Citation Nr: 22017273 Decision Date: 03/24/22 Archive Date: 03/24/22 DOCKET NO. 16-22 291 DATE: March 24, 2022 ORDER Entitlement to an initial rating in excess of 10 percent for a pilonidal cyst status-post excision with residual tenderness is denied. Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for tinnitus is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) is denied. FINDINGS OF FACT 1. Throughout the period on appeal, the Veteran's pilonidal cyst status-post excision with residual tenderness was manifested by, at worst, two scars on his posterior trunk, to include one painful scar. His scars were not unstable, deep, nonlinear or associated with underlying soft tissue damage, did not cover an area of 144 square (sq.) inches (in.) (929 sq. cm.) or more, and did not cause functional impairment. 2. The Veteran's bilateral hearing loss did not originate in service, within a year of service, and is not otherwise etiologically related to his active service. 3. The Veteran's tinnitus did not originate in service, within a year of service, and is not otherwise etiologically related to his active service. 4. The evidence of record does not reflect that the Veteran is unable to secure or follow substantially gainful employment as a result of his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial rating in excess of 10 percent for a pilonidal cyst status-post excision with residual tenderness have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code (DC) 7819-7804. 2. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 1154, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.385. 3. The criteria for service connection for recurrent tinnitus have not been met. 38 U.S.C. §§ 1131, 1154, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 4. The criteria for entitlement to a TDIU have not been met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1967 to January 1970. These matters come before the Board of Veterans' Appeals (Board) on appeal from July 2011, August 2015, and March 2016 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). In February 2020, the Veteran testified at a hearing before the undersigned. By way of background, these matters were previously before the Board in March 2021, when they were remanded for additional development. The Board notes that the March 2021 Board decision also granted the Veteran's claim for entitlement to service connection for an acquired psychiatric disorder, to include generalized anxiety disorder and depression. See March 2021 BVA Decision. The RO implemented the Board decision in a subsequent March 2021 rating decision and assigned a 30 percent disability rating, effective May 11, 2016. See March 2021 Rating Decision Narrative. Accordingly, the only issues on appeal are entitlement to an initial rating in excess of 10 percent for a pilonidal cyst, entitlement to service connection for bilateral hearing loss and tinnitus, and entitlement to a TDIU. Increased Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability ratings is the ability of the body as a whole, or of the psyche, or of a system or organ of the body, to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more nearly approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When a reasonable doubt arises regarding the degree of disability, that reasonable doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Staged ratings are appropriate for an increase rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 1. Entitlement to an initial rating in excess of 10 percent for a pilonidal cyst status-post excision with residual tenderness is denied. As an initial matter, the Veteran filed his claim for entitlement to service connection for a pilonidal cyst in March 2007, and in a July 2011 rating decision, the RO granted entitlement to service connection for status-post excision of pilonidal cyst with residual tenderness and assigned a 10 percent rating, effective March 12, 2007, the date of the Veteran's claim. See March 2007 VA Form 21-4138 Statement in Support of Claim; July 2011 Rating Decision Narrative. During the pendency of the appeal, an October 2021 rating decision granted service connection for scars, residuals of pilonidal cyst removal, and assigned a non-compensable rating, effective October 23, 2008, the date that VA's Rating Schedule was amended to allow for separate evaluations of scars. See October 2021 Rating Decision Narrative. The Veteran's service-connected pilonidal cyst is rated pursuant to 38 C.F.R. § 4.118, DC 7819-7804, and as noted above, his service-connected scars, residuals of pilonidal cyst removal, are rated as non-compensable pursuant to 38 C.F.R. § 4.118, DC 7805. Hyphenated diagnostic codes are utilized when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. Here, the hyphenated diagnostic code indicates that the Veteran's service-connected pilonidal cyst is manifested by benign skin neoplasms under DC 7819, to be rated as an unstable or painful scar pursuant to DC 7804. See October 2021 Rating Decision Codesheet. The Board notes that the rating criteria for evaluating scars under 38 C.F.R. § 4.118 were amended effective October 23, 2008. See 73 Fed. Reg. 54,708 (Sept. 23, 2008). However, the amended rating criteria only apply to claims filed on or after October 23, 2008, although a claimant may specifically request consideration under the amended criteria. 38 C.F.R. § 4.118. In the present case, the Veteran filed his claim in March 2007, prior to the October 2008 effective date, but VA has not received a specific request from the Veteran for consideration under the amended October 2008 criteria. Regardless, the RO appears to have considered both versions of the rating criteria in the March 2016 statement of the case (SOC), and as a result, the Board will also consider both sets of criteria, to avoid any potential prejudice to the Veteran. Bernard v. Brown, 4 Vet. App. 384, 392-94 (1993); see also March 2016 SOC. The Board further notes that the applicable rating criteria for skin disorders under 38 C.F.R. § 4.118 were also amended in August 2018. However, the 2018 revisions did not substantively change the diagnostic codes applicable to the Veteran's pilonidal cyst, and as such, will not be discussed further herein. Under the pre-October 2008 rating criteria, scars, other than head, face, or neck, that were deep or that caused limitation of motion were rated pursuant to DC 7801. Under DC 7801, a 10 percent rating was assigned for areas exceeding 6 sq. in., a 20 percent rating was warranted for areas exceeding 12 sq. in., and a 30 percent rating was assigned for areas exceeding 72 sq. in. Under DC 7801, a maximum 40 percent rating was warranted for areas exceeding 144 square inches. Notes following the rating criteria explain (1) scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of the extremities or trunk, would be rated separately and combined in accordance with 38 C.F.R. § 4.25, and (2) a deep scar was one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7801. Scars, other than of the head, face, or neck that were superficial and did not cause limitation of motion were rated pursuant to DC 7802 under the pre-October 2008 rating criteria. Under DC 7802, a maximum 10 percent rating was assigned for areas of 144 sq. in. or greater. 38 C.F.R. § 4.118, DC 7802. In addition, prior to the October 2008 regulatory change, unstable superficial scars and scars that were painful on examination were respectively rated and assigned a maximum 10 percent rating pursuant to DC 7803 and DC 7804. 