Citation Nr: 21040023 Decision Date: 07/02/21 Archive Date: 07/02/21 DOCKET NO. 17-19 008 DATE: July 2, 2021 ORDER Entitlement to a rating in excess of 20 percent for post-operative, anterior cruciate ligament tear of the right knee with medial and lateral menisco-capsular separation (except for a period when a temporary 100 percent rating was in effect) is denied. Entitlement to a separate 10 percent rating, but no higher, for limitation of motion of the right knee with arthritis, from June 9, 2014 (except for a period when a temporary 100 percent rating was in effect), is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to a separate 10 percent rating, but no higher, for right knee instability, from June 9, 2014 (except for a period when a temporary 100 percent rating was in effect), is granted, subject to controlling regulations governing the payment of monetary awards. FINDINGS OF FACT 1. The Veteran's post-operative, anterior cruciate ligament tear of the right knee with medial and lateral menisco-capsular separation is assigned the maximum schedular rating for right knee cartilage dislocation with locking, pain, and effusion. 2. From June 9, 2014 through the date of his death, the Veteran experienced right knee arthritis with limitation of flexion of the knee to at most 110 degrees; knee extension was normal (0 degrees) and there was no additional significant additional loss of motion due to such factors as pain, weakness, lack of endurance, fatigability, and incoordination with repeated use over time and during flare ups. 3. The evidence is at least evenly balanced as to whether, from June 9, 2014 through the date of his death, the Veteran experienced symptoms most nearly approximating mild right knee instability. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for post-operative, anterior cruciate ligament tear of the right knee with medial and lateral menisco-capsular separation (except for a period when a temporary 100 percent rating was in effect), are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.71a, Diagnostic Code (DC) 5258 (in effect prior to February 7, 2021). 2. The criteria for a separate 10 percent rating, but no higher, for limitation of motion of the right knee with arthritis, from June 9, 2014 through the date of the Veteran's death (except for a period when a temporary 100 percent rating was in effect), are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DCs) 5003, 5260-5261 (in effect prior to February 7, 2021). 3. With reasonable doubt resolved in favor of the appellant, the criteria for a separate 10 percent rating, but no higher, right knee instability, from June 9, 2014 through the date of the Veteran's death (except for a period when a temporary 100 percent rating was in effect), are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.71a, Diagnostic Code (DC) 5257 (in effect prior to February 7, 2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Air Force from July 1987 to July 1991. He had additional service with the Air Force Reserve, to include a period of active duty for training (ACDUTRA) from February 1994 to May 1994. The appellant is his surviving spouse. The Veteran died and the appellant was substituted for the Veteran with respect to the issues on appeal in January 2016. This matter initially came before the Board of Veterans' Appeals (Board) from a September 2014 rating decision. The appellant testified before the undersigned Veterans Law Judge (VLJ) at a December 2019 hearing and a transcript of the hearing has been associated with the claims file. In December 2019, the Board remanded this matter for further development. Specifically, the Board instructed the agency of original jurisdiction (AOJ) to ask the appellant to identify any outstanding treatment records and to complete the appropriate authorization form to allow VA to obtain any outstanding private medical records (to include records from Dr. Price and Results Physiotherapy) and obtain the Veteran's outstanding VA treatment records. Pursuant to the Board's remand, the appellant was asked to identify any outstanding treatment records and to complete the appropriate authorization form to allow VA to obtain any outstanding private medical records (to include records from Dr. Price and Results Physiotherapy) by way of a July 2020 letter. Copies of the authorization forms (VA Forms 21-4142 and 21-4142a) were included with the letter. Also, all outstanding VA treatment records were obtained and associated with the claims file. Therefore, the AOJ substantially complied with the Board's remand instructions. See Dyment v. West, 13 Vet. App. 141, 146- 47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). As for characterization of the issues on appeal, in the September 2014 rating decision, the AOJ awarded a temporary 100 percent rating for the service-connected right knee disability due to surgical or other treatment requiring convalescence, from July 1, 2014 through October 31, 2014. In December 2014, the AOJ extended the temporary 100 percent rating for the service-connected right knee disability through January 31, 2015. As the Veteran was awarded a 100 percent rating from July 1, 2014 through January 31, 2015 for his service-connected right knee disability, the rating for this disability during this period will not be addressed by the Board. Cf. AB v. Brown, 6 Vet. App. 35, 38 (1993). Increased Rating Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disabilities evaluated on the basis of limitation of motion require VA to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. The United States Court of Appeals for Veterans Claims (Court) has instructed that in applying these regulations VA should obtain examinations in which the examiner determines whether the disability is manifested by weakened movement, excess fatigability, incoordination, pain, or flare-ups. