Citation Nr: 21041862 Decision Date: 07/10/21 Archive Date: 07/10/21 DOCKET NO. 06-38 928 DATE: July 10, 2021 ORDER Entitlement to a rating in excess of 30 percent, prior to March 31, 2011, for coronary artery disease (CAD) is denied. Entitlement to a rating in excess of 20 percent for diabetes mellitus, type II, is denied. Entitlement to a total rating based on individual unemployability due to service-connected disability (TDIU) prior to March 31, 2011, is denied. INTRODUCTION The Veteran served on active duty from September 1966 to September 1969. He died in November 2020. The Appellant is the Veteran's surviving spouse and she has been substituted as the claimant. These matters come before the Board of Veterans' Appeals (Board) on appeal from an April 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. This appeal involves an extensive adjudicative history that need not be repeated here in its entirety. The Board most recently remanded these claims in February 2020, for additional development. After the issuance of a September 2020 supplemental statement of the case, the appeal was remitted to the Board for further appellate review. VA then learned of the Veteran's death and the Board dismissed the appeal in December 2020. After the Appellant was substituted as the claimant, the appeal returned to the Board for consideration on the merits. FINDINGS OF FACT 1. Prior to March 31, 2011, the Veteran's CAD was manifested with a workload of 5 to 7 METs resulting in fatigue, dizziness, and dyspnea. 2. The Veteran's diabetes required insulin and a restricted diet but did not require regulation of activities, as defined by regulation. 3. Prior to March 31, 2011, the service-connected disabilities were CAD, rated as 30 percent disabling; diabetes mellitus, type II, with nephropathy and impotence, rated as 20 percent disabling; peripheral neuropathy of the right lower extremity due to diabetes, rated as 10 percent disabling; and peripheral neuropathy of the left lower extremity due to diabetes, rated as 10 percent disabling; the service-connected disabilities combined to a level of 60 percent disabling. 4. The Veteran reported education through one year of high school and employment as a truck driver; he reported that he became too disabled to work in July 2005. 5. Prior to March 31, 2011, a service-connected disability, by itself, did not preclude the Veteran from securing or following a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 30 percent, prior to March 31, 2011, for CAD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.104, Diagnostic Code 7005. 2. The criteria for a rating in excess of 20 percent for diabetes mellitus are not met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. § 4.119, Diagnostic Code 7913. 3. The criteria for TDIU are not met prior to March 31, 2011. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Preliminarily, in February 2020, the Board remanded the above-captioned claims for additional development. Specifically, the Board directed the RO to ask the Veteran to submit or identify relevant evidence not already associated with the claims file pertaining to the severity of his CAD prior to March 31, 2011. Further, the Board directed the RO to obtain supplemental opinions from VA examiners and to refer the Veteran's CAD and diabetes mellitus, type II, claims for extraschedular consideration. In a February 2020 letter, the RO requested that the Veteran submit or identify additional relevant evidence. The RO also obtained and associated with the evidence additional VA treatment records. The requested supplemental opinions, rendered by the specified specialists, were obtained in April 2020. In September 2020, the RO obtained an opinion from the Director of Compensation and Pension Service that denied assigning the Veteran's CAD and diabetes mellitus, type II, an extraschedular rating. In September 2020, the RO re-adjudicated the Veteran's claims, confirming and continuing the denial of each. The RO then issued a September 2020 supplemental statement of the case before remitting the appeal to the Board for further appellate review. Based on the above, the Board finds that the RO substantially complied with the February 2020 remand directives. Consequently, a remand for corrective action is not warranted, and the Board will address the merits of the claims herein. See Stegall v. West, 11 Vet. App. 268, 271 (1998). CAD The salient question presented by the Veteran's claim is the severity of his CAD prior to March 31, 2011. A brief review of the adjudicative history is important to understand the claim. In a March 25, 2011 decision, the Board denied the Veteran's claim of entitlement to a rating in excess of 30 percent for CAD. Following the decision, the Veteran both appealed to the U.S. Court of Appeals for Veterans Claims (Court) and submitted a "new" claim of entitlement to an increased for CAD that was date-stamped as received by VA on March 31, 2011. The RO developed the Veteran's March 31, 2011 "claim" despite the appeal pending before the Court. This development included VA examinations in July/August 2011. Subsequent to this development, the RO issued a rating decision in September 2011, wherein the rating assigned to the Veteran's CAD was increased to 60 percent, effective March 31, 2011 (which is the date the RO recognized as the date of claim). All of the relevant evidence of record was reviewed in the September 2011 rating decision, including a December 27, 