veteran had mild incomplete paralysis of the median and radial nerves in the left upper extremity. As to functional impact, the Veteran reported difficulty gripping and turning his steering wheel, despite continued employment as a driver. The weight of the evidence is against an award of increased rating in excess of 20 percent for peripheral neuropathy of the left upper extremity during this period. While the Veteran was found to have pain and numbness, the Veteran's deep tendon reflexes were normal with only slight reduction in strength on pinching but with full strength of other functions of the left upper extremity, including elbow flexion and extension, wrist flexion and extension, and grip strength. Light touch was decreased in the forearm and hand/fingers, but positions sense, vibration, and cold sensation were all normal. The Veteran continued to engage in physical activity and to be employed as a driver, which supports examination findings showing the Veteran's incomplete paralysis of the radial and median nerves to be mild in nature. The Board finds that the preponderance of the evidence is against a finding that the Veteran's symptoms are moderate or severe, and a rating in excess of 20 percent rating for peripheral neuropathy of the left upper extremity is denied for this period of the appeal. From May 20, 2021 Pursuant to the August 2020 remand, an addendum medical opinion was provided and the Veteran underwent a new VA examination for assessment of his peripheral neuropathy in May 2020. When explaining the disability of, and symptoms caused by, the Veteran's nonservice-connected scaleus anticus syndrome, the examiner did not explicitly state that symptoms could reliably be distinguished for the purposes of assessing a disability rating. As such, all symptoms and limitations impacting the Veteran's left upper extremity from her combined impairments have been considered in assessing the Veteran's peripheral neuropathy herein and were reflected in the disability ratings assigned in the June 2021 rating decision. On examination, the Veteran reported severe constant pain in his extremities with moderate numbness and paresthesias and/or dysesthesias. The Veteran recorded 4/5 strength in elbow flexion and extension, wrist extension, and grip strength. He had 5/5 strength with wrist flexion. He recorded normal deep tendon reflexes and sensation. He was found to have moderate incomplete paralysis of the median and radial nerves in the left upper extremity. The examiner stated that, as to functional impact, the Veteran has a limited ability to push, pull, and lift for prolonged periods of time due to his combined impairments. The weight of the evidence is against a finding of severe incomplete paralysis of the minor extremity in order to support an increased rating in excess of 30 percent during this period. While the Veteran has reported numbness and pain, he has exhibited normal sensation and reflexes with only slightly reduced muscle strength, no less than 4/5 for some movements of the left upper extremity but full muscle strength with wrist flexion during this part of the period on appeal. The examiner documented there was no atrophy of the left upper extremity. The record shows that the Veteran maintained employment through the majority of the relevant period, and no examiner has described the Veteran's incomplete paralysis of the left upper extremity to be more than moderate in severity. The Board finds that the preponderance of the evidence is against the Veteran's symptoms being more than moderate or severe, and a rating in excess of 30 percent rating for peripheral neuropathy of the minor upper extremity is denied for this period of the appeal. TDIU Total disability will be considered to exist where there is present any impairment of mind and body that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation because of service-connected disabilities, provided that the Veteran meets the schedular requirements. Specifically, if there is only one such disability, the disability shall be ratable at 60 percent or more; if there are two or more disabilities, there shall be at least one disability that is ratable at 40 percent or more and enough additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). The Veteran is currently service connected for obstructive sleep apnea with a 50 percent disability rating from April 6, 2011; diabetic nephropathy with hypertension with a 60 percent disability rating from December 1, 2014, and a 30 percent disability rating from February 1, 2020; peripheral neuropathy of the left upper extremity with scalene anticus syndrome with a 30 percent disability rating from April 6, 2011, a 20 percent disability rating from December 31, 2019, and a 30 percent disability rating from May 20, 2021; diabetes mellitus with erectile dysfunction with a 20 percent disability rating from November 8, 2006; peripheral neuropathy of the right upper extremity with a 20 percent disability rating from October 12, 2018; residuals of postoperative bunionectomy with bilateral wedge osteotomy with a 10 percent disability rating from April 1, 1995; peripheral neuropathy of the left lower extremity (femoral nerve) with a 10 percent disability rating from April 6, 2011; peripheral neuropathy of the right lower extremity (sciatic nerve) with a 10 percent disability rating from November 18, 2013; peripheral neuropathy of the right lower extremity (femoral nerve) with a 10 percent disability rating from November 18, 2013; and peripheral neuropathy of the left lower extremity (sciatic nerve) with a