Citation Nr: 21030728 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 18-20 977 DATE: May 19, 2021 ORDER Entitlement to service connection for a heart disorder, to include as due to tactical herbicide agent exposure, is DENIED. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is DENIED. Entitlement to service connection for a thyroid disorder, to include as due to tactical herbicide agent exposure, is DENIED. Entitlement to service connection for tinnitus is GRANTED. REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) is REMANDED. FINDINGS OF FACT 1. The preponderance of the evidence is against the finding that the Veteran's current mitral valve regurgitation and sclerotic aortic valve were incurred in, or the result of, service in the United States Army. 2. The weight of the evidence does not establish that the Veteran has a current acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). 3. The preponderance of the evidence is against a finding that the Veteran's current thyroid condition was incurred during service in the United States Army. 4. There is at least an approximate balance of positive and negative evidence as to whether the Veteran's current tinnitus first manifested during service in the United States Army. CONCLUSIONS OF LAW 1. The criteria for service connection for a heart disorder have not been met. 38 U.S.C. §§ 1110, 1111, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.310 (2020). 2. The Veteran does not have a current acquired psychiatric disability for VA compensation purposes. 38 U.S.C. §§ 1101, 1131, 1133, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2020). 3. The criteria for service connection for a thyroid condition have not been met. 38 U.S.C. §§ 1110, 1111, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.310 (2020). 4. The criteria for service connection for a tinnitus disability have been satisfied. 38 U.S.C. §§ 1101, 1131, 1133, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably in the United States Army from September 1967 to April 1969. The certificate of release from active duty (DD214) reflects that the Veteran served as a Pioneer (engineer), and he received the Vietnam Service Medal and a Vietnam Campaign Medal. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted while in the active military, naval, or air service. 38 U.S.C. § 1110. Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303 (d). In order to establish service connection for the claimed disorder on a direct basis, generally there must be probative evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). In each case where service connection for any disability is sought, due consideration shall be given to the places, types, and circumstances of the Veteran's service as shown by the Veteran's service record, the official history of each organization in which the Veteran served, the Veteran's medical records, and all pertinent medical and lay evidence. 38 U.S.C. § 1154 (a). In making these determinations, the Board must consider and assess the credibility and weight of all evidence in the claim file, including the medical and lay evidence, to determine its probative value. In doing so, the Board must provide its reasoning for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Barr v. Nicholson, 21 Vet. App. 303 (2007). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board must give the benefit of the doubt to the Veteran. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Veterans who served in the Republic of Vietnam between January 9, 1962, and May 7, 1975, are presumed to have been exposed to certain herbicide agents during that service, absent affirmative evidence to the contrary. 38 U.S.C. § 1116 (f) (West 2014); 38 C.F.R. § 3.307 (a)(6)(iii) (2020). In consultation with the National Academy of Science (NAS), and under 38 U.S.C. § 1116 (b) and 38 C.F.R. § 1.17, the Secretary of VA is required by law to issue a presumption of service connection when sound medical and scientific evidence shows a positive association between a disease and exposure to herbicides. The diseases for which presumptive service connection based on herbicide exposure is available include chloracne or other acneform diseases consistent with chloracne, Type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes), Hodgkin's disease, chronic lymphocytic leukemia, multiple myeloma, non-Hodgkin's lymphoma, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma), hairy cell leukemia and other chronic B-cell leukemias, Parkinson's disease, and ischemic heart disease. 38 C.F.R. § 3.309 (e). The VA is responsible for determining whether the evidence supports the claim or is in relative equipoise (with the Veteran prevailing in either event) or whether a preponderance of the evidence is against the claim (in which case the claim is denied). Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (b). 1. Entitlement to service connection for a heart disorder, to include as due to tactical herbicide agent exposure, is denied. In August 2017, the Veteran submitted a VA Form 21-526EZ. Therein, the Veteran initiated an appeal to reopen a claim for service connection for a heart disorder. Again, direct service connection generally requires probative evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson, 12 Vet. App. at 253. In October 2015, the Veteran's service treatment records (STRs) were associated with the claims file. After review, the Board observes that STRs do not reflect that the Veteran was seen for, or diagnosed with, a heart condition during service in the United States Army. In July 2017, a letter from the Veteran's private medical provider was associated with the claims file. The provider reported a diagnosis for ischemic heart disease (IHD). The provider opined that the cardiovascular disorder was more probable than not secondary to the Veteran's military service. The Board notes that ischemic heart disease was one of many diagnoses on a list supplied by the private provider. The provider identified how the diagnosis for a thyroid condition was generated. Unfortunately, the private provider did not identify how the diagnosis for IHD was developed / determined. Consequently, the Board finds that this report and opinion can be afforded limited probative value for this analysis. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (an opinion without any rationale against which to evaluate the probative value of the determination is inadequate). In November 2017, the Veteran underwent a VA examination that addressed the nature and etiology of any currently endured heart conditions. The examiner did not report a current diagnosis for a heart condition. The examiner reported that the Veteran did not demonstrate symptoms that were generally accepted for the medical definition of IHD. The examiner reported that, "veteran denies history of CHF, MI, Angina. Veteran denies history of heart procedures. Veteran at time of evaluation denies chest pain, palpitation, shortness of breath." The examiner remarked that, "at time of evaluation, no objective or subjective evidence of a claimed heart condition as per today's examination and available records reviewed." In November 2018, the Board found that new and material evidence had been received, after the final February 2016 rating decision, sufficient to reopen the Veteran's claim for service connection for a heart disability. At that time, the Board remanded the claim to the agency of original jurisdiction (AOJ) in order to associate medical records with the claims file. In October 2020, the Veteran underwent a VA examination that addressed the nature and etiology of any currently endured heart conditions. The examiner reported diagnoses for mild mitral valve regurgitation and sclerotic aortic valve. The examiner reported that the Veteran denied any history of, or diagnosis for, a heart condition. The examiner noted that the Veteran reported a history of hypertension, which started in 2006. The examiner opined that it was less likely than not (less than 50 percent probability) that the diagnosed heart conditions were incurred in, or caused by, an in-service injury, event, or illness. The examiner supplied the following rationale: "mild mitral valve regurgitation / sclerotic aortic valve is not considered presumed condition related to agent orange exposure. Mild mitral valve regurgitation is due to hypertension and sclerotic valve is due to the aging process." Importantly, the examiner relayed that, "the letter from Dr. CMQ, dated June 10, 2017, indicated the Veteran has a diagnosis of IHD, but no physical exam findings or diagnostics are included in the letter to support this diagnosis. Based on the current exam and recent diagnostics, there is no objective evidence to warrant a diagnosis for IHD. Mild mitral valve regurgitation / sclerotic aortic valve are not considered IHD." On multiple occasions during the claim period, the Veteran's government and non-government treatment records were associated with the claims file. After review, the Board observes that the treatment records do not contain a current diagnosis for IHD. The Board notes that the private provider supplied a diagnosis for IHD in July 2017. However, as noted above, the Board affords this diagnosis little probative value, because the provider did not identify how the diagnosis was determined / developed. Moreover, the multiple treatment records in the Veteran's claims file to do support a diagnosis for ischemic heart disease. Consequently, presumptive service connection for IHD is not warranted under 38 U.S.C. § 1116 (b), 38 C.F.R. §§ 1.1738, and 3.309 (e). The Board observes that the Veteran is currently diagnosed for mitral valve regurgitation and sclerotic aortic valve. Consequently, the first requisite element for direct service connection has been substantiated. See Hickson, 12 Vet. App. at 253. However, the STRs do not reveal that the Veteran was seen for, or diagnosed with, a heart condition during service in the United States Army. In fact, after deliberate review of the available medical treatment documents and examination reports, the Board finds that the Veteran was not diagnosed with a heart condition until decades after separation from the United States Army. Consequently, the second requisite element has not been substantiated for this direct service-connection claim. See id. Ultimately, the Board finds that the preponderance of the evidence stands counter to the Veteran's claim for service connection for a heart disability, to include as secondary to the presumed tactical herbicide agent exposure. Since the preponderance of the evidence is against this claim, the provisions of 38 U.S.C. § 5107(b), regarding reasonable doubt, are not applicable. The Veteran's claim for service connection for a heart disability must be denied, because the preponderance of the evidence weighs against his claim. 2. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is denied. In August 2017, the Veteran submitted a VA Form 21-526EZ. Therein, the Veteran initiated a claim for service connection for an acquired psychiatric disorder. Again, direct service connection generally requires probative evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson, 12 Vet. App. at 253. Service connection for PTSD has unique evidentiary requirements. It generally requires: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125 (a) (i.e., DSM-IV or DSM-5); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304 (f); see also Cohen v. Brown, 10 Vet. App. 128 (1997). In July 2017, a letter from the Veteran's private medical provider was associated with the claims file. Therein, the provider reported diagnoses for generalized anxiety disorder and major depression disease. The provider also reported that the Veteran satisfied the DSM-5 criteria for a PTSD diagnosis. The provider opined that the Veteran's acquired psychiatric disorders were more probable than not secondary to the Veteran's military service. The Board notes that the private provider delivered a succinct, conclusory statement without support for the report and/or opinion. Specifically, the provider did not address the multiple, requisite DSM-5 criteria that are needed to substantiate a diagnosis for an acquired psychiatric disorder, to include PTSD. Notably, did not identify a particular to which the diagnosis was attributed. Rather, the examiner noted unspecified "traumatics [sic] experiences during active duty." Consequently, the Board finds that this report and opinion can be afforded limited probative value for this analysis. See Reonal, 5 Vet. App. at 461 (an opinion without any rationale against which to evaluate the probative value of the determination is inadequate) In December 2017, the Veteran underwent a VA examination that addressed the nature and etiology of acquired psychiatric disorders. The VA examiner noted that the Veteran did not substantiate the DSM-5 criteria for a mental disorder. During the examination, the Veteran denied a personal psychiatric history, denied referrals or personal requests for behavioral health services, and denied ever being in mental health treatment. The Veteran reported multiple traumatic events during service in the Republic of Vietnam, but he stated that he was able to deal with them. The VA examiner reported that the Veteran did not satisfy criteria B thru I for a DSM-5 diagnosis for an acquired psychiatric disorder. The examiner opined that the claimed acquired psychiatric disability was less likely than not (less than 50 percent probability) incurred in, or caused by, the claimed in-service injury, event, or illness. The examiner supplied the following rationale: "Veteran does not have symptoms that would meet DSM-5 criteria for a diagnosis of a mental disorder." In November 2018, the Board addressed the Veteran's claim for service connection for an acquired psychiatric disorder, to include PTSD. At that time, the Board remanded the claim to the AOJ to obtain a VA examination report that addressed the correspondence from the Veteran's private physician. In November 2020, a VA PTSD disability benefits questionnaire (DBQ) was generated. Therein, the examiner noted that the Veteran did not substantiate the DSM-5 criteria for a PTSD diagnosis. The examiner also noted that the Veteran did not demonstrate another acquired psychiatric disorder that conforms with the DSM-5 criteria. The examiner relayed that the Veteran did not demonstrate symptoms to substantiate the DSM-5 criteria B thru I. The examiner remarked that, "the veteran does not present any difficulty in performing daily tasks of daily living, in fact, he verbalizes that he arrived by himself to the office and at the same time, he make a complete lists the daily activities that he will have to carry out during the same day, he shows understanding and complies with single instructions. There is no evidence of current dysfunction." The examiner opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in, or caused by, the claimed in-service injury, event, or illness. The examiner supplied the following rationale: "it is concluded that there is no clinical evidence of any Mental Disorder in the veteran evaluated that can significantly cause Post Traumatic Stress Disorder (PTSD) . . .. The veteran presents some characteristics such as insomnia that are not necessarily related to PTSD. He also experienced a significant event in Vietnam as an active military man after the death of a sergeant in charge of him . . .. This event has not caused the veteran symptoms of intrusion, avoidance or cognitive or mood alteration that interferes with his daily life. The veteran maintains adequate interpersonal and family relationships. Maintains positive relationships with his neighbors. He performs activities of daily living independently: patio, cook, walk, visits mother-in-law. Veteran presents adequate social and family functioning." Importantly, the Board notes that the VA examiner was directed to address the acquired psychiatric diagnoses and etiological opinion supplied by the Veteran's private physician in July 2017. In response, the VA examiner relayed that, "(a)t the time of reviewing the available medical records and at the same time performing a clinical evaluation, the existence of any diagnosis related to Mental Health in relation to the above-described document (Letter) cannot be concluded. This evaluator does not know the used criteria by the aforementioned doctor to diagnose any mental health disorders. At the time of the current evaluation, there are no symptoms associated with any other diagnosis. In these terms, to issue a medical opinion in relation to the evaluation of another doctor is not possible in this case." On multiple occasions during the claim period, the Veteran's government and non-government treatment records were associated