Citation Nr: 21025852 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 16-12 350 DATE: April 29, 2021 ORDER Entitlement to an increased disability evaluation in excess of 20 percent for left-shoulder degenerative changes is denied. Entitlement to an increased disability evaluation in excess of 20 percent for left-shoulder recurrent dislocation is denied. Entitlement to total disability evaluation based on individual unemployability, due to service-connected disabilities (TDIU), is denied. FINDINGS OF FACT 1. The objective medical evidence shows at no time did the Veteran’s left-shoulder degenerative changes, as the non-dominant upper extremity, more closely approximate ankylosis or fibrous union, nonunion (false flail joint) or loss of head (flail shoulder) of the humerus, nor did it more closely approximate limitation of motion to 25 degrees or less from the side, ankylosis or fibrous union, nonunion (false flail joint) or loss of head (flail shoulder) of the humerus. 2. The objective medical evidence shows at no time did the Veteran’s left-shoulder recurrent dislocation, as the non-dominant upper extremity, more closely approximate limitation of motion to 25 degrees or less from the side, ankylosis or fibrous union, nonunion (false flail joint) or loss of head (flail shoulder) of the humerus. 3. The evidence of record does not show the Veteran’s service-connected disabilities alone precluded him or an average person from securing and following a substantially gainful occupation, CONCLUSIONS OF LAW 1. The criteria for an increased disability evaluation in excess of 20 percent for left-shoulder degenerative changes have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.6, 4.7, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010-5201, 5200, 5202, 5203 (2020). 2. The criteria for an increased disability evaluation in excess of 20 percent for left-shoulder recurrent dislocation have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.6, 4.7, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010-5202, 5200, 5201, 5203 (2020). 3. The criteria for TDIU have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.16 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from November 1968 to December 1970. These matters were previously remanded by the Board. Other issues concerning effective dates were decided therein. These issues have been returned to the Board. In a February 2016 rating a left shoulder disorder, previously rated 30 percent disabling was broken into the two ratings above with 20 percent ratings. This had the effect of a combined increased rating of 40 percent effective in 2011. The Veteran has disagreed with those rating leading to this appeal. Increased Schedular Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. When a reasonable doubt arises regarding the degree of disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Additionally, it is possible for a veteran to be awarded separate percentage evaluations for separate periods (staged ratings), based on the facts. See Fenderson v. West, 12 Vet. App. 119, 126–27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where an increase in the disability rating is at issue, the present level of the veteran’s disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, the relevant overall temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). The evaluation of the same disability under several diagnostic codes, known as “pyramiding,” must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. 38 C.F.R. § 4.14 (2019). When evaluating musculoskeletal disabilities, VA may, in addition to applying the schedular criteria, assign a higher disability rating when the evidence demonstrates functional loss due to limited or excessive movement, pain, weakness, excessive fatigability, or incoordination, to include during flare-ups and with repeated use, if those factors are not considered in the rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995); Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). Nonetheless, a disability rating higher than the minimum compensable rating is not assignable under any diagnostic code relating to range of motion where pain does not cause a compensable functional loss. Rather, the “pain must affect some aspect of ‘the normal working movements of the body’ such as ‘excursion, strength, speed, coordination, and endurance,’” as defined in 38 C.F.R. § 4.40, before a higher rating may be assigned. See Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011) (noting that while “pain may cause a functional loss, pain itself does not constitute a functional loss,” and, is therefore, not grounds for entitlement to a higher disability rating). Additionally, the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, with or without degenerative arthritis, actually painful, unstable or malaligned joints, due to a healed injury, are recognized as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59; see also Burton v. Shinseki at 5 (holding that the provisions of 38 C.F.R. § 4.59 are not limited to disabilities involving arthritis). 