Citation Nr: 21074006 Decision Date: 12/14/21 Archive Date: 12/13/21 DOCKET NO. 11-10 122 DATE: December 14, 2021 ORDER Entitlement to a rating in excess of 10 percent prior to December 10, 2017 for hypothyroidism, and in excess of 30 percent thereafter is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is denied. FINDINGS OF FACT 1. Prior to December 10, 2017, the Veteran's hypothyroidism disability did not manifest as moderately severe, severe, or pronounced hypothyroidism. 2. Since December 10, 2017, the Veteran's hypothyroidism disability did not manifest muscular weakness, mental disturbance, and weight gain; or cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance, bradycardia, and sleepiness; or myxedema, defined as cold intolerance, muscular weakness, cardiovascular involvement, and mental disturbance. 3. The Veteran's service-connected disabilities do not preclude substantially gainful employment, nor does the record present such an exceptional case to warrant referral to the Director of Compensation Services for extraschedular consideration. CONCLUSIONS OF LAW 1. The criteria for entitlement to a disability rating in excess of 10 percent for hypothyroidism prior to December 10, 2017, and in excess of 30 percent, thereafter, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.119, Diagnostic Code (DC) 7903 (1969, 2016 and 2019). 2. The criteria for assignment of TDIU are not met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1970 to March 1972. A Board of Veterans' Appeals (Board) hearing was held in May 2019 via videoconference, a transcript is of record. The hearing was before a now-retired Veterans Law Judge (VLJ). The Veteran was given the opportunity to request another hearing by VA written correspondence in September 2021. In September 2021 and October 2021 responses, the Veteran, through his representative, indicated that he did not want another hearing in this case. See Arneson v. Shinseki, 24 Vet. App. 379 (2011). As such, the Board finds that there is no additional development or hearing required under Arneson. This case was denied by the Board in November 2019. A March 2021 United States Court of Appeals for Veterans Claims (Court) Order vacated part of the Board's decision and remanded for additional development and re-adjudication of the claim. Thus, these issues have been returned to the Board for further consideration. The Board observes that the November 2019 Board decision also denied the issue of entitlement to service connection for a psychiatric disorder. The Veteran did not challenge this claim to the Court, this issue was considered abandoned by the Veteran and as such, is not before the Board. 1. Entitlement to a rating in excess of 10 percent prior to December 10, 2017 for hypothyroidism, and in excess of 30 percent thereafter The Veteran seeks a higher disability rating for his service-connected hypothyroidism. The Veteran contends that since service, his thyroid disorder resulted in protruding eyes that required surgery, vision problems, constant cold intolerance, anxiety, and his symptoms have remained the same since 1975 and has made it difficult for him to find and maintain employment. The Veteran further contends that he takes medication daily for this disability. See May 2019 Board Hearing. By way of history, in a January 1976 rating decision issued by the agency of original jurisdiction (AOJ), the Veteran was awarded permanent and total nonservice connected (NSC) pension with a rating of 60 percent for the combined disabilities of thyrotoxicosis with exophthalmos and nervous condition, effective July 1, 1975. In September 2009, the Veteran submitted an informal claim for service connection for a thyroid disability with exophthalmos and for a psychiatric disorder, which were both denied in an August 2010 rating decision. The Veteran disagreed with the decision and the Board denied the claims in August 2014. The Court adopted a joint motion for remand (JMR) in March 2015, vacating the Board's decision and remanding for additional development and readjudication of the claim. The Board remanded the claims in a June 2015 decision. The AOJ continued the denial of these matters in a January 2016 supplemental statement of the case (SSOC). The Veteran continued his disagreement with the denial of these claims. A June 2016 Board decision granted service connection for a thyroid disorder and remanded the claim of service connection for a psychiatric disorder, to include as secondary to a thyroid disorder. In a July 2016 rating decision, a 10 percent disability rating was assigned for the Veteran's hypothyroidism, effective September 8, 2009. Service connection was also separately granted for exophthalmos associated with hypothyroidism, a noncompensable disability rating was assigned, effective September 8, 2009. The Veteran disagreed with the 10 percent disability rating assigned for his hypothyroidism. A December 2018 rating decision increased the Veteran's disability rating for hypothyroidism from 10 percent to 30 percent, effective December 10, 2017. A November 2019 Board decision denied entitlement to service connection for an acquired psychiatric disorder, to include as secondary to hypothyroidism and also denied an increased rating in excess of 10 percent for hypothyroidism prior to December 10, 2017, and in excess of 30 percent thereafter. In March 2020, the Board granted