Citation Nr: 21040270 Decision Date: 07/03/21 Archive Date: 07/03/21 DOCKET NO. 14-09 405 DATE: July 3, 2021 ORDER Entitlement to an initial disability rating in excess of 30 percent for PTSD is denied. REMANDED Entitlement to a total disability rating based on individual unemployability is remanded. FINDING OF FACT The Veteran's service-connected PTSD was manifested by occupational and social impairment with decrease in efficiency and intermittent period of inability to perform occupational tasks, although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal. CONCLUSION OF LAW The criteria for entitlement to a disability rating in excess of 30 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 3.102, 3.400, 4.1, 4.2, 4.3, 4.7, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Marine Corps from November 1968 to November 1971. This matter comes to the Board of Veterans' Appeals (Board) on appeal of a March 2013 rating decision of the Department of Veteran Affairs (VA) Regional Office (RO). In July 2014, the Veteran presented testimony in a videoconference hearing before the undersigned Veterans Law Judge. A copy of the transcript has been associated with the claims folder. The Board remanded the claim for service connection of psychiatric disorder in June 2015 and took jurisdiction of an inferred claim for entitlement to a total disability rating due to individual unemployability (TDIU). See Rice v. Shinseki, 22 Vet. App. 447 (2009). In a December 2018 decision, the Board denied the claim for an increased PTSD rating and found referral of TDIU to the Director of Compensation Services (Director) was not warranted. The Veteran timely appealed to the United States Court of Appeals for Veteran's Claim (Court). The Court's May 2020 Memorandum Decision found remand necessary, citing insufficient reasons and bases for the Board's denial. The case has since returned to the Board for further appellate review. The Board notes the medical record available at the time of adjudication included medical records up to April 2016. The record has been developed extensively since the December 2018 decision and now contains VA treatment up to May 2021, new lay statements, representative arguments, and private medical or vocational assessments. Increased Disability Evaluations VA's schedular percentage ratings are based on the average impairment of earning capacity as a result of service-connected disability. 38 U.S.C. § 1155 ; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). A noncompensable rating is assigned when a mental condition has been formally diagnosed, but symptoms are not severe enough to either require continuous medication, or to interfere with occupational and social functioning. A 10 percent rating is assigned when mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of occasional stress, or symptoms controlled by medication cause occupational and social impairment. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). A 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name. The "such symptoms as" language of the diagnostic codes for mental disorders in 38 C.F.R. § 4.130 means "for example" and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). However, as the Court also pointed out in that case, "[w]ithout those examples, differentiating a 30% evaluation from a 50% evaluation would be extremely ambiguous." Id. The Court went on to state that the list of examples "provides guidance as to the severity of symptoms contemplated for each rating." Id. Accordingly, while each of the examples needs not be proven in any one case, the particular symptoms must be analyzed in light of those given examples. 1. Entitlement to an initial disability rating in excess of 30 percent for PTSD The Veteran is currently service-connected for PTSD rated as 30 disabling with an effective date of March 14, 2012. He contends the severity of his psychiatric symptoms warrant a higher initial rating. Specifically, the Veteran's representative contends a rating of 50 percent is warranted from March 14, 2012 and of 70 percent from July 2014. See Third Party Correspondence, 5/11/2021. He argues the Board did not analyze the frequency, severity, and duration of the Veteran's psychiatric symptoms and fully discuss any occupational and social impairment he experiences. Additionally, new symptoms have been asserted since the Court's remand, to include suicidal ideation and neglect of hygiene and personal appearance. See VA 21-8940, 5/11/2021. The Court found the Board's December 2018 denial inadequate for several reasons. The Memorandum Decision emphasizes that the Board did not provide adequate discussion of medical evidence in favor of an evaluation in excess of 30 percent. The Court's decision addresses symptoms contemplated in the 50 and 70 percent rating, provides specific examples in the record, and concludes the Board did not fully address these symptoms in conjunction with lay contentions. The Court and the Veteran's representative note the Board did not provide an assessment of credibility given the Veteran's testimony before the Board and written statements of increased symptoms. The Board has conducted a thorough de novo review of the record but finds the evidence continues to show an increased rating for PTSD is not warranted. The Veteran's PTSD symptoms did not result in the level of impairment anticipated by a disability rating in excess of 30 percent from March 14, 2012. Rather, the Veteran's symptoms continue to result in a level of impairment that most closely approximates impairment associated with a 30 percent rating as he is currently rated. First, the Court found the Board failed to adequately explain why the Veteran's report of mood disturbance and