1. Entitlement to an increased disability evaluation in excess of 20 percent for left-shoulder degenerative changes. 2. Entitlement to an increased disability evaluation in excess of 20 percent for left-shoulder recurrent dislocation. The Veteran’s left-shoulder degenerative changes have been rated under a hyphenated diagnostic code, 5010-5201. Generally, hyphenated diagnostic codes are used when an unlisted disability is at issue. See 38 C.F.R. § 4.27 (2020). In this case, the Agency of Original Jurisdiction (AOJ) assigned a hyphenated diagnostic code to recognize post-traumatic arthritis (Diagnostic Code 5010) as the Veteran’s underlying diagnosis and limitation of motion of the left arm (Diagnostic Code 5201) as the relevant rating criteria. See 38 C.F.R. § 4.20. Put more simply, the Veteran’s left-shoulder joint has been diagnosed with arthritis, but it is rated under the code criteria for the resulting symptoms. Diagnostic Code 5010 has been recently revised, effective February 7, 2021. However, as the Board will be considering evidence in the period prior to that, the pre-revision version of Diagnostic Code 5010 in turn provides that traumatic arthritis is to be evaluated as degenerative arthritis under Diagnostic Code 5003. See 38 C.F.R. § 4.20. Diagnostic Code 5003 provides that 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. The Board notes the criteria allow for only 10 and 20 percent ratings for the number of major or minor joints, but as the Veteran prior to November 17, 2011 was already rated at 30 percent, the Board need not look to rating criteria for this diagnostic code. As stated above, there can be no “extra” ratings for arthritis added on for the same limitations of movement under Diagnostic Code 5201, provided below, as this would be impermissible “pyramiding.” The evidence shows that the Veteran is right-handed. Thus, the ratings assigned for limitation of motion of the dominant (major) upper extremity in Diagnostic Code 5201 do not apply. See 38 C.F.R. § 4.69. Under the pre-revision or revised versions of Diagnostic Code 5201 provides a 30 percent rating for the minor or non-dominant upper extremity for flexion and/or abduction limited to 25 degrees from the side. 38 C.F.R. § 4.71a. The other criteria in this diagnostic code do not provide ratings beyond 20 percent, at which the Veteran is already rated, and, once again, the prohibition on “pyramiding” will not allow further ratings to be added one upon the other based on one diagnosis or set of symptoms. A July 1972 rating decision granted service connection at 20 percent effective April 12, 1972, the date VA received the Veteran’s claim. An October 2005 rating decision increased the rating to 30 percent. However, when a February 2016 rating decision now rated the Veteran’s left-shoulder disorder as 2 separate disorders, left-shoulder degenerative changes was then rated at 20 percent, as was the second claim of left-shoulder recurrent dislocation, both effective November 17, 2011. This had the combined effect of assigning a 40 percent rating for shoulder impairment, and there has been disagreement with those ratings. Turning to the record, the April 1972 VA examiner noted the Veteran’s reports of his left shoulder coming out of its joint, but always returning to its position, it always aches with weather change and he has “some limitation of movement with elevation.” On examination, the April 1972 VA examiner found “elevation” of the shoulder was at 90 degrees, “external rotation is 40 percent limited” and internal rotation is full. He further found rotation “results in the humeral head easily protruding anteriorly, and results in some pain and discomfort when replacing this.” In a November 1997 VA examination for joints (to include shoulder), the VA examiner noted the Veteran’s reports of recurrent dislocations after the initial left-shoulder injury, subsequent surgery, left-shoulder pain, and decreased left-arm use, causing unemployment for the prior 4 years. On examination, relevant findings show left-shoulder flexion at 70 degrees and 70 degrees of abduction, both maneuvers with pain. The November 1997 VA examiner’s diagnostic impression was left-shoulder dislocation. An August 2005 VA examination for joints shows the Veteran’s reports of worsening left-shoulder pain since 1999, to include daily pain, night pain and trouble sleeping, but no current medications, no increased limitation with flare-ups or repetitive motion and resulting unemployment since January 2005. On examination, the August 2005 VA examiner found 60 degrees flexion and 50 degrees abduction. His diagnostic impression was left-shoulder dislocation, surgical repair, decreased left-shoulder range of motion, and left-shoulder acute and chronic pain, secondary to surgical repair and degenerative changes. In a November 17, 2008 VA examination for joints, the VA examiner noted the Veteran’s reports as above, adding he has difficulties with overhead activity and dressing. On examination, he found left-shoulder flexion at 70 degrees and abduction at 85 