Citation Nr: 21011193 Decision Date: 03/01/21 Archive Date: 03/01/21 DOCKET NO. 14-11 139 DATE: March 1, 2021 ORDER An initial rating in excess of 30 percent for dizziness is denied. A total disability rating based on individual unemployability due to service-connected disabilities (TDIU) for the period from March 24, 2011 to August 11, 2018 is granted, subject to the regulations governing payment of monetary awards. REMANDED Entitlement to TDIU for the period prior to March 24, 2011 is remanded. FINDINGS OF FACT 1. The Veteran is currently in receipt of the maximum 30 percent rating under Diagnostic Code 6204. 2. The weight of the evidence is against finding the Veteran’s dizziness is more appropriately rated under Diagnostic Code 6205. 3. For the period from March 24, 2011 to August 11, 2018, the Veteran’s service-connected disabilities precluded him from securing or following substantially gainful employment.   CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 30 percent for dizziness have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.87, Diagnostic Code 6204. 2. The criteria for entitlement to TDIU for the period from March 24, 2011 to August 11, 2018 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16 4.18, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1996 to June 2000. These matters are before the Board of Veterans’ Appeals (Board) on appeal from an October 2010 rating decision of a Department of Veterans’ Affairs (VA) Regional Office (RO). A Board hearing was held before the undersigned in May 2017. A transcript of the hearing is of record. These matters were previously before the Board in March 2018 and August 2019 when they were remanded for further development. 1. An initial rating in excess of 30 percent for dizziness is denied. The Veteran and his attorney contend the Veteran is entitled to a rating in excess of 30 percent for his service-connected dizziness. Specifically, they allege the Veteran has Meniere’s syndrome and is entitled to a 60 percent rating under Diagnostic Code (DC) 6205. Generally, disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The Rating Schedule is primarily a guide used in the evaluation of disabilities encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. A Veteran's entire history is to be considered when making disability evaluations. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board acknowledges that with respect to a claim for an increased rating for an already service-connected disability, a Veteran may experience multiple distinct degrees of disability that might result in different levels of compensation. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The following analysis is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The Veteran’s dizziness is currently rated under 38 C.F.R. § 4.87, DC 6204 for peripheral vestibular disorders. Under DC 6204, a 10 percent rating is warranted for occasional dizziness and a 30 percent rating is warranted for dizziness and occasional staggering. A Note provides that objective findings supporting the diagnosis of vestibular disequilibrium are required before a compensable evaluation can be assigned under this code. Hearing impairment or suppuration shall be separately rated and combined. Under DC 6205, for Meniere’s syndrome (endolymphatic hydrops) a 30 percent rating is warranted for hearing impairment with vertigo less than once a month, with or without tinnitus. A 60 percent rating is warranted for hearing impairment with attacks of vertigo and cerebellar gait occurring from one to four times a month, with or without tinnitus. A maximum 100 percent rating is warranted for hearing impairment with attacks of vertigo and cerebellar gait occurring more than once weekly, with or without tinnitus. A Note provides that Meniere’s syndrome shall be evaluated either under these criteria or by separately evaluating vertigo (as a peripheral vestibular disorder), hearing impairment, and tinnitus, whichever method results in a higher overall evaluation. However, an evaluation for hearing impairment, tinnitus, or vertigo and an evaluation under DC 6205 cannot be combined. It is permissible to switch DCs to reflect more accurately a claimant's current symptoms. See Read v. Shinseki, 651 F.3d 1296, 1302 (Fed. Cir. 2011) (holding that service connection for a disability is not severed when the DC associated with it is changed to determine more accurately the benefit to which a veteran may be entitled). Turning to the evidence in this case, a review of the record reflects that the Veteran underwent a VA examination in September 2010. During the examination, the Veteran reported that he began experiencing dizziness episodes in 1999. He stated that he experienced the episodes two to three times per day and that they last about 30 seconds each time. The examiner noted that the Veteran’s episodes seemed to be related to postural changes. It was also noted that MRI scans had been conducted and revealed no definitive diagnosis. The examiner noted that the Veteran denied vertigo and that the etiology of the Veteran’s dizziness was unknown. In a November 2010 report, Dr. L.V. noted that the Veteran had been receiving treatment for dizziness for seven years. It was also noted that the Veteran reported experiencing multiple dizziness episodes per day and that the episodes caused him to lose all sense of balance and that he staggers or grasps onto something to avoid falling down. In February 2011, the