Citation Nr: 21073619 Decision Date: 12/09/21 Archive Date: 12/09/21 DOCKET NO. 10-27 342 DATE: December 9, 2021 ORDER Entitlement to service connection for right eye diabetic retinopathy and cataracts (right eye disabilities), to include as secondary to left eye disability, is denied. Entitlement to service connection for cervical spine degenerative disc disease (cervical spine disability) is granted. REMANDED Entitlement to a total disability rating due to individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran's right eye disability did not have its onset in service, was not caused or aggravated by the Veteran's service connected left eye exotropia, and is not otherwise related to service. 2. The evidence is at least evenly balanced as to whether the Veteran's cervical spine disability is related to service. CONCLUSIONS OF LAW 1. The criteria for service connection for right eye disability, to include as secondary to service connected left eye exotropia, are not met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. With reasonable doubt resolved in favor of the Veteran, the criteria for entitlement to service connection for cervical spine disability have been met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1975 to April 1985. This matter comes to the Board of Veterans' Appeals (Board) on appeal from September 2008, and June 2015 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) which, inter alia, and respectively, denied service connection for cervical spine disability, and bilateral eye condition. In April 2009, the Veteran filed his notice of disagreement with, among other things, the denial of service connection for cervical spine disability, was issued a statement of the case in May 2010, and in June 2010 perfected his appeal to the Board. In October 2011, the Board remanded the Veteran's claim for service connection for cervical spine disability for a VA examination to determine whether it was caused or aggravated by his service connected intervertebral disc syndrome (IVDS). The Board also remanded the Veteran's claim for TDIU raised by the record as part and parcel of an increased rating claim. In February 2014, the RO continued its denial of service connection for cervical spine disability, and denied a TDIU, notifying the Veteran in a supplemental statement of the case. In August 2015, the Veteran filed his notice of disagreement with, among other things, the denial of service connection for bilateral eye condition, was issued a statement of the case in February 2016, and in March 2016 perfected his appeal to the Board. In November 2017, the Board, among other things, denied the Veteran's claims for cervical spine disability and TDIU, and remanded his claim for service connection for bilateral eye disability. The Veteran appealed the Board decision to the Court of Appeals for Veteran's Claims (Court) which in November 2018 granted a Joint Motion for Partial Remand (JMPR) filed by the parties, vacating, and remanding part of the Board's November 2017 decision, finding that the Board erred in relying on an inadequate VA examination to determine that service connection was not warranted for cervical spine disability. The Court also found that the issue of TDIU was inextricably intertwined with the claim for service connection for cervical spine disability, and thus vacated and remanded the issue of entitlement to a TDIU. In July 2019, the Board remanded the claim to the RO for a new VA examination in accordance with the JMPR. In a July 2019 rating decision, the RO granted service connection for left eye exotropia, evaluating it as 10 percent disabling. In July 2019, the RO denied service connection for right eye disability, notifying the Veteran in a supplemental statement of the case. In January 2020, the Board remanded the Veteran's claim for service connection for right eye disability for an addendum opinion to clarify the Veteran's right eye diagnosis, and determine the etiology of any diagnosed disability. In June 2020, the RO continued its denials of the Veteran's claims for service connection for a right eye disability, cervical spine disability, and denied TDIU, notifying the Veteran in supplemental statements of the case. In September 2020, the Board remanded the Veteran's claims for service connection for right eye disability, cervical spine disability, and TDIU for additional addendum medical opinions. In October 2020, the RO continued its denials of service connection for right eye disability, cervical spine disability, and TDIU, notifying the Veteran in supplemental statement of the case. In April 2021, the Board remanded the Veteran's claims for further development, to include new medical opinions regarding the etiology of the Veteran's cervical spine disability, and right eye disability. In August 2021, the RO again continued its denials of the Veteran's claims for service connection for right eye disability, cervical spine disability, and a TDIU, notifying the Veteran in a supplemental statement of the case. The law requires that the Veterans Law Judge who conducts a hearing on an appeal must participate in any decision made on that appeal. 