Citation Nr: 21008720 Decision Date: 02/17/21 Archive Date: 02/17/21 DOCKET NO. 15-06 378A DATE: February 17, 2021 ORDER Entitlement to a rating in excess of 30 percent prior to June 8, 2015, and in excess of 50 percent thereafter, for post-traumatic stress disorder (PTSD), is denied. Entitlement to a 50 percent rating beginning June 8, 2015, for PTSD, is granted. Entitlement to a rating greater than 20 percent for left leg neuropathy is denied. Entitlement to a total disability rating based upon individual unemployment (TDIU), to include extraschedular referral, for the period prior to June 8, 2015, is denied. Entitlement to a TDIU beginning June 8, 2015 is granted. FINDINGS OF FACT 1. For the period prior to June 8, 2015, the Veteran’s PTSD was manifested by occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal) due to various symptoms. 2. Beginning June 8, 2015, the evidence is in equipoise as to whether the Veteran’s PTSD worsened causing occupational and social impairment with reduced reliability and productivity, but his symptoms did not cause deficiencies in most areas or total social and occupational impairment. 3. For the entire appeal period, the Veteran’s service-connected left leg neuropathy has been manifested by, at worst, symptoms comparable to moderate incomplete paralysis of the sciatic nerve. 4. Prior to June 8, 2015, the Veteran’s service-connected disabilities did not preclude the Veteran from securing or following a substantially gainful occupation. 5. Beginning June 8, 2015, the Veteran’s service-connected disabilities precluded the Veteran from securing or following a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent for the period prior to June 8, 2015, and in excess of 50 percent, thereafter, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.130, Diagnostic Codes 9400, 9411. 2. The criteria for a 50 percent rating for PTSD, beginning June 8, 2015, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.130, Diagnostic Codes, 9400, 9411. 3. The criteria for a rating greater than 20 percent for left leg neuropathy have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.124a, Diagnostic Code 8520. 4. For the period prior to June 8, 2015, the criteria for entitlement to a TDIU have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.16. 5. Beginning June 8, 2015, the criteria for entitlement to a TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from August 2003 to September 2010. In October 2018, the Veteran had a hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the claims folder. This matter was previously before the Board in April 2019. In the decision, the Board granted service connection for hypertension which was initially on appeal as well. As the full benefits sought have been granted, this claim is no longer before the Board. The remaining claims were remanded for additional development and have been returned to the Board for further appellate review. The Board also notes that in a July 2020 rating decision, the Veteran’s claim for entitlement to TDIU was granted, effective May 11, 2017. However, the Board is cognizant of the decision in Harper v. Willkie, 30 Vet. App. 356 (2018), in which the partial grant of a Rice TDIU does not bifurcate it from the underlying increased rating claim on appeal and the issue of entitlement to TDIU must be considered for the entire appellate period. Thus, the Board will adjudicate the issue of entitlement to TDIU prior to May 11, 2017 in the decision herein. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Increased Rating Disability evaluations are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (rating schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation is assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3. Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a Veteran’s service-connected disability. 38 C.F.R. § 4.14; see Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be “staged.” Hart v. Mansfield, 21 Vet. App. 505 (2007) (staged ratings are appropriate when the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 1. Entitlement to a rating greater than 30 percent for the period prior to January 30, 2020, and in excess of 50 percent thereafter for PTSD. The Veteran’s psychiatric disorder has been assigned staged ratings throughout the appeal period and has been evaluated under Diagnostic Codes 9400 and 9411 under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, Diagnostic Codes 9400, 9411. Prior to January 30, 2020, the Veteran was assigned a 30 percent rating for generalized anxiety disorder under Diagnostic Code 9400; however, beginning January 30, 2020, a 50 percent rating was assigned under Diagnostic Code 9411 for PTSD. Under the General Rating Formula, a 30 percent rating is assigned when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversion normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Codes 9400, 9411. A 50 percent rating is assigned when a veteran’s psychiatric disorder causes occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-term and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Codes 9400, 9411. A 70 percent evaluation is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Codes 9400, 9411. The maximum schedular rating of 100 percent is warranted when there is total occupational and social impairment due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation or own name. 38 C.F.R. § 4.130, Diagnostic Codes 9400, 9411. When determining the appropriate disability evaluation to assign, the Board’s primary consideration is a veteran’s symptoms, but it must also make findings as to how those symptoms impact a veteran’s occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because the use of the term “such as” in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran’s impairment must be “due to” those symptoms, a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. In addition, when evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the lengths of remissions, and the Veteran’s capacity for adjustment during periods of remission. 