Citation Nr: 21072955 Decision Date: 12/07/21 Archive Date: 12/07/21 DOCKET NO. 15-19 989 DATE: December 7, 2021 ORDER Service connection for a blood clot of the right leg is granted. Service connection for a liver disability is granted. Service connection for memory loss is denied. A rating in excess of 10 percent for right hip limitation of extension is denied. A compensable rating for right hip limitation of flexion is denied. A compensable rating for right hip limitation of abduction and adduction is denied. A rating in excess of 10 percent for left hip limitation of extension is denied. A compensable rating for left hip limitation of flexion is denied. A compensable rating for left hip limitation of abduction and adduction is denied. A rating in excess of 10 percent for a lumbar spine disability is denied. Prior to May 21, 2020, a 10 percent rating for radiculopathy of the right lower extremity is granted. Prior to May 21, 2020, a 10 percent rating for radiculopathy of the left lower extremity is granted. Since May 21, 2010, a rating in excess of 10 percent for radiculopathy of the right lower extremity is denied. Since May 21, 2020, a rating in excess of 10 percent for radiculopathy of the left lower extremity is denied. Prior to August 1, 2019, a total disability rating based upon individual unemployability (TDIU) is denied. Since August 1, 2019, a TDIU is granted. REMANDED Entitlement to service connection for a nasal disability is remanded. FINDINGS OF FACT 1. Resolving the benefit of the doubt in favor of the Veteran, his blood clot of the right leg was worsened in service due to superimposed injury. 2. The Veteran's liver disability is likely caused or aggravated by his service-connected hypertension. 3. The Veteran does not have a disability manifested by memory loss. 4. The Veteran's right and left hip disabilities are manifested by pain, limitation of extension greater than to 5 degrees and limitation of flexion to greater than 45 degrees, with the ability to toe-out to more than 15 degrees on each side, and the ability to cross the legs unimpaired. 5. The Veteran's lumbar spine disability has been manifested by forward flexion to greater than 60 degrees, a combined range of motion of the spine to greater than 170 degrees, and without evidence of muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 6. Throughout the appeal period, the radiculopathy affecting the Veteran's right and left lower extremities has caused what amounts to "mild" incomplete paralysis of the sciatic nerve. 7. Prior to August 1, 2019, the Veteran was gainfully employed. 8. Since August 1, 2019, the Veteran's service-connected disabilities preclude him from obtaining and maintaining substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for service connection for a blood clot of the right leg are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for a liver disability are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for service connection for memory loss are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. A rating in excess of 10 percent for the limitation of extension of the right hip have not been met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.7, 4.10, 4.21, 4.71a, Diagnostic Code (DC) 5251. 5. A rating in excess of 10 percent for limitation of extension of the left hip have not been met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.7, 4.10, 4.21, 4.71a, DC 5251. 6. A compensable rating for limitation of flexion of the right hip have not been met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.7, 4.10, 4.21, 4.71a, DC 5252. 7. A compensable rating for limitation of flexion of the left hip have not been met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.7, 4.10, 4.21, 4.71a, DC 5252. 8. A compensable rating for limitation of abduction/adduction of the right hip have not been met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.7, 4.10, 4.21, 4.71a, DC 5253. 9. A compensable rating for limitation of abduction/adduction of the left hip have not been met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.7, 4.10, 4.21, 4.71a, DC 5253. 10. The criteria for a rating in excess of 10 percent for the lumbar spine disability have not been met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. § 3.102, 3.303, 4.71(a), DC 5242. 11. Prior to May 21, 2020, a 10 percent rating for the associated radiculopathy of the right lower extremity have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.124a, DC 8520. 12. Prior to May 21, 2020, a 10 percent rating for the associated radiculopathy of the left lower extremity have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.124a, DC 8520. 13. Since May 21, 2020, the criteria for a rating in excess of 10 percent for the associated radiculopathy of the right lower extremity have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.124a, DC 8520. 