Veteran’s wife provided a statement in which she reported that the Veteran has to balance himself by holding onto walls whenever he walks indoors. She also reported that they cannot go dancing anymore because the Veteran is afraid that he will fall. The Veteran also provided a statement in February 2011 in which he reported that his dizzy spells occur almost daily. He stated that, when he has the episodes, he has to grab onto something to prevent falling. He also reported that his condition was interfering with his work as a firefighter, noting that he had to change his work position because having dizzy spells on his job was dangerous. In a December 2012 statement, the Veteran reported that he was prescribed medication for his dizziness. He also reported that he had to quit his job as Fire Chief because it was unsafe for him to complete his job duties with his dizzy spells. In January 2013, the Veteran underwent a General Medical VA examination. He was diagnosed with hearing loss, tinnitus, recurrent otitis media, and status post tympanostomy tube. He also underwent a VA Ear Conditions examination in which he was diagnosed with dizziness of unknown etiology and bilateral tympanostomy tube. He was not diagnosed with Meniere’s syndrome. During the examination, the Veteran reported that his dizziness episodes occur twice per week and last for 30 seconds to 15 minutes. He also reported that, two years ago, he started having headaches that occur with and without the dizziness and that his doctors seemed to think the headaches were related to his dizziness. He stated that no one had been able to determine the etiology of his dizziness, noting that a neurologist had evaluated him. He also reported that his tinnitus occurs separately from his dizziness and that his hearing loss was constant. The examiner noted that the Veteran had signs and symptoms of a vestibular condition including tinnitus, staggering, and dizziness. The staggering was noted to occur one to four times a month and to last for less than one hour. The examiner also noted that the Veteran had serous discharge from the external ear canal and hearing impairment and/or tinnitus, which were signs and symptoms attributable to infections, inflammatory, or other ear conditions. There was no evidence of a benign neoplasm of the ear. It was noted that the Veteran had surgical treatment, bilateral status post tympanostomy tube, in 1979 or 1980, and that there were no residuals as a result of the surgery. Physical examination of the ear revealed the external ear and ear canal were normal (no deformity or loss of auricle) and there was evidence of a bilateral healed tympanic membrane perforation. The Romberg, Dix Hallpike, gait, and limb coordination tests were all normal. The examiner noted that the Veteran’s dizziness impacted his ability to work, noting that it impaired his ability to perform occupational tasks that require operating machinery or being in a situation where he could fall from any height. A January 2013 VA Hearing Loss and Tinnitus examination revealed normal hearing in the right ear, sensorineural hearing loss in the frequency range of 6000 Hertz or higher frequencies in the left ear, and a tinnitus diagnosis. In November 2013, the Veteran underwent an additional VA examination. The examiner diagnosed Meniere’s syndrome or endolymphatic hydrops, vertigo, tinnitus, and hearing loss. The Veteran reported that his dizziness was sometimes followed by headaches and nausea. The examiner noted that the Veteran’s treatment plan included continuous medication, noting the Veteran takes Meclizine when his dizziness gets really bad. The examiner also noted that the Veteran had signs and symptoms of vestibular conditions, including hearing impairment with vertigo and hearing impairment with attacks of vertigo and cerebellar gait that occur one to four times per month for one to 24 hours, tinnitus, vertigo, and staggering that occur more than once weekly and last for one to 24 hours. There was no evidence of a benign neoplasm of the ear. Physical examination of the ear revealed the external ear, ear canal, and tympanic membrane were normal. Gait testing was normal. The Romberg test was abnormal or positive for unsteadiness; however, the Dix Hallpike test and limb coordination tests were normal. The examiner also indicated that the Veteran’s condition impacted his ability to work, noting that the dizziness interfered with his duties as Fire Chief because he was unable to climb ladders and operate machinery. In January 2014, the Veteran underwent an additional VA examination. A review of the examination report reflects that the Veteran reported his dizziness episodes occur several times per day that last from a few seconds to an hour and that he has mild staggering on occasion. The examiner noted that the episodes do not seem to be positional related, noting that the Veteran reported that he sometimes thinks lights in stores trigger the episodes. The Veteran did not describe vertigo and on repeated questioning, described mostly unsteadiness and dizziness without spinning sensations. He reported that when he has episodes if he is driving, he will pull over and let them pass and if he has them at work, he will sit down and let them pass. Physical examination of the ear revealed normal ears. The examiner also noted that the Veteran did not meet criteria for a diagnosis of Meniere’s syndrome as the Veteran did not describe true vertigo or decreased