noncompensable disability rating from November 8, 2006, and a 10 percent disability rating from April 6, 2011. Accordingly, the Veteran has had a combined total disability rating of 80 percent from April 6, 2011, 90 percent from November 18, 2013, 100 percent from October 12, 2018, and 90 percent from February 1, 2020. Accordingly, the Veteran has qualified for schedular TDIU consideration for the period on appeal. From October 2018 to February 2020, the Veteran was in receipt of a 100 percent total disability rating. A grant of a 100 percent schedular rating does not necessarily render the issue of entitlement to a TDIU rating moot, as a TDIU rating could, in certain circumstances, render the Veteran eligible for special monthly compensation (SMC). SMC may be warranted if the Veteran has a 100 percent disabling rating for a single disability, and VA finds that a TDIU rating is warranted based solely on disabilities other than the disability that is rated at 100 percent. See Buie v. Shinseki, 24 Vet. App. 242 (2011); Bradley v. Peake, 22 Vet. App. 280 (2008). However, in this instance, the Veteran has not received a 100 percent disability rating for any individual disability. Hence, the Board finds as fact that entitlement to a TDIU rating is moot for the period from October 12, 2018 to February 1, 2020. Findings during this period may still be discussed and considered to the extent that they are indicative of the Veteran's present functioning. "Substantially gainful employment" is that employment "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." Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). "Marginal employment shall not be considered substantially gainful employment." 38 C.F.R. § 4.16. In determining whether a veteran can secure and follow a substantially gainful occupation, the Court in Ray v. Wilkie directed the Board to consider the following factors: (1) the veteran's history, education, skill, and training; (2) whether the veteran has the physical ability (both exertional and non-exertional) to perform the type of activities required by the occupation at issue; and (3) whether the veteran has the mental ability to perform the activities required by the occupation at issue. 31 Vet. App. 58, 73 (2019). In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training, and previous work experience, but not to his age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. The responsibility for making the ultimate TDIU determination is placed on the adjudicator and not a medical examiner. See Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). A medical examiner's role is limited to describing the effects of disability upon the person's ordinary activity. See Floore v. Shinseki, 26 Vet. App. 376, 381 (2013). The Veteran is competent to testify as to facts he personally observed or described; this includes recalling what he personally felt, saw, smelled, heard, or tasted. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Veteran received a Social Security Administration (SSA) disability determination dated in July 2017, which found that he is disabled and unable to sustain full-time employment effective in August 2016. It is noted that such a finding is not binding on any determinations made by VA. VA and SSA use different definitions and standards for determining disability and SSA also considers limitations from all disabilities, versus considering disabilities that are related to service or a service-connected disability. In this instance, the Veteran was found to be disabled based on the listed disabilities of peripheral vascular (arterial) disease and disorders of the back (discogenic and degenerative). The Veteran is not currently service connected for PAD or any discogenic or degenerative back disability. Accordingly, these disabilities are not relevant to the Veteran's TDIU claim. While records submitted by SSA have been considered along with the totality of the evidence, the SSA determination itself is not instructive of findings made by VA. The above discussion of the Veteran's increased rating claim is incorporated herein, to the extent relevant. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against a finding that the Veteran was precluded from securing and following substantially gainful employment during the period on appeal. The reasons follow. The Veteran has alleged that his combined service-connected disabilities of diabetes with neuropathy preclude him from substantially gainful employment. He has reported chronic pain and numbness in his extremities with reduced mobility. In a January 2020 application for TDIU, the Veteran stated that his disabilities affected his full-time employment as of January 2018 but that he became too disabled to work in June 2017. He reported that he worked 65 hours per week as a cab driver from 2008 to 2017. As an initial matter, while the Veteran is competent to report his observed symptoms, the Veteran's credibility is reduced due to inconsistent reporting relating to his employment history in his TDIU claim. For example, on the January 2020 TDIU application, the Veteran was asked to list all employment in the last five years he worked. The Veteran did not report any employment after 2017, when he indicated that his work as a cab driver ended. However, treatment records from 2019 and 2020 show that the Veteran reported active employment as a cab driver, including treatment for a motor vehicle accident that he reported to have incurred while driving to work. SSA records from 2017, when he was found disabled by SSA, show that the Veteran reported