loss of motivation does not warrant a higher evaluation. The Court cites evidence throughout 2012 indicating the Veteran reported mood swings, lack of motivation, and difficulty completing tasks at home. However, records show the Veteran's motivation disturbances were related to life circumstances, including retirement and "life-span issues" and are not shown as a consistent worsening throughout this period. See, e.g., CAPRI, 2/22/2017, pg. 315/436. At his initial mental health consultation in April 2012, the Veteran is noted as having stable mood and calm affect with fluent and logical speech and normal rate and rhythm. In June 2012, an improvement in the Veteran's symptoms is noted by his psychiatrist, the Veteran reported a better mood, and both his wife and therapist noted he is calmer and more relaxed since starting medication and therapy. At the Veteran's November 2012 VA examination, he reported his symptom onset as noticing "his depressive symptoms more significantly since he stopped abusing substances" but the examiner ultimately concluded his symptoms caused only "mild functional impairment." In March 2013, he was found to have stable symptoms, despite his recent unemployment, and reported looking forward to traveling to see friends and planting a garden. In October 2013, he was found to be in a good mood with stable symptoms. He reported feeling reasonably well in the past few months as he had been traveling to several states and found the surroundings peaceful. Additionally, the Court notes in March 2014 the Veteran's wife reported he had a lack of motivation to complete home projects. However, a mental health note taken two weeks later indicates the Veteran stated he had been feeling reasonably well without acute issues in the past few months. He reported lethargy and lack of motivation to complete home improvement projects but also stated he recently traveled out of state with his wife and "enjoyed the peacefulness." In June and December 2014, he reported feeling well, presented with good mood, and notes he keeps busy with gardening and traveling. With the exception of his November 2014 VA examination, mental health records do not show an increase in his symptoms from 2012 to 2014. He was noted throughout 2013 and 2014 as having good clinical control of his condition and found to present with stable baseline PTSD symptoms. Further, depression screening during this period was negative. The Board does not find the Veteran's motivation disturbance noted in March 2014 occurred with a frequency or severity resulting in social or occupational impairment as anticipated by a 50 percent rating. The evidence indicates he is employed at this time with no interruptions or impact due to his PTSD symptoms and he maintains an effective relationship with his wife. The Board finds this evidence to be more probative of the Veteran's functioning at the time than his statements made years later in conjunction with his claim. Throughout 2015 the Veteran reported to mental health assessments with good mood and baseline symptoms with one exception. In September 2015, the Veteran notes a lack of motivation in relation to selling his house and moving out of state. However, a month later he reported a stable mood and stated, "I'm better." Additionally, he noted he completed the necessary home improvements he was previously concerned about and was planning a move out of state soon for work at a vineyard. In January 2016 the Veteran reported stable mood, anxiety, sleep, and appetite. The first mention of dysphoric mood was at his March 2016 VA examination. However, the Veteran notes he saw an improvement in symptoms when he is able to be productive while working at the vineyard. Subsequently, at his regular mental health check-up in April 2016, he again reported, "I'm better." since his January 2016 appointment. The Veteran's increase in mood symptoms occurred during a major life event and the evidence does not show they persisted thereafter or cause an impact on his general functioning. The Court also cites a December 2017 record that shows mood swings and a lack of motivation. However, treatment prior to and after December note this as a consequence of medication rather than a consistent mental state. Treatment records from November 2017 indicate he stopped his psychiatric medication and did not immediately resume or change prescriptions. This resulted in an increase in mood swings, however, his anxiety and PTSD were found to be stable and his mood was euthymic. The December 2017 note shows the Veteran then began feeling more depressed since quitting his medicine and that he presented as anxious. The Veteran resumed psychiatric medication and regular mental health treatment within a month, and in January 2018, he presented as euthymic and engaged throughout his therapy session. He noted his anxiety became more manageable and less intense, indicating a decrease in symptoms and return to baseline. In June 2018 his wife reported to his treating physician that the Veteran "still has some moody irritation," however, the physician notes the Veteran's PTSD remains stable and his mood was calm. In February 2019, the Veteran reported he had been "doing okay, fine" and found his medication to help with his mood disorder. More recent treatment records from late 2018 to 2021 are consistent with the above evidence. The Veteran's anxiety was found to be controlled, his PTSD was stable, and at no point did he have a positive depression screening. Thus, although he had periods of disturbances in motivation, they were fleeting. Regular and frequent VA mental health treatment shows the Veteran's symptoms remain at baseline throughout the appeal period. Further, at no time from 