entitlement to an effective date of July 1, 1975 for the awards of service connection for hypothyroidism and exophthalmos associated with hypothyroidism. A March 2020 rating decision assigned a 10 percent disability rating for hypothyroidism and a noncompensable disability rating for exophthalmos, both effective July 1, 1975. As previously mentioned, a March 2021 Court Order vacated part of the Board's November 2019 decision and remanded for additional development and readjudication of the claim. The Veteran did not challenge the Board's denial of service connection for an acquired psychiatric disorder and that claim is deemed abandoned. The Court found that the Board erred by failing to evaluate the Veteran's claim under the provisions of 38 C.F.R. § 3.344 and failing to determine whether the Veteran's disability rating was stabilized. Specifically, the Court found that since the Veteran was awarded a 60 percent rating in January 1976 for his NSC pension benefits, the Board should address whether the "reduction" to 10 percent under the compensation program was proper. As discussed below, the Board finds that this does not warrant a reduction. Reduction The Board finds that an analysis of the Veteran's claim under 38 C.F.R. § 3.344 is not warranted. The Board acknowledges the Veteran's contention, via his attorney, that under 38 U.S.C. § 1521, disabilities for pension are to be evaluated under the rating code found at Part 4 of the C.F.R., and claimants must generally meet a schedular requirement. The Veteran's attorney contends that under both claims for service connection and claims for NSC pension benefits, disabilities are evaluated using the same criteria, under the VA's Schedule for Rating Disabilities. See April 2020 Brief of Appellant at 8. Initially, the Board notes that NSC pension and service connection disability compensation are completely different programs. Each program has different and distinct criteria with which to assign rating percentages. Service connection disability compensation is a benefit provided to compensate for disabilities resulting from personal injury suffered or disease related to his military service. See 38 U.S.C. § 1110. Distinctly, the rating criteria for the pension program is focused on a veteran's income and not necessarily in rating one particular disability but all of the NSC disabilities affecting a veteran's ability to work. See C.F.R. § 4.17. NSC pension benefits are meant to compensate a disabled veteran of a period of war, below a certain income level, and is permanently and totally disabled, regardless of whether that disability is related to service. See 38 U.S.C. §§ 1521-1525; see also 38 C.F.R. §§ 3.271-3.279. The ratings for NSC pension are to serve the purpose of whether a veteran's disabilities equate to a finding of permanent and total disability. See 38 C.F.R. § 4.15. A veteran is considered permanently and totally disabled if the veteran is any of the following: (1) a patient in a nursing home for long-term care because of disability; (2) disabled as determined by the Commissioner of Social Security for the purpose of any benefits administered by the Commissioner; (3) unemployable as a result of disability reasonably certain to continue throughout the life of the person: or (4) suffering from any disability which is sufficient to render it impossible for the average person to follow a substantially gainful occupation, but only if it is reasonably certain that such disability will continue throughout the life of the person, or any disease or disorder determined by VA to be of such a nature or extent as to justify a determination that persons suffering from that disease or disorder are permanently and totally disabled. 38 C.F.R. § 3.3(a)(3)(vi)(B). Here, it is not specifically stated what evidence the AOJ considered in the finding that the Veteran was permanently and totally disabled in the January 1976 rating decision. However, the AOJ noted that the Veteran was a high school graduate, he last worked as a laborer and electrician helper in June 1974; and the AOJ combined the Veteran's left knee, thyroid, exophthalmos, and psychiatric disabilities when making this determination. The Board notes that the Veteran's present hypothyroidism disability is not the same disability discussed in the January 1976 rating decision. Specifically, the January 1976 award of the 60 percent NSC pension was evaluated based on the combined disabilities of thyrotoxicosis, exophthalmos, and nervous condition. The Veteran is now separately service-connected for hypothyroidism and exophthalmos, disability ratings have been assigned. Additionally, the Veteran's acquired psychiatric disorder, to include the claimed nervous condition, is not service connected, it has been found to be unrelated to his hypothyroidism and is no longer on appeal. As such, the Board finds that the 60 percent NSC pension rating assigned in the January 1976 decision encompassed three disabilities: hypothyroidism, exophthalmos, and a psychiatric disorder. Thus, the Board is unable to conclude that the three combined disabilities warranting a 60 percent rating for NSC pension benefits in 1976 is evidence that a higher disability rating should be assigned solely for the Veteran's current hypothyroidism disability under the compensation program. The Board also acknowledges the Veteran contention, via his attorney, that the January 