hearing during his attacks and his history and records indicate he does not have any low frequency hearing loss. It was the examiner’s impression that the Veteran has dizziness of unknown etiology and mild hearing loss. The examiner noted a diagnosis of a peripheral vestibular disorder and noted the presence of tinnitus more than once weekly and staggering one or four times a month. Gait, Romberg, and limb coordination tests were normal. Lastly, the examiner noted that the Veteran’s condition impacted his ability to work because it interfered with his ability to climb ladders, be at certain heights, and drive a fire truck. In July 2015, Dr. J.B. provided a medical opinion regarding the Veteran’s dizziness. Dr. J.B. noted that currently the Veteran experienced daily attacks of dizziness that last up to 30 minutes and are immediately followed by headaches, photophobia, and nausea that last several hours. In the opinion, Dr. J.B. reported that the Veteran’s dizziness was more likely than not due to Meniere’s syndrome. In support of the opinion, Dr. J.B. noted that Meniere’s disease is a disorder of the inner ear that is known as idiopathic endolymphatic hydrops, which refers to a condition of increased hydraulic pressure within the inner ear. Excess accumulation in the endolymph can cause symptoms including fluctuating hearing loss, occasional episodic vertigo (usually a spinning sensation, sometimes violent), tinnitus, and aural fullness. Dr. J.B. also noted that the term endolymphatic hydrops is often used synonymously with Meniere’s disease and Meniere’s syndrome, but Meniere’s syndrome is endolymphatic hydrops caused by a specific condition and Meniere’s disease is endolymphatic hydrops of unknown etiology. He indicated that complications of Meniere’s disease include injury due to falls, anxiety regarding symptoms, accidents due to vertigo spells, disability due to unpredictable vertigo, progressive imbalance and deafness, and intractable tinnitus. In May 2017, the Veteran testified at a Board hearing. During the hearing, he indicated that he experienced multiple dizziness episodes per day. He reported that the episodes cause loss of balance and that it interferes with his work, noting that he cannot pass physicals because of his dizziness so he cannot respond to emergencies and that he cannot be on roofs. He also testified that his balance issues cause falls and that his doctor recently suggested he stop driving. In August 2018, the Veteran underwent another VA examination. A diagnosis of dizziness, unknown etiology was noted. Regarding the Veteran’s medical history, it was noted that the Veteran had dizziness episodes since 1998, vertigo (which occurs daily and lasts minutes to an hour), accompanying headaches, and staggering. It was also noted that he was recently prescribed Nortriptyline and Sumatriptan from a neurologist. Physical examination of the ear revealed a normal external ear, ear canal, and tympanic membrane. Gait, Romberg and limb coordination tests were normal. The examiner then opined that the Veteran does not have Meniere’s syndrome; rather, he has dizziness and vertigo which have remained without a definitive diagnosis. The examiner indicated that the most likely diagnosis was vertiginous migraines, which is a known entity of migraine headaches associated with vertigo. The examiner noted that the Veteran fit the pattern for a diagnosis of vertiginous migraines because of his vertigo, sensitivity to noise and light, and episodes of vertigo-dizziness followed with headache. In March 2020, the Veteran underwent another VA examination. The examiner noted a diagnosis of dizziness of unknown etiology. The Veteran reported that his dizziness occurs multiple times per week lasting at least an hour or two. He also reported that he was prescribed Sumatriptan for headaches and over-the-counter Meclizine for his dizziness. The examiner noted signs and symptoms of his vestibular condition include dizziness, headaches, and tinnitus. It was also noted that he had symptoms of infectious, inflammatory, and other ear conditions including purulent drainage of the left ear. There was no evidence of a benign neoplasm of the ear or any residuals for a 1978 surgery. Physical examination of the ear revealed a normal external ear (no deformity or loss of auricle), tympanic membrane, a normal right ear canal, and a left ear canal with purulent drainage. Gait, Romberg test, Dix Hallpike test, and lumb coordination test were normal. There was no evidence of any benign neoplasms. The examiner noted that a January 2020 audiogram showed normal hearing sensitivity in the right ear and conductive hearing loss in the left ear. It was also noted that he had otorrhea in the left ear and bilateral tinnitus that were not directly related to the claimed conditions. In September 2020, a VA examiner opined that the Veteran’s most likely diagnosis was migraine variant (migraine with vestibular aura/vestibular migraine), not Meniere’s syndrome. In support of the opinion, the examiner indicated that the medical evidence of record, including headache examinations from October 2013 and June 2018, support this diagnosis. Additionally, the examiner noted that a 2019 VA neurology note suggested the diagnosis was migraines with vestibular aura and that the neurologist’s opinion would be considered the expert's opinion, superseding other diagnoses relevant to the headache and associated vestibular component. The examiner further noted