degrees, both maneuvers with pain. He further found repetitive use caused more pain, but with no further loss of motion, no flare-ups, and no effect on function due to incoordination, fatigue, weakness, or lack of endurance. He diagnosed left-shoulder anterior dislocation, with subsequent Bristow procedure, with limited painful range of motion, secondary to degenerative joint disease of the glenohumeral joint and rotator cuff tendinopathy with impingement. As Diagnostic Code 5201 can offer no higher ratings beyond the 30 percent already assigned to the Veteran in the period prior to November 17, 2011, the Board, in order to afford the Veteran every possibility of establishing evidence warranting an increased evaluation, has also considered whether closely related or analogous diagnostic codes pertaining to impairment of the shoulder and arm are applicable. However, the 4 VA examinations above show no findings of ankylosis, as would be required for any higher evaluation under Diagnostic Code 5200. Nor are there findings of fibrous union, nonunion (false flail joint) or loss of head (flail shoulder) of the humerus, as required for ratings of 40, 50 and 70 percent, respectively, under Diagnostic Code 5202. Although dislocation was found, Diagnostic Code 5203 offers no evaluations higher than 20 percent and is therefore not relevant. Looking to the record from November 17, 2011, the Veteran underwent an April 2013 VA examination for shoulder and arm, in which the VA examiner noted the Veteran’s reports as above, adding he has developed left-shoulder arthritis, impingement syndrome and flare-ups, resulting in severe pain with movement and moderate pain at rest and 20 of 30 days per month of heavy medication, ice, heat, and rest. The April 2013 VA examiner found left-shoulder flexion at 50 degrees (with pain beginning at 30) and left-shoulder abduction at 40 degrees (pain beginning at 25). Repetitive use testing showed left-shoulder at 45 degrees and abduction at 35 degrees. She further found excessive fatigability, incoordination, impaired ability to execute skilled movements smoothly, and pain on movement. She specifically found there is no left-shoulder-joint ankylosis. She further found a history of recurrent left-shoulder dislocation, with infrequent episodes and guarding of all arm movements. She made no findings of malunion of the clavicle or scapula or nonunion, with or without loose movement, and no findings of any clavicle, scapula, acromioclavicular (AC) joint or sternoclavicular joint disorders. She noted available imaging studies document degenerative or traumatic arthritis. The April 2013 VA examiner found the Veteran would have difficulty doing work with tasks requiring overhead movement of left shoulder/arms or frequent moving of the left shoulder or arm and noted the Veteran’s report he can only use his right arm to drive a car and cannot lift anything with his left arm. As directed in the Board’s September 2018 Remand, the Veteran was afforded an October 2019 VA examination for current shoulder and arm findings, in which the VA examiner stated a June 2013 diagnosis of left-shoulder recurrent dislocation, degenerative changes and post-operative anterior dislocation. He added his diagnosis of left-shoulder rotator-cuff tear. He noted the Veteran’s reports of worsening symptoms of pain and loss of range of motion. On examination, the October 2019 VA examiner found left-shoulder flexion at 90 degrees and abduction at 90 degrees, with pain noted in both maneuvers. He found during repeated use over time, pain, fatigue, and weakness significantly limited functional ability, estimating flexion and abduction both will decreased to 85 degrees. He found the same would occur during flare-ups. He found there was no left-sided ankylosis. He further found a history of recurrent left-shoulder dislocation ,with frequent episodes. He made no findings of malunion of the clavicle or scapula or nonunion, with or without loose movement. He specifically found there is no loss of head (flail shoulder), nonunion (false flail shoulder) or fibrous union of the humerus and no malunion of the humerus with moderate or marked deformity. He noted available imaging studies document degenerative or traumatic arthritis. The October 2019 VA examiner lastly found the Veteran is unable to perform any job duties requiring lifting and carrying. In the period at issue the revised version of Diagnostic Code 5201 can offer no higher ratings beyond the 20 percent already assigned to the Veteran. As shown in the April 2013 flexion and abduction findings exceed the 25-degree limitation for a 30 percent rating under Diagnostic Code 5201 and in the October 2019 examination they well exceed that limitation of movement. Once again, the closely related or analogous diagnostic codes pertaining to impairment of the shoulder and arm offer no higher ratings, there were no findings of ankylosis (Diagnostic Code 5200), no findings of fibrous union, nonunion (false flail joint) or loss of head (flail shoulder) of the humerus (Diagnostic Code 5202) and, once