38 C.F.R. § 4.126 (a). The rating agency shall assign an evaluation based on all evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment; but shall not assign an evaluation on the basis of social impairment. 38 C.F.R. § 4.126 (b). Factual Background A review of the evidence shows the Veteran received a mental disorders examination in October 2012. In the examination, the Veteran reported being married for the past couple of years, and that marriage is good in general. He reported having one child, with whom he has a good relationship with. The Veteran also reported having a good relationship with his family and friends and stated that he talks to his mom at least once a week, his brothers and sisters about once a month, and that he has friends spread throughout the country. Occupationally, the Veteran reported being out of work just over a year since he was discharged. He reported being told that he was overqualified, underqualified, or that the position had been filled. He further reported going to school full-time in the spring and summer of this year and that he has a 2.5 GPA. The examiner noted symptoms of depressed mood and anxiety and diagnosed the Veteran with dysthymic disorder and anxiety disorder. The examiner described the Veteran’s occupational and social functioning by indicating a mental condition has been formally diagnosed but symptoms are not severe enough to interfere with occupational and social functioning or to require continuous medication. In his June 2019 mental disorders examination, the Veteran reported that he lives with his girlfriend and their two sons. He explained that they are not married but have lived together for 10 years. He reported that he is involved in his kids’ life and has regular phone contact with his mothers and sisters. Occupationally, the Veteran reported that he has not worked full-time for about 4 years, and that he did not work for about a year after getting out of the Navy. He reported working on a road crew holding the sign to stop traffic, but that it was too difficult to stand for so long with his hip problem. He stated that he was also seen as aloof by his co-workers who got mad at him, so the job ended. The Veteran reported doing part-time carpet cleaning, but the equipment was too heavy to lift, which was hard with his hip. He indicated he went to college for three years and obtained an Associate degree but felt he wasn’t good in schoolwork. Then, he worked odd jobs doing yard work. He reported he tried to do sit down jobs but that his hip stiffens up and he can’t get back up. With regard to treatment, the Veteran reported that he takes trazodone for sleep and anxiety. He reported that he used to get therapy from VA but stopped long ago because he felt it did not help much. He also reported that he continues to be vigilant and watchful, but mainly at night and not much during the day, which is an improvement. However, he is still avoidant of people, especially in crowds, and he cannot go to Disneyland. The Veteran also reported having occasional panic attacks in public where he can feel his heart racing; he gets sweaty, and his mind gets foggy. The examiner noted symptoms of depressed mood, anxiety, panic attacks that occur weekly or less often, and chronic sleep impairment. The examiner diagnosed the Veteran with anxiety disorder and explained that the Veteran has mild generalized anxiety disorder which affects his sleep and his ability to feel comfortable around groups of people. The examiner found occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. In his January 2020 PTSD examination, the Veteran reported that he lives with a friend. He denied a history of marriage and reported having two children. The Veteran further reported that he has not been employed for two years and explained that he ended his last job with administrative work due to social conflict/discomfort and PTSD symptoms. The examiner noted symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The examiner diagnosed the Veteran with PTSD and found occupational and social impairment with reduced reliability and productivity. The examiner found that PTSD was a progression of and replacement of his previous diagnosis of generalized anxiety disorder. Analysis Based on the above and remaining evidence, the Board finds that staged ratings are appropriate. Specifically, the Board finds that an increased rating to 50 percent, but no higher, is warranted beginning June 8, 2015. However, prior to June 8, 2015, the Board finds the Veteran was appropriately rated at 30 percent disabling; thus, a higher rating is not warranted. For the period prior to June 8, 2015, the evidence shows the Veteran’s psychiatric disorder was no more than mild in severity. This finding is best evidenced in the Veteran’s October 2012 mental disorders examination where the Veteran reported having a good relationship with