Citation Nr: 21026200 Decision Date: 04/30/21 Archive Date: 04/30/21 DOCKET NO. 15-16 542 DATE: April 30, 2021 ORDER Entitlement to an increased rating in excess of 30 percent disabling for service-connected acquired psychiatric disorder prior to December 4, 2014 is denied. Entitlement to an increased rating in excess of 10 percent disabling for service-connected cervical spine fusion prior to September 27, 2016, and in excess of 30 percent disabling thereafter is denied. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) prior to April 22, 2013 and as of September 27, 2016 is denied. FINDINGS OF FACT 1. Prior to December 4, 2014, service-connected acquired psychiatric disorder manifested as occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, depression, and impaired sleep. 2. Prior to September 27, 2016, with consideration of functional loss due to pain, stiffness, and flare-ups of pain on range of motion, service-connected cervical spine fusion manifested as no more than forward flexion limited to 40 degrees, with a combined range of motion of 300 degrees. 3. For the rating period as of September 27, 2011, with consideration of functional loss due to pain, stiffness, and flare-ups of pain on range of motion, service-connected cervical spine fusion manifested as no more than forward flexion limited to 15 degrees or less. 4. For the rating period prior to April 22, 2013, the Veteran has not been unable to secure or follow gainful or more than marginal employment due to service-connected disabilities. 5. For the rating period as of September 27, 2016, the Veteran has been in receipt of a 100 percent combined schedular rating for service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for entitlement to an increased rating in excess of 30 percent disabling for service-connected acquired psychiatric disorder prior to December 4, 2014 have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.20, 4.130, Diagnostic Code 9400-9411 (2019). 2. The criteria for entitlement to an increased rating in excess of 10 percent disabling for service-connected cervical spine fusion prior to September 27, 2016, and in excess of 30 percent disabling thereafter have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.1-4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5241 (2019). 3. The criteria for entitlement to a TDIU prior to April 22, 2013 and as of September 27, 2016, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 3.340, 3.341, 4.16 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1989 to August 1996. This case comes to the Board of Veterans’ Appeals (Board) on appeal from a January 2015 rating decision of the RO in Nashville, Tennessee. In the January 2015 rating decision, the RO granted service connection and a 30 percent rating for acquired psychiatric disorder, including PTSD and adjustment disorder with anxiety and depression, and granted service connection for a cervical spine disability (characterized as cervical fusion). The RO assigned an initial temporary 100 percent rating for the cervical spine disability, with a 10 percent rating effective April 1, 2011. The Veteran perfected an appeal for higher ratings for these disabilities. A videoconference hearing was held in July 2015 before the undersigned Veterans Law Judge (VLJ). A copy of the hearing transcript has been associated with the record. In a November 2015 Board decision, in pertinent part, the Board denied entitlement to an initial rating for PTSD in excess of 30 percent prior to December 4, 2014, and granted a 50 percent disability rating, but no higher, thereafter. The Veteran appealed the Board’s November 2015 decision as to this claim, specifically as to the rating period prior to December 4, 2014, to the United States Court of Appeals for Veterans Claims (Court). By Order dated in August 2016, the Court granted a Joint Motion for Partial Remand (Joint Motion), vacating the Board’s decision as to this issue and remanding the matter to the Board for further proceedings consistent with the Joint Motion. Specifically, the parties agreed that the Board needed to provide adequate reasons and basis for denying a rating in excess of 30 percent disabling for service-connected acquired psychiatric disorder, to include Social Security Administration (SSA) records, and to consider Global Assessment of Functioning (GAF) scores throughout VA treatment records during 2012. The claims for an increased rating for a cervical spine disorder and entitlement to a TDIU were also remanded by the Board in November 2015. On remand, entitlement to a TDIU was subsequently granted in a December 2016 rating decision, fully resolving the Veteran’s appeal as to the claim for the period from April 22, 2013 to September 27, 2016. However, the instant appeal stems from a December 2010 claim. The Board notes TDIU was raised as part of the Veteran’s claim for an increased initial rating for her service-connected psychiatric and cervical spine disabilities. See February 2015 statement. As such, the Board has jurisdiction to consider TDIU in accordance with Rice v. Shinseki, 22 Vet. App. 447 (2009) (holding that every claim for a higher evaluation includes a claim for TDIU where the appellant contends that his or her service-connected disabilities prevent employment). In the December 2016 decision, the RO also increased the rating for cervical fusion to 30 percent effective from September 27, 2016. In January 2017, the RO received a letter from the Veteran’s representative requesting an earlier effective date for the increased rating for the cervical fusion. The issue of entitlement to higher ratings than those assigned for cervical fusion remains on appeal because the Veteran has not indicated a desire to withdraw the issue. AB v. Brown, 6 Vet. App. 35 (1993). In a May 2017 Board decision and remand, the Board denied entitlement to a higher 50 percent disability rating for service-connected acquired psychiatric disorder prior to December 4, 2014, and continued a 30 percent rating for this period on appeal. The Veteran appealed the Board’s May 2017 decision as to this claim to the United States Court of Appeals for Veterans Claims (Court). By Order dated in June 2018, the Court granted a Joint Motion for Partial Remand (Joint Motion), vacating the Board’s decision as to this issue and remanding the matter to the Board for further proceedings consistent with the Joint Motion. In pertinent part, the Board was requested to weigh the Veteran’s own lay statements as well as SSA records referenced in the May 2017 decision, and to also consider favorable evidence found within VA treatment records. In the May 2017 Board remand, the Board remanded the issue of entitlement to an increased rating for service-connected cervical spine fusion for a VA examination in accordance with Correia v. McDonald, 28 Vet. App. 158 (2016), Sharp v. Shulkin, 29 Vet. App. 26 (2017), DeLuca v. Brown, 8 Vet. App. 202 (1995). See also 38 C.F.R. § 4.40, 4.59 (2019). Additionally, the issue of entitlement to a TDIU prior to April 22, 2013 and since September 27, 2016 was remanded as it was inextricably intertwined with the remanded increased rating claim. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). On remand, an April 2018 VA examination of the cervical spine was obtained, which substantially complied with the May 2017 remand directives. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The appeal was again before the Board in December 2018 and was remanded for further development, specifically, to obtain records from the Tennessee Department of Labor regarding the Veteran’s unemployment benefits. Unfortunately, while on remand, the RO only requested medical records from the Tennessee Department of Labor, to which they responded with a negative result in April 2019 because they did not handle medical documentation. The Board remanded the appeal again in April 2020 for substantial compliance with the December 2018 Board remand directives, specifically, to request all of the Veteran’s records with the Tennessee Department of Labor related to her claim for TDIU, not just her treatment records. See Stegall v. West, 11 Vet. App. 268, 271 (1998). While on remand, the RO made three separate attempts to obtain records from the Tennessee Department of Labor, and notified the Veteran of such efforts with the opportunity to submit the records requested in November 2020. The Board finds that substantial compliance with prior remand directives was obtained, and it may proceed with further appellate adjudication at this time. See Dyment, 13 Vet. App. at 146-47 (remand not required under Stegall, 11 Vet. App. 268, where the Board’s remand instructions were substantially complied with), aff’d, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002). This appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.900 (c). 38 U.S.C. § 7107 (a)(2) (2019). Increased Rating Disability evaluations are determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.321 (a), 4.1 (2019). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2019). The Board notes that the United States Court of Appeals for Veterans Claims (Court) has distinguished a new claim for an increased rating of a service-connected disability from a case where the veteran expresses dissatisfaction with an initial rating of a disability that has just been service-connected. See Fenderson v. West, 12 Vet. App. 119 (1999). In the latter case, VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim, a practice known as “staged rating. See Id. In this case, the Board finds that the staged ratings as assigned by the RO are appropriate. In rendering a decision on appeal, the Board must analyze the credibility and probative value of all medical and lay evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. 38 U.S.C. § 1154 (a) (2012); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). The standard of proof to be applied in decisions on claims for veterans’ benefits is set forth in 38 U.S.C. § 5107. A claimant is entitled to the benefit of the doubt when there is an approximate balance of evidence for and against the claim. See 38 C.F.R. § 3.102, 4.3 (2019). When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert, 1 Vet. App. 49. The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). 1. Entitlement to an increased rating in excess of 30 percent disabling for service-connected acquired psychiatric disorder prior to December 4, 2014 For the rating period prior to December 4, 2014, the Veteran was in receipt of a 30 percent disability rating for service-connected acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and adjustment disorder with anxiety and depression, under Diagnostic Code 9400-9411. Although PTSD, chronic adjustment disorder, generalized anxiety disorder and depressive disorder are rated under different Diagnostic Codes, each of these disorders is evaluated under the same rating criteria found in the General Rating Formula for Mental Disorders at 38 C.F.R. § 4.130. See Diagnostic Codes 9411 (PTSD), 9440 (chronic adjustment disorder), 9400 (generalized anxiety disorder), 9433 (persistent depressive disorder (dysthymia), 9434 (major depressive disorder), and 9435 (unspecified depressive disorder). The Board will rate all of the Veteran’s symptoms from her service-connected psychiatric disorders together, as rating each psychiatric disorder separately would violate the rule against pyramiding. See Esteban v. Brown, 6 Vet. App. 259 (1994); see also 38 C.F.R. § 4.14. The Board finds that the evidence does not reflect that she has separate and distinct manifestations from each psychiatric disorder. Under the General Rating Formula for Mental Disorders, a 30 percent rating is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, DC 9411 (2019). A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped, speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent disability rating is assigned for 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 that is 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 worklike setting); and inability to establish and maintain effective relationships. Id. A 100 percent disability rating is assigned 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 to time or place; and memory loss for names of close relatives, or for the veteran’s own occupation or name. Id. The above set of symptoms is not an exclusive or exhaustive list, as evidenced by use of the phrase “such symptoms as,” followed by a list of examples. Rather, it serves as merely an example of the symptoms that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The Veteran’s actual symptomatology, and resulting social and occupational impairment, will be the primary focus when assigning a disability rating for a mental disorder, and the Veteran may qualify for a particular rating by demonstrating the particular symptoms associated with that percentage, or other symptoms of similar severity, frequency, and duration. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-117 (Fed. Cir. 2013). In determining whether the Veteran meets the criteria for a higher rating, the Board must consider whether she has deficiencies in most of the following areas: work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11 (2001). In Golden v. Shulkin, 29 Vet. App. 221 (2018), the Court held that, given that the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5) abandoned the GAF scale and that VA has formally adopted the DSM-5, GAF scores are inapplicable to assign a psychiatric rating in cases where the DSM-5 applies when the appeal was certified after August 4, 2014. Here, the Veteran’s appeal was certified to the Board in a May 2015 VA Form 8; thus, the DSM-5 applies and GAF scores are inapplicable. Here, during a VA examination in March 2011, the examiner noted that approximately 90 minutes into the examination, the Veteran told him that she had withdrawn her claim for service connection for depression and anxiety secondary to chronic low back strain. Thus, a complete medical opinion was not provided. Nonetheless, he conducted an examination. The Veteran stated that she injured her back in service when she fell five feet from a B-52 to the tarmac, falling backwards as the ropes that were usually present to grasp had been removed. She reported that she was sexually assaulted on the night of the back injury after returning to her hotel from the emergency department. Currently, she had two good girlfriends, and she and her children did things with them and their children. She had been married to her third husband for the past 17 years, and had three children. She said that in the summer, everyone came to their house because they own a pool. She stated that she gardened, swam, walked to tennis courts, watched movies on family Friday night, and played games on Saturday night. She denied any suicide attempts or history of violence. She denied substance use, and denied problems with alcohol. She provided the examiner with a written statement regarding military sexual trauma (MST). On examination, speech was unremarkable, attitude was cooperative, affect was normal, mood was good, attention was intact, and she was oriented to person, place and time. Thought process and content were unremarkable, and there were no delusions or hallucinations. With regard to judgment and insight, the examiner indicated that she understood the outcome of behavior, and understood that she had a problem. She had no sleep impairment. She had no inappropriate behavior, no obsessive or ritualistic behavior, no panic attacks, no