Citation Nr: 21022956 Decision Date: 04/19/21 Archive Date: 04/19/21 DOCKET NO. 14-28 683 DATE: April 19, 2021 ORDER Entitlement to service connection for Type II diabetes mellitus (“diabetes mellitus”), to include as due to exposure to herbicide agents, is denied. Entitlement to service connection for a heart disability, to include as due to exposure to herbicide agents, is denied. Entitlement to service connection for a dental disability for compensation purpose is denied. A total disability rating based on individual unemployability (TDIU) from February 20, 2015, is warranted. REMANDED Entitlement to service connection for obstructive sleep apnea (“sleep apnea”) is remanded. Entitlement to service connection for a left hand disability is remanded. Entitlement to service connection for a left hip disability is remanded. Entitlement to service connection for a left foot disability is remanded. Entitlement to service connection for a right foot disability is remanded. Entitlement to service connection for a right hip disability is remanded. Entitlement to service connection for a left arm disability is remanded. Entitlement to service connection for an acquired psychiatric disability is remanded. Entitlement to service connection for a liver disability is remanded. Entitlement to service connection for Hepatitis C is remanded. FINDINGS OF FACT 1. The Veteran was not exposed to an herbicide agent during service. 2. The Veteran’s diabetes mellitus did not have its onset in service, did not manifest to a compensable degree within service or first post-service year, continuity of symptomatology is not established, and the disability is not otherwise etiologically related to an in-service injury or disease. 3. The Veteran’s heart disability did not manifest in service and is not shown to be causally or etiologically related to his military service. 4. The Veteran did not have a dental disability for which service-connected compensation is payable. 5. From February 20, 2015, the evidence is at least evenly balanced as to whether the Veteran’s service-connected disabilities precluded him from obtaining and maintaining substantially gainful employment consistent with his education and occupational experience. CONCLUSIONS OF LAW 1. The criteria for service connection for diabetes mellitus have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for service connection for a heart disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for service connection for a dental disability for compensation purposes have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.381, 4.150, 17.161. 4. The criteria for a TDIU from February 20, 2015, have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from October 1971 to June 1974. The Veteran died in April 2020; the appellant is his surviving spouse. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from September 2012 (regarding the claims of service connection for heart disability, diabetes mellitus, sleep apnea, and dental disability) and February 2015 (regarding the claims of service connection for left hand disability, left hip disability, left foot disability, right foot disability, right hip disability, left arm disability, low back disability, acquired psychiatric disability, liver disability, and hepatitis C) rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). By way of background, in April 2017, the Board remanded the issues on appeal. During the appeal process, the Veteran passed away in April 2020. As such, in May 2020, the Board dismissed the issues on appeal. Since then, the Veteran’s surviving spouse has been properly substituted within one year of the Veteran’s death and is recognized as a valid substitute appellant. See September 2020 Notification Letter. The Board observes that additional VA treatment records were received following the last adjudication by the RO in the February 2020 supplemental statement of the case. The Board has reviewed these records and observes that they are duplicative, cumulative, and/or not pertinent to the issues on appeal addressed in the decision below. Moreover, the appellant expressed interest in adjudicating the claim with the information in the file with no further delay. See March 2021 VCAA/DTA Letter. Service Connection Generally, to establish service connection a veteran must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.” Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). VA laws and regulations provide that if a veteran was exposed to an herbicide agent during service, certain listed diseases, including type 2 diabetes, is presumptively service connected. 38 U.S.C. § 1116(a)(1); 38 C.F.R. § 3.309(e). A veteran who “served in the Republic of Vietnam” between January 9, 1962, and May 7, 1975, is presumed to have been exposed during such service to an herbicide agent. 38 U.S.C. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). VA now recognizes that tactical or tactical-like herbicides were used on the fenced-in perimeters of military bases in Thailand. VA has determined that exposure to herbicide agent will be conceded for veterans whose duties placed them at or near the perimeters of certain Thailand military bases, including Udorn, during the Vietnam era (February 28, 1961, to May 7, 1975), allowing for presumptive service connection of the diseases associated with herbicide exposure. VA based this determination of evidence contained on a declassified Vietnam era Department of Defense document titled “Project CHECO Southeast Asia Report: Base Defense in Thailand.” Specifically, if a veteran served as an Air Force security policeman, security patrol dog handler, member of the security police squadron, or otherwise near the base perimeter as shown by evidence of daily work duties, performance evaluation reports, or other credible evidence, herbicide exposure is to be conceded on a direct/fact-founds basis. In addition, if an Army veteran provides a statement that he was involved in perimeter duty, and there is additional credible evidence supporting such statement, herbicide agent exposure is also to be conceded on a direct/fact-founds basis. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Exposure to an Herbicide Agent The Veteran claims that he was exposed to herbicide agents while serving in Thailand. Specifically, he stated that “he would see people spraying Agent Orange in the field nearby and [that] he could smell it.” See March 2021 VA 21-4138 Statement in Support of Claim. For the following reasons, the evidence does not support that the Veteran was exposed to an herbicide agent during service. The records show that the Veteran was stationed in Thailand between 1973 and 1974 at the Udorn RTAFB. See April 2012 VA Memo. The Veteran’s military personnel records reflect that he was an aircraft fuel systems mechanic. His duties were listed as determining maintenance requirements on structural tank repair; removing, repairing, inspecting, installing and modifying aircraft fuel systems; and locating leaks in integral sealed tanks. See August 2014 STR – Medical. The Veteran’s military duties did not include working as a security policeman, security patrol dog handler, or a member of the security police squadron. Furthermore, the evidence of record does not reflect that the Veteran’s MOS, as an aircraft fuel systems mechanic, and military duties brought him near the air base perimeter. In fact, the Veteran did not contend that he was assigned to duties near the perimeter of the base or that he was near the perimeter of the base. The Board finds this lack of documentation or indication in the service personnel records more probative than the Veteran’s assertion later in time that he was exposed to herbicide agents. In addition, a memorandum regarding herbicide use in Thailand during the Vietnam Era noted that tactical herbicides were conducted in Thailand from April 2, 1964 to September 8, 1964 and modified ranch hand aircraft flew 17 insecticide missions in Thailand from August 30, 1963 to September 16, 1963 and again from October 14, 1966 to October 17, 1966. See April 2012 VA Memo. The Veteran was not in Thailand during these periods of time. The evidence of record does not show that the Veteran was exposed to herbicide agents during his military service and therefore the theory of presumptive service connection based on herbicide agent exposure is not applicable. Nevertheless, the appellant is not precluded from establishing service connection on a direct basis. See 38 U.S.C.§ 1113(b); 38 C.F.R. § 3.303(d) (the availability of service connection on a presumptive basis does not preclude consideration of service connection on a direct basis); Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). 1. Service connection for diabetes mellitus. During the Veteran’s lifetime and during the appeal period, the Veteran was diagnosed as having diabetes mellitus. See August 2020 CAPRI. As such, the first element of service connection is met. Certain chronic diseases, such as diabetes mellitus, will be presumed related to service if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service, with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137. As to the in-service event, injury, or disease element, the Veteran was not diagnosed as having diabetes mellitus or symptoms thereof during service. A review of the service treatment records shows that in the July 1971 enlistment examination and the April 1974 separation examination the Veteran had normal endocrine system with no endorsement of frequent urination or having sugar or albumin in urine. See August 2014 STR – Medical. Further, the Veteran only alleged that his diabetes mellitus manifested due to his alleged exposure to herbicide agents and that it was not the result of any other event or injuries in service. Moreover, the Veteran did not claim that his diabetes mellitus manifested in service or shortly thereafter. In fact, the Veteran was diagnosed with diabetes mellitus in 2004, about 30 years after service. See January 2005 Medical Treatment Record – Government Facility. Thus, as the Veteran was diagnosed as having diabetes mellitus several years after his separation from service, his diabetes mellitus did not manifest to a compensable degree within a presumptive period following separation from service. As such, the evidence does not show the diabetes mellitus had its onset in service, manifested to a degree of 10 percent or more, or was noted, during active service or within a year of discharge from service. The Board acknowledges that the Veteran was not afforded a VA examination with respect to his claim of service connection for diabetes mellitus but finds no such examination was required because the evidence does not indicate that the claimed disability, or symptoms thereof, may be associated with the Veteran’s active service. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Under McLendon, VA is obligated to provide an examination when the record contains (1) competent evidence of a current disability (or persistent or recurrent symptoms of a disability), (2) evidence establishing that an event, injury, or disease occurred in service, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service, but (4) there is insufficient competent medical evidence on file to decide the claim. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Here, the service treatment records do not show any complaints, signs, or symptoms of diabetes mellitus. Further, the Veteran did not claim that his diabetes mellitus manifested in service or shortly thereafter. In fact, the records show that the Veteran was diagnosed with diabetes mellitus in 2004, more than 30 years after service. See January 2005 Medical Treatment Record – Government Facility. Or, in the alternative, the Veteran stated that his diabetes mellitus manifested around 1990, more than 15 years after service. See January 2005 VA 21-4142 Authorization for Release of Information. As there is no evidence establishing an event, injury or disease occurred in service, the Board finds that a VA examination/medical opinion is not required. The medical evidence of record does not contain any opinions linking the Veteran’s diabetes mellitus to his military service or suggest that there was causal relationship. The Veteran or the appellant is not competent to provide a nexus between diabetes mellitus and his active military service because he or the appellant does not have the requisite medical training or expertise to do so. Jandreau, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Therefore, the Veteran’s statements where he relatds his diabetes mellitus to his military service are not competent and, thus, afforded no probative value. There is no competent evidence that tends to indicate a nexus between the Veteran’s diabetes mellitus and his active military service. The weight of the evidence is against manifestation of diabetes mellitus in service, within the one-year presumptive period, or for many years thereafter, and there is no evidence of a nexus between the Veteran’s diabetes mellitus and his military service. The preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application, and the claim of service connection for diabetes mellitus is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 2. Service connection for a heart disability. The Veteran had a diagnosis of acute congestive heart failure and coronary artery disease. See August 2020 CAPRI. As such, the first element of service connection is met. As to the in-service event, injury, or disease element, the Veteran was not diagnosed as having a heart disability or symptoms thereof during service. In the April 1974 separation examination, the Veteran endorsed having shortness of breath and pain/pressure in chest. Specifically, the Veteran stated that he had shortness of breath after extended periods of brisk walking or running with occasional sharp pain in the chest. The examiner determined that the pain was likely muscular in origin. On examination, the Veteran was noted to have normal heart and vascular system with no endorsement of palpitation or pounding of the heart, or heart trouble. See August 2014 STR – Medical. Accordingly, the Board finds the April 1974 endorsement of pain or pressure in the chest was due to muscular pain and unrelated to the heart. Accordingly, the evidence does not establish an in-service incurrence. The Board acknowledges that the Veteran has not been afforded a VA examination with respect to his claim for service connection for a heart disability but finds no such examination was required because the evidence does not indicate that the claimed disability, or symptoms thereof, may be associated with the Veteran’s active service. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Under McLendon, VA is obligated to provide an examination when the record contains (1) competent evidence of a current disability (or persistent or recurrent symptoms of a disability), (2) evidence establishing that an event, injury, or disease occurred in service, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service, but (4) there is insufficient competent medical evidence on file to decide the claim. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Here, the service treatment records do not show any complaints, signs, or symptoms of a heart-related disability. More importantly, the Veteran did not claim that his heart disability manifested in service or shortly thereafter. In fact, based on the medical records, the Veteran was diagnosed with coronary artery disease in February 2011, more than 35 years after service. See December 2011 Medical Treatment Record – Non-Government Facility. As there is no evidence establishing an event, injury or disease occurred in service, the Board finds that a VA examination/medical opinion is not required. The medical evidence of record does not contain any opinions linking the Veteran’s heart disability or any heart symptoms to his military service or suggest that there is causal relationship. The Veteran was not competent to provide a nexus between a heart disability and his active military service because he did not have the requisite medical training or expertise to do so. Jandreau, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Therefore, the Veteran’s statements where he related his current heart disability to his military service are not competent and, thus, afforded no probative value. There is no competent evidence that tends to indicate a nexus between the Veteran’s heart disability and his active military service. There is not a reasonable basis to find that the Veteran’s heart disability was incurred in, or is otherwise related to, his active service. Accordingly, service connection for a heart disability must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 3. Service connection for a dental disability for compensation purposes. The dental disabilities for which service-connected compensation benefits are available are set forth under 38 C.F.R. § 4.150, Diagnostic Codes 9900-9916. Disability compensation and VA outpatient dental treatment may be provided only for certain specified types of service-connected dental disorders. For other types of service-connected dental disorders, the claimant may receive treatment only and not compensation. 