his girlfriend, whom he referred to as his wife. He also reported having good relationships with his children, his mother, and his siblings. Although he reported being unemployed, he did not attribute his unemployment to his psychiatric disorder, but noted that he was overqualified, underqualified, or that the positions had been filled. Mental status examination showed the Veteran was alert and fully oriented. Thought content and thought process were unremarkable. The Veteran’s mood presented as euthymic to mildly anxious with full and reactive affect. There was no observable responsiveness to internal stimuli; hallucinations, delusions, suicidal/homicidal ideations were denied. There was no observable impairment in attention, concentration, or memory. Furthermore, the examiner found that symptoms from the Veteran’s psychiatric disorder were not severe enough to interfere with occupational and social functioning or to require continuous medication. The Board notes that although the Veteran is rated at 30 percent disabling, this finding corresponds to a noncompensable rating. In addition, VA treatment records from a January 2013 primary care visit shows the Veteran reported that he was handling stress well, sleeping well, and not feeling down, depressed, or hopeless. In a subsequent January 2013 psychiatric consult, he reported intermittent symptoms at best. For example, he reported being depressed off and on since 2006, sleep difficulties, and concentration was difficulties at times. The Veteran denied suicidal/homicidal thoughts or intent, and he reported no periods of abnormally elevated mood, psychotic symptoms, or hallucinations or delusions. Moreover, he reported no symptoms of obsessive-compulsive disorder or panic attacks. Alternatively, in April 2013, the Veteran had positive PTSD and depression screens which resulted in an increase in his prescribed Sertraline. Additionally, in a September 2013 mental health visit, the Veteran reported having periods of irritability for 2 to 4 days, mood swings, decreased sleep, periods of time where he was more talkative than usual, distractibility, flight of ideas, racing thoughts, increase in goal-directed activity or excessive involvement in pleasurable activities. He also reported having problems with anger and that he got into arguments. A question mark was noted as to auditory hallucinations and the Veteran reported being paranoid at times. However, his mental status examination showed the Veteran was well-groomed; alert and oriented x 3. His mood was noted as dysphoric and irritable at times, but thought process was logical and goal-directed, with no looseness of associations or flight of ideas; and thought content showed no evidence of hallucinations or delusions. The Veteran also denied suicidal/homicidal thoughts. In addition, records show that the Veteran did not have further mental or medical treatment until 2015. Specifically, VA treatment records show the Veteran presented to an April 2015 primary care visit where he sought to re-establish care and reported no problems relative to his psychiatric disorder. In addition, his depression and PTSD screens were negative. Given the above, the Board finds that there is no factually ascertainable evidence prior to June 8, 2015 that would suggest the Veteran’s symptoms were more than mild, or that his symptoms were of such severity, frequency, or duration to warrant a rating greater than 30 percent. While the Veteran had a brief period of increased symptomatology in April 2013, there is no evidence that this period was of any duration, or that the severity of these symptoms equated to the 50 percent criteria. In fact, he stopped treatment after this and when he began again noted no problems relative to his psychiatric condition. As such, the preponderance of evidence is against the claim and the benefit-of-the-doubt doctrine is inapplicable. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Accordingly, an increased rating for anxiety disorder prior to June 8, 2015 is denied. Beginning June 8, 2015, however, the Board finds a 50 percent rating is warranted. The Board notes that the Veteran was awarded an increased rating to 50 percent, effective January 30, 2020, based on findings in his January 2020 PTSD examination. In the examination, the examiner found that the Veteran’s anxiety disorder had progressed to PTSD causing occupational and social impairment with reduced reliability and productivity. However, the evidence shows that the Veteran appears to have exhibited a worsening of his symptoms as early as June 8, 2015. Here, VA treatment records show the Veteran presented for a psychiatric evaluation on this date where he requested more medication. The examiner noted that the Veteran was last seen in 2013 and that he had not used medication in the last year. The examiner found symptoms of increased anxiety and depression in the context of being unemployed and struggling with a failed relationship. Other symptoms included sleep disturbance, loss of interest, poor energy level, anhedonia, change in appetite, and the Veteran endorsed paranoia when driving, related to his experience in Iraq. The examiner opined that the Veteran presented with distress and functional impairment, secondary to symptoms of depression and anxiety due to significant social stressors (being unemployed and living with his ex-girlfriend and their two kids) and prior combat exposure. The examiner also found that the Veteran did not currently