14. Since May 21, 2020, the criteria for a rating in excess of 10 percent for the associated radiculopathy of the left lower extremity have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.124a, DC 8520. 15. Prior to August 1, 2019, the criteria for a TDIU have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16, 4.18, 4.19. 16. Since August 1, 2019, the criteria for a TDIU have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16, 4.18, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from February 1977 to February 1997. 1. Service connection for a blood clot of the right leg is granted. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Congenital or developmental defects themselves are not diseases or injuries within the meaning of the applicable legislation and are generally not subject to service connection. 38 C.F.R. §§ 3.303 (c), 4.9 (2015); see Winn v. Brown, 8 Vet. App. 510, 516 (1996). Service connection is only possible if there is evidence of additional disability due to aggravation during service of the congenital defect by superimposed disease or injury. See VAOPGCPREC 82-90; Monroe v. Brown, 4 Vet. App. 513, 514-15 (1993); Carpenter v. Brown, 8 Vet. App. 240, 245 (1995); VAOPGCPREC 67-90; VAOPGCPREC 11-99. When weighing the evidence of record and resolving the benefit of the doubt in favor of the Veteran, the Board finds that service connection for blood clots of the right leg is warranted. On August 2021 VA examination, the examiner determined that the Veteran's right leg clotting disability, a Factor V Leiden Mutation, is a congenital defect. The record does not refute this finding. In that case, under the law, the congenital defect can only meet the criteria for service connection if there is evidence of additional disability due to aggravation by superimposed disease or injury while in service. A review of the remaining evidence reflects that this standard has been met, and that there was likely a superimposed injury that occurred in service that aggravated his congenital defect. Specifically, the Veteran contends that while in service his duties made it so that he had to sit for prolonged periods and such caused him to experience deep thrombosis in service and after service. In August 2012, a private physician opined that the Veteran suffered from deep vein thrombosis by history due to his heavy travel in service. The physician stated that this condition led to future poor venous flow and increased the chances of infection. In October 2013, a VA examiner found evidence of a diagnosis of right calf thrombophlebitis in the service treatment records, though the Board has not been able to find this particular record. Even still, the record shows that the Veteran was diagnosed with deep vein thrombosis in at least 2006. The Board notes that neither the August 2021 nor the January 2020 VA examiner appeared to consider or discuss the Veteran's contention that sitting for long periods of time while performing his duties in service caused superimposed injury to his blood clot defect. In that regard, the January 2020 VA examiner did state that stationary activity could cause deep vein thrombosis. When considering and placing probative weight on the August 2012 private opinion, it appears that the Veteran likely incurred a superimposed injury, that of prolonged sitting, while in service, and experienced resultant deep vein thrombosis superimposed on his blood clot congenital defect both in service (according to the October 2013 VA examiner) and following service as shown in the 2006 medical records. This conclusion is bolstered by the January 2020 VA opinion that listed prolonged sitting as a cause of deep vein thrombosis. Given such, there is evidence that the Veteran's congenital defect suffered aggravation in service. Thus, service connection is warranted. 2. Service connection for a liver disability is granted. The Board finds that service connection for a liver disability is warranted. First, the evidence reflects that the Veteran has been diagnosed with fatty liver disease during the appeal period. Next, on May 2021 VA examination, the VA examiner determined that it was least as likely as not that the Veteran's service-connected hypertension caused his fatty liver disease, stating that hypertension was known to be associated with metabolic syndrome which was strongly linked to the development of fatty liver disease (steatohepatitis). Given this positive opinion, the Board finds that service connection for a liver disability is warranted. 