38 C.F.R. § 4.118, DCs 7803, 7804. Lastly, under the pre-October 2008 rating criteria, DC 7805 indicted that other scars should be rated based on limitation of function of the affected part. 38 C.F.R. § 4.118, DC 7805. Under the amended rating criteria, DC 7805 provides that any disabling effects of other scars and other effects of scars evaluated under DCs 7800, 7801, 7802, and 7804 that are not considered in a rating provided under the aforementioned codes should be evaluated under an appropriate one. See 38 C.F.R. § 4.118. Under DC 7801, a 10 percent rating is warranted for burn scars or scars due to other causes, not of the head, face, or neck, that are deep and nonlinear, at least 39 sq. cm. in area, but less than 77 sq. cm. (or between 6 sq. in. and 12 sq. in.). Id. Pursuant to DC 7802, a maximum 10 percent rating is warranted for burn scars or scars due to other causes, not of the head, face, or neck, that are superficial (not associated with soft tissue damage) and nonlinear, affecting an area or areas of 144 sq. in. (929 sq. cm.) or greater. Id. DC 7804 provides a 10 percent rating for one or two scars that are unstable or painful, and a 20 percent rating for three or four scars that are unstable or painful. Under DC 7804, a maximum 30 percent rating is warranted for five or more scars that are unstable or painful. Id. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. See 38 C.F.R. § 4.118, DC 7804, Note (1). If one or more scars are both unstable and painful, 10 percent is to be added to the evaluation based on the total number of unstable or painful scars. See 38 C.F.R. § 4.118, DC 7804, Note (2). Scars can receive separate evaluations under DCs 7800, 7801, 7802, and 7805, despite also be rated under DC 7804. See 38 C.F.R. § 4.118, DC 7804, Note (3). Turning to the evidence of record, the Veteran reported pain at the site of his pilonidal cyst scar in March 2007. See March 2007 VA Form 21-4138 Statement in Support of Claim. During a March 2010 Board hearing, the Veteran testified that his service-connected pilonidal cyst status-post excision was manifested by a scar, which was approximately six cm. in length, tenderness, and pain. He also endorsed increased pain and irritation when he bumped his scar on objects and indicated that he had to sleep on his stomach or side to avoid additional irritation. See March 2010 Hearing Transcript, pages 12-14. The Veteran was afforded a VA examination for skin diseases in August 2010. The examiner diagnosed the Veteran with a pilonidal cyst status-post excision with residual tenderness. During the examination, the Veteran endorsed intermittent tenderness but stated that his pilonidal cyst did not open or bleed. No systemic symptoms were noted. On physical examination, the examiner noted an "L" shaped incisional scar at the Veteran's sacrum, which measured five cm in length by 3 cm in width with mild tenderness to palpation. The examiner further noted that the Veteran's skin was intact with mild tissue loss and adhesions, but no significant subcutaneous tissue loss was found. See May 2015 CAPRI. In a December 2010 statement, the Veteran described his pilonidal cyst as measuring eight in. in length and endorsed tenderness that prevented him from being able to lie on his back or on the ground. He further indicated that he experienced excruciating pain when he bumped his scar or sat in certain positions. He also endorsed functional impairment, which interfered with his work in construction. See November 2010 Correspondence. During a December 2012 Tennessee Disability Determination Services examination, the Veteran endorsed back problems, which he related to an injury he sustained after falling off a 30 ft high scaffold at work. In addition, during a subsequent January 2013 Tennessee Disability Determination Services examination, the Veteran reported that his back pain manifested 12 years prior to the date of that examination, in or around 2001. Specifically, he indicated that he sustained a crush injury after he fell off a scaffold at work and noted that he had pursued a Worker's Compensation case. See December 2012 VA examination. In September 2013, the Veteran endorsed constant pilonidal cyst pain, which prevented him from sleeping on his back, sitting in chairs, and from doing other unspecified things in life. See October 2013 Correspondence. The Veteran underwent a VA examination for skin diseases in January 2015. The examiner noted that the Veteran had been diagnosed with a cyst. During the examination, the Veteran endorsed residual pain and tenderness at the site of his pilonidal cyst excision but denied recurrence. The examiner indicated that the Veteran's pilonidal cyst did not cause scarring or disfigurement of the head, face, or neck, benign or malignant skin neoplasms, or systemic manifestations. In addition, he found that the Veteran had not been treated with oral or topical medications and had not undergone any treatments or procedures in the preceding 12 months. Following the examination, the examiner indicated that the surgical site of the Veteran's service-connected pilonidal cyst status-post excision was completely healed and did not impact his ability to seek or maintain appropriate employment. In April 2015, the Veteran reported that he had been experiencing increased chronic pain at the site of his pilonidal cyst excision for approximately one month. On examination, the examiner noted posterior thoracic tenderness to palpation, a marked right medial buttock fold, and scar tenderness. The assessment included pilonidal cyst status-post two surgeries with chronic residual parasthesia. See May 2015 CAPRI. The Veteran also underwent a pelvic CT scan for worsening pilonidal cyst pain in April 2015. The impression included a poorly distended/contracted urinary bladder with some diffuse wall thickening, multilevel lumbar degenerative spondylosis, and other chronic/nonacute findings. The examiner also found abnormal thickening of the skin and subcutaneous soft tissue (scar tissue) at the Veteran's pilonidal cyst surgical site. However, there was no formed fluid collection to suggest a recurrent cyst/abcess, no obvious acute inflammation at the site of the pilonidal cyst surgical scar, and no evidence of infection or recurrence. See July 2016 CAPRI. In his May 2016 substantive appeal, the Veteran stated that his service-connected pilonidal cyst should be rated as 30 percent disabling. In this regard, he endorsed constant itchiness and pain and indicated that is scar caused marked disfigurement. See May 2016 VA Form 9. The Veteran underwent a VA examination for back conditions in June 2016. The examiner noted that the Veteran had been diagnosed with degenerative disc disease of the spine. During the examination, the Veteran endorsed generalized pain in his back from arthritis and from his service-connected pilonidal cyst, which drained intermittently. He further indicated that he took oxycodone, gabapentin, and oxymorphone to deal with the pain from his re-current skin cyst and chronic back pain. After performing an examination and reviewing the evidence of record, the examiner opined that it was less likely than not that the Veteran's degenerative disc disease of the spine was proximately due to or the result of his service-connected pilonidal cyst. To the contrary, she found that degenerative disc disease and pilonidal skin cysts were separate, unrelated medical conditions. See June 2016 C&P examination. In a February 2017 substantive appeal, the Veteran indicated that his initial pilonidal cyst operation damaged his L5 disk resulting in constant pain. See February 2017 VA Form 9; see also April 2017 NOD; March 2018 VA Form 9. During the February 2020 Board hearing, the Veteran testified that the severity and intensity of symptoms that he ascribed to his service-connected pilonidal cyst had progressively worsened over time. In this regard, the Veteran reported that his back pain had increased to the point that he was no longer able to get out of bed or move without Oxycodone. He also indicated that he had a large scar on his back from the pilonidal cyst excision that extended into his spine and damaged his L5 and L6 vertebrae. See February 2020 Hearing Transcript, pages 9-12; see also May 2021 Buddy/Lay Statement. The Veteran underwent a VA examination for skin diseases in May 2021. The examiner noted that the Veteran had been diagnosed with a pilonidal cyst status-post excision with residual tenderness. During the examination, the Veteran reported tightness, tugging, intermittent pain, occasional numbness and tingling, and worsening inflexibility. He also indicated his skin became irritated when he