Citation Nr: 21010249 Decision Date: 02/24/21 Archive Date: 02/24/21 DOCKET NO. 17-05 187 DATE: February 24, 2021 ORDER Entitlement to an increased evaluation for fibromyalgia, higher than 10 percent prior to December 19, 2019, and higher than 40 percent thereafter is denied. Entitlement to an increased evaluation for chronic constipation, higher than 10 percent prior to December 19, 2019, and higher than 30 percent thereafter is denied. Entitlement to service connection for hypothyroidism is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) is denied. FINDINGS OF FACT 1. For the period prior to December 19, 2019, the Veteran’s fibromyalgia more nearly approximated fibromyalgia with symptoms that require continuous medication for control. 2. For the period beginning December 19, 2019, the Veteran’s fibromyalgia most nearly approximated musculoskeletal pain and tender points, with associated fatigue, and other associated symptoms that are constant, or nearly so, and refractory to therapy; furthermore, the Veteran is in receipt of a 40 percent rating, the schedular maximum under Diagnostic Code 5025 and factors warranting extraschedular consideration are neither alleged nor shown by the record. 3. Prior to December 19, 2019, the Veteran’s chronic constipation manifested by frequent episodes of bowel disturbance with abdominal distress. 4. From December 19, 2019, the Veteran’s chronic constipation manifested by with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress, but not of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 5. The preponderance of the evidence is against findings that het Veteran has hypothyroidism due to an event, injury or disease in service. 6. It is not reasonably shown that the Veteran’s service-connected disabilities preclude her from securing or following a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for entitlement to an increased evaluation for fibromyalgia, higher than 10 percent prior to December 19, 2019, and higher than 40 percent thereafter, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.21, 4.71a, Diagnostic Code 5025. 2. The criteria for entitlement to an increased evaluation for chronic constipation, higher than 10 percent prior to December 19, 2019, and higher than 30 percent, thereafter, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.7, 4.114, Diagnostic Code (DC) 7319. 3. The criteria for service connection for hypothyroidism are not met. 38 U.S.C. § 1131; 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.307, 3.309, 3.310. 4. The criteria for entitlement to TDIU, have not been met. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served on active duty from November 1990 to May 1991, and from January 2004 to March 2005. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). Increased Rating 1. Entitlement to an increased evaluation for fibromyalgia, higher than 10 percent prior to December 19, 2019, and higher than 40 percent thereafter The Veteran is currently assigned a 10 percent evaluation prior to December 19, 2019, and a 40 percent rating thereafter under 38 C.F.R. § 4.71a, Diagnostic Code 5025 for fibromyalgia. Fibromyalgia refers to widespread musculoskeletal pain and tender points, with or without associated fatigue, sleep disturbance, stiffness, paresthesias, headaches, irritable bowel syndrome, depression, anxiety, or Raynaud’s like symptoms. Widespread pain means pain in both the left and right sides of the body, that is both above and below the waist, and that affects both the axial skeleton (i.e., cervical spine, anterior chest, thoracic spine, or low back) and the extremities. 38 C.F.R. § 4.71a , Diagnostic Code 5025. Diagnostic Code 5025 provides that fibromyalgia (fibrositis, primary fibromyalgia syndrome) with widespread musculoskeletal pain and tender points, with or without associated fatigue, sleep disturbance, stiffness, paresthesias, headache, irritable bowel symptoms, depression, anxiety, or Raynaud’s-like symptoms, is to be rated 10 percent disabling if the symptoms require continuous medication for control; 20 percent disabling if the symptoms are episodic, with exacerbations often precipitated by environmental or emotional stress or by overexertion, but symptoms that are present more than one-third of the time; and 40 percent disabling if the symptoms are constant or nearly constant, and are refractory to therapy. A Note to Diagnostic Code 5025 provides that widespread pain means pain in both the left and right sides of the body, that is both above and below the waist, and that affects both the axial skeleton (i.e., cervical spine, anterior chest, thoracic spine, or low back) and the extremities. 38 C.F.R. § 4.71a , Diagnostic Code 5025. In July 2013, the Veteran underwent an examination. She was noted as having been diagnosed with polyarthralgia and rheumatoid arthritis (RA). In October 2013, the RO denied service connection for fibromyalgia and granted service connection for rheumatoid arthritis of the sacroiliac joints and bilateral wrists with a noncompensable evaluation. In a July 2016 statement from Dr. N. A., he reported the Veteran having had fibromyalgia since 2004. Dr. A. noted the Veteran to have her current fibromyalgia symptoms at their current level since at least 2011. Her representative submitted a statement in August 2016, explaining that she should be in receipt of a 40 percent evaluation for RA. The representative argued that the Veteran’s RA is productive of more than four exacerbations per year. The representative went on to argue that she should be awarded a separate evaluation for fibromyalgia. She submitted a RA DBQ dated August 2016, indicating her RA causes all