Citation Nr: 21023016 Decision Date: 04/19/21 Archive Date: 04/19/21 DOCKET NO. 16-04 654 DATE: April 19, 2021 ORDER Entitlement to an initial rating in excess of 70 percent for insomnia with bipolar disorder, alcohol use disorder, and cannabis use disorder in remission is denied. Entitlement to an initial rating in excess of 10 percent for left hip based on painful limitation of movement of the thigh is denied. Entitlement to an initial compensable rating for left hip based on limitation of flexion is denied. Entitlement to an initial rating in excess of 10 percent for right hip based on painful limitation of movement of the thigh is denied. Entitlement to an initial compensable rating for right hip based on limitation of flexion is denied. REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) due to his service-connected disabilities prior to February 4, 2013 is remanded. FINDINGS OF FACT 1. For the entire appeal period, the Veteran’s insomnia with bipolar disorder, alcohol use disorder, and cannabis use disorder in remission did not result in total social impairment. 2. For the entire appeal period, the evidence of record does not show limitation of abduction of the left thigh lost beyond 10 degrees. 3. For the entire appeal period, the evidence of record does not show that the Veteran’s left hip flexion is limited to 45 degrees or less. 4. For the entire appeal period, the evidence of record does not show limitation of abduction of the right thigh lost beyond 10 degrees. 5. For the entire appeal period, the evidence of record does not show that the Veteran’s right hip flexion is limited to 45 degrees or less. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 70 percent for insomnia with bipolar disorder, alcohol use disorder, and cannabis use disorder in remission have not been met. See 38 U.S.C. § 1155; 38 C.F.R. § 4.130; Diagnostic Code (DC) 9432. 2. The criteria for an initial rating in excess of 10 percent for impaired thigh in the left hip have not been met. See 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, DC 5003-5253. 3. The criteria for an initial compensable rating for impaired flexion in the left hip have not been met. See 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, DC 5003-5252. 4. The criteria for an initial rating in excess of 10 percent for impaired thigh in the right hip have not been met. See 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, DC 5003-5253. 5. The criteria for an initial compensable rating for impaired flexion in the right hip have not been met. See 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, DC 5003-5252. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1983 to March 1987. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a September 2014 rating decision that granted service connection for insomnia with bipolar disorder with a 70 percent evaluation effective February 4, 2013 and a November 2015 rating decision that granted service connection for left hip with a 10 percent evaluation based on painful thigh effective April 7, 2009 and granted service connection for right hip with a 10 percent evaluation based on painful thigh effective April 7, 2009. The Veteran requested a hearing but subsequently withdrew his request. See January 2019 VA 21-0820. An October 2020 rating decision granted service connection for left hip limitation of flexion with a noncompensable rating effective November 27, 2019 and granted service connection for right hip limitation of flexion with a noncompensable rating effective November 27, 2019. In the May 2019 Board remand, the Board instructed the Regional Office (RO) to provide VA examinations (VAXs) for his mental health and hips. In accordance with the remand instructions a VAX was provided for his hip disability. The Veteran was also scheduled for a mental health VAX but the Veteran did not attend. The RO contacted the Veteran’s representative to inquire about the cancelled appointment. See October 2020 VA 27-0820. The representative informed the RO that the Veteran gave short notice that he would be unable to attend and did not provide a reason why. As the Veteran canceled his mental health VAX without a showing of good cause the Board will proceed with adjudication on this matter. INCREASED RATING FOR MENTAL HEALTH CONDIITON The Veteran is rated under DC 9432 for his insomnia with bipolar disorder, alcohol use disorder, and cannabis use disorder in remission. Disability ratings are assigned in accordance with VA’s Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Separate DCs identify the various disabilities. See generally 38 C.F.R. Part 4. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. See 38 C.F.R. § 4.3. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a “holistic analysis” that considers all associated symptoms, regardless of whether they are listed as criteria. See Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). When the appeal arises from an initial assigned rating consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. See Fenderson v. West, 12 Vet. App. 119 (1999). Consistent with the facts found, the rating may be higher or lower for periods of the time under review on appeal, that is, the rating may be “staged.” See Fenderson v. West, 12 Vet. App. 119 (1999). Under DC 9432, a 70 percent rating is prescribed when there is evidence of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating is prescribed when there is evidence of total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations, grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation as to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442-3 (2002). However, a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the symptoms associated with that percentage, or others of similar severity, frequency, and duration, and that such symptoms have resulted in the type of occupational and social impairment associated with that percentage. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117-18 (Fed. Cir. 2013). 1. Entitlement to an initial rating in excess of 70 percent for insomnia with bipolar disorder, alcohol use disorder, and cannabis use disorder in remission is denied. The February 2013 Fayetteville VA treatment records show that the Veteran was alert, oriented to all spheres, mood was somewhat angry, and affect was appropriate. He was negative for auditory hallucinations, visual hallucinations, thought disorder, paranoid ideation, suicidal ideation, or homicidal ideation. He had good impulse control and judgment. He had insight. The June 2013 W.G. Hefner Salisbury VA treatment records show that the Veteran was away on a fishing trip. The July 2013 Fayetteville VA treatment records show that the Veteran was alert, oriented to all spheres, mood was somewhat irritable, and affect was angry. He was negative for auditory hallucinations, visual hallucinations, thought disorder, paranoid ideation, suicidal ideation, or homicidal ideation. He had good impulse control and judgment. He had insight. The December 2013 Fayetteville VA treatment records show that the Veteran was alert, oriented to all spheres, mood was somewhat irritable, and affect was labile. He was negative for auditory hallucinations, visual hallucinations, thought disorder, paranoid ideation, suicidal ideation, or homicidal ideation. He had good impulse control and judgment. He had insight. The March 2014 Fayetteville VA treatment records show that the Veteran was alert, oriented to all spheres, mood was less irritable, and affect was appropriate. He was negative for auditory hallucinations, visual hallucinations, thought disorder, paranoid ideation, suicidal ideation, or homicidal ideation. He had good impulse control and judgment. He had insight. In August 2014, the Veteran reported having a good relationship with his wife, child, as well as grandchildren, and attends church regularly and feels supported by his church family. In August 2014 Winston Salem treatment records, the Veteran also reported contact with friends or relatives about once a day or more and that he often feels loved and cared for by friends and relatives. In September 2014, the Veteran was afforded a VAX. The VA medical examiner determined that the Veteran has insomnia, bipolar disorder, alcohol use disorder, and cannabis use disorder in remission. The examiner determined that it was not possible to differentiate what symptoms are attributable to each diagnosis. Overall, the examiner determined that the symptoms his psychiatric disorder resulted in occupational and social impairment with reduced reliability and productivity. The examiner found that he had the following symptoms for VA rating purposes: depressed mood, anxiety, suspiciousness, chronic sleep impairment, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances including work or a worklike setting, inability to establish and maintain effective relationships, impaired impulse control such as unprovoked irritability with periods of violence, and grossly inappropriate behavior. He was found capable of managing his financial affairs. He denied any adult charges or convictions. He has been married for 30 years and has one child. The November 2014 Raleigh VA treatment records show that the Veteran was well groomed and had normal psychomotor activity. He was alert and oriented to all spheres. His mood was euthymic, affect was appropriate, speech was normal, memory was grossly intact, concentration was good, insight was fair, judgment was good, and thought process was linear, coherent, and goal directed. He had no suicidal ideation, homicidal ideation, or psychotic symptoms. The March 