Citation Nr: 21012132 Decision Date: 03/03/21 Archive Date: 03/03/21 DOCKET NO. 13-22 441 DATE: March 3, 2021 ORDER Entitlement to service connection for a chronic skin condition is denied. Entitlement to service connection for hypertensive vascular disease (HTN), to include as secondary to coronary artery disease (CAD), diabetes mellitus (DM), and posttraumatic stress disorder (PTSD), is denied. Entitlement to service connection for sleep apnea, to include as secondary to PTSD, is denied. Entitlement to an initial compensable rating for bilateral hearing loss is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) is denied. FINDINGS OF FACT 1. The Veteran’s skin condition first manifested many years after his separation from service and is not related to his service or any incident therein, including Agent Orange exposure. 2. The Veteran’s HTN was not incurred in, and is not etiologically related to, military service, including Agent Orange exposure, and was not caused or aggravated by his service-connected CAD, DM, or PTSD. 3. The Veteran’s sleep apnea was not incurred in, and is not etiologically related to, military service, including Agent Orange exposure, and was not caused or aggravated by his service-connected PTSD. 4. Throughout the entire appeal period, the Veteran’s bilateral hearing loss has manifested in no worse than Level I hearing impairment in the right and Level II hearing impairment in the left ear. 5. The Veteran’s service-connected disabilities did not preclude him from securing or maintaining substantially gainful employment prior to October 30, 2019. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a skin condition have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309. 2. The criteria for service connection for HTN have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.310, 3.307, 3.309. 3. The criteria for service connection for sleep apnea have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303, 3.304, 3.310, 3.307, 3.309. 4. The criteria for an initial compensable rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.16, 4.85, 4.86, Diagnostic Code (DC) 6100. 5. The criteria for a TDIU prior to October 30, 2019 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from September 1966 to September 1968, with service in the Republic of Vietnam from January 1967 to January 1968. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from July 2010, January 2013 and July 2013 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO).   The Veteran provided testimony at hearings before a Decision Review Officer (DRO) at the RO in September 2012 and July 2014. Transcripts are of record. The claims were remanded by the Board in June 2015 in order to schedule the Veteran for a requested Board hearing. He withdrew his request in December 2016. The claims were again remanded by the Board in May 2018 and January 2020 for further development. The Board’s remand directives have been substantially completed. See Stegall v. West, 11 Vet. App. 268 (1998).     For the purpose of more accurately reflecting the scope of the Veteran’s claims, the claims for service connection for HTN and sleep apnea have been recharacterized as shown on the title page. Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during active service.  38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Generally, to establish service connection, there must be competent, credible evidence of 1) a current disability, 2) in-service incurrence or aggravation of an injury or disease, and 3) a nexus, or link, between the current disability and the in-service disease or injury. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). In addition to service connection on a direct basis, service connection may also be granted for a disability that is proximately due to or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310; see also Allen v. Brown, 7 Vet. App. 439 (1995). Where there is a chronic disease shown as such in service or within the presumptive period under 38 C.F.R. § 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. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity.  38 C.F.R. § 3.303(b). Service connection may be established for chronic diseases, to include HTN, manifesting to a compensable degree within a year after service. 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309(a). In addition, service connection may be established on a presumptive basis for certain diseases resulting from exposure to herbicide agents, such as Agent Orange, if a Veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period from January 9, 1962 to May 7, 1975, absent affirmative evidence to establish that the Veteran was not exposed to such herbicide agent during that service. See 38 C.F.R. § 3.307(a)(6)(iii). If a Veteran is presumably exposed to an herbicide agent, then there is a presumption of service connection for the specified enumerated diseases.  38 U.S.C. § 1116; 38 C.F.R. §§ 3.307(a) and 3.309(e). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to service connection for a chronic skin condition. The Veteran asserts that his chronic skin condition is related to herbicide agent exposure during his military service in Vietnam. For the reasons that follow, the Board finds that the Veteran’s service connection claim must be denied. First, the Board acknowledges that the present disability element for service connection has been established. The evidence of record shows that the Veteran has been diagnosed with or has had residuals of Seborrheic Dermatitis, squamous cell carcinoma, impetigo, Actinic Keratoses, Seborrheic Keratoses, and basal cell carcinoma, during the appeal period. See August 2020 VA examination. However, the Board notes that service connection is not warranted on a presumptive or a direct basis. The Veteran is presumed to have been exposed to herbicide agents as his military personnel records show that he served in the Republic of Vietnam from January 1967 to January 1968. See DD Form 214. However, the provisions of 38 C.F.R. § 3.309(e) are limited to certain specifically listed conditions, such as chloracne, and do not apply to other skin