wore clothes and continued to report that he slept on his side to avoid lying on his scar due to irritation. He further stated that he occasionally put Aspercreme on the surgical scar, which relieved some of his pain, and reported that he took Neurontin three times per day, which although prescribed for another disability, helped with his numbness and tingling of his surgical scar. As a result, the examiner noted that the Veteran used topical Aspercreme for skin irritation due to his surgical scars for six weeks or more, but not constantly, over the past 12 months. On physical examination, the examiner noted that the Veteran's pilonidal cyst covered less than five percent of his total body area but was not present in exposed areas. To this end, the examiner noted that the Veteran had visible excision scars, to include one horizontal scar and one vertical scar on the cleft of his buttocks with mildly stretched skin at the edges of the horizontal scar. Following the examination, the examiner found that the Veteran's service-connected pilonidal cyst impacted his ability to bend over due to inflexibility of the skin at the site of the surgical scar. The Veteran was also afforded a VA examination for scars and disfigurement in May 2021. The examiner noted that the Veteran had been diagnosed with surgical scars status-post pilonidal cyst removal, and the Veteran continued to report the symptoms noted on the May 2021 VA examination report for skin diseases. On examination, the examiner noted that the Veteran had scars on his posterior trunk, to include one horizontal scar and one vertical scar located at the top of the cleft of his buttocks. The Veteran's first scar measured five cm in length and was manifested by intermittent pain and tenderness to palpation irritation; he also endorsed irritation when clothes contacted the scar. His second scar was three cm in length but was not painful or tender to palpation. The examiner further noted that both scars were inflexible, but indicated that they were not unstable or caused by burns and did not cover an area greater than 39 in. Following the examination, the examiner reported that the Veteran's scars impacted his ability to work by making it difficult to bend over due to inflexible scar tissue. See May 2021 C&P examination. After a review of the evidence of record, the Board finds that an initial rating in excess of 10 percent for the Veteran's service-connected pilonidal cyst status-post excision with residual tenderness is not warranted. Specifically, the Board finds that the Veteran's pilonidal cyst status-post excision was located on his posterior trunk and was manifested by two scars, to include one painful scar, throughout the period on appeal, which is consistent with a 10 percent disability rating under DC 7804. To this end, the Board has considered the Veteran's assertion that his current lumbar spine disability was caused by his service-connected pilonidal cyst. Specifically, the Veteran stated that his initial pilonidal cyst operation damaged his L5 disk resulting in constant pain. See February 2017 VA Form 9; April 2017 NOD; March 2018 VA Form 9; May 2021 Buddy/Lay Statement. In this regard, the Board notes that a veteran is competent to report purported symptoms such as pain or whether he has received a diagnosis from a medical professional. 38 C.F.R. § 3.159(a)(2); Barr v. Nicholson, 21 Vet. App. 303 (2007). However, the question of whether such a relationship exists is a complex medical issue that is far beyond the purview of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (2007) (providing that the question of whether lay evidence is competent and sufficient is an issue of fact that is to be addressed by the Board); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (noting that personal knowledge is "that which comes to the witness through the use of his senses-that which is heard, felt, seen, smelled, or tasted"). To this end, the April 2015 pelvic CT did not show any abnormal thickening of the skin or subcutaneous soft tissue (scar tissue) at the Veteran's pilonidal cyst surgical site, and the examiner found no formed fluid collection to suggest a recurrent cyst/abcess, no obvious acute inflammation at the site of the pilonidal cyst surgical scar, and no evidence of infection or recurrence. See July 2016 CAPRI. In addition, the June 2016 VA examiner noted that the Veteran had been diagnosed with degenerative disc disease of the spine, and after performing an examination and reviewing the evidence of record, opined that it was less likely than not that the Veteran's degenerative disc disease of the spine was proximately due to or the result of his service-connected pilonidal cyst. To the contrary, she found that degenerative disc disease and pilonidal skin cysts were separate, unrelated medical conditions. See June 2016 C&P examination. In this regard, while the Board recognizes that the April 2015 medical treatment record indicates that the Veteran's pilonidal cyst status-post two surgeries was manifested by chronic residual parasthesia, the Board finds that that examiner's conclusions appear to be based entirely on statements from the Veteran, as there is no indication that they performed diagnostic testing or otherwise reviewed the evidence of record. To the contrary, the Board finds that the April 2015 VA examiner's finding that the Veteran's pilonidal cyst was manifested by chronic paresthesia is contradicted by the abovementioned medical evidence. Thus, the Board concludes that the Veteran's lay assertions that his service-connected pilonidal cyst and related surgeries damaged his L5 disc and subsequently led to his constant back pain are outweighed by the medical evidence of record, to include an April 2015 pelvic CT scan and the June 2016 VA examination report. The Board has also considered whether the Veteran would be entitled to a rating in excess of 10 percent under another diagnostic code under both the pre-October 23, 2008 and revised Rating Criteria. However, as the Veteran's pilonidal cyst scars are located on his posterior trunk, DC 7800 is not for application under either version of the diagnostic code. The Board further finds that the Veteran would not be entitled to a rating in excess of 10 percent under DCs 7801, 7802, or 7803, under either the pre-October 23, 2008 or the revised Rating Criteria, because his service-connected pilonidal cyst scars were not shown to be deep, unstable, or nonlinear and did not cover an area exceeding 12 sq. in. or an area of at least 39 square cm.. The Board acknowledges that the May 2021 VA examiners found that the Veteran's service-connected pilonidal cyst impacted his ability to bend over, and as such, has considered whether a separate compensable rating is warranted based on limitation of motion. See May 2021 C&P examination. Disabilities of the spine are rated, in relevant part, by application of the General Rating Formula for Diseases or Injuries of the Spine. Under the General Rating Formula, a 10 percent disability rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees. 38 C.F.R. § 4.71a. However, the Board finds that, although the evidence of record indicates that the Veteran's service-connected pilonidal cyst impacted his ability to bend over, it does not support a finding that such resulted in limitation of motion. To this end, the Board notes that the January 2015 VA examiner determined that the Veteran's connected pilonidal cyst status-post excision was completely healed and did not impact his ability to seek or maintain appropriate employment. See May 2015 CAPRI. Moreover, although the May 2021 VA examiners found that the Veteran's service-connected pilonidal cyst impacted his ability to bend over, neither found that it prevented or reduced his ability to do so or that it caused limitation of range of motion. See May 2021 C&P examination. Moreover, as noted above, the Veteran has been diagnosed with a separate disability, degenerative disc disease of the spine, which has been shown to cause his reported limitation of motion. To this end, the Board recognizes that a July 2015 