with the claims file. After review, the Board observes that the treatment records do not contain a current diagnosis for an acquired psychiatric disorder, to include PTSD. The Board notes that the Veteran's private provider supplied diagnoses for multiple psychiatric disorders in July 2017. As previously noted, the Board assigns little probative value to the July 2017 VA providers diagnoses and conclusion, because no analysis and/or discussion was supplied. Ultimately, the Board affords more probative weight to the multiple government and non-government treatment records, and the VA examination reports, which do not supply a DSM diagnosis for an acquired psychiatric disorder, to include PTSD, during the claim period. The Board notes that, under any theory of entitlement, a current disability is required. Sanchez-Benitez v. Principi, 259 F.3d 1356, 1361 (2001). After carefully reviewing the Veteran's medical and lay evidence, the Board concludes that the preponderance of the evidence does not show that the Veteran has a current acquired psychiatric disability. Ultimately, the Board finds that the preponderance of the evidence stands counter to the Veteran's claim for service connection for an acquired psychiatric disability, to include PTSD. Since the preponderance of the evidence is against this claim, the provisions of 38 U.S.C. § 5107(b), regarding reasonable doubt, are not applicable. The Veteran's claim for service connection for an acquired psychiatric disability must be denied, because the preponderance of the evidence weighs against his claim. 3. Entitlement to service connection for a thyroid disorder, to include as due to tactical herbicide agent exposure, is denied. In August 2017, the Veteran submitted a VA Form 21-526EZ. Therein, the Veteran initiated a claim for service connection for a thyroid disorder. The Secretary of Veterans Affairs has determined that there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See 72 Fed. Reg. 32,395 (2007). The United States Court of Appeals for the Federal Circuit has held, however, that a claimant is not precluded from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). In other words, the fact that a Veteran may not meet the requirements for service connection on a presumptive basis does not in and of itself preclude the establishment of service connection, as entitlement may alternatively be established on a non-presumptive / direct-incurrence basis. The Veteran served in the Republic of Vietnam and, therefore, is presumed to have been exposed to tactical herbicide agents. However, thyroid disorders are not included on the 38 C.F.R. § 3.309 (e) list for presumptive service connection. Consequently, the Board will review the Veteran's claim under the direct service connection criteria. Again, direct service connection generally requires probative evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson, 12 Vet. App. at 253. In October 2015, the Veteran's service treatment records (STRs) were associated with the claims file. After review, the Board observes that the Veteran was not seen for, or diagnosed with, a thyroid condition during service in the United States Army. In February 2016, the Veteran's treatment records from the San Juan VA Medical Clinic were associated with the claims. On September 2008, a Primary Care Note was generated. Therein, the provider reported that a thyroid sonogram revealed "subcentimeter right solid nodules NAD left cysts." In October 2009, the Veteran was assessed with hypothyroidism. In January 2010, the Veteran's medication list included levothyroxine, which was for treatment of the thyroid gland. In July 2017, a letter from the Veteran's private medical provider was associated with the claims file. Therein, the provider noted a diagnosis for multinodular thyroid gland. The provider opined that the Veteran's "metabolics" are more probable than not secondary to military service. Again, the Board affords this provider's succinct, conclusory opinion on etiology limited probative value, because it was supplied without analysis and discussion of how the conclusion was formulated. See Reonal, 5 Vet. App. at 461 (an opinion without any rationale against which to evaluate the probative value of the determination is inadequate). In November 2018, the Board addressed the Veteran's claim for service connection for a thyroid condition. At that time, the Board found that the July 2017 private report and opinion were insufficient for adjudication of the claim, because it provided no explanation or rationale for the etiology between the Veteran's current thyroid disorder and military service. The Board remanded the Veteran's claim to the AOJ to obtain a VA examination report that addressed the nature and etiology of any currently diagnosed thyroid disorder. In October 2020, the Veteran underwent a VA examination that addressed the nature and etiology of thyroid conditions. The examiner noted a 2008 diagnosis for hypothyroidism. The examiner opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in, or caused by, the claimed in-service injury, event, or illness. The VA examiner supplied the following rationale: "medical literature review does not support an etiological link between hypothyroidism and herbicide exposure during service." The Board notes that the Veteran currently maintains a diagnosis for a thyroid disorder. Consequently, the first requisite element for direct service connection has been substantiated. See Hickson, 12 Vet. App. at 253. The Board also notes that the STRs do not reflect that the Veteran demonstrated a thyroid disorder during active