conditions. Since none of the Veteran’s skin diagnoses are specifically listed, service connection on a presumptive basis in this regard is not warranted. Nonetheless, service connection on a direct basis may still be established. Combee v. Brown, 34 F.3d 1039 (Fed.Cir.1994) (when a veteran is found not to be entitled to a regulatory presumption of service connection for a given disability the claim must nevertheless be reviewed to determine whether service connection can be established on a direct basis). As noted, diagnoses of skin disorders are of record and herbicide exposure has been conceded. However, the probative and persuasive evidence fails to show that the Veteran’s skin disorders began in service or are in any way related to service or any event of service. Specifically, the Veteran’s service treatment records (STRs) contain no mention of any skin disorder symptoms or diagnosis during service other than May 1668 treatment note for dry skin. In addition, on the Veteran’s August 1968 separation Report of Medical Examination form, the medical provider checked “Normal” for “Skin, Lymphatics” and on the Veteran’s August 1968 separation Report of Medical History form, the Veteran himself checked “No” for “Skin Diseases.” Accordingly, in-service onset has not been established. Further, the Veteran underwent a VA examination for his skin condition in August 2020. The Veteran reported having skin lesions from his head to his feet since his separation from service and that he had a number of them surgically removed. The examiner noted a lack of evidence indicating that the Veteran’s skin condition began during service. The examiner opined that the claimed skin condition was less likely than not incurred in or caused by any in-service injury, event or illness. The examiner noted that current medical literature does not support a causal link between the Veteran’s skin condition and exposure to an herbicide agent, to include Agent Orange. The examiner further explained the likely cause of each of the Veteran’s diagnosed skin conditions. In this regard, the examiner noted that Actinic Keratoses, squamous and basal cell carcinomas are caused by ultraviolent sun rays and are more common in fair skinned individuals. This includes childhood sun exposure. The Veteran reported engaging in recreational outdoor activities that result in significant sun exposure, such as golf and outdoor sporting events. The examiner added that his treatment records reveal that he was repeatedly advised to use sun protection. As to Seborrheic Keratoses, the examiner noted that the current medical literature reveals no link between this benign skin condition and Agent Orange exposure. The examiner explained that the condition is likely genetic in nature with a possible link to sun exposure. With regards to Seborrheic dermatitis, the examiner noted that currently there is no known cause for this condition. However, the examiner added that a review of medical literature fails to reveal exposure to Agent Orange as a risk factor for its development. Lastly, the examiner noted that impetigo is a superficial bacterial skin infection caused by a staph infection, and the current medical literature does not show a link between exposure to Agent Orange and the development of impetigo. While the examiner initially indicated that there was a lack of evidence indicating that the Veteran’s skin condition began during service and it is acknowledged that the absence of evidence alone cannot be used to deny the Veteran’s claim, the Board points out that the examiner’s opinion considered the Veteran’s history, complaints, medical and environmental factors, and examination findings. As such, the Board accords great probative weight to the August 2020 VA opinion as the examiner considered all of the pertinent evidence of record, to include the statements of the Veteran, and provided a complete rationale, relying on and citing to the records reviewed.  The examiner also offered a conclusion with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008).  Most importantly, there is no contrary medical opinion of record.  The Board also finds that the medical opinion is consistent with other objective evidence of record. Thus, the Board finds VA opinion probative to address the Veteran’s claim.  A review of evidence of record shows that the Veteran’s skin condition is related to sun exposure. Significantly, a February 1988 private treatment record notes that the Veteran was examined for skin lesions, diagnosed with Actinic Keratoses, and was given samples and information on sunscreens. A September 1994 private treatment record notes that the Veteran had a tremendous amount of actinic damage and deep wrinkling on his skin, and that he spends a lot of time playing golf. A September 2005 private treatment record reveals a diagnosis of Actinic and Seborrheic Keratoses, and notes that the Veteran continued to spend a lot of time in the sun without sun protection. A June 2015 private treatment record also shows that the Veteran underwent a “skin evaluation due to significant UV exposure.” April and August 2018 private treatment records note that the Veteran has been diagnosed with squamous cell carcinoma, Actinic Keratoses and Seborrheic Keratoses, for which he was advised to use broad spectrum sunscreen and wear sun protective clothing. The April 2018 private treatment record also notes that Actinic Keratoses occur within sun damaged skin. In addition, the August 2018 private treatment record notes that Seborrheic Dermatitis is chronic in nature with periods of remissions and flare-ups that may be triggered by stress, and Seborrheic Keratoses are age-related with no treatment necessary as they are benign. In light of the foregoing, the Board finds that service connection for skin condition is not warranted. In reaching this decision, the Board has considered the arguments of the Veteran and his representative in support of his claim.  The Board acknowledges that the Veteran is competent, as a lay person, to attest to factual matters of which he has first-hand knowledge.  Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). However, he is not competent to offer an opinion to an intricate medical question, including a diagnosis of a complex condition or a nexus between a diagnosed disability and his military service. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions).  The determination that the Veteran has a diagnosis of a skin condition as a result of his military service involves examination, laboratory testing, and knowledge of an impact of certain activities of the disease. Further, to the extent that the Veteran is alleging that his skin condition is a result of exposure an herbicide agent during his service in Vietnam, the Board finds that he is not competent to make this assertion as this requires a scientific determination and generally must be established by scientific findings and expert opinion. The Board also considered whether service connection is warranted based on the continuity of symptomatology framework.  38 C.F.R. § 3.303(b). Specifically, at the July 2014 RO hearing, the Veteran’s wife testified that she remembers symptoms of bumps on his arms continuously since his return from service in Vietnam. The Veteran’s wife is competent to report what she personally observed. Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, the evidence contemporaneous to the Veteran’s service and following active service is more reliable as to the state of his health. In this regard, the Veteran’s STRs do not reflect any diagnosis of a skin condition. While his STRs show treatment for dry skin, his separation examination shows no abnormalities or diagnosis related to his skin. This contemporaneous evidence as to his then-existing physical condition, including his medical examination report at discharge (as opposed to his later statements of memory or belief to prove the fact remembered or believed) is particularly probative.  See Fed. R. Evid. 803(3); Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (providing that although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate).  Further, as noted, at his separation examination in August 1968, the Veteran denied having any health issues. As such, the Board finds that the objective, persuasive evidence substantiates the August 2020 VA opinion. Accordingly, even though the Board remains sympathetic to the Veteran’s assertions, the evidence of record does not support his continuity of symptomatology statements.  In sum, upon review of all of the evidence of record, the Board finds that entitlement to service connection for a skin condition is not warranted.  The Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); Gilbert, supra. Thus, the claim is denied.  2. Entitlement to service connection for HTN, to include as secondary to CAD, DM, and PTSD. The Veteran asserts that his HTN is related to his military service, to include secondary to service-connected CAD, DM and PTSD. Upon review of all evidence of record, the Board finds that the Veteran’s service connection for HTN is not warranted. Initially, the Board notes that the first element of service connection is met. The Veteran has been diagnosed with HTN. See August 2020 VA examination. At the outset, the Board notes that service connection on a presumptive basis is not warranted. As noted, the Veteran is presumed to have been exposed to herbicide agents. However, HTN is not one of the disabilities listed under 38 C.F.R. § 3.309(e). In fact, HTN is specifically excluded from the list of diseases associated with exposure to herbicide agents. See 38 C.F.R. § 3.309(e), note 2. As such, the Veteran’s HTN cannot be service connected on a presumptive basis. Nonetheless, service connection can be established on a direct basis or on a secondary basis. Combee, supra. In this regard, although a current diagnosis is present, the probative and persuasive evidence does not show that the Veteran’s hypertension began in service, manifested to a compensable degree within a year of service, is in any way related to service, to include herbicide exposure, or was caused by or aggravated by service-connected disability. STRs are silent for any complaints, treatment, or diagnosis related to HTN. The Veteran’s blood pressure reading was noted as normal on his August 1968 clinical evaluation at separation. The Veteran also did not report any issues related to blood pressure on his Report of Medical History at separation. Accordingly, the Board finds that the second element of in-service incurrence is not met. As to the causal nexus element, the Veteran underwent a VA examination for HTN in August 2020. The Veteran reported that he has had high blood pressure for a long time and that it is related to his military service. He also reported that his blood pressure is well-controlled with medication. According to the January 2020 Board remand directives, the examiner was asked to address whether it is at least as likely as not that the Veteran’s HTN is related to his presumed exposure to herbicide agents. Specifically, the examiner was asked to provide an opinion with consideration of the fact that the National Academies of Sciences, Engineering and Medicine (NAS), upgraded HTN from its previous classification in the category of “limited or suggestive” evidence of a relationship to exposure to Agent Orange to the category of “sufficient” evidence of an association. In response, the examiner opined that the Veteran’s HTN was less likely than not related to his presumed exposure to herbicide agents. The examiner explained that the decision of the NAS to change the classification was motivated in large part by a study that notes a significant increase in self-reported HTN rates in “Vietnam-deployed sprayers.” The examiner noted that the Veteran’s duties would not have required him to handle or spray Agent Orange. The examiner added that while a possible risk of exposure for non-sprayers existed, that cannot outweigh decades of medical literature clearly documenting the Veteran’s HTN. The examiner further opined that it is less likely as not that the Veteran’s service-connected CAD caused or aggravated his HTN. The examiner noted that a review of the Veteran’s records shows that he had HTN prior to his CAD