38 U.S.C. § 1712; 38 C.F.R. §§ 3.381, 4.150, 17.161. Dental disabilities that may be awarded compensable disability ratings are set forth under 38 C.F.R. § 4.150. These disabilities include chronic osteomyelitis or osteoradionecrosis of the maxilla or mandible, loss of the mandible, nonunion or malunion of the mandible, loss of the maxilla, nonunion or malunion of the maxilla, limited temporomandibular motion, loss of the ramus, loss of the condyloid or coronoid processes, loss of the hard palate, loss of teeth due to the loss of substance of the body of the maxilla or mandible and where the lost masticatory surface cannot be restored by suitable prosthesis, when the bone loss is a result of trauma or disease but not the result of periodontal disease. 38 C.F.R. § 4.150, Diagnostic Codes 9900-9916. In this case, there is no competent lay, medical or dental evidence of loss of teeth due to loss of substance of the body of the maxilla or mandible or any other condition on which service connection could be allowed. The Board notes that in a May 1972 service treatment record (STR) the Veteran was struck in the mouth by a land line and was knocked out briefly. On examination, the Veteran’s mandible was stable, but the lower molars appeared misaligned and the Veteran experienced pain on manipulation of the jawbone. See August 2014 STR – Medical. There was no maxillary discomfort. The Veteran was diagnosed with bony trauma of the jaw and soft tissue trauma of the chin. The Veteran reported that he complained of dental issues in service, and that he had several teeth pulled following service. However, these statements do not establish that the loss of teeth was due to loss of substance of the body of the maxilla or mandible. Thus, the statements do not establish the presence of a dental disability for which VA may award disability compensation. The Veteran was afforded a dental examination in June 2017 and November 2018. In the June 2017 VA examination, the examiner stated that the Veteran had missing teeth, bone loss, gingival inflammation, periodontal disease, and impacted premolars in the mandible. However, the examiner did not opine as to whether the missing teeth and bone loss were due to loss of substance of the body of the maxilla or mandible. As such, a new examination was afforded to the Veteran. In the November 2018 VA examination, the examiner did not render a dental diagnose as there was no pathology to render a diagnosis. The examiner opined that the Veteran’s dental disability was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner explained that there was no significant injury to result in long term disability and mandibular or dental disfigurement as noted in the STRs. The Veteran had very few teeth remaining at this point, so it was not possible to speculate how the arrangement of his teeth were affected at the time of reported injury. The Board affords great probative value to the November 2018 examiner’s assessment as there was no evidence that the examiner was either not competent or credible. Further, the examiner’s assessment was based on both the Veteran’s reports and an objective dental examination. As such, the Board finds that the examination report is entitled to significant probative weight as to the presence of a dental disability for which disability compensation may be awarded. Nieves-Rodriguez, 22 Vet. App. 295. No other evidence of record reflects that the Veteran’s loss of teeth is due to loss of substance of the maxilla or mandible. In sum, there is no competent evidence that the Veteran had a current dental disability for which compensation is payable. 38 C.F.R. § 4.150. Based on the foregoing, there is no basis under the law for the award of service-connected VA disability compensation for a current dental disorder, as there is simply no evidence that the Veteran had a dental disability falling under the categories of compensable dental conditions. Id. When, as here, the law is dispositive of the claim, it should be denied because of lack of entitlement under the law. Sabonis v. Brown, 6 Vet. App. 426, 42930 (1994). For these reasons, the claim is denied. TDIU It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. See 38 C.F.R. § 4.16. A finding of total disability is appropriate “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.” See 38 C.F.R. §§ 3.340(a)(1), 4.15. TDIU may be assigned where the schedular rating is less than total and it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of either (1) a single service-connected disability ratable at 60 percent or more, or (2) two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). An extraschedular total rating based on individual unemployability may be assigned in the case of a veteran who fails to meet the percentage requirements but who is unemployable by reason of service-connected disability. 38 C.F.R. § 4.16(b). If a sufficient rating is present, then it must be at least as likely as not that the veteran is unable to secure or follow a substantially gainful occupation as a result of that disease. See 38 C.F.R. § 4.16(a). 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). The issue is not whether the veteran can find employment generally, 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). Consideration may be given to the veteran’s education, special training, and previous work experience, but not to his age or to the impairment cause by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Van Hoose, 4 Vet. App. at 363. Where these percentage requirements are not met, entitlement to benefits on an extraschedular basis may be considered when the veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities, and consideration is given to the veteran’s background including his or her employment and educational history. 