that there was no evidence of cerebellar gait in the record. The examiner concluded that the Veteran does not have a primary vestibular disorder but a headache disorder with vestibular aura. VA treatment records also provide details regarding the Veteran’s symptoms. In September 2010, it was noted that the Veteran complained of dizziness. He reported experiencing sudden episodes of spinning sensation and feeling as if things and objects were moving. He also reported that the episodes were associated with nausea, tinnitus, and headaches. It was noted that the episodes were getting longer and more frequent. It was also noted that he has baseline hearing loss from recurrent otitis media infections and that it was recommended he place tubes in his ears. A November 2011 note reflects that the Veteran was diagnosed with mild hearing loss and tinnitus. Another note, however, reflects that there were no signs of hearing loss, vertigo, or fullness. The Veteran had ear drainage that was treated with antibiotics. A February 2012 note reflects that the Veteran presented to the emergency room complaining of an earache with sharp pain and drainage. He denied experiencing dizziness, headaches, visual changes, fever/chills, nausea/vomiting, chest pain, cough, or shortness of breath. He was diagnosed with acute otitis media and otalgia. Additionally, it was noted that the Veteran has a normal gait, tinnitus, and mild hearing loss. In December 2012, a note reflects that the Veteran’s dizziness had gotten worse over the past month. Additionally, it was noted that the Veteran reported a history of recurrent dizzy spells and headaches and feeling pressure in the ears. He was diagnosed with otitis media. Additional December 2012 notes indicate the Veteran reported right ear pain and dizziness. He was treated for an ear infection. In February 2013, the Veteran reported two incidents where his dizziness caused him to fall. In July 2013, he reported that he had a headache accompanied with dizziness. He reported that the dizziness included loss of balance, vertigo, nausea, and feeling as if everything is moving. He denied feeling faint or loss of hearing. Another July 2013 note reflects that the Veteran reported headaches and dizziness, noting that he feels imbalances and vertigo. He also complained of tinnitus and nausea and denied vomiting. In September 2013, it was noted that the Veteran had a week of right ear pain and drainage. It was also noted that he has recurrent otitis media, tinnitus, vertigo, and hearing loss. He also had a neurology consult and the clinician reported that the Veteran’s vertigo, tinnitus, and deafness were likely related to his chronic, recurrent ear infections. The neurologist indicated that the Veteran’s history is not very typical of Meniere's disease. In May 2015, the Veteran reported occasional dizziness that occurred two to three times per week and had led to falls in the past. In August 2015, he reported falling while working in his yard because of a dizzy spell. In August 2016, the Veteran reported getting dizzy and falling off a dock at work. He also indicated that his dizziness had increased and that he has about 12 episodes per week. A July 2017 note reflects that the Veteran had recurrent ear infections, tinnitus, vertigo, and headaches and that he was previously evaluated by neurology for Meniere's disease but that it was determined he did not have the condition. In a September 2017 note, it was noted that the Veteran reported a fall due to a dizzy spell. Vertigo was also noted, and the clinician reported that Meniere's disease was likely given the episodic pattern and intact hearing. In August 2018, the Veteran reported episodes of illusory motion with spinning that more likely occurs while walking. He indicated that the episodes last minutes, occur about once per week, and that the vertigo is then followed by a unilateral headache with nausea and photophobia which lasts hours to a day. Finally, an October 2019 note reflects that the Veteran reported a fall due to his dizziness. For the reasons that follow, the Board concludes that the Veteran’s dizziness is not more appropriately rated under DC 6205 for Meniere’s syndrome (endolymphatic hydrops). In this regard, the Board notes that VA can change the DC that a particular disability is rated under so long as the rating under that Diagnostic Code has not been in effect for 20 years. See 38 C.F.R. § 3.951(b); see Murray v. Shinseki, 24 Vet. App. 420, 425 (2011). VA must explain the change in the DC. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Here, service connection for the Veteran’s dizziness has been effective since March 29, 2010; therefore, it has not been in effect for 20 years. However, a preponderance of the evidence of record is against finding the Veteran has a current diagnosis of Meniere’s syndrome or that his symptoms are more appropriately evaluated under Diagnostic Code 6205. As noted above, a January 2013 VA examiner did not diagnose Meniere’s syndrome. Additionally, in September 2013, the Veteran was evaluated by a neurologist who indicated that the Veteran’s symptoms, including his vertigo, tinnitus, and deafness, were likely related to his chronic and recurrent ear infections. The neurologist noted that the Veteran’s history was not very typical of Meniere's disease. A January 2014 VA examiner also opined that the Veteran did not meet criteria for a diagnosis of Meniere's syndrome, noting that the Veteran did