2010 stress test. This stress test resulted in a maximum METs level of 1.0, but it failed to show that at this METs level, the Veteran exhibited symptoms of dyspnea, fatigue, angina, dizziness, or syncope. The grant of the 60 percent rating was primarily predicated on the results of the July/August 2011 VA examinations, which showed the Veteran exhibited symptoms of fatigue at 4.6 METs. In February 2012, the involved parties filed a Joint Motion to Vacate and Remand (Joint Motion), asking the Court to vacate that part of the Board's March 25, 2011 decision that denied the claim of entitlement to rating in excess of 30 percent for CAD. The parties agreed that the Veteran testified during a January 2009 Board hearing that his CAD had worsened and, thus, a remand should have been granted on March 25, 2011 in order to provide him a new examination. By a February 2012 Order, the Court granted the Joint Motion and remanded the matter to the Board for action consistent with the directives of the Joint Motion. In August 2012, the Board remanded the Veteran's claim, captioned as entitlement to a rating in excess of 30 percent prior to March 31, 2011, and in excess of 60 percent on and after March 31, 2011, for CAD (which incorporates the grant in the RO's September 2011 rating decision). While the Veteran's claim was in remand status, the RO issued an April 2014 rating decision granting the maximum 100 percent rating for CAD, effective May 14, 2013. As this is the maximum benefit allowable under the regulations, no further appellate action was taken. Additionally, in a May 2015 letter, the Veteran specifically withdrew the issue of entitlement to a rating in excess of 60 percent, from March 31, 2011 to May 14, 2013, for CAD. The Board addressed both the April 2014 rating decision and the May 2015 letter in an August 2015 remand. Consequently, the only issue that remained pending before VA was entitlement to a rating in excess of 30 percent prior to March 31, 2011, for CAD. The Board details this portion of the extensive adjudicative history to emphasis the fact that March 31, 2011, is an "artificial" date. The original increased rating claim for CAD that was denied by the Board on March 25, 2011, was still pending before VA (i.e., before the Court). Thus, the March 31, 2011 "claim" was duplicative. Despite this, the Board is tasked with determining whether the Veteran is entitled to a rating in excess of 30 percent prior to March 31, 2011, for his CAD. As has been discussed, prior to March 31, 2011, the Veteran's service-connected CAD has already been assigned a 30 percent rating under 38 C.F.R. § 4.104, Diagnostic Code 7005. Diagnostic Code 7005 provides for a 30 percent rating when a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or, with evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent rating is assigned with more than one episode of acute congestive heart failure in the past year; when workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or for left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is assigned for chronic congestive heart failure; or when workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope; or for left ventricular dysfunction with an ejection fraction of less than 30 percent. One MET is defined as the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note (2). Pertinent evidence to this issue includes a report from an October 2004 VA examination that referenced a normal June 2004 stress test and a METs level of 6. The physical examination revealed an essentially normal cardiac size and sounds with no evidence of deep venous thrombosis. A February 2006 VA examination noted a history of METs of 7-8. The examination of the heart again showed a normal heart size and sounds with no evidence of peripheral vascular disease or peripheral edema. Findings from a November 2007 VA examination included stress testing that resulted in a 10 METs capability. Testing for left ventricular dysfunction showed an ejection fraction of greater than 50 percent. An echocardiogram showed a normal heart size and it was noted that there was no history of congestive heart disease. The examiner stated that the Veteran's coronary artery disease did not result in any significant occupational effects and no effects on usual daily activities. As agreed to by the parties to the February 2012 Joint Motion, the Veteran testified during January 2009 Board hearing that his CAD had worsened since his then most recent VA examination. In May 2009, the Board remanded the Veteran's claim in order to obtain outstanding treatment records, but not to provide him with another VA examination. Subsequent to the March 25, 2011 Board decision that denied the Veteran's claim, he submitted the above-referenced December 27, 2010 stress test. Further, additional VA treatment records were associated with the claims file. Pursuant to several remands, most recently in February 2020, the Board requested that a cardiologist review the pertinent evidence of record and provide a retrospective opinion as to the severity of the Veteran's CAD prior to March 31, 2011. Ultimately, in April 2020, a VA examiner (credentialed as a cardiologist) provided the following opinion: [The Veteran] had multivessel CAD and underwent [coronary bypass graft in] 1998. This should have taken care of his ischemia. However, risk factors were not well controlled partly due to the nature of his diabetes and partly due to noncompliance (smoking). His