Citation Nr: 22018701 Decision Date: 03/30/22 Archive Date: 03/30/22 DOCKET NO. 16-53 340A DATE: March 30, 2022 ORDER Entitlement to an evaluation greater than 10 percent for coronary artery disease prior to January 18, 2013, and greater than 30 percent prior to July 24, 2016, is denied. Entitlement to a total rating based on individual unemployability (TDIU), to include referral on an extraschedular basis, prior to July 24, 2016, is denied. FINDINGS OF FACT 1. Prior to January 18, 2013, the evidence persuasively weighs against a finding that symptoms of the Veteran's coronary artery disease manifested in a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. 2. Prior to January 18, 2013, the evidence persuasively weighs against a finding that symptoms of the Veteran's coronary artery disease manifested in a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. 3. Prior to January 18, 2013, the evidence persuasively weighs against a finding that symptoms of the Veteran's coronary artery disease manifested in chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. 4. From January 18, 2013, to July 23, 2016, the evidence persuasively weighs against a finding that symptoms of the Veteran's coronary artery disease manifested in more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. 5. From January 18, 2013, to July 23, 2016, the evidence persuasively weighs against a finding that symptoms of the Veteran's coronary artery disease manifested in chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. 6. Prior to July 24, 2016, the evidence persuasively weighs against a finding that a there is sufficient evidence to substantiate a reasonable possibility that the Veteran is unemployable due to his service-connected disability, to include referral to the Director of Compensation Service for consideration on an extraschedular basis. 7. Prior to July 24, 2016, the evidence persuasively weighs against a finding that the Veteran's service-connected disability rendered him unable to secure or follow a substantially gainful occupation. 8. Prior to July 24, 2016, the evidence persuasively favors a finding that the average impairment in earning capacity due to the Veteran's service-connected disability symptoms are adequately compensated and accounted for in the Veteran's schedular ratings. CONCLUSIONS OF LAW 1. The criteria for entitlement to an evaluation greater than 10 percent for coronary artery disease prior to January 18, 2013, and greater than 30 percent prior to July 24, 2016, 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, 4.104, Diagnostic Code 7005. 2. The criteria for entitlement to a TDIU, to include referral on an extraschedular basis, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.340, 3.341, 4.15, 4.16, 4.18. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from July 1964 to June 1966, to include service in the Republic of Vietnam. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a November 2013 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO), which serves as the Agency of Original Jurisdiction in this case. In an October 2016 rating decision, the evaluation for the Veteran's coronary artery disease was increased to 100 percent, effective July 24, 2016. As the increase was not a full grant of the benefits sought on appeal, an issue remains for the Board to adjudicate. See AB v. Brown, 6 Vet. App. 35 (1993). The Board remanded this case in April 2018 for "the RO [to] clarify the effective date of the award of a 100 percent rating" and to "adjudicate whether the Veteran's [coronary artery disease] renders the Veteran unable to obtain substantially gainful employment." See April 2018 BVA Decision. In an April 2020 decision, the Board denied entitlement to a disability rating greater than 30 percent prior to July 24, 2016, entitlement to a disability rating greater than 100 percent from July 24, 2016, and entitlement to a TDIU. See April 2020 BVA Decision. In a January 2022 Joint Motion for Partial Remand (JMPR), the Court vacated that portion of the Board's April 2020 decision to the extent that it denied the Veteran entitlement to a rating greater than 30 percent prior to July 24, 2016, and entitlement to a TDIU. See January 2022 CAVC Joint Motion for Partial Remand. This case has been advanced on the docket pursuant to 38 U.S.C. § 7107(b) and 38 C.F.R. § 20.902(c). Duty to Notify and Assist Neither the Veteran nor his representative have raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board...to search the record and address procedural arguments when the veteran fails to raise them before the Board"); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). The decision below substantially complies with the instructions contained in the January 2022 CAVC remand. See Stegall v. West, 11 Vet. App. 268 (1998). An additional remand for further development of this claim would serve no useful purpose. Accordingly, the Board finds that no prejudice to the Veteran will result from the adjudication of his claim in this Board decision. The Board notes that it has thoroughly reviewed the record in conjunction with this case. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that "absent specific evidence indicating otherwise," VA is presumed to have reviewed all evidence in the record when making a determination.). Although the Board has an obligation to provide adequate reasons and bases for its decisions, there is no need to discuss, in detail, the entire body of evidence. See Dela Cruz v. Principi, 15 Vet. App. 143, 149 (2001) (holding that the Board is not required to discuss all of the evidence of record but rather it must address the relevant evidence.); see also Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). To that end, the Board's analysis will focus specifically on what the evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant). Any failure by the Board to mention evidence in its decision does not trigger a presumption that it was not considered. See Newhouse v. Nicholson, 497 F.3d 1298, 1302 (Fed. Cir. 2007). 1. Entitlement to an evaluation greater than 10 percent for coronary artery disease prior to January 18, 2018, and greater than 30 percent prior to July 24, 2016. The Veteran asserts that he is entitled to a 60 percent rating for his service-connected coronary artery disease prior to July 24, 2016. See May 2014 VA Form 21-0958, Notice of Disagreement. The Veteran also contends that the evidence "more closely approximates the 100 percent rating under Diagnostic Code 7005 for his coronary artery disease throughout the pendency of this claim." See March 2018 and March 2020 DAV Appellate Briefs. Increased Ratings A disability claim includes "five common elements...status as a veteran, the existence of a disability, a connection between the veteran's service and the disability, the degree of the disability, and the effective date of the disability." See Collaro v. West, 136 F.3d 1304, 1308 (Fed. Cir. 1998); see also Grantham v. Brown, 114 F.3d 1156, 1160 n.1 (Fed. Cir. 1997). Disability evaluations are determined by the application of facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) in 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred in or aggravated during military service and the residual conditions in civilian occupations. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. See 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Under 38 C.F.R. § 4.2, a rating specialist is directed to review the recorded history of a disability to make a more accurate evaluation. However, the regulations do not give past medical reports precedence over current findings. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt as to the degree of disability will be resolved in favor of the Veteran. See 38 C.F.R. § 4.3. A claim for an increased rating is a new claim. See Suttmann v. Brown, 5 Vet. App. 127, 136 (1993) (claim for increase "based upon facts different from the prior final claim"); see also Proscelle v. Derwinski, 2 Vet. App. 629, 631-32 (1992) (in claim for increased rating "veteran claims that his service-connected disability has undergone an increase in severity since that prior claim" (emphasis in original)). The period of consideration for "factually ascertainable" evidence in a new claim for increased rating begins one year prior to the claim for increase and extends until VA makes a final decision on the claim. See 38 C.F.R. § 3.400(o); Fenderson v. West, 12 Vet. App. 119, 126 (1999). While older evidence is not necessarily irrelevant, it is generally not needed to determine the effective date of an increased rating. See Francisco v. Brown, 7 Vet. App. 55 (1994). The United States Court of Appeals for Veterans Claims (CAVC) noted in Hart v. Mansfield, 21 Vet. App. 506 (2007), "As with an initial rating, the question of whether the evidence is in conflict or merely demonstrates a changing level of disability is a factual question for the Board to make." See also Layno v. Brown, 6 Vet. App. 465, 469 (1994). In Hart, the CAVC held "that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart, supra. When initially rating an original claim, "separate ratings can be assigned for separate periods of time based on facts found," a practice known as "staged" ratings. See 38 C.F.R. §§ 3.400, 3.500; see also McClain v. Nicholson, 21 Vet. App. 319, 323 (2007) (If VA's adjudication of an increased claim is lengthy, a claimant may experience multiple distinct degrees of disability that would result in different levels of compensation from the time the increased rating claim was filed until a final decision on that claim is made. Thus, VA's determination of the "present level" of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased rating claim has been pending.). Evidence of record from the time an application for disability benefits is presented should be considered in an initial evaluation of a service-connected disability. See Fenderson, supra; see also Moore v. Nicholson, 21 Vet. App. 211, 216-17 (2007) (for initial disability rating, VA must consider severity of disability during period for which veteran is eligible for service connection starting on