1976 rating decision that evaluated his thyroid disorder as 60 percent for NSC pension purposes is a final decision and binding on the Board and protected under 38 C.F.R. § 3.951(b). See April 2020 Brief of Appellant at 8. To that end, the Board notes that the January 1976 decision is final as to the NSC pension matter and not to compensation, which is presently before the Board. Additionally, the Veteran was in receipt of NSC pension under Section 306 from July 1, 1975 to October 1, 1981. His benefits were terminated because he did not meet the income requirements. He applied for NSC pension benefits again in January 2006. The Veteran was awarded Improved Pension in a May 2006 rating decision, effective January 31, 2006. The Veteran was subsequently informed that he did not meet the income requirements for NSC pension benefits. He applied for NSC pension benefits again in August 2008, which was denied in December 2008. The Veteran disagreed with the denial of his pension claim. However, he did not perfect his appeal following the September 2010 SOC. Thus, that appeal became final, the January 1976 NSC evaluation is not protected under 38 C.F.R. § 3.951(b), and the January 1976 rating decision is not final or binding on the Board as the Veteran's attorney suggests. As discussed above, the currently assigned ratings did not revise the January 1976 decision awarding NSC pension and the assignment of a 10 percent disability rating prior to December 10, 2017, and 30 percent, thereafter, does not constitute a reduction of the 60 percent rating assigned for NSC pension purposes only. Finally, the Board is further unaware of any precedential decision stating that prior pension disability ratings must be adopted if the disability is later service connected. Increased Ratings Disability ratings are determined by applying a schedule of ratings (Ratings Schedule) that is based on the average impairment of earning capacity. Separate DCs identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). All reasonable doubt will be resolved in the Veteran's favor. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event; or, whether a preponderance of the evidence is against the claim, in which case the claim is denied. Id.; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staged ratings." See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). The Veteran's service-connected hypothyroidism has been rated 10 percent from July 1, 1975 to December 10, 2017 and 30 percent thereafter under DC 7903. The rating criteria for hypothyroidism have changed several times during the period on appeal. VA revised the regulations pertaining to the evaluation of disabilities of the endocrine system, including hypothyroidism, in 1981, 1991, 1996, and 2017. The criteria effective from March 3, 1969, hypothyroidism was rated as follows: a noncompensable rating was warranted if the condition was in remission. A 10 percent rating was warranted for moderate hypothyroidism, with symptoms such as to produce definite and appreciable industrial inadaptability. A 30 percent was warranted for moderately severe hypothyroidism; sluggish mentality and other indications of myxedema, low basal metabolic rate, such as to produce considerable industrial inadaptability. A 60 percent rating was warranted for severe hypothyroidism; the same symptoms under the "pronounced" criteria but somewhat less marked (except that the basal metabolic rate must be below minus 30), and such as to produce severe industrial inadaptability. A 100 percent rating was warranted for pronounced hypothyroidism with a long history and slow pulse, low blood pressure, low basal metabolic rate below minus 30, high blood cholesterol, sluggish mentality, sleepiness, etc. in symptom combinations such as to produce complete industrial incapacity. 38 C.F.R. § 4.119, DC 7903. The criteria effective from August 13, 1981, hypothyroidism was rated as follows: a noncompensable rating was warranted if the hypothyroidism was in remission. A 10 percent rating was warranted if the condition was "moderate" with fatigability or if it required continuous medication to control. A 30 percent rating was warranted if the condition was moderately severe, with the claimant being sluggish mentally and showing other indications of myxedema, decreased levels of circulating thyroid hormones. A 60 percent was warranted for "severe" hypothyroidism with the same symptoms under the "pronounced" criteria but somewhat less marked, with decreased levels of circulating thyroid hormones. A 100 percent rating was warranted for "pronounced" hypothyroidism with a long history and slow pulse, deceased levels of circulating thyroid hormones, sluggish mentality, sleepiness, and slow return of reflexes. 38 C.F.R. § 4.119, DC 7903. The criteria effective from August 6, 1991, hypothyroidism was rated as follows: a noncompensable rating was warranted for hypothyroidism in remission. Moderate hypothyroidism with fatigability, or the need of continuous medication, warranted a 10 percent disability evaluation. A 30 percent disability evaluation requires moderately severe hypothyroidism with sluggish mentality and other indications of myxedema, decreased levels of circulating thyroid hormones (T4 and/or T3 by specific assays). A 60 percent disability evaluation required severe hypothyroidism, with symptoms under "pronounced" somewhat less marked, and decreased levels of circulating thyroid hormones (T4 and/or T3, by specific assays). Pronounced hypothyroidism with a long history and slow pulse, decreased levels of circulating thyroid hormones (T4 and/or T3, by specific assays), sluggish mentality, sleepiness, and slow return of reflexes warranted a 100 percent disability evaluation. 