Citation Nr: 21012856 Decision Date: 03/05/21 Archive Date: 03/05/21 DOCKET NO. 17-66 823 DATE: March 5, 2021 ORDER A rating higher than 50 percent for cervical radiculopathy of the right upper extremity is denied. A rating higher than 20 percent for cervical herniated nucleus pulposus at C5-C6 is denied. Prior to June 18, 2018, an initial 60 percent for coronary artery disease (CAD), is granted, subject to controlling regulations governing the payment of monetary awards. From October 1, 2018, a 100 percent rating for chronic congestive heart failure status-post myocardial infarction (MI) is granted, subject to controlling regulations governing the payment of monetary awards. From October 1, 2018 to March 2, 2020, special monthly compensation (SMC) based on the housebound criteria is granted, subject to controlling regulations governing the payment of monetary awards. From August 11, 2011 to June 18, 2018, a total disability rating based on individual unemployability (TDIU) is granted, subject to the applicable laws and regulations governing the payment of monetary benefits. FINDINGS OF FACT 1. The Veteran’s radiculopathy of the right upper extremity is manifested by no more than severe incomplete paralysis. 2. The Veteran’s cervical spine disability does not result in forward flexion of the cervical spine 15 degrees or less; favorable ankylosis of the entire cervical spine is not shown. 3. Prior to June 18, 2018, the Veteran’s CAD was manifested left ventricular dysfunction with an ejection fraction of 30 to 50 percent. 4. From October 1, 2018, the Veteran has chronic congestive heart failure status-post MI. 5. From October 1, 2018, the Veteran has a 100 percent disability rating for congestive heart failure status-post MI and additional service-connected disability independently rated at 60 percent or more. 6. From August 11, 2011 to June 18, 2018, the Veteran’s service-connected disabilities preclude him from securing or following substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for a rating higher than 50 percent for radiculopathy of the right upper extremity are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code (DC) 8610. 2. The criteria for a rating higher than 20 percent for a cervical herniated nucleus pulposus at C5-C6 are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5237. 3. The criteria for an initial 60 percent rating for CAD, prior to June 18, 2018, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.104, DC 7005. 4. The criteria for a 100 percent rating for congestive heart failure status-post MI, from October 1, 2018, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.104, DC 7006. 5. The criteria for SMC at the housebound rate, from October 1, 2018 to March 2, 2020, are met. 38 U.S.C. §§ 1114(s), 5107; 38 C.F.R. §§ 3.102, 3.350. 6. The criteria for a TDIU, from August 11, 2011 to June 18, 2018, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1963 to August 1976. The case is on appeal from August 2012 and February 2014 rating decisions. In January 2020, the Board remanded the appeal for additional development. During the course of the appeal, the RO assigned a temporary total rating for CAD for three months following the Veteran’s from June 18, 2018. From October 1, 2018, a 60 percent rating was assigned. In addition, the Veteran was awarded SMC based on the housebound criteria from June 18, 2018 until September 30, 2018. The Veteran’s CAD is assigned an initial 10 percent rating under DC 7005, increased to 100 percent for three months following the Veteran’s MI in 2018 under DC 7006. From October 1, 2018, a 60 percent rating is assigned under DC 7006 for chronic congestive heart failure. By rating decision in October 2020, the rating for CAD status-post MI was increased to 100 percent based on congestive heart failure, and SMC based on the housebound criteria was awarded, from March 2, 2020. As the increase did not satisfy the appeal in full as to congestive heart failure, the issue remains on appeal. See AB v. Brown, 6 Vet. App. 35 (1993). In addition, as the Board awards the 100 percent rating for congestive heart failure from October 1, 2018 in the decision below, the Board has inferred a claim for SMC based on the housebound criteria from October 1, 2018. See Akles v. Derwinski, 1 Vet. App. 118, 121 (1991); see also Bradley v. Peake, 22 Vet. App. 280 (2008) (finding that SMC “benefits are to be accorded when a Veteran becomes eligible without need for a separate claim”); Buie v. Shinseki, 24 Vet. App. 242, 250-51 (2011) (requiring the Board to consider awarding SMC at the housebound rate if a veteran meets the requisite schedular or extraschedular criteria). As SMC based on the housebound criteria is in effect since June 18, 2018, the issue with respect to a TDIU since June 18, 2018 is moot. See Bradley, Buie. A TDIU prior to that date remains on appeal. The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Legal Criteria 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. Staged ratings must be considered, which are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods during the appeal. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). In determining when an increase is “factually ascertainable,” all of the evidence must be looked to, including testimonial evidence and expert medical opinions, and an effective date must be assigned based on that evidence. See McGrath v. Gober, 14 Vet. App. 28, 35-36 (2000); VAOPGCPREC 12-98. Thus, “it is the information in a medical opinion, and not the date the medical opinion [that] was provided that is relevant when assigning an effective date.” Tatum v. Shinseki, 24 Vet. App. 139, 145 (2010); see also Young v. McDonald, 766 F.3d 1348 (Fed. Cir. 2014). Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent rating is warranted for forward flexion of the cervical spine to 15 degrees or less; or favorable ankylosis of the entire cervical spine. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. Ankylosis is defined as “immobility and consolidation of a joint due to disease, injury, or surgical procedure.” Dorland’s Illustrated Medical Dictionary, 94 (32nd ed. 2012). Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. at Note 5. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). Under DC 7005, a 60 percent rating is warranted when there is more than one episode of acute congestive heart failure in the past year; a workload of greater than 3 METs (metabolic equivalent), but not greater than 5 METs, resulting in dyspnea, fatigue, angina, dizziness, or syncope; or for left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is warranted when there is chronic congestive heart failure; a workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104, DC 7005. Diagnostic Code 7006 governs coronary artery disease associated with myocardial infarction and provides as follows: (1) a 10 percent evaluation is warranted upon evidence of any one of the following symptoms: (a) a workload of greater than 7 metabolic equivalents (METs) but not greater than 10 METs that results in dyspnea, fatigue, angina, dizziness, or syncope; or (b) continuous medication required; (2) a 30 percent evaluation is warranted upon evidence of any one of the following symptoms: (a) a workload of greater than 5 METs but not greater than 7 METs that results in dyspnea, fatigue, angina, dizziness, or syncope; or (b) evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray; (3) a 60 percent evaluation is warranted upon evidence of any one of the following symptoms: (1) more than one episode of acute congestive heart failure in the past year; (2) a workload of 3.0 to 5.0 METs that results in dyspnea, fatigue, angina, dizziness, or syncope; or (3) left ventricular dysfunction with an ejection fraction (LVEF) of 30 to 50 percent; and (4) a 100 percent evaluation is warranted upon evidence of any one of the following symptoms: (1) chronic congestive heart failure; (2) a workload of 3.0 METs or less that results in dyspnea, fatigue, angina, dizziness, or syncope; or (3) an LVEF measurement of less than 30 percent. See 38 C.F.R. § 4.104, DC 7006. For rating diseases of the heart, one MET (metabolic equivalent) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for rating, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note 2. Diseases of the peripheral nerves are evaluated under the Schedule of Ratings for Diseases of the Peripheral Nerves. See 38 C.F.R. § 4.124a, DCs 8510-8540, 8610-8630, and 8710-8730. Under DC 8610, pertaining to upper extremity paralysis, a 20 percent rating is assigned for mild incomplete paralysis, and a disability rating of 40 percent is assigned for moderate incomplete paralysis (major). A disability rating of 50 percent is assigned for severe incomplete paralysis (major), and a disability rating of 70 percent is assigned for complete paralysis (major). 38 C.F.R. § 4.124a, DC 8610. The words “mild,” “moderate,” and “severe” as used in the various Diagnostic Codes are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at “Diseases of the Peripheral Nerves.” The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). 