Citation Nr: 21012346 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 15-41 598 DATE: March 4, 2021 ORDER Entitlement to service connection for blood clots other than deep vein thrombosis is denied. Entitlement to service connection for deep vein thrombosis is denied. Entitlement to service connection for the residuals of meningitis is denied. Entitlement to an evaluation in excess of 30 percent for sinusitis is denied. Entitlement to a compensable evaluation for post-operative residuals of pinguecula is denied. Entitlement to an evaluation in excess of 60 percent for asthma is denied. Entitlement to an evaluation in excess of 30 percent for bipolar disorder is denied. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) from September 2, 2010 is granted. REMANDED The issue of entitlement to service connection for hypothyroidism is remanded. FINDINGS OF FACT 1. The preponderance of the evidence of record is against finding that the Veteran has had blood clots other than deep vein thrombosis at any time during or approximate to the pendency of the claim. 2. The preponderance of the evidence is against finding that deep vein thrombosis began during active service, or is otherwise related to an in-service injury or disease, to include service-connected disabilities. 3. The preponderance of the evidence of record is against finding that the Veteran has had an episode of meningitis or residuals thereof at any time during or approximate to the pendency of the claim. 4. The symptoms of the Veteran’s sinusitis have most nearly approximated more than six non-incapacitating episodes of sinusitis per year characterized by headaches, pain, and purulent discharge or crusting; surgery has not been contemplated during the claims period. 5. The Veteran’s bilateral eye pinguecula does not cause any characteristics of disfigurement. 6. The evidence does not show that at any time during the appeal period, the Veteran’s respiratory disability was productive of FEV-1 less than 40 percent predicted, or; FEV-1/FVC less than 40 percent, or; more than one attack per week with episodes of respiratory failure, or; requires daily use of systemic (oral or parenteral) high dose corticosteroids or immuno-suppressive medications. 7. The evidence supports the finding that for the entire appeal period, the Veteran’s psychiatric disability was manifested by symptoms, in their frequency, severity, and duration, resulting in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, without more severe manifestations that more nearly approximate occupational and social impairment with reduced reliability and productivity, occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. 8. The Veteran’s service-connected psychiatric disability and physical disabilities render her unable to secure or follow a substantially gainful occupation consistent with her education, training, and work experience. CONCLUSIONS OF LAW 1. The criteria for service connection for blood clots other than deep vein thrombosis have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for deep vein thrombosis have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for the residuals of meningitis have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for an evaluation in excess of 30 percent rating for sinusitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.97, Diagnostic Code 6513. 5. The criteria for a compensable rating for bilateral eye pinguecula have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.79, 4.118, Diagnostic Code 6037. 6. The criteria for a rating in excess of 60 percent for asthma have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.97, Diagnostic Code 6602. 7. The criteria for an evaluation in excess of 30 percent rating for bipolar disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.126, 4.130, Diagnostic Code 9432 8. With resolution of reasonable doubt in the Veteran’s favor, the criteria for entitlement to TDIU since September 2, 2010 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16, 4.18, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1990 to March 1994. The Board previously remanded the issue for further development in February 2019. The case has now been returned to the Board for appellate review. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). To establish entitlement to service-connected compensation benefits, a veteran must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010). Service connection may be granted for any disease initially diagnosed after service 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). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). This permits service connection not only for a disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In the case of aggravation by a service-connected disability, a veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Id; see also 38 C.F.R. § 3.310 (b). In addition, for veterans with 90 days or more of active service during a war period or after December 31, 1946, certain chronic diseases, including arthritis and other organic diseases of the nervous system, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Pursuant to 38 C.F.R. § 3.303 (b), where a chronic disease is shown as such in service, subsequent manifestations of the same chronic disease are generally service connected. If a chronic disease is noted in service but chronicity in service is not adequately supported, a showing of continuity of symptomatology after separation is required. Entitlement to service connection based on chronicity or continuity of symptomatology pursuant to 38 C.F.R. § 3.303 (b) applies only when the disability for which the Veteran is claiming compensation is due to a disease enumerated on the list of chronic diseases in 38 U.S.C. § 1101 (3) or 38 C.F.R. § 3.309 (a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In its determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran’s particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). 