38 U.S.C. § 7107 (c); 38 C.F.R. § 20.707 (2016). In September 2021, the Board sent a letter to the Veteran, which explained that the Veterans Law Judge who presided over his hearing was no longer available to participate in the appeal and offered the Veteran a hearing before a different Veterans Law Judge; otherwise, the case would be reassigned. He was instructed that if he did not respond to this letter within 30 days, the Board would assume that he did not wish to have another hearing before a Veterans Law Judge currently employed by the Board. In October 2021, the Veteran responded to the letter, indicating that he did not wish to appear at another hearing, and requested that his appeals be adjudicated based on the evidence of record. Thus, the Board will proceed with the matters on appeal. SERVICE CONNECTION Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, air, or space service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection is also warranted for disability proximately due to or the result of a service connected disease or injury. 38 C.F.R. § 3.310 (a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (b). Right Eye Disability In his August 2015 notice of disagreement, the Veteran reported that he was denied entry into the school for air traffic control while he was stationed in Italy due to his eye condition. He reported that before he was discharged, he was issued eyeglasses due to his poor sight. June 1977 service treatment records reflect that the Veteran was treated for burning and red eyes which he stated felt like muscles pulling at the top of his eye. The Veteran's June 1979 medical examination report for flying class reflects that the Veteran has accommodation of 7.7 in the right eye. October 1981 service treatment records indicate that the Veteran complained of pain in his eyes which was causing headaches. A January 1985 medical examination report indicates that the Veteran has 20/20 vision in his right eye. November 2011 VA treatment records reflect that the Veteran has a history of open angle glaucoma. In an April 2018 disability benefits questionnaire (DBQ), the examining physician reported a diagnosis of bilateral senile cataract, and stated that the date of onset was the day of the DBQ. The examiner also noted that there was no exotropia of the right eye and no complaint of diplopia. He opined that the Veteran's eye disability was less likely than not (less than a 50 percent probability) incurred in, or caused by the claimed in-service injury, event, or illness, stating that the Veteran was noted to have exotropia in the late 1970s which appears to be a congenital misalignment of the eyes which was not caused by, or aggravated by military service. He also reported that there was no evidence that the exotropia was aggravated by any superimposed disease, and that any progression of the condition is due to the natural history of the disease process. The examiner also opined that the Veteran's exotropia, which clearly and unmistakably pre-existed service, was not caused by or aggravated by military service, stating that there is no evidence that the exotropia was aggravated by any superimposed disease. The examiner provided the same rationale in opining that the Veteran's bilateral eye disability was less likely than not (less than a 50 percent probability) incurred in, or caused by his bilateral eye disability during service. In a June 2019 DBQ, the examining optometrist opined that the Veteran's bilateral eye disability, which clearly and unmistakably existed prior to service, was aggravated beyond its natural progression by an in-service injury, event, or illness, but reported that there was no evidence presented which allows for the conclusion that there was clearly and unmistakably a claimed condition that existed prior to service. The optometrist stated that it would be very unusual for a congenital or developmental defect such as strabismus or amblyopia to change over time due to the natural process of the disorder, noting that amblyopia limits are typically set by about 3 to 5 years of age, thus if a change were to occur, it would likely be due to some other external factor such as exposure to radiation, or trauma or disease. The optometrist additionally noted that the claimed condition was at least as likely as not (at least a 50 percent probability) incurred in, or caused by the claimed in-service injury, event, or illness, stating if one is precluded from the assumption that the condition was preexisting induction into service, one must presume that the possibility exists for exposure to trauma or some other injury to be causative. The optometrist referenced a few articles supporting his rationale. The Veteran was diagnosed with bilateral mild nonproliferative diabetic retinopathy without macular edema, and the optometrist additionally noted that the Veteran's monocular exotropia with other noncomitancies of the left eye affects both eyes. The optometrist reported that the Veteran's eye disabilities did not impact his ability to work. In a March 2020 DBQ, the optometrist opined that the Veteran's current disabilities of cataract and diabetic retinopathy were less likely than not (less than a 50 percent probability) incurred in, or