and CAD could not have caused a pre-existing condition. The examiner explained that the current medical literature reveals no evidence that CAD aggravates HTN. Instead, the examiner noted that HTN is a risk factor for CAD and uncontrolled HTN may aggravate CAD. However, as noted, the Veteran’s HTN is well-controlled to the point that he has had his medication decreased. Next, the examiner opined that the Veteran’s service-connected DM less likely than not caused an increase in severity of his HTN. The examiner based this opinion on the fact that upon examination of the Veteran and review of his treatment records, there is no evidence of worsening of his HTN since the development of diabetes. The Veteran’s HTN remains well-controlled despite his DM. Finally, the examiner opined that it is less likely as not that the Veteran’s service-connected PTSD caused or aggravated his HTN. The examiner explained that although mental disease and stress may temporarily elevate blood pressure during an acute phase of the disease, current medical research does not support a finding that the increase is permanent in nature. In other words, essential HTN is not caused by or permanently aggravated by PTSD. The examiner noted that the Veteran has a well-controlled essential HTN and his blood pressure readings show no evidence of an increase due to his PTSD. The Board accords great probative weight to the August 2020 VA opinion. The examiner considered all of the pertinent evidence of record, to include the Veteran’s statements, and provided a complete rationale, relying on and citing to the records reviewed. Moreover, the examiner offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez, supra. The Board is aware of the United States Court of Appeals for Veterans Claims (Court) holding in Ward v. Wilkie, 31 Vet. App. 233 (2019), that a “permanent worsening” of a non-service-connected disability is not required to establish secondary service connection on the basis of aggravation (i.e., aggravation may include temporary worsening of a disability). Nonetheless, based on the totality of evidence of record, the Board finds that the Veteran’s HTN was not aggravated by his PTSD or any other service-connected disability. As noted, a review of the Veteran’s post-service treatment records shows that he has a history of HTN. See July 2008 private treatment record. However, his HTN is well-controlled. See October 2007 private treatment record. In fact, his HTN medication was stopped due to low blood pressure. See January 2008 private treatment record. As such, the objective evidence of record does not substantiate the Veteran’s claim as there is no indication that any service-connected disability, including PTSD, caused an increase in his blood pressure readings. The Board acknowledges the Veteran’s statements attributing his HTN to his service-connected disabilities. See July 2014 RO hearing. Nonetheless, he is not competent to provide a nexus opinion in this case. This issue is medically complex, as it involves internal disease processes and requires knowledge of interpretation of complicated diagnostic medical testing. Jandreau, supra; Woehlaert, supra. Thus, the August 2020 VA opinion is more probative to address the Veteran’s claim. The Board has considered whether service connection is warranted on a presumptive basis for chronic diseases. 38 C.F.R. § 3.309(a). The evidence does not show that the Veteran’s HTN manifested to a degree of 10 percent or more within a year of separation from service; therefore, presumptive service connection under this provision is not warranted. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). The Board also has considered whether service connection is warranted based on a continuity of symptomatology framework. 38 C.F.R. § 3.303(b). In this regard, the Board finds that the evidence contemporaneous to the Veteran’s service and following active service is more reliable in regard to the state of his health. Significantly, his blood pressure readings during his military service were within normal limits and he was not diagnosed with or treated for HTN. This evidence as to his then-existing physical condition, including his medical examination report at discharge (as opposed to his later statements of memory or belief to prove the fact remembered or believed) is particularly probative.  See Fed. R. Evid. 803(3); Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (providing that although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate).  Further, at his separation examination in August 1968, as noted, the Veteran affirmatively denied having any blood pressure issues. Additionally, the evidence of record shows that the Veteran was diagnosed with HTN and his treatment began in the late 1990s/early 2000s. See February 2008 private treatment record; September 2008 SSA record. As such, even though the Board remains sympathetic to the Veteran’s assertions, the evidence of record does not support his continuity of symptomatology statements.  Accordingly, the evidence weighs against the Veteran’s claim and is not in equipoise. Entitlement to service connection for HTN is not warranted. 38 U.S.C. § 5107(b); Gilbert, supra. Thus, the claim is denied.    