over joint pain. In October 2016, she underwent a fibromyalgia examination. She reported diffuse body aches from her time during the first Gulf War. She was taking Embril and methotrexate with fair success. She had stiffness, fatigue, sleep disturbances, depression, anxiety, chronic muscle stiffness and pain, and poor sleep. She had all of the trigger points, indicating she has fibromyalgia. The examiner concluded it is impossible to separate the rheumatoid arthritis symptoms from the fibromyalgia symptoms. In October 2016, the RO granted an evaluation for fibromyalgia, with a notation that it was previously rated as rheumatoid arthritis of the sacroiliac joints and bilateral wrists, with a 10 percent evaluation, effective December 20, 2011. In December 2019, she underwent an examination. She was taking medication for her fibromyalgia as well as for her RA. Her symptoms include widespread musculoskeletal pain, stiffness, weakness, fatigue, sleep disturbance, paresthesias, headache, depression, and anxiety. A VA medical opinion was rendered in October 2020. The examiner stated some of the symptoms of the Veteran’s arthritis and fibromyalgia are distinguishable from each other. The anxiety, depression, and headaches are due to the fibromyalgia, and the noted joint stiffness, pain, and worsening in cold temperatures is indistinguishable between the two conditions. Prior to December 19, 2019 The Board finds that, for the period prior to December 19, 2019, an evaluation higher than 10 percent is not warranted. The Veteran’s reported symptoms for the period in question do not reflect that they were constant or nearly constant, but rather show symptoms of stiffness, fatigue, sleep disturbances, depression, anxiety, chronic muscle stiffness and pain, and poor sleep, but not more severe than symptoms requiring constant medication. There is no evidence that the Veteran’s fibromyalgia meets the criteria for a higher rating. As such, the Board finds that an increased rating is not warranted for the service-connected fibromyalgia for the period prior to December 19, 2019. From December 19, 2019 The Board notes that the Veteran’s claim for an increased rating for her fibromyalgia for the period beginning December 19, 2019, will be decided based on law and not the facts of this case. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). The Veteran’s service-connected fibromyalgia is currently assigned a 40 percent rating under 38 C.F.R. § 4.71a , Diagnostic Code 5025, effective December 19, 2019. She generally contends that a higher rating is warranted for her fibromyalgia but has provided no specific argument in support of his claim. Furthermore, as previously noted, the Veteran’s service-connected fibromyalgia has been assigned the maximum schedular rating available for such under 38 C.F.R. § 4.71a , Diagnostic Code 5025, effective December 19, 2019. As there is no legal basis upon which to award a higher schedular disability rating for fibromyalgia, her claim for a rating in excess of 40 percent on a schedular basis must be denied. The law, in particular the regulation governing schedular evaluation of fibromyalgia, is dispositive of the claim. As is for the assertion that the Veteran be awarded a separate evaluation for her rheumatoid arthritis, the October 2020 examiner indicated that the anxiety, depression, and headaches are due to the fibromyalgia, and the noted joint stiffness, pain, and worsening in cold temperatures is indistinguishable between the two conditions. The Board finds that the evidence of record does not establish any additional diagnoses beyond the already compensated fibromyalgia. Finally, the Veteran’s fibromyalgia is not shown (or alleged) to have manifestations or cause impairment not encompassed by the schedular criteria. The Veteran’s symptom reports are the basis for the 40 percent rating for fibromyalgia assigned. Therefore, the schedular criteria are not inadequate, and referral for extraschedular consideration is not necessary. In reaching its decision, the Board has also considered rating the Veteran’s rheumatoid arthritis separately, as she has relayed, she suffers from musculoskeletal pain. However, as is stated above, the examiner was unable to differentiate separate symptoms (other than her psychiatric symptoms and headaches) for her rheumatoid arthritis and fibromyalgia. The musculoskeletal pain has been considered in assigning the maximum schedular rating available for fibromyalgia. Therefore, application of a separate rating for the Veteran’s rheumatoid arthritis would constitute impermissible pyramiding. See 38 C.F.R. § 4.14 ; Brady v. Brown, 4 Vet. App. 203 (1993). Therefore, the preponderance of the evidence is against ratings in excess of 10 percent disabling prior to December 19, 2019, and in excess of 40 percent disabling thereafter for her service-connected fibromyalgia. 