Citation Nr: 21028630 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 15-37 042 DATE: May 11, 2021 ORDER Service connection for bilateral carpal tunnel syndrome is denied. A disability rating in excess of 20 percent for diabetes mellitus is denied. A total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is denied. REFERRED The claims of entitlement to service connection for diabetic retinopathy, a cardiac condition, and hypertension were raised by the Veteran's representative in an October 2018 Informal Hearing Presentation. See also June 2015 Disability Benefits Questionnaire (DBQ). Accordingly, these claims are referred to the Agency of Original Jurisdiction (AOJ) for adjudication. FINDINGS OF FACT 1. The Veteran's bilateral carpal tunnel syndrome was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease. 2. The Veteran's diabetes mellitus does not require insulin treatment or regulation of activities, and is not productive of episodes of ketoacidosis, hypoglycemic reactions, or progressive loss of weight and strength. 3. The Veteran meets the schedular requirements for a TDIU, but his service-connected disabilities do not preclude him from obtaining and retaining substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for an award of service connection for bilateral carpal tunnel syndrome are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for an award of disability rating in excess of 20 percent for diabetes mellitus have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.119, Diagnostic Code 7913 3. The criteria for entitlement to a TDIU have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1970 to July 1990. This appeal is before the Board of Veterans' Appeals (Board) from multiple rating decisions from Department of Veterans Affairs (VA) Regional Offices (RO). A November 2018 Board decision reopened and denied the Veteran's claim for service connection for bilateral carpal tunnel syndrome and denied his claims for a higher rating for diabetes mellitus and a TDIU. The Veteran appealed this decision to the United States Court of Appeals for Veterans Claims (Court). In January 2020, the Court granted a Joint Motion for Partial Remand (JMPR) filed by the parties to the appeal (the Veteran, through an attorney, and representatives from VA General Counsel), thereby vacating the Board's decision insofar as it denied service connection for carpal tunnel syndrome, a higher rating for diabetes mellitus, and a TDIU, and remanding the matter for readjudication. In September 2020, the Board remanded the issues currently on appeal to the agency of original jurisdiction (AOJ) for additional development. After taking further action, the AOJ confirmed and continued the prior denial(s) and returned the case to the Board. See February 2021 supplemental statement of the case. Relevant to this appeal, a November 2012 rating decision granted service connection for diabetes mellitus and assigned a 20 percent disability rating effective July 26, 2010. In a November 2015 rating decision, the AOJ severed service connection for diabetes mellitus effective February 1, 2016. Subsequently, in a February 2021 rating decision, the RO restored service connection for diabetes mellitus with an evaluation of 20 percent effective February 1, 2016. Accordingly, the Veteran's claim for a higher rating for diabetes mellitus spans the entire rating period on appeal from July 23, 2010. 1. Service connection for bilateral carpal tunnel syndrome is denied. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110, 1131; 38 C.F.R. § 3.303(a). Service connection requires: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). If a Veteran serves 90 days or more of active, continuous service after December 31, 1946, and manifests certain chronic diseases, such as organic disease of the central nervous system, to a degree of 10 percent or more during the one-year period following his separation from that service, service connection for the condition may be established on a presumptive basis, notwithstanding that there is no in-service record of the disorder. See 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307) and (ii) subsequent manifestations of the same chronic disease, or (b) if the fact of chronicity in service in not adequately supported, by evidence of continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In rendering a decision on appeal, the Board must analyze the credibility and probative value of all medical and lay evidence of record, 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); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board must resolve reasonable doubt in favor of the Veteran. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49. To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). For the reasons set forth below, the Board finds that the evidence weighs against the Veteran's claim. The Veteran contends that he has carpal tunnel syndrome as a result of the many years he worked on aircrafts as an aircraft electrician technician during service. The earliest record of evidence to indicate a diagnosis of carpal tunnel syndrome is dated in 2000. An August 2013 VA medical record illustrates a diagnosis of carpal tunnel syndrome. As such, the Veteran has a current diagnosis of carpal tunnel syndrome. The remaining questions before the Board is whether there is an in-service disease or injury to which such disability is etiologically related. The Veteran's service treatment records (STRs) indicate that in October 1976 he had a left forearm x-ray after having his wrist closed on by a car hood and the impression section noted a "hematoma over the distal third of the radius at its junction with the middle third... No underlying bone abnormality noted." A separate record from the same day indicated that the Veteran had a "glancing blow to his left forearm" and suffered from a laceration. The assessment noted an "ulnar compression- muscle [unknown] injury." In November 1976 noted that the Veteran suffered a left forearm injury with residuals in his left hand after falling on his forearm two weeks prior. An October 1979 record indicated that the Veteran suffered from loss of sensation and swelling in his left hand and loss of sensation in his thumb to forefinger. In March 1981, he experienced pain on movement of the forearm and a corresponding x-ray revealed "incomplete greenstick fractures of the midshafts of the radius and ulna with between 5 and 10 [degrees] volar bowing." In April 1981 he underwent a radiographic follow up for his forearm fracture and the report determined "satisfactory progression of healing with good bony repair." An August 1987 service treatment record indicated that the Veteran experienced right wrist soreness and a diagnosis of right wrist tendonitis. In December 1987, he experienced a left elbow racquetball injury and a corresponding x-ray revealed no fracture, dislocation or other osseous abnormalities. In September 1988. he received treatment for right arm numbness from the elbow to the wrist with no pain upon palpitation and the assessment states, "ulnar nerve compression, etiology unknown. In November 1988, he underwent an x-ray after experiencing 6 weeks of tingling, numbness, and weakness in his "ulnar [right] distribution." The provisional diagnosis section noted "ulnar neuritis." The consultation report stated that he experienced six months of right elbow pain when lifting heavy objects, the ulnar nerve was normal, and that he was diagnosed with bilateral epicondylitis but there was no evidence of a neurological disease. In December 1988, he underwent an electromyography consultation which determined his right ulnar nerve and motor responses were normal and there was no evidence of ulnar neuropathy. Also, in December 1988, he underwent physical therapy for his bilateral epicondylitis. The June 1990 service separation examination report noted that his upper extremities were determined to be clinically normal, and concurrent report of medical history shows that the Veteran denied swollen or painful joints. The Veteran did not otherwise report any symptoms of carpal tunnel syndrome at service separation. In a December 2000 letter to the VA, the Veteran alleged he did not receive a service separation examination stating, "I was just asked if I felt anything was bothering me that I felt might be a disability issue," and that during this interaction, his attention was drawn to the deteriorating health of his father and thus he did "not have [an] effective opportunity to evaluate my health condition." There is a "presumption of regularity" under which it is presumed that Government officials have properly discharged their official duties. Clear evidence to the contrary is required to rebut the presumption of regularity. Ashley v. Derwinski, 2 Vet. App. 307 (1992) (citing United States v. Chemical Foundation, Inc., 272 U.S. 1, 14-15 (1926)). The presumption of regularity may be rebutted by submission of clear evidence to the contrary. Statements made by a veteran, without more, do not constitute the type of clear evidence to the contrary sufficient to rebut the presumption of regularity. Jones v. West, 12 Vet. App. 98 (1999); Mindenhall v. Brown, 7 Vet. App. 271, 274 (1994). In this case, there is a presumption of regularity that must be accorded service department examinations, to include the service separation examination. In the present case, the June 1990 service separation examination report was conducted by a physician and is adequate and presumed accurate in its findings. The service doctor specifically assessed that all body systems were normal, except for the skin (noted the Veteran's psoriasis). The service doctor also recorded all of the Veteran's complaints, symptoms, and history, to include notations of psoriasis. Moreover, as noted above, the June 1990 report of medical history, which was completed by the Veteran at service separation, shows that the Veteran denied swollen or painful joints. The Veteran did not otherwise report any symptoms of carpal tunnel syndrome at service separation. Accordingly, the Board finds that Veteran's assertion without more, does not rebut the presumption of regularity in the present case. In March 1991, the Veteran experienced left