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. Analysis 1. A rating higher than 50 percent for cervical radiculopathy of the right upper extremity. The Veteran contends that a higher rating is warranted for radiculopathy of the right upper extremity. Pursuant to the Board’s January 2020 remand, the Veteran was afforded a VA examination in April 2020. The examiner reported only mild radiculopathy of the right upper extremity involving nerve roots C5-C6. Mild incomplete paralysis under DC 8610 warrants only a 20 percent rating. As such, a rating higher than 50 percent is clearly not warranted. Complete paralysis of the right upper extremity due to radiculopathy is not shown at any time during the rating period on appeal. The Board has considered all other potentially applicable DCs, but there is no evidence showing the Veteran has neurological impairment associated with any other peripheral nerves that have not already been service-connected. Therefore, a separate or higher rating under a different DC is not warranted. The preponderance of the evidence is against a rating higher than 50 percent for right upper radiculopathy. Thus, the benefit-of-the-doubt rule does not apply, and a rating higher than 50 percent for radiculopathy of the right upper extremity is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 2. A rating higher than 20 percent for cervical herniated nucleus pulposus at C5-C6. The Veteran seeks a higher rating for his service-connected cervical spine disorder. He maintains that a higher rating is warranted due to pain. The 20 percent rating was assigned under DC 5237. 38 C.F.R. § 4.71a, DC 5237. Pursuant to the Board’s January 2020 remand, the Veteran was afforded a VA examination in April 2020. The examiner reported forward flexion of the cervical spine to 45 degrees and extension to 30 degrees. Right lateral flexion was to 35 degrees and left lateral flexion was to 45 degrees. Right lateral rotation was to 30 degrees and lateral rotation was to 25 degrees. No ankylosis was specifically reported. The Board notes that the examiner estimated forward flexion of the cervical spine was 20 degrees during flare ups, and the combined range of motion during flare ups was 120 degrees. Thus, even in consideration of additional functional loss during flare ups, the evidence shows forward flexion of the cervical spine greater than 15 degrees, and thus, the Veteran’s cervical spine disability does not meet the criteria for a higher rating. 38 C.F.R. § 4.71a, DC 5237. In addition, the examiner stated that the cervical spine is not a weight bearing joint. The Veteran is competent to report his symptoms, to include neck pain. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465 (1994). The Board considered the lay statements and the clinical findings of record. The Board attributes greater probative value to the clinical findings which do not reflect forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine, including during flare ups. The preponderance of the evidence is against a rating higher than 20 percent for the cervical spine disability. Thus, the benefit-of-the-doubt rule does not apply, and a rating higher than 20 percent for cervical herniated nucleus pulposus at C5-C6 is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 3. A rating higher than 10 percent for CAD prior to June 18, 2018. 4. A rating higher than 60 percent for chronic congestive heart failure status-post MI, prior to March 2, 2020. The Veteran’s CAD is assigned an initial 10 percent rating under DC 7005, increased to 100 percent for three months following the Veteran’s MI in 2018 under DC 7006. From October 1, 2018, a 60 percent rating is assigned under DC 7006 for chronic congestive heart failure, increased to 100 percent, from March 2, 2020. Pursuant to the Board’s January 2020 remand, the Veteran was afforded a VA examination in April 2020. The examiner reported the Veteran’s congestive heart failure and valvular disorder was progression of the service-connected CAD status-post MI. The examiner stated that was impossible to distinguish between symptoms associated with CAD and valvular heart disease, aortic stenosis, noting symptom overlap, and that the Veteran’s fatigue and chest pain can result from both conditions. Thus, the examiner concluded that an opinion as to the degree to which aortic stenosis contributed to the Veterans symptoms would require resort to speculation. VA regulations require that when the symptoms and/or degree of impairment due to a veteran’s service-connected disability cannot be distinguished from a nonservice-connected disorder, VA must consider all symptoms in the adjudication of the claim. See Mittleider v. West, 11 Vet. App. 181 (1998). The Board notes that although the November 2018 VA opinion states that the Veteran’s CAD is unrelated to his valvular heart disease, the opinion also notes that medical literature reflected that that the aortic valve is intimately related anatomically to the left ventricle and to the aorta, and that the left ventricle response to aortic stenosis is, in part, related to the transaortic resistance. In addition, both the October 2018 and the