38 C.F.R. § 4.119, DC 7903. The criteria effective from June 6, 1996, hypothyroidism was rated as follows: When there is fatigability or when continuous medication is required for control of hypothyroidism, a minimum rating of 10 percent is assigned. A 30 percent disability rating is assigned when there is fatigability, constipation, and mental sluggishness. The next higher, or 60 percent disability rating, requires muscular weakness, mental disturbance, and weight gain. The highest, or 100 percent disability rating contemplates cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance (dementia, slowing of thought, depression), bradycardia (less than 60 beats per minute) and sleepiness. 38 C.F.R. § 4.119, DC 7903. The Court has addressed the specific application of the rating criteria for DC 7903 and found that all the symptoms listed for a particular disability rating were not required to be demonstrated in order to establish entitlement to a higher disability rating. See Tatum v. Shinseki, 23 Vet. App. 152, 155 (2009). The Court noted that symptoms that meet some of the rating criteria should be considered in light of 38 C.F.R. § 4.7 and resolved based on the evidence of record. The Court also stated that the rating criteria for DC 7903 are not successive. Tatum, 23 Vet. App. at 155. A claimant could potentially establish all the criteria required for a 30 percent or 60 percent rating without establishing any of the criteria for a lesser disability rating. Id. at 156. The most recent revision was effective December 10, 2017. Under revised DC 7903, a 100 percent rating is warranted for hypothyroidism manifesting as myxedema (cold intolerance, muscular weakness, cardiovascular involvement (including, but not limited to hypotension, bradycardia, and pericardial effusion), and mental disturbance (including, but not limited to dementia, slowing of thought and depression)). Note (1): This evaluation shall continue for six months beyond the date that an examining physician has determined crisis stabilization. Thereafter, the residual effects of hypothyroidism shall be rated under the appropriate diagnostic code(s) within the appropriate body system(s) (e.g., eye, digestive, and mental disorders). A 30 percent disability rating is warranted for hypothyroidism without myxedema. Note (2): This evaluation shall continue for six months after initial diagnosis. Thereafter, rate residuals of disease or medical treatment under the most appropriate diagnostic code(s) under the appropriate body system (e.g., eye, digestive, mental disorders). 38 C.F.R. § 4.119, DC 7903. VA removed the rating criteria for 10 and 60 percent ratings. When the applicable regulation changes during an appeal, the Veteran is entitled to resolution of the claim under the criteria more advantageous. The old criteria can apply to the entire appeal period, but new criteria can only apply as to the effective date of the change. Here, the Board will evaluate the Veteran's hypothyroidism under each VA revision of DC 7903 during the relevant timeframe in order to determine which criteria are more favorable to the Veteran. The Board notes that the Veteran does not have relevant medical treatment records to analyze between the 1981 and the 1996 revisions of DC 7903. Prior to the June 6, 1996 revision Turning to the record, a May 1974 VA treatment note reveals that the Veteran was referred from the eye clinic because his right eye popped out while at work. The Veteran had heart interference and lost weight from 183 pounds to 173 pounds in the past month. The impression was early Graves' disease. The Veteran was prescribed propylthiouracil (PTU) to take every 8 hours and Lugol's 5 drops daily at that time. A September 1975 VA treatment note reveals that the Veteran reported feeling well and working full time as an electrician. The Veteran had gained weight from 173 pounds to 178 pounds with his normal weight listed as 183. The physician reported the Veteran's thyroid was smaller and he continued to take his prescriptions as prescribed. An October 1975 VA treatment note reveals that the Veteran had hypothyroidism, was under treatment at the Dallas VA medical center, and he should not do heavy manual labor or work in a hot environment until at least November 1975. The Board observes that these VA treatment records are unavailable. See July 2010 VA Memorandum. The November 1975 VA examiner noted that the Veteran was very anxious, tense, and nervous, it was undeterminable whether these symptoms were all associated with his endocrine disease, but they are characteristic of this disease process. No other findings were indicated. A June 1980 treatment note reveals that the Veteran underwent permanent tarsorrhaphy of the right eye. The Veteran reported to the physician because his Graves' disease had been exacerbated. He reported increasing anxiety, nervousness, and a 25-pound weight loss. He also reported occasional palpitations and noticed his heart to be pounding. These findings have not been found to be related to the Veteran's hypothyroidism. Under