primary care physician outpatient note recorded forward flexion of the Veteran's back to approximately 80 degrees. However, the Board finds it significant that neither the Veteran nor the examiner attributed such to his service-connected pilonidal cyst. In addition, the June 2015 VA examination report for back conditions indicates that the Veteran's diagnosed degenerative disc disease resulted in limitation of forward flexion to 70 degrees. See May 2015 CAPRI. To this end, although the Veteran reported that his back pain was caused by his service-connected pilonidal cyst and his nonservice-connected lumbar spine disability and stated that he was prescribed pain medications, to include oxycodone, gabapentin, and oxymorphone, for both conditions during the June 2015 VA examination, the examiner found that the conditions were unrelated. Moreover, the Board finds it significant that neither the January 2015 nor the May 2021 VA examiners indicated that the Veteran's pain medications were prescribed for pain related to his service-connected pilonidal cyst. To the contrary, the January 2015 VA examiner found that the Veteran had not been treated with oral or topical medications in the preceding 12 months for any skin conditions, and the May 2021 VA examiner indicated that the Veteran's medications were limited to topical Aspercreme, an over-the-counter pain reliever. See July 2016 CAPRI. Thus, the Board finds that a separate compensable rating is not warranted based on limitation of motion. The Board has also considered the Veteran's reports that his pilonidal cyst was manifested by pain and tenderness, which prevented him from sleeping on his back and sitting in certain positions. However, the Board finds that such symptoms are specifically contemplated by the Rating Criteria, and as a result, assignment of a separate compensable rating under DC 7805 is also not warranted on that basis. Thus, the Board finds that the evidence of record does not show that the Veteran's service-connected pilonidal cyst caused disabling effects not considered under DCs 7800-7804 or functional impairment, and as a result, that a separate compensable rating under DC 7805 is not warranted. Lastly, the Board acknowledges, and has considered, the Veteran's description of the problems caused by his service-connected pilonidal cyst. Martinak v. Nicholson, 21 Vet. App. 447 (2007). However, for the reasons discussed above, the Veteran has not shown that his symptoms affect him in a way not contemplated by the Rating Criteria. Thus, to the extent the Veteran may argue or suggest that the clinical data supports an increased disability rating or that the Rating Criteria should not be employed, he is not competent to make that assertion. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Accordingly, based upon the evidence of record, the Board finds that the Veteran's pilonidal cyst, status post-excision with residual tenderness, was not manifested by any symptoms subject to a rating in excess of 10 percent pursuant to 38 C.F.R. § 4.118, under either version of the Rating Criteria considered herein, at any time during the period on appeal. Thus, the Board finds that the evidence is persuasively against the claim. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable and the claim for entitlement to an initial rating in excess of 10 percent for the Veteran's service-connected pilonidal cyst is denied. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.7, 4.118, DC 7804; Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Service Connection Generally, to establish service connection a veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Certain diseases, including hearing loss and tinnitus, may be presumed to have been incurred in service when they manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection for a recognized chronic disease can also be established through continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (2013); 38 C.F.R. §§ 3.303(b), 3.309. To establish the presence of hearing loss for VA compensation purposes, the Veteran must show his bilateral hearing loss constitutes a disability by proffering evidence that the auditory threshold in any of the frequencies 500 Hertz (Hz), 1000 Hz, 2000 Hz, 3000 Hz, 4000 Hz are 40 decibels or greater; or at least three of the frequencies 500 Hz, 1000 Hz, 2000 Hz, 3000 Hz, 4000 Hz are 26 decibels or greater; or when speech recognition scores are less than 94 percent (Maryland CNC Test). 38 C.F.R. § 3.385. 2. Entitlement to service connection for bilateral hearing loss is denied. 3. Entitlement to service connection for tinnitus is denied. During his February 2020 hearing, the Veteran testified that he had in-service traumatic noise exposure due to his Air Force Specialty Code (AFSC) as an electrical power production specialist, which is confirmed by his DD-214. Specifically, the Veteran stated that he was exposed to extreme noise from large diesel engines and turbines during service. He further reported that his hearing loss and tinnitus initially manifested while he was serving on active duty. See February 2020 Hearing Transcript, pages 3, 14-17; June 2017 Certificate of Release or Discharge from Active Duty (e.g. DD 214, NOAA 56-16, PHS 1867). In support of his claim, the Veteran submitted a letter from his post-service roommate, K.B., dated in December 2017. K.B. indicated that the Veteran had a hard time hearing and shook his head when he returned from active duty service. He further stated that he and the Veteran researched hearing and tinnitus on the computer, and found that military and the Occupational Safety and Health Administration (OSHA) rules indicated that 90 percent of individuals who worked around diesel power plants for any length of time experienced hearing loss or tinnitus. The Veteran also submitted a letter from B.S., dated in December 2017. B.S. stated that the Veteran grabbed his ear and complained that it was ringing while they were running around. B.S. further stated that the Veteran's hearing also seemed "a little bit off" when he returned from active duty service but indicated that the Veteran declined to seek medical treatment at that time because he did not have insurance or extra money to cover the cost and did not want to go to VA. See December 2017 Buddy/Lay Statement. In addition, the Veteran submitted an article, titled Noise and Military Service: Implications for Hearing Loss and Tinnitus, which indicates that people serving in the military will, at some point, be exposed to high-intensity noise of various types and may develop tinnitus and/or hearing loss, especially for high frequency sounds. The article further states that time-weighted average noise exposures of approximately 85 dBa for eight hours per day for a 40-hour work week, or the equivalent, are considered to be hazardous for people exposed for multiple years; however, impulse noise with peak levels exceeding 140 dB SPL may be hazardous with a single exposure. He also submitted an article published on the Engineer website. See May 2017 Correspondence; April 2021 Correspondence. A review of the service treatment records (STRs) shows a December 1967 enlistment report of medical examination that notes the Veteran's ears and drums to be normal, and an audiogram obtained in connection with the examination revealed the following audiometric testing results: HERTZ 500 1000 2000 3000 4000 Right -5 -5 -5 --- 5 Left -5 -5 -5 --- 5 Audiological testing conducted 11 days after the Veteran's enlistment examination revealed the following audiometric testing results: HERTZ 500 1000 2000 3000 4000 Right -5 -5 -5 0 90 Left 0 0 -5 70 20 Thereafter, a May 1968 reference audiogram shows that the Veteran had been exposed to noise as a diesel operator without ear protection. The examiner noted the following audiometric testing results: HERTZ 500 1000 2000 3000 4000 Right -10 -10 -10 -5 5 Left -5 -5 -10 5 5 The Veteran also underwent audiometric testing in August 1969. The examiner indicated that the Veteran had been exposed to noise for 40 hours per week for one year and six to eleven months. The