meet the full criteria for PTSD, but he had many symptoms of PTSD. Although the examiner diagnosed the Veteran with unspecified depressive/anxiety disorder, the evidence shows the Veteran received no treatment in 2016 or 2017, and he was eventually diagnosed with PTSD after he resumed treatment in June 2018. In his June 2018 psychiatric evaluation, the examiner noted that the Veteran reported PTSD symptoms of reliving thoughts and memories of trauma from the war, nightmares, feelings of detachment and isolation from others at times, decrease loss in interest in events, difficulty with sleep irritability, outburst of anger, muscle tension, and dislikes of crowds of people. The examiner diagnosed the Veteran with PTSD and prescribed additional medications. Given the above, the Board finds the evidence is in equipoise as to whether the Veteran’s symptoms worsened as of June 8, 2015. Therefore, resolving all doubt in favor of the Veteran, a 50 percent rating is granted beginning June 8, 2015, and no earlier. However, a rating greater than 50 percent is not warranted because his symptoms did not cause occupational or social impairment with deficiencies in most areas, nor were his symptoms of the severity, frequency, or duration to warrant a higher rating. Although the Veteran reported increased symptoms during his June 2015 visit, the Veteran denied symptoms of psychosis or significant symptoms suggestive of a manic episode. In addition, mental status examination showed the Veteran’s hygiene was good. He was alert and oriented in all spheres; eye contact was adequately maintained, and there was no obvious psychomotor abnormality. Although he exhibited a depressed and anxious mood, his thought processes were logical, linear, and goal-directed without evidence of thought disorder. Insight was fair; judgment and impulse control were adequate. There were no loose associations and no expressed delusional content, and he denied suicidal/homicidal ideation. Moreover, in a July 2015 follow-up visit, the Veteran reported that he was feeling better. As noted above, the Veteran received no additional treatment until he reconnected with mental health in June 2018. Although the Veteran reported symptoms of PTSD and was restarted on medication, he denied suicidal/homicidal ideations, and hallucinations. Additionally, his mental status examination showed that he was neat and well-groomed. He was alert and oriented in all three spheres and his thought process was coherent with no loose associations. Insight and judgment were also noted as good. Moreover, the Veteran’s symptoms were not of the severity, frequency, or duration to warrant a higher rating as the Veteran reported occasional nightmares, some distress as it pertained to his job, decrease loss in interest in events at times, and occasional excessive emotions with difficulties relating to others. Furthermore, during an April 2019 annual primary care visit, his depression was noted as stable with no recent follow-ups with behavioral health; and, in his June 2019 mental disorders examination, he was found to have occupational and social impairment with occasional decrease in work efficiency, which corresponds to a 30 percent rating. The Board recognizes that the Veteran reported having panic attacks in his hearing; however, these were not of the severity, frequency, or duration that would warrant a higher rating as the examiner in his June 2019 examination found that these occur weekly or less often, and the Veteran reported that these occur occasionally. For these reasons, the Board finds that a 50 percent rating, but no higher, is warranted from June 8, 2015. 2. Entitlement to a rating greater than 20 percent for left leg neuropathy. The Veteran is currently in receipt of a 20 percent rating for left leg peripheral neuropathy under Diagnostic Code 8520, 38 C.F.R. § 4.124a. Under Diagnostic Code 8520, an evaluation of 10 percent is warranted for mild incomplete paralysis, an evaluation of 20 percent is warranted for moderate incomplete paralysis, an evaluation of 40 percent is warranted for moderately severe incomplete paralysis, an evaluation of 60 percent is warranted for severe incomplete paralysis with marked muscular atrophy, and an evaluation of 80 percent is warranted for complete paralysis. In rating the peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment in motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. Words such as “severe,” “moderately severe,” “moderate,” and “mild” are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, it is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for an increased disability rating. 38 U.S.C. § 7104; 38 C.F.R. §§ 4.2, 4.6. A review of the evidence shows the Veteran received a peripheral nerves Disability Benefits Questionnaire (DBQ) in October 2012 where he reported having a burning feeling with tingling from his back down to the top of his toes. He reported that the feeling increases with more strain, such as cutting the grass or lifting heavy objects. The examiner noted symptoms of moderate intermittent pain, paresthesias, and numbness. Muscle strength testing and reflexes were normal and there was no muscle atrophy. Sensory examination showed decreased sensation in the left thigh/knee; but there were no tropic changes and the Veteran had a normal gait. The examiner found that the Veteran had mild incomplete paralysis of the left sciatic nerve. The examiner noted that the Veteran’s symptoms are sensory