Citation Nr: 21015407 Decision Date: 03/17/21 Archive Date: 03/17/21 DOCKET NO. 15-25 993 DATE: March 17, 2021 ORDER Entitlement to a rating in excess of 20 percent for diabetes mellitus, type 2, is denied. Entitlement to a rating in excess of 10 percent prior to December 18, 2020 for peripheral neuropathy of the right lower extremity is denied. Entitlement to a rating in excess of 20 percent beginning December 18, 2020 for peripheral neuropathy of the right lower extremity is denied. Entitlement to a rating in excess of 10 percent prior to December 18, 2020 for peripheral neuropathy of the left lower extremity is denied. Entitlement to a rating in excess of 20 percent beginning December 18, 2020 for peripheral neuropathy of the left lower extremity is denied. Entitlement to a total disability rating based on individual unemployability as due to service-connected disabilities (TDIU) is denied. FINDINGS OF FACT 1. For the entire period of the appeal, management of the Veteran’s service-connected diabetes mellitus type II required an oral hypoglycemic agent and a restricted diet; it also did not require regulation of activities. 2. Prior to December 18, 2020, the service-connected bilateral peripheral neuropathy of the lower extremities did not nearly approximate moderate incomplete paralysis of the sciatic nerve. 3. From December 18, 2020, the service-connected bilateral peripheral neuropathy of the lower extremities did not nearly approximate severe incomplete paralysis of the sciatic nerve, as the Veteran exhibited symptomatology that was no more than sensory in nature. 4. The weight of the evidence fails to establish that the Veteran was unable to secure or follow substantially gainful employment due solely to his service-connected disabilities for the entire appeal period. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 20 percent for the service-connected diabetes mellitus type II have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 3.159, 4.20, 4.40, 4.119, Diagnostic Code 7913. 2. Prior to December 18, 2020, the criteria for a disability rating in excess of 10 percent for right and left peripheral neuropathy of the lower extremities have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.3, 4.7, 4.21, 4.124a, Diagnostic Code 8520. 3. From December 18, 2020, the criteria for a disability rating in excess of 20 percent for right and left peripheral neuropathy of the lower extremities have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.3, 4.7, 4.21, 4.124a, Diagnostic Code 8520. 4. The criteria for entitlement to a TDIU have not been met. 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.3, 4.15, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1967 to December 1970. This matter was last before the Board in July 2020, whereupon it was remanded to the Agency of Original Jurisdiction (AOJ) for further development of the record. After completing said development, the AOJ issued a January 2021 rating decision increasing the rating for right and left peripheral neuropathy to 20 percent effective December 18, 2020. Furthermore, the AOJ also issued a January 2021 supplemental statement of the case continuing the denials of the other claims listed above as well as additional increased ratings for the right and left peripheral neuropathy conditions. The case was then returned to the Board for its adjudication. As a reminder, the Veteran testified at a February 2020 videoconference before the undersigned Veterans Law Judge; a copy of the transcript of that hearing is of record. Increased Rating Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In cases in which a claim for a higher initial evaluation stems from an initial grant of service connection for the disability at issue, multiple (“staged”) ratings may be assigned for different periods of time during the pendency of the appeal. See generally Fenderson v. West, 12 Vet. App. 119 (1999). Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994); 38 C.F.R. § 4.2. Staged ratings are, however, 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. 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. See 38 C.F.R. § 4.7. 1. Diabetes Mellitus, Type II The Veteran is in receipt of a 20 percent rating for service-connected diabetes mellitus, type II, effective February 24, 2011. He seeks a rating in excess of that 20 percent for the entirety of the appeal period. To that end, the Board notes that the Veteran submitted his claim seeking an increased rating for his diabetes mellitus, type II in November 20, 2012. At that time, he was in receipt of a 10 percent rating for the condition effective August 23, 2010. Even when considering that the Veteran is entitled to an effective date up to one year prior to the date of his increased ratings claim where the increase was “factually ascertainable”, the effective date of the 20 percent rating is still outside this one-year refer back period. 