3. Entitlement to service connection for sleep apnea, to include as secondary to PTSD. The Veteran asserts that his sleep apnea is related to his active military service, to include his service-connected PTSD. For the reasons that follow, the Board finds that the Veteran’s service connection claim must be denied. First, the Board acknowledges that the present disability element for service connection has been established. The Veteran has been diagnosed with obstructive sleep apnea. See August 2020 VA examination. It is also noted that while the Veteran is presumed to have been exposed to Agent Orange during service, sleep apnea is not one of the disabilities listed under 38 C.F.R. § 3.309(e). As such, the Veteran’s sleep apnea cannot be service connected on a presumptive basis of herbicide exposure. The Board also notes that service connection is not warranted on a direct or secondary basis. The Veteran’s STRs do not show complaints, treatment or diagnosis related to his sleep apnea. In fact, the Veteran was not diagnosed with sleep apnea until many years after service, which is a factor that weighs against the claim. See April 2015 private treatment record. Thus, the Board finds that the second element of service connection is not satisfied. As to the nexus element, the Veteran underwent a VA examination for sleep apnea in August 2020. The Veteran reported undergoing a sleep study and currently using CPAP at night. He reported having a history of sleep interruptions due to nightmares. The examiner opined that the Veteran’s sleep apnea was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner based this opinion on the fact that upon review of all of the evidence of record and taking the Veteran’s lay statements into consideration, there is no subjective or objective evidence showing that his sleep apnea symptoms began during military service. Regarding service connection on a secondary basis, the examiner further opined that the Veteran’s sleep apnea was less likely than not caused or aggravated by his service-connected PTSD. The examiner noted that sleep apnea is a biomechanical condition that has no nexus to PTSD. The examiner explained that while studies suggest that comorbid sleep apnea leads to an increase in PTSD complaints, the Veteran has moderate sleep apnea based on two different sleep studies. The examiner added that the current medical literature suggests that treatment for sleep apnea may actually improve PTSD symptoms. The examiner did not suggest that the Veteran’s PTSD aggravated his sleep apnea. The Board finds this opinion, supported by a rationale based on an accurate medical history with clear conclusions and supporting data, is highly probative. Nieves-Rodriguez, supra. The Board acknowledges the Veteran’s assertions that his sleep apnea was caused or aggravated by his service-connected PTSD or related to his military service, including his wife’s statements of him snoring and gasping for air while sleeping since his service. Even though the Veteran is competent to report sleep apnea, he is not competent to provide a nexus opinion in this case. See Jandreau, supra. Similarly, while the Veteran’s wife is competent to report what she personally observed, she is not competent to offer an opinion to an intricate medical question. Layno, supra; Woehlaert, supra. As noted, the Board finds the August 2020 VA opinion more probative to address the Veteran’s claim. The Board also acknowledges the Veteran’s contention that he has experienced symptoms of sleep apnea in service and since service, and that his statements, in conjunction with his spouse’s statements, suggest continuity of symptomatology. However, the continuity of symptomatology framework only applies to certain enumerated diseases. See 38 C.F.R. § 3.309(a). Sleep apnea is not one of the enumerated diseases, and thus, the continuity of symptomatology theory of entitlement is not for application. In light of the foregoing, the Board finds the most competent and probative evidence of record weighs against a finding of service connection for the Veteran’s sleep apnea. As such, service connection is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable. 38 U.S.C. § 5107(b); Gilbert, supra. 4. Entitlement to an initial compensable rating for bilateral hearing loss. The Veteran contends that the severity of his hearing loss warrants a compensable rating. In May 2010 rating decision, the RO granted service connection for bilateral hearing loss and assigned a noncompensable rating effective May 14, 2010, based on November 2012 VA audiological examination findings. The Veteran appealed. For the reasons that follow, the Board finds that a compensable rating is not warranted. Ratings are based on a schedule of reductions in earning capacity from specific injuries or combination of injuries. The ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civil occupations. 38 U.S.C. § 1155. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Hearing loss ratings range from noncompensable to 100 percent based on organic impairment of hearing acuity, as measured by controlled speech discrimination tests in conjunction with average hearing thresholds determined by puretone audiometric testing at frequencies of 1000, 2000, 3000 and 4000 cycles per second. “Puretone threshold average” is the average of the puretone thresholds at 1000, 2000, 3000 and 4000 Hertz. This average is used in all cases (including those in §4.86) to determine the Roman numeral designation for hearing impairment from TABLE VI or VIA. 38 C.F.R. § 4.85, DC 6100. The rating schedule establishes eleven auditory acuity levels, designated from level I for essentially normal hearing acuity, through level XI for profound deafness. The horizontal rows in TABLE VI represent nine categories of the percentage of discrimination based on the controlled speech discrimination test. The vertical columns in TABLE VI represent nine categories of decibel loss based on the puretone audiometry test. The Roman numeral designation is located at the point where the percentage of speech discrimination and puretone threshold average intersect. Id. Under certain exceptional patterns of hearing impairment, auditory acuity levels may be calculated using either TABLE VI, as described above, or TABLE VIA, which derives a Roman numeral designation based solely on the puretone audiometry test. 38 C.F.R. § 4.86. The TABLE that produces the higher Roman numeral will be used. Id. These auditory acuity levels are entered into TABLE VII of the rating schedule to determine the percentage disability rating. 