Citation Nr: 22015315 Decision Date: 03/17/22 Archive Date: 03/17/22 DOCKET NO. 17-12 691 DATE: March 17, 2022 ORDER Entitlement to a rating in excess of 10 percent prior to August 7, 2019, and in excess of 30 percent as of August 7, 2019, for a cervical spine disability is denied. Entitlement to a rating in excess of 10 percent prior to August 7, 2019, and in excess of 40 percent as of August 7, 2019, for right carpal tunnel syndrome with right upper extremity radiculopathy is denied. Entitlement to a 30 percent rating, but not higher, effective April 7, 2015, but not earlier, for esophageal stricture is granted. REMANDED Entitlement to a total rating for compensation purposes based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. Prior to August 7, 2019, a cervical spine disability was not shown to be manifested by forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or the combined range of motion of the cervical spine not greater than 170 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 2. Effective August 7, 2019, a cervical spine disability has not been shown to be manifested by ankylosis. 3. Prior to August 7, 2019, right carpal tunnel syndrome with right upper extremity radiculopathy has been manifested by mild incomplete paralysis of the major median nerve; but not moderate incomplete paralysis of the major median nerve or worse. 4. Effective August 7, 2019, right carpal tunnel syndrome with right upper extremity radiculopathy has been manifested by moderate incomplete paralysis of the major middle radicular nerve; but not severe incomplete paralysis of the major middle radicular nerve. 5. Effective April 7, 2015, but not earlier, esophageal stricture symptoms were moderate in nature but not severe, permitting liquids only CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating in excess of 10 percent prior to August 7, 2019, and in excess of 30 percent as of August 7, 2019, for a cervical spine disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.71a, Diagnostic Codes 5237- 5243. 2. The criteria for entitlement to a rating in excess of 10 percent prior to August 7, 2019; and in excess of 40 percent as of August 7, 2019, for right carpal tunnel syndrome with right upper extremity radiculopathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.124(a), Diagnostic Codes 8511 and 8515. 3. The criteria for entitlement to a 30 percent rating, but not higher, effective April 7, 2015, but no earlier, for esophageal have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.114, Diagnostic Code 7203. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1979 to May 1999. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an August 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. In August 2019, the Veteran appeared at a hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript is of record. In November 2019 and May 2021, the Board remanded these claims to the Agency of Original Jurisdiction for additional action. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Schedule is primarily a guide in the rating of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period for which the appeal has been pending. Powell v. West, 13 Vet. App. 31 (1999). Consideration must be given as to whether staged ratings should be assigned to compensate entitlement to a higher rating at any point during the pendency of the claim. When the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings is necessary. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). While the Board must provide reasons and bases supporting a decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (Board must review the entire record but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence of record. The Veteran should not assume that the Board has overlooked pieces of evidence that are not explicitly discussed. Timberlake v. Gober, 14 Vet. App. 122 (2000). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Equal weight is not given to each piece of evidence contained in the record. Every item of evidence does not have the same probative value. When the evidence is assembled, the Board is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to a rating in excess of 10 percent prior to August 7, 2019, and in excess of 30 percent as of August 7, 2019, for a cervical spine disability. Disabilities of the spine that are rated under the General Rating Formula for Diseases and Injuries of the Spine include vertebral fracture or dislocation (Diagnostic Code 5235), sacroiliac injury and weakness (Diagnostic Code 5236), lumbosacral or cervical strain (Diagnostic Code 5237), spinal stenosis (Diagnostic Code 5238), unfavorable or segmental instability (Diagnostic Code 5239), ankylosing spondylitis (Diagnostic Code 5240), spinal fusion (Diagnostic Code 5241), and degenerative arthritis of the spine (Diagnostic Code 5242). Degenerative arthritis of the spine can also be rated using Diagnostic Code 5003. 