1. Blood clots other than deep vein thrombosis 2. Deep vein thrombosis The Veteran filed a claim for entitlement to service connection for blood clots, together with deep vein thrombosis in September 2010. A review of the evidence indicates that the Veteran sought treatment for deep vein thrombosis in the right lower extremity in June 2007. A June 2007 VA treatment record indicates that the etiology of deep vein thrombosis was unknown at this time and that it was likely related to recent long car trip. Coumadin was prescribed. A December 2007 VA treatment record indicates that she had had intermittent therapy over the last 6 months with a recent episode of pain and swelling in the right leg, but a test did not reveal deep vein thrombosis and she was advised to stop taking Coumadin. The record notes past medical history of deep vein thrombosis due to a prolonged auto ride and no serological etiology of deep vein thrombosis was found. Moreover, this recent episode was deemed not related to deep vein thrombosis because pain and swelling resolved spontaneously. A May 2008 VA treatment record indicates that she had finished 6 months on Coumadin and on exam, there was no concerning feature related to deep vein thrombosis. A September 2016 VA treatment record indicates that she complained about pain in the right calf since the night before. She reported history of “blood clot,” but did not recall which leg the past incident was present except for taking Coumadin. First, the weight of the evidence is against finding that the Veteran has had blood clots other than in her leg. Indeed, during an August 2012 VA examination, the Veteran stated that she had a blood clot in her leg years ago, but she did not want to claim for the condition. The rest of the evidence does not show that the Veteran has a current diagnosis related to blood clots other than deep vein thrombosis. Thus, the claim for service connection for blood clots other than deep vein thrombosis is denied. As for deep vein thrombosis, the evidence shows that the Veteran has had pain in the right calf, which she associated with her past episode of deep vein thrombosis, diagnosed prior to the filing of the claim. The evidence, however, does not show any in-service incurrence. Her service treatment record does not reflect disability, complaint, or symptom related to deep vein thrombosis. Moreover, the weight of the evidence is against a finding that deep vein thrombosis is related to her service. In fact, the medical evidence of record shows that her deep vein thrombosis resulted from driving for a prolonged period of time. Lastly, the evidence does not indicate that her deep vein thrombosis is proximately due to or aggravated beyond natural progression by a service-connected disability. Accordingly, the claims must be denied. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the claims, the doctrine is not for application. 38 U.S.C. § 5107. 3. Meningitis The Veteran filed a claim for service connection for meningitis in September 2010. A review of the post-service evidence indicates that the Veteran had an episode of meningitis approximately around 2007 after a shunt revision related to her service-connected pseudotumor cerebri. The evidence does not show that she has had a current episode of meningitis or any residuals thereof, during the appeal period. The Veteran indicated that after having meningitis, she noticed having some memory problems on multiple occasions during mental health assessment. See e.g., December 2013 VA psychology note. However, the Board notes that memory issues have already been evaluated as a symptom of her service-connected bipolar disorder, as discussed below in the increased rating claim for the psychiatric disability. Therefore, the weight of the evidence is against finding that the Veteran has a residual of meningitis. In the absence of competent evidence that a current chronic disability exists, the criteria for establishing service connection for a finger disability have not been established. 38 C.F.R. § 3.303; see Brammer v. Derwinski, 3 Vet. App. 223, 225 (1993) (finding that without proof of a current disability, there can’t be a valid claim for service connection). Accordingly, the Board concludes that the preponderance of the evidence is against the claim for service connection for meningitis, and the benefit-of-the-doubt rule enunciated in 38 U.S.C. § 5107 (b) is not for application. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, 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. The Veteran filed a claim for increased rating in September 2010 and is requesting higher ratings for the already established service-connected disabilities. As such, the present disability level is the primary concern and past medical reports do not take precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, “staged” ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). 