the rating criteria that were in effect at that time, the Veteran's hypothyroidism more closely approximates a 10 percent disability rating because his disability manifested as moderate hypothyroidism with symptoms such as to produce definite and appreciable industrial inadaptability. His treatment records do not indicate moderately severe, severe, or pronounced hypothyroidism. Specifically, the Veteran's treatment records reveal that his symptoms were well controlled with medication. He reported anxiety and nervousness that was neither then nor now shown to be related to the Veteran's hypothyroidism. There was no evidence of myxedema. Based on the evidence of record, the Board finds that the symptoms associated with the Veteran's service-connected hypothyroidism disability prior to the June 6, 1996 revision of DC 7903 more closely paralleled the type of symptoms described in the criteria for the currently assigned 10 percent disability rating. During this period of the appeal, the Veteran's hypothyroidism manifested with symptoms such as to produce definite and appreciable industrial inadaptability. 38 C.F.R. § 4.119, DC 7903. After the June 6, 1996 revision A January 2006 VA treatment note reveals that the Veteran reported feeling a fluttering in his chest, not associated with nausea/vomiting, but is associated with diaphoresis on face. The Veteran reported being treated for this in 2003, but he was unsure what the result was. He reported some shortness of breath and light-headedness with the fluttering. The Veteran was prescribed aspirin daily to reduce the risk of stroke and heart attack. These findings have not been attributed to the Veteran's hypothyroidism. A March 2006 VA treatment note reveals that the Veteran was diagnosed with angina pectoris (chest or heart pain caused by inadequate blood flow to the heart muscle). These findings were not attributed to the Veteran's hypothyroidism. A March 2006 VA treatment note shows the Veteran was treated for psychiatric symptoms and he reported chronic back pain that was exacerbated when sitting for long periods of time and is relieved with Flexeril and with moving about to loosen up his muscles. The Veteran reported anhedonia, low energy and impaired concentration. Again, these findings were not attributed to the Veteran's hypothyroidism. A February 2010 VA treatment note reveals that the Veteran's hypothyroidism was well controlled at that time. In June 2010, the Veteran denied fatigue. A March 2011 private treatment note reveals that the Veteran's Graves' disease was stable. An April 2013 private treatment note for a hypothyroidism evaluation reveals that the Veteran had an elevated thyroid stimulating hormone (TSH) of 18 and was started on thyroid hormone replacement. The Veteran had symptoms of increased weight, fatigue, and dry eyes. The Veteran did not have hair changes, palpitations, diarrhea/constipation, tremors, heat/cold intolerance, skin changes, or mentation changes. Physical examination revealed the Veteran to be positive for exophthalmus and proptosis. In April 2015, the Veteran denied significant weight gain. A January 2016 VA examiner marked that the Veteran's claims file was not reviewed and noted that the Veteran was on continuous medication and had exophthalmos surgery in 1980. The Veteran was on continuous medication and had undergone surgery on the eyelid for exophthalmos. A five-pound weight gain was noted on examination. There were no findings, signs, or symptoms of hyper parathyroid or hypoparathyroid. The eyes showed exophthalmos. The neck was normal with no palpable thyroid enlargement or nodules. Heart rate was 75 and blood pressure was 109/78. There were no scars or other disfigurement of the neck related to treatment for any thyroid or parathyroid condition. There were no tumors or malignant neoplasm, or metastases related to any diagnosis. There were no findings, signs or symptoms attributable to hyper-parathyroid, hypoparathyroid, or due to pressure on adjacent organs. The Veteran's thyroid or parathyroid condition did not impact his ability to work. Under the rating criteria that were in effect at that time, the Veteran's hypothyroidism more closely approximates a 10 percent disability rating because his disability manifested as fatiguability and continuous medication required for control of hypothyroidism. His treatment records do not indicate constipation, mental sluggishness, muscular weakness, mental disturbance, weight gain, cold intolerance, or cardiovascular involvement that is related to the Veteran's hypothyroidism, as required for higher ratings. Specifically, the Veteran's treatment records reveal that his symptoms were well controlled with medication and he periodically reported fatiguability. He did not report symptoms warranting a higher disability rating. Based on the evidence of record, the Board finds that the symptoms associated with the Veteran's service-connected hypothyroidism disability after the June 6, 1996 revision of DC 7903 more closely paralleled the type of symptoms described in the criteria for the currently assigned 10 percent disability rating. During this period of the appeal, the Veteran's hypothyroidism manifested with as periodic fatiguability and continuous medication required for control of hypothyroidism. 