Citation Nr: 21006438 Decision Date: 02/04/21 Archive Date: 02/04/21 DOCKET NO. 12-13 789 DATE: February 4, 2021 ORDER Entitlement to an initial disability rating in excess of 10 percent for peripheral neuropathy of the left lower extremity (LLE) for the period from August 20, 2009 to June 11, 2013, and in excess of 20 percent thereafter is denied. Entitlement an initial disability rating in excess of 10 percent for peripheral neuropathy of the right lower extremity (RLE) for the period from August 20, 2009 to June 11, 2013, and in excess of 20 percent thereafter is denied. Entitlement to an initial disability rating coronary artery disease (CAD) in excess of 10 percent for the period from August 4, 2004 to March 26, 2013, and in excess of 30 percent thereafter is denied. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities for the period prior to May 8, 2013 is granted. Entitlement to service connection for soft tissue sarcoma, also claimed as skin cancer, to include as a result of exposure to herbicides is denied. REMANDED Entitlement to service connection for hepatitis C is remanded. Entitlement to service connection for a disability manifested by constipation, to include as secondary to the service connected diabetes mellitus type 2 is remanded. Entitlement to service connection for a gastrointestinal condition to include gastroesophageal reflux disease (GERD) and diarrhea as secondary to the service connected disability of diabetes mellitus type 2 is remanded. Entitlement to special monthly compensation by reason of being housebound for the period prior to May 8, 2013 is remanded. Entitlement to special monthly compensation based on the aid and attendance of another person is remanded. FINDINGS OF FACT 1. The Veteran’s left lower extremity peripheral neuropathy was manifested by no more than mild incomplete paralysis prior to June 11, 2013, and manifested by no more than moderate incomplete paralysis thereafter. 2. The Veteran’s right lower extremity peripheral neuropathy was manifested by no more than mild incomplete paralysis prior to June 11, 2013, and manifested by no more than moderate incomplete paralysis thereafter. 3. Prior to March 26, 2013, the Veteran’s coronary artery disease manifested in Metabolic equivalent (MET) testing by interview shows 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. 4. As of March 26, 2013, the Veteran’s coronary artery disease Metabolic equivalent (MET) testing shows the Veteran did not develop dyspnea, fatigue, angina, dizziness, or syncope at a workload of 5 METs or less, and there was no evidence of left ventricular dysfunction with an ejection fraction of 30 to 50 percent or more than one episode of active congestive heart failure in the past year. 5. Prior to May 8, 2013, the evidence reflects that the Veteran was unemployable due to his service connected disabilities. 6. The Veteran’s basal cell carcinoma was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease to include exposure to herbicides. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 10 percent prior to June 11, 2013, and in excess of 20 percent thereafter for right lower extremity peripheral neuropathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8599-8520. 2. The criteria for a disability rating in excess of 10 percent prior to June 11, 2013, and in excess of 20 percent thereafter for left lower extremity peripheral neuropathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8599-8520, 8522. 3. The criteria for rating in excess of 10 percent prior the March 26, 2013 and in excess of 30 percent thereafter for coronary artery disease not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.100, 4.104, Diagnostic Code 7005. 4. The criteria for a TDIU prior to May 8, 2013 have been met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16, 4.18, 4.19. 5. The criteria for service connection for basal cell carcinoma have not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1964 to February1968, to include service in the Republic of Vietnam (RVN). These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. In March 2015, the Veteran and his spouse testified before the undersigned at a hearing conducted at the above RO. A copy of the hearing transcript has been associated with the electronic record. In July 2016 and September 2017, the Board, in part, remanded the matters on appeal to the Agency of Original Jurisdiction (AOJ) for additional development. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4. The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran’s medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where an appeal is based on an initial rating for a disability, however, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence “used to decide whether an original rating on appeal was erroneous.” Fenderson v. West, 12 Vet. App. 119, 126 (1999). In either case, if later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Fenderson, 12 Vet. App. at 126; Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). 