4. Sinusitis The Veteran’s sinusitis is rated as 30 percent disabling under Diagnostic Code 6513. Under Diagnostic Code 6513 for sinusitis, a 10 percent disability rating is awarded for sinusitis manifested by one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or by three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting; a 30 percent disability rating is awarded for sinusitis manifested by three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or by more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting; and a 50 percent disability rating is awarded for sinusitis following radical surgery with chronic osteomyelitis, or manifested by near constant sinusitis characterized by headaches, pain, and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. An incapacitating episode of sinusitis is one requiring bed rest and treatment by a physician. 38 C.F.R. § 4.97. The Board finds that the Veteran’s symptoms documented in the evidence of record do not more nearly approximate the criteria for a rating higher than 30 percent. A 50 percent rating requires either radical surgery with chronic osteomyelitis, which is not shown; or, near constant sinusitis with symptoms such as headaches, pain, and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. The evidence does not include radical surgery with chronic osteomyelitis, or purulent discharge or crusting after repeated surgeries. As reported during the December 2019 VA examination, the Veteran reported she had frequent sinus pain, blood mucus, and crusting of nasal discharge in the morning and also reported having 7 or more non-incapacitating episodes in a 12-month period. The Veteran did not report incapacitating episode and she has never had a sinus surgery. The rest of the medical evidence does not indicate that she had a surgery since then. Thus, the 50 percent rating criteria under Diagnostic Code 6513 are not more nearly approximated. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.97, Diagnostic Code 6513. Therefore, an evaluation in excess of 30 percent for sinusitis is not warranted. As the preponderance of the evidence is otherwise against the increased rating claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 4.3, 4.7. 5. Residuals of bilateral pinguecula The Veteran’s bilateral pinguecula is rated non-compensable under Diagnostic Code 6001, a code for keratopathy. An appropriate code for the Veteran’s bilateral pinguecula is Diagnostic Code 6037, the code for pinguecula. Thus, the Board evaluates the Veteran’s pinguecula under Diagnostic Code 6037. Diagnostic Code 6037 applies to rating pinguecula and instructs to rate based on disfigurement (Diagnostic Code 7800). The Board notes that during the pendency of the appeal, VA issued a final rule revising the portion of the VA Schedule for Rating Disabilities that addresses the organs of special sense and schedule of ratings-eye. 89 Fed. Reg. 15316 (Apr. 10, 2018). However, Diagnostic Code 6037 was not amended. Diagnostic Code 7800 provides ratings for scars or disfigurement of the head, face, or neck. These rating criteria were amended once during the appeal period. See 83 Fed. Reg. 32592 (Aug. 13, 2018). Under both versions of the rating criteria, a 10 percent rating is warranted for one characteristic of disfigurement. There are eight characteristics of disfigurement: (1) scar 5 or more inches in length; (2) scar at least one-quarter inch wide at widest part; (3) surface contour of scar elevated or depressed on palpation; (4) scar adherent to underlying tissue; (5) skin hypo- or hyper-pigmented in an area exceeding six square inches; (6) skin texture abnormal in an area exceeding six square inches; (7) underlying soft tissue missing in an area exceeding six square inches; and (8) skin indurated and inflexible in an area exceeding six square inches. 38 C.F.R. § 4.118. In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. See 38 C.F.R. § 4.31. Here, the evidence shows that the Veteran underwent pingueculectomy in both eyes while in service. However, the weight of the evidence is against finding that the Veteran had recurring pinguecula in either eye or the status post pingueculectomy resulted in any residual disability, to include scarring. In fact, a November 2019 VA examination reflects a finding of no scarring or disfigurement in the eyes. Moreover, the examiner noted that the Veteran’s pinguecula is no longer present and thus resolved. The examination and the evidence of record indicate that the Veteran has visual field defect; however, this visual impairment has been attributed to another service-connected idiopathic intracranial hypertension (pseudotumor cerebri) and the rating for that disability incorporates an evaluation of the Veteran’s visual field loss. Therefore, a compensable evaluation for pinguecula is not warranted. As the preponderance of the evidence is otherwise against the increased rating claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 4.3, 4.7. 