2008 to May 2021 did the Veteran present with a flattened affect as contemplated by a 50 percent rating. His affect was consistently reported as constricted or euthymic, and mood congruent throughout the claims period. The Board acknowledges the Veteran experienced disturbances in mood and motivation, but finds the symptoms are not of the severity and frequency as the symptomology contemplated by a rating of 50 percent or higher. The Veteran's symptoms are shown to decrease efficiency only during occasional periods of significant stress, and do not actually result in reduced reliability and productivity in social and occupational function as he is shown to generally function satisfactorily. The Veteran's intermittent mood and motivation disturbances are reasonably anticipated at the currently assigned 30 percent rating under symptoms of depressed mood, anxiety, and suspiciousness. Second, the Court found that the Board did not adequately address the Veteran's reports of short-term memory loss or panic attacks more than once a week, as they are symptoms contemplated by a 50 percent rating. The Board acknowledges the Veteran's statement; however, the remainder of the medical record lacks any indication of frequent panic attacks, panic symptoms, or a level of anxiety or distress equivalent to that reported. At his initial PTSD evaluation in April 2012, the Veteran reports debilitating anxiety attacks when going out in public. However, subsequent mental health treatment in June 2012 shows an improvement in anxiety symptoms and he did not report panic attacks at his November 2012 VA examination or at regular treatment until years later in his July 2014 hearing. The Court cites the Veteran's hearing testimony stating that he experiences panic attacks "once or twice a week." Hearing Transcript, 8/9/2014, pg. 4/12. However, there is no mention of panic attacks with any frequency in the medical record immediately prior to or following the hearing. The evidence shows the Veteran reported frequent anxiety attacks in December 2017 and was noted as no longer taking medication. However, in January 2018 his symptoms were noted as improved, and the Veteran reported his anxiety symptoms were "more manageable" and less intense. There are no further reports of panic attacks in the record. The Board finds the Veteran's contemporaneous mental health record is more probative than his hearing testimony, and that it does not support regular occurrences of panic symptoms related to his PTSD occurred more than once a week. Statements made to doctors in an effort to improve one's health are more credible than those made several years later in the context of obtaining benefits. The Court cites evidence the Veteran experienced "episodes of panic attacks with depersonalization and derealization." MTR- Non-Gov, 10/17/2012. The Board notes the October 2012 letter from LCSW P.H.B. citing these symptoms, however, additional evidence of this behavior is not found elsewhere in the Veteran's medical record and no indicators of similar symptoms is noted at any time from 2012 to 2021. Further, the letter does not demonstrate a lengthy clinical relationship with the Veteran. LCSW P.H.B states the Veteran first sought treatment with him on March 27, 2012, two weeks after filing his claim. There is no indication how often the Veteran reported having panic attacks at that time. Nonetheless, VA mental health treatment subsequent to October 2012 shows no indication of continued panic attacks or any emotional disturbances of equivalent severity. Throughout the period on appeal, the Veteran did not exhibit other symptoms of cognitive impairment associated with a rating of 50 percent such as impaired judgment, impaired abstract thinking, or difficulty in understanding complex commands. The Veteran testified that he had shot-term memory problems, noting difficulties recalling items he intended to retrieve from his cellar. However, at every mental health and primary care appointment from 2008 to 2021 the Veteran was found to have productive thought processes, fair to good judgment and insight, and preserved memory. At his initial VA mental health consultation in March 2012, the Veteran had no memory, concentration, or attention deficits and was found to have good insight. The Veteran did not report memory problems at his initial PTSD evaluation in November 2012, and at neurology consultations in December 2012 and March 2013, the Veteran was reported to have no memory problems. Although concentration problems are noted in the record, the Veteran's cognition is intact, and no clinical evidence of impairment of judgment, thinking, or memory is found. Of note, the evidence shows in March 2013 the Veteran was prescribed medication for essential tremors, a non service-connected condition, which resulted in slow concentration and reaction. His medication was reduced due to these side effects and he has continued use of the medication as of May 2021. There is no indication the Veteran's memory is impacted by his psychiatric disorder as his memory was noted as intact most recently in May 2017, February 2018, September 2020, and May 2021. Further, throughout the period, the Veteran's thought process elicited no delusions, hallucinations, paranoia, disorientation, compulsions. He was not found to have fragmented thought as his speech was organized, linear, goal directed, and within normal limits at every check-up, and he was found to be fully oriented and alert with good to fair eye contact at each assessment. Third, the Court found that the Board did not fully consider symptoms associated with a 70 percent rating, including obsessional rituals, impaired impulse control such as unprovoked irritability, and difficulty