3. Service connection for memory loss is denied. The Veteran contends that he suffers from a disability manifested by memory loss. However, a review of the record does not reflect a diagnosis of a disability manifested by memory loss aside from symptoms of an already diagnosed disability. Specifically, the Veteran is in receipt of service connection for insomnia with associated memory loss issues. Aside from this already service-connected disability, there is no other memory loss disability demonstrated by the record. On May 2021 VA examination, the examiner concluded such, stating that the Veteran did not have a memory loss disability aside from his insomnia disorder. On that same examination, the Veteran denied experiencing any significant cognitive impairment or memory impairment. In July 2019, a private physician stated the same, that the Veteran suffered from memory loss due to his lack of sleep or insomnia, only. In February 2020, a VA examiner stated that an opinion as to whether the Veteran suffered from clinically significant memory loss could not be made based upon the present examination. The Veteran has made general contentions that he suffers from memory loss related to his service and/or to medications, however, the record does not support a finding of a separate memory loss disability. Significantly, the Veteran underwent psychiatric testing in May 2021, and it was determined that he did not suffer from a memory loss disability. In fact, at the time of that examination, the Veteran denied experiencing memory impairment aside from his sleep disorder. While the Veteran is competent to state that he suffers from memory loss, he does not have the necessary medical knowledge or expertise to diagnose a memory loss disability. In that regard, the competent and probative medical evidence of record demonstrates that his memory loss is a symptom of his service-connected insomnia. The Board has considered the February 2020 VA examiner's statement that a neuropsychiatric examination would be necessary to determine if an actual cognitive impairment was present. However, given that the Veteran denied a cognitive impairment on 2021 VA examination, obtained on remand, further development does not appear to be necessary in that regard. Significantly, neither VA examiner found evidence of a clinical memory disorder following examination. Based on the above, service connection for an additional or separate memory loss disability is denied. 4. A rating in excess of 10 percent for right hip limitation of extension is denied. 5. A compensable rating for right hip limitation of flexion is denied. 6. A compensable rating for right hip limitation of abduction and adduction is denied. 7. A rating in excess of 10 percent for left hip limitation of extension is denied. 8. A compensable rating for left hip limitation of flexion is denied. 9. A compensable rating for left hip limitation of abduction and adduction is denied. Disability ratings are determined by comparing the Veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate codes identify the various disabilities. 38 C.F.R. Part 4. When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal exertion, strength, speed, coordination and endurance. It is essential that the examination upon which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40. Evidence of pain, weakened movement, excess fatigability, or incoordination must be considered in determining the level of associated functional loss, taking into account any part of the musculoskeletal system that becomes painful on use. 38 C.F.R. § 4.40; DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions regarding the avoidance of pyramiding do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare ups. 38 C.F.R. § 4.14. The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, however, should only be considered in conjunction with the Codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. With respect to the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); (b) more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); (c) weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); (d) excess fatigability; (e) incoordination, impaired ability to execute skilled movements smoothly; and (f) pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing are related considerations. 38 C.F.R. § 4.45. The Veteran is in receipt of 10 percent ratings for limitation of extension of both the right and left hip. He is in receipt of noncompensable, or 0 percent ratings, for limitation of flexion, and limitation of adduction, of the hips. Diagnostic Code 5251 provides a maximum 10 percent rating for limitation of thigh extension to 5 degrees. Diagnostic Code 5252 provides for 20, 30 and 40 percent evaluations where flexion of the thigh is limited to 30 degrees, 20 degrees and 10 degrees, respectively. Diagnostic Code 5253 provides for a 10 percent evaluation for limitation of rotation of the thigh of (cannot toe-out more than) 15 degrees, or limitation of adduction (cannot cross legs); a 20 percent evaluation is warranted for limitation of adduction of the thigh where motion is lost beyond 10 degrees. The Veteran has not been shown to suffer from ankylosis of the hip, flail joint of the hip, or impairment of the femur. Thus, DCs 5250, 5254, and 5255 are not pertinent to his claim. Turning to the evidence of record, on March 2017 VA examination, the Veteran reported dull pain in his hips that worsened as he walked throughout