Citation Nr: 21010828 Decision Date: 02/25/21 Archive Date: 02/25/21 DOCKET NO. 20-10 286 DATE: February 25, 2021 ORDER Entitlement to a rating in excess of 30 percent from February 9, 2010 to August 24, 2015 for ischemic heart disease is denied. Entitlement to a rating in excess of 60 percent from October 1, 2015 to December 16, 2015 for ischemic heart disease is denied. Entitlement to a rating of 60 percent from February 1, 2016 for ischemic heart disease is granted. Entitlement to a rating in excess of 10 percent for atrial flutter associated with ischemic heart disease (atrial flutter) is denied. Entitlement to an effective date prior to February 9, 2010 for the grant of service connection for ischemic heart disease is denied. Entitlement to an effective date prior to February 9, 2010 for the grant of service connection for atrial flutter is denied. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) from January 29, 2013 is granted. REMANDED Entitlement to TDIU from February 9, 2010 to January 29, 2013 is remanded. FINDINGS OF FACT 1. From February 9, 2010 to August 24, 2015, ischemic heart disease manifested with cardiac hypertrophy shown on echocardiogram. 2. From October 1, 2015 to December 16, 2015, ischemic heart disease manifested with left ventricular dysfunction ejection fraction of 50 percent or Metabolic equivalents (METs) of greater 3, but not greater than 5. 3. From February 1, 2016, ischemic heart disease manifested with left ventricular dysfunction ejection fraction of 50 percent or METs of greater 3, but not greater than 5. 4. Atrial flutter manifested with permanent atrial fibrillation. 5. VA did not receive the Veteran’s claim for compensation benefits for ischemic heart disease prior to February 9, 2010. 6. VA did not receive the Veteran’s claim for compensation benefits for atrial flutter prior to February 9, 2010. 7. From January 29, 2013, the service-connected disabilities render the Veteran unable to secure and follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. From February 9, 2010 to August 24, 2015, the criteria for a rating in excess of 30 percent for ischemic heart disease have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1-4.7, 4.104, Diagnostic Code 7005. 2. From October 1, 2015 to December 16, 2015, the criteria for a rating in excess of 60 percent for ischemic heart disease have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1-4.7, 4.104, Diagnostic Code 7005. 3. From February 1, 2016, the criteria for a rating in excess of 60 percent for ischemic heart disease have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1-4.7, 4.104, Diagnostic Code 7005. 4. The criteria for a rating in excess of 10 percent for atrial flutter have been not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1-4.7, 4.104, Diagnostic Code 7010. 5. The criteria for an effective date prior to February 9, 2010 for the grant of entitlement to service connection for the grant of ischemic heart disease have not been met. 38 U.S.C. § 5110; 38 C.F.R. §§ 3.400, 3.816. 6. The criteria for an effective date prior to February 9, 2010 for the grant of entitlement to service connection for the grant of atrial flutter have not been met. 38 U.S.C. § 5110; 38 C.F.R. §§ 3.400, 3.816. 7. From January 29, 2013, the criteria for TDIU are met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.16, 4.18, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1955 to September 1976. Ratings Principles Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), found in 38 C.F.R., Part 4. The ratings are intended to compensate impairment in earning capacity due to a service-connected disease or injury. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If the evidence for and against a claim is an equipoise, the claim will be granted. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinksi, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where there is question as to which of the two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Staged ratings, however, are appropriate when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The determination of whether an increased evaluation is warranted is based on review of the entire evidence of record and the application of all pertinent regulations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows or fails to show. The Veteran should not assume that the Board has overlooked pieces of evidence that are not specifically discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000). 1. 30 percent rating for ischemic heart disease prior to October 1, 2015 The Veteran’s ischemic heart disease is rated at 30 percent disabling under diagnostic code 7005. The Veteran’s current rating is in effect from February 9, 2010, with convalescent ratings under 38 C.F.R. § 4.30 in effect from August 24, 2015 to October 1, 2015 and again from December 16, 2015 to February 1, 2016. The Veteran also had a 60 percent evaluation in effect from October 1, 2015 to December 16, 2015. Neither the Veteran nor the representative nor the evidence argue or show that the convalescent rating should be extended. In September 2017, the Regional Office (RO) found clear and unmistakable error (CUE): an earlier effective date for atrial flutter/fibrillation to February 2010, as the Veteran’s claim for ischemic heart disease included a claim for atrial flutter, as atrial flutter