Citation Nr: 21013651 Decision Date: 03/10/21 Archive Date: 03/10/21 DOCKET NO. 17-25 665 DATE: March 10, 2021 ORDER Entitlement to a disability rating in excess of 20 percent for diabetes mellitus, type II, (diabetes mellitus) is denied. From May 11, 2016 to September 27, 2016, entitlement to a 10 percent rating, but not higher, for peripheral neuropathy of the left lower extremity associated with diabetes mellitus is granted. From May 11, 2016 to September 27, 2016, entitlement to a 10 percent rating, but not higher, for peripheral neuropathy of the right lower extremity associated with diabetes mellitus is granted. Entitlement to special monthly compensation (SMC) for erectile dysfunction associated with diabetes mellitus and loss of use of a creative organ is granted, effective February 4, 2015. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is denied. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran’s diabetes mellitus has been manifested by insulin dependence, an oral hypoglycemic agent, and a restricted diet, but not by a need for regulation of activities. 2. From May 11, 2016 to September 27, 2016, the Veteran was shown to have mild peripheral neuropathy of the left lower extremity associated with diabetes mellitus. 3. From May 11, 2016 to September 27, 2016, the Veteran was shown to have mild peripheral neuropathy of the right lower extremity associated with diabetes mellitus. 4. The Veteran has a diagnosis of erectile dysfunction associated with his diabetes mellitus and is unable to attain and maintain an erection without medication, but he does not have a penile deformity. 5. The Veteran’s service-connected disabilities do not prevent him from obtaining or maintaining substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for entitlement to a disability rating in excess of 20 percent for diabetes mellitus have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.119, Diagnostic Code 7913. 2. The criteria for a separate 10 percent rating for peripheral neuropathy of the left lower extremity associated with diabetes mellitus are satisfied from May 11, 2016 to September 27, 2016. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.124a, Diagnostic Code 8520. 3. The criteria for a separate 10 percent rating for peripheral neuropathy of the right lower extremity associated with diabetes mellitus are satisfied from May 11, 2016 to September 27, 2016. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.124a, Diagnostic Code 8520. 4. The criteria for special monthly compensation for loss of use of a creative organ have been met, effective February 4, 2015. 38 U.S.C. § 1114(k); 38 C.F.R. § 3.350(a). 5. The criteria for entitlement to a TDIU have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1967 to October 1969 and from November 1969 to November 1971. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In March 2017, the RO awarded separate 10 percent ratings for peripheral neuropathy of the left lower extremity and peripheral neuropathy of the right lower extremity associated with diabetes mellitus, respectively, effective September 28, 2016. The Veteran did not appeal the 10 percent ratings assigned. However, the Board must determine whether separate ratings are warranted for peripheral neuropathy of the lower extremities at any time during the appellate period prior to September 28, 2016. In November 2019, the Veteran testified at a video-conference hearing before the undersigned Veterans Law Judge (VLJ). A transcript of that hearing has been associated with the claims file. In December 2019, the Board remanded this matter for further development. That development having been completed, this matter has returned to the Board for further appellate review. The Board has considered the Veteran’s claim and decided entitlement based on the evidence. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record, with respect to his claim. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 1. Entitlement to a disability rating in excess of 20 percent for diabetes mellitus is denied. VA has adopted a Schedule for Rating Disabilities (Schedule) to evaluate service-connected disabilities. See 38 U.S.C. § 1155; 38 C.F.R., Part IV. Disability evaluations assess the ability of the body as a whole, the psyche, or a body system or organ to function under the ordinary conditions of daily life, to include employment. 38 C.F.R. § 4.10. The percentage ratings in the Schedule represent the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The percentage ratings are generally adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the disability. Id. The Schedule assigns Diagnostic Codes to individual disabilities. Diagnostic Codes provide rating criteria specific to a particular disability. If two Diagnostic Codes are applicable to the same disability, the Diagnostic Code that allows for the higher disability rating applies. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the claimant. 38 C.F.R. § 4.3. The Schedule recognizes that a single disability may result from more than one distinct injury or disease; however, rating the same disability or its manifestation(s) under different Diagnostic Codes-a practice known as pyramiding-is prohibited. Id.; see 38 C.F.R. § 4.14. In disability rating cases, VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the course of the claim, a practice known as “staged ratings.” See Fenderson v. West, 12 Vet. App. 119, 126 (1999); see also Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007) (holding that staged ratings may be warranted in increased rating claims). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102 (providing, in pertinent part, that reasonable doubt will be resolved in favor of the claimant). When the evidence supports the claim or is in relative equipoise, the claim will be granted. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); see also Wise, 26 Vet. App. at 532. If the preponderance of the evidence weighs against the claim, it must be denied. See id.; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The Veteran’s diabetes mellitus, type II, has been assigned a 20 percent rating pursuant to 38 C.F.R. § 4.119, Diagnostic Code 7913, which pertains to diabetes mellitus. Under Diagnostic Code 7913, a 20 percent rating is assigned for diabetes mellitus requiring insulin and a restricted diet or an oral hypoglycemic agent and a restricted diet. A 40 percent rating is warranted when the disability requires insulin, restricted diet, and regulation of activities. A 60 percent disability rating is assigned when the diabetes mellitus requires insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A maximum 100 percent rating is warranted if the disorder requires more than one daily injection of insulin, a restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring three hospitalizations a year or weekly visits to a diabetic provider, plus either progressive loss of weight and strength or signs that would be compensable if separately evaluated. 38 C.F.R. § 4.119. Compensable complications of diabetes are evaluated separately unless they are part of the criteria used to support a 100 percent evaluation. Noncompensable complications are considered part of the diabetic process under code 7913. 38 C.F.R. § 4.119, Diagnostic Code 7913, Note (1). The Court has held that, in order to demonstrate a regulation of activities, “medical evidence” is required to show that both occupational and recreational activities have been restricted. Camacho v. Nicholson, 21 Vet. App. 360, 364 (2007). The phrase “regulation of activities” means “avoidance of strenuous occupational and recreational activities.” Id. at 362 (quoting 38 C.F.R. § 4.119, Diagnostic Code 7913 (defining the term within the criteria for a 100 percent rating)). In other words, a medical provider must indicate that the claimant’s “diabetes is of such severity that he should curtail his activities such as to avoid strenuous activity.” Id. In addition, the Board observes that the rating criteria contained in Diagnostic Code 7913 are “successive.” That is, the evaluation for each higher disability rating includes the criteria of each lower disability rating, such that if a component is not met at any one level, the veteran can only be rated at the level that does not require the missing component. See Tatum v. Shinseki, 23 Vet. App. 152, 156 (2009). Each higher rating requires the elements of the lower rating: the 10 percent rating requires a restricted diet; the 20 percent rating requires a restricted diet and insulin or oral hypoglycemic agent; the 40 percent rating requires insulin, restricted diet, and regulation of activities; and so forth. Accordingly, under this and other diagnostic codes that are successive, consideration of 38 C.F.R. § 4.7 is not required. See Camacho, 21 Vet. App. at 366. In fact, the Federal Circuit has held that if disability rating criteria are written in the conjunctive and are successive, “a veteran must demonstrate all of the required elements in order to be entitled to that higher evaluation,” and 38 C.F.R. § 4.7 cannot be used to circumvent the need to demonstrate all required criteria. Middleton v. Shinseki, 727 F.3d 1172, 1178 (Fed. Cir. 2013). As such, in the instant case, each separate element of insulin, restricted diet, and regulation of activities must be met for the Veteran to meet the criteria for a higher 40 percent rating. Middleton, 727 F.3d 1172. See also 38 C.F.R. § 4.119, Diagnostic Code 7913. Throughout the appeal period, the evidence clearly establishes that the Veteran’s diabetes mellitus requires a restricted diet in addition to a prescribed oral hypoglycemic agent and/or the use of insulin. See October 2011 Diabetes Mellitus Disability Benefits Questionnaire (DBQ); May 2015 Diabetes Mellitus DBQ; May 2017 VA Form 9 (stating his diabetes now requires insulin); May 2018 Endocrinology Note; June 2019 Endocrinology Note; January 2020 Diabetes Mellitus DBQ. Therefore, the Veteran need only show that a regulation of his occupational and recreational activities has been medically prescribed in order to qualify for a 40 percent rating under Diagnostic Code 7913. However, the Board finds that there is no probative evidence that suggests the Veteran has been advised or prescribed to avoid strenuous activity by any medical professional. Rather, his treatment records reflect that he has continued to exercise to help manage his weight. In August 2018 and December 2018, it was noted that he exercised three times a week. See August 2018 and December 2018 Endocrinology Notes. In June 2019, it was noted that he had been working hard on managing his blood sugar and had changed his diet and continued to work out. See June 2019 Endocrinology Note. In October 