38 U.S.C. § 5110 (b)(2); 38 C.F.R. § 3.400(o); VAOPGCPREC 12-98 (1998). The Board is unable to determine on what basis the AOJ concluded that an increased rating effective more than one year prior to the Veteran’s claim was appropriate. Although the Board will not disturb the current effective date, it must be noted that the period on appeal extends back only to November 20, 2011. The 20 percent evaluation was awarded pursuant to 38 C.F.R. § 4.119, Diagnostic Code 7913. Under this code section, diabetes mellitus type II requiring insulin and restricted diet, or; oral hypoglycemic agent and restricted diet, is rated 20 percent disabling. 38 C.F.R. § 4.119. Diabetes mellitus type II requiring insulin, restricted diet, and regulation of activities, is rated 40 percent disabling. Id. Diabetes mellitus type II requiring 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, is rated 60 percent disabling. Id. Diabetes mellitus type II requiring more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated, is rated 100 percent disabling. Id. The rating schedule in Note 1 also instructs to evaluate compensable complications of diabetes separately unless they are part of the criteria used to support a 100 percent evaluation. Noncompensable complications are considered part of the diabetic process. Here, separate but associated ratings have been assigned for bilateral upper and lower extremity radiculopathy, retinopathy, erectile dysfunction, and hypertension. These ratings are not presently on appeal. At the outset, the Board acknowledges that the Veteran’s diabetes mellitus, type II has required the use of insulin and a restricted diet for control, thus warranting the currently assigned 20 percent rating. What is still in question, however, is whether the Veteran’s diabetes mellitus required the regulation of activities, as would be necessary to warrant an increase of the disability evaluation to 40 percent. The Veteran was first afforded a VA examination to evaluate the severity of the diabetes mellitus, type II in March 2013, during which it was noted that the Veteran utilized a prescribed oral hypoglycemic agent for regulation of his diabetes mellitus, type II. The examiner did not find any evidence that the Veteran required regulation of his activities to manage his diabetes mellitus, type II, and did not note any history of hospitalizations for ketoacidosis or hypoglycemia. In summation, the examiner did not find that the diabetes mellitus, type II resulted in any impairment of occupational functioning. As the examiner reviewed the entire claims file and considered the Veteran’s full medical history, the Board finds his opinion to be highly probative of the ultimate determination as to the severity of the diabetes mellitus, type II during the appeal period. Sklar v. Brown, 5 Vet. App. 140 (1993). The Veteran was next afforded a VA examination in June 2014 to evaluate the severity of the diabetes mellitus, type II, during which it was noted that the Veteran utilized a prescribed oral hypoglycemic agent for regulation of his diabetes mellitus, type II. Diabetic peripheral neuropathy was the only noted complication of the diabetes mellitus, type II. The examiner did not find any evidence that the Veteran required regulation of his activities to manage his diabetes mellitus, type II, and did not note any history of hospitalizations for ketoacidosis or hypoglycemia. In summation, the examiner did not find that the diabetes mellitus, type II resulted in any impairment of occupational functioning. Once again, as the examiner reviewed the claims file and considered the Veteran’s full medical history, the Board finds his opinion to be highly probative of the ultimate determination as to the severity of the diabetes mellitus, type II during the appeal period. Sklar, supra. Pursuant to the Board’s remand instructions, the Veteran was scheduled for a new VA diabetes examination in December 2020, during which it was noted that the Veteran utilized a prescribed oral hypoglycemic agent and restricted his diet in order to regulate his diabetes mellitus, type II. The examiner did not find any evidence that the Veteran required regulation of his activities to manage his diabetes mellitus, type II, and did not note any history of hospitalizations for ketoacidosis or hypoglycemia. It was noted, however, that the Veteran experienced diabetic peripheral neuropathy, erectile dysfunction, and a cardiac condition, all as complications of the diabetes mellitus, type II. In summation, the examiner did not find that the diabetes mellitus, type II resulted in any impairment of occupational functioning. Once again, as the examiner reviewed the entire claims file and considered the Veteran’s full medical history, the Board finds her opinion to be highly probative of the ultimate determination as to the severity of the diabetes mellitus, type II. Sklar, supra. A review of VA outpatient records as well as private medical records corresponding to the appeal period does not indicate that the Veteran has had to regulate his activities in any specified manner that was attributable to his diabetes mellitus, type II. The Veteran receives