in adapting to stressful circumstances. Thorough review of records made in the course of regular treatment does not support a finding that the Veteran frequently exhibited such symptoms. As discussed above, clinical evidence lacks indicators of impulsive or aggressive behavior and at no time is the Veteran found to exhibit periods of unprovoked irritability with periods of violence. In March 2014, the Veteran's wife reported more frequent outbursts toward her, but the evidence does not support that the Veteran exhibits this symptom consistently or frequently. There is no allegation or evidence the Veteran's irritability amounted to violent behavior or resulted in presenting a danger to himself or others. The record is otherwise silent as to impulse control deficiencies. The Veteran's symptom of irritability is well documented and supported by the record. However, the Board does not find the severity of this symptom causes a functional impact in most areas of the Veteran's life. There is additional evidence to suggest the Veteran experiences increased irritability due to his lack of quality sleep. The same evidence suggests the Veteran experiences sleep disturbance due non service-connected conditions of obstructive sleep apnea and nocturia. Although, the Veteran has consistently reported occasional nightmares that wake him, he has reported improvement in his nightmare and flashback symptoms and has stated they are often unrelated to his military trauma and he does not have recollection of the content. While the Veteran reports his hypervigilance causes him to perform perimeter checks at night, the Board does not find the severity of these rituals rise to a level of impairment causing the Veteran to be unable to perform the activities of daily living. For example, despite episodes of heightened hypervigilance and suspiciousness, these actions did not prevent him from sleeping, eating, or otherwise performing day-to-day activities. The Board acknowledges the Veteran's difficulty in adapting to stressful circumstances. The record supports that the Veteran's symptoms are often noted as a response to external or circumstantial life stressors, such as lifestyle changes since retirement, an unrelated physical disorder, moving out of state, interpersonal disagreements, and medication. For example, the Veteran's initial social distress and avoidance of public spaces was reported early in the claims period as the result of his essential tremors and his anxiety about eating in public or at work. The Veteran also reported increased anxiety in October 2012 following his original denial of service connection for PTSD. Years later the Veteran reported an increase in symptoms as a response to a dispute with his neighbor. These examples, among others, of life stressors are shown to account for instances of acute distress or fluctuations of symptoms throughout the claims period. However, taken as a whole, the evidence does not demonstrate these periods result in impairment on par with the symptomology anticipated at the higher ratings for psychiatric disorder. Rather, the record supports a finding the Veteran retains the ability to function independently, appropriately, and effectively even during periods of stressful circumstances. Further, the Board finds the Veteran experiences lengthy remission of his symptoms and retains a high capacity to adjust during remission periods. See 38 C.F.R. § 4.126 (a). Further, the evidence does not support the Veteran experiences symptoms associated with a total disability rating for PTSD. At no time did the Veteran report suicidal ideation, suicide attempts, or present as a suicide risk at his regular mental health treatment or VA examinations from 2000 to 2021. His most recent lay statement indicates he has had fleeting thoughts about "what it would be like not being here anymore" but that he would never harm himself. The Veteran is consistently screened for suicide risk throughout his VA treatment and was not found to be at risk. There are no other reports of thoughts of self-harm, homicidal thoughts or intents, or psychotic or manic symptoms. The Veteran did not experience delusions or hallucinations, disorientation to time or place, gross impairment of thought processes or communication, persistent danger of harming self or others, memory loss of close relative, occupation, or self, intermittent inability to perform activities of daily living, or other manifestations on par with the level of severity contemplated by those symptoms. Although the Veteran has experienced some symptoms associated with a 50 percent rating for mental health disorders, these symptoms do not amount to occupational and social impairment with reduced reliability and productivity. The Veteran's other remaining symptoms were either contemplated by or more consistent with a 30 percent rating based on their frequency, severity, and duration. The November 2012 VA examiner concluded the Veteran experienced reduced social functioning and a lack of interest in developing interpersonal relationships. However, the examiner also opined the Veteran retained the ability to interact appropriately with coworkers and supervisors and adapt to routine work environments. Similarly, the March 2016 VA examiner noted the Veteran's symptoms of depressed mood, anxiety, chronic sleep impairment, and disturbances of motivation and mood, but declined to conclude the Veteran's symptoms resulted in occupational and social impairment with reduced reliability and productivity. While the Veteran displays withdrawal and avoidance behavior, he is not shown to demonstrate an impairment in social relationships as the rating of 50 percent anticipates. The March 2016 VA examiner concluded