again, although dislocation was found, Diagnostic Code 5203 offers no evaluations for dislocation higher than 20 percent. The Board has again considered whether closely related or analogous diagnostic codes pertaining to impairment of the shoulder and arm are applicable for higher ratings, but in the period there are no findings of ankylosis and fibrous union, nonunion (false flail joint) or loss of head (flail shoulder) of the humerus and dislocation criteria do not rate high enough. The Veteran’s left-shoulder recurrent dislocation has been rated under a hyphenated diagnostic code, 5010-5202. Under the recently revised version of Diagnostic Code 5010, effective February 7, 2021, post-traumatic arthritis will be rated as limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with §4.25. As stated above, under the revised version of Diagnostic Code 5202 for impairments of the humerus, the only rating criteria for the non-dominant upper extremity which could provide a higher rating than the 20 percent already assigned allow a 40 percent rating for fibrous union of the humerus. Nonunion of the humerus (false flail joint) warrants a 50 percent rating. A 70 percent rating would be assigned for loss of head of the humerus (flail shoulder). As stated above, the February 2016 rating decision rated the Veteran’s left-shoulder disorder as 2 separate disorders. Left-shoulder recurrent dislocation was rated at 20 percent, effective November 17, 2011, as an assigned “date of claim.” The Board will begin is consideration of the evidence approximately one year prior to that date. As already shown above, flexion and abduction findings in the April 2013 and October 2019 VA examinations do not show 25-degree limitation or less from the side for a 30 percent rating under Diagnostic Code 5201. There are no findings of ankylosis or fibrous union, nonunion (false flail joint) or loss of head (flail shoulder) of the humerus. The closely related or analogous diagnostic codes, now to include Diagnostic Code 5201, offer no higher ratings. For both claims, functional loss due to pain were noted in the above 6 VA examinations, as well as changes affecting normal working movements, which were sufficiently reviewed, they were included in the examination findings and considered in the assignment of the Veteran’s current disability evaluation, but they have not presented a basis for further higher evaluations beyond those assigned prior to and after November 17, 2011. See 38 C.F.R. §§ 4.40, 4.45, 4.59; See DeLuca v. Brown, 8 Vet. App. at 204-07; Mitchell v. Shinseki, 25 Vet. App. at 37; Burton v. Shinseki, 25 Vet. App. at 5. The Board has carefully considered the Veteran’s September 2008 Statement in Support of Claim, as well as his reports to treatment providers and examiners as they appear throughout the record. The Board is well aware lay persons are competent to report on matters they observe or within their personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Therefore, the Veteran is competent to provide statements of symptoms which he feels and sees and there is no reason to doubt his credibility. However, his lay evidence in turn must be weighed against other evidence, as all relevant evidence of varying kinds must be considered. The Veteran contends in the September 2008 statement and his reports that, since leaving service, he has continually lost range of motion and experienced chronic pain on a daily basis. The Board has looked to the findings of no less than 6 VA examinations prior to and after November 17, 2011, as well as to the rating criteria of the diagnostic codes assigned to each left-shoulder disorder and to the criteria of 3 other closely related or analogous diagnostic codes in an effort to provide the Veteran with any possible alternatives for evaluations at higher ratings. However, the record of examinations and treatment visits over the periods prior to November 17, 2011 and thereafter did not produce findings which satisfy any of the relevant rating criteria. Without such findings, there is no basis on which to assign higher ratings. The Board therefore assigns more probative value to the findings of the VA examiners from April 1972 to October 2019. The Veteran’s examinations and testing were conducted by medical professionals during in-person sessions with the Veteran, they thoroughly reviewed the Veteran’s medical history and their findings, for the reasons stated above, exhibit sound clinical conclusions. See generally Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (noting that the central issue in assessing the adequacy of an opinion is whether the examiner was informed of the relevant facts in rendering a medical opinion). For the foregoing reasons and based on the medical evidence of record, the Board finds the preponderance of the evidence is against an increased disability evaluation in excess of 20 percent for left-shoulder degenerative changes and is against an increased disability evaluation in excess of 20 percent for left-shoulder recurrent dislocation. 