that he stopped working as a driver in October 2016. Inadvertent or otherwise, such an oversight damages the Veteran's overall credibility, as the Veteran's work history and functional capabilities are highly relevant to the within claims. However, the Veteran's ability to work up to 65 hours per week as a cab driver up to 2017, far exceeding normal standards of full-time work and substantially gainful employment, is probative evidence against the Veteran being unable to secure or follow substantially gainful employment during that period. The Veteran underwent a VA examination for assessment of his diabetes and related complications, including peripheral neuropathy, in March 2015. The examiner found that the Veteran's diabetes and related complications do not impact the Veteran's ability to work. VA examinations relating to the Veteran's hypertension and diabetic nephropathy also indicated these disabilities to have no impact on the Veteran's ability to work. On VA examination in November 2018, a VA examiner again indicated that the Veteran's diabetes does not impact his ability to work. It was noted that the Veteran's peripheral neuropathy restricts the Veteran from "physical work," which the Board interprets to mean that the examiner found the Veteran would be capable of performing sedentary activities. An examination relating to the Veteran's diabetic nephropathy also indicated that there was no functional impact on the Veteran's ability to work. Within the May 2019 VA examination report, the examiner wrote that the Veteran's hypertension does not impact the Veteran's ability to work. A December 2019 VA examination report stated that the Veteran's peripheral neuropathy requires sedentary employment without prolonged walking, climbing, or weightbearing and without requiring the Veteran to lift his left arm above his head. Within the April 2020 VA examination report, the examiner documented the Veteran reported his peripheral neuropathy impacts his ability to manipulate the steering wheel and foot pedals, although he reported continued employment as a cab driver. A June 2020 VA examination indicated that the Veteran's diabetic nephropathy and hypertension do not impact his ability to work. A May 2021 VA examination found that the Veteran's peripheral neuropathy limited the Veteran's ability to push, pull, lift, and walk for prolonged periods of time. In records submitted to SSA in June 2017, the Veteran reported that he is able to travel independently in public, by car or by using public transportation. He reported the ability to go shopping in stores and reported regularly attending church. He reported that he had no problems with his own personal care. As discussed above, in 2018 and 2019, the Veteran reported that he was engaged in an exercise program multiple times per week that included weightlifting, a step machine, and riding a stationary bike. Multiple treatment records in 2019 show that the Veteran reported that he had no issues related to his ability to drive. The Veteran has generally not alleged, nor does the record support that his erectile dysfunction impacts his ability to work. Such findings were also made by VA examiners in July 2018, November 2018, and April 2020. Likewise, the Veteran has not required recurrent and ongoing treatment relating to residuals of postoperative bilateral bunionectomy with bilateral wedge osteotomy during the relevant period. Similarly, the Veteran's obstructive sleep apnea, which was found to be aggravated by the Veteran's diabetes, has not been shown to cause the Veteran significant functional limitations. The Veteran has not indicated that these conditions prevent him from securing or following substantially gainful employment, and they did not stop him from working full time as a cab driver during the relevant period. The record shows that the Veteran participated in vocational rehabilitation and education services through VA during the relevant period, looking to acquire new skills and transition to separate areas of work, which indicates that the Veteran did not believe that his service-connected disabilities would preclude him from all forms of employment. Treatment records from December 2015 state that the Veteran was motivated for employment and was focused on federal employment. Notes stated that the Veteran would like an entry-level position, either part or full time. In 2016, the Veteran sought a personal computer through VA so that he could develop his computer skills. Records thereafter show that the Veteran was enrolled at DePaul University in a certificate training program for Office Support. The weight of the evidence is against a finding that the Veteran's service-connected conditions prevented him from substantially gainful employment. The Veteran reported working 65 hours a week as a cab driver until mid-2017. However, records thereafter indicate continued employment as a cab driver into 2020. Also, during the relevant period, the Veteran sought additional training in order to develop computer skills and earn a certification in Office Support. Additionally, records since 2018 show that the Veteran reported losing weight through an exercise program and gym membership that included lifting weights, riding a stationary bike, and using a step machine, all of which involve use of his upper and lower extremities. For these reasons, the preponderance of the evidence is against a finding that the Veteran is prevented from securing or following substantially gainful employment due to service-connected disabilities. Regarding the Veteran's