the Veteran did not experience a change in social function since 2012 and this is supported by the remainder of the record. The Veteran reports a good relationship with his wife of 20 years despite his periods of irritability. He indicates she is a supportive partner and is often noted as accompanying him to appointments. He also maintains a positive relationship with his son, stepchildren, and grandchildren and feels comfortable socializing with other veterans. From 2013 to 2018 the Veteran reported several successful trips out of state with his wife, visits with friends, and attending small social functions. The record reflects the Veteran shows recent improvement in his social withdrawal behavior. Further, the evidence does not show the Veteran's PTSD symptoms alone result in occupational impairment. To the contrary, his symptoms are found to improve when he has tasks and activities to complete. VA examiners concluded he experienced mild occupational impairment but remained capable of being productive. The record does not support a finding the Veteran is currently unemployed due to his PTSD symptoms. The evidence instead shows the Veteran was unhappy with the duties of his employment and disagreed with program management. This is supported by the March 2016 VA examiner's conclusion the Veteran's "difficulties as a part-time drive were related to the circumstances of the position rather than the Veteran's mental health conditions." The Veteran is also shown to participate in Color Guard functions and other Veteran activities, demonstrating an ability to participate in structured, delineated tasks. The Veteran submitted a private opinion regarding his vocational abilities, concluding the Veteran is not able to maintain substantially gainful employment. The Board acknowledges the opinion and analysis but affords it little probative value on the issue of increased rating for PTSD as it considers all of the Veteran's service-connected disabilities in reaching the conclusion. The Veteran is competent to report his symptoms and experiences and the Board has given full consideration to his testimony. See Barr v. Nicholson, 21 Vet. App. 303 (2007). However, he is not competent to opine on clinical manifestations or determine they meet the schedular requirements for a higher evaluation of psychiatric disorders. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed Cir. 2006); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The medical record does not support a finding the Veteran's cumulative symptoms result in impairment anticipated by a higher evaluation. Although the Board finds the Veteran credible, statements made in the course of regular medical treatment are inherently more credible than statements made in connection with a claim for compensation. The level of frequency, severity, and duration of all PTSD symptoms throughout the claims period paint a Veteran's disability picture, necessitating an assessment of the level of functional impact. Giving consideration to the duration of the claims period, the Board affords the lengthy medical record significant probative value. Regular, oftentimes monthly, mental health assessments for his condition indicate a stable, or baseline, status of the disability. The observations of the several VA clinicians, VA examinations, and regular mental health treatment for the period of April 2012 to May 2021 are given significant weight. Accordingly, the evidence weighs against the claim for an increased rating. The Veteran's symptoms do not satisfy the criteria of the higher 50 percent rating but do satisfy all of the criteria of the lower rating of 30 percent. As such, there is no question as to which evaluation shall be applied. See 38 C.F.R. § 4.7; Middleton v. Shinseki, 727 F.3d 1172, 1178 (Fed. Cir. 2013). After careful consideration, the Board concludes the Veteran's PTSD symptoms more closely approximated and resulted in a level of impairment associated with a 30 percent rating for mental disorders. As the preponderance is against an increase, the benefit of the doubt doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). REASONS FOR REMAND 1. Entitlement to a total disability rating based on individual unemployability is remanded. The Veteran contends he is entitled to a total disability rating based on individual unemployability. Specifically, he contends his hearing loss disability impacted his work performance such that he retired in 2007. He asserts his PTSD symptoms since increased and now prevent him from maintaining substantially gainful employment since 2012. A total disability rating may be assigned when it is established that service-connected disabilities are so severe, standing alone, as to prevent the retaining or obtaining of substantially gainful employment. Substantially gainful employment is employment which is ordinarily followed by the nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the Veteran resides. Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). Marginal employment shall not be considered substantially gainful employment. 