reasonably falls within the scope of the claim. It was also noted the March 2011 VA Rating Decision was clearly and unmistakably erroneous for failing to grant a 30 percent evaluation for the service-connected ischemic heart disease. The Veteran’s representative submitted a NOD to the September 2017 rating decision arguing for the earliest effective date and highest rating possibly be assigned. Diagnostic Code 7005 provides a 30 percent evaluation is warranted for a workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; or evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent evaluation is warranted for more than one episode of acute congestive heart failure in the past year, or workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is warranted for chronic congestive heart failure, or when a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104, Diagnostic Code 7005. A note prior to the Diagnostic Code explains that one MET is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note (2). A May 2006 echocardiogram showed there to be left ventricular hypertrophy. The Veteran had stents placed in 1999 and 2007. Another echocardiogram dated in June 2010, conducted in connection with a May 2010 VA examination, also showed left ventricular hypertrophy. The 2010 examiner recorded that the Veteran stated that he never had much of a problem with his heart, only rare episodes of angina with exertion, occurring approximately monthly or less. The examiner noted the Veteran had rare dizziness occurring less frequently recently, that the Veteran denied dyspnea, fatigue and syncope. There was no evidence of any acute cardiac illness including myocardial infarction, congestive heart failure, or rheumatic heart disease. Current treatment includes prescribed amlodipine, hydrochlorothiazide, and metoprolol. An echocardiogram shows left ejection fraction to be 55 percent and METs were estimated to be at 10. The Veteran denied having any atrial fibrillation. There were no effects on usual activity and the Veteran was able to exercise daily without complication. On examination, heart size was normal with a regular rhythm. Chest x-ray was normal, and the examiner noted that there were no other tests deemed pertinent or necessary. The diagnosis was ischemic heart disease on prescribed medication for control. A VA examination dated in February 2013 showed evidence of cardiac hypertrophy on echocardiogram. Workload was greater than five METs but not greater than seven METs, resulting in dyspnea, fatigue, and he was able to walk about a mile comfortably. The Veteran had atrial flutter, intermittent, no episodes in the prior year, with two episodes total, most recently in 2007. Additional symptoms were continuous medication is required and left ventricular ejection fraction of greater than 50 percent. ECG showed 60 percent left ventricular ejection fraction, with wall motion and thickness normal. VA examination dated in February 2015 indicated a diagnosis of intermittent (paroxysmal) atrial flutter with no episodes in the past 12 months documented by EKG. There has been no destabilization in his cardiac status, since February 2013. Peripheral pulses were diminished. The Veteran had coronary artery diseases status post revascularization. New diagnostic tests were an EKG dated in October 2013 showing normal sinus rhythm at 63 and ECG dated in February 2015 showing left ventricular ejection fraction: 60-65 percent. Interview basad METs test – reflects the lowest activity level at which the Veteran reports any of the following symptoms attributable to a cardiac condition – showed dyspnea and fatigue, with same METs level as in February 2013. METs level was greater than 7 but less than 10. All other findings were identical to the 2013 VA examination or were normal. An October 2015 VA examination report (with examination occurring in September 2015) notes that the Veteran was admitted to a hospital for myocardial infraction in August 2015. The Veteran was on medications and it was being determined if a pacemaker should be implanted. He had atrial flutter constantly. Echocardiogram from August 2015 showed cardiac hypertrophy. Left ventricular ejection fraction was unchanged (60 percent). Interval-based METs test also showed the same symptoms, but with METs Level greater than 3 METs but not greater than 5 METs. Review of VA and private treatment records does not show any episodes of atrial flutter/atrial fibrillation nor do they provide any METs testing. Review of the private treatment records shows history of atrial flutter. The records noted normal heart rate, regular rhythm, and normal heart sounds. A February 2019 statement from the representative reports that a June 2007 VA treatment record indicates that the Veteran had imaging showing mild anteroapical hypokinesis with an ejection fraction calculated at 49 percent and therefore a 60 percent rating should be warranted for the entire period on appeal. A 30 percent evaluation was awarded based on evidence of cardiac hypertrophy on echocardiogram with additional continuous use of medication, left ventricular ejection fraction was 60 percent on the lowest result. The examiner estimated METs to be greater than 7. A higher evaluation of 60 percent is not warranted unless there is evidence of left ventricular dysfunction with an ejection fraction of 30 to 50 percent; or, more