38 C.F.R. § 4.71a. The Veteran's cervical spine disability has been rated under Diagnostic Code 5243. Under the General Rating Formula for Rating Diseases and Injuries of the Spine, with or without symptoms such as pain, stiffness or aching in the area of the spine affected by residuals of injury or disease, the following ratings will apply: A 10 percent rating is warranted when forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted when forward flexion of the cervical spine is greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent rating is assigned for forward flexion of the cervical spine of 15 degrees or less; or favorable ankylosis of the entire cervical spine. A 40 percent rating is assigned for unfavorable ankylosis of the entire cervical spine. A 100 percent rating is assigned for unfavorable ankylosis of the entire spine. For VA compensation purposes, normal forward flexion of the cervical spine is to 45 degrees, extension to 45 degrees, left and right lateral flexion are to 45 degrees, and left and right lateral rotation to 80 degrees. The normal combined range of motion of the cervical spine is 340 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (2), Plate V. Unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (0 degrees) always represents favorable ankylosis. The rater is to round each range of motion measurement to the nearest five degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (5). Disability of the thoracolumbar and cervical spine segments are to be rated separately, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. The rater is to round each range of motion measurement to the nearest five degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (6). Diagnostic Code 5243 provides that intervertebral disc syndrome (IVDS) is to be rated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. The Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes provides that a 10 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months. A 20 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. A 40 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months. A 60 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. An incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Note (1). If intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, each segment is to be rated on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Note (2). This increased rating claim was received by VA on April 7, 2015. The Veteran's intervertebral disc syndrome and degenerative disc disease of the cervical spine has been rated under Diagnostic Code 5243 as 10 percent, prior to August 7, 2019; and 30 percent as of August 7, 2019. The Veteran contends that the cervical spine disability is more severe than compensated by the assigned ratings. In a February 2015 statement, the Veteran complained of increasing pain and discomfort and decreasing range of motion (ROM) in the neck. A July 2015 VA examination diagnosed intervertebral disc syndrome (IVDS) and degenerative disc disease of the cervical spine. The Veteran was found to have range of motion to, at worst, 45 degrees forward flexion, 45 degrees extension, 45 degrees right lateral flexion, 45 degrees left lateral flexion, 80 degrees right lateral rotation, and 80 degrees left lateral rotation. The Veteran did not report experiencing flare-ups of pain. The Veteran did not have muscle atrophy, guarding or muscle spasm of the cervical spine nor was he found to have ankylosis. The Veteran was found to have IVDS, but it did not result in episodes of acute signs and symptoms that required bed rest prescribed by a physician and treatment by a physician in the past 12 months. The neck condition was found to have no impact on the Veteran's ability to work. At an August 2019 Board hearing, the Veteran described current symptoms associated with the service-connected disability and how it impacted his life. The Veteran indicated a worsening of the neck disability. The Board notes that the Veteran underwent VA neck examination in February 2020. However, a May 2021 Board Remand found the February 2020 neck examination to be incomplete and of limited probative value. Therefore, the February 2020 VA neck examination report is incomplete for rating purposes and will not be considered in adjudication of this claim. A February 2020 X-Ray found degenerative disc disease of the cervical spine. A June 2021 radiology imaging found straightening of the cervical lordosis. There was no significant spondylolisthesis. Vertebral body heights were maintained. No compression fracture was seen. There was advanced multilevel discogenic degenerative disease. There was multilevel bilateral foraminal narrowing. The prevertebral soft tissue contour was unremarkable. The visualized lung apices were clear. At a December 2021 VA neck examination, the Veteran complained of pain, reduced range of motion, and cracking of the neck, all of which he treated with heating pads and Ibuprofen as needed. The Veteran was found to have range of motion to, at worst, 30 degrees forward flexion, 0 degrees extension, 0 degrees right lateral flexion, 0 degrees left lateral flexion, 15 degrees right lateral rotation, and 10 degrees left lateral rotation. The Veteran was found to have guarding of the cervical spine. He was not found to have muscle atrophy nor ankylosis. The Veteran was found to have IVDS, but it did not result in episodes of acute signs and symptoms that required bed rest prescribed by a physician and treatment by a physician in the past 12 months. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The record currently contains no other examinations that are valid for rating purposes. Initially, the Board notes that there has been no medical evidence of ankylosis of the cervical spine during the course of the appeal. Thus, a higher rating cannot be assigned on that basis. The Board also notes that the Veteran has been rated separately for neurological deficits associated with the cervical spine disability. Thus, any issues pertaining to the service-connected neurologic deficits associated with the cervical disability are not currently before the Board and will not be addressed in this decision. Prior to August 7, 2019, the Board finds that a higher rating was not warranted. Prior to August 7, 2019, the evidence of record does not demonstrate forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis commensurate with an increased rating of 20 percent pursuant to Diagnostic Code 5237. Pursuant to Diagnostic Code 5237, that level of impairment is consistent with the currently assigned 10 percent rating. The Board has considered any additional functional loss due to pain or other factors but finds that the evidence of record does not show additional functional loss that would warrant elevation to any higher ratings. Prior to August 7, 2019, the Board has also considered whether a higher rating could be assigned under the intervertebral disc syndrome formula based on incapacitating episodes. However, the Veteran has not been shown to have incapacitating episodes of intervertebral disc syndrome having a total duration of at least two weeks but less than 4 weeks during the appeal period. Thus, an increased rating of 20 percent cannot be assigned pursuant to Diagnostic Code 5243. Effective August 7, 2019, the Board finds that a higher rating is not warranted. The evidence of record does not show that the Veteran has ever had ankylosis of the cervical spine commensurate with an increased rating of 40 percent pursuant to Diagnostic Code 5237. Pursuant to Diagnostic Code 5237, that level of impairment is consistent with the currently assigned 30 percent rating. The Board has considered any additional functional loss due to pain or other factors but finds that the evidence of record does not show additional functional loss that would warrant elevation to any higher ratings. Effective August 7, 2019, the Board has also considered whether a higher rating could be assigned under the intervertebral disc syndrome formula based on incapacitating episodes. However, the Veteran has not been shown to have incapacitating episodes of intervertebral disc syndrome having a total duration of at least four weeks but less than six weeks during the appeal period. Thus, an increased rating of 40 percent cannot be assigned pursuant to Diagnostic Code 5243. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of a rating greater than 10 percent, prior to August 7, 2019, and against the assignment of a rating greater than 30 percent as of August 7, 2019, for a cervical spine disability. The Board finds that the evidence is not in relative equipoise, the evidence does not more nearly approximate the criteria for higher ratings, and there is no reasonable doubt to resolve in favor of the Veteran. Therefore, the appeal must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to a rating in excess of 10 percent prior to August 7, 2019; and in excess of 40 percent as of August 7, 2019, for right carpal tunnel syndrome with right upper extremity radiculopathy. The Veteran's service-connected carpal tunnel syndrome with right upper extremity radiculopathy has been rated pursuant to Diagnostic Codes 8515 and 8511. The Board will consider any potentially applicable Diagnostic Code in its analysis. Disease of the peripheral nerves of the upper extremities are rated under 38 C.F.R. § 4.124a, Diagnostic Codes 8510 to 8719. Diagnostic Code 8515 provides different criteria for the major (dominant) and minor (non-dominant) extremities. Pursuant to VA regulation, only one extremity is considered dominant, which will be determined by the evidence of record or by VA testing. Therefore, in rating an upper extremity disability, it is necessary to distinguish between the predominant, or major, upper extremity and the minor upper extremity, as such distinction may affect the criteria for a particular level of impairment. 38 C.F.R. § 4.69. In the case at hand, examination reports of record note that the Veteran is right-handed. Thus, for rating purposes, the Veteran's right extremity will be considered the major extremity. Diagnostic Code 8511 provides that mild incomplete paralysis of the middle radicular group is rated 20 percent on the major side, moderate incomplete paralysis is rated 40 percent on the major side; and severe incomplete paralysis is rated 50 percent on the major side. Complete paralysis is rated 70 percent disabling on the major side. 38 C.F.R. § 4.124a, Diagnostic Codes 8511. Diagnostic Code 8515 provides that mild incomplete paralysis of the median nerve is assigned a 10 percent rating for the major side; moderate incomplete paralysis is assigned a 30 percent rating for the major side; and severe incomplete