Citation Nr: 21008912 Decision Date: 02/18/21 Archive Date: 02/18/21 DOCKET NO. 15-13 838 DATE: February 18, 2021 ORDER A compensable rating for right inguinal hernia is denied. From September 18, 2013, a separate rating of 10 percent for a surgical scar of the right inguinal hernia is granted. Prior to September 18, 2013, an initial compensable rating for scars, status post lipoma excision, right side of the neck, right flank and left arm is denied. From September 18, 2013, a rating of 20 percent, but not higher, for scars, status post lipoma excision, right side of the neck, right flank and left arm is granted. An extraschedular rating for scars, status post lipoma excision, right side of the neck, right flank and left arm is denied. A total disability rating based on individual unemployability (TDIU) is denied.   FINDINGS OF FACT 1. The Veteran’s right inguinal hernia is not recurrent, readily reducible, or well-supported by a truss or belt. 2. The Veteran underwent an August 2010 repair of a right inguinal hernia; he has a scar approximately 5 cm x 1 cm which has been shown to be painful from September 18, 2013. 3. Prior to September 18, 2013, the Veteran’s scars on the right side of the neck, right flank and left arm were not painful. 4. From September 18, 2013, the Veteran’s scars on the right side of the neck, right flank and left arm were productive of pain. 5. The Veteran’s scars on the right side of the neck, right flank and left arm do not present such an exceptional disability picture that it renders the rating schedule inadequate. 6. The Veteran’s service-connected disabilities have not precluded substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for a compensable rating for right inguinal hernia have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.114, Diagnostic Code (DC) 7338. 2. From September 18, 2013, the criteria for a separate 10 percent disability rating for a surgical scar of the right inguinal hernia have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.118, DC 7804. 3. Prior to September 18, 2013, the criteria a compensable rating for scars, status post lipoma excision, right side of the neck, right flank and left arm have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.118, DC 7804. 4. From September 18, 2013, the criteria for a 20 percent rating, but not higher, for scars, status post lipoma excision, right side of the neck, right flank and left arm have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.118, DC 7804. 5. The criteria for an extraschedular rating for scars, status post lipoma excision, right side of the neck, right flank and left arm have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.118, DC 7804. 6. The criteria for a TDIU have not 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 served on active duty from June 1974 to August 1994. The case is on appeal from a November 2012 rating decision. In October 2018, the Veteran testified at a Board hearing. In May 2019, the Board remanded the case for further development. The Board notes additional evidence was submitted following the October 2020 supplemental statement of the case (SSOC), including private and VA medical records. The Board finds these records are not pertinent to the issues being decided herein. Therefore, remand for initial agency of original jurisdiction (AOJ) review is not required. See 38 C.F.R. §§ 19.37(a), 20.1305(c). The November 2012 rating decision granted service connection for scars on the right side of the neck, right flank and left arm, and assigned a noncompensable rating. While the case was in remand status, in an August 2019 rating decision, the RO increased the rating to 20 percent effective October 23, 2018. The increased rating matter remains in appellate status as the maximum scar ratings have not been assigned for the entire period on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The Board notes that in July 2020, the Veteran filed a request for higher level review for the claims for increased ratings for right inguinal hernia with scar and scars, status post lipoma excision, right side of the neck, right flank and left arm. However, this was not a proper opt-in from the Legacy appeal system to the Appeals Modernization Act (AMA) appeal system. Therefore, these two claims remain in the Legacy appeal system. See 38 C.F.R. § 19.2(d). The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran, his spouse, his representative and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Increased Rating General Legal Criteria Ratings are based on a schedule of reductions in earning capacity from specific injuries or combination of injuries. The ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civil occupations. 38 U.S.C. § 1155. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Staged ratings must be considered, which are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods during the appeal. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). 1. A compensable rating for right inguinal hernia. 