than one episode of acute congestive heart failure in the past year; or, workload of greater than three METs but not greater than five METs. The Board notes there was one report of 49 percent prior to the period on appeal and this note has been considered, but the 2010 VA examination (within several months of the claim being filed) showed the current 30 percent rating is warranted. The medical records from the appeal period on more pertinent regarding disability. The 2010 VA examination found ejection fraction better than 50 percent, at 55 percent. A 30 percent evaluation was awarded for cardiac hypertrophy shown on echocardiogram. Medical records and VA examinations do not show any of the manifestations required for a higher rating during these periods of the appeal. There is no showing of workload of greater than 3 METs and not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular dysfunction with an ejection fraction below 50 percent. The VA examinations specifically showed better results than required for a higher rating. The Board has considered the Veteran’s report of symptoms, but they are less probative of the rating criteria as compared with the medical evidence. His assertions of greater severity have been considered. However, the more probative evidence consists of the medical evidence prepared by a skilled examiner. The preponderance of the evidence is against a rating in excess of 30 percent. A review of the relevant medical records and the examination does not indicate multiple episodes of acute congestive heart failure, a workload of greater than 3 METs and not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular dysfunction with an ejection fraction below 50 percent. The evidence weighs against a rating in excess of 30 percent at any point. 2. Rating for ischemic heart disease from October 1, 2015 As noted above, the Veteran was assigned a 60 percent rating on October 1, 2015 and (after periods in which a temporary total disability rating was assigned) was reduced to 30 percent from February 1, 2016. In a February 2019 statement, the representative stated a 60 percent rating was sought for the whole period on appeal. As an initial matter for this part of the rating, a May 2017 rating decisions shows that the current effective date for the assignment of the 30 percent rating is incorrect, according to the RO. The rating decision reads: an evaluation of 60 percent is assigned from February 1, 2016, the first day of the month following 30-day convalescence period. An evaluation of 30 percent is assigned from March 28, 2017 based on the evidence shown at a compensation examination dated March 28, 2017. Therefore, a 60 percent rating should have been granted to March 28, 2017, not the current date of February 1, 2016 (the date shown on the code sheet). A September 2016 VA examination report (examination itself occurred in August 2016) noted acute, subacute, or old myocardial infarction (diagnosed in 2016), atherosclerotic cardiovascular disease (2016), stable angina (2016), congestive heart failure (2016), ventricular arrythmia (2016), and implanted cardiac pacemaker (2013). The examiner noted hospitalization in August 2015 and December 2015. The examiner stated the Veteran had atrial intermittent (paroxysmal) fibrillation with 0 episodes in the previous year. EKG showed intermittent atrial fibrillation and arrythmia. Echocardiogram continued to show 60 percent left ventricular ejection fraction. METs level greater than 3 METs but not greater than 5 METs. Symptoms were the same as in the prior examination report. A VA examination dated March in 2017 provided a diagnosis of constant atrial fibrillation, and a medical opinion dated July 2017 related it to service-connected ischemic heart disease. The examiner reporter constant atrial flutter with no atrial fibrillation or supraventricular tachycardia. Echocardiogram from March 2017 showed left ventricular ejection fraction (LVEF): 50-60 percent with wall thickness abnormal (concentric LVH). Interview-based METs testing showed dyspnea, fatigue, angina, and dizziness. METs level were greater than 5, but less than 7 METS. Exercise test was not performed, as it is required as part of the Veteran’s current treatment plan and this test is not without significant risk. A VA examination was conducted in February 2019. The examiner stated the heart conditions had stayed the same since the last increase in the Veteran’s disability rating. Every now and then the Veteran reported getting shortness of breath and chest pain. Both atrial fibrillation and atrial flutter were intermittent, with no episodes in the last 12 months. It was noted that atrial fibrillation/atrial flutter was due to service-connected coronary artery disease. All other findings and the history were either the same as the prior examination or normal. No other findings were noted on examination. Exercise tests were not performed, as it is not required as part of the Veteran’s current treatment plan and this test is not without significant risk. An interview based METs test was provided and the level is shown as greater than 3, but not greater than 5 METs. For this period, it is shown that the Veteran had examination in March 2017, showing that the examiner found that METs testing gave a range for the left ventricular dysfunction with ejection (50 percent to 60 percent), which (at the low end of the range) would warrant a 60 percent rating. Further, a 2019 VA examination found METs greater than 3, but not greater 5. Based on this, a 60 percent is warranted from March 2017 onward. Also, such a finding prevents a rollercoaster-type evaluation. Such an evaluation violates the rule about stabilization of ratings. For the period, according to a February 2019 statement, a 60 percent rating was the highest rating sought. Accordingly, an evaluation in excess of 60 percent is not warranted. 