Citation Nr: 21010569 Decision Date: 02/25/21 Archive Date: 02/25/21 DOCKET NO. 14-19 614 DATE: February 25, 2021 ORDER Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD), is denied. Entitlement to a disability rating in excess of 10 percent for residuals of a closed fracture of the right parietal is denied. Entitlement to a compensable disability rating for bilateral hearing loss is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) is denied. FINDINGS OF FACT 1. An acquired psychiatric disorder, including PTSD, has not been shown to exist at any time during the pendency of this claim or proximate to that. 2. The residuals of the closed fracture of the Veteran’s right parietal have manifested no worse than in subjective complaints of mild concentration issues, irritability, moodiness, anxiety, and slow speech with word finding problems; the highest level of evaluation for any facet for the traumatic brain injury (TBI) during the period on appeal has been under the “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified” table (the Table), which is level 1. 3. The Veteran’s bilateral hearing loss was manifested by Level I hearing acuity in both ears in September 2010 and more recently in July 2018. 4. The Veteran did not return a completed TDIU application (VA Form 21-8940) to support this claim and provide needed information, and there is no indication in the competent and credible evidence of record that he is unable to secure or follow a substantially gainful occupation due to his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria are not met for entitlement to service connection for an acquired psychiatric disorder, including PTSD. 38 U.S.C. §§ 1110, 1310, 5103, 5103A, 5106, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. 2. The criteria are not met for entitlement to a disability rating higher than 10 percent for the residuals of a closed fracture of the right parietal. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. §§ 4.124a, Diagnostic Code 8045. 3. The criteria are not met for entitlement to a compensable disability rating for bilateral hearing loss. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. §§ 4.85, 4.86, Diagnostic Code 6100. 4. The criteria are not for entitlement to a TDIU. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.3, 4.15, 4.16, 4.18, 4.19.   REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1969 to September 1973. This appeal to the Board of Veterans’ Appeals (Board) is from an October 2010 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded these claims back to the Agency of Original Jurisdiction (AOJ), i.e., RO, in December 2015 and July 2019 for further development and consideration. Service Connection Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active military service in the line of duty. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or a disease, and (3) a causal relationship (“nexus”) between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). 1. Entitlement to service connection for an acquired psychiatric disorder, including PTSD. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (meaning in accordance with the criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM)); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). The law requires verification of a claimed stressor, except in certain circumstances. Where a determination is made that the Veteran did not “engage in combat with the enemy,” or the claimed stressor is unrelated to combat, his lay testimony alone generally will not be enough to establish the occurrence of the alleged stressor. See Moreau v. Brown, 9 Vet. App. 389, 395 (1996). In such cases, the record instead must include service records or other credible evidence that supports and does not contradict his testimony. Doran v. Brown, 6 Vet. App. 283, 289 (1994). Moreover, a medical opinion diagnosing PTSD generally does not suffice to verify the occurrence of the claimed in-service stressors. See Moreau, 9 Vet. App. at 395-396; Cohen v. Brown, 10 Vet. App. 128, 42 (1997). Aside from combat experience contemplated by subpart (f)(2), the exception to that general rule also occurs when the claim is predicated on fear of hostile military or terrorist activity (subpart (f)(3)), the Veteran was a prisoner of war, i.e., POW (subpart (f)(4)), or there was military sexual trauma, i.e., MST (subpart (f)(5)). In those other cases, there also are distinct pleading-and-proof requirements and acceptance that a medical opinion offered after the fact may link a PTSD diagnosis to a particularly traumatic event (“stressor”) that occurred during the Veteran’s time in service. Here, though, at the outset, the Board finds that there simply is no evidence of record indicating the Veteran has received the requisite diagnosis of PTSD or has at any time during the pendency of this claim or proximate to that. The evidence of record is equally unremarkable for any diagnoses or treatment for any other psychiatric disorder. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. §§ 1110, 1131; Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (in the absence of proof of a present disability there can be no valid claim); see also Degmetich v. Brown, 8 Vet. App. 208 (1995); 104 F.3d 1328 (1997). At the very least, the evidence must show that, at some point during the appeal period, the Veteran has the disability for which benefits are being claimed. McClain v. Nicholson, 21 Vet. App. 319 (2007) (a claim for service connection may be granted if a diagnosis of a chronic disability was made during the pendency of the appeal, even if the most recent medical evidence suggests that the disability resolved); see also Romanowski v. Shinseki, 26 Vet. App. 289, 294 (2013) (even accepting a diagnosis preceding a claim, if contemporaneous to it). Here, though, the presence of a psychiatric disorder, to include PTSD, is not shown proximate to, or during, the period on appeal. The Veteran’s claim was received in July 2010. Since there is no confirmed diagnosis of any psychiatric disorder, the Board cannot conclude that any such disorder is currently present or has been at any point since or proximate to the filing of this claim. The Veteran was afforded a VA examination in September 2010. The examiner found no evidence to support a diagnosis of a psychiatric disorder, to include PTSD. After clinically interviewing the Veteran and administering mental status testing and evaluation, the examiner concluded that mental disorder symptoms were not severe enough to interfere with occupational and social functioning. However, it was noted that the Veteran had received treatment for PTSD and depression at a VA outpatient clinic from 2004 to 2008. An August 2011 psychiatric review report in the Veteran’s Social Security records shows a diagnosis of alcohol abuse, in partial remission. It was noted that he had no restriction of activities of daily living (ADLs) or episodes of decompensation of extended duration. There were mild difficulties in maintaining social functioning, concentration, persistence or pace. As to his functional capacity, the examining psychologist noted that the Veteran’s ability to understand, remember, and carry out simple/concrete instructions, ability to work independently, ability to work with supervisors, coworkers and general public, and ability to work with pressures common to most every day work settings appeared adequate. In July 2018, the Veteran was provided another VA examination. The examiner indicated that, based on the examination, the Veteran’s symptoms did not meet the diagnostic criteria for PTSD or any other psychiatric disorder according to the DSM-5 criteria. The Veteran described an in-service stressor that met the DSM-5 Criterion A for PTSD; however, he did not endorse symptoms meeting the remaining diagnostic requirement for PTSD. He also did not endorse symptoms or threshold for another mental health disorder. When specifically asked about current emotional symptoms or problems related to PTSD stressors, he stated “it’s not as bad as it was,” and he was unable to identify any symptoms or another mental health problems. He had not had any recurrent nightmares or dreams since 2009 and he stated he did not want to talk about his war experience, but he did not avoid talking about it. The examiner explained that, at one time, the Veteran might have met the full criteria for PTSD but that, since 2009, he had been asymptomatic to such a degree that he did not meet the criteria for PTSD. Pursuant to the July 2019 Board remand, the Veteran underwent yet another VA examination in December 2020. He reported that he was not in treatment for mental health problems and was not prescribed any medications for mental health. When asked about the last time he was in treatment, he responded, “it’s been years, too long to remember.” The examiner surmised that, as the Veteran’s reported experience during his military service meeting PTSD criteria, it is more than likely that he met full diagnostic criteria for PTSD at one time. However, currently, the examiner noted the Veteran described his faith and close relationship with God and daily reading of the Bible as primary supportive factors, and that it is likely this played a significant role in reducing his symptoms to subclinical levels. The examiner concluded that the Veteran did not meet the diagnostic threshold for PTSD or another mental health diagnosis at this time. The Board affords significant probative weight to the September 2010, July 2018, and December 2020 VA examiners’ opinions as they are predicated on a thorough review of the record, which includes medical records, lay statements, clinical evaluations and careful observation of the Veteran. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). Although private hospital records dated in March 2011 and VA treatment records note impression of, or medical history of, anxiety and PTSD, no mental health diagnosis conforming to the DSM-5 criteria is shown. The Board also has considered the Veteran’s lay statements concerning his stressor events in Thailand. He is competent to report psychiatric symptomatology he may have experienced, which is within the realm of his personal experience. 