2. A separate compensable rating for a surgical scar of the right inguinal hernia. Specific Legal Criteria DC 7338 provides ratings for inguinal hernia. A small inguinal hernia, reducible, or without true hernia protrusion, is rated noncompensably disabling. An inguinal hernia that is not operated on, but is remediable, is rated noncompensably disabling. A postoperative recurrent inguinal hernia, readily reducible, well supported by truss or belt, is rated 10 percent disabling. A small inguinal hernia, postoperative recurrent, or unoperated irremediable, not well supported by truss, or not readily reducible, is rated 30 percent disabling. A large inguinal hernia, postoperative recurrent, not well supported under ordinary conditions and not readily reducible, when considered inoperable, is rated 60 percent disabling. A Note to DC 7338 provides that 10 percent is to be added for bilateral involvement, provided the second hernia is compensable. This means that the more severely disabling hernia is to be rated, and 10 percent, only, added for the second hernia, if the second hernia is of compensable degree. 38 C.F.R. § 4.114. Regarding the Veteran’s right inguinal hernia, a separate compensable rating is available based on the Veteran’s surgical scar. Under DC 7804, a 10 percent rating is warranted for one or two scars that are unstable or painful. 38 C.F.R. § 4.118, DC 7804. Three or four scars that are unstable or painful scars warrants a 20 percent rating. F ive or more scars that are unstable or painful warrants a 30 percent rating. 38 C.F.R. § 4.118. Note 1 to DC 7804 instructs that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar.   Analysis The Veteran contends that an increased rating is warranted for his service-connected right inguinal hernia. As noted, the Veteran underwent a right inguinal hernia repair in August 2010. Following the August 2010 surgery and claim, the Veteran was afforded an October 2010 VA examination. The examiner indicated the examination revealed no inguinal hernia present. He stated there were no striae on the abdominal wall, no distension of superficial veins, no ostomy, tenderness or palpable mass, as well as no splenomegaly, ascites, liver enlargement or aortic aneurysm. With regard to the surgical scar, the examiner reported there is a scar located over the right inguinal area secondary to herniorrhaphy which is approximately 7 cm x 0.3 cm. He stated this scar is not painful. A November 2010 statement was submitted from the Veteran’s spouse which indicated he was having more pain in the right inguinal area after the surgery than prior. She noted he would suddenly move to relieve the excruciating pain which impacted his driving, standing and lifting. The Veteran was afforded a July 2012 VA examination in which the examiner indicated there was no inguinal hernia detected on examination. The examiner noted the presence of the right hernia scar, but found it was not painful or unstable. Following the November 2012 rating decision, the Veteran submitted a September 2013 notice of disagreement (NOD). He stated since his hernia surgery he has had chronic inguinal, abdominal (intestine) pain. He indicated the pain was worse than prior to the surgery. The Veteran submitted an April 2015 substantive appeal in which he indicated the scar from his hernia repair causes pain which is ongoing. The Veteran was afforded an October 2018 Board hearing in which he testified that he experiences pain in the inguinal hernia area. He stated even after his scar healed, following the surgery, the pain continued. The claim was remanded by the Board in May 2019 for further development, including a VA examination to determine the severity of the hernia disorder. The Veteran was afforded an August 2019 VA examination in which the examiner determined there was no hernia detected. He reported there is also no indication for a supporting belt. The examiner indicated the Veteran’s hernia scar is approximately 5 cm x 1 cm but is not painful or unstable. He further stated there is slight tenderness on the skin in the area of the scar, most likely attributed to the Veteran’s lowered pain threshold from his fibromyalgia. The Veteran was afforded an additional October 2020 VA examination in which the examiner indicated no hernia was detected with no indication for support, such as a supporting belt. The Board determines a compensable rating is not warranted for the Veteran’s right inguinal hernia. The evidence supports that he has been appropriately compensated for his right inguinal hernia and there is insufficient evidence that the hernia has recurred or requires support by a truss or belt. However, separately from the prior hernia itself, the Board determines a separate 10 percent rating is warranted under DC 7804 for the right inguinal hernia surgical scar which has been reported as causing pain from September 18, 2013. With regard to the hernia claim, the medical evidence throughout the appeal period supports that the right inguinal hernia has not recurred. Moreover, the October 2010, July 2012, August 2019 and October 2020 VA examination reports all indicated that the hernia was not present, did not require support such as a belt and no other symptoms were present. The Board acknowledges that the Veteran has reported experiencing pain and other symptoms in the area of his hernia surgery. However, the Board determines such symptoms were related to other disorders, including the hernia scar addressed herein, and were not associated with the right inguinal hernia for which he underwent