the day. Flexion of the right hip was to 100 degrees, extension of the right hip was to 20 degrees, and adduction of the right hip was to 15 degrees. Flexion of the left hip was to 75 degrees, extension of the left hip was to 15 degrees, and adduction of the left hip was to 10 degrees. The Veteran's adduction was not limited such that he could not cross his legs. There was evidence of pain on weightbearing on range of motion. There was evidence of moderate, diffuse tenderness on palpation of the right hip, and there was evidence of moderately severe diffuse pain on palpation of the left hip. On repetitive testing, there was no evidence of further loss of range of motion. The examiner stated that on repetitive use, there was likely pain, fatigue, and weakness. Additional loss of motion following flare-ups could not be stated since flare-ups differed based upon the activity performed. Muscle strength testing in the right hip was 4/5 and muscle strength testing in the left hip was 3/5. There was evidence of pain on weightbearing and non-weightbearing, and on passive and active ranges of motion. On August 2021 VA examination, the Veteran reported increased aching in his hips with weather changes, as well as prolonged walking and standing. Alleviating factors included rest and pain medication. During a flare-up, he could not squat or lunge. Flexion of the right hip was to 115 degrees, extension of the right hip was to 25 degrees, and adduction of the right hip was to 20 degrees. Flexion of the left hip was to 115 degrees, extension of the left hip was to 30 degrees, and adduction of the left hip was to 25 degrees. The ranges of motion were the same on passive range of motion. There was pain on all ranges of motion. The Veteran was able to cross his legs. There was evidence of pain on weight-bearing and non-weight-bearing. The examiner provided an estimated loss of range of motion on flares-ups, finding that on right side, flexion would be limited to 105 degrees, extension would be limited to 20 degrees, and adduction would be limited to 15 degrees, and on the left side, flexion would be limited to 105 degrees, extension would be limited to 20 degrees, and adduction would be limited to 15 degrees. In this case, when reviewing the above evidence, as well as the remaining evidence of record, the Board finds that higher ratings are not warranted. Specifically, even when considering the Veteran's symptoms of pain on motion and his symptoms during flares, a higher rating is not warranted under any of the above diagnostic codes. The Veteran has not been shown to suffer from any of the limitation of motions indicated in DCs 5251, 5252, or 5253. The Veteran's primary symptoms related to his right and left hip disabilities are pain on movement and loss of endurance on repetitive movement throughout the day. These symptoms are contemplated by the 10 percent ratings assigned, which are assigned based upon functional loss due to pain without evidence of the requisite showings of limitation of motion as set forth by 38 C.F.R. §§ 4.40, 4.45 and 4.59 and Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Thus, the Veteran is compensated for his symptoms as directed by the rating schedule, and there are no other symptoms not already accounted for by this schedule. Therefore, higher ratings for his right and left hip disabilities are denied. 10. A rating in excess of 10 percent for a lumbar spine disability is denied. 11. Prior to May 21, 2020, a 10 percent rating for radiculopathy of the right lower extremity is granted. 12. Prior to May 21, 2020, a 10 percent rating for radiculopathy of the left lower extremity is granted. 13. Since May 21, 2010, a rating in excess of 10 percent for radiculopathy of the right lower extremity is denied. 14. Since May 21, 2020, a rating in excess of 10 percent for radiculopathy of the left lower extremity is denied. The Veteran's lumbar spine disability is evaluated under the General Rating Formula for Diseases and Injuries of the Spine. Under these criteria, a 10 percent rating is warranted 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 warranted for forward flexion of the lumbar spine greater than 30 degrees but not greater than 60 degrees, or the combined range of motion of spine not greater than 120 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait pattern or spine contour such as scoliosis, reverse lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the lumbar spine 30 degrees or less, or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted when there is unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted when there is unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is from zero to 90 degrees, extension is from zero to 30 degrees, left and right lateral flexion (side bending) are from zero to 30 degrees, and left and right lateral rotation (twisting) are from zero to 30 degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (2). The Board finds