only with no motor involvement, and that despite the Veteran’s subjective complaints, there are no objective findings to support a diagnosis for lumbar radiculopathy at this time. In his July 2019 peripheral nerves examination, the Veteran reported that his foot and leg are always numb and feel heavy. He reported that the condition has worsened as it was intermittent but is now constant. The examiner noted mild symptoms of constant pain and paresthesias and/or dysesthesias, and moderate symptoms of numbness. Muscle strength was reduced to a 4 out of 5 for his left knee extension, ankle plantar flexion, and ankle dorsiflexion. There was no muscle atrophy and reflexes were normal. Sensory examination showed a decrease in left upper anterior thigh, left thigh/knee, left lower leg/ankle, and there was no sensation in his left foot/toes. There were no tropic changes and the Veteran’s gait was normal. The examiner found that the Veteran had moderate incomplete paralysis of the left sciatic nerve. The examiner explained the diagnosis is more accurately a radiculopathy and not a peripheral neuropathy and found the condition has not changed. In his January 2020 peripheral nerves examination, the Veteran reported severe symptoms of intermittent pain, paresthesias, and numbness. Muscle strength, reflexes, and sensory examination were normal. There was no muscle atrophy or tropic changes and the Veteran had a normal gait. The examiner found moderate incomplete paralysis of the left sciatic nerve Based on the above, the Board finds a higher rating is not warranted. As noted above, all of the VA examiners determined that the Veteran’s left leg neuropathy was no more than moderate in severity. This finding is further evidenced in the Veteran’s January 2020 VA back examination as the examiner described the Veteran’s left leg radiculopathy as moderate. Moreover, VA treatment records also do not support a higher rating as there is no evidence that the Veteran’s left leg neuropathy was no more than moderate in severity. For example, in his January 2013 primary care visit, the examiner found no paresthesias, edema, joint problems, or new neurologic symptoms. Similarly, in a May 2013 primary care note, the Veteran reported toe numbness and slight persistent numbness when walking; however, his symptoms were not considered severe as he was instructed to walk at least 20 minutes daily, his gait was stable, and he was determined to not be a fall risk. In addition, subsequent VA treatment records are silent for complaints or treatment pertaining to the Veteran’s left leg neuropathy which was confirmed in an April 2019 annual visit where it was noted that the Veteran was last seen in 2015. In addition, during his annual visit, the Veteran complained of low back pain, but there were no complaints of pain, numbness, or otherwise to his left leg. Given these findings, the Board finds the preponderance of evidence weighs against the claim as there is no evidence of record that shows the Veteran’s left leg neuropathy was more than moderate in severity. Therefore, as the preponderance of evidence is against the claim, the benefit-of-the-doubt doctrine is inapplicable. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Accordingly, the claim for an increased rating is denied. 3. Entitlement to a TDIU prior to May 11, 2017. VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that a veteran is precluded, by reason of his service- connected disabilities, from obtaining and maintaining any form of gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. Unemployability is synonymous with inability to secure and follow a substantially gainful occupation. VAOPGCPREC 75-91; 57 Fed. Reg. 2,317 (1992). Marginal employment shall not be considered substantially gainful employment. 38 C.F.R. § 4.16 (a). In Ray v. Wilkie, 31 Vet. App. 58 (2019) the Court clarified that substantially gainful employment contains economic and noneconomic components. The Court provided guidance as to the meaning of a veteran’s ability to “secure and follow” such employment, noting that attention must be given to: the veteran’s occupational history, education, skill and training; whether the veteran has the physical ability to perform occupational activities; and whether the veteran has the mental ability to perform occupational activities. Id. at 73. A TDIU may be granted only when it is established that the service-connected disabilities are so severe, standing alone, as to prevent the retaining or obtaining of substantially gainful employment. If there is only one service-connected disability, it must be ratable at 60 percent or more to qualify for benefits based on individual unemployability. If there are two or more such disabilities, there must 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). For the period prior to May 11, 2017, the Veteran was service connected for the following disabilities: favorable ankylosis, left hip, rated 10 percent from September 28, 2010; PTSD and migraines, both rated 30 percent from July 16, 2012; left leg peripheral neuropathy, rated 20 percent from July 16, 2012; right shoulder tendonitis, tinnitus, and GERD, all rated 10 percent from September 28, 2010; lumbar spine and hypertension, both rated 10 percent from July 16, 2012; left hand strain, right hand strain, eustachian tube dysfunction, allergic rhinitis, erectile dysfunction, right testicular epididymitis, and tinea pedis, all rated as noncompensable. Although the Veteran had