April 2020 VA examiners reported that a left ventricle ejection fraction was the best indicator of the Veteran’s cardiac function. In August 2013, the ejection fraction was 50 percent, and moderate to severe aortic symptoms were noted. See August 2017 VA examination report. A September 2013 examination report reflects an ejection fraction of 47 percent, noting cardiac arrythmia, exertional dyspnea and lightheadedness, as well as a requirement for continuous medication for CAD. In addition, the February 2014 VA opinion reflects the ejection fraction was 50 percent. Left ventricular dysfunction with an ejection fraction of 30 to 50 percent warrants a 60 percent rating under DC 7005. As MI is not shown prior to June 18, 2018, the maximum 100 rating is not warranted. The Board further finds that the evidence supports the 100 percent rating assigned, from October 1, 2018. In that respect, the April 2020 VA examiner reported that the Veteran’s ejection fraction was 30-35 percent in 2018 and 2019, noting it was severely below normal, and would result in fatigue with activity as described by the Veteran. The Board notes that VA treatment records in October 2018 reflect that the Veteran remained on medication for at least six months following angioplasty in June 2018, that continuous medication for congestive heart failure included Plavix, and that he had a disease management plan for congestive heart failure. See January 2019 VA treatment records. Further, electrocardiogram (EKG) in December 2019 was noted to reflect changes compared to a prior EKG, and although no chest pain was noted, at the time of the March 2020 EKG that showed even more prominent findings compared to the EKG in December 2019, the Veteran was noted to be completely asymptomatic. Therefore, and when affording all reasonable doubt in the Veteran’s favor, the Board finds that a 60 percent rating for CAD is warranted prior to June 18, 2018, and a 100 percent rating is warranted from October 1, 2018. See Swain, 27 Vet. App. at 224. These are the earliest dates factually ascertainable increases occurred. 5. SMC based on the housebound criteria from October 1, 2018 to March 2, 2020. As noted in the introduction, the Board has inferred a claim of SMC based on the housebound criteria from October 1, 2018. SMC at the housebound rate is payable where a veteran has a single service-connected disability rated as 100 percent and: (1) has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). In view of the Board’s grant of the 100 percent rating for congestive heart failure status post MI, from October 1, 2018, in the decision above, and the Veteran’s additional service-connected disabilities independently ratable to a combined rating of 60 percent or more from October 1, 2018, see 38 C.F.R. § 4.25, the criteria for SMC based on the housebound criteria are met for the period from October 1, 2018 to March 2, 2020. The Board notes although a separate award of a TDIU predicated on a single disability may form the basis for an award for purposes of SMC under 38 U.S.C. § 1114, the Board’s grant of a TDIU in the decision below is based on the combined effects of the Veteran’s service-connected disabilities. As such, SMC based on the housebound criteria is not warranted prior to June 18, 2018. 6. A TDIU. The Veteran seeks a TDIU. He maintains that he is unemployable due to his service-connected disabilities. 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, such disability shall be ratable as 60 percent or more, and 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). In determining whether a veteran can secure and follow a substantially gainful occupation, attention must be given to: • The veteran’s history, education, skill, and training; • Whether the veteran has the physical ability (both exertional and nonexertional) to perform the type of activities (e.g., sedentary, light, medium, heavy, or very heavy) required by the occupation at issue. Factors that may be relevant include, but are not limited to, the veteran’s limitations, if any, concerning lifting, bending, sitting, standing, walking, climbing, grasping, typing, and reaching, as well as auditory and visual limitations; and • Whether the veteran has the mental ability to perform the activities required by the occupation at issue. Factors that may be relevant include, but are not limited to, the veteran’s limitations, if any, concerning memory, concentration, 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). As noted above, SMC based on the housebound criteria is in effect from June 18, 2018, and thus, the issue of a TDIU from that date is moot. Prior to June 18, 2018, the Veteran has the following compensable service-connected disabilities: posttraumatic stress disorder (PTSD), rated 70 