repair surgery. With regard to the hernia surgical scar, the Board finds that the evidence is at least in equipoise regarding whether a separate compensable rating for the scar is warranted. The October 2010 and July 2012 VA examiners determined the scar was present but was not painful or unstable. However, in the September 2013 NOD, the Veteran reported experiencing pain. Further, in the April 2015 substantive appeal, the Veteran indicated the scar causes pain, and that the pain is consistent and ongoing. While there is medical evidence which conflicts with the Veteran’s reports of a painful surgical scar in the right hernia area, the Board notes that “objective” medical evidence is not categorically necessary to award this benefit. See English v. Wilkie, 30 Vet. App. 347 (2018). The Board finds the Veteran’s “subjective” lay statements reporting hernia scar pain are consistent since the September 2013 NOD, which is when a factually ascertainable increase occurred. Thus, the Board finds a compensable rating is not warranted for the right inguinal hernia. However, when resolving reasonable doubt in the Veteran’s favor, the Board finds that from September 18, 2013, his right inguinal hernia surgical scar is painful. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Accordingly, a separate 10 percent rating is warranted for the right inguinal hernia scar from September 18, 2013, under DC 7804. 3. An initial compensable rating for scars, status post lipoma excision, right side of the neck, right flank and left arm, prior to Prior to October 22, 2018; and in excess of 20 percent thereafter. Specific Legal Criteria Under DC 7804, a 10 percent rating is warranted for one or two scars that are unstable or painful. 38 C.F.R. § 4.118, DC 7804. Three or four scars that are unstable or painful scars warrants a 20 percent rating. Five or more scars that are unstable or painful warrants a 30 percent rating. 38 C.F.R. § 4.118. Note 1 to DC 7804 instructs that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note 2 states if one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Note 3 states scars evaluated under DCs 7800, 7801, 7802, or 7805 may also receive an evaluation under this DC, when applicable. Analysis Procedurally, the November 2012 rating decision granted service connection for scars on the right side of the neck, right flank and left arm, and assigned a noncompensable rating from August 16, 2010. As noted above, the August 2019 rating decision increased the rating to 20 percent effective October 23, 2018, due to the presence of 3 painful scars. Thus, the Board will review the evidence to determine if an increased rating is warranted, to include determining whether an earlier effective date is supported for the 20 percent rating. 38 C.F.R. § 4.118, DC 7804. The October 2010 VA examiner indicated the Veteran has a scar on the neck which is 2 cm x 0.2 cm and is not painful on examination. He noted the scar is superficial with no underlying tissue damage. The two scars on the Veteran’s left arm and right flank were not addressed by the examiner. The Veteran underwent a July 2012 VA examination in which the examiner indicated the Veteran has scars on the neck, left arm and flank. The examiner found that none of the three scars were painful or unstable on examination. Thereafter, the Veteran submitted the September 2013 NOD in which he stated he had 3 lipomas removed in the areas addressed, and these lipomas are painful and sensitive to the touch. The April 2015 substantive appeal indicated an increased rating for his scars is warranted due to the pain he experiences in these areas. He stated the pain from his neck scar radiates down to his right shoulder and arm, the scar on his right flank is painful and affects his lower torso and the left arm scar causes pain, as well as tingling and numbness. He reported that the pain related to these three scars has worsened and become constant. The claim was remanded by the Board in May 2019 for a VA examination and the Veteran was afforded an August 2019 VA examination. The Veteran reported a lot of pain in the areas surrounding the three noted scars, along with being tender. The examiner opined that all three scars are painful. The examiner noted the pain associated with the scars is out of proportion to the physical examination and that the Veteran’s decreased pain threshold is due to his fibromyalgia. The Veteran was also afforded an October 2020 VA examination in which the examiner opined the Veteran’s scars on the right flank, neck and left arm are painful. The Board finds that the Veteran’s three scars of the neck, right flank and left arm were painful from the September 2013 NOD. As such, an increased rating to 20 percent under DC 7804 is warranted from September 18, 2013, but not earlier. The October 2010 and July 2012 VA examination reports indicated the Veteran’s scars were not painful. Thereafter, the September 2013 NOD reported pain in the scars which was confirmed in the April 2015 substantive appeal. The RO found that the 20 percent rating for the three painful scars was effective October 23, 2018. However, the Board determines when affording the Veteran reasonable doubt, that the 20 percent rating should be effective from September 18, 2013, as this is the earliest