38 C.F.R. §§ 4.119, DC 7903. After the December 10, 2017 revision The Veteran's hypothyroidism is rated 30 percent, effective the date of the December 10, 2017 revision. An October 2018 VA examiner reviewed the Veteran's claims file and noted the residuals as thyroid endocrine dysfunction and post treatment with PTU and now hypothyroid. The examiner further noted the Veteran's cold intolerance and slowing of thought, which included slowed mentation, poor concentration, and decreased short-term memory, psychosis (not sure whether this is from the Veteran's psychiatric diagnosis or long-standing hypothyroidism). Reflex exam was normal. Functional impact was described as difficulty focusing. The examiner indicated that there was no evidence of muscular weakness and no excessive weight gain from October 2016 to September 2018. The examiner further indicates that the Veteran has a history of a mental disorder that is unrelated to hypothyroidism. The Veteran had eye involvement and myxedema described as cold intolerance. The Veteran had mental disturbance identified as slowing of thought. He had slow mentation, poor concentration, and decreased short-term memory. There was psychosis but it was unsure if this was from paranoid schizophrenia or longstanding hypothyroidism. The eyes were abnormal with exophthalmus (proptosis, lid lag). The neck was normal and there was no palpable thyroid enlargement or nodules. Blood pressure was 159/102 and heart rate was 92. Reflex examination was normal. There were no scars or disfigurement and no tumors or neoplasms. The Veteran's thyroid condition was noted to impact his ability to work, and the examiner identified the mental symptoms. An additional note regarding the Veteran's thyroid revealed no evidence of muscular weakness and no excessive weight gain. There was slowed mentation, poor concentration, and decreased short-term memory. The Veteran reported cold intolerance. There was no evidence of bradycardia or sleepiness. The Veteran had a history of mental disorder which was not related to hyperthyroidism or hypothyroidism. The October 2018 examiner provided an addendum clarification opinion in November 2018 stating that the Veteran never had myxedema as his thyroid level has been monitored and remains within normal recommended levels. It was noted that the Veteran did not have a myxedema coma and that the medical history since separation did not reveal a myxedema coma. The Veteran had cold intolerance which was a subjective report. Myxedema coma was defined as severe hypothyroidism leading to decreased mental status, hypothermia, and other symptoms. The Veteran never had myxedema/myxedema coma. His thyroid level has been monitored and remained within normal recommended levels. He has subjective report of cold intolerance not the acute hypothermia due to myxedema. The Veteran reported cold intolerance which occurred frequently with hypothyroidism, no evidence of bradycardia, no evidence of sleepiness, and a history of mental disorder which was not related to hyperthyroid or hypothyroidism. The Veteran's hypothyroidism does not warrant a higher disability rating. Specifically, as there is no evidence of myxedema it follows that there was no crisis following which an examining physician would need to determine that there has been stabilization, warranting an increased 100 percent rating, for a period of six months after an examiner has determined the condition to be stabilized. Moreover, the October 2018 VA examiner noted that the Veteran's hypothyroidism was not manifested by fatigability, constipation, or mental sluggishness, as the condition was well-controlled with on-going treatment. At no point have any residuals warranted rating under the appropriate body system and subsequent diagnostic code(s) within the appropriate body systems (e.g., eye, digestive, and mental disorders), such an increased 100 percent rating is not warranted under the updated DC 7903. Entitlement to an evaluation in excess of 10 percent prior to December 10, 2017, and in excess of 30 percent thereafter, for hypothyroidism, status-post Graves' disease is not warranted. At no point on appeal prior to December 10, 2017, did the Veteran's hypothyroidism disability manifest moderately severe hypothyroidism; sluggish mentality and other indications of myxedema, low basal metabolic rate, such as to produce considerable industrial inadaptability; or as fatiguability, constipation, and mental sluggishness; muscular weakness, mental disturbance, and weight gain; or cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance, bradycardia, and sleepiness. As such, the Veteran's symptoms associated with his hypothyroidism do not meet or approximate the criteria for a disability rating greater than 10 percent, prior to December 10, 2017, under the former DC 7903. Beginning December 10, 2017, the Veteran's hypothyroidism disability did not manifest muscular weakness, mental disturbance, and weight gain; or cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance, bradycardia, and sleepiness. As such, the Veteran's symptoms associated with his hypothyroidism do not meet or approximate the criteria for a disability rating greater than 30 percent, beginning December 10, 2017, under the former DC 7903. The October 2018 VA examiner indicated that the Veteran had myxedema, described as cold intolerance. However, in the November 2018 VA addendum opinion, it was clarified that the Veteran did not have and never had a myxedema coma. The