caused by the claimed in-service injury, event, or illness, stating that they do not have any link to military service unless the diabetes itself is deemed service connected. The optometrist also stated that the Veteran does not have clinically significant and debilitating cataract, but does have early cataract formation which is not greater than expected for the Veteran's age. He reported that the cataract is not likely the result of a service connected event in so much as there is no relevant event put forth, and there is no abnormality noted beyond that which would be found in the great majority of human beings of the same age. The optometrist noted that he was able to determine a baseline level of severity of right eye disabilities based upon medical evidence available prior to aggravation or the earliest medical evidence following aggravation, stating the right eye conditions could be related to medical service only if the underlying diabetic condition is deemed to be service connected. He reported that there is clinically significant retinopathy, but no service connection for the diabetes. The optometrist stated that the right eye is not technically the eye with exotropia, and that the loss of binocular vision itself is not a medical diagnosis per se, but that while there is great loss to the vision system, current diagnostic and tradition would only claim the left eye. He also noted that the right eye does not have a vision threatening cataract, only a small normal amount for the Veteran's current age, thus no treatment is needed. The optometrist concluded that none of the diagnoses have any apparent service connection as there is no significant cataract, and no right eye exotropia. He added that there is no connection provided to link the diabetes, and therefore the diabetic retinopathy to the Veteran's military service. The optometrist explained that diabetic retinopathy is always related to diabetes, but the claims file does not show that diabetes is service connected. Thus, if service connection is found for diabetes, diabetic retinopathy would have service connection. He additionally noted that the right eye disability is not congenital and does have the potential for improving or deteriorating, therefore it is classified as a disease. He also explained that left eye exotropia is not actually in either eye, but in the brain thus impacting the use of the eyes as a team even though technically the right eye has not been diagnosed as having exotropia. The optometrist opined that the while the current severity of the Veteran's right eye disability is greater than the baseline, it was not at least as likely as not (at least a 50 percent probability) aggravated beyond its natural progression by a service connected disability, explaining that it is related to diabetes which is not service connected. In a September 2020 DBQ, the examining ophthalmologist reported that he could not determine a baseline level of severity of his right eye disability based upon medical evidence available prior to aggravation or the earliest medical evidence following aggravation, stating that the medical evidence is not sufficient to support a determination of a baseline of severity. She noted that regardless of an established baseline, the Veteran's right eye disability was not at least as likely as not (at least a 50 percent probability) aggravated beyond its natural progression by his service connected left eye disability. She explained that the ocular hypertension is either hereditary or idiopathic, the early cataracts are an age related progression of lens changes, and the presbyopia is an age related progression of refraction that confirms that the Veteran needs reading glasses. The ophthalmologist noted that the Veteran's right eye disability was less likely than not (less than a 50 percent probability) proximately due to, or the result of his service connected left eye disability, reporting that a review of the records reveals that there is no ocular condition in the right eye that would be due to the left eye exotropia. A May 2021 DBQ reflects that the optometrist, after a review of the claims file, opined that the Veteran's right eye disability was less likely than not (less than a 50 percent probability) incurred in or caused by the claim in-service injury, event, or illness, stating that the current right eye conditions are age related cataracts and non-proliferative diabetic retinopathy without macular edema. The optometrist also noted that the claimed condition, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness, stating that no congenital defect was identified, and both right eye diagnoses are acquired. The optometrist reported that the etiology of the visual field constriction of the right eye is unknown, but that a visual field constriction is an inconsistent finding for both right eye diagnoses. The optometrist also noted that the treatment record is negative for both right eye diagnoses during the Veteran's period of service, and that the treatment record does not document any evidence that the Veteran's current right eye diagnoses were pre-existed by the Veteran's service. He reported that the Veteran's entrance examination