38 C.F.R. § 4.85. As noted, the Veteran underwent a VA audiological examination in November 2012. On examination, puretone thresholds (in decibels) and speech discrimination scores were as follows: Hertz 1000 2000 3000 4000 Average Right ear 45 50 45 45 46.25 Left ear 50 70 65 65 62.5 As shown in the table, objective testing produced a puretone average of 46.25 decibels in the right ear and 62.5 decibels in the left ear. Maryland CNC speech discrimination scores were recorded as 100 percent in the right ear and 96 percent in the left ear. No exceptional patterns of hearing impairment were noted, and the examiner did not indicate that the speech discrimination test was not appropriate. As such, neither ear examination results meet the criteria of § 4.86 and the application of TABLE VIA to those results is not warranted. Applying the right and left ear results to TABLE VI yields a numeric designation of Level I hearing impairment for right ear and Level II hearing impairment for left ear. Entering Level I hearing impairment for the right ear and Level II hearing impairment for the left ear into TABLE VII yields a 0 percent rating. 38 C.F.R. § 4.85, DC 6100. The Veteran underwent another VA audiological examination in September 2017. On examination, puretone thresholds (in decibels) and speech discrimination scores were as follows: Hertz 1000 2000 3000 4000 Average Right ear 35 45 50 35 41.25 Left ear 35 55 80 55 56.25 As shown in the table, objective testing produced a puretone average of 41.25 decibels in the right ear and 56.25 decibels in the left ear. Maryland CNC speech discrimination scores were recorded as 94 percent in the right ear and 98 percent in the left ear. No exceptional patterns of hearing impairment were noted, and the examiner did not indicate that the speech discrimination test was not appropriate. As such, neither ear examination results meet the criteria of § 4.86 and the application of TABLE VIA to those results is not warranted. Applying the right and left ear results to TABLE VI yields a numeric designation of Level I hearing impairment bilaterally. Entering Level I hearing impairment for the right ear and left ear into TABLE VII yields a 0 percent rating. 38 C.F.R. § 4.85, DC 6100. A review of the Veteran’s treatment records shows that he has had a left ear mastoidectomy in 2004 and he wears bilateral hearing aids. See VA treatment records; April 2009 private treatment record. His hearing loss is noted as mild to moderate, which is reflected in both VA examination findings. See February 2019 and February 2020 VA treatment records. Based on review of all of the evidence of record, the Veteran’s bilateral hearing loss does not approximate the criteria more nearly corresponding to a compensable rating. The Board does not discount the Veteran’s assertion of the severity and functional effects of his hearing loss; however, schedular disability ratings for hearing loss are based on the results of the objective audiological studies of record. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). Moreover, the rating criteria for hearing loss contemplate the functional effects of decreased hearing and difficulty understanding speech in an everyday work environment as these are the effects that VA’s audiometric tests are designed to measure. Doucette v. Shulkin, 28 Vet. App. 377 (2017). The Veteran’s bilateral hearing loss does not produce any other functional effects not contemplated by the rating schedule. Id. In sum, a compensable rating for bilateral hearing loss is not warranted. The Board has considered the use of staged ratings; however, the Veteran’s bilateral hearing loss is rated noncompensable for the entire appeal period and at no point during that period has it more nearly approximated the criteria corresponding to a higher rating. Accordingly, the application of a staged rating is not warranted. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119, 126-27 (1999). Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. Doucette, supra. 5. Entitlement to a TDIU. The Veteran asserts that his service-connected disabilities have rendered him unemployable. See May 2017 VA Form 21-8940 (VA 21-8940); June 2017 VA Form 21-4192 (VA 21-4192). For the reasons that follow, the Board finds that entitlement to a TDIU is not warranted. Total disability ratings for compensation may be assigned when a veteran is unable to secure and follow a substantially gainful occupation.  See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16.  In reaching such a determination, the central inquiry is “whether the Veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability.” See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993); also see Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (the ultimate question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment). Additionally, entitlement to a TDIU is based on an individual’s particular circumstances. 38 C.F.R. § 4.16; Ray v. Wilkie, 31 Vet. App. 58, 72 (2019).  Thus, in adjudicating a TDIU claim, VA must consider the individual veteran’s education, training, and work history, but not his or her age or the impairment caused by nonservice-connected disabilities.  See 38 C.F.R. §§ 3.341, 4.16, 4.19.  The phrase “unable to secure and follow a substantially gainful occupation” in 38 C.F.R. § 4.16 has both an economic and a noneconomic component.  Ray, supra. The economic component means an occupation earning more than marginal income outside of a protected environment. Id.  The noneconomic component concerns whether the Veteran is able to “secure or follow” gainful employment.  Id.  In determining whether a Veteran can secure and follow a substantially gainful occupation, in addition to the Veteran’s history, education, skill, and training, the Board should consider whether he or she “has the physical ability (both exertional and nonexertional) to perform the type of activities (e.g., sedentary, light, medium, heavy, or very heavy) required” to work in a substantially gainful occupation, and “whether the Veteran has the mental ability to perform the activities required” to work in a substantially gainful occupation.  Id.   Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when a Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability, this disability shall be ratable at 60 percent or more; 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.  38 C.F.R. § 4.16(a).    For purposes of TDIU, 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, Bureau of the Census. Marginal employment may also be held to exist, on a facts-found basis including, but not limited to, employment in a protected environment such as a family business or sheltered workshop-when earned annual income exceeds the poverty threshold. 