elbow tendonitis and complaints of intermittent pain in his left elbow and wrist and the record stated that both were "within normal limits." Another record from March 1991 indicated that he experienced left elbow edema and deformity, as well issues pertaining to his grip and wrist, bilaterally. In October 1999 he was treated for wrist pain with numbness and elbow pain. In March 2004 he underwent a VA examination for multiple injuries. As a part of the examination the examiner reported he did not experience in-service wrist injuries and a wrist examination determined they were "unremarkable" with no neurovascular deficits and "no signs of a disability." A February 2005 VA record indicates he subjectively reported that his carpal tunnel syndrome started while on active service. The first post-service evidence of carpal tunnel was in 2000, which is approximately a decade after service separation. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (the passage of many years between discharge from active service and complaint of a claimed disability is one factor to consider as evidence against a claim of service connection). A March 2000 VA treatment record noted a diagnosis of carpal tunnel. An August 2000 VA treatment record indicated that he was given bilateral wrist splints for carpal tunnel syndrome. The Veteran was afforded a VA examination in July 2015. The examiner opined that the Veteran's bilateral carpal tunnel syndrome (CTS) is not related to service. In explaining his rationale, the examiner discussed the Veteran's contentions and in-service treatment and symptoms. First, the right arm numbness and tingling symptoms the Veteran experienced in service resulted in an initial diagnosis of ulnar nerve compression. The examiner described how the tingling and numbness involves the ulnar nerve at the elbow and not the median nerve at the wrist. CTS involves median nerve compression at the wrist so the Veteran's complaints of right arm numbness from elbow to wrist cannot be a result of CTS. The examiner also addressed the separate complaint of right wrist pain in service. The description of the pain and examination was not consistent with a diagnosis of CTS. In fact, the in-service diagnosis was right wrist tendonitis. Lastly, the examiner accounted for the separate complaint of left lateral elbow pain and also The Veteran was afforded a VA examination in July 2015. The examiner opined that the Veteran's bilateral carpal tunnel syndrome is not related to service. In explaining his rationale, the examiner discussed the Veteran's contentions and in-service treatment and symptoms. First, the right arm numbness and tingling symptoms the Veteran experienced in service resulted in an initial diagnosis of ulnar nerve compression. The examiner described how the tingling and numbness involves the ulnar nerve at the elbow and not the median nerve at the wrist. The examiner explained that carpal tunnel syndrome involves median nerve compression at the wrist so the Veteran's complaints of right arm numbness from elbow to wrist cannot be a result of carpal tunnel syndrome. The examiner also addressed the separate complaint of right wrist pain in service and explained that the description of the pain and examination was not consistent with a diagnosis of carpal tunnel. The examiner noted that, in fact, the in-service diagnosis was right wrist tendonitis. Lastly, the examiner accounted for the separate complaint of left lateral elbow pain and also concluded that the pain and examination were not consistent with a diagnosis of carpal tunnel syndrome and was appropriately diagnosed in service as left lateral epicondylitis. The Veteran was afforded another VA examination in November 2020. The examiner opined that the Veteran's carpal tunnel syndrome was less likely than not incurred in or caused by service. The examiner provided the following rationale Service records were positive for complaints of right wrist sore (08/17/1987). At the time, [service member] was diagnosed with tendonitis. Tendonitis a load related localized pain coinciding with increased activities. It is caused by acute inflammation, which is usually resolved with the use of NSAIDS. The [service member] worked as an aircraft electrician while in service, which involved the use of his hands mostly. In addition to this, [service member] also complained of left forearm condition (specifically fracture of his radial and ulnar shaft 04/02/1981). The pain involved with this is mostly at the forearm. Also, notably (10/0/1999) [service member] complained of wrist pain and numbness, which used to bother him while in active duty. He reported that it hurts when he tries to use a screwdriver, draw, or write. Assessment at that time noted that the wrist was not tender to palpitation. [Carpal tunnel syndrome] is caused by the compression of the median nerve. Patients typically experience pain and paresthesias in the distribution of the median nerve, which involve the Palmer aspects of the thumb, index, middle finger, and radial half of the ring finger. These were all lacking symptoms in the complaints noted above. The Board finds