1. Entitlement to an initial disability rating in excess of 10 percent for peripheral neuropathy of the left lower extremity (LLE) for the period from August 20, 2009 to June 11, 2013, and in excess of 20 percent thereafter 2. Entitlement an initial disability rating in excess of 10 percent for peripheral neuropathy of the right lower extremity (RLE) for the period from August 20, 2009 to June 11, 2013, and in excess of 20 percent thereafter The Veteran contends that he is entitled to an initial disability rating in excess of 10 percent for the service connected peripheral neuropathy of the lower left and the lower right extremities and asserts that his current rating percentage does not adequately represent his level of disability. He is currently rated under Diagnostic Code 8599-8520. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. Diagnostic Code 8599 indicates that peripheral neuropathy of the lower extremities are rated by analogy under closely related injuries (Diagnostic Code 8520 is used for paralysis of the sciatic nerve, respectively) in which not only the functions affected, but also the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. A disability that has its own Diagnostic Code may not be rated under another Diagnostic Code, yet peripheral neuropathy, regardless of the extremity, does not have its own Diagnostic Code. Copeland v. McDonald, 27 Vet. App. 333 (2015). All potentially applicable Diagnostic Codes thus must be considered. Butts v. Brown, 5 Vet. App. 532. Under 38 C.F.R. § 4.124a, Diagnostic Code 8520, which provides criteria for rating impairment of the sciatic nerve, a 10 percent evaluation is warranted for mild incomplete paralysis. A 20 percent rating requires moderate incomplete paralysis, and a 40 percent rating requires moderately severe incomplete paralysis of the sciatic nerve. The next higher evaluation of 60 percent requires severe incomplete paralysis of the sciatic nerve with marked muscular atrophy. An 80 percent evaluation requires complete paralysis of the sciatic nerve, in which the foot dangles and drops, no active movement of the muscles below the knee is possible, and flexion of the knee is weakened or lost. Diagnostic Code 8522, which provides that rating criteria of impairment of the musculocutaneous nerve, a 10 percent evaluation is warranted for moderate incomplete paralysis. A 20 percent evaluation is warranted for severe incomplete paralysis. A 30 percent evaluation is warranted for complete paralysis; eversion of foot weakened. The Board notes the Rating Decision Code sheet notes that the Veteran’s left lower extremity neuropathy was rated under Diagnostic Code 8599-8520 for the sciatic nerve and the right lower extremity neuropathy was rated under Diagnostic Code 8599-8522 for the musculocutaneous nerve. However, after reviewing the Rating Decisions, the RO has made determinations based upon the rating criteria listed in Diagnostic Code 8520, which provides more favorable rating for the Veteran’s right lower extremity. Therefore, the Board will consider the rating criteria for Diagnostic Code 8520 for both of the Veteran’s lower extremities. The Board acknowledges that words such as "moderate," "moderately severe," and "severe," are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. Use of terminology such as "severe" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Under 38 C.F.R. § 4.123, neuritis (characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating) is to be rated on the scale for the nerve involved, with a maximum equal to severe incomplete paralysis. This code further provides that for neuritis (other than for the sciatic nerve) not characterized by the organic changes referred to the maximum rating will be that for moderate incomplete paralysis. Under 38 C.F.R. § 4.124, neuralgia (characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve) is to be rated with a maximum equal to moderate incomplete paralysis. The term "incomplete paralysis," with this and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type 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 wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. A February 2010 VA diabetes mellitus examination report shows that the Veteran reported numbness and tingling in his lower extremities which started in the back and extended to his calf areas. Numbness of the foot was also reported. Motor strength was 5/5 and deep tendon reflexes were 2+ in the lower extremities. Left foot was impaired to sensation testing. A March 2012 diabetic sensory motor peripheral neuropathy VA examination report shows that the Veteran was assessed with peripheral neuropathy of the bilateral lower extremities. The Veteran reported right leg tingling and numbness that was “off and on.” The Veteran was noted to be right hand dominant. Symptoms were noted as mild numbness of the right lower extremity. Constant pain, intermittent pain, paresthesias were not assessed. Muscle strength testing for the lower extremities were 5/5. Deep tendon reflexes were assessed as 2+. Light touch testing and vibration sensation were decreased for the bilateral foot/toes. Muscle atrophy was not assessed. Veteran was noted to have smooth and shiny skin bilateral lower extremities with dystrophic toenails. The examiner noted that the Veteran’s lower extremities were assessed with diabetic neuropathy with severity indicated as normal. The examiner also remarked that the right leg exhibited numbness and assessed the Veteran with mild sensory peripheral neuropathy. A June 2013 VA diabetic peripheral neuropathy examination report shows that the Veteran reported symptoms affecting his feet for several years and getting worse. Symptoms attributable to