examiner described the term myxedema coma as a severe condition that is a medical emergency with a high mortality rate. The Veteran did not have bradycardia, sleepiness, or mental disorder associated with hypothyroidism that are identified in the current rating criteria for an evaluation in excess of 30 percent disabling for myxedema, which is defined as cold intolerance, muscular weakness, cardiovascular involvement, and mental disturbance. As the Veteran's hypothyroid disability has not manifested myxedema, as defined in the criteria and explained by the VA examiner in November 2018, during the period beginning December 10, 2017, the criteria for an evaluation in excess of 30 percent disabling, effective December 10, 2017, have not been met. Therefore, entitlement to an evaluation in excess of 10 percent prior to December 10, 2017, and in excess of 30 percent thereafter, for hypothyroidism, status-post Graves' disease, is denied. 2. Entitlement to a TDIU due to service-connected disabilities The Veteran is seeking entitlement to a TDIU. A finding of TDIU is appropriate "when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation." 38 C.F.R. §§ 3.340 (a)(1), 4.15. Consideration may be given to the Veteran's level of education, special training and previous work experience in arriving at a conclusion, but not to age or to the impairment caused by non-service-connected disabilities. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19. In reaching such a determination, the central inquiry is "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). The record must reflect that circumstances, apart from non-service-connected conditions, place the claimant in a different position than other veterans having the same compensation rating. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in and of itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question is whether the veteran, in considering his service-connected disabilities, can perform the physical and mental acts required by employment, not whether he can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). 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 as a result of service-connected disabilities, provided that, if there is only one such disability, the disability shall be ratable at 60 percent or more. If there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16 (a). The combined rating is achieved by "adding" the disability ratings together. However, this is not the conventional addition of numerical values. The efficiency of the individual for employment purposes is not reflected as a numerical value equivalent to the assigned disability rating; in terms of actual efficiency, the number will be lessened under the regulation. However, VA recognizes that earning capacity is affected exponentially as a less severe service-connected disability is added to the most severe service-connected disability, thereby reflecting the ever-diminishing efficiency of the individual. See 38 C.F.R. § 4.25. The United States Court of Appeals for the Federal Circuit has held that determination of whether a veteran is unable to secure or follow a substantially gainful occupation due to service-connected disabilities is a factual rather than a medical question and that it is an adjudicative determination properly made by the Board or the VA Regional Office. See Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). Additionally, "substantially gainful employment" is defined as an occupation that provides an annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days that a veteran actually works and without regard to the veteran's earned annual income. See Faust v. West, 13 Vet. App. 342 (2000). The determination as to whether a TDIU is appropriate should not be based solely upon demonstrated difficulty in obtaining employment in one particular field, which could also potentially be due to external bases such as economic factors, but rather to all reasonably available sources of employment under the circumstances. See Ferraro v. Derwinski, 1 Vet. App. 326, 331-332 (1991). As stated, consideration may be given to level of education, special training and previous work experience in arriving at a conclusion, but not to age or impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. Marginal employment is not considered substantially gainful employment and generally is deemed to exist when a veteran's earned income does not exceed the amount established by the United States Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Marginal employment may also be held to exist in certain cases when earned annual income exceeds the poverty threshold on a facts-found basis. Marginal employment, odd-job employment and employment at half the usual remuneration is not incompatible with a determination of unemployability if the restriction to securing or retaining better employment is due to disability. See 38 C.F.R. § 4.17 (a). The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. The Federal Circuit has held that the Board must review the entire record but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. During the period on appeal the Veteran was in receipt of service-connected benefits for hypothyroidism, status post Graves' disease, evaluated as 10 percent disabling prior to December 10, 2017, and 30 percent disabling thereafter; hypertension, evaluated as 10 percent disabling; and exophthalmos associated with hypothyroidism, status post Graves' disease, evaluated as noncompensable. As such, the Veteran does not meet the schedular criteria for entitlement to a TDIU. That notwithstanding, it is the policy of the VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of a service-connected disability shall be rated totally disabled. 