paralysis is assigned a 50 percent rating for the major side. Complete paralysis of the median nerve, with the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb at right angles to palm; flexion of wrist weakened; pain with trophic disturbances, is assigned a 70 percent rating for the major side. 38 C.F.R. § 4.124a, Diagnostic Codes 8515. The words mild, moderate, and severe are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. The use of terminology such as mild and moderate by VA examiners or other physicians, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. The term incomplete paralysis indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to a varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. This increased rating claim was received by VA on April 7, 2015. The Veteran's right carpal tunnel syndrome with right upper extremity radiculopathy has been rated under Diagnostic Code 8515 as 10 percent, prior to August 7, 2019, and 40 percent under Diagnostic Code 8511, effective August 7, 2019. The Veteran contends that the right extremity disability is more severe than represented by the assigned ratings. At a July 2015 VA peripheral nerves examination, the Veteran was found to have mild, intermittent right upper extremity pain. The Veteran did not have loss of strength, muscle atrophy, decreased reflexes, decreased sensation, or trophic changes. The Veteran was diagnosed with mild incomplete paralysis of the right median nerve. The Veteran's condition was found to have no impact on the ability to work. At an August 2019 Board hearing, the Veteran described current symptoms associated with the service-connected disability and how it impacted his life. The Veteran indicated a worsening of the disability. The Veteran complained of increased pain due to overuse at work. At a February 2020 VA peripheral nerve examination, the Veteran was found to have moderate, constant, right upper extremity pain and severe intermittent pain. He was also found to have moderate numbness in the right upper extremity. The Veteran did not have muscle atrophy or decreased reflexes. The Veteran had 4/5 strength in the right upper extremity and decreased sensation in the right hand. The Veteran was positive for Phalen's sign and Tinel's sign. He was diagnosed with moderate incomplete paralysis of the right median nerve. The Veteran's condition was found to have no impact on the ability to work. The Board notes that the Veteran underwent VA neck examination in February 2020. However, a May 2021 Board Remand found the February 2020 neck examination to be incomplete and of limited probative value. Therefore, the February 2020 VA neck examination report is incomplete for rating purposes and will not be considered in adjudication of the claim. At a December 2021 VA peripheral nerve examination, the Veteran was found to have mild, intermittent pain of the right upper extremity, and moderate, paresthesias and/or dysesthesias, and moderate numbness. He was also found to have moderate numbness in the right upper extremity. The Veteran did not have muscle atrophy, decreased reflexes, or trophic changes. The Veteran had 4/5 strength in the right grip and decreased sensation in the right hand. He was diagnosed with moderate incomplete paralysis of the right ulnar nerve. The Veteran's condition was found to have no impact on the ability to work. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The record currently contains no other examinations that are valid for rating purposes. Prior to August 7, 2019, the Board finds that a higher rating is not warranted. Prior to August 7, 2019, the evidence of record does not demonstrate moderate incomplete paralysis of the median nerves commensurate with an increased rating of 20 percent pursuant to Diagnostic Code 8515, nor does the evidence demonstrate mild, incomplete paralysis of the middle radicular nerves commensurate with an increased rating of 20 percent pursuant to Diagnostic Code 8511. That level of impairment is consistent with the currently assigned 10 percent rating under the applicable diagnostic codes. Effective August 7, 2019, the Board finds that a higher rating is not warranted. Effective August 7, 2019, the evidence of record does not demonstrate severe incomplete paralysis of the median nerves commensurate with an increased rating of 50 percent pursuant to Diagnostic Code 8515. The evidence also does not demonstrate severe, incomplete paralysis of the middle radicular nerves commensurate with an increased rating of 50 percent pursuant to Diagnostic Code 8511. That level of impairment is consistent with the currently assigned 40 percent rating under the applicable diagnostic codes. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of a rating greater than 10 percent, prior to August 7, 2019, and the preponderance of the evidence is against the assignment of a rating greater than 40 percent as of August 7, 2019, for right carpal tunnel syndrome with right upper extremity radiculopathy. The Board finds that the evidence is not in relative equipoise, the evidence does not more nearly approximate the criteria for higher ratings, and there is no reasonable doubt to resolve in favor of the Veteran. Therefore, the appeal must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Entitlement to an increased rating of 30 percent disabling, but no higher, effective April 7, 2015, and no earlier, for esophageal stricture. The Veteran's service-connected esophageal stricture has been rated pursuant to Diagnostic Code 7203. Pursuant to Diagnostic Code 7203, a 30 percent rating is warranted for moderate stricture of the esophagus. A 50 percent rating is warranted for severe stricture of the esophagus, permitting liquids only. A maximum 80 percent rating is warranted for stricture of the esophagus, permitting passage of liquids only, with marked impairment of general health. 38 C.F.R. § 4.114, Code 7203. This increased rating claim was received by VA on April 7, 2015. The Veteran's esophageal stricture has been rated under Diagnostic Code 7203 as 0 percent disabling, prior to August 7, 2019; and 30 percent disabling, effective August 7, 2019. The Veteran contends that the disability is more severe than represented by the assigned ratings. At a July 2015 VA examination, the Veteran complained of dysphagia and substernal pain. The Veteran was noted as taking Prilosec to treat the condition. The Veteran was not found to have esophageal stricture, spasm, diverticula, or any other pertinent findings, complications, conditions, signs or symptoms. The condition was found to have no impact on the Veteran's ability to work. A December 2016 upper endoscopy found esophageal stricture at 43 centimeters, which was dilatated to 18, 19, 20 millimeters HG and then fracture biopsied. An April 2018 esophagogastroduodenoscopy (EGD) found mild stricture with a few linear furrows visualized. At an August 2019 Board hearing, the Veteran described current symptoms associated with the service-connected disability and how it impacted his life. The Veteran indicated a worsening of the disability. The Veteran testified that he had to take Omeprazole to reduce swelling in the esophagus, and that food got stuck if he ate too fast or didn't concentrate on chewing thoroughly. In December 2018, the Veteran was taken emergently to the operating room after a piece of chicken became stuck in his throat. An EGD with a balloon dilatation in the esophagus was performed. In a November 2019 gastroenterology note, the Veteran denied any history of heartburn but had one episode of solid food dysphagia a couple of weeks prior. It was associated with chest pain and an inability to swallow but passed while he was waiting to be seen in the emergency departments. During that visit, the Veteran denied abdominal pain, nausea, vomiting, dyspepsia, diarrhea, constipation, hematochezia, melena, hemorrhoids, and any change in bowel movement. At a February 2020 VA examination, the Veteran was noted as taking Omeprazole to treat the condition. The Veteran was found to have symptoms productive of severe impairment of health, persistently recurrent epigastric distress, dysphagia, regurgitation, substernal pain, and vomiting. The Veteran also had a moderate esophageal stricture that was dilatated five separate times. Resolving all reasonable doubt in favor of the Veteran, the Board finds that, effective April 7, 2015, the date the increased rating claim was first filed, the Veteran's esophageal stricture symptoms were moderate. Thus, a 30 percent rating, but not higher, effective April 7, 2015, but not earlier, for esophageal stricture is warranted. However, during the entire appeal period, the Board finds that a rating in excess of 30 percent is not warranted. Throughout the appeal period, the evidence of record does not demonstrate severe stricture of the esophagus, permitting liquids only commensurate with an increased rating of 50 percent pursuant to Diagnostic Code 7203. There is no evidence of record to suggest that Veteran has been placed on a liquid diet or can only tolerate a liquid diet. During the Board hearing, the Veteran acknowledged that he was able to eat solid foods as long as he ate slowly and chewed thoroughly. That level of impairment is consistent with the currently assigned 30 percent rating under the applicable diagnostic code. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of a rating greater than 30 percent for esophageal stricture during the course of this appeal. The Board finds that the evidence is not in relative equipoise, the evidence does not more nearly approximate the criteria for higher ratings, and there is no reasonable doubt to resolve in favor of the Veteran. Therefore, the appeal for any higher rating must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to a total rating for compensation purposes based on individual unemployability due to service-connected disabilities (TDIU) is remanded. It is the established policy of VA 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. 38 C.F.R. § 4.16. A finding of total disability is appropriate when there is present any impairment of mind or body which is sufficient to make it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. §§ 3.340(a)(1), 4.15. Substantially gainful employment is that 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 (1991). Marginal employment shall not be considered substantially gainful employment. 