3. Entitlement to TDIU. A finding of TDIU 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.” 38 C.F.R. §§ 3.340 (a)(1), 4.15. Consideration may be given to the Veteran’s level of education, special training, and previous work experience in arriving at a conclusion, but not to age or to the impairment caused by non-service-connected disabilities. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19. In reaching such a determination, the central inquiry is “whether the Veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability.” Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). The record must reflect that circumstances, apart from non-service-connected conditions, place the claimant in a different position than other veterans having the same compensation rating. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in and of itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question is whether the veteran, in considering his or her service-connected disabilities, can perform the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). Additionally, “substantially gainful employment” is defined as an occupation that provides an annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days that a veteran actually works and without regard to the veterans earned annual income. See Faust v. West, 13 Vet. App. 342 (2000). Marginal employment is not considered substantially gainful employment and generally is deemed to exist when a veteran’s earned income does not exceed the amount established by the United States Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Marginal employment may also be held to exist in certain cases when earned annual income exceeds the poverty threshold on a facts-found basis. Marginal employment, odd-job employment, and employment at half the usual remuneration is not incompatible with a determination of unemployability if the restriction to securing or retaining better employment is due to disability. See 38 C.F.R. § 4.17 (a). Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, the disability shall be ratable at 60 percent or more. If there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16 (a). The combined rating is achieved by “adding” the disability ratings together. However, this is not a conventional addition of numerical values. The efficiency of the individual for employment purposes is not reflected as a numerical value equivalent to the assigned disability rating; in terms of actual efficiency, the number will be lessened under the regulation. However, VA recognizes that earning capacity is affected exponentially as a less severe service-connected disability is added to the most severe service-connected disability, thereby reflecting the ever-diminishing efficiency of the individual. See 38 C.F.R. § 4.25. The United States Court of Appeals for the Federal Circuit has held that determination of whether a veteran is unable to secure or follow a substantially gainful occupation due to service-connected disabilities is a factual rather than a medical question and that it is an adjudicative determination properly made by the Board or the VA Regional Office. See Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). In the period in which the Board is considering evidence, he was service-connected for left-shoulder recurrent dislocation at 20 percent from November 17, 2011, depressive disorder at 70 percent from November 17, 2011, coronary artery disease (CAD) at 10 percent from May 31, 2005 and at 30 percent from November 13, 2019, diabetes mellitus, type II at 20 percent from May 13, 2001, right-lower-extremity peripheral neuropathy at 10 percent from November 27, 2012, left-lower-extremity peripheral neuropathy from November 27, 2012, and left-shoulder scar at a noncompensable rating. From November 17, 2011, the Veteran’s combined rating is 90 percent, satisfying the regulatory threshold of one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. However, although combined at their highest in the period prior to November 17, 2011, the Veteran’s service-connected disabilities were at no more than 50 percent. That combination does not satisfy the regulatory threshold of a single 60 percent rating or a combined rating of 70 percent. That notwithstanding, it is the policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of a service-connected disability shall be rated totally disabled. 38 C.F.R. § 4.16 (b). Therefore, although the schedular criteria for TDIU, as set out in 38 C.F.R. § 4.16 (a), are not met, a total rating on an extraschedular basis may nonetheless be granted in exceptional cases (and pursuant to specifically prescribed procedures) when a Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. 