2015 Raleigh VA treatment records show that the Veteran was well groomed and had normal psychomotor activity. He was alert and oriented to all spheres. His mood was angry and irritable, affect was appropriate, speech was normal, memory was grossly intact, concentration was good, insight was fair, judgement was good, and thought process was linear, coherent and goal directed. He had no suicidal ideation, homicidal ideation, or psychotic symptoms. In May 2015, the Veteran reported being married for 37 years. In November 2015 Winston Salem treatment records, the Veteran reported that his wife is very supportive. The October 2015 Raleigh VA treatment records show that the Veteran was well groomed and had normal psychomotor activity. He was alert and oriented to all spheres. His mood was euthymic, affect was appropriate, speech was normal, memory was grossly intact, concentration was good, insight was fair, judgment was good, and thought process was linear, coherent, and goal directed. He had no suicidal ideation, homicidal ideation, or psychotic symptoms. The January 2016 Raleigh VA treatment records show that the Veteran had friends over for his birthday. The January 2016, March 2016, May 2016, and August 2016 Raleigh VA treatment records show that the Veteran was well groomed and had mildly increased psychomotor activity. He was alert and oriented to all spheres. His affect was appropriate, speech was normal, memory was grossly intact, concentration was good, insight was fair, judgment was good, and though process was linear, coherent and goal directed. He had no suicidal ideation, homicidal ideation, or psychotic symptoms. The February 2017 and May 2017 Raleigh VA treatment records show that the Veteran was well dressed, alert, and oriented in all spheres. His affect was appropriate, speech was normal, memory was grossly intact, concentration was fair, insight was fair, judgment was fair, and thought process was coherent. He had no suicidal ideation, homicidal ideation, or psychotic symptoms. The May 2017 Raleigh VA treatment records show that the Veteran reported tales of historical violence in preparation for requesting the psychiatrist to fill out a disability questionnaire from his lawyer. The Veteran took the liberty of pre-answering many of the questions with “markedly impaired.” The July 2018, October 2018, January 2019, June 2019, October 2019, and November 2019 Raleigh VA treatment records show that the Veteran was well groomed, alert, and oriented to all spheres. His affect was appropriate, speech was normal, memory was grossly intact, concentration was fair, insight was fair, judgment was fair, and thought process was coherent. He had no suicidal ideation, homicidal ideation, or psychotic symptoms. The February 2020 Wake County VA treatment records show that the Veteran was well groomed, alert, and oriented in all spheres. His affect was appropriate, speech was normal, memory was grossly intact, concentration was fair, insight was fair, judgment was fair, and thought process was coherent. He had no suicidal ideation, homicidal ideation, or psychotic symptoms. The June 2020 Wake County VA treatment records show that the Veteran reported planning a fishing trip in the mountains with his wife later this summer. He denied suicidal ideation or homicidal ideation. In July 2020, the Veteran reported going fishing. The August 2020 Durham VA treatment records show that the Veteran reported living with his wife. The totality of the evidence fails to support a finding of total social impairment. The Veteran’s judgement was fair, his insight was fair, his thought process was linear, and goal directed, he was well groomed, and he did not have auditory hallucinations or visual hallucinations. Consideration has been given to the Veteran's assertion that he is entitled to an increased rating and his competent and credible lay statements describing his symptomology. Nevertheless, even considering these statements, the weight of the medical and lay evidence simply does not show total social impairment. The contrary is shown. Most notably, the records show that the Veteran reported a good and supportive relationship with his wife. There is also reference to him having a good relationship with his child. He identified having some friends and having a good support system with the church. All-in-all the nature of these relationships belies the notion of the Veteran experiencing total social impairment, which would be required for assigning a 100 percent rating. When all the evidence is assembled VA is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim in which case the claim is denied. See Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). The preponderance of the evidence in this case is against the claim. Therefore, the claim must be denied. INCREASED