his treatment from VA as well as private medical providers, and he has not indicated that this private medical provider has found that the diabetes mellitus, type II mandates any regulation of his activities. When queried during the February 2019 hearing, the Veteran stated that his treating doctors at his local VA medical center told him that he needed to regulate his activities in order to manage his diabetes mellitus, type II. However, he did not elaborate as to which doctor stated this or to what degree he was instructed to regulate his activities. In summation, the Veteran has not submitted any evidence or argument which convincingly shows that his diabetes mellitus, type II requires a regulation of his activities. Although it is acknowledged that he has had to regulate his activities due to the limitations imposed by his bilateral lower extremity peripheral neuropathy, the Board will not consider this distinct symptomatology in considering the severity of the diabetes mellitus, type II alone, as that would violate the regulations listed above. See 38 C.F.R. § 4.119, Note 1. The objective medical evidence includes the three VA examinations as well as the available VA and private medical records, all of which indicate that while the diabetes mellitus, type II does require regular insulin treatment as well a restricted diet, it does not require any regulation of activity above that which is attributed to the separately service-connected bilateral lower extremity peripheral neuropathy. Therefore, the preponderance of the evidence is against a finding that the diabetes mellitus type II mandates any regulation of activities as would be necessary to award a higher 40 percent rating, and, as such, the Board concludes that a rating in excess of 20 percent for diabetes mellitus type II is not warranted. Consequently, the benefit-of-the-doubt doctrine does not apply, and the rating claim must be denied. 2. Peripheral Neuropathy of the Bilateral Lower Extremities The Veteran contends that he is entitled to increased ratings for his peripheral neuropathy of the right and left lower extremities. Both conditions are rated as 10 percent disabling prior to December 18, 2020 and as 20 percent disabling therefrom. As the evidence in support of both claims is essentially identical, the Board will evaluate the separate increased ratings claims together. The separate ratings in this case were assigned pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8520, corresponding to complete or incomplete paralysis of the sciatic nerve. Under Diagnostic Code 8520, a disability rating of 10 percent is awarded for mild incomplete paralysis of the sciatic nerves, while a 20 percent rating is warranted for moderate incomplete paralysis and a 40 percent rating is warranted for incomplete paralysis of the sciatic nerves that is moderately severe in nature. In rating diseases of the peripheral nerves, the term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type of 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 should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. The words “mild,” “moderate” and “severe,” as used in the various diagnostic codes, are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence for “equitable and just decisions.” 38 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, it is not dispositive. Instead, all evidence must be evaluated. 38 U.S.C. § 7104; 38 C.F.R. §§ 4.2, 4.6. During the appeal period, the Veteran was first afforded a VA examination to evaluate the severity of the bilateral lower extremity peripheral neuropathy in March 2013. He reported that he experienced a burning pain in his bilateral lower extremities associated with prolonged standing and walking that began about three months prior. Symptoms were noted as mild intermittent pain in the right lower extremity, moderate pain in the left lower extremity, mild bilateral lower extremity paresthesias, and mild bilateral lower extremity numbness. Strength, sensation and reflex testing revealed no abnormalities other than a decrease in sensation of the feet and toes bilaterally. After completing an in-person evaluation, the examiner found that the Veteran’s peripheral neuropathy was mild in severity for both the right and left lower extremities. The examiner then found that the bilateral lower extremity peripheral neuropathy contributed to functional occupational impairment in the form of limited walking and standing beyond 60 to 90 minutes. The Veteran was next afforded a VA examination in June 2014 to evaluate the severity of the bilateral lower extremity peripheral neuropathy, during which he reported experienced burning and numbness in his feet as well as pain with weight bearing, standing and walking. According to the examiner the Veteran had recently been diagnosed with bilateral plantar fasciitis, which, when combined with the peripheral neuropathy, prevented the Veteran from standing and/or walking for more than 60 to 90 minutes at a time. Symptoms were noted as mild bilateral intermittent