38 C.F.R. § 4.16 (b). Therefore, to accord justice in the exceptional case where the schedular ratings are found to be inadequate, the Director of the Compensation Service, upon field station submission, is authorized to approve an extraschedular rating commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. Neither the Regional Office (RO) nor the Board is permitted to assign an extraschedular rating in the first instance. Floyd v. Brown, 9 Vet. App. 88, 95 (1996)). However, the Board may review the later determinations of the Director of the Compensation Service. Anderson v. Shinseki, 22 Vet. App. 423, 427. The Board has reviewed all the evidence in the Veteran’s claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. The Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. However, at the outset, the Board notes that the record does not contain an Application for Increased Compensation based on Individual Unemployability (VA Form 21-8940). Absent a completed Form 21-8940, the Board cannot be certain of the circumstances surrounding Veteran’s past employment status and the Board has consistently denied claims for TDIU on that basis. However, the record gives some indication which can assist the Board, such as the Veteran’s reports to the January 2013 VA examiner and Dr. H.H. in her October 2017 private Disability Benefits Questionnaire (DBQ) for mental disorders, as well as in the Veteran’s fairly extensive and detailed military personnel records. The Board therefore has proceeded on the basis there appears to be sufficient evidence to adjudicate this claim without the submission of VA Form 21-8940. Turning to the record, the summary of the record for treatment and examination for the 2 left-shoulder disorders is set forth in the previous section. In visits to VA between May and September 1996, the Veteran denied current complaints of or concerns with diabetes mellitus, type II. In May 1996, he further denied symptoms of neuropathy. An electrocardiogram (EKG) showed results within normal limits for the Veteran’s heart. A VA cardiology note in December 2001 noted, although the Veteran has cardiac risk factors, with a recent chest pain episode with some atypical features, indicating the possibility of an unstable coronary syndrome with elevated enzymes, there was otherwise currently no evidence of recurrent ischemia, but rather “good rate-pressure product control.” In June 2003, the Veteran began to exhibit mild numbness in the lower extremities. A VA pre-operative note in September 2005 noted in its assessment that “[c]ardiovascular status looks good (no limitation on exertion), normal EKG.” Although reporting depression symptoms in December 2005, in routine visits to VA for various treatment between October 2001 through February 2012, the Veteran’s depression screenings were negative. A December 2005 VA ambulatory care note shows regarding the Veteran’s heart exhibited a normal precordium normal, with regular S1 and S2 (heart-beat intervals). VA treatment notes from November 2007 through November 2008 show the Veteran’s diabetes was non-insulin dependent. In a November 2008 VA visit, the Veteran’s depression screening was negative. Additionally, his heart precordium was again normal with regular S1 and S2. To summarize, the record for the period prior to November 17, 2011 shows in the 4 VA examinations for left-shoulder degenerative changes no findings for a rating beyond the 30 percent assigned. Moreover, the August 2005 VA examiner, although noting repetitive use caused left-shoulder pain on movement, also found it caused no further loss of motion, no flare-ups, and no effect on function due to incoordination, fatigue, weakness, or lack of endurance. Although the Veteran reported symptoms of depression in December 2005, in the long period of visits to VA between October 2001 and February 2012, the Veteran’s numerous depression screenings were otherwise negative. Prior to November 17, 2011, he was non-insulin dependent in his treatment for diabetes. Although he had a history of chest pains, there was yet no evidence of ischemia, good rate-pressure product control and overall normal findings for heart. Additionally, the neuropathies were just being detected in 2003. Briefly looking to the Veteran’s education, training, and work history. The Veteran completed a high-school eduction in-service under the General Eduction Development (GED ) program. He had experience before entering service as a stock boy, construction laborer and a “lot boy,” each for a few months’ duration. His in-service training pertained to “hydraulic test stand” and flight-deck fire-fighting duties. He was also trained for “aircraft mechanics.” Further training included mechanics, clerical, sonar, and radio. However, as reported by the Veteran to a treatment provider, his longest post-service employment post-service was for 16 years as a maintenance painter for a food-distribution company. The foregoing history of treatment in this period does not present a disability picture indicating exceptional or unusual aspects of the effects of the Veteran’s service-connected disabilities on his functionality, for example, specifically precluding in any way the manipulation of essential tools for the precision work of a trained aviation mechanic, other than hindered overhead maneuvers requiring full left-shoulder range of motion and left-sided lifting restrictions, or necessarily precluding sedentary activities. For these