Veteran was also noted to have been exposed to gunfire during basic training and light duty arms. In addition, the examiner found that the Veteran always or frequently wore ear protection, most often muffs, during exposure to loud noise, and the Veteran did not report tinnitus prior to first exposure to noise or following exposure to noise at that time. The examiner noted the following audiometric testing results: HERTZ 500 1000 2000 3000 4000 Right 20 15 15 15 25 Left 25 15 15 15 25 The Veteran endorsed ear, nose, or throat trouble on his December 1969 separation report of medical history, but the examiner explained the Veteran's report referred to occasional non-incapacitating sore throats that he experienced in the past without complications or sequelae. To this end, the Veteran's ears and drums were noted to be normal on the corresponding report of medical examination, and audiometric testing conducted during the examination revealed the following audiometric testing results: HERTZ 500 1000 2000 3000 4000 Right 5 0 0 10 10 Left 0 5 0 10 10 In summary, there is no showing of any hearing loss for VA purposes in the Veteran's STRs. See January 2015 STR Medical; May 2017 Medical Treatment Record Government Facility. A review of the post-service treatment records shows that the Veteran was noted to have some hearing loss in September 2011. See May 2015 CAPRI. The Veteran was afforded a VA examination for hearing loss and tinnitus in June 2015. The examiner noted the following audiometric testing results: HERTZ 500 1000 2000 3000 4000 Right 15 20 15 55 60 Left 15 15 20 45 45 Speech recognition scores were 94 percent for the right ear and 96 percent for the left ear. The examiner diagnosed the Veteran with bilateral sensorineural hearing loss in the frequency range of 500-4000 Hz. After performing an examination and reviewing the evidence of record, the examiner opined that it was less likely than not that the Veteran's bilateral hearing loss was caused by or the result of an event in service. In support of her opinion, the examiner noted that the Veteran served as a power plant specialist from December 1967 through January 1970. In this regard, the examiner recognized the Veteran's assertions that he was exposed to noise from large diesel engines during service with some use of hearing protection devices but noted his puretone hearing evaluation at separation was normal. She further explained that the Veteran reported that his hearing loss manifested in or around 2013 during the examination and that he endorsed post-service occupational noise exposure. Specifically, the examiner noted that the Veteran worked as a carpenter until he retired at age 62 and that he had denied using hearing protection devices in his post-service occupation. Thus, the examiner found that the Veteran's bilateral hearing loss was not due to in-service noise exposure, as evidenced by his normal, stable hearing sensitivity at his separation from active duty service, significant post-military occupational noise exposure, and by his report that his hearing loss manifested in or around 2013, approximately 43 years after he was discharged from active duty service. With regard to tinnitus, the examiner noted that the Veteran had been diagnosed with tinnitus, and during the examination, the Veteran reported that he had been experiencing occasional tinnitus for two years. Following the examination, the examiner opined that it was at least as likely as not that the Veteran's tinnitus was a symptom of his diagnosed hearing loss because tinnitus was known to be a symptom associated with hearing loss. See June 2015 C&P examination. In August 2015, VA obtained an addendum medical opinion with regard to the Veteran's claim for entitlement to service connection for tinnitus. After reviewing the evidence of record, the examiner opined that it was less likely than not that the Veteran's tinnitus was caused by or the result of in-service noise exposure. The examiner noted that the Veteran's December 1967 enlistment audiogram, March 1968 reference audiogram, and December 1969 separation audiogram revealed normal hearing bilaterally. She further explained that tinnitus was a subjective complaint, that no objective measurements existed to verify the presence or absence thereof, and that the etiology of tinnitus could not be established using current clinical technologies. In this regard, the examiner reported that etiology of tinnitus was typically inferred by patient history and a review of the medical records. In this case, the VA examiner reported that the Veteran's claims file and STRs revealed no record or complaint of treatment for tinnitus, and that the Veteran reported a two year onset of tinnitus during the June 2015 VA examination. To this end, the examiner noted that it was widely accepted that noise-induced tinnitus occurred at the time of the noise exposure and did not develop years after. In addition, the examiner referenced a 2006 Institute of Medicine (IOM) study, which showed that the possibility that tinnitus would be triggered by other factors increased as the interval between a noise exposure and the onset of tinnitus increased. As such, the examiner opined that it was less likely than not that the Veteran's tinnitus was caused by or the result of in-service noise exposure. See August 2015 C&P examination. An October 2015 audiology note shows that the Veteran received hearing aids through VA. See August 2021 Correspondence. In support of his claim, the Veteran submitted a private audiological evaluation and medical opinion from Beltone, dated in February 2020, which showed the following audiometric testing results: HERTZ 500 1000 2000 3000 4000 Right 35 40 60 80 80 Left 40 40 40 60 55 Speech recognition scores were 88 percent for the right ear and 96 percent for the left ear, however, the report indicate whether Maryland CNC word list was not used to conduct speech recognition testing. The private treatment record further indicates that the Veteran had been diagnosed with bilateral sensorineural hearing loss, which was indicative of noise induced hearing loss in the frequency range from 3000 Hz to 8000 Hz. In this regard, the report notes that the Veteran had a history of exposure to high frequency power plant operation and diesel generations, which could explain his noise induced hearing loss. See March 2020 Medical Treatment Record Government Facility. The Veteran underwent a private audiological evaluation in January 2021, which revealed the following audiometric testing results: HERTZ 500 1000 2000 3000 4000 Right 50 45 25 60 60 Left 10 10 15 45 40 Speech recognition scores were 56 percent for the right ear and 100 percent for the left ear, however, the private audiologist did not indicate whether the Maryland CNC word list was used to conduct speech recognition testing. The impression was mild to moderately severe sensorineural hearing loss in the Veteran's right ear and normal sloping to moderate sensorineural hearing loss in his left ear. However, the private physician did not opine as to whether the Veteran's bilateral hearing loss was etiologically related to his active duty service. See December 2016 Medical Treatment Record Non-Government Facility. A February 2021 summary of electrophysiological testing from the Balance and Hearing Institute shows that the Veteran reported buzzing tinnitus in his right ear only, which began approximately two months prior, and a longstanding history of high-pitched ringing tinnitus for the right ear. The testing revealed normal peripheral vestibular function. See August 2021 Correspondence. After a review of the evidence of record, the Board finds that service connection for bilateral hearing loss and tinnitus is not warranted. In the present case, there is sufficient evidence the Veteran meets the threshold criterion for service connection of a current disability. Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000). Specifically, the June 2015 VA examiner diagnosed the Veteran with bilateral sensorineural hearing loss in the frequency range of 500 Hz through 4000 Hz and recurrent tinnitus. See June 2015 C&P examination. Accordingly, the Veteran meets the regulatory criteria for impaired hearing and recurrent tinnitus, and the remaining question is whether his claimed disabilities are related to service. 