2019, it was noted that he had intentionally lost over 20 pounds over the last few months and felt very good about his progress. See October 2019 Endocrinology Note (noting recent intentional weight loss). Earlier records dated in May 2016 reflect that the Veteran’s diabetes mellitus was in poor control due to his habits and he was counseled to exercise. The Veteran testified that his doctor has restricted his activities and that he requires assistance around the house and mowing his lawn. See November 2019 Hearing Transcript. However, the record does not contain any indication that any regulation of his activities has been specifically prescribed by a doctor because of his diabetes. To the contrary, as noted above, the VA treatment notes reflect that the Veteran exercises regularly. Therefore, the Veteran’s lay statements are not found to be credible in this regard. Further, there is no medical evidence of regulation of activities due to his diabetes mellitus. The Board finds that there is no basis for awarding a higher rating. In so finding, the Board notes that there is simply no probative evidence establishing that the Veteran’s diabetes has required the regulation of activities required for all ratings in excess of 20 percent. Additionally, the record does not reflect that the Veteran meets the criteria for a rating in excess of 40 percent, as the ratings for 60 and 100 percent continue to require regulation of activities, in addition to more advanced symptoms. 38 C.F.R. § 4.119, Diagnostic Code 7913. Accordingly, in light of the foregoing, the Board concludes that the preponderance of the evidence weighs against the criteria for assignment of a rating higher than 20 percent for the Veteran’s diabetes at any point during the appellate period, as it is not manifested by regulation of activities in terms of a medical professional advising or prescribing avoidance of strenuous occupational and recreational activities in order to manage diabetes. See Tatum, 23 Vet. App. at 156; Middleton, 727 F.3d at 1178. See, too, 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102. 2. From May 11, 2016 to September 27, 2016, entitlement to a 10 percent rating, but not higher, for peripheral neuropathy of the left lower extremity associated with diabetes mellitus is granted. 3. From May 11, 2016 to September 27, 2016, entitlement to a 10 percent rating, but not higher, for peripheral neuropathy of the right lower extremity associated with diabetes mellitus is granted. Note (1) to 38 C.F.R. § 4.119, Diagnostic Code 7913 provides that compensable complications of diabetes are to be rated separately unless they are part of the criteria used to support a 100 percent rating (under Diagnostic Code 7913). Noncompensable complications are considered part of the diabetic process under Diagnostic Code 7913. 38 C.F.R. § 4.119. As noted above, in March 2017, the RO awarded separate 10 percent ratings for peripheral neuropathy of the left lower extremity and peripheral neuropathy of the right lower extremity associated with diabetes mellitus under DC 8520, respectively, effective September 28, 2016. The Veteran did not appeal the 10 percent ratings assigned. However, the Board must determine whether separate ratings are warranted for peripheral neuropathy of the lower extremities at any time during the appellate period prior to September 28, 2016. Paralysis of the sciatic nerve is rated under 38 C.F.R. § 4.124a, DC 8520. Under DC 8520, a 10 percent evaluation is assigned for mild incomplete paralysis of the sciatic nerve; a 20 percent evaluation is assigned for moderate incomplete paralysis; a 40 percent evaluation is assigned for moderately severe incomplete paralysis; and a 60 percent evaluation is assigned for severe incomplete paralysis with marked muscular atrophy. A maximum 80 percent evaluation requires complete paralysis of the sciatic nerve where the foot dangles and drops, there is no active movement possible of muscles below the knee, and flexion of the knee is weakened or (very rarely) lost. 38 C.F.R. § 4.124a. The term "incomplete paralysis," with peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to the partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a; Note prefacing DC's 8510 through 8730. The criteria for separate 10 percent ratings for right lower extremity peripheral neuropathy and left lower extremity peripheral neuropathy have been satisfied as of May 11, 2016, the date of a VA treatment note, which is the earliest evidence of lower extremity neuropathy symptoms. Specifically, a May 11, 2016 VA treatment contains and assessment of diabetes mellitus neuropathy, diminished sensation, denied pain. Physical evaluation showed decreased sensation in the toes bilaterally. Peripheral pulses were present and skin/visual inspection was normal. In August 2016, findings were consistent, with bilateral decreased sensation in the feet and no pain to palpation of the feet. Here, the criteria for a 10 percent rating are more nearly approximated as of May 11, 2016. Prior to this date, the medical evidence, including the Veteran’s VA treatment records and the May 2015 VA examination report, shows that the Veteran did not have neurological signs and symptoms of the lower extremities. The criteria for a 10 percent rating under DC 8520 are more nearly approximated as of May 11, 2016 based on bilateral decreased sensation of the feet. See 38 C.F.R. § 4.124a. The evidence shows that there is no functional impairment on use of the lower extremities, pain, or weakness. The decreased sensation of the lower extremities, with no other signs, symptoms, or functional impairment, warrants a 10 percent rating under DC 8520, but no higher. The criteria for a rating higher than 10 percent have not been satisfied at any point between May 11, 2016 and September 27, 2016. 