RATING FOR BILATERAL HIPS The Veteran is rated under DC 5003, DC 5252, and DC 5253. Under DC 5003, degenerative arthritis established by X-ray findings, will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion. Id. Each hip is considered a major joint. See 38 C.F.R. § 4.45(f). Normal range of motion of the hip is from 0 to 125 degrees of flexion and 0 to 45 degrees of abduction. See 38 C.F.R. § 4.71, Plate II. Limitation of motion of the hip or hip or thigh may be rated under DC 5250 (ankylosis of the hip), DC 5251 (limitation of extension), DC 5252 (limitation of flexion), or DC 5253 (impairment of the thigh), DC 5254 (flail joint), and DC 5255 (impairment of the femur). DC 5250 provides a 60 percent rating for favorable ankylosis in flexion at an angle between 20 degrees and 40 degrees and slight abduction or adduction. A 70 percent rating for intermediate ankylosis. A 90 percent rating for unfavorable ankylosis, extremely unfavorable ankylosis, the foot not reaching ground, crutches necessitated. DC 5251 provides a 10 percent disability rating for limitation of extension of the hip or thigh that is limited to 5 degrees. See 38 C.F.R. § 4.71a, DC 5251. Under DC 5252, ratings for limitation of flexion of the hip or thigh are assigned as follows: flexion limited to 45 degrees is 10 percent; flexion limited to 30 degrees is 20 percent; flexion limited to 20 degrees is 30 percent rating; and flexion is limited to 10 degrees is 40 percent. See 38 C.F.R. § 4.71a, DC 5252. Under DC 5253, where there is limitation of rotation of the hip or thigh to the point that the claimant cannot toe-out more than 15 degrees, a 10 percent evaluation is assigned. A 10 percent rating is also assigned where there is limitation of abduction to the point at which the claimant cannot cross his legs. A 20 percent rating is assigned where there is limitation of abduction of the hip or thigh, motion lost beyond 10 degrees. See 38 C.F.R. § 4.71a, DC 5253. Under DC 5254, an 80 percent rating is assigned for flail joint of the hip. DC 5255 addresses the impairment of the femur. A 10 percent rating is assigned for malunion with slight knee or hip disability. A 20 percent rating is assigned for malunion with moderate knee or hip disability. A 30 percent rating is assigned for malunion with marked knee or hip disability. A 60 percent rating is assigned for fracture of surgical neck of, with false joint or fracture of the shaft or anatomical neck with nonunion without loose motion, weightbearing preserved with aid of brace. An 80 percent rating for fracture of shaft or anatomical neck with loose motion. Changes to DC 5255 became effective February 7, 2021. The former “marked,” “moderate,” and “slight” language for “malunion of” were deleted and provides that “malunion of” the femur is now rated under appropriate hip or knee DCs, “whichever results in the highest evaluation.” Assigning multiple ratings based on the same symptoms or manifestations of a disability constitutes prohibited pyramiding. See 38 C.F.R. § 4.14. Separate ratings under different diagnostic codes may be assigned where "none of the symptomatology for any of [the] conditions are duplicative of or overlapping with the symptomatology of the other ... conditions." See Estaban v. Brown, 6 Vet. App. 259 (1994). Here, the key consideration has been met, in that limitation of extension, flexion, adduction, and rotation concern excursions of movements in different planes, and these limitations therefore constitute different bases for rating the hip. See 38 C.F.R. § 4.45. If these limitations are demonstrated, they must be rated separately to adequately compensate for functional loss associated with the service-connected hip disability. See 38 C.F.R. § 4.40; see also VAOPGCPREC 9-2004 (separate ratings may be assigned for disability of the same joint where veteran has both limitation of flexion and limitation of extension of same leg). 2. Entitlement to an initial rating in excess of 10 percent for left hip based on painful limitation of movement of the thigh is denied. 3. Entitlement to an initial compensable rating for left hip based on limitation of flexion is denied. 4. Entitlement to an initial rating in excess of 10 percent for right hip based on painful limitation of movement of the thigh is denied. 