38 C.F.R. § 3.159; see Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). But he is not competent to relate such symptomatology to a diagnosed acquired psychiatric disorder. In this regard, the diagnosis of an acquired psychiatric disorder requires the administration and interpretation of specialized psychiatric testing and evaluation (screening) and must be made in conformance with the DSM-5. There is no indication the Veteran possesses the requisite medical knowledge to perform such testing or interpret the results. As such, the question of diagnosis in this case may not be competently addressed by lay evidence, and the Veteran’s statements are nonprobative evidence. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Moreover, throughout the appeal period, he has denied experiencing psychiatric symptoms for several years. Consequently, the Board finds that the most probative evidence addressing whether the Veteran has a current disability owing to a psychiatric disorder of any sort is the September 2010, July 2019 and December 2020 VA opinions, all of which ultimately found that he did not have a diagnosis of a psychiatric disorder at any time pertinent to his claim and, as such, did not have any functional impairment related to a psychiatric disorder. As such, where, as here, there is no probative evidence indicating the Veteran has the disability for which service connection is sought, there can be no valid claim because there necessarily is no present-day disability to, in turn, relate or attribute to his service. See Brammer, 3 Vet. App. at 225. In reaching this conclusion, the Board has considered the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, this doctrine is inapplicable, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Increased Ratings Disability ratings are determined by the application of the VA’s Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Evaluation of a service-connected disability requires a review of a veteran’s medical history with regard to that disorder. However, the primary concern in a claim for an increased evaluation for service-connected disability is the present level of disability. While the entire recorded history of a disability is important for more accurate evaluations, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Additionally, in determining the present level of a disability for any increased rating claim, the Board must consider the application of “staged” ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary, irrespective of whether an initial or established rating. 2. Entitlement to a compensable disability rating for bilateral hearing loss. The severity of a hearing loss disability is determined by comparisons of audiometric test results with specific criteria set forth at 38 C.F.R. § 4.85. Evaluations of bilateral defective hearing range from 0 percent (noncompensable) to 100 percent based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests together with the average hearing threshold level as measured by pure tone audiometry tests in the frequencies of 1,000, 2,000, 3,000, and 4,000 cycles per second (Hertz (Hz)). The Rating Schedule allows for such audiometric test results to be translated into a numeric designation ranging from Level I for essentially normal hearing to Level XI for profound deafness in order to evaluate the degree of disability from bilateral service-connected defective hearing. An examination for hearing impairment must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test (Maryland CNC) and a pure tone audiometry test. Examinations must be conducted without the use of hearing aids. 38 C.F.R. § 4.85.   The Veteran underwent a VA audiology examination in September 2010. On audiological evaluation, pertinent pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 25 30 35 25 LEFT 15 20 35 45 40 The speech recognition score, using Maryland CNC word list, was 96 percent in the right ear and 92 percent in the left ear. The audiologist stated that the use of speech discrimination scores was appropriate for the Veteran. The diagnosis was sensorineural hearing loss, bilaterally. As to the disability’s functional impact, the examiner noted that the Veteran reported some difficulty understanding conversational speech, the television and over the telephone requiring the use of hearing aids. See Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007). The Veteran underwent another VA audiology examination in July 2018. On audiological evaluation, pertinent pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 20 35 35 35 LEFT 10 20 40 45 60 The speech recognition score, using Maryland CNC word list, was 100 percent, bilaterally. The audiologist stated that the use of speech discrimination scores was appropriate for the Veteran. The diagnosis was sensorineural hearing