4. Entitlement to SMC for erectile dysfunction associated with diabetes mellitus and loss of use of a creative organ is granted, effective February 4, 2015. Erectile dysfunction is rated under 38 C.F.R. § 4.115b, Diagnostic Code 7522. To warrant a compensable rating of 20 percent for erectile dysfunction, the evidence must show deformity of the penis with loss of erectile power. 38 C.F.R. § 4.115(b), Diagnostic Code 7522. A footnote to Diagnostic Code 7522 also states that the disability is to be reviewed for entitlement to SMC for loss of use of a creative organ under 38 C.F.R. § 3.350(a). The Board notes that a May 2015 VA examination report reflects that the Veteran’s erectile dysfunction was caused by his diabetes mellitus. The examiner noted the Veteran’s penis had no deformity and he was able to achieve an erection with medication. See May 2015 Male Reproductive Systems DBQ. There is no evidence showing that the Veteran has any deformity of the penis which would warrant the assignment of a 20 percent rating for erectile dysfunction under DC 7522. Rather, the Veteran’s erectile dysfunction, a noncompensable complication, is considered part of the diabetic process under Diagnostic Code 7913. Regarding SMC for loss of use of a creative organ, the Board finds that the evidence does indicate that the Veteran has loss of erectile power. See May 2015 Male Reproductive Systems DBQ. Therefore, SMC for loss of use of a creative organ is warranted effective February 4, 2015, the date of the Veteran’s claim for an increased rating. 38 U.S.C. § 1114(k); 38 C.F.R. § 3.350(a). 5. Entitlement to a TDIU is denied. Total disability ratings for compensation may be assigned, where the schedular rating is less than 100 percent, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of one or more service-connected disabilities without regard to advancing age or nonservice-connected disabilities. 38 C.F.R. §§ 3.340, 3.341(a), 4.16(a), 4.19; Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993) (holding that the central inquiry is whether the Veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability). The claimant’s service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be considered. 38 C.F.R. § 4.16(b). Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 4.15. While the rating is based primarily upon the average impairment in earning capacity, full consideration must be given to unusual physical or mental effects in individual cases, to peculiar effects of occupational activities, to defects in physical or mental endowment preventing the usual amount of success in overcoming the handicap of disability, and to the effect of combinations of disability. Id. Substantially gainful employment is defined as work which is more than marginal and which permits the individual to earn a living wage. 38 C.F.R. § 4.16(a); Moore v. Derwinski, 1 Vet. App. 356 (1991). Marginal employment shall generally be deemed to exist when a veteran’s earned income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. 38 C.F.R. § 4.16(a). Marginal employment may also be established, on a facts-found basis, when earned annual income exceeds the poverty threshold, including but not limited to employment in a protected environment, such as a family business or sheltered workshop. Id. Consideration must be given in all claims to the nature of the employment and the reason for termination. Id. Although the Board must fully consider “the effect of combinations of disability” in its determination, “neither the statute nor the relevant regulations require the combined effect to be assessed by a medical expert.” Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). Indeed, regulation places responsibility for the ultimate determination of unemployability on the Board or rating agency, not a medical examiner. Id. (citing 38 C.F.R. § 4.16(a)). Where separate medical opinions address the impact on employability resulting from independent disabilities, the Board is authorized to assess the aggregate effect of all disabilities. Id. Certain percentage requirements must be satisfied to qualify for schedular consideration of entitlement to TDIU. Specifically, if unemployability is the result of only one service-connected disability, this disability must be ratable at 60 percent or more. 38 C.F.R. § 4.16(a). If it is the result of two or more service-connected disabilities, at least one must be ratable at 40 percent or more, with the others sufficient to bring the combined rating to 70 percent or more. Id. Disabilities of one or both upper extremities, or one or both lower extremities, including the bilateral factor, disabilities resulting from a common etiology or a single accident, and the disabilities affecting a single body system such as orthopedic disabilities, will be considered as one disability for TDIU purposes. Id. Entitlement to a total rating must be based solely on the impact of service-connected disabilities on the ability to keep and maintain substantially gainful employment. See 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.” Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). For VA purposes, the term “unemployability” is synonymous with an inability to secure and follow a substantially gainful occupation. VAOPGPREC 75-91; 57 Fed. Reg. 2317 (1992). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55. In February 2015, the Veteran filed his claim for entitlement to TDIU. He last worked as an aerospace welder from November 1996 to January 2015. He asserted that he was no longer able to work due to his posttraumatic stress disorder and diabetes mellitus. See February 2015 VA Form 21-8940 The Veteran’s service-connected disabilities include diabetes mellitus, rated as 20 percent disabling, effective December 22, 2009; PTSD, rated as 50 percent disabling effective June 13, 2011; and peripheral neuropathy of the left and right lower extremities, each rated as 10 percent disabling effective May 11, 2016. The Veteran’s combined rating, in pertinent part, was 60 percent from June 13, 2011 to May 10, 2016; and 70 percent disabling from May 11, 2016, forward. Therefore, as of May 11, 2016, the Veteran met the schedular requirement for TDIU. Prior to that date, he did not meet the schedular requirement for TDIU. Regardless, if the schedular requirements for TDIU are not satisfied, but the veteran is still found to be unable to work due to service-connected disabilities, the case will be submitted to the Director of the Compensation Service (Director) for extra-schedular consideration. 38 C.F.R. § 4.16(b). The Veteran submitted statements by two former co-workers. Both statements described the Veteran experiencing unprovoked mood swings at work and isolating himself. He was also described as easily irritable, angry, and throwing tools when he was stressed due to work or family issues. See November 2011 A.M.F. Statement; November 2011 R.A.R. Statement. In a June 2020 statement from the Veteran’s wife, she stated that the Veteran does not sleep well and that his temper and mood were unstable. Treatment records reflect the Veteran reported he stopped working as a result of continued physical pain, to include in his back, arms and legs. See January 2015 Progress Note. He further reported being unable to work due to work related injuries and subsequent physical problems. He stated that he had to work hard to avoid outbursts and conflicts at work. See February 2015 Progress Note. Prior to his retirement, the Veteran experienced sporadic panic attacks at work, believing them to be related to a cardiac condition. See May 2014 Progress Note. He was worried about not being able to work and enjoyed staying busy at work. After retiring, in May 2015 the Veteran sought a volunteer position at a museum. In March 2015, the Veteran stated that he retired as he was not able to grab objects due to left wrist pain, following an injury in January 2015. The Veteran was afforded VA examinations in May 2015. Concerning his PTSD, the examiner found his PTSD to manifest in 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. His psychiatric symptoms were noted as anxiety, suspiciousness, chronic sleep impairment, and mild memory loss. See May 2015 PTSD DBQ. In regard to his diabetes mellitus, the it was noted that regulation of activities as part of medical management of the Veteran’s condition was not required. The examiner concluded that the Veteran’s diabetes mellitus did not impact his ability to work. See May 2015 Diabetes Mellitus DBQ. In November 2015, the Veteran reported he was unable to work as a welder due to his diabetes mellitus. See November 2015 Social Work Note. However, in a September 2015 internal medicine note he had reported that he retired in January 2015 due to left shoulder pain. In November 2015, an examiner noted that the Veteran had requested a letter stating that he is not able to work anymore. The examiner wrote, “I cannot write not specific note about this, it seems he got new condition lately and was getting state disability and now it seems he wants to link it to military service, not able to help due to incongruency.” The examiner noted previous treatment notes showing that the Veteran worked as a welder until January 6, 2015 when he was injured at home, had been attending physical therapy for his left wrist and left shoulder from April 2015 to June 2015, was getting state disability until May 14, 2015, and was offered to continue working but “he cannot do it anymore.” Also of record are February 2017 VA examination reports. The Veteran’s bilateral lower extremity peripheral neuropathy was found to manifest in pain, paresthesias and/or dysesthesias and numbness in his toes. The examiner found that this had no impact on the Veteran’s ability to work. See February 2017 Diabetic Sensory-Motor Peripheral Neuropathy DBQ. The Veteran’s PTSD was found to manifest in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The Veteran reported he stopped working in January 2015 due to a shoulder injury. His psychiatric symptoms were listed as depressed mood, anxiety, suspiciousness, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and impaired impulse control. See February 2017 PTSD DBQ. At the November 2019 hearing before the Board, the Veteran testified that he had difficulty getting along with other people when he was working. He further testified that he did not finish high school. He reported that his previous jobs were all physical in nature. See November 2019 Hearing Transcript. January 2020 VA examination reports reflect that the Veteran’s diabetes mellitus and peripheral neuropathy have no impact on his ability to work. See January 2020 Diabetes Mellitus DBQ; January 2020 Diabetic Sensory-Motor Peripheral Neuropathy DBQ. In Ray v. Wilkie, the United States Court of Appeals for Veterans Claims (Court) held that the phrase “unable to secure and follow a substantially gainful occupation” in section 4.16(b) has two components: one economic and one noneconomic. Id. at 73. The economic component “simply means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person.” 