38 C.F.R. § 4.16(b). See Johnson v. McDonald, 762 F.3d 1362 (2014). The Board does not have the authority to assign an extraschedular total disability rating based on individual unemployability in the first instance. Bowling v. Principi, 15 Vet. App. 1 (2001). Entitlement to a TDIU. The Veteran filed an informal claim for entitlement to service connection for various impairments in June 2013. In February 2015, the Veteran was granted service connection and during the appeal period in January 2019 the Board found that the issue of entitlement to a TDIU was raised by the record. The Veteran’s service-connected disabilities included right radial neuropathy rated at 30 percent effective June 19, 2013; bilateral plantar calluses rated at 10 percent effective November 3, 2010, and 20 percent effective February 20, 2015; right shoulder strain rated at 10 percent effective June 19, 2013; cervical strain rated at 10 percent effective June 19, 2013; right knee strain rated at 10 percent effective June 19, 2013; left knee strain rated at 10 percent effective June 19, 2013, and radiculopathy of the right upper extremity rated at 10 percent effective June 19, 2013. The Veteran had a combined evaluation of 10 percent effective November 3, 2010; 60 percent effective June 19, 2013, and 70 percent effective February 20, 2015. As the Veteran did not have one disability rated at 60 percent or a combined rating of 70 percent prior to February 20, 2015, the Board will consider whether referral for extraschedular consideration under 38 C.F.R. § 4.16(b) is warranted. Regarding the period from February 20, 2015, the Board has considered 38 C.F.R. § 4.26, wherein it states that when a partial disability results from disease or injury of both arms, or of both legs, or of paired skeletal muscles, the ratings for the disabilities of the right and left sides will be combined as usual, and 10 percent of this value will be added (i.e., not combined) before proceeding with further combinations, or converting to degree of disability. The bilateral factor will be applied to such bilateral disabilities before other combinations are carried out and the rating for such disabilities including the bilateral factor will be treated as one disability for the purpose of arranging in order of severity and for all further combinations. 38 C.F.R. § 4.26. It is further provided under 38 C.F.R. § 4.26(b) that the correct procedure when applying the bilateral factor to disabilities affecting both upper extremities and both lower extremities is to combine the ratings of the disabilities affecting the 4 extremities in the order of their individual severity and apply the bilateral factor by adding, not combining, 10 percent of the combined value thus attained. Here, the Board combines the 20 percent bilateral plantar calluses, 10 percent left knee strain, and 10 percent right knee strain, resulting in 35 percent rating. The Board then takes 10 percent of 35 percent, resulting in a bilateral factor of 3.5 percent. The Board then adds the 3.5 bilateral factor to the 35 percent figure, resulting in a total of 38.5 percent, which is rounded to 40 percent. Based on the foregoing, from February 20, 2015, the Veteran is eligible for TDIU consideration on a schedular basis. A review of the records shows that the Veteran has a high school education with a past work history of being a pipefitter from 1974 to 1984, and a machine operator from 1988 to 1993. See April 2014 Medical Treatment Records – Furnished by SSA. Additionally, in a January 2005 VA treatment record, the Veteran reported that he was a welder, a business owner in extermination, and even worked in remodeling. See February 2015 CAPRI. Regarding the Veteran’s bilateral knee disability, in the February 2015 VA examination the Veteran reported that he could not stand or walk for long periods. The Veteran also stated that squatting was difficult because of his knees. The examiner did not opine as to the Veteran’s functional limitation but reiterated the Veteran’s statement that he could not stand or walk for long periods and that squatting was difficult. Concerning the Veteran’s bilateral plantar calluses, in the July 2012 VA examination the Veteran reported that his skin condition does not affect his ability to do activities of daily living. However, the Veteran reported that the lesion is tender when he walks around, which would sometimes make it difficult when he was working. Then, in the May 2014 VA examination, the Veteran claimed that it would hurt to stand on his feet. However, he was able to independently perform activities of daily living. The examiner opined that the Veteran’s bilateral plantar calluses do not impact his ability to work. As for the Veteran’s cervical strain, in the February 2015 VA examination the Veteran reported that because of his neck condition he cannot turn his head to the right “too much.” The examiner did not opine as to the Veteran’s functional limitation but reiterated the Veteran’s statement that due to the cervical disability he is unable to turn his head to the right too much. Regarding the Veteran’s right shoulder disability, the February 2015 VA examiner opined that due to the Veteran’s right shoulder disability, he had decreased range of motion, difficulty working above shoulder height, and pain with lifting and carrying. Concerning the Veteran’s neuropathy, the February 2015 VA examiner opined that the Veteran’s right ulnar neuropathy precludes him from an occupation requiring constant, prolonged, or