reasons and based on the medical evidence of record, the Board finds the preponderance of the evidence is against referral to the Director of Compensation Service for extraschedular consideration of TDIU. In the period from November 17, 2011, between July 2012 and June 2013, VA notes show heart precordium was normal with regular S1 and S2. VA progress notes between December 2012 and February 2013 note CAD as a complication of the Veteran’s diabetes. Between December 2012 and March 2013, the Veteran denied episodes of hypoglycemia. However, February 2013 VA notes show the Veteran was insulin-dependent. In this period, although positive for lower-extremity neuropathy, with diminished sensation bilaterally, the Veteran’s pulses were within normal limits and his feet negative for cuts, sores, or ulcers. However, from October 2013 through September 2016, weakened bilateral pulses were noted. In a January 2013 VA examination for PTSD, although the VA examiner found the Veteran does not have a diagnosis of PTSD which conforms to the required criteria, he diagnosed him with depressive disorder, NOS (not otherwise specified) and alcohol abuse. He further found occupational and social impairment with reduced reliability and productivity. The Veteran’s associated symptoms included depressed mood, chronic sleep impairment, flattened affect, 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, and the inability to establish and maintain effective relationship. In an October 2017 private DBQ for mental disorders, Dr. H.H. diagnosed recurrent, moderate major depressive disorder. In her extensive November 2017 private psychiatric symptom statement accompanying the DBQ, Dr. H.H. identified symptoms, as reported by the Veteran, associated with his major depressive disorder, and discussed their effects. On examination, she found occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. She further found associated symptoms of depressed mood, anxiety, suspiciousness, panic attacks more than once a week, near-continuous panic, sleep impairment, impaired memory, flattened affect, motivation and mood disturbances, and difficulty with social relationships and adapting to stressful situations, such as at work. Mental status examination results were basically normal, with below average knowledge, intellect, and abstraction capacity. The Veteran’s mood was anxious and nervous, with restricted affect. His responses were vague and he exhibited suspiciousness. Dr. H.H. also offered an “Employability Review,” in which she concludes the Veteran “cannot sustain the stress from a competitive work environment or be expected to due to his major depressive disorder.” She adds that the 2 left-shoulder disorders “manifest as major depressive disorder” and opined the disorders have aggravated major depressive disorder. A November 2019 VA ambulatory care notes the Veteran reported his left-shoulder pain was better, but he also refused physical therapy. In an April 2020 VA examination for heart conditions, the VA examiner diagnosed CAD, status post stents placement. He noted continuous medication was required to control the disorder. He further noted the Veteran has not had a myocardial infarction and does not have congestive heart failure. On examination, the April 2020 VA examiner found a regular heart rhythm, normal heart sounds, clear auscultation of the lungs, normal peripheral pulses, and blood pressure at 140/78. He noted in the record an August 2017 EKG, showing left-ventricular ejection fraction (LVEF) at 60 percent. Although METs testing is not required as part of the Veteran’s current treatment plan, in an interview-based METs test, the April 2020 VA examiner estimated that was greater than 5 – 7 METs, consistent with activities such as walking 1 flight of stairs, golfing (without cart), mowing a lawn (push mower), and heavy yard work (digging). Regarding CAD’s impact on the Veteran’s ability to work, the April 2020 VA examiner concluded he would have difficulties walking, standing, and climbing over prolonged periods, due to fatigue related to CAD with a history of 2 stents. Also in April 2020, the Veteran underwent a VA examination for diabetes mellitus, in which the VA examiner diagnosed diabetes mellitus, type II. She noted that the Veteran’s treatment is managed by prescribed oral hypoglycemic agent(s) and more than 1 insulin injection per day. The Veteran does not require regulation of activities. His visits to his diabetic care provider for episodes of ketoacidosis and hypoglycemia are less than 2 times per month. There were no episodes requiring hospitalization over the past 12 months. There was no progressive unintentional weight loss and loss of strength attributable to diabetes mellitus. The April 2020 VA examiner found no complications related to diabetes mellitus. She further found diabetes mellitus has no impact on the Veteran’s ability to work. In an April 2020 VA examination for diabetic peripheral neuropathy, the VA examiner diagnosed lower-extremity diabetic peripheral neuropathy. She found mild numbness and tingling