homicidal or suicidal thoughts, and no episodes of violence. Impulse control was good, and she could maintain minimum personal hygiene. Remote, recent, and immediate memory were normal. She reported that she had been taking psychiatric medication for several years and it had been working well. She was a paralegal, and had held her current job for 5 to 10 years. She lost time from work due to cervical spine surgery. No Axis I diagnosis was indicated, and the current GAF was 75. The examiner said he was unable to diagnose either depression or anxiety secondary to chronic low back strain as requested by the RO, as the Veteran stated that she had confirmed her withdrawal of these claims, and moreover, he did not perceive any symptoms of such. He noted that although panic disorder was reportedly the reason she was taking sertraline and buspirone, the Veteran said she had not had an episode in years, as it was well-controlled with these medications. The examiner indicated that he found no current psychiatric disorders, and the Veteran had reported panic disorder in the past with no current symptoms. In a November 2011 VA examination, the VA examiner diagnosed the Veteran with adjustment disorder with mixed anxiety and mood, and did not diagnose any other current psychiatric disorder. The examiner opined that although a mental condition had been formally diagnosed, the symptoms were not severe enough either to interfere with occupational and social functioning or to require continuous medication. During the examination, the Veteran reported good ongoing relationships with her husband and children, and spent most of her free time with them. She also said she had a good friend who was also a Veteran. She spent her leisure time with her kids, going to the pool with her children, reading, and gardening. She returned to work in April 2011 after cervical neck surgery and was averaging 20 hours of work per week, and she planned to increase her hours in the future with better pain management. Upon interview and examination of the Veteran, the VA examiner indicated that the Veteran had symptoms of depressed mood and anxiety due to her current psychiatric disorder. The Veteran said her anxiety was related to her fear of pain, and fear that the cervical neck surgery left her vulnerable. The examiner indicated that at the time of the examination, her mood appeared euthymic and affect was normal, and that episodes of increased anxiety about possibly being without her pain medication did not meet the full criteria for panic episodes. The Veteran reported that she effectively used “self-talk” to manage episodes and they resolved within ten minutes. The VA examiner noted that the Veteran was oriented to person, place, time and situation, was cooperative, eye contact was within normal limits, and mood appeared generally euthymic with congruent affect. Thought associations were relevant and goal-directed, and thought content was normal and non-delusional. She did not report hallucinations, and none were elicited. Speech was normal in rate and volume and was appropriate. Psychomotor activity was within normal limits. The examiner indicated that the Veteran’s symptoms of depression and anxiety reflected concern about financial difficulties, and an adjustment reaction to learning that the recent cervical fusion surgery will not permanently relieve her cervical pain, developing headaches since the surgery, and learning that she should be careful so as not to reinjure the cervical spine surgery site. The examiner indicated that while she continued to experience low back pain, her worry, concern, and depressive symptoms seemed to predominantly follow from her ongoing pain, headaches and caution related to the cervical repair. Prior to the surgery, she tried not to limit her actions/behavior as a way to fight back against the pain and maintain a normal life. The examiner indicated that it is common to experience fluctuations in mood and affect when faced with accepting or adjusting to losses in physical health and functioning, self-image, or life plans. VA treatment records include a February 2012 VA psychiatry outpatient note, which shows that the Veteran had been referred for depression and anxiety. She said her back pain had worsened and was exacerbating her depression. She denied suicidal or homicidal ideations but indicated that she had suicide ideas or gestures. On examination, she was neatly groomed and dressed, was friendly, calm and cooperative, with no tremors or ataxia, good eye contact, and speech was normal. She described her mood as “fair.” There was a full range in affect, there were no obsessions, paranoia or delusions, thought process was linear and goal-directed, there were no hallucinations, memory and concentration were intact, and insight and judgment were good. The Veteran was diagnosed with mood disorder due to chronic back pain, and panic disorder without agoraphobia. The physician increased her dosage for Sertraline for depression/anxiety, and continued the current dosage of Buspirone for anxiety. In September 2012 VA treatment note, the Veteran reported that she recently lost her job due to having to deal with chronic pain, and her mood was “crappy” as a result. The diagnosis was mood disorder due to chronic back pain, and panic disorder without agoraphobia. The Veteran denied suicidal and homicidal ideation and wanted a sleep aid due to her tossing and turning at night. The Veteran was prescribed an increased dose of sertraline 200mg a day for depression and anxiety. In March 2013, a VA psychiatric note reflects that the Veteran reported that she was recently fired from her job as a paralegal due to missing work after a hysterectomy. She complained of significant depression due to financial problems and because of her attempts to obtain service connection. She also reported a history of MST. The diagnostic impression was major depressive disorder versus mood disorder due to medical condition. It was noted that she had financial problems and was unemployed. An April 2013 VA treatment note reflects that the Veteran complained of depression because of pain. She was diagnosed with mood disorder due to chronic back pain, and panic disorder without agoraphobia. Primary care notes reflect that she was seen for chronic neck and back pain and had insomnia. An August 2013 SSA decision that found the Veteran to be disabled from September 5, 2012, due, in part, to depression. As noted in the August 2013 SSA decision, the Veteran alleged her depression and medication use caused her difficulty with concentration and task completion. The Veteran also stated that on some days she could not get out of bed due to depression and pain and that she was eventually terminated from her job due to absenteeism. A December 2013 VA psychology note reflects that the Veteran was alert and oriented, with appropriate dress and grooming, and normal kinetics. Her mood was mildly depressed and anxious, and her affect was consistent with this. Speech was logical and goal directed, with normal rate and rhythm. There was no current suicidal or homicidal ideation, and no delusions or hallucinations. The diagnoses were depression NOS, anxiety NOS, and chronic pain. Her occupational functional impairment was described as moderate. A February 2014 treatment note shows the Veteran was referred for depression and anxiety. She only slept 4 hours nightly. She denied suicidal or homicidal ideations. Her psychiatric medication was increased as it passed too quickly through her system status post gastric bypass procedure. A March 2014 psychology note reflects that the Veteran reported that she was getting better sleep, and said she had been resting during the day, which was helpful. On examination, she was alert and oriented with appropriate