diabetic peripheral neuropathy of the bilateral lower extremities were noted as moderate intermittent pain, mild paresthesias, and numbness. Strength testing for the lower extremities were 5/5. Light touch testing and position sense were assessed as normal for the bilateral lower extremities. Muscle atrophy was not diagnosed. Trophic changes were not assessed. The examiner remarked that the diabetes peripheral neuropathy of the lower extremities may cause difficulty performing jobs that require prolonged standing and walking but should not preclude otherwise sedentary employment. The examiner also reported that the Veteran’s clinical presentation was consistent with sensory peripheral neuropathy bilateral lower extremities. No paralysis was noted. Moderate incomplete paralysis was assessed. An August 2015 VA foot neurological examination noted normal monofilament testing for the feet. A December 2016 VA peripheral neuropathy examination report shows the Veteran reported pain in this legs, relieved at rest, and aggravated by activity. He also reported numbness and tingling which required medication. The examiner noted symptoms affecting the bilateral lower extremities of moderate intermittent pain, mild paresthesias, and mild numbness. Strength testing was 5/5 for the lower extremities. Deep tendon reflexes were 2+ for the lower extremities. Light touch and vibration sensation were decreased. Muscle atrophy was not assessed. The examiner noted that the bilateral sciatic nerves affected with mild incomplete paralysis. The examiner reported that the Veteran could not work in occupations requiring prolonged standing or walking. Sedentary occupation was noted to possible. A review of VA treatment records from 2017 to 2020 shows that the Veteran maintained a diagnosed of diabetic peripheral neuropathy with decreased vibration sensation to the bilateral feet. Ratings in excess of 10 percent for bilateral peripheral neuropathy from August 20, 2009 to June 11, 2013 After a thorough review of the record, the Board finds that the Veteran's right and left lower extremities do not approximate moderate incomplete paralysis under Diagnostic Code 8520. During this period on appeal, the VA examinations were consistent with mild incomplete paralysis affecting the lower extremities. The examiners in February 2010 and March 2013 both described the Veteran's level of disability as mild, and more significantly, did not note that there was a significant amount of impairment as a result of right and left lower extremity peripheral neuropathy alone. Specifically, muscle strength testing and deep tendon reflexes were assessed as normal. The other major symptoms were noted as tingling and numbness of the lower extremity. The evidence did not show that the next higher rating, for moderate incomplete paralysis of the sciatic nerve, was approximated. Accordingly, the preponderance of the evidence is against a finding that the level of disability due to peripheral neuropathy of the right and left lower extremities is greater than mild in light of findings of mild disability from August 20, 2009 to June 11, 2013. The Board finds the preponderance of the evidence is against a rating higher in excess of 10 percent prior to June 11, 2013. Ratings in excess of 20 percent for bilateral peripheral neuropathy as of June 11, 2013 For the entire period on appeal the evidence does not more nearly approximate moderately severe incomplete paralysis. At the June 2013 and December 2016 VA examination, there was normal muscle strength without atrophy. Bilateral lower extremities were assessed with normal reflexes. There was decreased sensations. At the 2017 VA examination, there was slightly reduced strength, but no atrophy. The examiners found mild incomplete paralysis and moderate incomplete paralysis of the right and left sciatic nerve. Both examiners noted that while the Veteran’s would be restricted regarding certain types of labor, he was not unemployable due to the peripheral neuropathy disability. These findings do not warrant a finding of moderately severe incomplete paralysis. Accordingly, the preponderance of the evidence is against a finding that the level of disability due to peripheral neuropathy of the right and left lower extremities is greater than moderate incomplete paralysis as of June 11, 2013. The Board finds the preponderance of the evidence is against a rating higher than 20 percent as of June 11, 2013. 3. Entitlement to an initial disability rating coronary artery disease (CAD) in excess of 10 percent for the period from August 4, 2004 to March 26, 2013, and in excess of 30 percent thereafter The Veteran’s CAD is rated under Diagnostic Code 7005, which provides for a 10 percent rating where there is evidence of a workload of greater than 7 metabolic equivalents (METs) but not greater than 10 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required. A 30 percent rating is warranted for a workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent rating is warranted for more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs, resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is warranted for chronic congestive heart failure, or; workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104, Diagnostic Code 7005. A note underneath the Rating Schedule for diseases of the heart explains that one MET