3. Evaluation of atrial flutter Facts are largely the same as the proceeding two sections. The Veteran’s supraventricular tachycardia is currently rated at 10 percent under the criteria of 38 C.F.R. § 4.104, Diagnostic Code 7010. Under Diagnostic Code 7010, a 10 percent rating is warranted for permanent atrial fibrillation (lone atrial fibrillation), or; one to four episodes per year of paroxysmal atrial fibrillation or other supraventricular tachycardia documented by ECG or Holter monitor. A higher and maximum 30 percent rating is warranted for paroxysmal atrial fibrillation or other supraventricular tachycardia, with more than four episodes per year documented by ECG or Holter monitor. In addition to the medical evidence, mainly examinations, mentioned in the prior sections, VA and private treatment records from noted persistent atrial flutter which was corrected by a permanent pacemaker implant on December 2015. The Veteran also had cardiac ablation in December 2015 due to atrial flutter. Based on the foregoing, the Board concludes that a higher rating is not appropriate here. In so finding, the Board notes that VA examinations found that the Veteran has permanent atrial fibrillation. There is no probative evidence showing paroxysmal atrial fibrillation or other supraventricular tachycardia, with more than four episodes per year documented by ECG or Holter monitor. At no point during the appeal period is a rating in excess of 10 percent warranted. Accordingly, a 10 percent rating under Diagnostic Code 7010 is appropriate. The Board has considered the applicability of other diagnostic codes but has found none. Accordingly, the Board finds that a rating in excess of 10 percent is not warranted. The preponderance of the evidence is against the claim, and there is no doubt to be resolved. Effective Dates Unless specifically provided otherwise, the effective date of an award based on an original claim, a claim reopened after final adjudication, or a claim for increase, of compensation, dependency and indemnity compensation, or pension, shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor. 38 U.S.C. § 5110(a). The effective date of an award of disability compensation to a veteran shall be the day following the date of the veteran’s discharge or release if application therefor is received within one year from such date of discharge or release. 38 U.S.C. § 5110(b)(1). VA amended its adjudication regulations effective March 24, 2015, to require that all claims governed by VA's adjudication regulations be filed on standard forms prescribed by the Secretary, regardless of the type of claim or posture in which the claim arises. 79 Fed. Reg. 57660 (Sept. 25, 2014). Given the facts of this case, the amendments are not applicable in this instance and the regulations in effect prior to March 24, 2015, will be applied. Under the applicable regulations, a claim is a formal or informal written communication requesting a determination of entitlement or evidencing belief in entitlement, to a benefit. 38 C.F.R. § 3.1(p). Any communication or action indicating an intent to apply for VA benefits from a claimant or representative may be considered an informal claim. Such an informal claim must identify the benefit sought. 38 C.F.R. § 3.155(a). VA is required to identify and act on informal claims for benefits. 38 U.S.C. § 5110(b)(3); 38 C.F.R. §§ 3.1(p), 3.155(a). However, VA is not required to anticipate any potential claim for a particular benefit where no intention to raise it was expressed. See Brannon v. West, 12 Vet. App. 32, 35 (1998). 4. & 5. Earlier effective date – ischemic heart disease & atrial fibrillation The RO originally granted service connection for ischemic heart disease effective February 9, 2010 and a 30 percent evaluation has been assigned from that date. The assigned effective date of service connection for atrial fibrillation is also February 9, 2010, the original date of claim for heart disorder. There was no claim for any disability prior to this. According to a May 2010 VA examination, coronary artery disease was identified in November 1999. Private treatment records from the year 2000 also note ischemic heart disease and atrial flutter were found in September 1999. The current effective date was assigned based on the receipt of the application in February 2010. Atrial flutter was granted after a July 2017 VA opinion found flutter secondary to coronary artery disease. While VA has established an exception for effective dates for presumptive service connection due to herbicide exposure (Nehmer exception). The Veteran is a Nehmer class member and he is a Vietnam veteran that was diagnosed with a covered herbicide disease. See 38 C.F.R. § 3.816(b)(1). A covered herbicide disease is defined as a disease for which the Secretary of Veterans Affairs has established a presumption of service