38 C.F.R. § 4.16 (b). Therefore, although the schedular criteria for TDIU, as set out in 38 C.F.R. § 4.16 (a), are not met, a total rating on an extraschedular basis may nonetheless be granted in exceptional cases (and pursuant to specifically prescribed procedures) when a veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. 38 C.F.R. § 4.16 (b). To accord justice, therefore, in the exceptional case where the schedular ratings are found to be inadequate, the Director of the Compensation Service, upon field station submission, is authorized to approve an extraschedular rating commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. Neither the AOJ nor the Board is permitted to assign an extraschedular rating in the first instance. Floyd v. Brown, 9 Vet. App. 88, 95 (1996)). However, the Board may review the later determinations of the Director of the Compensation Service. Anderson v. Shinseki, 22 Vet. App. 423, 427. The Veteran's service-connected disabilities, employment history, education and vocational attainment, and all other factors bearing on the issue will be considered. 38 C.F.R. §§ 3.341, 4.16 (b), 4.19. Here, this case has not been referred to the Director of Compensation Service. The Board has considered whether the Veteran's disability picture warrants referral for consideration of an extraschedular rating for a TDIU. However, the Board finds that a remand for referral of the Veteran's claim for consideration of TDIU is not warranted in this case. In the Veteran's October 2016 Application for Increased Compensation Based on Unemployability, the Veteran reported that he last worked in July 2008. He indicated that he was no longer able to work due to his thyrotoxicosis, knee injury, hypertension, Grave's disease, and exophthalmos. He indicated that he had a high school level education. The Veteran was afforded a VA examination in January 2016 and the Veteran's thyroid disability was noted to not impact his ability to work. In a September 2016 VA examination report the Veteran reported that he worked in maintenance at VA for a little over a year following service. He was at work when his eye popped out. Thereafter, he reported being diagnosed with Graves' disease and was let go from his job. He reported that he did not work again until 1975. Then he applied for benefits and had not worked since that time. Upon examination in October 2018, the Veteran's hypertension was noted to not have an impact on the Veteran's ability to work. The Veteran's hypothyroid condition was noted to impact the Veteran's ability to work due to slowed mentation, poor concentration, and decreased short-term memory. Psychosis was also noted but it was not certain whether this was from paranoid schizophrenia or longstanding hypothyroidism. In an examination note dated in November 2018 it was reported that the Veteran's mental disorder is not related tohis thyroid disability and the Veteran's thyroid levels were monitored and remained within normal, recommended levels. Entitlement to TDIU is not warranted. Multiple examinations have noted that the Veteran's service-connected disabilities do not impact the Veteran's ability to work. It is acknowledged that a VA examiner did indicate that the Veteran's mental disability impact the Veteran's ability to work. However, it has been found that the Veteran's mental disability is not related to his hypothyroid disability and is not otherwise related to service. Finally, the Veteran's thyroid levels have been noted to be monitored and within normal, recommended levels. Although the Veteran believes that he could not secure or follow a substantially gainful occupation as a result of his service-connected disabilities, the more persuasive medical evidence is against the claim, including the Veteran's own statements to his VA medical providers that he began working again in or around 2006 until 2008. The Board notes that, as a lay person, lacking in medical training and expertise, the Veteran cannot provide a competent opinion on a matter as complex as whether he can secure or follow a substantially gainful occupation as a result of service-connected disability. See, e.g., Davidson, 581 F.3d at 1313. Any probative value of the Veteran's own conclusions is far outweighed by that of the competent medical evidence that indicates his service-connected disabilities were not productive of impairment that would rise to the level of unemployability. See Jandreau, 492 F.3d at 1372. (Continued on the next page) Consequently, because the preponderance of the evidence indicates that the Veteran was not unemployable by reason of service-connected disabilities, referral of this case to the Director of the Compensation and Pension Service for extraschedular consideration under 38 C.F.R. § 4.16 (b) is not warranted. See 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16; Ray v. Wilkie, 31 Vet. App. 58, 66 (2019). Emily Tamlyn Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Frazier, Associate Attorney 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.