38 C.F.R. § 4.16(a). TDIU may be assigned, if the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one service-connected disability it is ratable at 60 percent or more; or if there are two or more service-connected disabilities at least one is ratable at 40 percent or more and the combined rating is 70 percent or more. 38 C.F.R. § 4.16 (a). A claim for a total disability rating based upon individual unemployability, presupposes that the rating for the service-connected condition is less than 100 percent, and only asks for TDIU because of subjective factors that the objective rating does not consider. Vettese v. Brown, 7 Vet. App. 31 (1994). In evaluating a Veteran's employability, consideration may be given to the level of education, special training, and previous work experience in arriving at a conclusion, but not to age or impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. The central inquiry is whether the service-connected disabilities alone are of sufficient severity to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524 (1993). Neither nonservice-connected disabilities nor advancing age may be considered in the determination. 38 C.F.R. §§ 3.341, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). The fact that a Veteran is unemployed or has difficulty finding employment is not enough, as a high rating in itself is recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the claimant is capable of performing the physical and mental acts required for employment, not whether the claimant can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). The Veteran's combined service-connected rating is 80 percent, effective April 7, 2015, with at least one disability rated at least 40 percent. Therefore, the Veteran meets the schedular criteria for consideration of the assignment of TDIU as of April 7, 2015. The Board's consideration turns to whether the Veteran was unable to secure or follow a substantially gainful occupation as a result of the service-connected disabilities. In numerous statements to the Board, and during the August 2019 hearing, the Veteran testified that he was unable to work due to the service-connected disabilities. As the record currently stands, it is unclear, at best, whether the Veteran is unable to secure or follow substantially gainful employment. The Veteran's current employment status is and employment history are unclear. In December 2019, VA notified the Veteran that he needed to complete and return VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability. The Veteran has not responded. The record contains several examiner opinions concerning the effect of specific disabilities on the Veteran's ability to work. In light of the changes that have occurred during the course of the appeal, and to avoid any prejudice to the Veteran, the Board finds that the Veteran should be allowed a final opportunity to file a formal claim for a TDIU through submission of a VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability. Bernard v. Brown, 4 Vet. App. 384 (1993). The Board finds that information regarding the Veteran's employment history, such as when he was employed, and whether it was full time employment, is needed prior to adjudication of the claim for TDIU. The Board wants to make clear to the Veteran that, while VA has a statutory duty to assist in developing evidence pertinent to a claim, a Veteran also has a duty to assist and cooperate with VA in developing evidence; the duty to assist is not a one-way street. Wood v. Derwinski, 1 Vet. App. 190 (1991). VA's duty must be understood as a duty to assist a Veteran in developing his or her claim, rather than a duty on the part of VA to develop the entire claim with the Veteran performing a passive role. Turk v. Peake, 21 Vet. App. 565 (2008). The Veteran is notified that it is his responsibility to cooperate in the development of the claim. The Veteran is placed on notice that pursuant to 38 C.F.R. § 3.655 failure to cooperate with any examination may result in an adverse determination. Connolly v. Derwinski, 1 Vet. App. 566 (1991). The matters are REMANDED for the following action: 1. Send the Veteran and representative a letter requesting that the Veteran furnish any additional information or evidence pertinent to the claim for TDIU, to include completion of VA Form 21-8940. The letter should specifically notify the Veteran of the criteria to establish entitlement to TDIU and supply the form to apply for TDIU. Take all appropriate action needed to develop employment information related to the TDIU claim, to include the nature, hours, and income relating to any part time work. 2. Obtain all VA treatment records not already of record and associate them with the claims file. 3. Then, review the evidence associated with the record since issuance of the December 2021 supplemental statement of the case for the claim for TDIU. After a review of the additional evidence, conduct any other development deemed necessary and readjudicate the claim for TDIU. If any decision is averse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the case to the Board. Harvey P. Roberts Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mondesir, Eric 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.