38 C.F.R. § 3.385. As to whether the Veteran's current bilateral hearing loss and tinnitus disabilities are related to service, the Board finds the June 2015 VA examination report, considered in conjunction with the August 2015 VA addendum medical opinion, to be the most probative evidence of record. In this regard, the Board finds the February 2020 private medical opinion to be inadequate as it is speculative in nature. To this end, the Board notes that speculative language such as "could explain" does not create an adequate nexus for the purposes of establishing service connection, as it does little more than suggest the possibility of a relationship. See Warren v. Brown, 6 Vet. App. 4, 6 (1993); Utendahl v. Derwinski, 1 Vet. App. 530, 531 (1991); Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992); Obert v. Brown, 5 Vet. App. 30, 33 (1993). The Board further notes that the Maryland CNC word list was not used to determine the Veteran's speech recognition scores, and it is unclear whether testing was conducted by a state-certified audiologist. See March 2020 Medical Treatment Record Government Facility. In contrast, the Board finds the June 2015 VA examination report, considered in connection with the August 2015 addendum medical opinion, to be the most probative evidence of record. After conducting an audiometric evaluation and reviewing the evidence of record, the June 2015 VA examiner opined that it was less likely than not that the Veteran's bilateral hearing loss and recurrent tinnitus disabilities were caused by or a result of an event in service. In coming to this conclusion, the June 2015 VA examiner noted that the Veteran had normal, stable hearing sensitivity when he was discharged from active duty service, significant post-military occupational noise exposure, and that he reported that his hearing loss manifested in or around 2013, approximately 43 years after he was discharged from active duty service, during the examination. See June 2015 C&P examination. With regard to tinnitus, the June 2015 VA examiner opined that it was at least as likely as not that the Veteran's diagnosed tinnitus was a symptom of his diagnosed bilateral hearing loss, and the August 2015 VA examiner opined that it was less likely than not that the Veteran's tinnitus was caused by or the result of military noise exposure. In support of her opinion, the examiner noted that the Veteran's STRs and post-service treatment records were absent for complaints or treatment for tinnitus, and that the Veteran reported a two year onset of tinnitus during the June 2015 VA examination. To this end, the examiner explained that it was widely accepted that noise-induced tinnitus occurred at the time of the noise exposure and did not develop years after. See August 2015 C&P examination. Thus, the Board finds that the June 2015 and August 2015 VA examiners thoroughly reviewed the claims file and discussed the relevant evidence, considered the contentions of the Veteran, and provided an adequate supporting rationale for the conclusions reached. Barr v. Nicholson, 21 Vet. App. 303 (2007); Stefl v. Nicholson, 21 Vet. App. 120 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board further acknowledges the Veteran's assertion that his hearing loss and tinnitus initially manifested while he was serving on active duty, and the December 2017 letters from K.B and B.S., which indicate that the Veteran experienced some degree of hearing loss after he returned from active duty service. See December 2017 Buddy/Lay Statement; February 2020 Hearing Transcript, page 21.. However, the Board finds that the most probative evidence of record reflects that the Veteran did not report hearing loss or tinnitus or seek treatment therefor until many years after his separation from service. The Board notes that there is no showing of any hearing loss for VA purposes or any records or complaints of tinnitus in the Veteran's STRs. To this end, the Veteran denied running ears on his December 1969 separation report of medical examination, and although he endorsed ear, nose, or throat trouble, the examiner clarified that the Veteran was referring to occasional sore throats in the past with no complications or sequelae. Significantly, however, the Veteran reported other symptoms and diagnoses, to include mumps, whooping cough, hay fever, and venereal disease, on his December 1969 separation report of medical history. See January 2015 STR Medical; May 2017 Medical Treatment Record Government Facility. Thus, the Board presumes that had the Veteran been experiencing hearing loss or tinnitus symptoms during service, he would have reported such symptoms in some form on his medical history report at separation. See May 2017 Medical Treatment Record Government Facility. In addition, the Board notes that the Veteran has provided inconsistent statements regarding the onset of his bilateral hearing loss and tinnitus symptoms. As noted above, the Veteran reported that his hearing loss and tinnitus symptoms manifested while he was serving on active duty during his February 2020 Board hearing. See, e.g., February 2020 Hearing Transcript, page 21. However, post-service treatment records show that the Veteran was initially noted to have some hearing loss in September 2011, approximately 41 years post-service, and he endorsed a two year onset of tinnitus on his June 2015 VA examination, indicating that his symptoms manifested 45 years after he was discharged from active duty service. See May 2015 CAPRI; June 2015 C&P examination. Also, for these same reasons, to the extent the Veteran is alleging continuity of hearing loss and tinnitus symptomatology since service, the Board does not find such an allegation persuasive. In this regard, the Board finds it significant the Veteran worked as a carpenter from 1972 until he retired in 2007 at age 62, denied using hearing protection devices in his post-service occupation, and was initially diagnosed with some degree of hearing loss in September 2011. See March 2015 CAPRI; June 2015 C&P examination. Accordingly, the Board cannot credit the Veteran's statements with regard to the onset and continuity of his bilateral hearing loss and tinnitus symptomatology. See Gardin v. Shinseki, 613 F.3d 1374, 1379 (Fed. Cir. 2010) (stating that the Board acted appropriately in its fact-finding role in its determination that lay statements of record were not credible because they are in direct contradiction to the medical evidence of record). In this regard, contemporaneous evidence may have greater probative value than history as reported by the Veteran at a later date. Curry v. Brown, 7 Vet. App. 59, 68 (1994). For the reasons cited above, the Board finds that the evidence is persuasively against a finding that the Veteran began to experience either hearing loss or tinnitus during or immediately after service. The Board further recognizes the Veteran's assertion that his claimed bilateral hearing loss and tinnitus disabilities are related to his in-service noise exposure. In this regard, a Veteran is considered competent to report the observable manifestations of his claimed disability. See Charles v. Principi, 16 Vet. App. 370, 374 (2002) ("ringing in the ears is capable of lay observation"); Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (lay testimony iterating knowledge and personal observations of witness are competent to prove that claimant exhibited certain symptoms at particular time following service). While a Veteran can competently report the onset and continuity of hearing loss symptoms, an actual diagnosis of sensorineural hearing loss requires objective testing to determine whether it is severe enough to be considered a disability for VA compensation purposes. Moreover, hearing loss can have many causes, and the Veteran is not competent to opine as to etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376, 1377 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). However, for the reasons stated above, the Board concludes that any lay assertions by the Veteran in the present case are outweighed by the medical evidence of record, including the June 2015 and August 2015 VA medical opinions. As stated above, the examiners have training, knowledge, and expertise on which they relied to form their opinions and they provided persuasive rationales. Accordingly, the Board finds that the evidence is persuasively against the claim. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable and service connection for bilateral hearing loss and tinnitus is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 4. Entitlement to a TDIU is denied. At the outset, the Board notes that the Veteran filed his claim for entitlement to a TDIU in August 2011. To this end, the Veteran reported that his service-connected pilonidal cyst status-post excision with residual tenderness prevented him from obtaining and maintaining substantially gainful employment. See August 2011 VA 21-8940 Veterans Application for Increased Compensation Based on Unemployability. A TDIU may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16(a). TDIU will be granted when the evidence shows that the veteran, due to service-connected disabilities, is precluded from obtaining or maintaining any gainful employment consistent with their education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. It is the established policy of the Department of Veterans Affairs 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. Therefore, rating boards should submit to the Director, Compensation Service, for extra-schedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in paragraph (a) above. The Veteran has been service connected for the following disabilities: pilonidal cyst status-post excision with residual tenderness rated as 10 percent disabling from March 12, 2007; scars associated with pilonidal cyst removal rated as non-compensable from October 23, 2008; and an acquired psychiatric disorder, to include generalized anxiety disorder and depression, rated as 30 percent disabling from May 11, 2016. See October 2021 Rating Decision Codesheet. Thus, the Veteran's combined disability rating was 10 percent from March 12, 2007 to May 11, 2016, and 40 percent thereafter. Thus, the Veteran did not meet the schedular criteria for assignment of a TDIU at any point during the period on appeal. See 38 C.F.R. § 4.16(a). However, the Board must still consider whether referral for extraschedular consideration is warranted. Turning to the evidence of record, in a December 2010 statement, the Veteran endorsed excruciating pain when he bumped his scar or sat in certain positions, which interfered with his work in construction. See November 2010 Correspondence. In August 2011, the Veteran reported that his service-connected pilonidal cyst prevented him from securing or following any substantially gainful employment. In this regard, he indicated that he last worked as a carpenter for United Realty Group from 2001 until he became too disabled to work in December 2006, and noted that he lost 10 months of time due to illness. The Veteran further stated that he left his last job because of his service-connected disability and indicated that he did not receive disability retirement or workers compensation benefits. He further reported that he completed two years of high school. See September 2011 VA Form 21-8940 Veterans Application for Increased Compensation Based on Unemployability. An application for service disabled veterans insurance, received in August 2011, shows that the Veteran reported that his previous employer, United Realty, had to let him go from his carpentry work because he was unable to perform some of the work because the surgery he underwent to have his pilonidal cyst removed caused residual tenderness. He also indicated that he had never required any form of drug treatment of rehabilitation or been forced to discontinue employment as a result of the use or alcohol or drugs. In addition, he endorsed anxiety and hearing loss and stated that he gained approximately 35 pounds because he was unable to work. See August 2011 Third Party Correspondence. A letter the Veteran's former employer, received in December 2011, indicates that the Veteran worked as a sub-contractor from 2001 to 2006. However, it further states that the Veteran had to be released from his duties because he was unable to perform required duties due to his back problems. See September 2011 Third Party Correspondence. A November 2012 work history report completed in connection with the Veteran's claim for SSA disability benefits shows that the Veteran intermittently worked as a carpenter from 1972 to 2007. He noted that he was employed as a lead, worked and supervised five people, with the power to hire and fire employees, during that time. He subsequently worked as a plumber's helper from 2008 through 2009 and as a salesperson at a flea market from 2010 through 2012. In addition, functional reports completed by the Veteran and his wife in November 2012 indicate that the Veteran was unable to work, in part, because of his severe anxiety and depression. They also noted that his non-service connected disabilities, to include severe back pain and numbness and tingling in his bilateral feet and legs, which led him to forget things and lose concentration, and stomach damage limited his ability to work. A disability determination and transmittal form, dated in January 2012, shows that the Social Security Administration (SSA) found the Veteran to be disabled from April 2012 and reported his primary diagnosis as discogenic and degenerative disorders of the back. Anxiety related disorders were noted as secondary diagnoses. See June 2014 Medical Treatment Records Furnished by SSA. A December 2012 examination obtained in connection the Veteran's claim for benefits from the Tennessee Disability Determination Services shows that the Veteran reported neuropathy in his hands and feet, cholesterol problems, and back problems resulting from a work injury in which he fell off of a 30 ft high scaffold. In addition, he endorsed anxiety and noted that his family doctor had started prescribing anti-depressant medication. In addition, during a subsequent January 2013 examination, the Veteran continued to report back pain, which manifested after he fell off a scaffold and sustained a crush fracture 12 years earlier. To this end, he indicated that saw a neurosurgeon and pursued a Worker's Compensation case. The Veteran further reported that he did not do any chores or grocery shop and indicated that he last worked three years prior and that he had been in construction for "his whole life." In addition, the disability determination services examiner noted that the Veteran brought in a cane but did not use it and that the Veteran had a 10th grade education with some military training. See December 2012 VA examination. In addition, a December 2012 disability evaluation shows that the Veteran's diagnosed generalized anxiety disorder, dysthymic disorder, and panic disorder with agoraphobia mildly impaired his ability to sustain concentration and attention and interact with others, mildly to moderately impaired his ability to understand and remember information, and moderately impaired his ability to adapt to changes and requirements. See June 2015 Medical Treatment Records Furnished by SSA. In September 2013, the Veteran reported that his tenderness and soreness associated with his pilonidal cyst prevented him from performing jobs that required working under the floors of houses and running duct work in small, contained areas. He indicated that he had to stop performing work that required him to lie on his back, to include duct work, and reported that he had to stop performing that type of work. He further reported that his pilonidal cyst and anxiety impaired his ability to work. See October 2013 Correspondence. The Veteran underwent a VA examination for skin diseases in January 2015. The examiner noted that the Veteran had been