6. Asthma The Veteran’s asthma is currently rated as 60 percent disabling under Diagnostic Code 6602. Under Diagnostic Code 6602, a 30 percent rating is warranted for FEV-1 of 56 to 70 percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; daily inhalational or oral bronchodilator therapy, or; inhalational anti-inflammatory medication. A 60 percent rating is warranted for FEV-1 of 40 to 55 percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; at least monthly visits to a physician for required care of exacerbations, or; intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. A 100 percent rating is warranted for FEV-1 less than 40 percent predicted, or; FEV-1/FVC less than 40 percent, or; more than one attack per week with episodes of respiratory failure, or; requires daily use of systemic (oral or parenteral) high dose corticosteroids or immuno-suppressive medications. 38 C.F.R. § 4.97, Diagnostic Code 6602. Here, a May 2013 pulmonary function test indicates that the Veteran’s FEV-1 was 82% at worst and FEV-1/FVC was 80% at worst. During a November 2019 VA examination, the Veteran reported that she was getting short of breath. She felt tightness in the chest and found that when she exercised, she felt like she was breathing through a straw and that she could not take a full breath. This had occurred only with exertion in the past and now it happened at rest. The Veteran’s asthma did not require the use of oral or parenteral corticosteroid medications. She intermittently used inhalational bronchodilator therapy. She did not have any asthma attacks with episodes of respiratory failure in a 12-month period prior to the examination. The pulmonary function testing showed FEV-1 at 83 percent predicted at worst and FEV-1/FVC at 81 percent predicted at worst. The examiner determined that the Veteran’s asthma did not impact her ability to work. The medical treatment record during the appeal period indicates that the Veteran was treated for her asthma, but it does not indicate she had asthma attacks with episodes of respiratory failure. The Board finds that the Veteran has manifested respiratory symptoms of the type and extent, frequency, and/or severity do not warrant a 100 percent rating during the entire claim period. The evidence does not show that at any time during the appeal period, the Veteran’s respiratory disability was productive of FEV-1 less than 40 percent predicted, or; FEV-1/FVC less than 40 percent, or; more than one attack per week with episodes of respiratory failure, or; requires daily use of systemic (oral or parenteral) high dose corticosteroids or immuno-suppressive medications. Her symptoms have not met or approximated the criteria for a 100 percent rating at any time during the claim period. Therefore, a rating in excess of 60 percent for asthma is not warranted. 7. Bipolar disorder The Veteran’s bipolar disorder is currently rated as 30 percent disabling under Diagnostic Code 9432, which provides that such disability is evaluated pursuant to the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130. Under the General Rating Formula, a 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted when there is 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 understanding complex commands; impairment of short- 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; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, 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 the 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); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The United States Court of Appeals for the Federal Circuit has held that the evaluation under 38 C.F.R. § 4.130 is “symptom-driven,” meaning that “symptomatology should be the fact-finder’s primary focus when deciding entitlement to a given disability rating” under that regulation. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-117 (Fed. Cir. 2013). The symptoms listed are not exhaustive, but rather “serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating.” Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering “not only the presence of certain symptoms, but also that those symptoms have caused occupational and social impairment in most of the referenced areas” - i.e., “the regulation...requires an ultimate factual conclusion as to the Veteran’s level of impairment in most areas.” Vazquez-Claudio, 713 F.3d at 117-118; 38 C.F.R. § 4.130, DC 9411. Further, when evaluating a mental disorder, the Board must consider the “frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remission,” and must also “assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination.” 38 C.F.R. § 4.126 (a). Turning to the evidence, an August 2012 VA examination reflects a diagnosis of bipolar disorder, not otherwise specified. The examiner found that the Veteran’s psychiatric disability was productive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The examiner noted symptoms of depressed mood, chronic sleep impairment, described as mild-moderate. It is also noted that symptoms were fairly well-controlled with medication according to the VA medical records. The Veteran reported being currently prescribed lithium, quetiapine fumarate, lamotrigine, verapamil (for headaches, but noted by her psychiatrist to help with bipolar), and trazodone. The Veteran reported having symptoms of hypomania and depressed mood. The Veteran reported that her relationship with mother and siblings was good. She attended church and had friends at church. She stated that