date a factually ascertainable increase occurred. See Swain v. McDonald, 27 Vet. App. 219, 224 (2015). While an increased rating to 20 percent is effective from September 18, 2013, the Board finds a further increased rating is not supported. As noted, a 20 percent rating is warranted under DC 7804 for three or four scars that are unstable or painful. The Board has considered other DCs pertaining to scars. However, a higher or separate rating for the scars addressed herein is not warranted under any other DC for evaluating scars as the type of symptoms required (such as area covered or to the head, face, or neck) are not shown. Lastly, the Board notes that the rating criteria for evaluating the skin was amended effective August 13, 2018. The Board finds the changes are not applicable to the Veteran’s case as DC 7804 remained unchanged. In sum, the Board finds that an increased rating to 20 percent, but not higher, is warranted for the scars of the right side of the neck, right flank and left arm, from September 18, 2013. However, the preponderance of the evidence is against an initial increased rating prior to September 18, 2013, or further increased rating from that awarded. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3.   4. An extraschedular rating for scars, status post lipoma excision, right side of the neck, right flank and left arm. Specific Legal Criteria The Court has held that there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. Thun v. Peake, 22 Vet. App. 111 (2008), aff’d sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first element requires the Board to determine whether the “evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate.” Id. This requires the Board to compare a veteran’s specific symptoms and their severity with those contemplated by the rating schedule. King v. Shulkin, 29 Vet. App. 174, 178-79 (2017). If the Board determines that a veteran’s symptoms or their severity is not contemplated by the rating schedule, the second element requires the Board to “determine whether the claimant’s exceptional disability picture exhibits other related factors,” such as marked interference with employment or frequent periods of hospitalization. Thun, 22 Vet. App. at 116. Finally, if the first two elements are met, the final element mandates that the Board refer the claim to the Director of Compensation Service for a determination about whether an extraschedular rating is warranted. Id.; see also 38 C.F.R. § 3.321(b). The Court has also stated that a manageable judicial standard does not require absolute clarity and, in the case of an extraschedular rating, the standard is “average impairment in earning capacity.” See Kuppamala v. McDonald, 27 Vet. App. 447, 454 (2015). Facts The Veteran is seeking an extraschedular rating for his service-connected scars, status post lipoma excision, of the right side of the neck, right flank and left arm. At the October 2018 Board hearing, the Veteran’s representative asserted “special schedular consideration” is needed under DC 7800 due to the impact the Veteran’s scars have on his activities of daily living. Therefore, the issue of whether an extraschedular rating is warranted has been expressly raised and will be addressed. The evidence related to the Veteran’s service-connected scars of the neck, right flank and left arm has been largely addressed above. The October 2010 VA examiner indicated the Veteran’s scars are not painful and are superficial with no underlying tissue damage. The July 2012 VA examiner stated the Veteran’s scars are also not painful or unstable on examination. In the September 2013 NOD, the Veteran stated he had 3 lipomas removed in the areas noted, and these lipomas are painful and sensitive to the touch. The April 2015 substantive appeal indicated an increased rating for his scars is warranted due to the pain he experiences in these scars. He further stated the pain from his neck scar radiates down to his right shoulder and arm, the scar on his right flank is painful and affects his lower torso and the left arm scar causes pain, as well as tingling and numbness. He reported that the pain related to these three scars has worsened and become constant. He indicated the neck scar causes pain that ranges to a 5-8 out of 10. He stated the pain related to the left arm scar impacts his hand, causing weakness, tingling and numbness. The Veteran stated he has many additional lipomas that have not been removed and are too numerous to count. As noted, at the October 2018 Board hearing, the Veteran’s representative asserted “special schedular consideration” is needed under DC 7800 due to the impact the Veteran’s scars have on his activities of daily living. The Veteran noted the pain is “consuming” and there are activities of daily living the Veteran can no longer perform. He stated there are lipomas (not the scars from the removal of such) that are painful and very sensitive to the touch, making it difficult to perform normal activities. The Veteran reported he has trouble raising his arm, holding objects and sleeping due to his current lipomas. Following the May 2019 Board remand, as addressed above, the August 2019 VA examiner indicated the Veteran’s three scars are painful. Similarly, the October 2020 VA examiner found the scars to be painful. Analysis The Board determines that the Veteran’s rating for scars, including the increase awarded in the present decision, does not present such an exceptional disability picture that it renders the rating schedule inadequate against a higher rating on an extraschedular basis. As such, the Board finds that the first Thun element is not satisfied for the claimed disability, as the Veteran’s scars of the neck, right flank and left arm and the severity caused by such scars are contemplated by the rating criteria. In this regard the Board notes the Court has found that a DC need not list every word or type of symptom to contemplate the functional loss associated with such disability. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). The Court has recently addressed the standard for extraschedular claims in Long v. Wilkie, No. 16-1537 (U.S. Vet. App. Dec. 30, 2020). Focusing on Thun’s first step, the Court in Long explained that because an extraschedular determination is, by nature, fact bound and highly contextual, it should be approached as a totality of the factors inquiry that considers whether the veteran’s symptomatology presents an impairment so exceptional that the rating schedule is not capable of assessing it in the first instance. Thus, the first step in Thun is not met simply because the symptoms of the disability are not considered in the rating criteria for that disability; rather, it is met when the impairment cannot be evaluated by the rating schedule. To facilitate proper analysis of Thun’s first step, the Court in Long provided six non-exhaustive or mandatory guiding principles. First, the sole focus of Thun’s first step is on the ability of the rating schedule to evaluate the veteran’s symptomatology; extraschedular consideration is not applicable to claims that may be properly evaluated with conventional schedular rating tools. See Morgan v. Wilkie, 31 Vet. App. 162, 168 (2019). Second, Thun’s first step deals exclusively with whether the veteran’s symptoms are exceptional, whereas Thun’s second step considers the functional effects of those symptoms. See Yancy v. McDonald, 27 Vet. App. 484, 494 (2016). Third, where a symptom or impairment is not compensable under the rating schedule, it also does not warrant extraschedular consideration as this would amount to a backdoor means to obtaining compensation for a condition the rating schedule intends to exclude. Fourth, extraschedular consideration is not warranted for symptoms or effects that lack a nexus to service or to a service-connected disability. Fifth, the Board is only required to discuss the theories of entitlement raised by the veteran or reasonably raised by the record. Sixth, in reviewing the Board’s analysis of referral for extraschedular consideration, the CAVC will be mindful of the rule against prejudicial error. Thus, a failure of the Board to discuss whether extraschedular consideration is warranted for a particular symptom does not require an automatic remand. In looking to the Veteran’s case, the Board finds the rating schedule is adequate to evaluate the Veteran’s scars of the neck, right flank and left arm. The Veteran has reported pain and sensitivity in the areas of the three scars, and as such, he has been afforded a 20 percent rating under DC 7804, from September 18, 2013. Additionally, the Veteran reported symptoms of radiating pain from his neck scar down to his right shoulder and arm and left arm pain, tingling and numbness. He indicated he has lipomas that are painful, and which make it difficult to perform normal activities, such as raising his arm, holding objects and sleeping. The Board acknowledges the Veteran’s symptoms; however, his scar symptoms of pain and tenderness have been properly compensated under DC 7804. The other reported symptoms are related to the Veteran’s current lipomas, not the scars which resulted from the removal of three of the lipomas on the Veteran’s neck, right flank and left arm. The Board finds there are no reported symptoms related to the service-connected scars which cannot be properly evaluated by the rating schedule. As the symptoms related to the scars do not present an exceptional disability picture, extraschedular consideration is not warranted. In sum, the preponderance of the evidence shows that the Veteran’s scars, status post lipoma excision, of the right side of the neck, right flank and left arm do not present such an exceptional disability picture that it renders the rating schedule inadequate. See 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 115. Thus, the benefit-of-the-doubt doctrine is not applicable and an extraschedular rating for scars of the right side of the neck, right flank and left arm is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 5.   6. A TDIU. Specific Legal Criteria Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when a veteran 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, such disability shall be ratable as 60 percent or more, and if there are two or more 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). Marginal employment shall not be considered substantially gainful employment. In addition, it is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. Therefore, rating boards should submit to the Director for extra-schedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in paragraph (a) of this section. The rating board will include a full statement as to the veteran’s service-connected disabilities, employment history, educational and vocational attainment and all other factors having a bearing on the issue. 