not describe true vertigo and, according to his history and records, does not have any low-frequency hearing loss or associated decreased hearing during his attacks. An August 2018 VA examiner also opined that the Veteran did not have Meniere’s syndrome. In support of the opinion, the examiner indicated that the likely diagnosis was vertiginous migraine, which is a known entity of migraine headaches associated with vertigo, because of his pattern with vertigo, sensitivity to noise and light, and episodes of vertigo-dizziness, followed with a headache. Lastly, a September 2020 VA examiner indicated that the Veteran’s likely diagnosis was migraine variant (migraine with vestibular aura/vestibular migraine), noting that medical evidence of record supported the opinion. The examiner also indicated that the neurology note suggested a diagnosis of migraine with vestibular aura and that it was an expert opinion, thereby superseding any other opinions. The examiner further noted that the Veteran does not have a primary vestibular disorder but a headache disorder with vestibular aura. The Board finds these opinions persuasive and places great probative value on them as they contain adequate supporting rationales and reflect adequate consideration of the Veteran’s medical history, including his noted history of ear infections and headaches. The Board acknowledges the medical evidence of record, including a November 2013 VA examination, a private opinion from Dr. J.B., and a September 2017 VA treatment record, which indicate the Veteran does meet criteria for a diagnosis of Meniere’s syndrome. However, the Board places little probative value on the opinions. Regarding the November 2013 VA examination, there was no supporting rationale included in the examination report explaining why the Veteran’s symptoms support a diagnosis of Meniere’s syndrome. Additionally, the Board finds Dr. J.B. failed to provide an adequate rationale supporting his July 2015 opinion that the Veteran’s dizziness was due to Meniere’s syndrome. Although Dr. J.B. provided extensive information about Meniere’s syndrome in general, he failed to adequately explain how that information related to the Veteran and supported the conclusion that the Veteran has Meniere’s syndrome. Lastly, regarding the September 2017 VA treatment record, the Board finds the record does not contain a clear diagnosis as the clinician noted that Meniere’s was “likely.” Additionally, there’s no information explaining how the Veteran’s history and intact hearing supported a diagnosis of Meniere’s syndrome. Consequently, the Board finds the probative value of the evidence against a diagnosis of Meniere’s syndrome outweighs the evidence in favor of a diagnosis for the condition. The Board acknowledges that the Veteran and his attorney contend that, in the absence of a diagnosis of Meniere’s syndrome, it is still appropriate to evaluate the Veteran’s disability under DC 6205 by analogy based on his symptoms. Specifically, in a November 2020 brief, the Veteran’s attorney stated that the March 2020 VA examination report reflects that the Veteran has dizziness, headaches, and bilateral ringing in the ears. However, as explained above, a higher evaluation of 60 percent is warranted where there is hearing impairment with attacks of vertigo and cerebellar gait occurring from one to four times a month, with or without tinnitus. Although the medical evidence has indicated the Veteran experiences episodes of vertigo, VA treatment records and VA examinations have not revealed episodes of cerebellar gait. Gait testing on examinations has been normal and VA treatment records have not reflected evidence of a cerebellar gait. Therefore, the evidence does not more nearly approximate that the Veteran experiences attacks of vertigo and cerebellar gait from one to four times a month. As such a higher 60 percent rating is not warranted based on rating by analogy under DC 6205. The Board has also considered the Note to DC 6205, regarding evaluation by separately evaluating vertigo (as a peripheral vestibular disorder), hearing impairment, and tinnitus. In this case, the Veteran already has separate ratings under DC 6204 for peripheral vestibular disorder and DC 6260 for tinnitus. Regarding hearing impairment, the evidence has shown the Veteran has high frequency hearing loss in the 6000 Hertz level and such hearing loss does not meet the criteria for a separate compensable rating for hearing loss. 38 C.F.R. § 4.85, 4.86. Therefore, the Board concludes it is not more appropriate to evaluate the Veteran’s service-connected dizziness by analogy under DC 6205 for Meniere’s syndrome. The Veteran and his attorney also contend it is more appropriate to rate his condition under DC 8100 for migraine headaches. In this regard, the Board acknowledges that the Veteran’s diagnosis has recently been noted to be vertiginous migraines. However, the Veteran is already separately service-connected for headaches associated with his dizziness, and the evaluation of that condition is not currently before the Board. Lastly, the Board acknowledges the Veteran’s argument that the September 2020 VA examiner was not qualified to provide an opinion as to whether the Veteran has Meniere’s syndrome because the examiner is an OB GYN, as noted in the November 2020 brief. In this regard, the Board notes that VA benefits from a presumption that it has properly chosen a person who is qualified to provide a medical opinion in