bypass anatomy remained stable till 2014 when he had a stenosis in SVG-Diagonal which was stented successfully. This course after [coronary bypass grafts] is totally normal. His [ejection fraction] and the most recent stress test have been normal arguing against significant ischemia or congestive hearing failure. ... Based on his multiple stress tests, echocardiograms, cardiac cath[etherization]s with description of coronary and bypass anatomy[,] I can conclude with a high degree of certainty that [the Veteran] did not have significant ischemia to explain his symptoms. Soon after his [coronary bypass graft] his METs were in the 10+ range. From 2005 onwards, his clinical symptoms and stress tests would suggest minimal METs of 4 [to] 6 which is compatible with walking, daily chores around the office and at home, sexual activity and all activities of daily living. Also his [ejection fraction] and the most recent stress test have been normal arguing against significant ischemia or congestive heart failure. The evidence dated prior to March 31, 2011, does not reflect or more nearly approximate episodes of congestive heart, or a workload less than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope. 38 C.F.R. § 4.7. Left ventricular ejection fraction is shown to be over 50 percent, not the 30 to 50 percent required for a rating in excess of 30 percent. Review of the remaining evidence does not reflect findings that meet or more nearly approximate the criteria for a rating in excess of 30 percent prior to March 31, 2011. In making this determination, the Board acknowledges the Veteran's testimony during the January 2009 hearing. To the extent that the Veteran testified and otherwise asserts that his CAD met or more nearly approximated the criteria for a rating in excess of 30 percent prior to March 31, 2011, the Board finds his lay assertions as to the presence of lay observable symptoms (for example, fatigue) are considered competent evidence. However, as a lay person, the Veteran has not shown that he has specialized training sufficient to render such determinations, especially as to specific clinical results, as required by the applicable regulations. Accordingly, his testimony and assertions on such matters are not competent evidence because such a question requires medical expertise to determine. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). The Board notes that, but for the RO's acceptance of the March 31, 2011 submission as a "claim," the first evidence of record that met or more nearly approximated the criteria for a rating in excess of 30 percent for CAD was the July/August 2011 VA examination. As this examination is dated subsequent to March 31, 2011, the Board will not disturb the RO's determination herein. Accordingly, entitlement to an evaluation in excess of 30 percent, prior to March 31, 2011, for service-connected CAD is denied. The Board will address CAD on an extraschedular basis with diabetes mellitus, type II, below. Diabetes Mellitus, Type II Throughout the pendency of this appeal, a 20 percent rating has been assigned to the Veteran's service-connected diabetes mellitus, type II. Under Diagnostic Code 7913, a 20 percent rating is warranted for diabetes mellitus requiring insulin and restricted diet, or; oral hypoglycemic agent and restricted diet. A 40 percent rating is warranted for diabetes mellitus that requires insulin, a restricted diet, and regulation of activities. "Regulation of activities" is defined as the "avoidance of strenuous occupational and recreational activities." 38 C.F.R. § 4.119, DC 7913. Medical evidence is required to show that occupational and recreational activities have been restricted. Camacho v. Nicholson, 21 Vet. App. 360, 363-364 (2007). Compensable complications of diabetes will be rated separately and that noncompensable complications are considered part of the diabetic process under Diagnostic Code 7913. See 38 C.F.R. § 4.119, DC 7913, Note (1). The evidence of record demonstrates that the Veteran's diabetes requires insulin and a restricted diet. Consequently, a 40 percent rating could be assigned if there is sufficient evidence that the Veteran's diabetes requires the regulation of activities, as defined by the regulations. Camacho, 21 Vet. App. At 364. A June 2002 "Physician's Statement for Diabetes" noted that the Veteran's diabetes did require insulin and a restricted diet, but not the regulation of activities. A February 2006 VA examiner determined that the Veteran's diabetes did not require the regulation of activities aside from his inability to work as a truck driver due to insulin dependence. In December 2006, a private examiner concluded that the Veteran's diabetes required the regulation of activities, but the explanation as to why was limited to the Veteran's inability to sit, stand, or walk for prolonged periods due to his peripheral neuropathy. This does not satisfy the regulatory definition and, thus, is of no probative value. A November 2007 VA examination included the notation from the physician that the Veteran was not restricted in the ability to perform strenuous activities. In October 2008, a private physician noted that the Veteran should not engage in such activities as lifting, pulling, or pushing greater than ten pounds or perform rapid or repetitive motion of the upper extremities. However, significant non-service-connected disability was noted on this report, to include electromyographic findings suggestive of a C5 