the date application was filed). Analysis Under 38 C.F.R. § 4.7, the Veteran is entitled to the benefit of the rating criteria that will result in the higher evaluation of his disability. The Veteran has been evaluated under 38 C.F.R. § 4.104, Schedule of ratings cardiovascular system, Diagnostic Code 7005, Arteriosclerotic heart disease (coronary artery disease). Under Diagnostic Code 7005, a 10 percent rating is assigned for workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required. A 30 percent rating is assigned for workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent rating is assigned for more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Finally, a 100 percent rating is assigned for chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. See 38 C.F.R. § 4.104, Diagnostic Code 7005. [Amendments were made to the rating criteria for cardiac conditions effective November 9, 2021. However, since the Board is evaluating the rating for the Veteran's heart condition on and prior to July 24, 2016, those amendments (which include the establishment of a General Rating Formula for Diseases of the Heart) do not apply.] One MET (metabolic equivalent) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. See 38 C.F.R. § 4.104, Note 2. Applying the evidence in the record to the Veteran's claim for an increased rating prior to January 18, 2013, the evidence persuasively weighs against factually ascertainable evidence that the Veteran met the applicable evaluation criteria for a higher rating. Regarding a 30 percent evaluation, the record does not contain evidence of a workload greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram or X-ray. At the September 2010 VA medical examination, the Veteran expressed an ability to "lift 10 lbs...do laundry, rake leaves, use push lawn mower, limited by back pain / knee pain." See September 2010 VA Heart Conditions examination report. While mowing the lawn with a push mower and heavy yard work is associated with a workload of 5 7 METs, the Veteran did not report dyspnea, fatigue, angina, dizziness, or syncope associated with this type of workload. An EKG at the September 2010 VA examination produced electrical signals at 9 out of 10 points, with a normal sinus rhythm, and a heartbeat of 70 per minute. See September 2010 VA Heart Conditions examination report. In November 2011, the Veteran denied "chest pains [] shortness of breath...edema [] orthopnea, palpitations." See November 2011 VA Cardiology Note. While washing his truck in December 2011, the Veteran experienced "back and chest pain...no shortness of breath." The Veteran reported, "[T]his is the first episode since [the] September [2011] heart catherization," while he denied a history of "dizziness, fainting, headaches, blurred vision, weakness, fatigue, chest pain." See January 2012 VA Primary Care Nurse Practitioner / Physician Assistant Scheduled Visit. Regarding the criteria for a 60 percent evaluation prior to January 18, 2013, the record does not contain evidence of more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. The September 2010 VA examination reflects "METs level depending on veteran's level of activity and symptoms: 5 MET[s]," but there is no indication of whether this was the result of diagnostic stress testing or if it was an estimate by the Veteran or the examining physician. In January 2012, the Veteran attributed "dizzy spells" to an inner ear condition and reported they had resolved "after ear wash." See January 2012 Dr. K.T., MD Treatment Note. He continued to deny symptoms of "dizziness, fainting, headache, blurred vision, weakness, fatigue, chest pain, shortness of breath." See July 2012 VA Primary Care Nurse Practitioner / Physician Assistant Scheduled Visit, October 2012 VA Primary Care Note, and February 2013 VA Primary Care Note. As mentioned previously, the Veteran indicated the ability to "lift 10 lbs...able to do laundry, rake leaves, use push mower," which is consistent with a workload of 5 7 METs. See September 2010 VA Heart Conditions examination report. An August 2011 diagnostic exercise test measured METs of 8.5, consistent with activities such as climbing stairs quickly, moderate bicycling, sawing wood, and jogging at 6 mph. The March 2012 VA examination diagnosed congestive heart failure, but it was not chronic and did not occur more than once in the previous year. See March 2012 VA Heart Conditions examination report and March 2012 VA Form 21-0960A-1, Ischemic Heart Disease Disability Benefits Questionnaire. Regarding the criteria for a 100 percent evaluation prior to January 18, 2013, the record does not contain evidence of chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. As noted previously, the Veteran was diagnosed with congestive heart failure at the March 2012 VA examination. However, it was not determined to be chronic, and there was not more than one episode of acute congestive heart failure in the previous year. Also noted previously, an August 2011 diagnostic exercise test measured METs of 8.5, consistent with activities such as climbing