repeated grasping or fine motor skills involving his right hand. Given appropriate accommodations, the Veteran may nonetheless be reasonably expected to function otherwise in a sedentary capacity. The treatment records show that in an April 2011 VA treatment record the Veteran minimally exercised and walked. See May 2014 CAPRI. In a March 2015 VA treatment record, the Veteran reported that he has pain from his callus, but he still walks 30 minutes per day. See May 2017 CAPRI. For the reasons explained below, from February 20, 2015, a TDIU is warranted. The evidence shows that the Veteran had limited education and limited occupational experience. Furthermore, the evidence shows that the Veteran’s prior occupational experience was manual labor, as he was employed as a pipefitter and a machine operator. The evidence supports that the Veteran would had been unable to pursue an occupation consist with his occupation experience, as his service-connected disabilities precluded him from manual labor. For example, the evidence reveals that he could not stand or walk for long periods, he had painful feet when walking, he was unable to turn his head to the right too much, he had decreased range of motion, difficulty working above shoulder height, and pain with lifting and carrying due to his service-connected disabilities. Furthermore, as to any type of non-physical occupational, the Veteran does not have any background or skill set related to a sedentary type employment, as his occupational background consisted of manual labor. Therefore, the evidence reflects that the functional limitations caused by the Veteran’s service-connected disabilities precluded gainful employment consistent with his education and occupational experience. Although there are some medical opinions to the contrary on the question of employability, this determination is ultimately an adjudicatory and not a medical one. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013) (“[A]pplicable regulations place responsibility for the ultimate TDIU determination on the VA, not a medical examiner”). For these reasons, and resolving reasonable doubt in the appellant’s favor, a TDIU, from February 20, 2015, is warranted. REASONS FOR REMAND 1. Entitlement to service connection for sleep apnea is remanded. The Veteran claimed that his sleep apnea manifested in service, or, in the alternative that his psychiatric disability caused and/or aggravated his sleep apnea. See August 2016 Correspondence. In support of his claim, in November 2015, the Veteran submitted a private medical opinion from a licensed psychologist. In the November 2015 medical opinion, a psychologist opined that there is a high, complex correlation between psychological stress and sleep apnea. See August 2016 Correspondence. Additionally, the psychologist opined that the Veteran’s service-connected disabilities aggravated the Veteran’s depressive disorder. Because adjudication of the service connection claim for acquired psychiatric disability being remanded likely will impact adjudication of the service connection claim for sleep apnea, the Board finds that these issues are inextricably intertwined. See Henderson v. West, 12 Vet. App. 11, 20 (1998), citing Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that two issues are inextricably intertwined when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). Thus, adjudication of the service connection claim for sleep apnea is deferred. 2. Entitlement to service connection for a left hand disability is remanded. 3. Entitlement to service connection for a left hip disability is remanded. 4. Entitlement to service connection for a left foot disability is remanded. 5. Entitlement to service connection for a right foot disability is remanded. 6. Entitlement to service connection for a right hip disability is remanded. 7. Entitlement to service connection for a left arm disability is remanded. 8. Entitlement to service connection for an acquired psychiatric disability is remanded. 9. Entitlement to service connection for a liver disability is remanded. 10. Entitlement to service connection for Hepatitis C is remanded. In April 2017, the Board directed the RO to issue a Statement of the Case (SOC) for the issues of entitlement to service connection for a left hand disability, left hip disability, left foot disability, right foot disability, right hip disability, left arm disability, acquired psychiatric disability, liver disability, and Hepatitis C. On February 19, 2020, a SOC was rendered. However, before the 60 days expired, the Veteran died on April [REDACTED], 2020. Thereafter, the appellant was properly substituted. As the appellant has been substituted as a valid claimant on the Veteran’s appeal, she is entitled to the same procedural rights as the Veteran. As such, the appellant should be given an opportunity to file a substantive appeal. Accordingly, the Board must remand these issues so that the AOJ may issue an SOC. The matters are REMANDED for the following action: 1. Issue an SOC as to the issues of entitlement to service connection for a left hand disability, left hip disability, left foot disability, right foot disability, right hip disability, left arm disability, acquired psychiatric disability, liver disability, and Hepatitis C. The issues are to be certified to the Board only if a timely substantive appeal is received. 2. Finally, readjudicate the claims remaining on appeal, including the issue of service connection for sleep apnea. If the benefits sought remain denied, issue a supplemental statement of the case and return the case to the Board. Ashley Castillo Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P. Noh, 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.