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. The examiner should also determine the point, if any, at which such factors cause functional impairment. Moreover, the joints involved should be tested for pain on both active and passive motion, in weight-bearing and non weight-bearing and, if possible, with the range of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016); Mitchell v. Shinseki, 25 Vet. App. 32, 43-4 (2011); DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71A were amended effective February 7, 2021. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the claimant will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110 (g); see also Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110 (g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110; Kuzma, 341 F. 3d 1327. In this case, the Veteran died prior to February 7, 2021. Therefore, as the entire claim period is prior to February 7, 2021, the Board may only consider the appellant's claim under the former criteria and the revised criteria are not for application in this instance. 1. Background The Veteran's claim for an increased rating for his service-connected right knee disability was received on June 9, 2014. Medical records dated from June 2014 to January 2015 and a July 2014 letter from C.T. Price, M.D. indicate that the Veteran experienced right knee pain and instability (the knee would shift when on uneven ground). The pain was aggravated by running. Dr. Price reported that he initially evaluated the Veteran in June 2014 for complaints of right knee pain and instability. He had a long history of knee problems and underwent two ACL reconstructions, both of which had failed. Examinations revealed that the Veteran had an occasional antalgic gait, that his knee was occasionally unstable (e.g., grade 2 Lachman with questionable endpoint, positive anterior drawer testing, and positive pivot shift), that he was in severe pain, that there was occasional effusion and stiffness, that there was tenderness to palpation, and that the range of knee motion was occasionally restricted due to pain. An MRI revealed a complete tear of the ACL graft, but no meniscus tears. A right knee ACL reconstruction was performed in July 2014, the surgery was successful, and the Veteran had a stable knee. X-rays of the knee revealed minor degenerative changes. The report of an April 2015 VA knee examination and medical records dated in June and August 2015 indicate that the Veteran experienced daily right knee pain and occasional popping and catching of the knee. He did not report any flare ups of knee symptoms or any functional loss/impairment. The ranges of left and right knee motions were recorded and the ranges of right knee motion were flexion to 110 degrees and extension to 0 degrees. The ranges of motion themselves did not contribute to functional loss. There was pain associated with knee flexion and extension, but it did not result in/cause functional loss. There was evidence of pain with weight-bearing, mild tenderness over the anteromedial knee, and occasional crepitation on flexion of the knee. The Veteran was able to perform repetitive use testing with at least three repetitions and there was no additional functional loss or range of motion loss after three repetitions. He was being examined immediately after repetitive use over time and pain, weakness, fatigability, and incoordination did not significantly limit functional ability with repeated use over a period of time. There were no additional factors contributing to disability. Moreover, muscle strength associated with right knee flexion and extension was normal (5/5) and there was no muscle atrophy. There was no history of any recurrent subluxation, lateral instability, or recurrent effusion. Joint stability testing during the April 2015 VA examination was all normal, but treatment records reveal that there was occasional knee instability (e.g., grade 1 Lachman with good endpoint, pivot shift glide present, 1+ laxity). The Veteran did not have any recurrent patellar dislocation, shin splints (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, or any other tibial/fibular impairment. He had a meniscal tear and underwent an ACL and meniscus repair in July 2014. There was scarring related to the Veteran's knee disability, but none of the scarring was painful or unstable and the total area of the scarring was not equal to or greater than 39 square centimeters (6 square inches). The Veteran did not use any assistive devices and there was no functional impairment of an extremity such that no effective function remained other than that which would have been equally well served by an amputation with prosthesis. X-rays revealed arthritis (degenerative joint disease) of the knee and the examiner who conducted the April 2015 examination specified that the arthritis was most likely due to the Veteran's service-connected right knee disability. The Veteran was diagnosed as having a right knee meniscal tear, anterior cruciate ligament tear, and degenerative arthritis. This disability impacted his ability to work in that he experienced increased pain with prolonged standing and walking. However, there were no restrictions to non-physical work. The appellant reported during the December 2019 Board hearing that the Veteran experienced right knee pain which was aggravated by prolonged standing and weather changes, knee instability (especially when stepping backwards), and occasional flare ups of knee swelling that primarily limited knee flexion. The flare ups were treated with ice, heat, and topical ointments and the Veteran tried to keep his knee immobile during flare ups. He had to be cautious climbing stairs or ladders. 