a particular case. Sickels v. Shinseki, 643 F.3d 1362, 1366 (Fed. Cir. 2011). The presumption is not about the person or a job title; it is about the process. Parks v. Shinseki, 716 F.3d 581, 585 (Fed. Cir. 2013). Even though the law presumes that VA has selected a qualified person, the Veteran may rebut the presumption. Bastien v. Shinseki, 599 F.3d 1301, 1307 (Fed. Cir. 2010). A claimant challenging the qualifications of a VA-selected examiner must set forth specific reasons why the expert is not qualified to give a competent opinion. Id. In the absence of clear evidence to the contrary, VA medical examiners are presumed competent. Sickels, 643 F.3d at 1366; see also Williams v. Brown, 4 Vet. App. 270, 273 (1993); Cox v. Nicolson, 20 Vet. App. 563, 569 (2007). Here, however, the Board finds the Veteran's assertion that the September 2020 VA examiner was not competent to render an opinion on the issue because he is an OB GYN, without more specific allegations and evidence in support thereof, is insufficient to warrant a finding that the presumption has been rebutted. In this instance, the September 2020 examiner relied on the opinion of a VA treating neurologist and a full review of the treatment records to reach his conclusion and indicated that the neurologist’s opinion would be considered the expert opinion. The examiner also indicated that he is a general practice doctor and not just an OB GYN. Thus, the Board concludes the September 2020 VA examiner was qualified to provide the requested medical opinion. Moreover, although the Board has concluded based on the September 2020 opinion and other medical evidence of record that the Veteran does not have a diagnosis of Meniere’s syndrome, the Board has still considered whether he is entitled to a rating by analogy under the criteria for evaluating Meniere’s syndrome. In sum, the Board finds DC 6204 is the appropriate DC for rating the Veteran’s service-connected dizziness as it most accurately reflects the Veteran’s overall disability picture. The Veteran is currently in receipt of the maximum evaluation available under DC 6204; thus, entitlement to a rating in excess of 30 percent for service-connected dizziness is denied. The Board has considered the benefit-of-the-doubt rule; however, since a preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt rule is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. TDIU for the period from March 24, 2011 to August 11, 2018 is granted. The Veteran seeks entitlement to TDIU as he contends that he is unemployable due to his service-connected PTSD, dizziness, headaches, and IBS. 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. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). If there is only one such disability, it must be rated at 60 percent or more, and if there are two or more disabilities, there shall be at least one disability rated at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent. 38 C.F.R. § 4.16(a). For the purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable; disabilities resulting from common etiology or a single accident; disabilities affecting a single body system; multiple injuries incurred in action; or, multiple disabilities incurred as a prisoner of war. Id. The established policy of VA reflects 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). Factors such as employment history and educational and vocational attainments are to be considered. Id. For VA purposes, the term "unemployability" is synonymous with an inability to secure and follow a substantially gainful occupation. VAOPGCPREC 75-91; 57 Fed. Reg. 2317 (1992). The United States Court of Appeals for Veterans Claims (Court) recently held that "substantially gainful occupation" contains both economic and noneconomic components. Ray v. Wilkie, 31 Vet. App. 58 (2019). The economic component "simply means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. Id. The non-economic component requires consideration of the Veteran's history, education, skill, and training, and physical and mental ability to perform the activities required by an occupation. Further, the word "substantially" suggests an intent to impart flexibility into a determination of overall employability, as opposed to requiring the appellant to prove that he is 100 percent unemployable. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). The central inquiry is "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Entitlement to TDIU is based on an individual's particular circumstances. Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). During the period from March 24, 2011 to August 11, 2018, the Veteran had the following service-connected disabilities: an acquired psychiatric disorder to include major depressive disorder and posttraumatic stress disorder (PTSD), rated at 50 percent; obstructive sleep apnea, rated at 50 percent, effective November 14, 2011; dizziness, rated at 30 percent; irritable bowel syndrome (IBS), rated at 30 percent; headaches, rated at 10 percent from December 8, 2012 to May 30, 2018, and 30 percent from May 31, 2018; and tinnitus, rated at 10 percent. The combined rating for the service-connected disabilities was 80 percent from March 24, 2011 and 90 percent from November 14, 2011. As the Veteran’s acquired psychiatric disorder and obstructive sleep apnea were evaluated at 50 percent disabling and the combined total rating was 80 percent from March 24, 2011 to November 13, 2011 and 90 percent for the