Citation Nr: 21011744 Decision Date: 03/02/21 Archive Date: 03/02/21 DOCKET NO. 13-29 284 DATE: March 2, 2021 ORDER Entitlement to service connection for a skin disorder of the hands, claimed as spots on the hands, is denied. Entitlement to service connection for a skin disorder of the hands, claimed as spots on the feet, is denied. Entitlement to an initial 70 percent rating for major depressive disorder is granted. Entitlement to a total disability rating based upon individual unemployability due to service-connected disability (TDIU) prior to March 1, 2014, is denied. REMANDED Entitlement to service connection for a left shoulder disorder is remanded. Entitlement to service connection for Raynaud’s phenomena (claimed as bilateral leg condition, edema, swelling of the hands, ankles, legs and feet) is remanded. FINDINGS OF FACT 1. The preponderance of the evidence fails to establish that the Veteran has or had a skin disorder manifested by spots on the hands at any time during the pendency of the appeal. 2. The preponderance of the evidence fails to establish that the Veteran has or had a skin disorder manifested by spots on the feet at any time during the pendency of the appeal. 3. The Veteran's major depressive disorder has been productive of occupational and social impairment with deficiencies in work, family relationships, thinking and mood due to such symptoms as severe depression, social isolation, suicidal ideation, anxiety, and significant disturbances in motivation. 4. Prior to March 1, 2014, the effects of the Veteran’s service-connected disorders did not render her unemployable. CONCLUSIONS OF LAW 1. The criteria for service connection for a skin disorder of the hands, claimed as spots on the hands, are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). 2. The criteria for service connection for a skin disorder of the feet, claimed as spots on the feet, are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). 3. The criteria for a 70 percent rating for major depressive disorder have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.130, Diagnostic Code 9434 (2020). 4. The criteria for entitlement to a TDIU prior to March 1, 2014, are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.16(a) (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1980 to October 1983. In March 2020, the Board remanded the claims for additional development. They have since returned to the Board for appellate disposition. In compliance with the Board’s remand instructions, with respect to the claims herein decided, the Veteran was afforded examinations and updated records were obtained. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In July 2015, the AOJ granted entitlement to a TDIU, effective March 1, 2014, that is, the first date of the month after records showed the Veteran was not employed. However, as the Veteran's TDIU claim was raised during the course of the appeal for increased rating for major depressive disorder, and is therefore part-and-parcel of that claim. The award of a TDIU does not cover the entire period on appeal pertaining to major depressive disorder, which stems from a January 2010 claim. Rice v. Shinseki, 22 Vet. App. 447 (2009); Harper v. Wilkie, 30 Vet. App. 356 (2018); Payne v. Wilkie, 31 Vet. App. 373 (2019). As such, the Board will address the issue of entitlement to a TDIU prior to March 1, 2014. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Pertinent to a claim for service connection, such a determination requires a finding of current disability that is related to an injury or disease in service. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In McClain v. Nicholson, 21 Vet. App. 319, 321 (2007), the Court held that the requirement of the existence of a current disability is satisfied when a Veteran has a disability at the time he or she files the a claim for service connection or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim. However, in Romanowsky v. Shinseki, 26 Vet. App. 289 (2013), the Court held that when the record contains a recent diagnosis of disability prior to a Veteran filing a claim for benefits based on that disability, the report of diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency. With chronic disease shown as such in service (or within the presumptive period under § 3.307), so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). To show a chronic disease in service, a combination of manifestations sufficient to identify the disease entity is required, as is sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). 38 C.F.R. § 3.303(b), applies to only those chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 U.S.C. § 1101. Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 1. & 2. Entitlement to service connection for a skin disorder of the hands and feet, claimed as spots on the hands and feet. The Veteran’s VA outpatient treatment record largely reflect that the Veteran’s skin was normal with no lesions or rashes and no history of a skin disorder. Hyperpigmented spots on the bilateral soles of the feet were noted on VA treatment in June 2009. A lesion was noted on the left arm in 2014, and a questionable dermatofibroma was indicated. Outside of these two notations, no other skin disorder or treatment is indicated. During the Veteran’s Board hearing, she testified that she has spots on her hands and fingers and on the bottom of her feet. She indicated that she had met other people in the military with the same spots. She expressed that she thought the condition was due to going into a gas chamber during basic training, and that she first noticed the spots about a year and a half after service. She reported that her doctor told her they were age spots. On VA skin examination in March 2020, the Veteran reported that her skin condition of the hands and feet began in approximately 1983. She reported that more spots appear every year. The examiner noted that the Veteran had not been treated for a skin condition in the last 12 months. On physical examination, the examiner noted that there was no exposed or other area of the skin impacted by a skin disorder. Under “describe appearance” the examiner noted “none.” In the “Remarks” section of the exam, the examiner commented that there was no diagnosis of a current skin condition confirmed. Objective examination was normal and there was no diagnosis or treatment of spots on the hand or feet. The examiner indicate that the Veteran did not have a current skin condition and did not assign any diagnosis. The examiner also indicated that the Veteran did not previously have a skin condition that had completely resolved. The Veteran was also afforded a hand and finger examination, which was also normal, with no diagnosis indicated. The examiner determined that the claimed skin disorder of the feet and hands was less likely as not incurred in or caused by service. In so finding, the examiner noted that the Veteran’s symptoms were subjective only, and the objective examination was normal. There was no objective evidence of a chronic condition. The claims file was also silent for complaints, diagnosis, or treatment of the claimed hyperpigmentation of the feet or hands. There was no etiology of the current claimed hyperpigmentation and a nexus was therefore not established. The Board emphasizes that Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C. § 1110; see also McClain, 21 Vet. App. 321. While the Veteran was assessed with hyperpigmented spots on the bilateral soles of the feet, no underlying disorder was indicated. Further treatment records and the March 2020 VA examination have yielded normal findings with no skin diagnoses. Accordingly, where, as here, competent medical evidence indicates that the Veteran does not have the disability for which service connection is sought, there can be no valid claim for service connection for the disability. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer, 3 Vet. App. at 225. As there is no disability with respect to the claim, the Board does not reach the issue of whether the claimed disabilities are related to service. As a lay person, the Veteran is competent to report on that which she has personal knowledge, including observations of spots on the skin of the hands and feet, and the Board deems her credible in that regard. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board acknowledges that sometimes symptoms, even without an underlying diagnosis, can still constitute a current disability, for VA compensation purposes, if such symptoms reach the level of a functional impairment of earning capacity. See Saunders v. Wilkie, 886 F.3d 1356, 1367-68 (Fed. Cir. 2018). However, the Veteran has not alleged, and the weight of the evidence does not reflect, that her claimed spots on the hands and feet has had this effect during the period on appeal. In the absence of a current disability, service connection cannot be established. See Holton, 557 F.3d at 1366 (holding that entitlement to service connection requires, among other things, evidence of a current disability); see also Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (upholding VA's interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes). As the preponderance of the evidence is against the Veteran's claims, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating 3. Entitlement to an initial rating in excess of 50 percent for major depressive disorder Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). The Court has held that "staged" ratings are appropriate for any rating claim 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); Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran's major depressive disorder is rated as 50 percent disabling pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9434. Depressive disorder is rated under the General Rating Formula for evaluating psychiatric disabilities other than eating disorders. Under the General Rating Formula, a 50 percent rating is assigned when a psychiatric disorder causes occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-term and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives, own occupation, or own name. The symptoms listed in the rating schedule are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013) the Federal Circuit stated that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." It was further noted that "§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." A March 2009 VA mental health treatment report reflects that the Veteran assessed symptoms of depressed mood more days than not, loss of interest/pleasure in activities, weight loss, poor sleep, feelings of guilt/worthlessness and hopelessness. She described her energy and concentration as “okay.” She denied suicidal ideation. Symptoms of anxiety included excessive anxiety most