does not document either condition, and that the treatment does not have any evidence that either condition was aggravated beyond its natural progression. The optometrist additionally reported that the Veteran's right eye diagnoses of age-related cataracts and diabetic retinopathy are not due to, or causally related to left eye exotropia as cataracts are a consequence of age, and diabetic retinopathy is due to diabetes. He noted that the current severity of the Veteran's right eye disabilities is not greater than the baseline, as there was no aggravation. He explained that the mild visual acuity changes are due to cataracts, and that the cataracts are unrelated to the exotropia. The optometrist also reported that a review of the treatment record failed to locate evidence to support the contention that either right eye disability diagnosis is the result of an in-service injury, treatment, or illness. Considering the evidence of record under the laws and regulations as set forth above, the Board finds that the Veteran is not entitled to service connection for right eye disability. While the April 2018, June 2019, and May 2021 examiners' opinions indicate that the Veteran's right eye disability clearly and unmistakably existed prior to service, the Veteran's January 1985 medical examination report upon entry is normal, with no indication that the Veteran suffers from a right eye disability. A Veteran is presumed to have been sound upon entry into active service, except as to defects, infirmities, or disorders noted at the time of the acceptance, examination, or enrollment, or where clear and unmistakable evidence demonstrates that the condition existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304 (b). In other words, "[w]hen no preexisting condition is noted upon entry into service, the veteran is presumed to have been sound upon entry." Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). As a right eye disability or symptoms of a right eye disability is not noted on the Veteran's medical examination report upon entry into service, and there is no clear and unmistakable evidence within his service treatment records or the claims file which indicates the Veteran had a right eye disability prior to active duty service, the presumption of soundness has not been rebutted and the Veteran is presumed to have been sound upon entry into active duty service. The previously discussed DBQs reflect that the optometrists and ophthalmologists opined that the Veteran's right eye disabilities are less likely than not (less than a 50 percent probability) related to service, and less likely than not (less than a 50 percent probability) caused or aggravated beyond its natural progression by his service connected left eye exotropia. The examining optometrists and ophthalmologists provided thorough rationales to support their opinions based on an accurate characterization of the evidence of record. Therefore, their opinions are afforded significant probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). There are no contrary medical opinions in the evidence of record as to the etiology of the Veteran's right eye disabilities, and the evidence does not otherwise indicate that the Veteran's right eye disabilities had their onset during service, are related to his service connected left eye exotropia, or are otherwise related to service. The Board notes that while the prior opinions were found inadequate to the extent they did not address all current eye disabilities, the opinions were probative as to the disabilities they did address for the reasons above. See Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) ("even if a medical opinion is inadequate to decide a claim, it does not necessarily follow that the opinion is entitled to absolutely no probative weight"; "it may be given some weight based upon the amount of information and analysis it contains"). The Board acknowledges the Veteran's contention that his right eye disabilities are due to service, or related to his service connected left eye exotropia. While the Veteran is competent to provide testimony or statements relating to symptoms or facts of events that he has observed and are within the realm of his personal knowledge, he is not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). The record does not show, nor does the Veteran contend, that he has specialized education, training, or experience that would qualify him to render a diagnosis or render a medical opinion on this matter. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the issue in this case is outside the realm of common knowledge of a lay person because it involves a complex medical issue that goes beyond a simple and immediately observable cause-and-effect relationship. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n. 4 (Fed. Cir. 2007). Thus, the Veteran's statements in this regard are not competent and are afforded no probative weight. For the above stated reasons, the preponderance of the evidence weighs against a finding that the Veteran's claimed right eye disabilities had their onset in service, are otherwise related to service, or caused or aggravated by his service connected left eye exotropia. The benefit-of-the-doubt doctrine is therefore not for application, and service connection for right disabilities is not warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Cervical Spine Disability The Veteran's DD-214 reflects that his military occupational specialty (MOS) was as a correctional specialist, military policeman, and cannon crewman. In a May 2008 statement, the Veteran reported that he believes that his service connected IVDS caused or aggravated his cervical spine pain. The Veteran testified that his "pain doctor" informed him that his pain from his back spreads throughout his body. November 1983 service treatment records indicate that the Veteran suffered from a cervical muscle spasm. In a January 1985 medical examination report, the Veteran reported neck stiffness that was "not often". In an August 1987 VA medical examination report, the Veteran stated that he has suffered from pain in the right side of his neck. In an April 1998 letter, the Veteran's private physician reported that the Veteran's motor vehicle accident in 1997 did not seem to cause significant dysfunction in the sacroiliac spine as though the injury seemed to be more related to the upper back, neck, and head. February 2008 private post-service treatment records reflect that the Veteran was found to have decreased range of motion secondary to pain in his neck. March 2008 private treatment records reflect that spondylosis was noted at C4 to C7 of the Veteran's cervical spine. A June 2008 VA examination report reflects minimal degenerative osteoarthritis of the cervical spine with no recent bone trauma, disc space narrowing at C5-C6, and straightening of normal curvature or cervical spine. June 2008 private medical records indicate that the Veteran has been experiencing neck pain since a motor vehicle accident. In January 2009 private treatment records, the physician reported that the Veteran had disability conditions related to his cervical spine related to parachute jumps in the normal course of his military deployment. He stated that the Veteran's neck continues to show progression of spondylosis due to cumulative overuse injury due to parachute jumps. A May 2010 VA examination report indicates that the Veteran reported onset of pain in 1976 or 1977 which he described as a dull constant pain with intermittent sharp shooting pain during flare-ups. The examining physician's assistant (PA) stated that he found no supporting evidence that the degenerative joint/disc disease affecting the cervical spine was found on, or aggravated by military service, stating that the claims file revealed no specific complaints of, or evaluation for cervical spine pain. The PA concluded that the Veteran's cervical spine disability is less likely than not (less than a 50 percent probability) caused by, or a result of his service connected lumbar IVDS. August 2011 VA treatment records indicate that the Veteran reported that he had a total of 56 parachute jumps during service, and was discharged from the military due to back, neck, and hip pain. He stated that in the last year and a half, he has developed severe pain in the neck. In a March 2020 DBQ, the examining physician indicated that he could not determine a baseline of severity of the Veteran's cervical spine disability based upon medical evidence prior to aggravation or the earliest medical evidence following aggravation, stating that the medical evidence is not sufficient to support a determination of a baseline level of severity. The physician noted that the Veteran's cervical spine disability was not at least as likely as not (at least a 50 percent probability) aggravated beyond its natural progression by his service connected lumbar IVDS. The physician noted that there are no findings of a neck condition in the Veteran's service treatment records, thus it is less likely due to military service, and less likely than not due to his lumbar spine disability as the T11-L3 discs are unremarkable, and although there are mild degenerative changes on the thoracic spine x-rays in April 2010, significant arthritis in the neck would biomechanically not develop from the lumbar spine in absence of significant arthritic findings in the upper lumbar and throughout the thoracic spine. The physician stated that the Veteran's motorcycle accident is more likely to cause his neck condition. The physician reported a diagnosis of cervical fusion/discectomy, and cervical spine degenerative disc disease, noting onset in 2000 which has since worsened. The physician stated that the Veteran's cervical spine disability impacts his ability to work as he would have pain with work requiring frequent turning of the neck, or prolonged looking up and down. A September 2020 DBQ reflects that the physician opined that the Veteran's cervical spine disability is less likely than not (less than a 50 percent probability) proximately due to, or the result of his service connected lumbar spine IVDS, stating that a lumbar condition is independent of a cervical condition. He explained that biomechanically, the Veteran's low back condition would not cause his cervical arthritis, degenerative disc disease, or C3-C5 cervical fusion/discectomy, and