is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104. A June 2009 echogardiogram showed that the Veteran’s heart chambers, wall motions, wall thickness, were normal. The aorta was also noted as normal with ejection as 65 percent. No pericardial effusions were noted. A March 2013 EKG noted a diagnosis of cardiac hypertrophy or dilation. A left ventricular ejection fraction was noted as 62 percent from a December 2011 test. A June 2013 VA examination report shows that the Veteran was diagnosed with coronary artery disease which required the taking of continuous medication. The Veteran had a medical history of percutaneous coronary intervention and myocardial infarction. Congestive heart failure was not diagnosed. METs tested based on the Veteran’s response showed the lowest level of activity at which the Veteran reported symptoms were dyspnea, fatigue, and dizziness. METs estimate was 1 to 3, which was consistent with activities such as eating, dressing, taking a shower, slow walking (2 mph) for 1-2 blocks. Functional impact regarding employment would be difficulty with jobs requiring strenuous physical exertion but should not preclude sedentary employment. The examiner remarked that the METs estimate did not correlate accurately with the Veteran’s cardiac function as noncardiac conditions are contributing but cannot determine percentage contribution and that ejection fraction was a more objective assessment of his cardiac function. Evidence of cardia hypertrophy or dilation was noted as an EKG should a left ventricular ejection fraction of 62 percent noted in December 2011. A December 2016 VA heart examination report shows that the Veteran was diagnosed with coronary artery disease which required the taking of continuous medication. The examiner noted that the Veteran had a myocardial infarction in 1993. Congestive heart failure, arrhythmia, heart valve conditions, infectious heart conditions, and pericardial adhesions were not diagnosed. The examiner noted that diagnostic testing did not show evidence of cardiac hypertrophy or dilation. An echocardiogram showed left ventricular ejection fraction of 60-65 percent. Wall motion was abnormal. Wall thickness was normal. METs evaluation noted that exercise stress test could not be conducted due to the Veteran’s COPD, asthma, low back pain, and BPV. Interview based METs estimate was 1 to 3, which was consistent with activities such as eating, dressing, taking a shower, slow walking (2 mph) for 1-2 blocks due to COPD, asthma, low back pain, bilateral knee pain, bpv, and diabetic neuropathy. Functional impact regarding employment would be difficulty with jobs requiring strenuous physical exertion but should not preclude sedentary and light employment. The examiner remarked ejection fraction was a more accurate indicator of cardiac status than the estimate METs which was lower due to the non-cardiac comorbidities mentioned above. Rating in excess of 10 percent prior to March 26, 2013 Prior to March 26, 2013, the Board finds that the criteria for rating in excess of 10 percent for coronary artery disease have not been met. The evidence during that time frame to include VA treatment records illustrates that the Veteran's coronary artery disease was not manifested workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. VA treatment records note that a June 2009 echogardiogram showed that the Veteran’s heart chambers, wall motions, wall thickness, were normal. The aorta was also noted as normal with ejection as 65 percent. No pericardial effusions were noted. Therefore, the Board finds that a rating in excess of 10 percent are not warranted prior the March 26, 2013. Rating in excess of 30 percent as of March 26, 2013 The Board finds that the preponderance of the evidence of record is against an increased rating in excess of 30 percent for the service-connected CAD. While June 2013 and December 2016 VA examiners conducted interview-based testing which showed 1 to 3 and were associated with fatigue and dyspnea—which would meet the criteria that is commensurate with a 60 percent rating under DC 7005. Both VA examiner\s reported the LVF was a better indicator of cardiac status than the estimate METs which was lower due to the no- cardiac comorbidities. The Veteran’s left ventricular ejection fraction was noted to be 62 percent in June 2013 and 60 to 65 percent December 2016. In addition, that same report noted July 2016 echocardiogram , EKG, and chest x-ray that found the Veteran’s ejection fraction was 60 percent, and normal x-ray and EKG. The evidence of record does not show left ventricular ejection fraction of ejection fraction of 30 to 50 percent or that the Veteran suffered more than one episode of acute congestive heart failure during the appeal period. Although there is evidence of dyspnea and fatigue, the already assigned 30 percent rating contemplates those symptoms. Therefore, an increased rating of 60 percent for the service-connected CAD is not shown by the evidence of record. The Board notes that VA treatment records have been reviewed, but have not shown criteria that would support a rating in excess of 10 percent prior to March 26, 2013 and in excess of 30 percent thereafter. The records did not contain any additional METs testing or evidence that other schedular criteria for increased ratings had been met. 4. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities for the period prior to May 8, 2013 VA will grant a TDIU when the evidence shows that a Veteran is precluded from obtaining or maintaining any gainful employment consistent with her education and occupational experience, by reason of her service-connected disabilities. 38 C.F.R. §§ 3.340, 3.341, 4.16. A total rating for compensation purposes may be assigned where the schedular rating is less than total when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more service-connected disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16(a). VA will grant TDIU when the evidence shows that the Veteran is precluded, by reason of service-connected disabilities, from obtaining and maintaining any form of gainful employment consistent with his or her education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. TDIU benefits are granted only when it is established that the service-connected disabilities are so severe, standing alone, as to prevent the retaining of gainful employment. 38 C.F.R. § 4.16(a). The relevant issue is not whether the veteran is unemployed or has difficulty obtaining employment, but whether the veteran can perform the physical and mental acts required by employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). In determining whether unemployability exists, consideration may be given to the veteran's level of education, special training, and previous work experience, but no consideration may be given to age or impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 4.16, 4.19. Responsibility for the ultimate TDIU determination is with VA, not a medical examiner. Geib v. Shinseki, 733 F.3d 1350 (Fed. Cir. 2013). For a veteran to prevail on a claim based on unemployability, it is necessary that the record reflect some factor which places him or her in a different position than other veterans with the same disability rating. The sole fact that a veteran is unemployed or has difficulty obtaining employment is not enough to prove unemployability. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. 38 C.F.R. §§ 3.341(a), 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The ability to work sporadically or obtain marginal employment is not substantially gainful employment. 38 C.F.R. § 4.16(a); Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). Marginal employment, i.e., earned annual income that does not exceed the poverty threshold for one person, is not considered substantially gainful employment. 38 C.F.R. § 4.16(a). Marginal employment includes employment in a protected environment such as family business or sheltered workshop. 38 C.F.R. § 4.16(a). Where the evidence establishes that a veteran is gainfully employed on a full-time basis, a TDIU cannot be granted during this period as a matter of law. Sabonis v. Brown, 6 Vet. App. 426 (1994). Here, the Veteran is rated as 100 percent disabled and is in receipt of SMC at the equivalent of housebound status, effective May 8, 2013. Thus, entitlement to TDIU and SMC are only at issue prior to that date. Prior to May 8, 2013, the Veteran is service-connected for the following: post-traumatic stress disorder (70 percent disabling); CAD (10 percent disabling for the period from August 4, 2004 to March 26, 2013, and in excess of 30 percent thereafter); diabetes mellitus (20 percent disabling); peripheral neuropathy of the right lower extremity (10 percent disabling); peripheral neuropathy of the left lower extremity (10 percent disabling); urinary urgency incontinence (10 percent disabling); hypertension (10 percent disabling); tinea pedis and manus with onychomycosis (noncompensably disabling); cataracts (noncompensably disabling); and, erectile dysfunction (noncompensably disabling).Thus, the Veteran meets the criteria for a schedular TDIU as he has at least one disability ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. Therefore, the central question concerns whether the Veteran is unemployable due to his service-connected disabilities prior the May 8, 2013. A January 1995 letter from a VA physician reported that the Veteran had been unable to work since discharge in 1968, due to PTSD stemming from his prisoner of war experience. The VA physician reported that due to extreme psychoneurotic symptoms the Veteran was unable to sustain attention, maintain a stable mood due to frequent explosive outburst and frequent dissociative amnestic symptoms all of which combined to make gainful unemployment impossible. At a March 2012 VA peripheral nerve and male reproductive examination, the examiners concluded that neither the Veteran's diabetic peripheral neuropathy of the lower extremities nor erectile dysfunction had impacted his ability to work. The examiner noted that the Veteran was a retired plumber, as he was self-employed doing plumbing, electrical work, and construction. He last worked in 2002. A March 2012 PTSD examiner opined that the Veteran's PTSD did not impair his ability to engage in physical and sedentary employment. The examiner noted that the Veteran’s PTSD resulted in occupational and social impairment due to mild or transient symptoms which decreased work efficiency and ability to perform occupational task only during periods of significant stress, or symptoms controlled by medication. The Veteran reported that he dropped out of school in the 10th grade but obtain his GED. He reported attending community college