that, taken together, the July 2015 and November 2020 VA opinions are probative because they are based on an accurate medical history and provide explanations that contain clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). There are no medical opinions to the contrary. The Veteran submitted multiple pieces of medical literature in 2012, 2013 and 2015 as to the causes of carpal tunnel syndrome. A medical article or treatise can provide important support when combined with an opinion of a medical professional if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion. Sacks v. West, 11 Vet. App. 314 (1998); see also Wallin v. West, 11 Vet. App. 509 (1998). In this case, however, the medical text evidence submitted by the Veteran is not accompanied by the medical opinion of a medical professional. The articles submitted provide general information regarding common causes of carpal tunnel syndrome. However, these articles fail to demonstrate with any degree of certainty a relationship between the Veteran's carpal tunnel syndrome and his in-service complaints. For these reasons, the Board finds that the medical text evidence does not contain the specificity to constitute competent evidence of the claimed medical nexus in this case. Further, the Board finds that these general articles are outweighed by the July 2015 and November 2020 VA opinions that specifically focused on the etiology of the Veteran's carpal tunnel syndrome. Although, the Veteran is competent to report that he experienced pain or discomfort in his wrists while in service, the Board notes that he would not be competent to self-diagnose carpal tunnel syndrome. The Board acknowledges the Veteran's own opinion that the asserted events in service and current disability are related, but the Board finds that a preponderance of the evidence is against such a finding. The Veteran, as a lay person, does not have the education, training, or experience to diagnose carpal tunnel syndrome or opine as to the etiology of any current related illness. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (lay persons not competent to diagnose conditions such as cancer). "Competent medical evidence" is evidence that is provided by a person qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a); see also Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). Consequently, the Board gives more probative weight to the July 2015 and November 2020 VA opinions. The Veteran's carpal tunnel syndrome, which is an organic disease of the central nervous system, is an enumerated condition under 38 C.F.R. § 3.309(a); Walker, 708 F.3d 1331. However, the disability was not shown as chronic in service, did not manifest to a compensable degree within a presumptive period, and was not noted in service with attributable continuity of symptomatology. There is otherwise no competent and probative evidence that the Veteran's current carpal tunnel syndrome was manifested to a degree of 10 percent or more within one year of separation from service, or that it is otherwise related to service. As such, service connection on a direct and presumptive basis is not warranted. Based on the foregoing, because the preponderance of the evidence is against the claim for service connection for bilateral carpal tunnel syndrome, the benefit of the doubt doctrine is not for application, and the appeal of this issue must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49. 2. Entitlement to a disability rating in excess of 20 percent for diabetes mellitus is denied. The Veteran seeks a disability rating in excess of 20 percent for his service-connected diabetes mellitus. Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. Staged ratings are appropriate when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). Diabetes mellitus is evaluated under 38 C.F.R. § 4.119, DC 7913. The Veteran's current 20 percent rating is warranted for diabetes mellitus requiring insulin and restricted diet, or oral hypoglycemic agent and restricted diet. A higher rating of 40 percent is warranted for diabetes mellitus requiring insulin, restricted diet, and regulation of activities. Regulation of activities is defined as avoidance of strenuous occupational and recreational activities. A 60 percent rating is warranted for diabetes mellitus requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating is warranted for diabetes mellitus requiring more than one daily injection of insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. Note (1) following Diagnostic Code 7913 provides that compensable complications of diabetes are to be rated separately unless they are part of the criteria used to support a 100 percent evaluation. Noncompensable complications are considered part of the diabetic process. The Veteran underwent a VA examination in February 2012. The examiner confirmed the Veteran's 2006 diagnosis of diabetes mellitus type II. The treatment for his diabetes involved being managed by a restricted diet, prescribed oral hypoglycemic agent, and prescribed insulin more than one injection per day. Regulation of activities as part of his medical management was not