38 C.F.R. § 4.16 (a). A TDIU may be assigned when the schedular rating is less than total, where a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16 (a). To qualify for schedular consideration, if there is only one such disability, the disability shall be rated at 60 percent or more. If there are two or more disabilities, there shall be at least one disability rated at 40 percent or more and sufficient additional disability ratings to bring the combined rating to 70 percent or more. Id. For the purposes of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) Disabilities of one or both upper extremities, one or both lower extremities, including the bilateral factor, if applicable; (2) Disabilities resulting from common etiology or a single accident; (3) Disabilities affecting a single body system, e.g., orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric; (4) Multiple injuries incurred in action; or (5) Multiple disabilities incurred as a prisoner of war. 38 C.F.R. § 4.16 (a); see Moody v. Wilkie, 30 Vet. App. 329, 339 (2018) (combining disabilities as "one disability" to meet the rating threshold of § 4.16 (a) requires the use of the combined rating table). Based on the forgoing, the Veteran does not meet the percentage standards set forth in § 4.16 (a). The Veteran is service-connected for: (1) PTSD, rated as 30 percent disabling, effective March 14, 2012; (2) bilateral hearing loss, rated as 10 percent disabling, effective December 5, 2007; (3) tinnitus, rated as 10 percent disabling effective December 5, 2007; and (4) residual neck scar, rated as 10 percent disabling from March 14, 2012. The Board notes Veteran's combined evaluation is 20 percent from December 5, 2007, and 50 percent from March 14, 2012. Thus, the Board finds that the Veteran does not meet the schedular criteria of entitlement to a TDIU for the period on appeal. The extra-schedular TDIU provisions make clear that all Veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. However, the Board cannot make this determination on the first instance, and these claims must be remanded to the RO for a referral. See 38 C.F.R. § 4.16 (b); see also, Bowling v. Principi, 15 Vet. App. 1, 9-10 (2001) (holding that the Board could not award TDIU on an extra-schedular basis without first ensuring that the claim was referred to the appropriate first line authority for such consideration). The correct standard for referral is whether there is "sufficient evidence to substantiate a reasonable possibility that a veteran is unemployable by reason of his or her service-connected disabilities." Ray v. Wilkie, 31 Vet. App. 58, 66 (2019). The Board's December 2018 decision declined to refer the Veteran's TDIU claim to the Director, finding the Veteran's service-connected disabilities did not render him unable to establish or maintain substantially gainful employment. However, as noted above, the record has been developed since adjudication to include a private vocational assessment, new lay statements, Representative arguments and contentions, and VA Form 21-8940. Upon review of the additional medical and lay evidence of record, the Board finds there is sufficient evidence to substantiate the possibility the Veteran is unemployable as a result of his service-connected disabilities. The Veteran was employed as an automobile and equipment mechanic for city government from 1976 to 2007. He asserts his hearing loss and lack of concentration began to affect his work performance such that he began making mistakes. He felt it was unsafe for him to continue as a mechanic and retired. The Veteran did not maintain employment again until 2012 when he worked as a part-time driver for a medical transport company. He reports his tinnitus symptoms became worse after a day of working due to background noise and his difficulty with hearing others, and he became easily irritated with passengers. Mental health records suggest this return to work was at the urging of his therapist to assist with his depressive symptoms and provide positive coping activities, however he was unable to cope with the stresses of the job and left the position within four months. In August 2016, the Veteran began performing part-time lawn maintenance at a friend's vineyard but was released from the position in May 2017. He contends the characterization of the position was as needed, with no schedule or commitment. He reports increasing conflict with the owner as the cause of dismissal and ultimately, he was not compensated for his time. The evidence shows, at his May 2012 VA examination for hearing loss, the examiner noted the Veteran's disability impacted ordinary conditions of daily life, including the ability to work. At his May 2016 psychiatric examination, the Veteran reported occupational and social impairment due to his PTSD symptoms, specifically isolating behavior, irritability, and chronic sleep impairment. The Veteran recently submitted the findings of a vocational assessment performed in April 2021. The vocational consultant opined the Veteran is "unable to secure and follow substantially gainful employment, in any occupation regardless of skill or exertional level, since at least March 2012 to the present." Giving consideration to all service-connected disabilities and new evidence of record, the possibility that the Veteran's disabilities have rendered him unemployable has been sufficiently raised. As the Veteran does not meet the schedular criteria, the Board finds it appropriate to refer the issue to the Director of Compensation Service for initial determination. Accordingly, entitlement to a TDIU is REMANDED for the following action: 1. Obtain any outstanding VA and private treatment records and associate them with the claims file. 2. Submit the issue of entitlement to TDIU, on an extraschedular basis, to the Director of Compensation Service. All of the Veteran's service-connected disabilities should be considered. Also, the Veteran's employment history, educational and vocational attainment, and all other factors having a bearing on his employability (or lack thereof) should be considered under 38 C.F.R. § 4.16 (b). Of particular note, the Director is asked to consider the private vocational assessment submitted by the Veteran. Bethany L. Buck Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T.N. Chapman, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.