for 6 months but never graduated. A June 2012 diabetes mellitus examination, the VA examiner opined that the Veteran's diabetes mellitus impacted his ability to work because he had to watch his diet and take insulin regularly. An October 2019 VA Disability Benefits Questionnaire (DBQ), shows that the examiner reviewed the claims file to determine whether the Veteran’s service connected disabilities resulted in the Veteran inability in obtaining and maintaining any form of gainful employment consistent with his education and occupational experiences prior to May 8, 2013 The examiner reviewed the claims file and determined that the Veteran had a history of poor employability beginning in 1989, and cited to letters from a VA physician that noted PTSD resulted in difficulty sustaining gainful employment and difficulty in holding a steady job. Considering the pertinent evidence in light of the above, and resolving reasonable doubt in the Veteran's favor, the Board finds that TDIU is warranted due to the Veteran's service connected disabilities prior to May 8, 2013. The Board notes that the Veteran has reported having obtained his GED and attended 6 months of community college. While there is some evidence to indicate that the Veteran’s disabilities did not resulted in the Veteran’s employability being impaired due to service connected disabilities alone, the Board finds that the evidence is in relative equipoise, as the October 2019 VA examiner reported that the Veteran’s PTSD disability alone resulted in his inability to maintain gainful employment prior to May 8, 2013. Accordingly, entitlement to TDIU is warranted prior to May 8, 2013. 5. Entitlement to service connection for soft tissue sarcoma, also claimed as skin cancer, to include as a result of exposure to herbicides Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). A Veteran who served in the Republic of Vietnam during the Vietnam era is presumed to have been exposed during to an herbicide agent, unless there is affirmative evidence to the contrary. 38 C.F.R. § 3.307(a)(6)(iii). The Vietnam era is the period beginning on February 28, 1961 and ending on May 7, 1975 for veterans who served in the Republic of Vietnam, and the period beginning on February 28, 1961 and ending on May 7, 1975, in all other cases. 38 U.S.C. § 101(29)(A). For veterans presumed to have been exposed to herbicides, certain enumerated diseases shall be service connected even though there is no record of such disease during service, so long as the requirements of 38 U.S.C. § 1116 and 38 C.F.R. § 3.307(a)(6)(iii) are met, and the rebuttable presumption provisions of 38 U.S.C. § 1113 and 38 C.F.R. § 3.307(d) are also satisfied. 38 C.F.R. § 3.309(e). The enumerated diseases which are deemed to be associated with herbicide exposure do not include basal cell carcinoma. 38 C.F.R. § 3.309(e). A presumption of service connection based on exposure to herbicides used in the Republic of Vietnam during the Vietnam era is not warranted for skin cancer, including squamous cell carcinoma and basal cell carcinoma. See Diseases Not Associated with Exposure to Certain Herbicide Agents, 68 Fed. Reg. 27,630 (May 20, 2003); Diseases Not Associated with Exposure to Certain Herbicide Agents, 67 Fed. Reg. 42,600 (June 24, 2002); Diseases Associated with Exposure to Certain Herbicide Agents; Type 2 Diabetes, 66 Fed. Reg. 2,376 (Jan. 11, 2001); Diseases Not Associated with Exposure to Certain Herbicide Agents, 64 Fed. Reg. 59,232 (November 2, 1999). The Veteran served in the Republic of Vietnam, as noted by his service personnel records. A review of the Veteran’s service treatment records shows no diagnosis of basal cell carcinoma during active service or on separation from service. VA treatment records from 2006 indicate that the Veteran was diagnosed with basal cell carcinoma affecting the left lower lip region, which was then removed. A December 2016 VA addendum opinion report shows that in 2006 the Veteran had basal cell carcinoma removed from the lower lip area. He also had pigmented seborrheic keratosis resected from the neck. A lesion on his nose indicated sebaceous hyperplasia and actinic changes. In 2008, a lipoma was resected from his upper back area. The examiner remarked that none of these conditions were recognized as by VA as being related to agent orange exposure. A January 2017 VA examination report shows that the examiner noted the Veteran’s service treatment records were absent for skin cancer or soft tissue sarcoma. The examiner noted a past diagnosis of basal cell skin cancer that was diagnosed after separation from service and the weight of the current medical literature did not support that condition being secondary to herbicide exposure. Additionally, the examiner noted no diagnosis of sarcoma. Therefore, the examiner opined that it was less likely than not that the skin cancer was related to his active service or secondary to exposure to herbicides. After a review of the evidence of record the Board finds that the preponderance of the evidence does not support the Veteran’s claim for entitlement to service connection for basal cell carcinoma to include as due to exposure to herbicides. As noted above, basal cell carcinoma are not diseases that are deemed to be associated with herbicide exposure. 