31 Vet. App. 58, 72-73 (2019). As for the “noneconomic component,” the Court held that this refers to the individual claimant’s “ability to secure or follow” an occupation earning more than marginal income. Id. (emphasis in original). In determining whether a veteran can secure and follow a substantially gainful occupation, the Court stated that attention must be given to several relevant factors: (1) the veteran’s occupational history, education, skill, and training; (2) 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; and (3) whether the veteran has the mental ability to perform the activities required by the occupation at issue. Id. The Court noted that these potentially relevant factors were not a “checklist that must be completely run through in every case,” and that any factor need only be discussed if the evidence raises it as an issue. Id. Here, the economic component is clearly met, as the Veteran has not worked since January 2015. The issue is whether his service-connected disabilities, without regard to other factors, are sufficiently disabling as to prevent him from obtaining or maintaining substantially gainful employment in light of his occupational history, education, skill, and training. The Board finds that the evidence does not satisfy the noneconomic component. With regard to the first factor—the Veteran’s occupational history, education, skill, and training—the Veteran did not complete high school. He worked as an aerospace welder for the same company for nearly 20 years, from November 1996 to January 2015. His work required assembling, fabricating, welding aircraft parts, and lifting up to 70 pounds. See VA Hypertension examination report dated in June 2016. His treatment records show that he retired following an injury to his left wrist/shoulder in January 2015. With regard to the second and third noneconomic component factors—the Veteran’s physical and mental ability to perform the occupation at issue—VA examiners in May 2015, February 2017 and January 2020 concluded that the Veteran’s diabetes mellitus and peripheral neuropathy of the lower extremities did not impact his ability to work. With regard to his PTSD, the May 2015 VA examiner concluded that his PTSD manifested in 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. On VA examination in February 2017, the Veteran’s PTSD was found to manifest in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The findings regarding functional impairment by the VA examiners constitute probative evidence that the Veteran’s service-connected PTSD has not caused mental impairment to such degree as to render him unable to obtain or maintain substantially gainful employment consistent with his work background as a welder. The evidence does not show that the combined effects of the Veteran’s service-connected disabilities have caused physical and/or mental impairment sufficient to render him unable to obtain or maintain substantially gainful activity, including as a welder. Again, VA examiners concluded that the Veteran’s diabetes mellitus and peripheral neuropathy of the lower extremities did not impact his ability to work. The Veteran’s peripheral neuropathy of the lower extremities is manifested by pain, paresthesias and/or dysesthesias and numbness in his toes, which is not inconsistent with welding activities such as assembling, fabricating, welding aircraft parts, and lifting up to 70 pounds. As noted above, the Veteran reported retiring from his job in 2015 primarily due to an injury to his left upper extremity, i.e., the wrist and shoulder. While his PTSD is shown to cause some impairment in the Veteran’s ability to work, particularly due to an inability to get along with co-workers, irritability, sleep impairment, and mild memory loss, the evidence does not show that he is unable to secure or maintain any gainful employment as a result of his PTSD. Accordingly, the second Ray factor has not been met, as the evidence does not show that the Veteran lacks the physical or mental ability to obtain or maintain substantially gainful employment consistent with his education and work background due to his service-connected disabilities alone. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The criteria for a TDIU have not been met. For the period prior to May 11, 2016, referral to the Director of Compensation and Pension or the Under Secretary for Benefits for extraschedular consideration in accordance with 38 C.F.R. § 4.16(b) is not warranted. P.M. DILORENZO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. M. Stedman, 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.