pain in the lower extremity, moderate bilateral lower extremity paresthesias, and moderate bilateral lower extremity numbness. Strength, sensation and reflex testing revealed no abnormalities other than a decrease in sensation of the feet and toes bilaterally. After completing an in-person evaluation, the examiner found that the Veteran’s peripheral neuropathy was mild in severity for both the right and left lower extremities. The examiner then found that the bilateral lower extremity peripheral neuropathy contributed to functional occupational impairment in the form of limited walking and standing due to foot pain; the examiner reported that the Veteran believed he could work in a position that minimized standing and walking and which allowed him to rest his feet. Pursuant to the Board’s remand instructions, the Veteran was afforded a new VA examination in December 2020 in order to evaluate whether the bilateral lower extremity peripheral neuropathy had worsened in severity, during which he reported that the pain in his feet had increased significantly since his last examination. The only symptom noted on evaluation was constant moderate pain bilaterally. Strength, sensation, and reflex testing revealed no pertinent abnormalities other than a decrease in sensation of the knees bilaterally. The examiner further commented that the Veteran’s neuropathy bilaterally was best characterized as a moderate, sensory only neuropathy of small nerve endings in both feet to the level of the lower third of the legs. In summation, the examiner noted that the bilateral lower extremity peripheral neuropathy contributed to functional occupational impairment, as it caused the Veteran to experience pain in his feet after standing or walking for a prolonged period of time. During the February 2019 hearing, the Veteran attested to his difficulty with standing and walking due to pain and feeling pins and needles in his feet. According to the Veteran, he recently began to use a cane to assist with ambulation. A review of available VA medical records reflects that the Veteran was complaining of Morton’s neuroma as early as May 2012, which is a condition impacting the feet with many of the same characteristics as peripheral neuropathy for which the Veteran is currently seeking service connection, including pain as well as a tingling and burning sensation. Subsequent records show that the Veteran has consistently complained of experiencing pain in both feet. A June 2014 outpatient record shows that the Veteran also began reporting that he experienced a tingling sensation in his feet. Thereafter, the Veteran began reporting the tingling along with the constant bilateral foot pain. The Veteran has submitted private medical records documenting his course of treatment with a Dr. N.D., a podiatrist who has diagnosed him with diabetic neuropathy of the bilateral lower extremities as well as Morton’s neuroma of the left foot. These medical records show that the Veteran has reported experiencing bilateral foot pain as well as numbness and tingling. Upon review of the evidence, the Board finds that a rating in excess of 10 percent for bilateral peripheral neuropathy of the lower extremities is not warranted prior to December 18, 2020, or in excess of 20 percent therefrom. Although the Veteran has been experiencing some bilateral lower extremity neurological symptomatology centered around his feet for the entirety of the appeal period, there is no evidence which suggests that his symptomatology, which has been predominantly documented as pain only, has been more then mild in severity prior to December 18, 2020, the date of the most recent VA examination. Specifically, both the March 2013 and June 2014 examiners found that the symptomatology of the bilateral lower extremity peripheral neuropathy was no more than mild in severity. As both examiners reviewed the entire claims file and considered the Veteran’s full medical history, the Board finds their opinions to be highly probative of the ultimate determination as to the severity of the condition during the appeal period. Sklar, supra. Moreover, the Board notes that none of the available treatment records for the period prior to December 18, 2020 reflect that the Veteran has experienced more than pain and some additional neurological symptomatology; furthermore, none of the Veteran’s treating physicians have ever evaluated the severity of the bilateral peripheral neuropathy of the lower extremities. The Board acknowledges that the Veteran is competent to provide a statement of symptoms which are observable to his senses, and there is no reason to doubt his credibility. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, the Board must emphasize that the Veteran is not competent to diagnose or interpret accurately the past or current severity of the Veteran’s bilateral lower extremity peripheral neuropathy, as this requires highly specialized knowledge and training. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Ultimately, the Board must rely on the most probative evidence of record, that is, the March 2013 and June 2014 VA examiner evaluations, who both found that the Veteran’s symptomatology was no more than mild in severity. Similarly, from December 18, 2020, the Board must also conclude that an increased rating is not warranted; once again, the December 2020 VA examiner’s opinion is highly probative, as she reviewed the entire claims file and carried out an in-person evaluation prior to setting forth her findings. Sklar, supra. Moreover, there is no indication from the record that the Veteran has experienced any symptomatology that is more than sensory in nature at any time during the appeal period, which would be necessary to warrant a rating in excess of 20 percent. The Board has considered the benefit-of-the-doubt doctrine; however, the Board does not perceive an approximate balance of positive and negative evidence in support of assigning a rating for the peripheral neuropathy of the bilateral lower extremities in excess of 10 percent prior to December 18, 2020, and in excess of 20 percent therefrom. Therefore, the preponderance of the evidence is against the assignment of a rating in excess of those already assigned and the doctrine is not applicable in this instance. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. 3. Individual Unemployability TDIU may be assigned when the combined schedular rating for the claimant’s service-connected disabilities is less than 100 percent, and when it is found that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age, provided that, if there is only one such disability, this disability is ratable at 60 percent or more, or, if there are two or more disabilities, there is at least one disability ratable at 40 percent or more and additional disabilities sufficient to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16. The Veteran’s service-connected disabilities, alone, must be sufficiently severe to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). The relevant issue is not whether the veteran is unemployed or has difficulty obtaining employment, but whether the veteran is capable of performing the physical and mental acts required by employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). In determining whether unemployability exists, consideration may be given to the Veteran’s level of education, special training, and previous work experience, but not to age or to any impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. Pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009), a claim of TDIU is part and parcel to any increased rating claim where it is contended that the service-connected disability for which an increased rating is sought has contributed to an inability to secure and follow substantially gainful employment. A review of the record reflects that the Veteran has asserted that his diabetes mellitus, type II has contributed to his economic inadaptability; as such, the period on appeal for possible entitlement to TDIU corresponds to the period of review for the diabetes mellitus, type II claim, that is, from November 20, 2011. From that date, the Veteran was in receipt of a 60 percent rating for service-connected ischemic heart disease with myocardial infarction; a 20 percent rating for diabetes mellitus, type II; and a noncompensable rating for residual scars on the abdomen, for a combined total of 70 percent. Thereafter, the Veteran was awarded separate 10 percent ratings for right and left lower extremity peripheral neuropathy effective November 20, 2012; this did not increase the combined total rating for all of the Veteran’s service-connected disabilities. Most recently, effective December 18, 2020, the Veteran was awarded separate 20 percent ratings for right and left lower extremity peripheral neuropathy, which increased the combined total rating for all of the Veteran’s service-connected disabilities to 80 percent from that date. As the Veteran has been in receipt of a 60 percent rating for ischemic heart disease for the entire period of the appeal, he meets the schedular requirements for consideration of a grant of TDIU from November 20, 2011. That being said, the Board must still evaluate whether the service-connected disabilities precluded the Veteran from securing and maintaining substantially gainful employment during the appeal period. To begin, the Board notes that the United States Court of Appeals for Veterans Claims (Court) recently promulgated additional guidance to assist in the evaluation of claims for TDIU in Ray v. Wilkie, 31 Vet. App. 58, 71 (2019). The Court stated that: “[W]e interpret the phrase “unable to secure and follow a substantially gainful occupation” in [38 C.F.R.] § 4.16(b) to have two components: one economic and one noneconomic. 