she had had numerous friends at work, but noted she didn’t see them much after she stopped working. She reported enjoying shopping, going out to eat, and going to movies. She stated she felt she had enough to do most of the time. The examiner noted that she had symptoms of hypomania such as inflated self-esteem or grandiosity, decreased need for sleep, more talkative than usual or pressure to keep talking, flight of ideas or subjective experience that thoughts are racing, distractibility, increased in goal-directed activity or psychomotor agitation, excessive involvement in pleasurable activities, e.g., engaging in unrestrained buying sprees. She also reported having periods of depressed mood characterized by loss of interest, changes in appetite, insomnia or hypersomnia, psychomotor retardation or agitation, fatigue or loss of energy, feelings of worthiness or inappropriate guilt, diminished ability to think or concentrate, and suicidal ideation or thoughts of death. The examiner opined that her bipolar disorder did not render her unable to secure and maintain employment that is either physical or sedentary in nature. The rationale was that her symptoms were mild-moderate and the treatment record showed that she was a history of bipolar disorder and it had been managed well. A June 2016 disability benefits questionnaire (DBQ) by Dr. R.W., submitted by the Veteran, reflects a diagnosis of bipolar I disorder, severe, most recent episode. Depressed with anxious distress. The examiner determined that the Veteran’s bipolar disorder was productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The Veteran reported her inability to maintain healthy intimate/social relations since service and she correlated this to her bipolar disorder. As for her occupational history, she reported that she had taught for 13 years since military until her bipolar symptoms prevented her from working; she reported having sought emergency care twice due to severe mood instability. She had not worked since then and received social security benefits since 2010. The examiner identified the following symptoms: depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively, chronic sleep impairment, mild memory loss such as forgetting names, directions or recent events, impairment of short and long term memory, flattened affect, difficulty in understanding complex commands, impaired abstract thinking, gross impairment in thought processes or communication, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, inability to establish and maintain effective relationships, suicidal ideation, obsessional rituals which interfere with routine activities, impaired impulse control, neglect of personal appearance and hygiene, intermittent inability to perform activities of daily living, disorientation to time or place. The examiner indicated that the Veteran admitted to some suicidal ideation since the military, but then also noted that she denied ever having any suicidal/homicidal ideation. This private examiner provided a separate note that assesses the Veteran’s psychiatric disability. In the note, the examiner opined that her bipolar disorder is mentally and emotionally debilitating and causes functional impairments in daily living, social and work activity and continued that the symptoms were severe enough to preclude her from sustaining substantial, gainful employment since September 2010. The examiner noted that the Veteran preferred to stay home most of the time and usually only left the house for brief trips to grocery store, doctor’s appointments, and absolute necessities. On most days, she felt depressed, tried, lethargic and irritable. As for personal hygiene, the Veteran reported having gone a few days up to a week without showering, grooming, or basic self-care and she struggled some days just to get out of the bed. The rest of the note consists of summary of the evidence found in the claims file, citation to medical literature, and the examiner’s evaluation of the Veteran’s psychiatric disability, mostly as noted in the DBQ portion of the report. A November 2019 VA examination reflects a diagnosis of bipolar II disorder. The examiner found that the Veteran’s bipolar disorder was productive of occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. At the examination, the Veteran reported she had received her teaching degree in 1986. She was a manager for a large independent distributor of machine components for three years. She started her teaching career and taught until 2010, when she was not able to perform her duties as a teacher and felt the “home environment” of the school was no longer in place. She stated that it was at this time that she had an interpersonal issue with superintendent and she decided to stop teaching. The symptoms identified are depressed mood, chronic sleep impairment, mild memory loss, disturbances of motivation and mood. The examiner observed that she was casually dressed. She had some difficulty with memory for dates (long term). She denied suicidal or homicidal ideation or intent. She did not appear to be in emotional distress. A review of the medical treatment records during the appeal period indicates that the Veteran’s bipolar disorder has been managed by medications, with minimum psychotherapy. A December 2013 mental health consult conducted in preparation of her