dress and grooming. She had normal kinetics, her mood was irritable and depressed, and affect was flat. Speech was logical and goal-directed, with normal rate and rhythm. There were no current suicidal or homicidal ideations, or delusions or hallucinations. The diagnoses were depression NOS, anxiety NOS, and chronic pain. VA treatment notes from April 2014 show the Veteran called and reported she was having trouble sleeping and was having “night terrors”. She agreed to keep logging her sleep. A May 2014 note shows that her pain had been more difficult lately which caused more depression and anxiety. She reported that she shared her depression and anxiety with her family, which was positively received and they were supportive. They had been encouraging to her and helped her more at home and her and her husband’s relationship had been good. She reported that she wanted to receive more support from veterans who were going through the same thing and understood what it was like. During the session, the Veteran was alert, oriented, appropriately dressed and groomed. Mood was mildly depressed, and affect was consistent with this. Speech was logical and goal directed, with normal rate and rhythm. The Veteran did not have current suicidal or homicidal ideations, or delusions or hallucinations. The Veteran was diagnosed with depression NOS, anxiety NOS and chronic pain. There was no follow up but the Veteran wanted to know more about group therapy. In June 2014, her depression was noted to be mild. On mental status examination, she was alert and oriented times three, neatly groomed, neatly dressed, friendly, calm, cooperative, with no tremors or ataxia. Eye contact was good, speech had normal rate, volume and articulation, and was non-pressured. Her mood was described as “not good,” and she had a full range in affect. She denied acute suicidal or homicidal ideations. There were no obsessions, paranoia, or delusions. Her thought process was linear and goal-directed. She had no hallucinations, and memory was intact in all three domains. Concentration was intact, and insight and judgment were good. The diagnosis was mood disorder due to chronic back pain, and panic disorder. She was continued on Venlafaxine, which the Veteran stated was helpful. Based on the weight of the evidence, the Board finds that during the period prior to December 4, 2014, the Veteran’s service-connected acquired psychiatric disorder manifested as occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, depression, and impaired sleep. The Board notes that on VA examination in March 2011, the examiner found no current psychiatric disorder, and indicated that he did not perceive any symptoms of depression or anxiety. The Veteran reported that she had been taking psychiatric medication for several years and it had been working well, and she was working as a paralegal, a job which she had held for several years. She had been married for many years, and enjoyed many activities with good friends and their and her children. The Board finds that, even absent a diagnosis, the symptoms recorded within the March 2011 were controlled by continuous medication, which equate to the criteria for a 10 percent disability rating under Diagnostic Code 9411. On VA examination in November 2011, the examiner diagnosed adjustment disorder with mixed anxiety and mood, and did not diagnose any other current psychiatric disorder. The examiner opined that although a mental condition had been formally diagnosed, the symptoms were not severe enough either to interfere with occupational and social functioning or to require continuous medication. The Veteran reported that she was working 20 hours per week, continued to enjoy activities with her children and husband, and reported good ongoing relationships with them. The examiner indicated that she had symptoms of depressed mood and anxiety due to her current psychiatric disorder. The Board notes that the while August 2013 SSA decision determined the Veteran to be disabled from September 5, 2012, due, in part, to depression. While SSA determinations are not binding on the Board, these determinations are probative evidence. See Collier v. Derwinski, 1 Vet. App. 413, 417 (1991). However, the Board finds that VA treatment records in this case to be more probative than SSA records. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (statements made for the purposes of medical treatment may be afforded greater probative value because there is a strong motive to tell the truth in order to receive proper care); see also Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (VA “may properly consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the veteran” in determining whether documents submitted by a veteran are “satisfactory” or “credible” evidence.). As noted in the August 2013 SSA decision letter, the Veteran alleged her depression and medication use caused her difficulty with concentration and task completion. The Veteran also stated that on some days she could not get out of bed due to depression and pain and that she was eventually terminated from her job due to absenteeism. Here, although the Veteran alleged difficulty with concentration and task completion, there is no objective evidence that prior to December 4, 2014 the Veteran had decreased concentration and difficulty with task completion that rose to the level of occupational and functional impairment with reduced reliability and productivity. Specifically, VA treatment records reflect that her concentration was intact; insight and judgment were good; though content was without obsession, paranoia, and delusion; and her thought process was linear and goal directed. See February 2012, September 2012, December 2012, and February 2014 VA treatment records. Those VA treatment records also reflect the Veteran had either no difficulty with work and activities or thoughts and feelings of incapacity, fatigue, or weakness related to activities, work, or hobbies; however she had not decreased actual time spent in activities and there was no decrease in productivity. Thus, although the August 2013 SSA determination found the Veteran to be disabled from September 5, 2012, due, in part, to depression, her level of disability resulting from depression prior to December 4, 2014 is contemplated by the 30 percent rating assigned based on the more probative statements the Veteran made in VA treatment records. Lastly, while the June 2018 Order discussed that the Veteran had wished she was dead or had thoughts of possible death in a February 2012 VA treatment record, the Board notes that during this appointment, the Veteran denied suicidal or homicidal ideations but indicated that she had suicide ideas or gestures. Even in granting the Veteran the benefit of the doubt, the Board must also consider resulting social and occupational impairment when assigning a disability rating for a mental disorder. Vazquez-Claudio, 713 F.3d at 116-117; Bowling, 15 Vet. App. at 11. As discussed above, the Board has found that the Veteran had decreased concentration and difficulty with task completion that rose to the level of occupational and functional impairment with reduced reliability and productivity. Further, VA treatment records since the February 2012 note do not show suicidal ideation. While, it was stated within the June 2018 Order that VA treatment records in April and May 2014 indicated that the Veteran had “repeated suicidal thoughts,” the Board finds that the May 2014 VA treatment note actually dictates that the Veteran expressly denied suicidal or homicidal ideations. Also, the April 2014 VA treatment note discussed the Veteran’s sleep impairment, which has already been considered in assigning a continued 30 percent disability rating on appeal. Again, even