days, restlessness or feeling on edge, easily fatigue, irritability, and sleep impairment. On mental status examination, she was alert and oriented with a hopeful attitude but resistant to reframing. Concentration, attention, and memory were intact. Speech was of normal rate and tone with appropriate content and logical thought process. Mood was depressed. An assessment of depressive disorder and anxiety disorder was noted. On VA treatment in July 2009, the Veteran underwent cognitive-behavioral and interpersonal therapy for depression and anxiety. She reported that she had continued to struggle with ongoing symptoms of depression and anxiety, which were impacting her relationships and her occupational effectiveness. A January 2010 VA mental health note reflects assessment of anxiety and depression. She reported that her mood had worsened since being arrested and spending a night in jail for domestic violence. She stated that the end of the relationship and the domestic incident had been very distressing. She indicated poor sleep—approximately 3 to 4 hours per night—as well as poor appetite. Maladaptive behaviors including isolation, distancing self from family, poor nutrition, and no longer engaging in exercise were discussed. Mental status examination revealed that the Veteran was adequately dressed and groomed, alert and oriented with intact attention, memory, and concentration. Speech was of normal rate, rhythm and tone. Thought process and content were normal. Mood was depressed with congruent affect. No suicidal or homicidal ideation was evidenced. She was assessed with depressive disorder and anxiety disorder. A June 2012 VA mental health consult reflect that the Veteran reported symptoms of depression, including low energy and concentration. She worked but had missed days. On mental status examination, she was alert, oriented, and adequately groomed. Speech was coherent and well-organized. She displayed good eye contact and appropriate interpersonal interaction. Thought process was logical and goal-oriented. Thought content revealed no evidence of a thought disorder. Her mood was described as depressed and tearful, and affect was moderately constricted in range, appropriate to content. She denied thoughts of suicide/homicide as well as auditory or visual hallucinations. Sleep was poor and appetite intermittent. A September 2012 VA psychiatry inpatient note reflects that the Veteran was seen for an episode of severe depression and suicidal ideation with no plan. She admitted ot thoughts of harming herself, but no plan. She denied homicidal ideation. She denied audio/visual hallucinations. Although she did not feel the need to be admitted, she was very tearful during interview. The Veteran described difficulty dealing with her fibromyalgia pain, and indicated that at times she felt like hurting people, as people would not help her. She noted fleeting suicidal ideation because of her pain and the lack of help. On admission, she displayed good eye contact, normal motor activity, and spontaneous speech. Thought process was good and while mood was initially good, she became angry upon hearing of the recommendation that she be admitted. No delusional thought content was evidenced, but insight and judgement were limited. She was assessed with depressive disorder. In a June 2013 statement, the Veteran’s daughter reported that she had watched her mother’s mental state deteriorate over the years. A statement from friend J.D. reflect that the Veteran frequently declined invitations due to depression. On VA psychiatric examination in September 2013, the Veteran reported close relationships with her 2 children. She also remained close to her parents and siblings. She was not in a relationship and indicated that she did not have any friends. At that time, she was working as a telephone operator, but she felt that it was like working in a hostile work environment. She had been hospitalized in 2012 for suicidal ideation but had not been hospitalized since that time. She was not currently prescribed any psychotropic medication. Her current symptoms included frustration with VA, depressed mood every other day, social detachment, anhedonia, insomnia, fatigue, lack of appetite, some tendencies to miss small details at work, feeling easily overwhelmed, and a decline in short-term memory. On mental status examination, the Veteran presented as dysthymic and tearful. Her memory was described as good, but recall was impaired. Concentration was also impaired. She was alert an oriented. Speech was within normal limits and she was polite and cooperative. Thought content, psychomotor activity were within normal limits. Hallucinations/delusions were denied and insight and judgment were adequate. She denied any current suicidal ideation; though she admitted to thoughts in the past, she denied any intent or past suicide attempts. The examiner diagnosed major depressive disorder, recurrent, moderate. The examiner found the disability to be productive of occupational and social impairment with reduced reliability and productivity. A March 2014 VA behavioral health consult reflects that the Veteran was opposed to mental health treatment and taking an antidepressant. Noted symptoms included moderate depressed mood, decreased interest or pleasure in activities poor appetite, sleep problems, difficulty with concentration and memory, excessive worry or anxiety, irritability, and