loss, bilaterally. As to the disability’s functional impact, the examiner noted that the Veteran reported some difficulty hearing and understanding people taking. See Martinak, 21 Vet. App. at 455. The September 2010 VA audiological examination revealed a right ear pure tone threshold average of 28.75 decibels, at 1000, 2000, 3000, and 4000 Hertz, and a left ear pure tone threshold average of 35 decibels, at 1000, 2000, 3000, and 4000 Hertz, and speech discrimination ability of 96 in the right ear and 92 in the left ear, using the Maryland CNC word list. Applying the clinical findings from the September 2010 audiological evaluation to the rating criteria results in Level I hearing acuity in the both ears, so bilaterally. See 38 C.F.R. § 4.85, Table VI. Applying these numeral designations to Table VII results in a noncompensable disability rating for bilateral ear hearing loss disability. 38 C.F.R. §§ 3.383, 4.85. The July 2018 VA audiological examination revealed a right ear pure tone threshold average of 31.25 decibels, at 1000, 2000, 3000, and 4000 Hertz, and a left ear pure tone threshold average of 41.25 decibels, at 1000, 2000, 3000, and 4000 Hertz, and speech discrimination ability of 100 percent, bilaterally, using the Maryland CNC word list. Applying the clinical findings from the July 2018 audiological evaluation to the rating criteria again results in Level I hearing acuity in both ears, so again bilaterally. See 38 C.F.R. § 4.85, Table VI. Applying these numeral designations to Table VII therefore again results in a noncompensable disability rating for bilateral ear hearing loss disability. 38 C.F.R. §§ 3.383, 4.85. When the pure tone decibel loss values are 55 or greater at 1000 Hertz, 2000 Hertz, 3000 Hertz, and 4000 Hertz in either ear, or 30 or less at 1000 Hertz and 70 or more at 2000 Hertz, the criteria for exceptional patterns of hearing impairment must be considered. 38 C.F.R. § 4.86(a), (b). However, none of the examination results dated during the entire appeal period reflect an exceptional pattern of hearing impairment in either ear; as such, the criteria in 38 C.F.R. § 4.86(a) or (b) do not apply. As such, a compensable disability rating is not supported by the evidence of record at any time during the rating period on appeal. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). Moreover, the Veteran does not have symptoms or consequent impairment beyond what is contemplated by the regular schedular rating criteria. See Rossy v. Shulkin, 29 Vet. App. 142 (2017); Doucette v. Shulkin, 28 Vet. App. 366 (2017) (affirming a Board decision denying extra-schedular referral under 38 C.F.R. § 3.321(b)(1) when only the functional effects alleged were aspects of hearing loss). The Court concluded that Doucette directed the outcome of the appeal in Rossy, as well. In Doucette, the Court addressed how to conduct an extra-schedular analysis specifically, the first Thun inquiry in the contest of a hearing loss claim. The Court held that the rating criteria for §§ 4.85 and 4.86 contemplate, and thus compensate for, the functional effects of hearing loss, namely, difficulty understanding speech and the inability to hear sounds in various contexts. While leaving open the possibility that extra-schedular consideration for hearing loss might be warranted by other symptoms or functional effects associated with that disability, the Court further held that extra-schedular referral is not reasonably raised when complaints of difficulty hearing are the only complaints of record. The Court saw no basis to distinguish that appeal from Doucette; as in this case, the only hearing loss problem alleged by the Appellant was difficulty understanding conversations, particularly in noisy or crowded circumstances. Absent other factors, the Court found that this sort of complaint is squarely within the type of symptoms and functional effects contemplated and compensated by VA's schedular rating criteria. The Court found that the Appellant had failed to demonstrate any error regarding his bilateral hearing loss. The Court affirmed the Board's decision. Recognizing all of this, the threshold element for extra-schedular consideration is not met and any further consideration of governing norms or referral to the appropriate VA officials for extra-schedular consideration is unnecessary. Thun v. Peake, 22 Vet. App. 111 (2008). 3. Entitlement to a disability rating in excess of 10 percent for residuals of a closed fracture of the right parietal. The residuals of the closed fracture of the Veteran’s right parietal are evaluated under Diagnostic Code 5299-8045. Hyphenated Diagnostic Codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the evaluation assigned. See 38 C.F.R. § 4.27. In this case, the disability is rated based on the residual TBI (Diagnostic Code 8045).   