2. Entitlement to an increased evaluation for chronic constipation, higher than 10 percent prior to December 19, 2019, and higher than 30 percent thereafter The Veteran is in receipt of service connection for chronic constipation with a 10 percent prior to December 19, 2019, 30 percent thereafter under Diagnostic Code 7319. The Board notes that diseases of the digestive system, particularly within the abdomen, which, although differing in the site of pathology, produce a common disability picture characterized by varying degrees of abdominal distress or pain, anemia, and disturbances in nutrition. Consequently, certain coexisting diseases in this area, as indicated by the instructions under the title “Diseases of the Digestive System,” do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in 38 C.F.R. §§ 4.14, 4.113, 4.114. As such, ratings under Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive “will not be combined with each other.” The regulation specifically directs that a single rating will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher rating where the severity of the overall disability warrants elevation. See 38 C.F.R. § 4.114. Therefore, a single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. See 38 C.F.R. §§ 4.113, 4.114. The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various DCs is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). DC 7319 provides ratings for irritable colon syndrome (spastic colitis, mucous colitis, etc.). Mild irritable colon syndrome, with disturbances of bowel function with occasional episodes of abdominal distress, is rated noncompensable (0 percent) disabling. Moderate irritable colon syndrome, with frequent episodes of bowel disturbance with abdominal distress, is rated 10 percent disabling. Severe irritable colon syndrome, with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress, is rated 30 percent disabling. 38 C.F.R. § 4.114, DC 7319. The words “mild,” “moderate,” “moderately severe,” and “severe” as used in the various DCs are not defined in the VA Schedule for Rating Disabilities. 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. DC 7346 provides ratings for hiatal hernia. Hiatal hernia with two or more of the symptoms for the 30 percent rating of less severity is rated 10 percent disabling. Hiatal hernia with persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health, is rated 30 percent disabling. Hiatal hernia with symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health, is rated 60 percent disabling. 38 C.F.R. § 4.114. The Veteran initially filed a claim for a gastrointestinal disability. Effective December 2011, the RO granted service connection for chronic constipation. She then filed a claim to increase her evaluation for chronic constipation. In July 2013, the Veteran underwent an examination. She reported feeling constipated between three days to one week at a time. She reported a normal bowel habit of once per day and occasionally used docusate. She did not have episodes of bowel disturbance with abdominal distress, or exacerbations or attacks of the intestinal condition, nor did she have weight loss attributable to the gastrointestinal condition. In a July 2016 statement from Dr. N. A., he reported the Veteran having constipation lasting up to eight days, breakthrough heartburn two times a week related to GERD, diverticulosis, and gastroparesis. In an August 2016 statement, she reported having gastroparesis, chronic constipation, pelvic floor dysfunction, rectocele, diverticulosis, and IBS with constipation. In August 2016 statement, the Veteran’s attorney argued that the Veteran should be in receipt of a separate evaluation for each GI condition, namely idiopathic gastroparesis, IBS, pelvic floor dysfunction, dyspepsia, rectocele, GERD, and bloating. An MRI from Texas Tech revealed spastic pelvic floor syndrome, and the representative argued this is evidence that she has functional loss of use of the anal canal, secondary to constipation. Further, the representative argued, that her gastroparesis results in bloating, abdominal pain, and postprandial fullness. In August 2017, an IME was provided by Dr. P. S. She was diagnosed with functional gastroenterological disorders (FGID), which is a group of conditions characterized by chronic or recurrent symptoms unexplained by any structural endoscopic, laboratory or other signs of injury or disease and may be related to any part of the GI tract. She had a distinct and separate impairment of her lower esophageal sphincter, which slows the movement of nutrients and waste matter through the digestive tract. She had a distinct and separate impairment of her stomach, diagnosed as gastroparesis. She had bloating, pain, nausea, and early satiety. She had pelvic floor dysfunction, that is directly related to her motility dysfunction, as well as a rectocele. In December 2019, she underwent an examination, and was diagnosed with chronic constipation and diverticulosis, as well as gastroparesis. She reported heartburn, abdominal pain, nausea, regurgitation, vomiting, esophageal burning, bloating, chronic constipation, and vaginal bleeding with stool. She reported having a bowel movement once per week, and a rectocele. She was taking medication to treat her intestinal condition. She reported constant abdominal distention, nausea on a daily basis, vomiting once per month, and mushy and bloody stool once per week. She reported frequent episodes of bowel disturbance with abdominal distress. The examiner stated that the Veteran’s new diagnosis is gastroparesis and diverticulosis, is directly due to or related to the service-connected diagnosis. Diverticulosis occurs when small bulging patches develop in the digestive tract, and can cause mild cramps, bloating, or constipation. Gastroparesis is a disease in which the stomach cannot empty itself of food in a normal fashion, with symptoms of heartburn, nausea, vomiting, and feeling full quickly. In July 2020, the Board granted the Veteran service connection for gastroparesis and for diverticulosis. In an October 2020 decision, the RO implemented the Board’s grants, and awarded the Veteran a noncompensable evaluation for gastroparesis and diverticulosis, including these conditions under the same code as chronic constipation, 7319. With regard to assigning an increased rating under DC 7319, the Board finds that for the period prior to December 19, 2019, there is no evidence of record reflecting