bariatric surgery indicates that the Veteran reported she had retired from work in 2010 due to asthma and she felt quite stable on her current regimen. Moreover, it is indicated that she had support from her family members. She was appropriately dressed, groomed, and hygienic. She denied and had no indication of any problems maintaining her appearance or cleanliness. She complained memory problems, though the clinician noted that an objective test indicated her memory functioning was intact. However, it was noted that some minor difficulties were observed with attention and concentration, but insufficiently depressed to be considered an impairment. A March 2015 VA treatment record notes that her bipolar disorder was managed only with medications and she was on Lamictal, lithium, lurasidone, and trazodone. Moreover, a review of the VA treatment records during the appeal period indicates that the Veteran did have some flareup of bipolar disorder when she was off the medications, for instance, in April 2016. She had been in contact with the medical professional, and it appears that flareup was treated with medication adjustment. Over the course of years, the Veteran complained about sleep impairment, which is treated by medications. An August 2017 VA treatment record indicates that the Veteran complained about short-term memory loss and indicated that she was frustrated daily with this issue. She reported that her bipolar disorder was well controlled and declined individual therapy, but she indicated interest in any program to improve her memory. It was also noted that she reported having good relationship with her mother and siblings, with whom she talked weekly. An October 2017 VA treatment record indicates that while she felt more depressed, she hadn’t wanted to get out of the bed. She also complained lack of sleep, low energy, no motivation during depression. Based on the evidence, the Board finds that for the entire appeal period, the Veteran’s bipolar disorder was productive of symptoms such as depressed mood, anxiety, panic attacks, chronic sleep impairment, mild memory loss, difficulty in establishing and maintaining effective work relationships, and impaired impulse control and it was well managed by medication and timely clinical intervention addressing flareups of symptoms when they occurred. The June 2016 private evaluation indicates that the Veteran had more severe symptoms such as near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively, difficulty in understanding complex commands, impaired abstract thinking, gross impairment in thought processes or communication, difficulty in establishing and maintaining effective social relationships, inability to establish and maintain effective relationships, suicidal ideation, obsessional rituals which interfere with routine activities, neglect of personal appearance and hygiene, intermittent inability to perform activities of daily living, disorientation to time or place. The Board finds that those symptoms were not reflected as such or consistent and ongoing in the Veteran’s treatment records during the appeal period, including her contemporaneous report of symptoms and treating clinicians’ observations. Consequently, the June 2016 assessment affords less weight. In sum, the weight of the evidence is for finding that for the entire appeal period, the Veteran’s psychiatric disability was manifested by symptoms, in their frequency, severity, and duration, resulting in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, without more severe manifestations that more nearly approximate occupational and social impairment with reduced reliability and productivity, occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. Thus, the evidence preponderates against an evaluation in excess of 30 percent for the Veteran’s bipolar disorder for the entire appeal period. The benefit of the doubt doctrine is not applicable to the instant claim and his claim for a higher rating for her bipolar disorder must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 8. TDIU The Veteran contends that she is unable to maintain gainful employment due to her service-connected disabilities. September 2010 Report of General Information; June 2011 VA Form 21-8940. See also, November 2020 Appellant’s Brief. A TDIU 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 the result of service-connected disabilities. See 38 U.S.C. § 1155; 38 C.F.R. § 4.16. If the schedular rating is less than total, a total disability evaluation can be assigned based on individual unemployability if the veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disability rated at 60 percent or higher; or two service-connected disabilities, with one disability rated at 40 percent or higher and the combined rating is 70 percent or higher. 