38 C.F.R. § 4.16(b). The Board is required to obtain the Director’s decision in the first instance before it may award extraschedular TDIU. Wages v. McDonald, 27 Vet. App. 233, 236 (2015). In determining whether a veteran can secure and follow a substantially gainful occupation, attention must be given to: The veteran’s history, education, skill, and training; Whether the veteran has the physical ability (both exertional and nonexertional) to perform the type of activities (e.g., sedentary, light, medium, heavy, or very heavy) required by the occupation at issue. Factors that may be relevant include, but are not limited to, the veteran’s limitations, if any, concerning lifting, bending, sitting, standing, walking, climbing, grasping, typing, and reaching, as well as auditory and visual limitations; and Whether the veteran has the mental ability to perform the activities required by the occupation at issue. Factors that may be relevant include, but are not limited to, the veteran’s limitations, if any, concerning memory, concentration, ability to adapt to change, handle workplace stress, get along with coworkers, and demonstrate reliability and productivity. Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). For purposes of this decision, the Board uses the term “sedentary” to have the common meaning of a non-physical job, primarily involving sitting and usually performed in an indoor, office-type environment. See Withers v. Wilkie, 30 Vet. App. 139, 147-48 (2018). Facts The Veteran contends that he is unable to work due to his service-connected disabilities. In a July 2019 TDIU application, he reported the date he last worked full-time and the date he became too disabled to work was in October 2014. However, the Board notes he reported his full-time employment history was through October 31, 2015. He indicated his employment included as a work/life specialist, realty specialist, team leader and program manager. He indicated he is a college graduate and has additional education and training, which includes risk management and environmental issues in real estate practice. In his September 2013 NOD, the Veteran stated his hernia disorder causes chronic inguinal and abdominal (intestine) pain. He stated his fibromyalgia has worsened and he cannot take prescription medication due to the adverse side effects. He reported experiencing irritable bowel syndrome due to his fibromyalgia, stomach bloating and heartburn. He noted he had to miss 45 to 60 days in the prior year due to his disabilities. In the Veteran’s April 2015 substantive appeal, he indicated the scar from his hernia repair causes pain. He also stated the lipomas which are all over his body are painful and sensitive to the touch. He indicated these lipomas are associated with his fibromyalgia and are more painful when enflamed. During the Veteran’s October 2018 hearing, he indicated he stopped working due to his fibromyalgia. He stated he was placed “on telework,” but even then, it is hard to work while sitting. As noted, he testified his service-connected scars impact his activities of daily living. Private medical evidence was submitted from Dr. T.F. which supports the Veteran’s claim for a TDIU. She provides treatment to the Veteran for his fibromyalgia. A February 2015 medical opinion indicated the Veteran’s fibromyalgia causes deep muscle pain and soreness, morning stiffness, constant radiating pain to both upper and lower extremities, sensitivity to the touch, problems sleeping, fatigue, difficulty thinking clearly and difficulty performing everyday tasks. The examiner stated the Veteran requires medication (Tramadol) every four hours. Dr. T.F. submitted a May 2015 opinion which opined the Veteran is no longer able to perform his job as a Space Utilization and Consolidation Program Manager. She indicated based on the severity of the Veteran’s symptoms and his required daily medication he is no longer able to perform the duties required for this position. She noted his fibromyalgia impacts his focus, judgment, orientation, physical mobility and the ability to have the sustained cognitive focus and concentration required for such a job. The examiner indicated the Veteran can no longer work as a Program Manager or in any form of employment based on his disability. She further stated the Veteran’s disorder is expected to be a permanent and progressively deteriorating medical condition. In a statement received in July 2019, a former colleague of the Veteran indicated he had become dysfunctional in his job based on the physical limitations specified by Dr. T.F., and was placed in a leave without pay status resulting in the space management program being reassigned until he was physically able to perform his duties. He stated since the Veteran began teleworking, he lost weight, walked with a cane and experienced increased pressure. Following the Board’s May 2019 Board remand, the Veteran was afforded an August 2019 VA examination related to his scars on the right side of