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. As for the noneconomic component, the Secretary himself states that ‘determining eligibility for TDIU requires more than determining the presence or absence of employment producing income exceeding any particular threshold,’ and ‘the ultimate inquiry is instead on the individual claimant’s ability to secure or follow that type of employment’.” Factors for consideration in evaluating the noneconomic component are: (1) the veteran’s history, education, skill, and training; (2) whether the veteran has the 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. Factors that may be relevant include, but are not limited to, the limitations, if any, concerning lifting, bending, sitting, standing, walking, climbing, grasping, typing, and reaching, as well as auditory and visual limitations; and (3) whether the veteran has the mental ability to perform the activities required by the occupation at issue, with possibly relevant factors including, but not limited to, the limitations, if any, concerning memory, concentration, ability to adapt to change, handle work place stress, get along with coworkers, and demonstrate reliability and productivity. Id. With regards to the economic component of the Ray analysis, in the Veteran’s formal application for entitlement to TDIU dated in November 2012, he indicated that his ischemic heart disease precluded him from securing and following substantially gainful employment. He reported that his heart condition first affected his full-time employment in January 2012, when he became too disabled to work. According to the Veteran, he was working full time as a retail sales clerk and had been working in this position for 11 years; at the time he ceased working he reported an annual income of $21,000. This salary is considered more than marginal, as the Veteran’s earned income exceeded the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold in 2012. United States Federal Poverty Guidelines Used to Determine Financial Eligibility for Certain Federal Programs, available at https://www.census.gov/data/tables/time-series/demo/income-poverty/historical-poverty-thresholds.html (last accessed March 15, 2021). In a September 2014 correspondence, a representative from the Veteran’s former employer corroborated the information reported by the Veteran on the TDIU application as to his tenure with the company and his salary. The representative indicated that the Veteran did not receive any concessions for his disability while he worked with the company, and also detailed that the termination of his employment was not related to any disability. Taking into consideration the available records regarding the Veterans history of employment, the Board concludes that prior to January 2012, the Veteran did not meet the economic component of a TDIU grant under the guidelines set forth in Ray, as the evidence shows that he was able to secure and follow substantially gainful employment up until January 27, 2012, when he was terminated from his employment as a retail sales clerk. After this date, however, there is no evidence which suggests that the Veteran undertook further employment; accordingly, from January 27, 2012, the Board finds that the Veteran met the economic component of a TDIU grant under the guidelines set forth in Ray. That being said, entitlement to TDIU is not warranted unless the record suggests that his unemployability was attributable to his service-connected disabilities. After a thorough review of the record, the Board does not find that the Veteran’s service-connected disabilities precluded him from securing and following substantially gainful employment at any point in time from January 27, 2012. The Veteran was afforded a VA examination to evaluate the severity of his service-connected ischemic heart disease in March 2013, during which it was noted that he had a history of myocardial infarction and coronary artery disease and had a pacemaker installed in November 2007. A cardiac functional assessment revealed that the Veteran was expected to exhibit dyspnea at a level of 7-10 metabolic equivalents, consistent with rather strenuous physical activity. It was the examiner’s impression that the ischemic heart disease did not contribute to any impairment of occupational functioning. The Board also notes that the Veteran underwent a VA scars examination in March 2013, during which it was noted that he had two surgical linear scars on the anterior trunk that were nontender and non-adherent. It was the examiner’s impression that these two scars did not contribute to any impairment of occupational functioning. As part of the series of VA examinations the Veteran underwent in March 2013, the AOJ elicited an opinion as to the impact of the Veteran’s service-connected disabilities on his economic functioning. The examiner opined that the ischemic heart disease, diabetes mellitus, type II, and peripheral neuropathy together rendered him unable to secure and maintain employment requiring prolonged standing, walking or running. However, the examiner did not find that these disabilities precluded any sedentary work that limited standing, walking and running. The Veteran was afforded a new VA examination in June 2014 to evaluate the severity of his ischemic heart disease, during