required. He visited his diabetic care provider for episodes of ketoacidosis or hypoglycemic reactions less than two times per month. There were no episodes of ketoacidosis or hypoglycemia requiring hospitalization over the previous 12 months. The Veteran submitted a June 2015 DBQ by private physician Dr. J.T.S. The examiner noted that the only treatment included prescribed insulin more than one injection per day. Requirement for a restricted diet was not indicated. Regulation of activities as part of his medical management was not required. He visited his diabetic care provider for episodes of ketoacidosis or hypoglycemic reactions less than two times per month. There were no episodes of ketoacidosis or hypoglycemia requiring hospitalization over the previous 12 months. The Veteran underwent a third VA examination in November 2020. The treatment for his diabetes involved prescribed oral hypoglycemic agent and required one insulin injection per day. Regulation of activities as part of his medical management was not required. He visited his diabetic care provider for episodes of ketoacidosis or hypoglycemic reactions less than two times per month. There were no episodes of ketoacidosis or hypoglycemia requiring hospitalization over the previous 12 months. Following review of all the evidence, the Board finds that a disability rating in excess of 20 percent is not warranted for the Veteran's diabetes mellitus. There is no indication that the Veteran's physical activities were ever restricted as a result of diabetes. Records do not reflect any episodes of ketoacidosis, hypoglycemic reactions, or progressive loss of weight and strength. His current evaluation is warranted for diabetes mellitus requiring insulin and restricted diet, or oral hypoglycemic agent and restricted diet. This is a near-exact description of the Veteran's diabetes as reflected in his treatment records and his VA examination reports. At no time during the appeal period has the Veteran's diabetes treatment required regulation of activities. In addition, visits to his diabetic care provider for episodes of ketoacidosis or hypoglycemic reactions is less than two times per month and there was no indication of episodes of ketoacidosis or hypoglycemia that required hospitalization over a 12-month period. For these reasons, the Board finds that the preponderance of the evidence is against the assignment of a disability rating in excess of 20 percent for the Veteran's diabetes. In reaching this decision, the Board has considered the benefit-of-the-doubt doctrine. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. However, as the preponderance of the evidence is against the claim, that doctrine does not apply. The appeal of this issue is denied. 3. Entitlement to a TDIU is denied. The Veteran contends that he is unemployable due to the service-connected disabilities and is therefore entitled to a TDIU. In July 2015 the Veteran submitted VA Form 21-8940, filing a claim for total disability based on individual unemployability (TDIU). The RO denied entitlement to TDIU in a December 2015 rating decision. The representative has asserted that the TDIU is part of the claim for increase for diabetes in appellate status; on this basis, the Board finds that it is in appellate status. See Rice v. Shinseki, 22 Vet. App. 447 (2009). As the Veteran filed for an increased disability rating in July 2010 and according to his VA-Form 21-8940 he ceased working full time in April 2013, the appeal period commences in April 2013. Total disability ratings for compensation may be assigned where the schedular rating is less than total, and the disabled person is unable to secure or follow a substantially gainful occupation as a result of the service-connected disabilities. Marginal employment is not considered substantially gainful employment. 38 C.F.R. § 4.16(a). Substantially gainful employment means, essentially, that the work provides income above the poverty level established by the United States Department of Commerce, without benefit of protected family employment or a sheltered workshop. 38 C.F.R. § 4.16(a). There is no requirement that employment be in a certain field or provide a certain standard of living or income level beyond the poverty level. Basic eligibility is established where there is one disability rated 60 percent or more, or multiple disabilities rated at least a combined 70 percent, with one disability rated at least 40 percent. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). For the period from April 2013, the Veteran is service connected for psoriasis, rated at 60 percent, and diabetes mellitus, rated at 20 percent. His combined rating during that time frame was 70 percent. As he had two service-connected disabilities, with one rated at 40 percent or more with the combination at 70 percent or more, he met schedular. The Veteran meets schedular eligibility requirements under 38 C.F.R. § 4.16(a) during the entire time frame on appeal. The question, then, is whether the service-disabilities render the Veteran unable to obtain or retain substantially gainful employment. Factors to be considered include but are not limited to employment history, educational achievement, and vocational attainment. Age is not a factor to be considered. 