5. Entitlement to an initial compensable rating for right hip based on limitation of flexion is denied. The Veteran is seeking a higher rating for his left hip and right hip disability. In March 2015, the Veteran was afforded a VAX. The VA medical examiner determined that the Veteran had degenerative arthritis in both hips. His hips were found to be secondary to his back problems. He denied flare-ups. He had difficulty flexing his hips. Left hip flexion was 80 degrees, extension was 30 degrees, abduction was 45 degrees, adduction was 30 degrees, external rotation was 60 degrees, and internal rotation was 40 degrees. Adduction was not limited such that the Veteran could not cross legs. He was unable to fully flex his left hip because of pain. Pain was noted that caused functional loss. Right hip flexion was 75 degrees, extension was 30 degrees, abduction was 50 degrees, adduction was 30 degrees, external rotation was 60 degrees, and internal rotation was 40 degrees. Adduction was not limited such that the Veteran could not cross legs. Pain was noted on examination that caused functional loss. Pain was noted on right hip flexion. He was unable to perform full right hip flexion. Pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time bilaterally. He denied flare-ups. Muscle strength of the right and left hip was 5/5 on flexion, extension, and abduction. There was no reduction in muscle strength, muscle atrophy, or ankylosis. There was no malunion or nonunion of femur, flail hip joint or leg length discrepancy. He denied using any assistive devices. His condition would not equally be served by amputation with prosthesis. Repetitive motion was conducted and there was no change in ROM. In November 2019, the Veteran was afforded another VAX. The VA medical examiner determined that the Veteran’s initial ROM for his right hip on flexion was 75 degrees, on extension was 30 degrees, abduction was 45 degrees, adduction was 25 degrees, external rotation was 20 degrees, and internal rotation was 20 degrees. His adduction was not limited such that he could not cross legs. His abnormal ROM contributed to functional loss as he had increased stiffness causing inability to fully rotate internally or externally his hip. Pain was exhibited on external rotation. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was pain on weight bearing. There was no evidence of crepitus. The initial ROM for his left hip on flexion was 80 degrees, on extension was 30 degrees, on abduction was 45 degrees, on adduction was 25 degrees, on external rotation was 40 degrees, and internal rotation was 40 degrees. His adduction was not limited such that he could not cross legs. His abnormal ROM did not contribute to functional loss. Pain was exhibited on external rotation and internal rotation. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was pain on weight bearing. There was no evidence of crepitus. ROM for the right hip after repeated use over time on flexion was 70 degrees, on extension was 30 degrees, on abduction was 40 degrees, on adduction was 20 degrees, on external rotation was 15 degrees, and internal rotation was 15 degrees. His post-test adduction was not limited such that he cannot cross legs. There was pain, and lack of endurance that limited his functional ability with repeated use over time. ROM for the left hip after repeated use over time on flexion was 75 degrees, on extension was 30 degrees, on abduction was 40 degrees, on adduction was 20 degrees, on external rotation was 35 degrees, and on internal rotation was 35 degrees. His post-test adduction was not limited such that he cannot cross legs. He denied flare-ups of his hips or thigh. His right and left side interfered with sitting and standing. Muscle strength for the right and left hip was 4/5 on flexion, extension, and abduction. There was no muscle atrophy, ankylosis, or malunion or nonunion of the femur, flail hip joint, or leg length discrepancy. He denied the use of assistive devices. His condition would not equally be served by amputation with prosthesis. Bilaterally, there was objective evidence of pain on passive ROM and nonweight bearing. The Veteran was assigned a 10 percent rating each for both his left and right hips based on limitation of movement of the thighs. As previously noted, under DC 5253, where there is limitation of rotation of the thigh to the point that the claimant cannot toe-out more than 15 degrees, a 10 percent evaluation is assigned. A 10 percent rating is also assigned where there is limitation of abduction to the point at which the claimant cannot cross his legs. A 20 percent rating is assigned where there is limitation of abduction of the thigh, motion lost beyond 10 degrees. See 38 C.F.R. § 4.71a, DC 5253. The evidence of record does not show a rating in excess of those currently assigned for the right and left hips for limitation of movement of the thighs is warranted. The Veteran’s VAXs do not show limitation of abduction of either thigh lost beyond 10 degrees. Therefore, a rating in excess of 10 percent each is not warranted. The Veteran was also assigned a noncompensable rating for left hip based on limitation of flexion and a separate noncompensable rating for right hip based on limitation of flexion. As previously noted, under DC 5252, a 10 percent rating is assigned for flexion