radiculopathy, evidence of entrapment of the left ulnar nerve, capsulitis of the left shoulder and a rotator cuff tear of the right shoulder. Thus, the physician did not limit the determination as to the Veteran's need for a regulation of activities to his service-connected disability mellitus, type II. Consequently, the probative value of the opinion is diminished. Additional VA treatment records do not reflect evidence that the Veteran's diabetes requires the regulation of activities as defined by regulation. The Veteran was encouraged to exercise regularly after an October 2, 2009, visit to a VA outpatient clinic and for 30 minutes a day after such a visit on August 21, 2009. Pursuant to several remands, most recently in February 2020, the Board ultimately obtained a supplemental opinion from a VA examiner (credentialed as an Internist) regarding whether the Veteran's diabetes requires a regulation of activities as defined by the regulations. The April 2020 Internist opined as follows: The Veteran's medical records were reviewed and there is no documentation to support or substantiate that the Veteran required 'regulation of activities,' meaning 'avoidance of strenuous occupational and recreational activities.' As a point of fact, exercise was recommended to the Veteran at clinical visits. A Cardiology clinic visits in [September 2019] notes that the Veteran does yard work using clippers to cut limbs. Per records available the Veteran does not limit activities or avoid occupational or recreational activities due to his diabetes mellitus. The Board acknowledges the Veteran's contentions throughout the pendency of this appeal. To the extent that the Veteran asserts that his diabetes mellitus, type II, requires the "regulation of activities" for any distinct period throughout the pendency of this appeal, he has not shown that he has specialized training sufficient to render such determinations. Accordingly, his contentions on such matters are not competent evidence because such a question requires medical expertise to determine. See Jandreau, 492 F.3d at 1376-77. Accordingly, the Board finds that the preponderance of the evidence is against finding that the Veteran's service-connected diabetes mellitus, type II, required a regulation of activities, as that term is defined in the regulations, for any distinct period throughout the pendency of this appeal. Consequently, entitlement to an evaluation in excess of 20 percent for service-connected diabetes mellitus, type II, is denied. The Board will address diabetes mellitus, type II, and CAD on an extraschedular basis below. The 20 percent rating assigned throughout this appeal contemplates noncompensable ratings for associated nephropathy, impotence, bilateral cataracts, and retinopathy. The Veteran has not asserted, and the evidence of record does not otherwise demonstrate, that these disabilities are separately compensable. The Veteran has already been granted special monthly compensation for the loss of use of a creative organ (impotence) and has been granted separate 10 percent ratings for peripheral neuropathy of right and left upper extremities and right and left lower extremities. The ratings for these disabilities are not at issue here. Extraschedular Ratings for CAD and Diabetes Mellitus, Type II In the February 2020 remand, the Board observed that a June 2019 VA examiner opined that the Veteran's CAD risk factors "were not well controlled partly due to the nature of [the Veteran's] Diabetes..." The Board found that this suggested an interconnection between the Veteran's CAD and his diabetes mellitus, type II, such that applicable diagnostic codes may not be sufficient to adequately contemplate their respective severities. 38 C.F.R. § 3.321(b)(1); Thurlow v. Wilkie, 30 Vet. App. 231 (2018). Accordingly, the Board remanded the Veteran's claim in order to obtain an opinion from the Director of Compensation and Pension Services (Director). Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27. Because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but, nevertheless, would still be adequate to address the average impairment in earning capacity caused by disability. In exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b). The threshold factor for extraschedular consideration is a finding that the evidence resents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate, a task performed either by the RO or the Board. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (2009); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. In September 2020, the Director rendered, in relevant part, the following opinion: The Veteran's service-connected CAD is evaluated 30 percent from June 30, 2004, 60 percent from March 31, 2011, and 100 percent from May 14, 203. Service-connected [diabetes mellitus, type II,] is evaluated 20 percent from June 26, 2001. Complications associated with [diabetes mellitus, type II,] are nephropathy, impotence, bilateral peripheral vascular disease and bilateral cataracts. Each of those conditions would be evaluated [zero] percent is rated separately from [diabetes mellitus, type II, under] [Diagnostic Code] 7913. Special Monthly Compensation (SMC-K) is found from June 26, 2001, based on loss of use of creative organ (impotence). [detailed review of the evidence and history of the issues omitted] Extra-schedular evaluations are assigned in cases where an exceptional or unusual disability picture is presented with such related