considering suicidal ideations, within the April 2014 treatment note, she reported that she shared her depression and anxiety with her family, which was positively received and they were supportive. She noted improved social relationships with her family and wanted to join a Veteran’s support group. Vazquez-Claudio, 713 F.3d at 116-117; Bowling, 15 Vet. App. at 11. The Board acknowledges the listed symptoms are not exhaustive, but serve as examples of the type and degree of symptoms or effects that would justify a particular rating. Mauerhan, 16 Vet. App. at 442. Additionally, the Board has not required the presence of a specified quantity of symptoms to warrant a higher rating for a mental disorder. However, the Board finds that the Veteran has not demonstrated the type and degree of symptoms, or their effects, resulting in total occupational and social impairment justifying a rating of 50 percent disabling. Overall, the Veteran has demonstrated symptoms consistent with a 30 percent rating. Given the above, the Board finds the weight of the evidence shows occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to such symptoms as depression, anxiety and sleep impairment. Therefore, the Board finds that a higher 50 percent rating is not warranted for the rating period prior to December 4, 2014 and the claim must be denied. 2. Entitlement to an increased rating in excess of 10 percent disabling for service-connected cervical spine fusion prior to September 27, 2016, and in excess of 30 percent disabling thereafter Service-connected cervical spine fusion has been assigned a 10 percent disability rating prior to September 7, 2016, and in excess of 30 percent thereafter. The Board notes that, per a January 2015 rating decision, the Veteran was granted a temporary total rating for this disability, effective December 29, 2010, the date of the claim for service connection, based on surgical or other treatment necessitating convalescence. Effective April 1, 2011, the first day of the month following three months of convalescence period, a 10 percent rating was assigned for cervical spine fusion. Therefore, the relevant rating periods on appeal are from April 1, 2011 through September 27, 2016 for a 10 percent disability rating, and as of September 27, 2016 for a 30 percent disability rating. The Veteran’s service-connected cervical spine fusion has been assigned disability ratings under Diagnostic Code 5241, spinal fusion. The schedular criteria for the rating of spine disabilities evaluates degenerative arthritis of the spine either under the General Rating Formula for Disease and Injuries of the Spine or under the Formula for rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in a higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a, Diagnostic Codes 5241 and 5243. Under the General Formula, a 10 percent rating is assigned where forward flexion of the cervical spine is greater than 30 degrees but not greater than 40 degrees; or the combined range of motion of the entire cervical spine is greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height. A 20 percent evaluation is assigned for forward flexion of the cervical spine greater than 15 degrees, but not greater than 30 degrees; or the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent rating is assigned for forward flexion of the cervical spine at 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent evaluation is assigned for unfavorable ankylosis of the entire cervical spine. The General Formula of Diseases and Injuries of the Spine provides that for VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. Id. at Note 2. Further, the General Formula for Diseases and Injuries of the Spine provides that for VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision, restricted opening of the mouth and chewing, breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia, atlantoaxial or cervical subluxation or dislocation; or neurological symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. at Note 5. Under the formula for rating intervertebral disc syndrome based on incapacitating episodes, a 40 percent evaluation is assigned with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a maximum 60 percent evaluation is assigned with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a. Diagnostic Code 5243 provides the following Notes: Note (1): An incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a. Note (2): If intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, each segment should be evaluated on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. 38 C.F.R. § 4.71a. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. Weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, or atrophy of disuse are relevant factors in regard to joint disability. 38 C.F.R. § 4.45. With any form of arthritis, painful motion is an important factor of disability; therefore, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. Muscle spasm will greatly assist the identification. The intent of the schedule is to recognize painful motion with joint or particular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. The General Rating Formula for Diseases and Injuries of the Spine allows for separate evaluations for chronic orthopedic and neurologic manifestations. See 38 C.F.R. § 4.71a Note (1). Diagnostic Codes 8514-8719 address ratings for paralysis of the peripheral nerves affecting the upper extremities, neuritis, and neuralgia. 38 C.F.R. § 4.124a. Diagnostic Codes 8516, 8616, and 8716 provide ratings for paralysis, neuritis, and neuralgia of the ulnar nerve. Neuritis and neuralgia are rated as incomplete paralysis. Disability ratings of 10, 30, and 40 percent are warranted, respectively, for mild, moderate, and severe incomplete paralysis of the major ulnar nerve. Disability ratings of 10, 20, and 30 percent are warranted, respectively, for mild, moderate, and severe incomplete paralysis of the minor ulnar nerve. 38 C.F.R. § 4.124a, Diagnostic Code 8516. Entitlement to a 10 percent rating for service-connected cervical spine fusion prior to September 27, 2016 Within a December 2010 claim, the Veteran reported that she met with a VA physician in September 2010 regarding her back strain, and received an MRI which showed mild straightening of the cervical spine with loss of normal lordosis. VA treatment notes include a September 2010 note, which shows the Veteran had undergone an MRI of the cervical spine. The MRI showed findings of mild straightening of the cervical spine with loss of normal lordosis, the vertebral body height was grossly unremarkable otherwise. At the C5-6, broad based disc osteophyte complex slightly eccentric towards the right side causing mild right greater than left neural foraminal narrowing explained the Veteran’s pain. The physician was to obtain a neurosurgery opinion consult and prescribed the Veteran a 2- day prescription of oxycodone. A November 2010 VA neurosurgery consult note shows the Veteran complained of right arm and shoulder pain. The VA neurosurgeon found that on examination, the Veteran had weaker right bicep and tricep consistent with C6 radiculopathy. The VA neurosurgeon diagnosed the Veteran with C6 radiculopathy with disc C5-6 and recommended surgery. Private treatment notes include a December 2010 operative note, in which the Veteran had undergone a cervical discectomy, cervical fusion and instrumentation. In a May 2011 letter, the Veteran’s daughter indicated that after her surgery, things had not gotten better for her mother. She indicated that the Veteran was losing feeling in her arms, leg and neck, causing her to accidentally drop things or fall. She had trouble sleeping and completing small tasks. In a May 2011 letter, another daughter of the Veteran wrote that the Veteran’s