connection pursuant to the Agent Orange Act of 1991, Public Law 102-4, other than chloracne, as provided in § 3.309(e), which therefore includes ischemic heart disease. See 38 C.F.R. §§ 3.309(e), 3.816(b)(2). The Veteran was not denied compensation for a covered herbicide disease in a decision issued between September 25, 1985 and May 3, 1989 and therefore 3.816(c)(1) does not apply. If a Nehmer class member is entitled to disability compensation for a covered herbicide disease, if the Veteran had a claim for disability compensation for a covered herbicide disease between May 3, 1989 and the effective date of the statute or regulation establishing a presumption of service connection for the covered disease (here August 31, 2010 for ischemic heart disease), the effective date of the award will be the later of the date such claim was received by VA or the date the disability arose. See 38 C.F.R. § 3.816(c)(2); 75 Fed. Reg. 53202 (August 31, 2010) (amending 38 C.F.R. § 3.309 to include ischemic heart disease). Here, the current effective dates are prior to August 31, 2010 and the current date is consistent with the Nehmer rules. We also note that the rules regarding an effective date based upon a liberalizing law is not applicable. The Veteran’s current date is prior to the date of the change in the law. See 38 U.S.C. § 5110(g). While the Veteran’s two heart disabilities manifested prior to the current effective date, there is no evidence of a formal or informal service connection claim for ischemic heart disease prior to the current effective date. 38 C.F.R. § 3.155. The current date of the claim is the correct effective date for the Veteran’s award of service connection for ischemic heart disease. As VA received the Veteran's claim for compensation for a heart disorder after the Veteran’s disability arose, the date of the claim in February 2010 is the correct effective date for the Veteran's award of service connection for ischemic heart disease. Under the circumstances, the effective date is controlled by the date of receipt of the claim. Therefore, entitlement to an earlier effective date for the grant of service connection is not warranted. 5. Schedular TDIU The Veteran contends he has been unable to work due to service-connected disabilities since February 9, 2010. As noted by the April 2020 Statement of the Case, the Veteran filed the most recent claim for TDIU in October 22, 2018. A February 2019 rating decision found the issue moot, as the Veteran’s rating for PTSD was increased to 100 percent, effective October 22, 2018. This same document also noted that earlier claims for TDIU had been withdrawn. The Veteran has repeatedly filed unclear withdrawal statements. The Veteran may have intended to withdrawal the prior TDIU claim. However, as there was CUE found in an earlier March 2011 rating decision, finality therefore did not attach to the 2011 rating decision. A claim for a TDIU is deemed to have been submitted as part of any claim for an increased rating when evidence of unemployability is submitted at the same time as the claim and the Veteran seeks the highest rating possible. See Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001); Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran and representative would be properly raising a claim for TDIU when reporting disagreement to the rating assigned after the RO found CUE. Further, the Veteran submitted a TDIU claim as part of the claim for increased rating and earlier effective date for ischemic heart disease and never withdrew the underlying claim for an increase. Therefore, the claim for TDIU should be considered in conjunction with the claim for an increased rating since February 9, 2010. Here, the Veteran contends his service-connected disabilities render him unemployable. TDIU can be awarded where the scheduler rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16(a). Provided that if there is only one disability, this disability shall be ratable at 60 percent or more, and that, 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. Id. The Veteran's service-connected disabilities have a combined evaluation of 80 percent since January 29, 2013. PTSD has been rated at 50 percent from that same day. For this period, the Veteran meets the schedular requirements for consideration for TDIU under 38 C.F.R. § 4.16(a). Prior to this date, the combined evaluation rating was 40 percent from February 9, 2010 for the two heart disorders rated at 30 percent and 10 percent. Consideration may be given to the Veteran’s education, special training, and previous work experience, but not to his or her age or to the impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19; Hatlestad v. Derwinski, 1 Vet. App. 164, 168 (1991). The Veteran’s other disabilities include prostatectomy rated at 20 percent from January 29, 2013 and 60 percent from September 21, 2015; the two heart disabilities discussed in the prior sections, diabetes type 2 at 20 percent from January 29, 2013, left and right lower extremity neuropathy at 10 percent from January 29, 2013 and 20 percent from October 22, 2018; and one non-relevant disability at 0 percent disabling. Along with the Veteran’s already mentioned disabilities in the prior section. From January 2013, the RO found PTSD manifested with difficulty in establishing and maintaining effective work and social