Residuals of TBI are evaluated under 38 C.F.R. § 4.124a, the schedule of ratings for neurological conditions and convulsive disorders, as organic disease of the central nervous system, specifically under Diagnostic Code 8045. Under Diagnostic Code 8045, there are three main areas of dysfunction that may result from TBI and have profound effects on functioning: cognitive (which is common in varying degrees after TBI), emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation. 38 C.F.R. § 4.124a, Diagnostic Code 8045. Diagnostic Code 8045 includes a table titled “Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified,” which addresses 10 facets of a TBI. It provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and a 5th level – the highest level of impairment – labeled as “total.” A level 0 impairment is consistent with a 0 percent disability rating, level 1 with 10 percent rating, level 2 with 40 percent, level 3 with 70 percent disability rating, and the highest level (“total) with a 100 percent disability rating. Id. The overall evaluation assigned is based upon the highest level of severity for any facet. Only one evaluation is assigned for all the applicable facets. A higher evaluation is not warranted unless a higher level of severity for a facet is established on examination. Subjective symptoms that are residuals of a TBI, whether they are part of cognitive impairment, should be evaluated under the subjective symptoms facet. However, VA is to separately evaluate any residual with a distinct diagnosis that may be evaluated under another Diagnostic Code, even if that diagnosis is based on subjective symptoms, rather than under the “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified” table. Id. Note (1) in DC 8045 states that there may be an overlap of manifestations of conditions evaluated under the table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified” with manifestations of a comorbid mental, neurologic, or other physical disorder that can be separately evaluated under another Diagnostic Code. In such cases, the rater is not to assign more than one evaluation based on the same manifestations. If the manifestations of two or more conditions cannot be clearly separated, the rater should assign a single evaluation under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning due to both conditions. However, if the manifestations are clearly separable, assign a separate evaluation for each condition. Id. Note (2) provides that symptoms listed as examples at certain evaluation levels in the table are only examples and are not symptoms that must be present in order to assign a particular evaluation. Id. Note (3) states that “instrumental activities of daily living” refers to activities other than self-care that are needed for independent living, such as meal preparation, doing housework and other chores, shopping, traveling, doing laundry, being responsible for one’s own medications, and using a telephone. These activities are distinguished from “Activities of daily living,” which refers to basic self-care and includes bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet. Id. According to Note (4), the terms “mild,” “moderate,” and “severe” TBI, which may appear in medical records, refer to a classification of TBI made at, or close to, the time of injury rather than to the current level of functioning. This classification does not affect the rating assigned under Diagnostic Code 8045. Id. Turning now to the relevant medical and other evidence in this case at hand, the Veteran attended a VA examination in August 2010. He reported delayed-onset headaches and associated occasional blurry vision that the examiner clarified were not caused by or related to the Veteran’s TBI in service. He denied weakness or paralysis, sleep disturbance, fatigue, malaise, mobility or balance problems, speech or swallowing difficulties, sensory changes, or decreased sense of taste or smell. He reported delayed-onset memory impairment in the previous 6 to 8 years, which the examiner again opined is not caused by or related to TBI. In a review of the 10 facets for rating a TBI, he had a complaint of mild impairment in memory, attention, concentration, or executive functions, without objective testing, had normal judgment, had routinely appropriate social interaction, was always fully oriented, and had normal motor activity and visual spatial orientation. He had three or more subjective symptoms of headaches, hearing loss, irritability, moodiness, anxiety that mildly-moderately interfered with instrumental activities of daily living, family or other close relationships and a neurobehavioral effect of moodiness, anxiety, and irritability that occasionally interfered with social interaction but did not preclude it. He was able to communicate by and comprehend spoken and written language. His consciousness was normal. The diagnosis was mild TBI, resolved without residuals. A June 2018 VA TBI examination showed a complaint of mild memory loss, attention, concentration or executive functions, but without objective evidence on testing. The Veteran reported taking an early retirement due to his inability to maintain focus and concentration. The examiner also reported