that the Veteran’s chronic constipation, resulted in severe irritable colon syndrome, with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. Prior to December 19, 2019, the evidence indicates that the Veteran had chronic constipation estimated three times per week, and reported bloating, pain, nausea, and early satiety, which was indicative of moderate symptoms. Her symptoms were frequent; however, she did not report constant distress, or alternating diarrhea and constipation. In light of the foregoing, the Board finds no medical evidence of record reflecting that the Veteran’s chronic constipation at any time prior to December 19, 2019, met the criteria for a 30 percent rating under DC 7319. As such, an increased rating is not warranted under this DC for the period prior to December 19, 2019. From December 19, 2019, her symptoms more approximated the criteria for a severe symptomatology, and warrant the 30 percent evaluation. Her symptoms were chronic constipation, diverticulosis, gastroparesis, heartburn, nausea, vomiting, burning and bloating. She reported one bowel movement a week. The Board has also considered whether another diagnostic code for disabilities of the digestive system would allow for a higher evaluation, mindful that DC 7301-7329, 7331, 7342, and 7346-7348 cannot be combined. See 38 C.F.R. § 4.114. The record does not show additional symptoms such as melena, anemia, weight loss, or malnutrition that would warrant a higher rating under any of these diagnostic codes. Thus, none of these provides for a higher rating based on the Veteran’s current symptoms. Here, the Veteran is evaluated under 7319 for irritable colon, and her chronic constipation is her predominant digestive disability, and therefore, a separate compensable rating for diverticulosis and gastroparesis is not permitted. 38 C.F.R. §§ 4.14, 4.113, 4.114. Therefore, the Board finds that the preponderance of the evidence is against an evaluation higher than 10 percent for chronic constipation prior to December 19, 2019 and higher than 30 percent thereafter. Hence the appeal as to a higher rating for this disability must be denied. There is no reasonable doubt to be resolved as to this issue. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3. 3. Entitlement to service connection for hypothyroidism The Veteran filed a claim for a hypothyroidism in December 2011, reporting being diagnosed with hypothyroidism in August 2009. Treatment records confirm the Veteran has been diagnosed with hypothyroidism dating back to 2009. She was diagnosed with thyroid cancer in January 2019, and underwent a thyroidectomy in April 2019. The question that remains is whether hypothyroidism is at least as likely as not related to an in-service injury. The Board concludes that the preponderance of the evidence is against finding that the Veteran’s hypothyroidism is directly due to her military service. Service treatment records do not contain any evidence of treatment, complaints or diagnosis of hypothyroidism. STRs contain no evidence of complaints treatment or diagnosis of a condition pertaining to her thyroid. In December 2019, the Veteran underwent an examination. The examiner opined that hypothyroidism was less likely than not incurred in or caused by an in-service injury, event, or illness, with the rationale being there is no evidence of any complaints or treatment for hypothyroidism during service. In October 2020, an addendum opinion was rendered. The examiner concluded it was less likely than not that hypothyroidism was incurred in or caused by an in-service injury event or illness. The Veteran was diagnosed with unspecified hypothyroidism around 2010 with papillary thyroid carcinoma in 2019 with thyroidectomy. She was not diagnosed during service during service. The examiner concluded there was no objective evidence of specific chemical exposure over a prolonged period during service which would have led to the development of hypothyroidism. Although the Veteran believes her hypothyroidism is due to her time in service, to include chemical exposure, she is not competent to provide a nexus opinion in this case. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body/interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the VA examiners’ opinions. Although the Veteran is a pharmacist and has asserted that her history of hypothyroidism is related to service, she has not provided a discernible rationale for this assertion. Thus, the VA medical opinion is afforded greater probative weight. The December 2019 and October 2020 examinations and opinions, read together, concluded that the claimed hypothyroidism is not due service. The examiners referenced the Veteran’s STRs that are devoid of any reports of the claimed disability. Further, there is a gap of over 5 years between discharge and the first indication of hypothyroidism. In sum, the examiner’s opinions are highly probative, because they are based on an accurate medical history, considered the Veteran’s lay reports, and provided an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The most probative evidence of record does not show that the Veteran’s claimed hypothyroidism is directly due to service. The Board appreciates the Veteran’s sincere belief that the claimed disability is directly related to service. The Veteran is competent to describe the symptoms of her hypothyroidism, but she not competent to provide an opinion linking his disability to service. She has not been shown to have the requisite medical expertise to provide nexus opinions as to this matter. 