period from November 14, 2011, his disabilities met the schedular requirements for TDIU during this period. The question remaining is whether the Veteran’s service-connected disabilities rendered him incapable of participating in a substantially gainful occupation. Turning to the evidence, the Veteran reported on his October 2012 VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability, that he is too disabled to work as a result of all his service-connected disabilities. He indicated that he last worked full-time as a fire chief and became too disabled to work in November 2009. In addition, the record contains several opinions which indicate the Veteran’s dizziness affected his duties as a fireman. Specifically, a January 2013 VA examiner opined that the Veteran’s dizziness impaired his ability to perform occupational tasks that required operating dangerous machinery or work at certain heights. Another January 2013 VA examiner opined that the Veteran’s dizziness impacts his ability to perform occupational tasks requiring he operate dangerous machinery or being at certain heights, including working on roofs and ladders. A November 2013 VA examiner indicated that the Veteran’s dizziness rendered him unable to climb ladders or operate machinery while working as Fire Chief. A January 2014 VA examiner indicated that the Veteran’s dizziness episodes impact his ability to work, noting that his ability to climb ladders, be at certain heights, and drive a fire truck is affected. Regarding his IBS, a January 2013 VA examiner opined that the Veteran’s IBS requires he be in close proximity of a restroom and be allowed frequent bathroom breaks. However, November 2013 and August 2015 VA examiners opined that the Veteran’s IBS did not impact his ability to work. Regarding his headaches, a November 2013 VA examiner indicated that the Veteran’s headaches impacted his ability to work, noting that the Veteran reported occasionally missing work due to his headaches. Additionally, a June 2018 VA examiner opined that the Veteran’s headaches impacted his ability to work, noting that the Veteran reported missing an average of four to seven days of work monthly due to his headaches. In June 2011, following a psychiatric evaluation, W.D. opined that the Veteran was not a candidate to seek and maintain employment at the time due to a combination of his medical conditions and difficulties with his mental health issues. On a January 2013 VA PTSD examination, the examiner indicated that the Veteran was able to work. The examiner noted that the Veteran changed jobs because of politics and conflicts with his superiors. It was also noted that the Veteran quit his job due to family issues, not because of an inability to work. In March 2013, the Social Security Administration (SSA) found the Veteran had not engaged in substantial gainful activity from November 2009 to March 2011. The SSA also found the Veteran’s IBS, psychiatric conditions, and dizziness caused significant limitations in the Veteran’s ability to perform basic work activities. However, the SSA ultimately concluded the Veteran was not disabled, noting that he had the residual capacity to perform a full range of work at all exertional levels with some limitations. In April 2014, D.K., Psy.D., noted that there was evidence in the record establishing dizziness as one of multiple medical conditions which impair the Veteran’s ability to function. Therefore, D.K. concluded, “one might reasonably assume that a debilitating condition such as chronic dizziness would affect one’s ability to function on the job (particularly in the veteran’s profession of being a firefighter where such a condition could be dangerous to himself and others).” In January 2017, the Veteran was determined entitled to Vocational Rehabilitation and Employment Services (VR&E). The report reflects that the Veteran was found feasible for employment and that he chose to pursue an associate’s degree in psychology. However, it was noted that the Veteran quit training to take on employment and, while he seemed to have a great deal of problems with his medical issues, appeared able to maintain his employment. An additional note on the report, however, states the Veteran reported working as a custodian at the United States Postal Service (USPS) but that the occupation was not best for the Veteran due to his functional limitations. However, as the Veteran had leave under the Family Medical Leave Act (FMLA) and a reduced work schedule, the job was doable. In May 2017, Dr. A.D. indicated that the Veteran’s PTSD caused deficiencies in most areas, including work, thinking, mood, affect, cognitive functions manifested by poor concentration, impaired impulse control, and chronic sleep impairment, all of which prevented the Veteran from performing a job consistent with his training and experience. During the May 2017 Board hearing, the Veteran reported that he was unemployed from 2010 to 2015 but that he was currently working for USPS as a custodian. He testified that he missed almost 275 hours of work from January 2017 to May 2017 (which would equal about one to two days per week) due to his dizziness and IBS. He also testified that he was able to continue working for USPS, despite his extensive use of leave, because they supported disabled veterans and had sufficient coverage. In June 2018, P.C., a certified vocational evaluator, opined that, due to the Veteran’s chronic symptoms, he is unable to maintain competitive