2. Entitlement to a rating in excess of 20 percent for post-operative, anterior cruciate ligament tear of the right knee with medial and lateral menisco-capsular separation The Veteran's post-operative, anterior cruciate ligament tear of the right knee with medial and lateral menisco-capsular separation was rated under 38 C.F.R. § 4.71A, DCs 5257-5258. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating assigned. 38 C.F.R. § 4.27. Here, the use of DCs 5257-5258 reflects that the Veteran's right knee disability was partially described as recurrent subluxation or lateral instability under DC 5257 and semilunar cartilage dislocation under DC 5258. The September 2014 rating decision indicates that the Veteran's service-connected right knee disability is assigned a 20 percent disability rating under DC 5258 based on semilunar cartilage dislocation with frequent episodes of locking, pain, and effusion into the joint. Prior to the February 7, 2021 regulatory changes, a maximum 20 percent rating was provided under DC 5258. 38 C.F.R. § 4.71A, DC 5258 (in effect prior to February 7. 2021). Therefore, the Veteran's service-connected right knee disability is already assigned the maximum schedular rating for cartilage dislocation with frequent episodes of locking, pain, and effusion into the joint under DC 5258 during the entire claim period, and rating in excess of 20 percent for post-operative, anterior cruciate ligament tear of the right knee with medial and lateral menisco-capsular separation under this diagnostic code is not warranted at any time during the claim period. 3. Limitation of knee motion with arthritis The above evidence reflects that there was x-ray evidence of right knee degenerative arthritis during the claim period. Prior to the February 7, 2021 regulatory changes, degenerative arthritis established by X-ray findings was rated on the basis of limitation of motion under the appropriate codes for the specific joint or joints involved. If the limitation of motion is noncompensable, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 20 percent evaluation is merited for X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. A 10 percent evaluation is merited for X-ray evidence of involvement of two or more major joints or two or more minor joint groups. 38 C.F.R. § 4.71a, DC 5003 (in effect prior to February 7, 2021). Under DC 5260, limitation of knee flexion is rated as follows: a 10 percent rating is warranted when it is limited to 45 degrees; a 20 percent rating is warranted when it is limited to 30 degrees; and a 30 percent rating is warranted when it is limited to 15 degrees. 38 C.F.R. § 4.71A, DC 5260. VA's General Counsel has held that separate ratings can be provided for limitation of knee extension and flexion. VAOPGCPREC 9-2004 ; 69 Fed. Reg. 59,990 (2004). Under DC 5261, limitation of knee extension is rated as follows: a 10 percent rating is warranted when it is limited to 10 degrees; a 20 percent rating is warranted when it is limited to 15 degrees; a 30 percent rating is warranted when it is limited to 20 degrees; a 40 percent rating is warranted when it is limited to 30 degrees; and a 50 percent rating is warranted when it is limited to 45 degrees. 38 C.F.R. § 4.71A , DC 5261. For rating purposes, normal range of motion in a knee joint is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II. Considering the pertinent evidence in light of the applicable rating criteria and considerations, the Board finds, for the following reasons, that the Veteran's right knee arthritis with limitation of motion met the criteria for a single 10 percent rating, but no higher, during the entire claim period from June 9, 2014. The above evidence reflects that during the claim period, right knee flexion was limited to at most 110 degrees and extension was normal (0 degrees) during the April 2015 VA examination. These findings, by themselves and without consideration of potential functional impairment, are contemplated by no more than a single 10 percent rating for arthritis with noncompensable limitation of knee flexion under DCs 5003-5260. Therefore, a separate 10 percent rating for right knee arthritis with limitation of motion is warranted during the entire claim period from June 9, 2014 through the date of the Veteran's death. However, the Board also finds that a rating higher than 10 percent for right knee arthritis with limitation of motion is not warranted at any time during the claim period. With respect to functional impairment, there was pain associated with the Veteran's right knee disability. He did not report any flare ups during the April 2015 examination, but the appellant reported during the December 2019 Board hearing that the Veteran experienced occasional flare ups of knee swelling that