percent disabling; radiculopathy of the right upper extremity, rated 50 percent disabling; cervical herniated nucleus pulposus at C5-C6, rated 20 percent disabling; hearing loss, rated 20 percent disabling; tinnitus, rated 10 percent disabling; and CAD, rated 10 percent disabling. His combined rating was at least 80 percent, prior to June 18, 2018. Thus, the schedular requirements for a TDIU rating are met. The question remaining is whether the Veteran’s service-connected disabilities (alone) render him incapable of participating in a substantially gainful occupation. As noted in the Board’s January 2020 remand, a TDIU was raised in association with increased rating claims on appeal, to include the August 2011 higher rating claim for a cervical herniated nucleus pulposus at C5-C6. In his March 2013 TDIU application, the Veteran reported last working full time in June 2011 due to his service-connected neck disorder, PTSD, and hearing loss. He also reported completing high school and working as a truck driver. In March 2013, the Veteran’s employer reported the Veteran worked until June 8, 2011 when the Veteran’s physical limitations increased in severity. See March 2013 VA 21-4192. The July 2013 VA examiner reported that the Veteran’s PTSD symptoms included depressed mood; anxiety; chronic sleep impairment; mild memory loss; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. The examiner concluded that the Veteran’s service-connected psychiatric disorder was productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. Although the examiner opined that the Veteran’s PTSD symptoms alone would not prevent him from tolerating the stress, schedule requirements, and interpersonal interaction in employment settings, as noted above the 70 percent rating assigned contemplates occupational and social impairment with deficiencies in most areas. Moreover, PTSD has been rated at the 70 percent level throughout the rating period on appeal and the February 2019 VA PTSD examiner reported that the Veteran’s intrusive symptoms hypervigilance, increased startle response, and avoidant behaviors due to PTSD posed a challenge with respect to the Veteran’s ability to sustain effort in an occupational setting and/or tolerate being in an occupational setting with other people and to engage in a consistent way that is often required in occupational settings. Thus, the Board finds that the Veteran’s PTSD symptoms cause significant occupational impairment. Moreover, and although the Veteran’s PTSD is not productive of total occupational impairment, and even though no other single service-connected disability is shown to preclude the Veteran from obtaining and maintaining substantially gainful employment, including CAD, radiculopathy of the right upper extremity, cervical herniated nucleus pulposus at C5-C6, and hearing loss, the Board finds that the Veteran’s PTSD, as well the physical limitations due to service-connected radiculopathy of the right upper extremity rated as severe incomplete paralysis, hearing loss, noted to impact the Veteran’s ability work, see February 2012 VA audiological examination, cervical herniated nucleus pulposus at C5-C6, and CAD, the Veteran is unable to obtain or maintain substantially gainful employment due to his service-connected disabilities. The Board notes that although a July 2013 VA examination report indicates disability benefits from the Social Security Administration (SSA) due to a back condition since 2011, the determination and medical records upon which the determination was based are unavailable. See January 2018 Medical Treatment Records – Furnished by SSA. Moreover, VA is not bound by a determination of the SSA. See Collier v. Derwinski, 1 Vet. App. 413, 417 (1991); see also Martin v. Brown, 4 Vet. App. 136, 140 (1993). The ultimate question of whether a Veteran is capable of securing or following substantially gainful employment is an adjudicatory determination, not a medical one. See Geib v. Shinseki, 733 F.3d 1350 (Fed. Cir. 2013); Floore v. Shinseki, 26 Vet. App. 376 (2013). Based on the totality of the evidence, the Board finds that the overall evidence of record is at least in equipoise as to a finding that the Veteran would have difficulty with most occupations due to his service-connected disabilities. Therefore, the Board concludes the Veteran is unable to secure or follow a substantially gainful occupation due to his service-connected disabilities, throughout the rating period on appeal, prior to June 18, 2018, that is, from August 11, 2011. See August 2012, rating decision. Thus, for the period August 11, 2011 to June 18, 2018, a TDIU is warranted. H.M. WALKER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Taylor 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.