education, training, skills, and work history, the Veteran reported earning a GED after the military, as well as an associate's degree in culinary arts in 1997. The Veteran also sought to obtain computer skills in 2016 and enrolled at DePaul University to obtain a certification in Office Support, ending in Spring 2017. The Veteran's occupational history includes work as a cab driver, truck driver, deli supervisor, custodian, and Amtrak service assistant. Overall, the Veteran's diverse work history, training, and education experience demonstrate a capacity for learning, training, and adaptability that would not be hindered by his service-connected disabilities. These attributes would facilitate the Veteran's return to substantially gainful employment. As to the Veteran's physical ability to perform substantially gainful employment, the Veteran's service-connected disabilities cause pain in the Veteran's upper and lower extremities and limit his mobility and ability to lift his left arm above his head. However, the record shows that the Veteran is independent in activities of daily living, has no problems maintaining personal care, and has not required inpatient treatment for his service-connected disabilities. The Veteran has been able to go shopping, maintain an exercise regimen at the gym that involves using his upper and lower extremities, and has continued to drive without limitations, including work as a cab driver into 2020. Medical examiners since 2018 have generally indicated that the Veteran is capable of sedentary employment. Accordingly, the totality of the evidence shows that the Veteran is capable of performing work at least at the sedentary exertional level. The Department of Labor's Dictionary of Occupational Titles (DOT) defines sedentary work as exerting up to 10 pounds of force occasionally (i.e., up to one third of the time), and/or a negligible amount of force frequently (i.e., from 1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body. According to DOT's definition, sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met. The Board finds no prejudice to the Veteran in considering this definition for purposes of deciding the Veteran's claim. The longitudinal record indicates that the Veteran is capable of sedentary work, as he has been able to go to the gym and perform exercises involving hs upper and lower extremities and continued working as a cab driver into 2020, reporting driving a cab 65 hours per week up to 2017. Accordingly, the weight of the evidence shows that the Veteran is physically capable of performing substantially gainful employment. As to the mental ability to perform substantially gainful employment, the Veteran has no service-connected psychiatric disorder. The Veteran's service-connected disabilities have not been shown to cause the Veteran communication deficits. He has consistently demonstrated appropriate behavior throughout the longitudinal record. Records generally indicate the Veteran to be fully alert and oriented, with intact cognitive functioning. As the Veteran's service-connected disabilities do not cause him mental limitations, the weight of the evidence shows that he is mentally capable of performing substantially gainful employment. Based on the above assessment of the Veteran's physical and mental abilities with consideration of his education, training, skills, and work history, the Board finds that the Veteran is capable of work that would result in income at the level of substantially gainful employment. Prior to mid-2017, the Veteran was capable of substantially gainful employment as he reported working 65 hours per week as a cab driver prior to that time. Although he continued to work as a cab driver thereafter, the record does not verify that he worked full time and indicates that his service-connected disabilities may have impacted his driving. In that instance, the evidence still supports a finding that the Veteran was capable of substantially gainful employment. For example, the preponderance of the evidence is against a finding that the Veteran's service-connected disabilities would preclude him from jobs that can be performed at home such as a telemarketer, where the employee makes calls and reads a script, which does not require extensive training or experience, and would require minimal exertional activity. Similarly, a customer service agent interacts with customers to handle complaints, process orders, and answer questions. This occupation can also often be performed from home, with limited physical activity. These positions would utilize everyday skills primarily involving reading and conversing appropriately with others. The record, as well as the Veteran's education history supports that the Veteran possesses these abilities and such jobs would not require advanced training or experience. Furthermore, the Veteran's efforts to obtain computer skills and certification in Office Support prior to mid-2017 indicate that the Veteran would be capable of administrative or secretarial work in an office environment not exceeding the demands of sedentary employment. The Veteran could also perform jobs involving data entry. With data entry, the Veteran would be primarily responsible for entering data into a system. These jobs can often be done from home, would not require significant training or expertise, and could be performed while seated. Additionally, the Veteran appears capable of performing work as a library, theater, or museum attendant, positions that would not be physically demanding and could be performed primarily while seated. These examples are not