that a rating greater than 10 percent for the Veteran's lumbar spine disability is not warranted at any time during the appeal period. The VA examinations of record, as well as the VA treatment records, do not show limitation of motion that would warrant any higher rating. He has described painful motion of his low back but this is contemplated by his 10 percent rating. The assigned 10 percent rating contemplates painful motion as set forth by 38 C.F.R. §§ 4.40, 4.45 and 4.59 and Mitchell, supra. Specifically, on August 2021 VA examination, the Veteran reported moderate pain related to his low back. During flares he could not bend forward at the waist or pivot. However, he was able to forward flex to 80 degrees, extend to 30 degrees, and he could both laterally flex and laterally rotate bilaterally to 30 degrees. It was estimated that during a flare, his forward flexion would be limited to 70 degrees, extension would be limited to 25 degrees, and lateral flexion and rotation would be limited to 20 degrees. There was no evidence of guarding or muscle spasm. These results are similar to those on previous VA examinations conducted during the appeal period. None of these examinations demonstrate the requisite ranges of motion to meet the criteria for a higher rating. Additionally, there is no evidence of incapacitating episodes meaning resulting in bed rest prescribed by a physician, certainly not of the required frequency and direction, which would alternatively warrant assigning a higher rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. 38 C.F.R. § 4.71a, DC 5243, including Note (1). Even if the Veteran has felt the need, however often, to remain in bed or rest in bed because of this disability is not equivalent or tantamount to an incapacitating episode given the express requirement in the VA regulation of this having to be on prescription of a doctor, not instead at the Veteran's election. Next, in rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment and motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. Under 38 C.F.R. § 4.124a, disability from neurological disorders is rated from 10 to 100 percent in proportion to the impairment of motor, sensory, or mental function. With partial loss of use of one or more extremities from neurological lesions, rating is to be by comparison with mild, moderate, severe, or complete paralysis of the peripheral nerves. The term incomplete paralysis indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is only sensory, the rating should be for the mild, or at most, the moderate degree. In rating peripheral nerve disability, neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis. The maximum rating to be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate incomplete paralysis, or with sciatic nerve involvement, for moderately severe incomplete paralysis. 38 C.F.R. § 4.123. DC 8520 provides the rating criteria for paralysis of the sciatic nerve, and therefore neuritis and neuralgia of that nerve. Complete paralysis of the sciatic nerve, which is rated as 80-percent disabling, contemplates foot dangling and dropping, no active movement possible of muscles below the knee, and flexion of the knee weakened or (very rarely) lost. Disability ratings of 10 percent, 20 percent and 40 percent are assignable for incomplete paralysis that is mild, moderate or moderately severe in degree, respectively. A 60 percent rating is warranted for severe incomplete paralysis with marked muscle atrophy. 38 C.F.R. § 4.124a, DC 8520. DC 8620 refers to neuritis of the sciatic nerve, and DC 8720 refers to neuralgia of the sciatic nerve. The Board finds that the Veteran's right and left lower extremities have shown what amounts to mild impairment (incomplete paralysis) of his sciatic nerve, but no higher, throughout the appeal period to include prior to May 21, 2020. The VA examinations show that his radiculopathy of the lower extremities were assessed to be mild in severity in both 2020 and 2021. Repeatedly, his muscle strength was considered to be normal, or 5/5. Reflex examination was normal. He displayed symptoms of numbness and paresthesias that were mild in degree. The Veteran has not shown clinical signs of neurological deficits on motor examination, muscle strength testing, or sensation testing that would be considered to be moderate or severe in degree (as opposed to mild) on testing at any time during the appeal period. 15. Prior to August 1, 2019, a total disability rating based upon individual unemployability (TDIU) is denied. 