stairs quickly, moderate bicycling, sawing wood, and jogging at 6 mph. See March 2012 VA Heart Conditions examination report and March 2012 VA Form 21-0960A-1, Ischemic Heart Disease Disability Benefits Questionnaire. A February 2013 nuclear stress test measured left ventricle ejection fraction at 61 percent. See October 2013 VA Heart Conditions examination report. Applying the evidence in the record to the Veteran's claim for an increased rating from January 18, 2013, to July 23, 2016, the evidence persuasively weighs against a finding that an increased rating is warranted. The record does not provide factually ascertainable evidence that the Veteran met the applicable evaluation criteria: 1) more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent; or 2) Chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent for a rating greater than 30 percent during the relevant period on appeal. In the May 2014 notice of disagreement, the Veteran's representative declared: "Vet states that he suffers from constant fatigue is unable to complete simple tasks, i.e., mowing the lawn, walking distances of 40' or more, climbing staircases. He maintains that he gets dizzy very easily and has not been able to maintain any type of employment since the onset of his condition." See May 2014 VA Form 21-0958, Notice of Disagreement. For the reasons set forth below, the Board finds that the statements of the Veteran's representative regarding the health of the Veteran in May 2014 are inconsistent with one another and with the medical evidence of record. See Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). For these reasons, the Board affords less probative value and weight to the May 2014 statements provided by the Veteran's representative. Statements provided during medical treatment are usually afforded greater probative weight, particularly if close in time to the onset thereof. See Buchanan, supra. Contemporaneous medical evidence has greater probative value than the Veteran's reports of history. See Curry v. Brown, 7 Vet. App. 59 (1994). The contemporaneous medical evidence demonstrates: 1) that the Veteran complained of "back pain / knee pain," which precipitated "shortness of breath or chest pain" (See September 2010 VA Heart Conditions examination report); 2) that the Veteran reported "midback pain for 35 years" (See September 2013 VA Primary Care Nurse Practitioner / Physician Assistant Scheduled Visit); 3) that the Veteran reported "back and chest pain while washing his truck this past Saturday, no shortness of breath" (See January 2012 VA Primary Care Nurse Practitioner / Physician Assistant Scheduled Visit); 4) that the Veteran attributed "chest tightness" to "back spasms" three times in six months (See January 2013 VA Cardiology Progress Note); 5) that the Veteran's congestive heart failure was not considered chronic, and he did not experience more than one episode of acute congestive heart failure in the previous year (See March 2012 VA Heart Conditions examination report); 6) that the Veteran reported angina only at "high levels of activity" (See March 2012 VA Form 21-0960A-1, Ischemic Heart Disease Disability Benefits Questionnaire); 7) that the Veteran regularly denied "dizziness, fainting, headaches, blurred vision, weakness, fatigue, chest pain" at VA treatment (See July 2012, October 2012, February 2013, September 2013, September 2015, and March 2016 VA Cardiology Progress, VA Primary Care, and VA Primary Care Nurse Practitioner / Physician Assistant Scheduled Visit Notes); 8) that a February 2013 nuclear stress test measured left ventricle ejection fraction at 61 percent (See October 2013 VA Heart Conditions examination report); 9) that the Veteran reported "short pains in his left chest with exertion...primarily when he went to the mailbox and back" (See November 2013 VA Cardiology Progress Note; see also September 2015 VA Cardiology Progress Note, "has to go several hundred yards to get to the mailbox"); 10) that the Veteran reported "chest discomfort with some association with food, occurring every 2 weeks" (See November 2013 VA Cardiology Progress Note); 11) that the Veteran reported "occasional chest pains and shortness of breath" only with "exertion" (See February 2014 VA Primary Care Note); 12) that the Veteran regularly reported feeling "well" (See December 2013 VA Cardiology Progress Note, February 2014 VA Primary Care Note, and May 2015 VA Primary Care Nurse Practitioner / Physician Assistant Scheduled Visit Note); and 13) that the Veteran reported "very rare episodes of exertional angina, which resolve very quickly with rest" and "[n]o worsening" of symptoms or functioning prior to his June 2016 blood clot-based myocardial infarction (See September 2015 and March 2016 VA Cardiology Progress Notes). Still, the Veteran did report an isolated instance of feeling "lightheaded briefly while walking across the street to the VA [Medical Center]" during VA treatment. See June 2012 VA Cardiology Progress Note. However, there is no indication in the record that he became lightheaded simply because he