exhaustive but are merely illustrative of potential occupations that the Veteran could perform. Additionally, the above examples were limited to sedentary occupations, generally consistent with the assessment of some VA examiners beginning in 2018. Such classification is meant to consider the Veteran's minimal physical capabilities, despite the fact that he has reported performing activities that may otherwise exceed the physical limitations ascribed herein, such as his continued work as a driver and his work-out regimen. This is evidence against a finding that the Veteran is precluded from all forms of substantially gainful employment due to the service-connected disabilities, as well as the Veteran's contention that finding any suitable employment would be virtually impossible. For all the reasons described above, the Board finds that the preponderance of the evidence is against a finding that the Veteran is precluded from all forms of substantially gainful employment due to the service-connected disabilities and, therefore, is not entitled to a TDIU rating. The Board has considered the applicability of the benefit-of-the-doubt doctrine. However, it is not applicable where, as here, there is not an approximate balance of positive and negative evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Accordingly, entitlement to a TDIU rating is denied. REASONS FOR REMAND The Board remanded the Veteran's service connection claim in April 2018 for further development, to include an examination to determine whether it was as likely as not that the Veteran's PAD had "originated during his period of active service or is otherwise etiologically related to active service" or was "caused or aggravated by his service-connected diabetes mellitus, type II." The Veteran has previously asserted that his PAD was not diagnosed until he had diabetes. The Veteran underwent a VA examination for assessment of his PAD in December 2019. The examiner stated that "[PAD] did not originate during active service and military service did not play a role in the etiology of [PAD]." In considering the Veteran's service-connected diabetes, the examiner opined, "there is no evidence in the records that the progression of [PAD] fell outside its natural course which is deterioration with passage of time and aging." In the Joint Motion, the parties noted that the Veteran has been service-connected for diabetic nephropathy with hypertension since December 1, 2014, and that the examiner failed to provide an opinion as to whether this condition caused or aggravated the Veteran's PAD. Additionally, the parties stated that the Board provided a now-outdated definition for aggravation that did not acknowledge that entitlement to service connection based on aggravation does not require a permanent worsening of the claimed secondary condition, pursuant to Ward v. Wilkie, 31 Vet. App. 233, 240 (2019). The parties stated that remand is necessary in order to obtain an adequate medical opinion that complies with the April 2018 remand directives. Accordingly, the matter is REMANDED for the following action: Refer the claims file to an appropriate clinician to provide an addendum opinion as to whether the Veteran's peripheral artery disease (PAD) is etiologically related to service, to include as secondary to his service-connected diabetes mellitus, type II. If the examiner believes that an in-person examination is needed to provide an informed opinion, then schedule an examination. After review of the file, the examiner is asked to answer the following questions based upon the evidence of record and sound medical principles: 1. Does the Veteran have PAD that at least as likely as not (50 percent probability or greater) originated during his period of active service or is otherwise etiologically related to active service, which was from September 1971 to January 1975? 2. If the Veteran is found to have PAD that is NOT found to be directly related to service, is it at least as likely as not (50 percent probability or greater) that the Veteran's peripheral artery disability was caused by the service-connected diabetes mellitus, type II? 3. If the answer to (b.) is negative, is it at least as likely as not (50 percent or greater likelihood) that the Veteran's PAD is aggravated by the service-connected diabetes mellitus, type II? Aggravation is different from causation in that it did not cause the disability but rather caused an increase in severity that is not due to the natural progress of the disability. Please state upon what facts, medical principles, and/or medical literature support the opinion. 4. If the examiner finds that the service-connected diabetes mellitus aggravates the Veteran's PAD, the examiner is asked to state whether there is medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for the PAD prior to aggravation. If the examiner is unable to establish a baseline for the PAD prior to the aggravation, he or she should state such and explain why a baseline cannot be determined. A full rationale must be provided for all medical opinions given. If the examiner is unable to provide an opinion without resorting to mere speculation, he or she should explain why this is so. The examiner shall then explain whether the inability to provide a more definitive opinion is the result of a need for more information and indicate what additional evidence is necessary, or whether he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). A. P. SIMPSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Wonderling, 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.