16. Since August 1, 2019, a TDIU is granted. Total disability ratings for compensation may be assigned where the schedular rating is less than total, 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 a service-connected disability(ies) provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16 (a). For the purpose of determining whether these rating requirements are met, disabilities affecting both upper extremities or both lower extremities, disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric, or those resulting from a single accident or common etiology are considered as one, collective, disability. Id. Substantially gainful employment is defined as work that is more than marginal and that permits the individual to earn a living wage. See Moore v. Derwinski, 1 Vet. App. 356 (1991). In a precedent case, the Court held that "substantially gainful employment," in the TDIU context, contains economic and noneconomic components; 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," while the noneconomic component requires consideration of a veteran's ability to secure or follow that type of employment. The Court also provided guidance as to the meaning of a Veteran's ability to "secure and follow" such employment, noting that attention must be given to: the Veteran's occupational history, education, skill and training; whether the Veteran has the physical ability to perform occupational activities; and whether the Veteran has the mental ability to perform occupational activities. See Ray v. Wilkie, 31 Vet. App. 58 (2019). To establish entitlement to a TDIU, there must be impairment so severe that it is impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. In making this 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). First, the Veteran's combined rating, that of 90 percent throughout the appeal period, meets the criteria for consideration of a TDIU. In this case, the Board finds that a TDIU is warranted since August 1, 2019. Prior to this period of time, the Veteran was gainfully employed, as reported on his July 2019 application for a TDIU. Therefore, prior to August 1, 2019, a TDIU cannot be granted. The Veteran has stated at various times, both on VA examination and in statements in support of his claim, that he decided to retire from his position in acquisition logistics for the Air Force due to his ongoing low back pain and the time needed for related doctor appointments. In that regard, on August 2021 VA examination, the examiner concluded that the Veteran's low back disability impacted employment in that a physically demanding job would be difficult for the Veteran, as any prolonged sitting, standing, or walking would cause flare-ups. Similarly, in August 2014, the Veteran's private physician stated that the Veteran's low back pain symptoms affected his daily activities with symptoms of pain and the need to take significant pain medications, all of which potentially interfere with his work and daily activities. Although it is unclear whether the Veteran's previous employment was physically demanding, the Veteran has stated that sitting for prolonged periods of time, as referenced by the 2021 VA examiner as a significant functional impairment, caused him to experience back pain that interfered with his ability to complete his job duties. Additionally, the evidence reflects that the Veteran suffers from functional impairment related to his service-connected right and left hip disabilities, with similar symptoms of pain and limitation of function with movement. Furthermore, the evidence reflects that the Veteran suffers from longstanding insomnia and sleep apnea, both of which are service-connected disabilities, that have been shown interfere with his ability to function due to lack of sleep. When considering the totality of impact of the Veteran's service-connected disabilities on his ability to obtain and maintain substantially gainful employment, the Board finds that the criteria for a TDIU are met since August 1, 2019. REASONS FOR REMAND 1. Service connection for a nasal disability is remanded The issue of entitlement to service connection for a nasal disability was remanded in January 2021 so that a new opinion could be obtained that considered the Veteran's contentions of injury in service. However, the August 2021 VA opinion did not address these contentions, therefore, it is not adequate and a new examination and opinion is necessary. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The matters are REMANDED for the following action: Schedule the Veteran for a VA examination to determine the etiology of his nasal disability. Even if an examination is not possible to obtain, provide the following opinion: Is the Veteran's current nasal disability, variously diagnosed as chronic sinusitis, septal deviation, inferior hypertrophy and chronic rhinitis, caused or aggravated by his service, to include his August 2014 written contention that his nasal disabilities were caused by years of coaching and playing softball in service and getting hit in the face by the ball and a time in 1997 when he fell and hit his face against a metal rail? The examiner must discuss these contentions when providing the requested opinion. N. RIPPEL Acting Veterans Law Judge Board of Veterans' Appeals R. Erdheim, Attorney for the Board Department of Veterans Affairs 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.