38 C.F.R. § 4.16. After careful review of the evidence, the Board finds that the preponderance is against the Veteran's claim. In this regard, the most probative and credible evidence in this case fails to show that the Veteran's service-connected disabilities render him unable to obtain or maintain substantially gainful employment any time during the appeal period. In his VA Form 21-8940, the Veteran indicated that the last time he worked full-time was in 2013. He indicated that from 2006 to 2013 he worked full time as a teacher. He listed the date of April 2013 as the date he became too disabled to work, last worked full time and the date his disability affected his full-time employment. He contends that his psoriasis and diabetes mellitus prevent him from securing or following any substantially gainful occupation. He stated that he decided to cease working and retire because of his disabilities. According to his TDIU application, the Veteran completed four years of college. The February 2012 and November 2020 VA diabetes examiners concluded that the Veteran's diabetes mellitus did not impact his ability to work. The private physician who completed the June 2015 diabetes DBQ stated that obesity impacts the Veteran's work, but clearly noted that service-connected diabetes did not impact his ability to work. Obesity is not a service-connected disability. The November 2015 VA skin diseases examination report noted that the Veteran's psoriasis impacts his ability to work, describing the impact as flare-ups which cause itching that may impact his ability to concentrate. The examiner also concluded that the Veteran is able to perform activities of daily living with the above limitations. The November 2020 VA skin disease examination report noted that the Veteran's psoriasis did not impact his ability to work. A June 2014 Social Security Administration (SSA) Disability Determination and Transmittal noted that the Veteran was disabled, for SSA purposes, due to unspecified arthropathies as a primary diagnosis and dermatitis as a secondary diagnosis. Having carefully reviewed the evidence of record, the Board finds that the preponderance of the evidence does not show that the Veteran is precluded from obtaining and maintaining gainful employment consistent with his education and occupational experience due to his service-connected psoriasis and diabetes mellitus disabilities, at any time during the appeal period. Here, the evidence shows that the Veteran has been consistently employed from 2006 to 2013. The last time the Veteran worked full time was in 2013, after which he retired. He contends he became too disabled to work in 2013 as a result of his psoriasis and diabetes mellitus. There is no evidence of record to indicate that the Veteran's retirement and or his inability to work was due to his service-connected disabilities, nor has any medical professional opined that his service-connected disabilities alone impact his ability to work. The private physician who completed the June 2015 DBQ stated that the Veteran's psoriasis impacted his ability to work as the itching may cause him to lose concentration. However, the June 2015 private examiner did not indicate that this service-connected disability prevents substantially gainful employment. This examination report, however, To the extent that the Veteran's service-connected psoriasis caused some impairment to the Veteran's employability during the appeal period, the service-connected disabilities did not render the Veteran totally and permanently unemployable. The 60 percent rating in effect for the Veteran's psoriasis recognizes the occupational impact of this disability, as schedular ratings are assigned to compensate for reduced industrial capacity. Stated differently, a disability rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question is whether the claimant is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Thus, the sole fact that a claimant is unemployed or has difficulty obtaining employment is insufficient to establish entitlement to TDIU. In closing, the Board does not doubt that the Veteran's service-connected disabilities have some impact on his employability. However, the 70 percent combined schedular evaluation currently in effect recognizes significant industrial impairment resulting from his disabilities. Nevertheless, for the reasons and bases set forth above, the preponderance of the evidence is against finding his service-connected disabilities are of such severity so as to preclude his participation in any form of substantially gainful employment. In reaching this decision, the Board has considered the benefit-of-the-doubt doctrine. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. However, as the preponderance of the evidence is against the claim, that doctrine does not apply. The appeal of this issue is denied. J. Ragheb Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Law Clerk, Tyler R. Masters 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.