limited to 45 degrees; flexion limited to 30 degrees is 20 percent; flexion limited to 20 degrees is 30 percent rating; and flexion is limited to 10 degrees is 40 percent. See 38 C.F.R. § 4.71a, DC 5252. The current noncompensable rating assigned is the maximum schedular rating for limitation of flexion. His VAXs do not show he is anywhere near the limitation of 45 degrees in flexion needed for a compensable rating. Thus, a higher rating is not warranted. The Board has also considered whether other DC are applicable and determined that they are not. As the Veteran does not have ankylosis, flail joint, or a femur impairment. Although the Veteran is competent to report observable symptoms, he is not competent to self-diagnose ankylosis, flail joint, or a femur impairment. See Lewis v. Derwinski, 3 Vet. App. 259 (1992). Further, neither VAX showed that his extension was limited to 5 degrees. Thus, DC 5250, DC 5251, DC 5254, and DC 5255 are not applicable. As DC 5250, DC 5251, DC 5254, and DC 5255 are not applicable and the Veteran is in receipt of the highest maximum schedular rating under DC 5252 and DC 5253 the claims for a higher rating must be denied. REASONS FOR REMAND In accordance with 38 C.F.R. § 4.16(b), the Board will consider whether the Veteran's claim for TDIU should be referred to the Director for extraschedular consideration to determine whether the Veteran is unable to secure and/or maintain substantially gainful employment by reason of service-connected disabilities, prior to February 4, 2013. See Wages v. McDonald, 27 Vet. App. 233 (2015); see also Bowling v. Principi, 15 Vet. App. 1, 10 (2001) (the Board cannot consider entitlement to TDIU under 38 C.F.R. § 4.16(b) in the first instance but must first remand the claim for referral to VA's Director of Compensation Service if such consideration is warranted). The Veteran’s TDIU claim arose in July 2009. The Veteran has clearly asserted that he has been unable to secure or maintain substantially gainful employment by reason of his service-connected disabilities since at least 2008. SSA medical records are consistent with this assertion. The Veteran did not meet the schedular requirements for TDIU prior to February 4, 2013 pursuant to 38 C.F.R. § 4.16 (a). As he was service connected at 10 percent for lumbosacral strain and intervertebral disc disease, service connected at 10 percent for arthritis of the left hip, and service connected at 10 percent for arthritis of the right hip prior to February 4, 2013. However, a review of the record reflects that the Veteran’s limited educational and employment history, when considered in light of the medical evidence of record supports the inference that his service-connected disabilities precluded him from obtaining and maintaining substantially gainful employment, prior to February 4, 2013. The Veteran installed and serviced heating equipment, boilers, oil tanks, and furnaces. He has a 12th grade education and completed his HVAC training in 1989. SSA medical records indicate that he has residual functional capacity to perform light work, can only stand and/or walk up to 3 hours each in an 8 hour workday, he can only sit up to 4 hours in an 8 hour workday, and would be absent from work 3 or more days per month. See June 2015 SSA Judicial Review. He asserts that since 2008 he has had back pain flares that cause him to be bedridden for up to a week at a time. His hip pain has increased, and his legs have weakened. He is unable to fully flex his hips. He asserts that even on good days he could not sit longer than 30 minutes at a time or stand longer than 15 minutes. He must lay down intermittently throughout the day. His wife asserted that if he exerts himself, he will suffer for days afterwards. The June 2009 VAX found that he has pain in his low back that radiates down to his bilateral hips and his pain affects his ability to do his job. In a September 2014 VAX provided for mental health, he reported being bedridden for 10 months due to his back in 2008. Based on the above, the Board concludes that referral to the Director of Compensation Service for extraschedular consideration of a TDIU prior to February 4, 2013 is warranted given the Veteran’s physical limitation regarding sitting, bending, walking, and standing and his lack of job skills that would be transferrable to a substantially gainful sedentary occupation. The matter is REMANDED for the following action: (Continued on the next page)   Provide the Veteran's claims file, including a copy of this remand, to the Direct of Compensation Service for consideration of whether an assignment of TDIU is warranted on an extraschedular basis, prior to February 4, 2013. DUSTIN L. WARE Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Smith, 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.