in the right and left-lower extremities. On examination, she found no muscle atrophy and normal muscle strength in all segments of the lower extremities. She found mild, incomplete paralysis of the sciatic nerve for both lower extremities. She further found the neuropathies have no impact on the Veteran’s ability to work. The summary of the record for the period after November 17, 2011 shows pronounced effects of depression, as indicated by Dr. H.H. in her October 2017 private DBQ, in which she found occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or ,mood. Under the General Rating Formula for Mental Disorders (General Rating Formula), which provides the rating criteria for almost all diagnostic codes for mental disorders, to include the Veteran’s Diagnostic Code 9434 for major depressive disorder, Dr. H.H.’s finding warrants a 70 percent rating, which the Veteran received in the December 2018 rating decision. Nonetheless, neither Dr. H.H. nor the January 2013 VA examiner found any symptoms of total disability, such as impaired thought processes, diminished communication ability, delusions, hallucinations, grossly inappropriate behavior, or persistent danger of the Veteran hurting himself or others. Those are symptoms of total disability, effectively precluding all independent functioning. Although Dr. H.H. found occupational and social impairment, with deficiencies in most areas, and therefore concluded the Veteran cannot sustain the stress from a competitive work environment, the psychiatric evidence of record in this period does not support total mental disability. Looking to the Veteran’s other service-connected disabilities, he was rated at 10 percent for CAD in the period until November 13, 2019, when the evaluation was increased to 30 percent. Under Diagnostic Code 7005 providing the rating criteria, for a greater disability rating at 60 percent, the Veteran would have to have exhibited symptoms of more than one episode of acute congestive heart failure in the past year; or workload of greater than 3 METs, but not greater than 5 METs, which results in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction (LVEF) of 30 percent to 50 percent. The April 2020 VA examiner found the Veteran in fact does not have congestive heart failure, she noted an August 2017 EKG showing LVEF at 60 percent and, quite specifically, she estimated METs levels were consistent with activities such as walking 1 flight of stairs, golfing (without cart), mowing lawn (push mower), and heavy yard work (digging). The April 2020 VA examiner concluded the Veteran would have difficulties walking, standing, and climbing over prolonged periods due to fatigue to his heart disorder. As stated above, the April 2020 VA examiner’s diabetes examination showed daily insulin injection, oral hypoglycemic agent treatment and restricted diet. However, there were no findings of regulation of activities, episodes of ketoacidosis or hypoglycemic and the required number of hospitalizations or progressive loss of weight and strength, all of which would likely interfere with the performance of occupational tasks. She found the Veteran’s diabetes mellitus in fact has no impact on his ability to work. The April 2020 VA examination for diabetic peripheral shows only mild incomplete paralysis of the sciatic nerve for both lower extremities and, here too, she found the neuropathies have no impact on the Veteran’s ability to work. In considering the above medical record, as well as the Veteran’s training and work history for the period after November 17, 2011, upper-extremity maneuvers involving overhead movement and lifting are affected by the Veteran’s 2 left-shoulder disorders, but there is otherwise no indication of effects on sedentary employment, particularly any fine motor skills of the hands and fingers as might be required, to a degree to preclude it altogether. After considering the totality of the record, the Board finds the preponderance of the evidence in the period prior to November 17, 2011 does not show the Veteran’s service-connected disabilities alone preclude him or an average person from securing and following a substantially gainful occupation, nor does the record reveal exceptional aspects associated with the Veteran’s disabilities to warrant referral to the Director of Compensation Service for extraschedular consideration under 38 C.F.R. § 4.16 (b). In the period from November 17, 2011, the preponderance of the evidence does not show the Veteran’s service-connected disabilities alone preclude him or an average person from securing and following a substantially gainful occupation.   The Board has considered the benefit-of-the-doubt doctrine; however, the Board does not perceive an approximate balance of positive and negative evidence. As the preponderance of the evidence is against the claims, the doctrine is not applicable and the claims must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. MICHAEL D. LYON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P. Franke, 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.