service. Moreover, the Veteran's post-service treatment reflect that the Veteran was not diagnosed with a thyroid disorder for many decades after separation from the United States Army. Consequently, the second requisite element for direct service connection has not been substantiated. See id. The Board observes that the private provider supplied a positive etiological opinion in July 2017. For the reasons supplied above, the Board affords little probative value to the private opinion. The Board affords more probative value supplied by the VA examiner in October 2020. Specifically, the VA examiner drew support from medical literature, which did not identify a link between the current thyroid disorder and the presumed in-service exposure to tactical herbicide agents. Ultimately, the Board finds that the preponderance of the evidence stands counter to the Veteran's claim for service connection for a thyroid disorder. Since the preponderance of the evidence is against this claim, the provisions of 38 U.S.C. § 5107(b), regarding reasonable doubt, are not applicable. The Veteran's claim for service connection for a thyroid disorder must be denied, because the preponderance of the evidence weighs against his claim. 4. Entitlement to service connection for tinnitus is granted. In August 2017, the Veteran submitted a VA Form 21-526EZ. Therein, the Veteran initiated a claim for service connection for tinnitus. Tinnitus is defined as "a noise in the ears such as ringing, buzzing, roaring, or clicking." Smith v. Principi, 17 Vet. App. 168, 170 (2003) (quoting Dorland's Illustrated Medical Dictionary 1714 (28th ed. 1994)). Tinnitus is a type of disorder capable of lay observation and description. Charles v. Principi, 16 Vet. App. 370 (2002). Meaning, the Veteran is competent to report symptoms, including hearing ringing in his ears. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Board observes that the onset of tinnitus "may be gradual or sudden, and individuals are often unable to identify when tinnitus began." "Tinnitus can be triggered months or years after an underlying cause (such as hearing loss) occurred . . . [and] [t]herefore, delayed-onset tinnitus must be considered." See VBA Training Letter 10-02 (March 2010). As such, the absence of in-service medical documentation for tinnitus in this case is not fatal to the claim. In October 2015, the Veteran's service treatment records (STRs) were associated with the claims file. After review, the Board observes that the Veteran did not report tinnitus symptoms during active duty in the United States Army. In July 2017, a letter from the Veteran's private medical provider was associated with the claims file. The provider noted that the Veteran reported tinnitus after enduring high noises during military operations. The provider reported a diagnosis for tinnitus. The provider opined that the Veteran's sensorial disorder was more probable than not secondary to military service. In November 2018, the Board addressed the Veteran's claim for service connection for bilateral hearing loss and tinnitus The Board concluded that service connection for bilateral hearing loss was warranted. The Board noted that the Veteran denied tinnitus symptoms during the November 2017 VA examination. The Board remanded the tinnitus claim to reconcile conflicting evidence. In November 2020, the Veteran underwent a VA examination that addressed the nature and etiology of any currently endured tinnitus. The VA examiner noted the letter from the Veteran's private physician, which diagnosed tinnitus on June 10, 2017. During the VA examination, the Veteran reported recurrent tinnitus. The Veteran described the occasional tinnitus as intermittent, bilateral, steady humming that lasts up to a minute. The examiner noted that the Veteran reported the onset of intermittent ringing in both ears after service in the United States Army. The examiner relayed that, "Veteran's description is more consistent with a transient ear noise that is common in the general population without auditory pathology; therefore, it is less likely than not that the veteran's intermittent ringing is due to hearing loss, as it is not an abnormal finding." During the November 2020 VA examination, the Veteran competently reported current tinnitus. The Veteran also competently reported intermittent tinnitus after separation from service from the United States Army. As noted above, the Veteran's military occupational specialty (MOS) was Pioneer during service in the Republic of Vietnam. The Department of Defense's Duty MOS Noise Exposure Listing indicates that the Veteran's MOS, which mostly closely relates to "engineer," was accompanied by a "high" probability of hazardous noise exposure. Accordingly, the Board finds that the Veteran was routinely exposed to hazardous noises during his active-duty service. Furthermore, the Board finds it is reasonable to infer that the same acoustic trauma which caused the Veteran's service-connected bilateral hearing loss disability would have also caused him to develop tinnitus. In conclusion, after resolving all doubt in the Veteran's favor, the Board finds the evidence supports a grant of service connection for a bilateral tinnitus. This conclusion draws support from competent and credible evidence of in-service noise exposure, and post-service a bilateral hearing loss disability for VA compensation purposes. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Consequently, the Veteran's claim for bilateral tinnitus must be granted. REASONS FOR REMAND Upon review of the record, the Board concludes that further evidentiary and procedural development is necessary. A remand is necessary to ensure VA provides the Veteran with appropriate assistance and procedure in developing his claim prior to final adjudication. 5. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. In August 2017, the Veteran submitted a VA Form 21-526EZ. Therein, the Veteran initiated a claim for entitlement to a TDIU rating. A TDIU may be assigned when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16 (a). If there are two or more disabilities, at least one disability must be rated at 40 percent or more, with sufficient additional disability to bring the combined rating to 70 percent or more. Id. Entitlement to a total rating must be based solely on the impact of the Veteran's service-connected disabilities on his ability to keep and maintain substantially gainful employment. See 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is "whether the Veteran's service connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). For VA purposes, the term "unemployability" is synonymous with an inability to secure and follow a substantially gainful occupation. VAOPGPREC 75-91; 57 Fed. Reg. 2317 (1992). Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion. However, individual unemployability must be determined without regard to any nonservice-connected disabilities or the Veteran's advancing age. 38 C.F.R. §§ 3.341 (a), 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose, 4 Vet. App. at 363. If a Veteran fails to meet the threshold minimum percentage standards enunciated in 38 C.F.R. § 4.16 (a), rating boards should refer to the Director of Compensation and Pension Service for extraschedular consideration all cases where the Veteran is unable to secure or follow a substantially gainful occupation by reason of service-connected disability. 38 C.F.R. § 4.16 (b). See also Fanning v. Brown, 4 Vet. App. 225 (1993). In November 2017, the Veteran underwent a VA examination that addressed the severity of the service-connected hearing loss disability. The VA examiner reported that the Veteran's hearing loss impacted ordinary conditions of daily life, to include the ability to work. The Veteran described the impact as difficulty to understand conversations. In November 2018, the Board addressed the Veteran's claim for TDIU. The Board deferred further consideration of the TDIU claim, pending AOJ readjudication of the additional claims that were remanded at that time. In March 2019, correspondence from the Veteran was associated with the claims file. Therein, the Veteran relayed that, "my working experience was mostly in the manufacturing industries and inside buildings." In August 2019, a Subsequent Development Letter was associated with the claims file; therein, the AOJ informed the Veteran that it was developing his claims. The Board notes that the AOJ supplied the Veteran VA Forms 21-4142 and 14142a. However, the AOJ did not supply a VA Form 21-8940, which normally accompanies development of a TDIU claim. On remand, the AOJ should supply the Veteran with VA Form 21-8940. In November 2020, the Veteran underwent a VA examination that addressed the severity of the service-connected bilateral hearing loss and tinnitus. The examiner relayed that the Veteran's hearing loss and tinnitus would impact the ordinary conditions of daily lift, to include the ability to work. The Veteran described the hearing loss impact as "sometimes I don't understand what is said to me." The Veteran described the tinnitus impact as "it bothers me in the moment that it occurs." The examiner opined that, "(t)he veteran shows a mild to severe bilateral sensorineural hearing loss on today's examination. Hearing loss, no matter the degree, will cause difficulty with sound awareness and speech understanding especially if there is background noise, multiple persons speaking or if the speech is rapid. This can negatively impact communication and awareness in any setting and particularly in an occupational setting." The Board notes that the November 2017 and 2020 VA examiner's reported that hearing loss and tinnitus would impact the ordinary conditions of daily lift, to include the ability to work. Consequently, after completing the development identified below, the claims file should be forwarded to the Director, Compensation Services for extraschedular consideration of the Veteran's TDIU claim. Consequently, the matter is REMANDED to the AOJ for the following action: 1. Provide the Veteran with a VA Form 21-8940 and request that he provide all available information regarding his employment history for the period after August 20, 2017. The AOJ should request authorization to obtain employment information from any current and former employers identified by the Veteran. If the Veteran provides sufficient identifying information and the appropriate authorization, the AOJ should attempt to contact current and former employers to obtain information about the conditions of his current and former employment, including wage and hour information. An appropriate period of time should be allowed for response. 2. After completion of the first directive, the Veteran's TDIU claim should be forwarded to the Director of Compensation and Pension Service for extraschedular consideration. 3. If the benefit sought on appeal is denied, the Veteran should be provided a supplemental statement of the case. An appropriate period of time should be allowed for response before the case is returned to the Board. DAVID L. WIGHT Veterans Law Judge Board of Veterans' Appeals Attorney for the Board RLBJ, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.