38 C.F.R. § 3.309(e). As such, service connection on a presumptive basis is not warranted. Despite the presumptive regulations, a veteran may establish service connection based on exposure to Agent Orange with proof of actual direct causation. See Stefl v. Nicholson, 21 Vet. App. 120 (2007) (holding that the availability of presumptive service connection for some conditions based on exposure to Agent Orange does not preclude direct service connection for other conditions based on exposure to Agent Orange); Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994); Brock v. Brown, 10 Vet. App. 155 (1997). Here, the January 2017 VA examiner determined that it was less likely than not that the Veteran’s basal cell carcinoma was caused by active service to include as due to exposure to herbicides. The examiner cited to the evidence in the claims file and medical literature to support the rationale provided. Regarding basal cell carcinoma, the service treatment records are absent for diagnosis of skin cancer. Indeed, the first noted diagnosis of record places the onset of basal cell carcinoma around the year 2006 which is many years after service discharge. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991). This gap in time weighs against the Veteran's claim. To the extent the Veteran is alleging that his disabilities are related to service, he is not competent to do so. That is because the etiology of internal conditions, such as a skin disorder or cancer, is a complicated medical determination not capable of lay observation such as the presence of ringing in the ears or a broken leg. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (noting that lay testimony may establish the presence of tinnitus because ringing in the ears is capable of lay observation); Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (holding that a lay witness is competent to testify to that which the witness has actually observed and is within the realm of his personal knowledge). In short, the preponderance of the evidence consisting of the VA examination reports of record show a lack of a nexus between the Veteran's diagnosed basal cell carcinoma and his service, including his exposure to Agent Orange during service, the Board finds that service connection is not warranted for basal cell carcinoma. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claims, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to service connection for hepatitis C is remanded. After a review of the evidence of record, the Board finds that a remand is required to clarify whether the Veteran has had a current diagnosis of hepatitis C during the appeal periods as there is conflicting evidence that needs to be commented upon. A May 2009 VA lab report shows that Hep C testing was positive/negative. A June 2009 VA treatment record shows that the treating physicians remarked that a thorough evaluation Veteran was required in a setting of Hepatitis C. Another note, shows that the Veteran was recently diagnosed with Hepatitis C. An August 2009 VA treatment record shows that Hepatitis C was not detected. A July 2014 VA laboratory results indicated Hep BcAb referenced negative, but Hep ATOT was positive but reference interval that was negative. The Board finds that a remand is warranted to determine if the Veteran has a current diagnosed of hepatitis C and if so, whether such a condition was caused by active service. 2. Entitlement to service connection for a disability manifested by constipation, to include as secondary to the service connected diabetes mellitus type 2 is remanded. Regarding the Veteran’s claim for entitlement for service connection for a disability manifested by constipation, secondary to diabetes mellitus, he was afforded a VA examination in 2010 and an addendum VA opinion in December 2016. A July 2010 VA diabetes mellitus examination report shows that the Veteran had occasional constipation that was less likely than not secondary to diabetes. A December 2010 VA diabetes mellitus examination report shows that the Veteran reported rare constipation which he was not currently being treated for. During the March 2015 Board hearing, the Veteran testified that he had constipation all the time but he would just drink milk which would cause diarrhea. A December 2016 VA examination report shows that an addendum opinion regarding constipation revealed the Veteran stating to the examiner that he did not experience constipation and that once in a while he may have diarrhea after ingesting spicy foods. He also reported he never filed a claim for constipation but his lawyer did. However, the Board finds that both examination reports are inadequate for adjudication purposes. Here, while the July 2010 VA examiner opined that the Veteran’s constipation was less likely than not secondary to diabetes. The December 2016 VA examiner failed to provide any opinion as to aggravation. El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013) (a medical opinion is inadequate when it fails to adequately address the question of aggravation). VA has a duty to ensure that any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Therefore, on remand, an examination should be schedule to the Veteran to determine the etiology of the Veteran’s reported constipation and whether the condition was caused or aggravated by service connected diabetes mellitus. 