38 C.F.R. § 4.16(a). In pertinent part, the Veteran is service-connected for: (1) lymphoma, rated at 100 percent from October 30, 2019; (2) PTSD, rated at 70 percent from May 14, 2010; (3); CAD, rated at 10 percent from December 21, 2009, and 30 percent from September 15, 2010; (4) DM, rated at 20 percent from May 14, 2010; (5) tinnitus, rated at 10 percent from May 14, 2010; (6) bilateral hearing loss, rated noncompensable from May 14, 2010; and (7) erectile dysfunction, rated noncompensable from June 10, 2011. The Veteran’s combined evaluation is 10 percent from December 21, 2009, 80 percent from May 14, 2010, 90 percent from September 15, 2010, and 100 percent from October 30, 2019. The schedular percentage criteria for a TDIU are met from May 14, 2010. Thus, the crux of this case rests upon whether the Veteran has been unable to secure or follow a substantially gainful occupation by reason of his service-connected disabilities from May 14, 2010 to October 30, 2019.   As noted, from October 30, 2019, the Veteran is in receipt of a total schedular rating. Although receipt of a total rating does not necessarily moot the issue of entitlement to a TDIU, here the issue is rendered moot from October 30, 2019 because the Veteran is already in receipt of special monthly compensation (SMC) based on housebound status since that date. Bradley v. Peake, 22 Vet. App. 280, 293-94 (2008). Additionally, the Board notes there is no dispute that the Veteran was employed until December 30, 2015. See VA 21-8940; VA 21-4192. However, the evidence of record shows that the Veteran was working on a part-time basis, earning an amount below the poverty threshold. Id; Social Security Administration (SSA) records. As such, the Board finds that his last position constituted a marginal employment. Accordingly, as noted, the Board will consider and address disabilities for which the Veteran was service connected from May 14, 2010 until October 30, 2019. Turning to the evidence of record, the Veteran’s military occupational specialty (MOS) was a cargo handler. See DD Form 214. He primarily worked as a barber at his barbershop business since his separation from active service. See SSA records; VA 21-8940. With regards to the Veteran’s education level, his education includes barber school. See VA 21-8940. He has technical knowledge or skills, has experience using tools or equipment, and completed reports or other writing at his barbershop business. See SSA records. Based on the foregoing, the Board finds that the Veteran has the proficiency to work in an office-like setting, performing administrative or clerical work. As to the Veteran’s contentions, he asserts that he is unable to work as a barber because of his service-connected PTSD, CAD, DM, and tinnitus. Specifically, he asserts that service-connected PTSD prevents him from securing or following any substantially gainful occupation. See VA 21-8940. The Veteran underwent a VA evaluation for his PTSD in November 2012. The Veteran reported being a barber since separation from military service and working very little. The examiner noted that the Veteran’s PTSD symptoms result in disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships. Specifically, the examiner noted that the Veteran has a depressed mood, anxiety, chronic sleep impairment, irritability or outbursts of anger, difficulty concentrating, exaggerated startle response, and suicidal ideations. The examiner concluded that the Veteran’s symptoms result in occupational and social impairment with occasional decrease in work deficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. A November 2012 VA DM examination report shows that the Veteran reported numbness and tingling in his hands. The Veteran also reported that he last worked on regular basis prior to 2007. The examination revealed mild intermittent pain, numbness, and paresthesias and/or dysesthesias in all extremities. Muscle strength and reflexes were noted as normal. No diabetic peripheral neuropathy was noted. The examiner concluded that the Veteran’s DM does not impact his ability to work. The Board also notes that the Veteran’s current rating for DM and pertinent medical records reflect that regulation of activities is not required to control his disability. See e.g. August 2010 private treatment record; November 2012 VA DM examination report. In February 2017, the Veteran underwent a VA examination for his CAD. The Veteran reported the onset of condition in 2007. He had chest pain and had 3 stents placed. He has had periodic chest pain since then, but he reported no other symptoms that are clearly due to his heart. Upon examination, his heart rate, rhythm and sound were normal. The examiner noted symptoms of dyspnea and angina during an activity. The examiner concluded that the Veteran should avoid jobs with extreme exertion. As to the Veteran’s claims that his hearing issues impact his ability to work, he underwent a VA examination for tinnitus in September 2017. The Veteran reported longstanding tinnitus, but he was unsure of the onset. The examiner noted that the Veteran’s tinnitus does not impact ordinarily conditions of daily life, including ability to work. Although the Veteran reported difficulties hearing, the Board notes that his current rating for hearing loss is noncompensable. The Board finds that VA medical opinions to be highly probative. The opinions were rendered by specialists in their field. Additionally, when rendering the opinion, the examiners reviewed the record including the Veteran’s subjective complaints and objective findings. The examiners also provided reasons to support their opinions, which are consistent with the other objective evidence of record. A review of evidence of record shows that the Veteran underwent a psychiatric evaluation in 2008 for the purpose of determining his Social Security Disability benefits. The examiner noted none to mild functional limitations due to the Veteran’s symptoms. The examiner concluded that the Veteran’s mental impairments are not