restlessness. In a June 2014 statement, the Veteran’s former representative indicated that the September 2013 VA examiner failed to consider her condition without the ameliorative effects of her medication (she was on two antidepressants). He argued that her symptoms without medication more closely approximated a 70 percent rating. In addition, the representative pointed out that VA records included a September 2012 report documenting suicidal ideation. A September 2014 VA mental health consult reflects that the Veteran presented with increased depression and decreased appetite. She reported no social life or hobbies; she stopped physical activities due to pain. The Veteran indicated that she cried a lot and did not want to do anything. She stated that she would not hurt herself, but at times thought that it would be okay if she passed away tomorrow. She denied phobias, hyperactivity, or compulsions. She endorsed that she tended to worry in excess. Other symptoms included feelings of helplessness, being prone to tears, and limited motivation and concentration. On VA mental disorders examination in January 2015, the Veteran reported good relationships with her children, but reduced friendships. She indicated that she was “kind of a loner.” She last worked in January 2013 as an office assistant. Symptoms included depressed mood, anxiety, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. On mental status examination, the Veteran was alert and oriented. Her affect was congruent with stated mood and symptoms. She was tearful throughout the examination. Speech was of normal rhythm and content. She maintained focus on topics and appropriately responded to questions. There was no evidence of a formal thought disorder. Insight and judgment were grossly intact. Active suicidal ideation, planning, and intent was denied. The examiner noted that the Veteran reported occasional feelings of hopelessness, lack of pleasure in activities she used to enjoy, reduced appetite, occasional concentration impairments, decreased energy, frequent crying spells, worries that were difficult to control, and a perception that she was a burden on others. The examiner diagnosed major depressive disorder, moderate, recurrent. The examiner further remarked that the Veteran was experiencing moderate to serious symptom severity with moderate to serious impairments of social functioning and moderate impairments of occupational functioning. Specifically, her symptoms of social withdrawal, poor concentration, decreased energy and motivation, and poor sleep were contributing to moderate impairment in physical and sedentary occupational functioning. In January 2016, the Veteran presented for assessment of memory problems. She stated that she was in a constant depression and did not believe that anyone could help her. She had decreased appetite and increased anxiety, as well as short-term memory problems. She indicated that she was very closed to her family. Objectively, the Veteran presented as depressed and tearful with a somatic preoccupation. She was not agitated, delusional, or suicidal at that time. Insight and judgment were reportedly fair. No obvious cognitive impairments were observed. She was assessed with major depression, recurrent, moderate. An August 2016 VA mental health note reflects that the Veteran was referred for anxiety. The Veteran reported anxiety, especially in large stores. She felt the heat rising in her neck and had to leave. She engaged in some activities, such as crocheting, crosswords, and playing with her grandchildren Mental status examination indicated that the Veteran was initially guarded, but later pleasant and cooperative with the examiner. Mood was depressed, while affect was initially irritated, but later bright with wide range. Eye contact, concentration, attention, and memory were within normal limits. Thought processes were logical and goal-directed. Insight and judgment were fair. Unspecific depression and anxiety were indicated. During the Veteran’s April 2017 Board hearing, she testified that her depression had taken over her life. She noted that she was by herself more. Even though she attended family functions, she did not stay as long as she was normally would. She also noted that her pain contributed to her symptoms. She indicated that she crocheted and went to church. She denied thoughts of suicide. On VA examination in March 2020, the Veteran reported that she remained close with her parents and 3 siblings. She was divorced and not in a relationship. She had 2 adult children with whom she got along well. Regarding social support, the Veteran reported that she spent time with a friend and attended church every week. She had not worked since 2012. The Veteran reported that she was hospitalized in 2016 for mental health issues. She denied that she was suicidal or homicidal. She had not received any treatment since then. Her symptoms included depressed mood, feeling discouraged, withdrawal from others and activities, lack of drive, and insomnia. She noted that she was “totally disappointed with the VA.” The examiner noted that the following symptoms applied to the Veteran’s diagnosis: depressed mood, chronic sleep impairment, and disturbances of motivation and mood. The Veteran’s presented with adequate grooming and hygiene. No psychomotor abnormalities were noted. She displayed good eye contact. Affect was depressed and