substantially gainful employment on a regular and consistent basis even at the unskilled sedentary level since 2009, when he was last capable of performing the required job tasks of a fireman. P.C. opined that the Veteran’s psychiatric conditions completely interrupt his ability to maintain appropriate relationships with coworkers, supervisors, and the general public and indicated that the Veteran’s symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. It was noted that the Veteran’s past work history and education did not provide him with a transferable skill base to alternative sedentary occupations. Additionally, P.C. noted that, when the effects of the Veteran’s conditions are considered together, they result in a total inability for the Veteran to maintain substantial gainful employment even at the sedentary level. After review of the evidence of record and resolving reasonable doubt in the Veteran’s favor, the Board concludes that a balance of the evidence supports that the Veteran’s service-connected disabilities substantially impacted his ability to secure and engage in types of employment at any exertional level during the period from March 24, 2011 to August 11, 2018. The Board places great probative weight on the opinion provided by P.C. in June 2018 as the opinion is consistent with the record and contains adequate rationale. In addition, the opinion reflects adequate consideration of the Veteran’s work history, education, and skill set in determining that the Veteran was not suitable for sedentary occupations. The Board acknowledges the opinions of record which indicate the Veteran’s service-connected disabilities do not render him unable to secure or follow substantially gainful employment, including a January 2013 VA PTSD examiner’s opinion, the SSA determination, and the January 2017 VR&E report. However, the Board notes that the ultimate question of whether a Veteran is capable of securing or following substantially gainful employment is an adjudicatory determination, not a medical one. See Geib v. Shinseki, 733 F.3d 1350 (Fed. Cir. 2013); Floore v. Shinseki, 26 Vet. App. 376 (2013). Additionally, the Board is not bound by the findings of disability/and or unemployability from an administrative decision from SSA. See Collier v. Derwinski, 1 Vet. App. 413, 417 (1991) (finding that although it is probative evidence to be considered in the claim before VA, an SSA determination is not dispositive or altogether binding on VA since the agencies have different disability determination requirements). Lastly, while the VR&E report indicates the Veteran’s is able to work, it also contains a notation which indicates the Veteran had several issues with his employment as a result of his medical issues. The Board also acknowledges that the Veteran was employed as a custodian at USPS from 2015 to 2018; however, the Board finds the Veteran’s employment at USPS was in a protected work environment. The record reflects that accommodations, namely the grant of extensive amounts of leave, were made for the Veteran while he was employed for USPS. Additionally, as indicated above, the Veteran reported that he was granted about 275 hours of leave during a four-month period. His USPS employee earnings statement supports this contention as it reflects that he used 94 hours of annual leave, 16 hours of sick leave, 72 hours of wounded warrior leave, and 86 hours of leave without pay from January 2017 to May 2017. Furthermore, the evidence reflects that the Veteran ultimately resigned for health reasons.   Based on the foregoing, the Board finds that the overall evidence of record is at least in equipoise as to a finding that the Veteran had difficulty with obtaining and maintaining most occupations due to his service-connected disabilities for the period from March 24, 2011 to August 11, 2018. Therefore, the Board concludes the Veteran is unable to secure or follow a substantially gainful occupation due to his service-connected disabilities. In summary, the Board finds that entitlement to TDIU for the period from March 24, 2011 to August 11, 2018 is warranted. REASONS FOR REMAND Entitlement to TDIU for the period prior to March 24, 2011 is remanded. Although the additional delay is regrettable, the Board finds further development is required before a decision can be made regarding the Veteran’s claim. For the period prior to March 24, 2011, the Veteran had the following service-connected disabilities: dizziness (rated at 30 percent) and IBS (rated at 30 percent). His combined evaluation for compensation was 50 percent. Thus, the Veteran did not meet schedular requirements for TDIU under 38 C.F.R. § 4.16(a). However, evidence of record, including a February 2011 statement from the Veteran, indicates that the Veteran may have been unemployable due to his service-connected dizziness and IBS during the period on appeal. Thus, the Veteran's claim for TDIU should be referred to VA's Director of Compensation Service for extraschedular consideration. The matters are REMANDED for the following action: Refer the claim for entitlement to a TDIU for the period prior to March 24, 2011 to the Director of Compensation Service for an opinion as to whether the Veteran's   service-connected disabilities rendered him unable to secure and follow a substantially gainful occupation, pursuant to § 4.16(b). M. SORISIO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Jiggetts 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.