subjective symptoms not interfering with work, instrumental activities of daily living, or work, family or other close relationships. Specifically, the Veteran had anxiety in certain situations that led him to recluse and alone at times. For the neurobehavioral facet, the examiner noted no neurobehavioral effects. However, for communication, the Veteran’s comprehension or expression or both, either spoken or written language was occasionally impaired. The examiner noted the Veteran had a tendency of rushing his words and delay/hesitate with finding words that he intended on using. His consciousness was normal. To the extent that the Veteran has reported TBI residuals, the Board initially notes that he is in receipt of separate ratings for tinnitus and bilateral hearing loss. Such conditions are not for consideration in evaluating his TBI. See 38 C.F.R. § 4.14 (the evaluation of the same manifestation or disability under different diagnoses is to be avoided); see also 38 C.F.R. § 4.124, Diagnostic Code 8045, Note (1). With the regard to the remaining symptomatology, the August 2010 examination noted headaches associated with occasional blurry vision, and memory problems, however, the examining physician indicated that these symptoms were not caused by or related to the service-connected closed fracture of the right parietal given the delayed onset of those symptoms.   During a September 2010 VA mental disorder examination, the Veteran reported that he started having problems concentrating. However, examination testing revealed no objective evidence of impaired memory, attention, concentration, or executive functioning such as to warrant assignment of a “2” under this facet of the TBI criteria. The VA examiners reported that judgement, social interaction, orientation, motor activity, visual-spatial orientation, and cognitive screening results were all normal. The examiner noted that the Veteran’s TBI condition had resolved. Notably, none of the Veteran’s impairments found under any of the 10 facets exceed level 1 on any VA examination. While the Veteran contends that his TBI produces more significant and severe residuals, he has not been found to possess the medical expertise required to properly evaluate each facet. As such, greater probative weight is assigned to the findings of the experienced medical professionals who evaluated the Veteran’s condition on three occasions yielding relatively consistent results. The Board further notes that the clinical medical evidence of record does not show more significant impairment in the 10 facets related to TBI. As the competent and probative findings on clinical examination showed that the Veteran did not manifest with an impairment higher than mild (level 1 impairment) on any of the relevant facets, the Board concludes that a rating in excess of 10 percent is not warranted for residuals of TBI throughout the appeal period. 38 C.F.R. §§ 4.1, 4.10, 4.124a, Diagnostic Code 8045.   Entitlement to a TDIU. Total disability means that there is present any impairment of mind or body sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. §§ 3.340, 4.15. A substantially gainful occupation has been defined as “employment at which non-disabled individuals earn their livelihood with earnings comparable to the particular occupation in the community where the Veteran resides.” M21-1 VA Adjudication Procedure Manual, Part IV.ii.2.F.1.c. (Updated September 24, 2015). It also has been defined as “an occupation that provides an annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days that the Veteran actually works and without regard to the Veteran’s earned annual income.” Faust v. West, 13 Vet. App. 342 (2000). Marginal employment shall not be considered substantially gainful employment. Substantially gainful employment is defined as work that is more than marginal, which permits the individual to earn a “living wage.” Id. Marginal employment is defined as an amount of earned annual income that does not exceed the poverty threshold determined by the Census Bureau. 38 C.F.R. §§ 4.16(a), 4.18. When jobs are not realistically within his physical and mental capabilities, a veteran is determined unable to engage in a substantially gainful occupation. Moore v. Derwinski, 1 Vet. App. 356 (1991). In making this determination, consideration may be given to factors such as the veteran’s level of education, special training, and previous work experience, but not to age or impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, 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, this disability shall be ratable at 60 percent or more, and that, if there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. For the purpose of one 60 percent or one 40 percent disability in combination, disabilities resulting from a common etiology or a single accident or affecting both upper extremities or both lower extremities or a single bodily system will be considered as one disability. 