the neck, right flank and left arm. The examiner indicated the service-connected disability causes no functional impact on the Veteran’s ability to work. For the service-connected hernia, the examiner also reported no impact on his ability to work. In an August 2019 VA examination for the Veteran’s fibromyalgia, the examiner noted symptoms of widespread musculoskeletal pain, stiffness, muscle weakness, fatigue, sleep disturbance, paresthesias and headache. However, she found the Veteran’s fibromyalgia has no impact on his ability to work. In an August 2020 VA hearing loss examination, the examiner found the Veteran’s hearing loss causes him to miss things that people say, particularly when he is not face-to-face. The Veteran also reported his tinnitus can be loud at night. In an October 2020 VA examination, the examiner indicated the Veteran’s fibromyalgia impacts his ability to work, including that he requires daily support. The examiner opined the Veteran cannot lift more than 15 pounds due to his fibromyalgia and has difficulty even performing daily chores at home, such as with ambulation, cleaning and cooking. With regard to the Veteran’s hernia and scars, the examiner indicated there is no functional impact on the Veteran’s ability to work. Analysis After a careful review of the evidence, the Board finds that the Veteran is not prevented from all substantially gainful employment due to his service-connected disabilities. In this regard there is no doubt the Veteran’s fibromyalgia, hernia, scars, hearing loss and tinnitus impact his ability to work. However, the Board determines he is not prevented from all substantially gainful employment due to his service-connected disabilities. The Board notes the Veteran’s fibromyalgia impairs his ability to work in positions requiring manual labor. Moreover, the disability causes limitations with lifting, walking, or standing for long periods of time due to symptoms of pain, stiffness, muscle weakness, fatigue, sleep disturbance, burning and headache. However, the evidence supports the Veteran is not prevented from working in sedentary occupations due to his fibromyalgia. Sedentary work based on its commonly understood societal meaning is work requiring little physical exertion, such as working in an administrative capacity in an office or call center. The Veteran has a college degree and reported in the July 2019 TDIU application that he has additional training, including “Risk Management, Version 2.1; Online Course with Exam Environmental Issues in your Real Estate Practice.” Additionally, he reported previously working at Andrews Air Force Base as a work/life specialist, realty specialist, team leader and program manager. These occupations are primarily sedentary or non-physical jobs, performed in an indoor, office-type environment. The Board acknowledges that Dr. T.F. opined in May 2015 that the Veteran was no longer able to perform his job as a Space Utilization and Consolidation Program Manager. She indicated the Veteran’s fibromyalgia symptoms cause impaired focus, judgment, physical mobility, cognitive focus and concentration. While the May 2015 opinion suggests the Veteran could no longer work as a Program Manager, the examiner did not adequately discuss why the Veteran was incapable of performing any substantially gainful employment. The Board finds the medical evidence of record does not support that the Veteran is prevented from performing sedentary employment due to his service-connected fibromyalgia. Moreover, in the October 2020 VA opinion, the examiner found the Veteran’s fibromyalgia limits his lifting to 15 pounds, and causes difficulty performing chores, such as ambulation, cleaning and cooking. This opinion also does not suggest the Veteran is prevented from all employment, including sedentary employment, due to his service-connected fibromyalgia. The Board is sympathetic to the Veteran’s assertions regarding the impact his service-connected disabilities have on him, both professionally and personally. However, the limitations caused by the service-connected disabilities are compensated by the schedular ratings for such disabilities, including the increases awarded herein. Van Hoose v. Brown, 4 Vet. App. 361 (1993). Moreover, while the Veteran’s disabilities cause some economic impairment, his assigned disability ratings contemplate the level of occupational impairment for the service-connected conditions. The Board notes TDIU is not a purely medical question. Here, the Board has considered both the relevant medical evidence, as well as the non-medical evidence, such as work history and education level. As addressed above, the Veteran is a college graduate with additional training and his jobs were primarily sedentary or non-physical occupations performed in an office-type environment. In sum, the preponderance of the evidence shows that the Veteran has not been prevented from securing and following substantially gainful employment as a result of his service-connected disabilities, including his fibromyalgia. Therefore, the benefit-of-the-doubt rule is not applicable, and a TDIU is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. RYAN T. KESSEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Isaacs, 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.