pain has been exponentially severe since her surgery in December 2010. She indicated that because of the pain, the Veteran has not been able to functional normally or do many tasks that she found enjoyable. As of May 2011, the Veteran has regained some capacity to function normally, in that she can do more tasks, like driving and even working for a few short hours at the office. The Veteran was allowed to work half-days at the office but some days she cannot even complete these workdays. The Veteran’s daughter said that the Veteran’s limited range and duration of activity does not allow her to do much of what she used to do. VA treatment records include a May 2011 x-ray report of the cervical spine, which showed postoperative findings of a prior anterior diskectomy with anterior plate/screw fixation and intervertebral graft at the C-5/6 level appear stable without an obvious acute complication. No significant scoliotic curvature is appreciated. The visualized vertebral bodies and disc spaces appear to be maintained in height. No acute fracture or malalinement is appreciated. The prevertebral soft tissues remain of normal thickness. The impression was stable, grossly uncomplicated, postoperative findings of a prior anterior diskectomy, with no new/acute radiographic abnormality currently appreciated involving the cervical spine. A May 2011 private neurosurgery letter shows that the Veteran did well after her cervical disc surgery in December 2010. Her May 2011 films show excellent fusion construct, however, the Veteran reported numbness, so an MRI was ordered for her neck. The Veteran was prescribed Flexeril in the meantime. VA treatment records include a September 2011 neurosurgery consult, where the Veteran was advised that, upon review of a June 2011 private MRI, that there was not another further surgery that should be done or could even be done. The veteran did not have active radiculopathy and had questionable early findings of a peripheral neuropathy on the left upper extremity. Physical examination showed normal testing results. The Veteran was diagnosed with cervical spondylosis. A March 2012 typed letter is of record that was created by the Veteran and served as a template for her private neurosurgeon to sign. In a letter dated August 2012, from the above template created by the Veteran in March 2012, the Veteran’s private neurosurgeon indicated that an MRI report showed that the Veteran had minimal anterior end plate osteophyte formation involving the mid to lower thoracic spine, which cause intense pain and muscle spasms. The Veteran was prescribed numerous medications, to include Gabapentin for nerve pain, Oxycodone/Tylenol for pain and a Fentanyl patch for pain. A June 2014 VA examination shows a diagnosis of cervical spinal fusion. The Veteran reported that she has had increasing pain in her neck over the years, which was still painful after her surgery, and kept her from doing most things. She reported flare-ups as preventing her from doing most things. On examination, range of motion testing showed forward flexion to 40 degrees with pain; extension to 40 degrees, with pain; right lateral flexion to 30 degrees, with pain; left lateral flexion to 40 degrees, with pain; right lateral rotation to 75 degrees, with pain; and, left lateral rotation to 75 degrees, with pain. The Veteran was unable to conduct repetitive use testing due to pain. Pain on movement of the cervical spine caused functional loss. The Veteran had localized tenderness or pain to palpation to the joints/soft tissue of the cervical spine. She didn’t have muscle spasms or guarding of the cervical spine. The Veteran had normal muscle strength test results and did not have muscle atrophy. The Veteran did not have diagnosed IVDS or ankylosis of the cervical spine, and did not have radiculopathy or any other neurological abnormalities related to the cervical spine. Within a July 2015 videoconference hearing, the Veteran testified that she was in constant pain with regard to her neck. She indicated that sometimes her neck starts to fall, where the muscles in her neck give way and she has to wear a soft collar to keep her head up. She reported having trouble turning her head, which is a problem with driving, where she has to be very careful looking left and right. The Veteran testified that she was unable to go to amusement parks with her daughter and go on the rides because of the pain in her neck. She also testified that she tended to only do very light work when no one is home because she is worried that she might get hurt. After a review of all the evidence, lay and medical, the Board finds that for the rating period prior to September 27, 2016, with consideration of functional loss due to pain, stiffness, and flare-ups of pain on range of motion, the Veteran’s cervical spine disability manifested as forward flexion limited to 40 degrees, with a combined range of motion of 300 degrees. The Board finds probative the June 2014 VA examination which showed forward flexion of the cervical spine to 40 degrees with pain, with the combined range of motion of 300 degrees. The Board finds that at no point during the rating period did the cervical spine manifest as forward flexion of the cervical spine greater than 15 degrees, but not greater than 30 degrees; or the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Notably, within the June 2014 VA examination, the Veteran did not have muscle spasms or guarding of the cervical spine, and range of motion testing did not show forward flexion of the cervical spine to greater than 15 degrees but not greater than 30 degrees, or a combined range of motion not greater than 120 degrees. Further, VA treatment records include a May 2011 x-ray report of the cervical spine, which showed no significant scoliotic curvature, with disc spaces maintained in height and prevertebral soft tissues showing normal thickness. For these reasons, the Board finds that the Veteran has not met or approximated the criteria for a higher 20 percent rating for his cervical spine disability at any time during the appeal. The Board has considered whether separate or higher compensable ratings are warranted for service-connected cervical spine fusion. The June 2014 VA examination shows that the Veteran does not have diagnosed IVDS, and therefore, a rating under Diagnostic Code 5243 is not warranted. Further, while the Veteran, and lay statements from her daughters of record, indicate that the Veteran had numbness of her upper extremities, the Board finds probative the September 2011 VA treatment note finding no radiculopathy and the subsequent June 2014 VA examination which showed that the Veteran did not have radiculopathy or any other neurological abnormalities related to the cervical spine. Although lay evidence is acceptable to prove the occurrence of an injury or symptomatology over a period of time when such symptomatology is within the purview of or may be readily recognized by lay persons, lay testimony is not competent to prove a matter requiring medical expertise. Layno v. Brown, 6 Vet. App. 465, 469 (1994); Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Therefore, the Board finds that a separate evaluation for neurologic manifestations of the upper extremities is not warranted under Diagnostic Codes 8510-8719. 38 C.F.R. § 4.124a; see also 38 C.F.R. § 4.71a, Note (1). In sum, the Board finds that the preponderance of the evidence is against the claim for a rating in excess of 10 percent disabling for service-connected cervical spine fusion for the rating period prior to September 27, 2016. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2019). Entitlement to a 30 percent rating for service-connected cervical spine fusion as of September 27, 2016 Within a September 2016 VA examination, the Veteran was diagnosed cervical fusion, intervertebral disc syndrome (IVDS), paralysis of the middle radicular nerves, strain of fascia and tendon at neck level, and postlaminectomy syndrome. The Veteran reported that she had pain rated as an eight to 10 out of 10, described as aching, throbbing, burning, dull, grinding, popping, sharp and soreness, and was continuous. The Veteran described having flare-ups of her cervical spine disability daily, which was only partially relieved by ceasing the aggravating activity. Flare-ups of pain resulted from sitting, driving, prolonged standing, working overhead, reaching, walking, bending/twisting, lifting/carrying, and she avoided ladders, and stairs, and was unable to climb or use ladders. On examination, range of motion testing showed forward flexion to 15 degrees with pain; extension to 2 degrees, with pain; right lateral flexion to 5 degrees, with pain; left lateral flexion to 5 degrees, with pain; right lateral rotation to 15 degrees, with pain; and, left lateral rotation to 20 degrees, with pain. Range of motion resulted in functional loss. Repetitive use testing did not result in additional loss of function or range of motion. Repetitive use testing yielded the same range of motion, and pain, fatigue, weakness, lack of endurance and incoordination significantly limited functional ability with flare-ups. Pain, fatigue, weakness, lack of endurance and incoordination also significantly limited functional ability with flare-ups. The Veteran had localized tenderness or pain to palpation to the joints/soft tissue of the cervical spine. She had muscle spasms and guarding of the cervical spine that did not result in abnormal gait or abnormal spinal contour. Muscle strength testing showed active movement with gravity eliminated of the bilateral elbow flexion and extension, with palpable or visible muscle contraction, but no joint movement of bilateral wrist flexion and extension, and bilateral finger flexion and abduction. The Veteran did not have muscle atrophy. The Veteran did have radiculopathy of the bilateral upper extremity and did not have ankylosis of the cervical spine. The Veteran had IVDS of the cervical spine and did not have episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months. An April 2018 VA examination shows the Veteran had diagnosed cervical fusion and IVDS of the cervical spine. During the examination, the Veteran reported flare-ups as a reduction in range of motion, with functional loss or functional impairment when having to turn to look over he should in traffic and other quick turns of her head. On examination, range of motion testing showed forward flexion to 15 degrees with pain; extension to 15 degrees, with pain; right lateral flexion to 15 degrees, with pain; left lateral flexion to 15 degrees, with pain; right lateral rotation to 50 degrees, with pain; and, left lateral rotation to 50 degrees, with pain. Range of motion resulted in functional loss. There was evidence of pain with weight bearing and pain on palpation of the joint or associated soft tissue of the cervical spine. The Veteran was unable to perform repetitive use testing and repeated use over time was not tested. The VA examiner denoted that flare-ups manifested as pain, fatigue, and lack of endurance. Muscle strength testing showed active movement against gravity for bilateral elbow flexion and extension, bilateral wrist flexion and extension, and active movement against some resistance for bilateral finger flexion. There was now muscle atrophy. The Veteran had bilateral upper extremity radiculopathy and did not have ankylosis of the spine. The Veteran ad IVDS of the cervical spine and did not have episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months. After a review of all the evidence, lay and medical, the Board finds that for the entire rating period, with consideration of functional loss due to pain, stiffness, and flare-ups of pain on range of motion, the Veteran’s cervical spine disability manifested as forward flexion limited to 15 degrees or less. During both the September 2016 and April 2018 VA examinations, range of motion testing showed forward flexion of the cervical spine to 15 degrees, with pain, with no ankylosis of the cervical spine. Therefore, a higher, maximum, 40 percent rating under Diagnostic Code 5241 is not warranted where unfavorable ankylosis of the entire cervical spine was not shown by the objective medical evidence of record. In considering other relevant or applicable diagnostic codes, the Board notes that the Veteran is already service connected for radiculopathy of the left and right upper extremity, effective September 27, 2016, the date of the September 2016 VA examination; and these matters are not on appeal. And while the Veteran had diagnosed IVDS, the September 2016 and April 2018 VA examiners indicated that the Veteran did not have did not have episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months. In sum, the Board finds that the preponderance of the evidence is against the claim for a rating in excess of 30 percent disabling for service-connected cervical spine fusion for the rating period as of September 27, 2016. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2019). 3. Entitlement to a TDIU prior to April 22, 2013 and as of September 27, 2016 TDIU ratings may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of 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) (2019). For the purpose of one 60 percent or one 40 percent disability in combination, disabilities resulting from a common etiology or a single accident will be considered as one disability. 38 C.F.R. § 4.16 (a) (2019). Even when the percentage requirements are not met, entitlement to a total rating, on an extraschedular basis, may nonetheless be granted, in exceptional cases, when the veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. 38 C.F.R. §§ 3.321 (b), 4.16(b) (2019). Substantially gainful employment is defined as work which is more than marginal and which permits the individual to earn a living wage. Moore v. Derwinski, 1 Vet. App. 356 (1991). In evaluating a veteran’s employability, consideration may be given to his or her level of education, special training, and previous work experience in arriving at a conclusion, but not to age or impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19 (2019). The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether the veteran can find employment. 38 C.F.R. § 4.16 (a) (2019). For a veteran to prevail on a total rating claim, the record must reflect some factor which takes his or her case outside of the norm. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1996); 38 C.F.R. §§ 4.1, 4.15 (2019). As an initial matter, the Board notes that the Veteran is in receipt of TDIU benefits effective April 22, 2013 to September 27, 2016. Further, the Board notes that entitlement to a TDIU was considered part and parcel of the Veteran’s claim for entitlement to an increased rating for service-connected acquired psychiatric disorder, which was filed on December 29, 2010. See Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). Therefore, the first rating period on appeal for entitlement to a TDIU is from December 29, 2010 to April 22, 2013, with the second rating period on appeal as of September 27, 2016. Additionally, the Board notes that within the first rating period, from December 29, 2010 to March 31, 2011, the Veteran was in receipt of a temporary total disability rating for a period of convalescence; from April 1, 2011 to January 24, 2012, a 60 percent combined evaluation; and from January 25, 2021 to April 21, 2013, an 80 percent combined revaluation. From September 27, 2016, the Veteran was in receipt of a total combined evaluation (100 percent). Entitlement to a TDIU for the rating period prior to April 22, 2013 Aside from the instances of the assignment of a temporary total rating, the Veteran did not meet the schedular criteria for TDIU as she did not have a combined rating of 70 percent and did not have at least one disability which was rated 60 percent disabling. A Veterans Application for Increased Compensation Based on Unemployability, received in December 2013, shows that the Veteran reported that her service-connected disabilities affected her full-time employment in September 2011, when she last worked full-time, and reported that she became too disabled to work in December 2010. She had worked as a paralegal for 40 hours a week from October 2002 to September 2011. She had an Associate of Science, Paralegal Studies degree that she received in 2004. A November 2011 VA psychiatric examination shows that the Veteran was working 20 hours per week after her neck surgery, and was working up to 32 hours a week with better pain management. The VA examiner opined that the Veteran’s physiatric disability did not interfere with occupational functioning. An August 2013 SSA decision that found the Veteran to be disabled from September 5, 2012, due, in part, to depression. As noted in the August 2013 SSA decision, the Veteran alleged her depression and medication use caused her difficulty with concentration and task completion. The Veteran also stated that on some days she could not get out of bed due to depression and pain and that she was eventually terminated from her job due to absenteeism. In support of the SSA determination was a March 2012 statement from the Veteran’s private neurologist. The neurologist indicated that the Veteran was suffering from lumbar disc bulge which caused the Veteran pain and muscle spasms. It was also stated that the Veteran was experiencing pain due to her injuries, to include her cervical spine disability and subsequent cervical spine fusion. The neurologist opined that it was more likely than not that the physical trauma suffered during service caused, contributed, and aggravated her back disabilities and secondary conditions. Within a July 2015 videoconference hearing, the Veteran testified that she last worked in September 2012 as a paralegal, when she was fired for absenteeism. Around the time she was fired, she was taking pain medications and medications for depression and anxiety, to include Oxycodone. She reported that she was fuzzy headed, unsteady on her feet, had memory loss and was not sleeping. An April 2018 TDIU VA retroactive medical opinion showed that the Veteran’s cervical spine disability precluded occupations requiring frequent head rotation, flexion, or physical occupations such as lifting, loading, climbing. It did not preclude gainful sedentary occupation not involving the above. The cervical spine limitations along with her lumbar spine limitations precluding physical occupations such as bending, lifting, climbing as likely as not existed prior to April 22, 2013. Within a September 2018 letter, a private certified rehabilitation nurse opined that the Veteran should be afforded a TDIU as of September 2012, when the SSA determined the Veteran to be disabled. A September 2018 statement from the Veteran’s representative also dictates that TDIU should be warranted as of September 4, 2012 based on the SSA’s determination. The Board finds that referral for to the Director of Compensation Services for consideration of a TDIU under section 4.16(b) is not warranted. The Board finds that during this rating period on appeal, the Veteran was limited in performing physical labor due to her service-connected disabilities but was able to perform sedentary work. VA examinations and medical opinions show that the Veteran’s service-connected disabilities limited her physical abilities of lifting, loading, climbing due to back neck pain. And while an SSA determination found the Veteran to be disabled as of September 2012, the SSA adjudicator also indicated the Veteran was capable of performing light work. The Board notes that that SSA determinations are persuasive and not authoritative, as that agency uses significantly different criteria in determining disability eligibility. Thus, SSA findings are not binding on VA and the Board. The Board affords more weight to the April 2018 VA medical opinion, based on full review of the Veteran’s record, to include the above SSA determination, which found that the Veteran would have been capable of sedentary work during this period on appeal. The Board discounts the probative value of the private nurse’s opinion for the same reasons, The evidence does not otherwise indicate significant occupational impairment due to the Veteran’s service-connected disabilities, and does not reflect an unusual or exceptional disability picture due to his service-connected disabilities to warrant referral for consideration under 38 C.F.R. § 4.16 (b). There is nothing in the record to show that the Veteran’s service-connected disabilities alone cause impairment with employment over and above that which is contemplated in the assigned schedular ratings in this case, to include the medical opinion provided by the Veteran’s private neurologist in December 2013. To the extent the service-connected disabilities affect the Veteran’s employment, the assigned schedular ratings for the disabilities compensate the Veteran for such impairment. Therefore, as the Veteran has not provided any competent and credible evidence that her service-connected disabilities, either singly or combined, prevented her from securing or following any substantially gainful employment, the Board finds that referral for extraschedular consideration is not appropriate, and a TDIU rating is not warranted for the rating period prior to April 22, 2013. 38 C.F.R. § 4.16 (b) (2019). Because the preponderance of the evidence is against claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2019). Entitlement to a TDIU for the rating period as of September 27, 2016 From September 27, 2016, the Veteran is in receipt of a total combined evaluation (100 percent) based on all of her service-connected disabilities. A TDIU is considered a lesser benefit than the 100 percent scheduler rating, and the grant of a 100 percent scheduler rating generally renders moot the issue of entitlement to a TDIU for the period when the 100 percent rating is in effect. However, a grant of a 100 percent disability rating does not always render the issue of TDIU moot. VA’s duty to maximize a claimant’s benefits includes consideration of whether the disabilities establish entitlement to special monthly compensation (SMC) under 38 U.S.C. § 1114. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); see also Bradley v. Peake, 22 Vet. App. 280, 294 (2008). Specifically, SMC may be warranted if a veteran has a 100 percent disability rating for a single disability, and VA finds that TDIU is warranted based solely on the disabilities other than the disability that is rated at 100 percent. See Bradley, 22 Vet. App. at 294 (analyzing 38 U.S.C. § 1114); see also 75 Fed. Reg. 11,229-04 (Mar. 10, 2010) (withdrawing VAOPGCPREC 6-99). In this case, however, the Veteran does not have a single disability rated 100 percent disabling, but rather a 100 percent (“total”) combined disability rating based on multiple disabilities; thus, there is no basis for assignment of SMC per 38 U.S.C. § 1114. Accordingly, entitlement to a TDIU is not warranted for the rating period as of September 27, 2016. 38 C.F.R. § 4.16 (b) (2019). Because the preponderance of the evidence is against claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2019). K. Parakkal Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. R. Woodarek 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.