38 C.F.R. § 4.16(a). The ultimate question of whether a Veteran is capable of substantially gainful employment is not a medical one; that determination is for the adjudicator. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). Thus, the VA examiners’ conclusions are not dispositive. However, the observations of the examiners regarding functional impairment due to the service-connected disability go to the question of physical or mental limitations that may impact his ability to obtain and maintain employment. During the entire appeal period, the Veteran has had a combined evaluation of 40 percent for residuals of a fracture of his right clavicle, midshaft, rated as 20 percent disabling, for residuals of the closed fracture of his right parietal, rated as 10 percent disabling, for tinnitus, rated as 10 percent disabling, and for bilateral hearing loss, rated as 0 percent disabling (noncompensable). Thus, the ratings for his service-connected disabilities do not render him eligible for a TDIU under the schedular percentage requirements contemplated by VA regulation. See 38 C.F.R. §§ 3.340, 3.341, 4.16(a). Therefore, the schedular criteria have not been satisfied. Although the Veteran does not meet the schedular criteria for a TDIU for the entire appeal period, 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. 38 C.F.R. § 4.16(b). Rating boards should refer to the Director of the Compensation and Pension Service for extraschedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities but who fail to meet the percentage requirements set forth in 38 C.F.R. § 4.16(a). The veteran’s service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed. 38 C.F.R. § 4.16(b). The rating board did not refer this case for extraschedular consideration, but this referral is not shown to be warranted.   The Veteran has not provided the information or evidence requested by VA to determine whether he is entitled to a TDIU, including on an extra-schedular basis. Pursuant to the Board’s instruction in the July 2019 remand, the AOJ was directed to send him a TDIU application (VA Form 21-8940) to complete, sign and return. A substantially completed VA Form 21-8940 is required to establish entitlement to a TDIU. See Veterans Benefits Administration (BVA) Adjudication Procedure Manual (Manual), IV.ii.2.F.2.b. It provides relevant and indispensable information regarding a claimant’s disabilities and employment and educational histories and concludes with a series of sworn certification statements endorsing the Veteran’s employment status and signaling his or her understanding that TDIU benefits are incompatible with substantially gainful work. Id. When a claimant does not cooperate with development of a TDIU claim by not returning a completed VA Form 21-8940 when requested, the VBA Manual instructs that the claim is to be denied. VBA Manual, IV.ii.2.F.4.k. Because the Veteran did not return the application form, this claim is being denied. See id. In any event, the Board finds that the evidence does not show the Veteran is unable to secure or follow a substantially gainful occupation, particularly employment that is less physically demanding, if only considering his service-connected disabilities. During August 2010 VA examinations, the Veteran reported previously working as a carpenter, welder, fitter, and insulator and being unemployed since 2009, so since the prior year. He explained that he took an early retirement in September 2009 due to PTSD and mental health issues, causing difficulty focusing; however, he reported no effect of his service-connected right shoulder disability and, as already discussed, service connection is not warranted for PTSD or any other mental illness because his symptoms are not severe enough to meet the diagnostic criteria for any mental health disorder and the severity of his TBI is found to be relatively mild, without residuals. The Veteran’s records relating to his Social Security Administration (SSA) disability claim show that, in August 2011, he was found disabled based on a primary diagnosis of coronary artery disease (CAD) and a secondary diagnosis of disorders of the muscle, ligament, and fascia. His maximum work capacity was assessed in the light work range. He indicated that he completely stopped working in February 2011 because of his heart, tendonitis, restricted movement, previous head injury and PTSD conditions. Private treatment records reflect that he underwent coronary artery bypass grafting surgery in March 2011. During a July 2018 VA examination, the examiner indicated “[t]here does not appear to be any effect on [the Veteran’s] ability to function in an occupational environment from his reported/claimed disabilities from his military service.” Accordingly, given the Veteran’s failure to complete VA Form 21-8940 necessary to adjudicate his claim for a TDIU, and in light of other information of record, his claim of entitlement to this benefit is denied. KEITH W. ALLEN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. J. In, 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.