primarily limited knee flexion, and that he tried to keep his knee immobile during flare ups. The April 2015 examination report indicates that pain did not cause any functional loss and there was no additional functional loss/impairment or range of motion loss following repetitive use testing. Also, the examiner who conducted the April 2015 examination specified that the Veteran was being examined immediately after repetitive use over time, that pain, weakness, fatigability, and incoordination did not significantly limit functional ability with repeated use over a period of time, and that there were no additional factors contributing to disability. The Veteran was competent to report the symptoms associated with his service-connected right knee disability and the extent of his impairment following repetitive use, the appellant is competent to report her observations of the Veteran's symptoms and the extent of his impairment during flare ups, and the Board has no reason to challenge the credibility of these lay contentions. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). Regardless of the competent and credible reports of flare ups, pain, and other functional impairments, and despite the fact that painful motion was documented, the preponderance of the evidence nonetheless supports the conclusion that the Veteran's knee symptoms most closely approximated the criteria for at most a single 10 percent rating for arthritis with painful limitation of knee flexion under DC 5260 during the entire claim period. Specifically, the above evidence reflects that the flare ups and other functional impairments were not so severe, frequent and/or prolonged to warrant the next higher percent ratings at any time during the claim period. A preponderance of the evidence shows that even considering pain, flare ups, and other functional factors, the Veteran's knee symptoms were not shown to have been so disabling to actually or effectively result in limitation of knee flexion more nearly approximating 30 degrees or limitation of knee extension more nearly approximating 10 degrees, which are the requirements for a 20 percent rating for limitation of knee flexion under DC 5260 and a compensable (10 percent) rating for limitation of knee extension under DC 5261, respectively. Overall, the Veteran's right knee arthritis resulted in noncompensable limitation of knee flexion. Therefore, a separate 10 percent rating, but no higher, for right knee arthritis with limitation of motion, for the entire claim period from June 9, 2014, is warranted. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.71A, DCs 5003, 5260-5261. 4. Knee instability Prior to the February 7, 2021 regulatory changes, under DC 5257, knee impairment with recurrent subluxation or lateral instability is rated as follows: a 10 percent rating is warranted if the condition is slight; a 20 percent rating is warranted if the condition is moderate; and a 30 percent rating is warranted if the condition is severe. 38 C.F.R. § 4.71a, DC 5257. The above evidence reflects that the Veteran and the appellant reported that the Veteran experienced occasional knee instability during the claim period, and that some of the Veteran's treatment records reflected occasional instability. Despite the fact that stability testing of the knee was normal during the April 2015 VA examination, DC 5257 does not require medical evidence of lateral instability for a rating to be assigned. Instead, the Board must address any relevant lay evidence and compare it to the medical evidence to determine which is more probative, keeping in mind that objective medical evidence is not automatically more probative than lay evidence. English v. Wilkie, 30 Vet. App. 347, 349 (2018). The Veteran was competent to report knee instability and the appellant is competent to report her observations of the Veteran's symptoms. See Jandreau, 492 F.3d at 1372; Buchanan, 451 F.3d at 1331. Moreover, the Veteran experienced right knee meniscus tears. Thus, the Board finds that the lay reports of knee instability during the claim period are credible. Based on the clinical evidence and the competent and credible lay reports of knee instability during the claim period, the Board finds that the evidence is approximately evenly balanced on the question of whether the Veteran experienced recurrent subluxation or instability of the right knee during the claim period. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the appellant, a separate compensable rating for right knee instability is warranted for the entire claim period. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. In light of the normal stability findings during the April 2015 VA examination and the evidence of only occasional giving out of the knee, the Board also finds that the right knee instability was at most slight during the claim period (which equates to a 10 percent rating under DC 5257). Therefore, a separate 10 percent rating, but no higher, for right knee instability is warranted during the entire claim period from June 9, 2014. 5. Additional Considerations The Veteran was in receipt of a 20 percent rating under DC 5258 for symptoms relating to dislocated semilunar cartilage during the entire claim period. Also, separate ratings have been awarded for knee arthritis with limitation of motion and knee instability. Providing compensation for these symptoms as well as removal of symptomatic semilunar cartilage under DC 5259 would constitute pyramiding. 