which it was acknowledged that his pacemaker had been installed as likely due to his heart condition. A cardiac functional assessment revealed that the Veteran was expected to exhibit dyspnea at a level of 3-5 metabolic equivalents, consistent with light physical activity. The examiner further commented that the Veteran was able walk casually without chest pain but experienced dyspnea when walking up a flight of stairs. It was the examiner’s impression that the ischemic heart disease would preclude any job requiring strenuous physical activity but would not impair any employment with minimal physical activity. During the February 2019 hearing, the Veteran attributed his economic inadaptability primarily to his symptoms of persistent foot pain and his inability to stand or walk for long periods of time. His spouse also attested to his inability to carry out activities of daily functioning at his home due to the foot pain symptomatology as well as symptomatology from his ischemic heart disease. A review of available VA post-service medical records shows that ischemic heart disease has been listed as an active problem in the Veteran’s VA medical records for the entirety of the appeal period. The Veteran underwent regular evaluations for his pacemaker during this time, and at no point did any treating medical professional make a determination that the heart disease together with his other service-connected disabilities precluded him from securing and following substantially gainful employment. The Veteran has submitted records documenting his treatment at Sierra Vista hospital in July 2015 following an incidence of chest pain. According to the Veteran, his pacemaker fired four times and caused him significant pain. He did not endorse any further symptoms, to include shortness of breath or diarrhea. He was discharged with instructions to avoid strenuous activity. A review of additional private medical records submitted by the Veteran does not show specific complaints of or treatment for symptoms of ischemic heart disease. Taken together with the evidence already detailed regarding the separately claimed diabetes mellitus, type II and the bilateral lower extremity peripheral neuropathy, the record does not illustrate that the Veteran was precluded from engaging in substantially gainful employment by virtue of his service-connected disabilities at any point during the appeal period. While the question of whether a veteran is capable of substantially gainful employment is ultimately one for the adjudicator (see Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013)), the fact that none of the VA examiners who evaluated the nature of the service-connected disabilities during the applicable appeal period found that any of those disabilities would preclude the Veteran from securing and following substantially gainful employment is consistent with the rest of the medical evidence of record, and thus the Board considers those examinations to be highly probative. Sklar, supra. Although the record does reflect that the Veteran experienced significant foot pain hindering his ambulation and further exhibited dyspnea following strenuous physical activity, this degree of impairment does not suggest that he was precluded from physically performing sedentary or light work that allowed him to rest his feet regularly. Furthermore, there is no indication that the Veteran’s service-connected disabilities would result in any impairment in his mental ability to work during the relevant appeal period. The Board has considered the Veteran’s assertions that he was unable to work as a result of his service-connected disabilities from February 2012. However, the Veteran does not possess training or credentials in medical or vocational matters and, thus, cannot competently opine on the question of whether such symptoms actually rendered him unemployable during the period in question. Jandreau v. Nicholson, 491 F.3d 1372 (Fed. Cir. 2007). The Board also acknowledges that the Veteran was unemployed after his employment was terminated in January 2012; however, the mere fact that a Veteran is unemployed or underemployed, or has difficulty obtaining employment, is not enough to warrant a grant of TDIU. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Indeed, the Court in Ray reemphasized that the question is whether a veteran is capable of performing the physical and mental acts required by employment, not whether such veteran can find employment.  In summation, the Board finds that the preponderance of the evidence is against a determination that the Veteran’s service-connected disabilities precluded him from securing and following substantially gainful employment from November 20, 2011. Therefore, as the preponderance of the evidence weighs against the claim, the benefit-of-the-doubt doctrine does not apply, and the Veteran’s claim of entitlement to TDIU must be denied. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Christopher M. Collins, 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.