38 C.F.R. § 4.16 (a). Here, the Veteran is currently service-connected for pseudotumor cerebri with contraction of visual field, rated at 60 percent, asthma, rated at 60 percent, headaches as secondary to pseudotumor cerebri, rated at 30 percent, bipolar disorder, rated at 30 percent, sinusitis, rated at 30 percent, and pinguecula and slit ventricular syndrome, both rated non-compensable, with combined rating of 90 percent. Thus, she meets the percentage requirements for TDIU on a schedular basis under 38 C.F.R. § 4.16 (a) since September 2, 2010. The Court has held that the term “unable to secure and follow a substantially gainful occupation” in 38 C.F.R. § 4.16 has two components. First, there is an economic component which essentially contemplates an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. Second, there is a non-economic component dealing with the individual veteran’s ability to “follow and secure” employment. For the second component, attention must be given to: (a) the veteran’s history, education, skill and training, (b) the veteran’s physical ability (both exertional and non-exertional) to perform the type of activities (e.g., sedentary, light, medium, heavy or very heavy) required by the occupation at issue, with relevant factors such as lifting, bending, sitting, standing, walking, climbing, grasping, typing, reaching, auditory and visual, and (c) whether the Veteran has the mental ability to perform the type of activities required by the occupation at issue, with relevant factors such as memory, concentration, and ability to adapt to change, handle work place stress, get along with coworkers and demonstrate reliability and productivity. Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). The ultimate question of whether a veteran is capable of substantial gainful employment is not a medical one; rather, that determination is for the adjudicator. See 38 C.F.R. § 4.16 (a); see also Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). The medical evidence addressing the functional effects of a veteran’s disability on his ability to perform the mental and/or physical acts required for substantially gainful employment is relevant to the unemployability determination. See 38 C.F.R. § 4.10 ; Floore v. Shinseki, 26 Vet. App. 376, 381 (2013). When adjudicating entitlement to TDIU, VA is expected to give full consideration to the effect of combinations of disability. Geib v. Shinseki, 733 F.3d 1350, 1353-544 (Fed. Cir. 2013) (quoting 38 C.F.R. § 4.15 ). The Veteran has been unemployed since October 2010. The evidence shows that the Veteran completed college education and worked as a schoolteacher for 13 years before she stopped working in 2010. The Veteran has maintained that she quit the teaching job, though she liked it, due to her disabilities, though which disabilities she emphasized have varied over time. They include asthma, bipolar disorder, pseudotumor cerebri, and headaches, for all of which the Veteran is now service-connected. As for the medical conditions, the evidence shows that during the appeal period, the Veteran underwent multiple shunt surgeries for her pseudotumor cerebri and she frequently sought treatment for her headaches related to pseudotumor cerebri. It appears that the frequency increased a lot in the past couple of years as evidenced by her frequent visits to the Emergency Department for the conditions, as documented in the VA treatment records. Her psychiatric disability still manifested as memory difficulties, sleep impairment, though it was managed by medication very well. Her asthma resulted in tightness in the chess and shortness of breath, which now appeared even while at rest. Lastly, due to visual field defect secondary to pseudotumor cerebri, the Veteran was deemed unable to perform occupations that rely on good peripheral vision. Based on the above, the Board finds that the evidence is evenly balanced as to whether the Veteran is unable to secure or follow a substantially gainful occupation for her skill set and education in light of the combined severity of her service-connected mental and physical disabilities. Given this evidence, and resolving doubt in favor of the Veteran, the Board finds that the Veteran is unable to secure or follow a substantially gainful occupation as a result of her service-connected physical and mental disabilities. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Entitlement to TDIU since September 2, 2010 is therefore granted. REASONS FOR REMAND The issue of entitlement to service connection for hypothyroidism is remanded. A November 2019 psychiatric VA examination notes that the Veteran’s hypothyroidism is relevant to understanding or management of her bipolar disorder. This statement was not elaborated further in the examination. It appears that it is known in the medical field that a number of medications can contribute to hypothyroidism. One such medication is lithium, which is used to treat certain psychiatric disorder. Mayo Clinic, Hypothyroidism, https://www.mayoclinic.org/diseases-conditions/hypothyroidism/symptoms-causes/syc-20350284. Since the Veteran has been taking lithium for her bipolar disorder for some time and she is service-connected for bipolar disorder, a medical opinion is needed to ascertain etiology of her hypothyroidism. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). The matters are REMANDED for the following action: Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s hypothyroidism is at least as likely as not related to service, or otherwise   proximately due to or aggravated beyond its natural progression by service-connected disability, to include bipolar disorder. The impact of treatment and/or medications for her service-connected disabilities must be considered. MICHAEL D. LYON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Y. Taylor, 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.