4. Entitlement to a total disability rating based on individual unemployability A total disability rating 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 the result of service-connected disabilities. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. Consideration may be given to a Veteran’s level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or the impairment caused by any nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. To qualify for a total rating for compensation purposes, the evidence must show (1) a single disability rated as 100 percent disabling; or (2) that the Veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities and there is either one disability ratable at 60 percent or more, or, if more than one disability, at least one disability is ratable at 40 percent or more and the multiple service connected disabilities combine to a disability rating of 70 percent or greater. Id. Even if the Veteran is unemployed, the dispositive issue is whether she is capable of performing the physical and mental acts required by employment, not whether she can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). For a Veteran to prevail on a claim for a TDIU rating, the record must reflect some factor which takes the case outside the norm. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is a recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether the Veteran can find employment. See 38 C.F.R. § 4.16(a). Van Hoose v. Brown, 4 Vet. App. 361 (1993). In determining whether an appellant is entitled to a total disability rating based upon individual unemployability, neither appellant’s nonservice-connected disabilities nor may advancing age be considered. Service connection is in effect for PTSD with a 70 percent rating, hysterectomy with a 50 percent rating, fibromyalgia with a 10 then 40 percent rating, chronic constipation with gastroparesis and diverticulosis with a 10 then 30 percent evaluation, tinnitus with a 10 percent evaluation, and rosacea and hearing loss each with noncompensable evaluations. The total combined evaluation from July 2014 is 80 percent, from November 2016 is 90 percent, and as of December 2019 the Veteran is in receipt of a combined schedular rating of 100 percent. As such, the Veteran meets the percentage threshold requirements provided in 38 C.F.R. § 4.16(a) for consideration of entitlement to a total rating based on individual unemployability. In Hatlestad v. Derwinski, 5 Vet. App. 524, 529 (1993), the United States Court of Appeals of Veterans Claims (Court) held that the central inquiry in determining whether a Veteran is entitled to a total rating based on individual unemployability is whether the Veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability. Throughout the course of the appeal, the Veteran has been employed as a pharmacist at VA. The Veteran worked for the El Paso VA Health Care System in Home Based Primary Care from April 2013 to July 2016, and from July 2016 she worked in telehealth services. In the Veteran’s CV, she provides details around presentations she has given. She reported giving two presentations in 2011, two in 2012, five in 2014, one in 2015, and one in 2016. In a May 2017 statement, she reported being accommodated to work from home, and having to take roughly two days off a month. She reported having to make frequent trips to the restroom due to her stomach problems. At a September 2020 VAMC visit, she reported being employed with telehealth VA. A TDIU is not demonstrated by the record as the evidence of record fails to show that the Veteran is unable to secure to follow a substantially gainful occupation solely due to her service-connected disabilities. In other words, the functional impairment of her service-connected disabilities does not rise to the level of rendering the Veteran unemployable. Initially, the fact that the Veteran has multiple service-connected disabilities, rated at 90 percent from November 2016 and 100 percent from December 2019, is on its face suggestive that she has a complex disability picture with multiple factors causing unemployability as opposed to a single disability. From the VA examination reports, the examiners do not identify a specific disability that would preclude employment. Throughout the course of the appeal the Veteran reported challenges presented by her service-connected disabilities. Though there are reports that her disabilities affect her daily life, there is no indication employment is precluded. Importantly, a TDIU determination is not a medical one, it is a legal one. The most probative evidence of record does not support finding that her service-connected disabilities render her unable to secure and follow substantially gainful employment. Although she was accommodated to work from home, this has not precluded substantially gainful employment. The evidence shows that throughout the entire period on appeal she has maintained substantially gainful employment as a pharmacist for VA. There is no question that the Veteran’s service-connected disabilities have had an impact on her, however, as is clear by the record, she has been able to maintain employment, with reportedly missing one or two days per month as a result of her disabilities, which is not indicative of a severe impediment to her employment. Based on the totality of the evidence, the Board cannot find that the Veteran is unemployable due to her service-connected disabilities. The most probative evidence establishes that the Veteran’s service-connected disabilities do not render her unemployable, and she contains to maintain full time employment as a pharmacist. H.M. WALKER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Skiouris, 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.