diagnosed with a cyst but found that the surgical site of the excision was completely healed and did not impact his ability seek or maintain appropriate employment. See May 2015 CAPRI. A March 2015 VA Form 21-4192 shows that the Veteran worked in construction from January 2006 through May 2007. The Veteran was noted to work approximately three hours per day for a total of nine hours per week and indicated that he lost approximately thirty-one hours of time due to disability over the 12 months preceding his last day of employment. He further indicated that the Veteran was not working due to low back pain from his cyst operation. See March 2015 VA Form 21-4192 Request for Employment Information in Connection with Claim for Disability. In March 2015, the Veteran indicated that his service-connected pilonidal cyst was manifested by constant, progressive pain, tenderness, and soreness. He also indicated that he was not able to sleep on his back and noted that pain medication prescribed by VA did not help. See March 2015 VA Form 21-4138 Statement in Support of Claim. In March 2015, the Veteran reported that his service-connected low back pilonidal cyst operation prevented him from securing or following any substantially gainful employment. In this regard, he indicated that he retired in 2010 and last worked six hours per week at flea markets and yard sales from May 2012 to August 2012, when he became too disabled to work. The Veteran further stated that he left his last job because of his service-connected disability and indicated that he did not receive or expect disability retirement or workers compensation benefits. He further reported that he completed two years of high school and indicated that he was unable to obtain or maintain employment because he could only work two to three hours per week. See April 2015 Form 21-8940 Veterans Application for Increased Compensation Based on Unemployability. In his May 2016 substantive appeal, the Veteran reported that back pain and anxiety related to his service-connected pilonidal cyst caused him to become unemployable. See May 2016 VA Form 9. The Veteran underwent a VA examination for mental disorders in June 2016. The examiner found that the Veteran's generalized anxiety disorder was manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. During the examination, the Veteran reported that he worked in a rubber and plastics manufacturing plant after he was discharged from active duty service, stating that he found a job that allowed him to stand at work because he could not tolerate sitting for long periods due to his back problems at the time. He also reported that he helped run his father's small business, including a small store and rental properties, until his father's wife liquidated the assets. Thereafter, he stated that he worked as a carpenter in 2007, as a Plummer's Helper from 2008 through 2009, and as a flea marked salesman from 2010 through 2012. In addition, the Veteran indicated that he worked multiple odd jobs, and noted that, although he retired when he was 62 years old, he occasionally helped at his brother's handyman business and selling items at flea markets and on the internet at the time of the examination. See January 2017 CAPRI. In support of his claim, the Veteran submitted a letter from his post-service roommate, K.B., dated in December 2017. K.B. stated that the Veteran was unable to work due to his tremendous back pain and problems. See August 2021 Correspondence. The Veteran underwent VA examinations for skin diseases and scars/disfigurement in May 2021. Following the examinations, the examiner opined the Veteran's service-connected pilonidal cyst and residual scars made it difficult for him to bend over due to inflexibility of the skin at the site of his surgical scars. See May 2021 C&P examination. After a review of the evidence of record, the Board finds that the Veteran's service-connected disabilities did not prevent him from securing and maintaining substantially gainful employment at any point during the period on appeal. In this regard, the Board recognizes that the Veteran's pilonidal cyst, impacted his ability to work by making it difficult for him to bend over due to inflexibility of the skin at the site of his surgical scars. See May 2021 C&P examination. In addition, the Board acknowledges that the Veteran's service-connected acquired psychiatric disorder was manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks throughout the relevant period. See January 2017 CAPRI. To this end, the Board finds that the Veteran's acquired psychiatric disorder, at worst, imposes mild to moderate impairments on his ability to sustain concentration and attention, interact with others, understand and remember information, and adapt to changes and requirement. See June 2015 Medical Treatment Records Furnished by SSA. However, the Board finds that the Veteran's service-connected pilonidal cyst and acquired psychiatric disorder did not impose restrictions, which when considered collectively and independently, preclude him from obtaining or maintaining employment. In addition, the Board recognizes the Veteran's reports that his service-connected pilonidal cyst caused his diagnosed lumbar spine disabilities and related lower back pain, which prevented him from working. See, e.g., August 2021 Correspondence. In this regard, the Board notes that a disability determination and transmittal form, dated in July 2016, shows that SSA found the Veteran to be disabled due primarily to discogenic and degenerative disorders of the back. See November 2019 Medical Treatment Records Furnished by SSA. However, for the reasons discussed above, the Board finds that the Veteran's lumbar spine disability was not caused or aggravated by his service-connected pilonidal cyst, and the Board notes that the Veteran's nonservice-connected disabilities cannot be considered for determining entitlement to a TDIU. Thus, while it is clear that the Veteran has some occupational and functional impairment as a result of his service-connected disabilities, the evidence does not support that the Veteran's service-connected disabilities alone preclude him from securing and maintaining substantially gainful employment. Moreover, although the evidence shows that the Veteran has continued to work odd jobs, to include occasionally assisting his brother's handyman business and selling items at flea markets and on the internet, he was last employed full time as a plumber's helper in or around 2009. Thus, the Board finds that he has not been employed full-time at any time during the period on appeal. See January 2017 CAPRI. However, the Board notes that the Veteran reported that he was employed as a lead worker during while he was employed as a carpenter from 1972 to 2007. Specifically, he indicated that he supervised five people, with the power to hire and fire employees, during that time. See June 2014 Medical Treatment Records Furnished by SSA. The Board finds that the Veteran's experience as a supervisor would help qualify him for a less physical job that does not require frequent bending. (Continued on the next page) Thus, while it is clear that the Veteran experienced some occupational and functional impairment as a result of his service-connected disabilities, the evidence does not support that the Veteran's service-connected disabilities alone precluded him from securing and maintaining substantially gainful employment. Specifically, the Board finds that the records show the Veteran service-connected disabilities did not preclude him from performing work that does not require frequent bending. In sum, the Board finds that the evidence weighs against a finding that the Veteran meets the requirements for entitlement to a referral of his TDIU claim for consideration on an extraschedular basis. 38 C.F.R. § 4.16(a-b). Accordingly, the Board declines to refer the claim to the Director of VA Compensation Service for consideration of TDIU on an extraschedular basis. The claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Justis, 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.