tearful. Speech was normal for volume, rate, and rhythm. She had no unusual perceptual experiences as reported or noted. She was oriented to person, place, time and circumstance. Narrative was linear and there was no evidence of a though disturbance. She denied suicidal or homicidal ideation. The examiner diagnosed major depressive disorder, recurrent, moderate. The examiner indicated that the disability was productive of occupational and social impairment with reduced reliability and productivity. In a September 2020 correspondence, the Veteran reported that she had thought her depression was under control for years, but that she wanted assistance obtaining treatment outside of VA. The aforementioned evidence reflects that the Veteran's psychiatric disorder has been manifested by anger, anxiety, depression, sleep impairment disturbances in motivation and mood, occasional suicidal ideation, isolative behavior, concentration and memory impairment and difficulty maintaining relationships. In the opinion of the Board, the frequency, severity and duration of these symptoms have been productive of occupational and social impairment with deficiencies in work, family relationships, judgment and mood. Such symptomatology is consistent with a higher 70 percent rating. Accordingly, the Board finds that a 70 percent rating is warranted. However, at no point during the period of the appeal is the service-connected major depressive disorder shown to have met the criteria for a rating in excess of 70 percent. As noted, a 100 percent rating requires total occupational and social impairment due to symptoms such as gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives, own occupation, or own name. Although no particular symptom is required, the probative evidence does not show such symptoms as delusions, hallucinations, disorientation to time or place severe memory loss, gross impairment in thought process, persistent danger to herself or others, or grossly inappropriate behavior. While the Veteran was arrested for an incident of domestic violence in 2009, the have been no further incidents indicated in records. Similarly, the presence of suicidal ideation has been indicated with hospitalization on one occasion, but at other times the Veteran has denied suicidal ideation. Therefore, persistent danger to self or others is not demonstrated. Nor has the Veteran presented with symptoms of similar severity. Notably, with respect to social functioning, the record reflects that although the Veteran is socially withdrawn, she reports good relationships with her parents, siblings, and children, and engages in some social activities, such as church and playing with her children. Thus, it cannot be said that she has "total" social impairment, and such is consistent with the findings on examination. Without evidence of more serious social impairment, a higher rating is not warranted. Overall, the Veteran has not demonstrated symptoms consistent with or approximating the general level of impairment warranting a 100 percent evaluation or akin to the symptoms as found in the rating criteria. Mauerhan, supra. The Board has also considered the representative’s contention that the ameliorative effects of psychiatric medication should not be considered. See Jones v. Shinseki, 26 Vet. App. 56, 63 (2012) ("[T]he Board may not deny entitlement to a higher rating on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria."). The record reflects that the Veteran has not been on a consistent medication regimen throughout the appeal period and has at various points declined mental health treatment and medication due to side effects or feared repercussions from VA treatment. Regardless, the symptomatology demonstrated throughout the appeal period and as discussed above, even when the Veteran was noted to be without medication, does not support a rating in excess of 70 percent. Accordingly, the Board finds that a 70 percent rating for major depressive disorder, but no higher, is warranted. In reaching this decision, the Board has considered the benefit-of-the-doubt doctrine. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 55-56. TDIU 3. Entitlement to a TDIU prior to March 1, 2014 VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that the Veteran is precluded, by reason of his service- connected disabilities, from obtaining and maintaining substantially gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. Total disability ratings for compensation based on individual unemployability may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). For the above purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable; (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric, (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. Id. 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). Consideration may be given to the Veteran's education, special training, and previous work experience, but not to her age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). In order for a veteran to prevail in her claim for TDIU, the record must reflect circumstances, apart from non-service-connected conditions, that place him or her in a different position than other veterans who meet the basic schedular criteria. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question is whether the veteran, in light of his or her service-connected disorders, is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. See Van Hoose, 4 Vet. App. at 361. In Geib v. Shinseki, 733 F.3d 1350 (2013), the Federal Circuit held that VA's duty to assist did not require obtaining a single medical opinion regarding the combined impact of all service-connected disabilities. "Indeed, applicable regulations place responsibility for the ultimate TDIU determination on the VA, not a medical examiner." Id. at 1354. Marginal employment shall not be considered substantially gainful employment. For purposes of 38 C.F.R. § 4.16, marginal employment generally shall be deemed to exist when a Veteran’s earned annual income does not exceed the amount established by the U.S. Department of Commerce as the poverty threshold for one person. Marginal employment may also be held to exist, on a facts-found basis (includes but is not limited to employment in a protected environment such as a family business or sheltered workshop), when earned annual income exceeds the poverty threshold. In this case, the Veteran is service connected for major depressive disorder (rated as 50 percent disabling), muscle tension headaches (30 percent) and irritable bowel syndrome (30 percent from October 2011). Her combined rating is 70 percent prior to October 2011, and 80 percent from October 2011. Hence, the Veteran meets the criteria for schedular TDIU rating per 38 C.F.R. § 4.16(a). In this case, the Veteran has reported that she was working through approximately February 2014. An August 2012 Application for TDIU reflects that the Veteran was still working in an administrative role for the City of Rivera Beach. She reported highest gross earnings of over $1000 per month. Her total earned income for the previous 12 months was $18,000. In a September 2014 Application for TDIU, the Veteran reported that she last worked in January 2014, with highest gross earnings of over $2,000 per month. She indicated that her total earned income for the last 12 months was $13,000. A March 2014 report reflects that the Veteran was unemployed for a month. In this case, the Veteran's reported earnings were over the poverty threshold for an individual under age 65 in 2012 and 2013 ($11,945 and $12,119). See Department of Commerce, Bureau of the Census, Poverty Thresholds, https://www.census.gov/data/tables/time-series/demo/income-poverty/historical-poverty-thresholds.html; Bowling v. Principi, 15 Vet. App. 1, 7 (2001) (substantially gainful employment refers to, at the minimum, the ability to earn a living wage, and is not engaged in substantially gainful employment if annual income below the poverty threshold for one person). The record does not otherwise indicate that she was working in a protected environment while she was working. Accordingly, the Board finds that the evidence does not indicate that the Veteran was unable to maintain and sustain gainful employment prior to March 1, 2014. Accordingly, the Board concludes that a TDIU prior to March 1, 2014, must be denied. The benefit-of-the-doubt doctrine is therefore not for application, and the claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55-56. REASONS FOR REMAND Although the Board regrets the delay, upon review of the claims file, the Board believes that additional development on the remaining claims is warranted. 1. Entitlement to service connection for a left shoulder disorder The law provides that VA shall make reasonable efforts to notify a claimant of the evidence necessary to substantiate a claim and requires the VA to assist a claimant in obtaining that evidence. 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159. Such assistance includes providing the claimant a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on a claim. 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159. The threshold for determining whether the evidence “indicates” that there “may” be a nexus between a current disability and an in-service event, injury, or disease is a low one. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). Moreover, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In addition, the Court of Appeals for Veterans Claims (Court) has held "that a remand by this Court or the Board confers on the veteran or other claimant, as a matter of law, a right to compliance with the remand orders." Stegall v. West, 11 Vet. App. 268, 271 (1998). As such, compliance with the terms of the remand is necessary prior to further appellate review, and if not, "the Board itself errs in failing to ensure compliance." Id. As noted in the Board’s prior remand, the Veteran has been assessed with a history of osteoarthritis in the shoulders, as noted in VA treatment records dated in August 2016, March 2017, and March 2018. The Veteran was to be afforded an examination to determine the nature and etiology of the claimed shoulder disability. On the March 2020 VA examination, the examiner indicated that the examination of the left shoulder was normal and no diagnosis was assigned. Therefore, the examiner concluded that a nexus was not able to be established. However, the examiner report reflects that imaging studies were not performed, nor did the examiner comment on the prior assessments of osteoarthritis, as indicated above. Given the foregoing, the Board finds that remand is warranted to afford the Veteran an additional examination with medical opinion based on full consideration of the Veteran's documented medical history and assertions, and supported by clearly-stated rationale. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; Barr, 21 Vet. App. at 312. 2. Entitlement to service connection for Raynaud’s phenomena (claimed as bilateral leg condition, edema, swelling of the hands, ankles, legs and feet) The Veteran contends that she is entitled to service connection for disability manifested by swelling and edema of the legs, ankles, feet, and hands. She has reported that these symptoms onset in service and she has expressed that the disability is related to marching and standing in the cold in service, or related to training in a gas chamber. Service treatment records notes a few instances of complaints related to the hand, thumb and lower extremities. Following service, an August 2000 private treatment records complaint of leg swelling in the front of the shin. She indicated that she experienced the swelling frequently. Objectively, there mild edema in the lower left leg and the leg was shiny. An ultrasound of the left lower extremity was normal. On VA treatment and examination in 2010, a history of possible Raynaud’s phenomena was indicated. In March 2020, the Board remanded this matter to for examination and opinion to determine the nature and etiology the claimed swelling of the upper and lower extremities, to include a possible diagnosis of Raynaud’s phenomena. In rendering the requested opinion, the examiner was asked to elicit a full account of the Veteran’s symptoms of swelling during active service and her current condition. The March 2020 VA examination report reflects that the Veteran was afforded a peripheral nerves examination, at which time no symptoms attributable to a peripheral nerves condition were noted, and a diagnosis related to the claimed swelling was not assigned. However, there is no indication that the examiner elicited a symptom history from the Veteran, as there is no narrative included in the examination report. The prior history of potential Raynaud’s phenomena was not noted, nor were the Veteran’s reports of consistent extremity swelling in and since service noted. Moreover, the Board observes that Raynaud’s phenomena is a vascular disorder, not a peripheral nerves disorder, and therefore a peripheral nerves examination may not be sufficient to confirm the presence of a current disability. See 38 C.F.R. § 4.104 (listing Cold Injury Residuals as a disease of the arteries and veins) Given the foregoing, the Board finds that remand is warranted to afford the Veteran an additional examination with medical opinion based on full consideration of the Veteran’s documented medical history and assertions, and supported by clearly-stated rationale. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; Barr, 21 Vet. App. at 312. Stegall, 11 Vet. App. at 271. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the nature and etiology of the claimed left shoulder disability. Any indicated tests should be accomplished. The examiner should review the record prior to examination, and elicit from the Veteran a detailed medical history. The examiner should identify all left shoulder disorder(s), to include whether a diagnosis of osteoarthritis is appropriate. The examiner is asked to consider and address post-service VA treatment records from 2016 forward noting a history of shoulder osteoarthritis. The examiner should address whether it is at least at likely as not that the Veteran’s left shoulder disorder had its onset in service or within one year of discharge, or is otherwise related to service. The examiner is also advised that the Veteran is competent to report symptoms and treatment and that his reports, including her reports as to the onset and nature of her symptoms, must be taken into account, along with the other evidence of record, in formulating the requested opinions. The examiner should set forth all examination findings, along with the complete rationale for any conclusions reached. 2. Schedule the Veteran for a VA examination(s) to determine the nature and etiology of the claimed swelling of the bilateral upper and lower extremities. Any indicated tests should be accomplished. The examiner should review the record prior to examination, and elicit from the Veteran a detailed medical history. The examiner should identify any disorder related to the Veteran’s complaint of swelling of the bilateral upper and lower extremities, to include whether a diagnosis of Raynaud’s phenomena or other vascular disorder is appropriate. The examiner is asked to consider and address post-service VA treatment records from 2010 noting a history of Raynaud’s. The examiner should address whether it is at least at likely as not that any disorder had its onset in service or within one year of discharge, or is otherwise related to service, to include the reports of hand and leg pain and strain therein. (Continued on the next page)   The examiner is also advised that the Veteran is competent to report symptoms and treatment and that his reports, including her reports as to the onset and nature of her symptoms, must be taken into account, along with the other evidence of record, in formulating the requested opinions. The examiner should set forth all examination findings, along with the complete rationale for any conclusions reached. A. S. CARACCIOLO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. E. Wilkerson, 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.