relationships, disturbances of motivation and mood, occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), anxiety, chronic sleep impairment, depressed mood, and suspiciousness. An October 2013 PTSD examination noted anxiety, depression, paranoia, social isolation, multiple failed marriages, and no interest in leisure pursuits. A February 2015 VA examination was largely the same, it does report that the Veteran spends most of his time at home and was unable to cut the grass anymore due to neuropathy of the lower extremity. He had no relationships with his children, having not seen his daughter for five years and his son for 10 years, as a result of his psychiatric symptoms. The Veteran retired as an insurance salesman in 2000; the Veteran had worked as an independent contractor, meaning he worked for himself, and he maintained the job because he did not want to work around a lot of people, as such stimuli (being around people) triggers his PTSD. He tries to avoid these triggers. The Veteran reported that his wife complains about his frequent patterns of irritability. An October 2013 VA mental health note reported that the Veteran described negative alterations in cognitions and mood associated with military events including negative beliefs about others; diminished interest/participation in activities; feelings of detachment from others; and inability to experience positive emotions. The Veteran also reported difficulty sleeping (averages four hours per night and has trouble falling and staying asleep) and hypervigilance. The note reports that the Veteran retired in 2000 after working as an insurance agent. Functional impacts reported on VA examinations for service-connected disabilities include not able to do heavy duty work (February 2013), he would be limited to light sedentary/light duty work (October 2015), and limitations with strenuous activities (March 2017). For prostatectomy, the Veteran wears Depends when leaving the house (according to a December 2013 VA examination) due to urinary incontinence for the last eight years. He requires the use of the bathroom from between ever two hours (February 2015 VA examination) to every hour (March 2015 hearing) In October 2020, a certified rehabilitation counselor (Z.F) submitted a 17-page vocational report noting review of all 5000 plus pages of the Veteran’s file as well as interviewing the Veteran. This document notes that the Veteran only worked 20 hours a week after 1993 due to his cardiac symptoms and reduced his hours down to three to four hours by the year 2000. Z.F. reported that the Veteran had chronic fatigue, dyspnea, angina, dizziness with minimal physical exertion, chronic lower extremity pain and numbness, difficulty standing and walking, the need for excessive unscheduled breaks to adjust and use the restroom, severe limitations on concentration and focus, urinary incontinence, severe difficulty maintaining appropriate social behavior, and difficulty interacting with others (coworkers, peers, and the general public) due to service-connected disabilities since at least February 2010, specifically due to his heart disorders and neuropathy of the feet. The Veteran reported became dizzy after walking for ten minutes while working. Regarding PTSD, the Veteran would be off task, unreliable, and performing below expected productivity level for acceptable industry standard since January 2013. Given the above, the Board finds that from January 29, 2013, the Veteran would be unable to secure or follow a substantially gainful occupation, as his PTSD symptoms would cause the Veteran to be unable to successfully interact and work with other people, including co-workers, the general population, or employers; would prevent him from being able to concentrate in an employment setting or have interest and motivation to engage in employment activities. In addition, his other service-connected disabilities would cause functional impacts outlined above, including limitation to only light duties, needing frequent breaks for use of the bathroom, frequent adjustment when sitting due to urinary and lower extremity issues, and difficulty walking and standing. Given all of the above, the Veteran be unable to secure or follow a substantially gainful occupation. The Board finds that the evidence supports a finding that the Veteran is unable to secure and follow any substantially gainful occupation because of his service-connected disabilities. Given the above, the Board finds entitlement to TDIU is warranted from January 29, 2013. REASONS FOR REMAND 1. Extraschedular TDIU The Veteran’s service-connected disabilities do not meet the schedular requirements for TDIU under 38 C.F.R. § 4.16(a) prior to January 29, 2013. However, the evidence already refered to above in the prior sections indicates the Veteran may not be able to work due to service-connected disabilities prior to January 23, 2013.   The Veteran’s claim for TDIU is being remanded and referred to VA’s Director of Compensation Service for extraschedular consideration. The matters are REMANDED for the following action: Refer the Veteran’s claim for TDIU to VA’s Director of Compensation Service for extraschedular consideration for the period from February 9, 2010 to January 29, 2013. H. N. SCHWARTZ Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P. Yoffe, 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.