factors as marked interference with employment or frequent period of hospitalization that render application of regular schedular standards impractical. No unusual or exceptional disability pattern has been demonstrated that would render application of the regular rating criteria as impractical for either the 30 percent evaluation of CAD prior to March 31, 2011, or the 20 percent evaluation of [diabetes mellitus, type II]. When comparing these disability pictures with the symptoms contemplated by the Rating Schedule, the Board finds that manifestations of the Veteran's service-connected CAD and diabetes mellitus, type II, are contemplated by the disability picture represented by the respective ratings, especially with consideration of separate compensable ratings assigned for disability associated with diabetes mellitus, type II. Ratings in excess of those already granted (except for the period of 100 percent for CAD) are provided for certain manifestations of CAD and diabetes mellitus, type II, but the evidence demonstrates that those manifestations are not present here. Consequently, the Board concludes that schedular evaluations are adequate. See 38 C.F.R. § 4.104, 4.119, Diagnostic Codes 7005, 7913; see also Thun, 22 Vet. App. at 115; VAOGCPREC 6-96; 61 Fed. Reg. 66749 (1996). TDIU TDIU has been granted from March 31, 2011 to May 14, 2013. On and after May 14, 2013, a 100 percent rating has been assigned to the Veteran's CAD and, thus, entitlement to TDIU during this period is not for consideration. The issue before the Board is whether the Veteran is entitled to TDIU prior to March 31, 2011. VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that the Veteran is precluded, by reason of service-connected disabilities, from obtaining and maintaining any form of gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. Under the applicable regulations, benefits based on individual unemployability are granted only when it is established that the service-connected disabilities are so severe, standing alone, as to prevent the obtaining and retaining of gainful employment. Under 38 C.F.R. § 4.16, if there is only one such disability, it must be rated at least 60 percent disabling to qualify for benefits based on individual unemployability. If there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Where these percentage requirements are not met, entitlement to benefits on an extraschedular basis may be considered when the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities, and consideration is given to the Veteran's background including his employment and educational history. 38 C.F.R. § 4.16(b). The Board does not have the authority to assign an extraschedular total disability rating for compensation purposes based on individual unemployability in the first instance. Bowling v. Principi, 15 Vet. App. 1 (2001). In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training, and previous work experience, but it may not be given to his age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. Prior to March 31, 2011, the Veteran's service-connected disabilities are coronary artery disease, rated as 30 percent disabling; diabetes mellitus, type II, rated as 20 percent disabling (with noncompensable disabilities included therein); peripheral neuropathy of the right and left lower extremities, each rated as 10 percent disabling; and peripheral neuropathy of the right and left upper extremities, each rated as 10 percent disabling. Thus, the Veteran's combined disability rating prior to March 31, 2011, is 60 percent. 38 C.F.R. § 4.25. The Veteran's 60 percent combined rating prior to March 31, 2011, does not meet the schedular rating standards for TDIU. 38 C.F.R. § 4.16(a). Nevertheless, the RO referred the Veteran's claim to the Director for consideration on an extraschedular basis. 38 C.F.R. § 4.16(b); see Bowling, 15 Vet. App. at 6. As will be discussed below, the Director provided such an opinion in September 2020. In determining whether a veteran can secure and follow a substantially gainful occupation, attention must be given to: The veteran's history, education, skill, and training; Whether the veteran has the physical ability (both exertional and nonexertional) to perform the type of activities (e.g., sedentary, light, medium, heavy, or very heavy) required by the occupation at issue. Factors that may be relevant include, but are not limited to, the veteran's limitations, if any, concerning lifting, bending, sitting, standing, walking, climbing, grasping, typing, and reaching, as well as auditory and visual limitations; and Whether the veteran has the mental ability to perform the activities required by the occupation at issue. Factors that may be relevant include, but are not limited to, the veteran's limitations, if any, concerning memory, concentration, ability to adapt to change, handle work place stress, get along with coworkers, and demonstrate reliability and productivity. Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). The Board notes initially that the Social Security Administration (SSA) found in an April 2007 decision that the Veteran was disabled since August 2005 under the guidelines/regulations of that agency. In its April 2007 re-determination, SSA listed the Veteran's disabilities as hypertension, coronary artery disease, diabetes, degenerative disc disease, and degenerative joint disease. VA is not bound by the findings of disability and/or unemployability made by other agencies, including SSA. See Collier v. Derwinski, 1 Vet. App. 413, 417 (1991). Considering that SSA's determinations contemplate both service-connected and non-service-connected disabilities, its opinions have no probative value here. With respect to the Veteran's ability to drive a truck, an October 2004 VA examiner commented that the Veteran's diabetes and coronary artery disease did not prevent him from driving long distances, and that he was still able to work as a long distance truck driver "without problems except that he does not like the long hours involved." On a July 2005 TDIU application, the Veteran reported education through one year of high school and employment as a truck driver from 1993 to 2005. He reports that he became too disabled to work in July 2005. In a December 2006 letter, a private physician found that the Veteran's diabetes required the regulation of activities and noted that the Veteran was disabled for present and future employment as a truck driver due to insulin dependence. This physician also noted that the Veteran could not sit, stand, or walk for prolonged periods due to peripheral neuropathy associated his diabetes and that the Veteran had no transferable skills. A November 2007 VA examiner commented that, although the Veteran was unable to maintain a truck driver's license due to his being dependent on insulin to manage his diabetes and that physical employability was "problematic" due to CAD, sedentary employability was not precluded by the Veteran's medical conditions. It is noted that the Veteran required insulin well prior to October 2004 (See e.g., June 2002 Physician's Statement for Diabetes completed by a private physician). The Veteran submitted a copy of a regulation showing that employment as a commercial vehicle driver is prohibited for insulin-dependent diabetics. Additional pertinent evidence includes the previously discussed October 2008 private physician's statement. While this physician found that the Veteran had no transferrable skills and that he was permanently and totally disabled for gainful employment, it is again noted that this physician referred to non-service-connected conditions, to include entrapment of the left ulnar nerve, capsulitis of the left shoulder, and a rotator cuff tear of the right shoulder in describing the Veteran's disability picture, and did not say that service-connected disabilities, by themselves, rendered the Veteran unemployable. The Board acknowledges that the Veteran's service-connected disabilities undoubtedly affected his employment to some extent prior to March 31, 2011, particularly the Veteran's chosen occupation as a commercial truck driver. However, to conclude that all forms of employment were precluded by service-connected disability prior to March 31, 2011, would not be reasonable given the evidence as set forth above. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether the Veteran can find employment. See 38 C.F.R. § 4.16(b); Ray, 31 Vet. App. at 73; Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). In February 2020, the Board remanded the Veteran's TDIU for consideration contemporaneous to the other claims remanded therein. The Board did not direct the RO to refer the Veteran's TDIU claim to the Director. While this claim was in remand status, however, the RO referred it to the Director. In the September 2020 opinion, the Director purported to render an opinion as to TDIU on an extraschedular basis, but the scope of this opinion is limited to the Veteran's CAD and diabetes mellitus, type II. Further, the Director erroneously conflates an extraschedular analysis in an increased rating claim with a TDIU analysis on an extraschedular basis. Consequently, the Director's opinion has no probative value here. 38 C.F.R. §§ 3.321(b), 4.16(b). After reviewing all the evidence of record relevant to the period of time before March 31, 2011, the Board concludes that all employment, even sedentary, has not been precluded due solely to the Veteran's service-connected disability. Again, a VA examiner concluded that sedentary employment is not precluded. Moreover, the Veteran's physicians encouraged him to engage in regular exercise despite his disability. This evidence weighs against concluding that the Veteran was too disabled that all work could not be accomplished. Even with consideration of the December 2006 opinion, the Board finds that the preponderance of the probative evidence is against finding that the Veteran's service-connected disabilities, considered alone, prevented him from obtaining or maintaining substantially gainful employment prior to March 31, 2011. In making the above determination, the Board does not find from a review of the evidence of record that the credibility of the Veteran's written or sworn communications with regard to this issue is in significant question. His contentions are not, however, deemed to be competent evidence as to whether he is unemployable due solely to his service-connected disabilities under the pertinent legal criteria. In short, therefore, and for the reasons stated above, the Board finds that the preponderance of the evidence is against the Veteran's claim. As such, the benefit of the doubt doctrine is inapplicable, and the claim of entitlement to TDIU prior to March 31, 2011, is denied. See 38 C.F.R. § 5107(b); Gilbert, supra. T. REYNOLDS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Sean G. Pflugner, 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.