a combined rating of 80 percent from July 16, 2012, he did not have one disability ratable at 40 percent or more. The Board notes, however, that the Veteran has been granted a 50 percent rating for PTSD, effective June 8, 2015, in the decision herein. Therefore, the Veteran meets the schedular requirement for a TDIU, pursuant to 38 C.F.R. § 4.16 (a), as of June 8, 2015. However, for the period prior to June 8, 2015, the rating criteria for consideration of a TDIU under 38 C.F.R. § 4.16 (a) are not met since the Veteran does not have one disability ratable at 40 percent or more. Nevertheless, the law provides that where these percentage requirements are not met, entitlement to a total rating based on individual unemployability on an extraschedular basis may be considered when the claimant is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. See 38 C.F.R. § 4.16 (b). Since, the Board cannot decide extraschedular TDIU claims in the first instance, the Board must specifically adjudicate whether to refer the case for consideration of extraschedular TDIU. 38 C.F.R. § 4.16(b). Having reviewed the complete record, the Board concludes that the preponderance of the evidence is against referring the Veteran’s claim for a TDIU on an extraschedular basis for the period prior to June 8, 2015. At the outset, the Board notes that the Veteran has not asserted, nor is there evidence that the Veteran’s service-connected right shoulder, tinnitus, GERD, hypertension, bilateral hand strain, eustachian tube dysfunction, allergic rhinitis, erectile dysfunction, right testicular epididymitis, tinea pedis, or migraines impact the Veteran’s ability to work. Thus, the Board will not address these disabilities any further. However, at his October 2018 hearing, the Veteran reported that he has not worked in six years due to his mental health condition. In his June 2019 mental disorders examination, he attributed his inability to work to his left hip and mental disabilities. Prior to June 8, 2015, the record shows that the Veteran’s remaining service-connected disabilities, to include lumbar spine, left leg neuropathy, psychiatric disorder, and his left hip disability did not preclude the Veteran from obtaining or maintaining gainful employment. As noted above, his diagnosed anxiety was characterized as no more than mild in his October 2012 mental disorders examination. In fact, the examiner found that his symptoms were not severe enough to interfere with occupational and social functioning or to require continuous medication. Consistent with this finding is the Veteran’s own statement where he reported that his unemployment was due to being overqualified, underqualified, or simply that the position had been filled. Moreover, in a September 2013 mental health visit, he reported being unemployed but noted that he was currently going to school for a Health Program Management Associate degree. However, there is no evidence that his disabilities impacted his ability to attend school as his June 2019 mental disorders examination revealed that the Veteran obtained his Associate degree. In addition, the Veteran’s left leg neuropathy was characterized as mild in severity in his October 2012 VA examination and no more than moderate throughout the appeal period, and the examiner noted the condition did not impact his ability to work as his symptoms were sensory only with no motor involvement. Likewise, the examiner found that his left hip and lumbar spine disabilities caused mild functional limitations and that they did not impact his ability to work. Further, a January 2013 primary care visit showed no paresthesias, edema, or joint problems; and, a May 2013 primary care note indicated the Veteran had a stable gait, although he reported toe numbness and slight persistent numbness when walking. Given the above, the Board finds that the Veteran’s service-connected disabilities did not preclude the Veteran from obtaining or maintaining substantial gainful employment for the period prior to June 8, 2015. Moreover, the Veteran’s limitations due to his service-connected disabilities are considered in the 80 percent combined disability rating he was receiving at that time. Indeed, the assignment of the 80 percent schedular rating is recognition of the functional limitations caused by his disabilities and that rating contemplates the severity and overall impact the symptoms have on the Veteran’s life. As such, the evidence does not persuasively support a finding that the Veteran is unable to obtain and maintain substantially gainful employment due to his service-connected disabilities. See 38 C.F.R. §4.19. Thus, the Board finds that referral for extraschedular consideration is not warranted. For the period beginning June 8, 2015, the Board finds that a TDIU is warranted. As explained above, the June 2020 examiner determined that the Veteran’s anxiety disorder progressed to include a diagnosis of PTSD. The examiner specifically found symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The Veteran was awarded an increased rating to 50 percent disabling, and an award of TDIU based on these findings. However, the Board found evidence that suggested the Veteran’s PTSD symptoms worsened as early as June 8, 2015. Therefore, the Board resolves all doubt in favor of the Veteran and concludes a TDIU is warranted as of June 8, 2015. GAYLE STROMMEN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Laffitte, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.