38 C.F.R. § 4.14. Therefore, a separate rating under DC 5259 for cartilage injury is not warranted at any time during the claim period. Also, there is no evidence of any knee ankylosis, impairment of the tibia or fibula, or genu recurvatum at any time during the claim period. Therefore, separate/higher ratings are not warranted under DCs 5256, 5262, or 5263 at any time during the claim period. Moreover, as explained in the Board's December 2019 remand, an April 2015 letter from R.G. Powell, M.D. reflects that the Veteran was considered to be "totally disabled from all forms of gainful employment" due to his service-connected brain tumor. Therefore, the issue of entitlement to a total (100 percent) disability rating based on individual unemployability (TDIU) due to service-connected disabilities was raised as part and parcel of the Veteran's claim for an increased rating for his service-connected right knee disability. See Rice v. Shinseki, 22 Vet. App. 447 (2009). A TDIU may be assigned "where the schedular rating is less than total" and the evidence shows that a veteran is precluded, by reason of his service-connected disabilities, from securing and following "substantially gainful employment" consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16; VAOPGCPREC 75-91; 57 Fed. Reg. 2317 (1992). The Veteran was in receipt of a 100 percent rating for the entire claim period from July 1, 2014 through the date of his death. Therefore, there remains no time during this period where the schedular rating was "less than total," as required for a TDIU. See 38 C.F.R. § 4.16 (a). The Board is cognizant of the fact that the receipt of a 100 percent schedular disability rating for a service-connected disability or disabilities does not necessarily moot the issue of entitlement to a TDIU because a TDIU rating may still form the basis for assignment of special monthly compensation (SMC) pursuant to 38 U.S.C. § 1114 (s). See Bradley v. Peake, 22 Vet. App. 280 (2008). Regardless, the 100 percent rating which was assigned for the Veteran's service-connected brain tumor (glioblastoma multiforme) for the period from the January 13, 2015 effective date of service connection for that disability through the date of the Veteran's death specifically contemplates total unemployability (i.e., total occupational impairment) due to glioblastoma multiforme. Aside from glioblastoma multiforme (which was rated at 100 percent during the entire period from January 13, 2015 through the date of the Veteran's death), the other disabilities that are service-connected during this period are right and left knee disabilities. The evidence reflects that, during the period from January 13, 2015 through the date of his death, the impairment caused by the Veteran's service-connected glioblastoma multiforme or all of his service-connected disabilities, in combination, were sufficient to preclude all substantially gainful employment. Hence, the facts presented in this case are distinguishable from those in Bradley, 22 Vet. App. at 280, because the evidence reflects that it was the Veteran's glioblastoma multiforme (or at the very least the combination of all his service-connected disabilities) that rendered him unable to secure and follow substantially gainful employment during the period from January 13, 2015 through the date of his death. Under the facts presented in Bradley, there was no "duplicate counting of disabilities." Bradley, 22 Vet. App. at 293. If the Veteran were to be awarded a TDIU ("total" rating) based, at least in part, on service-connected glioblastoma multiforme rendering him unemployable for any time during the claim period, it would impermissibly result in the same disability being "counted twice" in the assignment of a total rating, as it would be rating the "total occupational impairment" twice. See generally 38 C.F.R. § 4.14. For these reasons, the issue of entitlement to a TDIU at any time during the claim period from January 13, 2015 through the date of the Veteran's death is now rendered moot and will not be addressed further by the Board. As for the remainder of the claim period, from June 9, 2014 through January 12, 2015, the Veteran was only service-connected for right and left knee disabilities during this period. As noted above, the Veteran was in receipt of a 100 percent rating for his service-connected right knee disability during the period from July 1, 2014 through January 12, 2015. Therefore, for the reasons explained above, a TDIU rating may not be based on the Veteran's service-connected right knee disability at any time during this period, and the only other service-connected disability during this period is his service-connected left knee disability. Moreover, a review of the evidence reflects that prior to the Veteran's diagnosis of and treatment for his service-connected brain tumor, he was gainfully employed. Thus, any further discussion of entitlement to a TDIU during any part of the claim period from June 9, 2014 is not warranted. Lastly, in conjunction with the claim for an increased rating for the service-connected right knee disability, no other related issues have been raised by the Veteran, the appellant, or her representative, and no other such issues have been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Jonathan Hager Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Elwood, 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.