severe, and he retains the mental-emotional capacity to sustain work-like activities. A general medical examination revealed that the Veteran suffers from angina from his CAD, which precludes his from doing strenuous activities. The examiner also noted that although the Veteran has a complete range of motion, his ability to work with his arms is very limited due to a degenerative joint disease of his shoulders. The examiner concluded that the Veteran is able to carry out activities of daily living, but he is not able to work as a barber full-time. Further, a September 2009 SSA evaluation of the Veteran’s degenerative joint disease of his spine revealed functional limitations. Specifically, he was noted to have a limited ability to lift and carry items and reach in all directions due to his spine disability. The examiner noted that the Veteran has the ability to stand, walk and sit for about 6 hours in an 8-hour workday. While SSA records are not controlling for VA determinations, they may be pertinent to VA claims. See Collier v. Derwinski, 1 Vet. App. 413, 417 (1991); see also Martin v. Brown, 4 Vet. App. 136, 140 (1993). In this regard, the Board notes that the SSA determination and associated records do not reflect a total impairment due to the Veteran’s service-connected disabilities. Rather, the SSA records indicate that the Veteran’s functional/work ability is limited as a result of his nonservice-connected disabilities, including the degenerative joint disease of his shoulder and spine. In light of the foregoing, the Board finds that the Veteran’s service-connected disabilities did not preclude him from being able to secure and maintain substantially gainful employment prior to October 30, 2019. Although it is clear that the Veteran had some difficulties with functioning in a role requiring strenuous physical labor, the Veteran was not precluded from performing a position where heavy labor is not required, consistent with his business ownership experience, such as in an office or similar setting. The evidence shows that he has technical knowledge and skills, experience using tools, and completed reports or other writing at his barbershop. See SSA records. Thus, the Board finds that any accommodations afforded by an employer that would have allowed the Veteran to work on solo projects or use his technical knowledge would be reasonable, not extraordinary. See Cantrell v. Shulkin, 28 Vet. App. 382, 396 (2017) (Lance, J., concurring) (“Where a claimant’s employer is required by law to provide reasonable accommodations pursuant to the ADA and those accommodations allow the claimant to engage in a substantially gainful occupation, a TDIU award would, in effect, constitute a second paycheck on the back of the taxpayer.”). In addition, frequent breaks would have minimalized any difficulties with the Veteran’s intermittent periods of inability to perform occupational tasks noted in November 2012 PTSD VA opinion. Accordingly, the Veteran’s service-connected disabilities would not have impacted his ability to perform administrative or clerical work. The Board also notes that the Veteran has not been found to be precluded from obtaining and/or maintaining employment due to his service-connected disabilities. Indeed, the November 2012 and February 2017 VA examiners found that the Veteran’s PTSD and CAD impact his ability to work, but neither examiner found that his occupational functioning is completely precluded due to such conditions. Additionally, the February 2017 VA examiner opined that the Veteran could perform roles that require minimal strenuous activity. The Board acknowledges the Veteran’s statements that he is unable to maintain employment due to his service-connected disabilities. See VA 21-8940; VA Form 29-4192. Nonetheless, the sole fact that a claimant has difficulty with certain tasks is not enough. The Veteran’s disability rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question, however, is whether the Veteran’s service-connected disabilities alone affect his occupational functioning to the point of rendering him unemployable. See Hatlestad, supra. As explained above, the Board finds that the Veteran’s service-connected disabilities alone do not preclude him from securing or maintaining substantially gainful employment. The Board also acknowledges the fact that the Veteran’s last job constituted marginal employment, as his position as a barber was on a part-time basis. See VA 21-8940; VA 21-4192. However, the evidence does not show that he was capable of marginal employment only due to his service-connected disabilities during the period on appeal. See Ortiz-Valles, supra; Ray, supra. In fact, as a business owner, the Veteran was able to set his own hours or solely perform administrative or managerial tasks, and there is no indication that his service-connected disabilities precluded him from working full-time in another more suitable occupation. See e.g. SSA records. Further, when analyzing whether a TDIU is warranted, the Board considers whether the Veteran has the potential to earn more than marginal income and his employment history, education, skill, and training. Ray, supra. As noted, the Veteran has the proficiency to work in an office-like setting, performing administrative or clerical work. Such an occupation would have likely provided more than marginal income. Accordingly, the Board finds that the Veteran’s service-connected disabilities did not preclude him from obtaining substantially gainful employment prior to October 30, 2019, and a TDIU on this basis cannot be granted. In sum, while the Veteran maintains that his service-connected disabilities prevented him from securing or following any substantially gainful occupation, the evidence does not show that the Veteran was unemployable due to these service-connected disabilities. The preponderance of the evidence is against the claim for a TDIU. As such, the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Therefore, entitlement to a TDIU is not warranted. C. CRAWFORD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Kuzniar, Associate 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.