there are no records that state such. In an October 2020 addendum opinion, the physician reported that it is not at least as likely as not (at least a 50 percent probability) that the Veteran's cervical spine disability was aggravated beyond its natural progression by his lumbar spine disability, stating that a lumbar condition is independent of a cervical condition, and that biomechanically his low back conditions would not aggravate his cervical arthritis, degenerative disc disease, or C3-C5 cervical fusion/discectomy beyond its normal progression, and there are no records that state such. In a June 2021 DBQ, the examining physician opined that the Veteran's cervical spine disability was less likely than not (less than a 50 percent probability) incurred in, or caused by the claimed in-service injury, event, or illness, stating that the service treatment records are silent for clinic visits for neck issues, complaints, evaluation, diagnoses, or treatment. The physician also noted that while the August 1987 VA examination report indicated that the Veteran reported acute "onset of pain in the right side of his neck" no neck abnormalities were documented, and no diagnosis was made of a neck condition, with no evidence indicating that the acute right sided neck pain was related to military service. The physician also noted that muscle spasms do not cause bony disc deterioration. She reported that she was not able to determine a baseline level of severity of the cervical spine disability based upon medical evidence available prior to aggravation or the earliest medical evidence following aggravation by his lumbar spine disability, stating that regardless of an established baseline, his cervical spine disability was not at least as likely as not (at least a 50 percent probability) aggravated beyond its natural progression by the service connected lumbar spine IVDS. The physician explained that from a biomechanical standpoint, the lower lumbar sacral degenerative disc disease would not aggravate or worsen the upper cervical spine degenerative disc disease as the conditions are non-contiguous, and the physician referenced 2 studies to support her rationale. The Board notes that while the Veteran has contended that his cervical spine disability was due to his service connected lumbar spine IVDS, the evidence including private and VA treatment records indicate that the Veteran's cervical spine disability may be related to service, thus a claim for direct service connection for cervical spine disability has been raised by the record, and the Board will consider this alternate theory of entitlement. See Robinson v. Shinseki, 557 F.3d 1355, 1361 (Fed. Cir. 2009) (in direct appeals, all filings must be read in a liberal manner); EF v. Derwinski, 1 Vet. App. 324, 326 (1991) (Board must review all issues reasonably raised from a liberal reading of all documents in the record). The preponderance of the evidence reflects that the Veteran's cervical spine disability is related to service. The Veteran has current diagnosis of degenerative osteoarthritis as evidenced by his June 2008 VA examination and the Veteran has competently and credibly reported that he executed a total of 56 parachute jumps during service. The Veteran's MOS during service was as a correctional specialist, military policeman, and cannon crewman, as well as a recipient of a Parachute Badge. Therefore, the Veteran's reports of executing parachute jumps during service are consistent with his circumstances of service. See 38 U.S.C. § 1154 (a); 38 C.F.R. § 3.303 (a) (each disabling condition for which a veteran seeks service connection must be considered based on factors including the basis of places, types, and circumstances of service as shown by service record). Therefore, the first two requirements for service connection have been satisfied. As for the nexus requirement, the May 2010 PA, March 2020 physician, and June 2021 physician each opined that the Veteran's cervical spine disability was less likely than not due to service, but based their opinions on a lack of service treatment records indicating that the Veteran suffered from neck issues during service which is an impermissible basis upon which to conclude that the Veteran's cervical spine disability is not related to service. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (examination inadequate where the examiner did not comment on the Veteran's report of in-service injury and relied on lack of evidence in service medical records to provide negative opinion). Therefore, the opinions are inadequate and afforded no probative weight. Alternatively, the January 2009 private physician opined that the Veteran's cervical spine disability was related to parachute jumps during service, noting that the disability has since progressed. While the January 2009 physician's rationale was not extensive, reading the opinion as a whole and in the context of the evidence of record, he found that the nature of the Veteran's military service and events that occurred therein, and subsequent symptoms, made it likely that they had resulted in his current cervical spine disability. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (the fact that the rationale provided by an examiner "did not explicitly lay out the examiner's journey from the facts to a conclusion," did not render the examination inadequate); Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (medical reports must be read as a whole and in the context of the evidence of record). For the foregoing reasons, the evidence is at least evenly balanced as to whether the Veteran's cervical spine disability is related to service. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for cervical spine disability is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND TDIU The Veteran testified that he retired from his job as a utility systems operator supervisor because of his back and neck pain. He stated he was not able to climb the steps, so if an alarm sounded, he would not be able to react to it which would jeopardize the lives of staff and inmates. The Veteran's form 21-8940 application indicates that the Veteran last worked full time and became too disabled to work in March 2007, and that he last worked in law enforcement. He noted that he completed 4 years of high school, and that he left his last job due to his disability. A TDIU is warranted where the combined schedular evaluation for service-connected disabilities is less than total, or 100 percent. 38 C.F.R. § 4.16(a). 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, by reason of his or her service connected disabilities. 38 C.F.R. §§ 3.340, 3.341, 4.16. Under 38 C.F.R. § 4.16(a), if there is only one such disability, it must be rated at 60 percent or more to qualify for benefits based on individual unemployability. If there are two or more such disabilities, there shall be at least one disability rated at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent. 38 C.F.R. § 4.16(a). However, for those veterans who fail to meet the percentage requirements set forth above in accordance with 38 C.F.R. § 4.16 (a), total disability ratings for compensation may nevertheless be assigned on an extra-schedular basis by VA's Director of Compensation Service when it is found that the service-connected disabilities are sufficient to produce unemployability. 38 C.F.R. § 4.16 (b). The Veteran is currently in receipt of service connection for: lower back IVDS, evaluated as 20 percent disabling; left metatarsalgia, evaluated as 10 percent disabling; left eye exotropia, evaluated as 10 percent disabling; tinnitus, evaluated as 10 percent disabling; and left ear hearing loss, evaluated as noncompensable. The Veteran has a combined 40 percent disability and therefore does not meet the requirements for a TDIU on a schedular basis under 38 C.F.R. § 4.16 (a), to include any of the exceptions in 38 C.F.R. § 4.16(a)(1)-(5). However, under 38 C.F.R. § 4.16 (b), all cases where the veteran is unable to secure or follow a substantially gainful occupation because of a service connected disability should be referred to the Director of Compensation Service. In Ray v. Wilkie, 31 Vet. App. 58, 66 (2019), the Court held that the initial extraschedular referral decision under § 4.16(b) should address whether there is "sufficient evidence to substantiate a reasonable possibility that a veteran is unemployable by reason of his or her service-connected disabilities." In the previously noted March 2020 DBQ, the examining physician stated that the Veteran's cervical spine disability impacts his ability to work as he would have pain with work requiring frequent turning of the neck, or prolonged looking up and down. Additionally, the Veteran has competently and credibly reported that his service connected lumbar spine IVDS pain prevents him from performing the requisite duties of a person with his education and experience as a utility systems operator as it impairs his ability to move and react to emergency situations. The Veteran's competent and credible reports that his pain prevents him for adequately performing his duties, and the assertions of the March 2020 physician substantiate a reasonable possibility that the Veteran is unemployable by reason of his service connected cervical spine disability and lumbar spine IVDS. The standard for remand for referral to the Director under 38 C.F.R. § 4.16(b) has thus been met. As the RO's implementation of the Board's grant of service connection for cervical spine disability could significantly impact a decision on the issue of entitlement to a TDIU, the issue of TDIU is being remanded to give the RO the opportunity to address TDIU after implementing these grants of service connection. If the Veteran does not meet the schedular standards, the issue of entitlement to a TDIU pursuant to 38 C.F.R. § 4.16(b) should be referred to the Director of Compensation. The matter is REMANDED for the following action: After implementing the grant of service connection for cervical spine disability, take appropriate action to develop and adjudicate the issue of entitlement to a TDIU. If the schedular standards are not met, refer the issue of entitlement to a TDIU to the Director of Compensation pursuant to 38 C.F.R. § 4.16(b). Jonathan Hager Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Maddox, 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.