3. Entitlement to service connection for a gastrointestinal condition to include GERD and diarrhea as secondary to the service-connected disability of diabetes mellitus type 2 is remanded. Regarding the Veteran’s claim for entitlement for service connection for a gastrointestinal condition to include GERD and diarrhea secondary to diabetes mellitus type II, remand is required for an adequate VA examination. In a secondary service connection claim, a medical opinion that a disorder is not the result of an already service-connected disability does not address the issue of aggravation. El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013). A February 2010 VA examination report shows that the examiner opined that it was less likely than not secondary to diabetes mellitus. A December 2016 VA addendum opinion report noted that the condition predated the diabetes mellitus disability. The Veteran denied worsening of his symptoms and reported no symptoms caused by his medication. The Veteran also reported that his GERD was well controlled and would only flare up if he ran out of his medication. The examiner also noted that VA primary care treatment records showed that the GERD was well controlled. The examiner noted that the Veteran had never reported aggravation or had a workup for the same. The Board finds that the opinions of the February 2010 and December 2016 VA examination reports are inadequate as the examiner did not address whether the Veteran’s diarrhea was aggravated by the service connected diabetes mellitus. 4. Entitlement to special monthly compensation by reason of being housebound for the period prior to May 8, 2013 5. Entitlement to special monthly compensation for aid and attendance of another Remand is required as this issue is inextricably intertwined with the Veteran’s claim s of service connection remanded herein, as the adjudication of that issue may affect the Veteran’s eligibility for SMC. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (stating two issues are “inextricably intertwined” when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). Additionally, the Board finds that the Veteran should be scheduled for a VA examination to determine if his service-connected disabilities render him so helpless as to require the regular aid and attendance of another person. While there are examination reports completed regarding this issues, the examiners have also considered the Veteran’s non-service connected disabilities to determine if aid and attendance is required. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination from an appropriate clinician to determine the nature and etiology of any diagnosis hepatitis C. The claims file must be made available to and reviewed by the examiner. Based on a review of the record and physical examination, the examiner is asked to provide an opinion as to whether the Veteran has a current diagnosis of hepatitis C or had a diagnosis of hepatitis C that has since resolved. The examiner must review and comment upon previous laboratory results of record that show positive/negative indications. If and only if the Veteran is diagnosed with hepatitis C then the examiner must provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that the Veteran's hepatitis C had its onset during the Veteran's active service or is otherwise etiologically related to such service. 2. Schedule the Veteran for a VA examination from an appropriate clinician to determine the nature and etiology of his constipation. All appropriate tests or studies should be accomplished, and all clinical findings should be reported in detail. The examiner should include a detailed rationale for all opinions provided. The examiner is requested to provide a medical opinion on the following: (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran's constipation is etiologically related to the Veteran's active service? (b) Is it at least as likely as not (50 percent or greater probability) that the constipation was caused by his service-connected diabetes mellitus type II? (c) Is it at least as likely as not (50 percent or greater probability) that the Veteran's constipation has been aggravated by the diabetes mellitus type II. 3. Schedule the Veteran for a VA examination from an appropriate clinician to determine the nature and etiology of his gastrointestinal condition to include GERD and diarrhea. All appropriate tests or studies should be accomplished, and all clinical findings should be reported in detail. The examiner should include a detailed rationale for all opinions provided. The examiner is requested to provide a medical opinion on the following: (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s gastrointestinal condition to include GERD and diarrhea is etiologically related to the Veteran’s active service? (b) Is it at least as likely as not (50 percent or greater probability) that the gastrointestinal condition to include GERD and diarrhea was caused by his service-connected diabetes mellitus type II? (c) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s gastrointestinal condition to include GERD and diarrhea has been aggravated by the diabetes mellitus type II. 4. Thereafter, obtain an addendum medical opinion as to whether the Veteran needs the regular aid and attendance of another person due only to his service-connected disabilities. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Dworkin, 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.