crossed the street. In Madden v. Gober, 125 F.3d 1477, 1480-1481 (Fed. Cir. 1997), the Court explicitly rejected the argument that, "[T]he Board must accept the Veteran's evidence at face value and reject or discount it only on the basis of rebuttal evidence proffered by the agency." The record does not contain additional evidence of the Veteran feeling "lightheaded," particularly on his way to VA treatment. In fact, the Veteran denied a history of "lightheadedness" in December 2013. See December 2013 VA Cardiology Progress Note. Moreover, the Veteran stated repeatedly that he experienced chest pain with "high levels of activity (See March 2012 VA Form 21-0960A-1, Ischemic Heart Disease Disability Benefits Questionnaire)," defined as "primarily when he went to the mailbox and back," further clarified as "several hundred yards to get to the mailbox (See November 2013 and September 2015 VA Cardiology Progress Notes)." Given the evidence to the contrary, the Board does not accept the June 2012 statement at face value, considers the statement by the Veteran to be an outlier when compared to recorded symptoms, or lack thereof, and affords less probative value and weight to the statement. See Madden, supra. Further, the Veteran provided an Ischemic Heart Disease Disability Benefits Questionnaire in October 2016. In pertinent part, the Questionnaire recorded the following responses: "3A. Does the Veteran have congestive heart failure? 'Yes.' 3B. Is the Veteran's congestive heart failure chronic? 'Yes.' 3C. If the Veteran's congestive heart failure is not chronic, has the Veteran had more than one episode of acute congestive heart failure in the past year? 'Yes'...4B. Lowest level of activity at which Veteran reports symptoms...'3 5 METs (This METs level has been found to be consistent with activities such as light yard work (weeding), mowing lawn (power mower), brisk walking (4 mph)).'" See October 2016 Ischemic Heart Disease Disability Benefits Questionnaire. The statements contained in the October 2016 Questionnaire are not confirmed by contemporary, objective medical evidence. See Curry, supra. For the reasons set forth, the Board affords limited credibility and little probative value to the October 2016 Questionnaire provided by the Veteran. First, the October 2016 Questionnaire does not indicate that the authoring physician, Dr. A.N., examined the Veteran in person. Second, the October 2016 Questionnaire does not indicate that the authoring physician, Dr. A.N., reviewed the claims file and evidence of record, including the Veteran's medical history, in preparation of the Questionnaire. Third, the October 2016 Questionnaire indicates both that the Veteran does and does not have chronic congestive heart failure, which is part of the evaluation criteria for a higher rating. Fourth, the October 2016 Questionnaire responses regarding cardiac functional assessments were based on the Veteran's responses and not objective medical criteria such as exercise stress tests, nuclear stress tests, spirometry testing, or echocardiogram reporting. See October 2016 Ischemic Heart Disease Disability Benefits Questionnaire. Fifth, echocardiogram testing in July 2016 estimated left ventricle ejection fraction at "50 55%." See July 2016 Christian Hospital Northeast Echocardiogram Report and October 2016 Ischemic Heart Disease Disability Benefits Questionnaire. Sixth, the October 2016 Questionnaire indicates that the Veteran had congestive heart failure in "8/2016" at "CNE [Christian Hospital Northeast]." The Veteran provided records from Christian Hospital Northeast from July 24 28, 2016. See July 24, 2016, Christian Hospital Northeast Emergency Department Triage Note and July 28, 2016, Discharge Summary. Seventh, the July 2016 Christian Hospital Northeast treatment records do not contain a diagnosis of congestive heart failure for the Veteran. See July 2016 Christian Hospital Northeast Portable Chest X-ray ("There is no evidence of pneumothorax or pleural effusion.") and Discharge Summary ("Admitting Diagnoses: 1. Acute anterior myocardial infarction; 2. Hypomagnesemia; 3. Hypertension, uncontrolled; 4. Dyslipidemia; 5. Medication noncompliance. Discharge Diagnoses: 1. Acute anterior ST-elevation myocardial infarction; 2. Coronary artery disease; 3. Hypertension; 4. Dyslipidemia; 5. Medication noncompliance."). The record does not indicate, nor does the Veteran contend, in favor of the application of any other diagnostic code under 38 C.F.R. § 4.104, Schedule of ratings cardiovascular system, for the Veteran's service-connected coronary artery disease. The Veteran has not been diagnosed with Valvular heart disease, Rheumatic heart disease, Endocarditis, Pericarditis, Pericardial adhesions, Syphilitic heart disease, Hypertensive heart disease, Hyperthyroid heart disease, Supraventricular arrhythmias, Ventricular arrhythmias (sustained), Atrioventricular block, Heart valve replacement (prosthesis), Coronary bypass surgery, Implantable cardiac pacemaker, or Cardiac transplant. See November 2013 VA Cardiology Progress Note, July 2016 Christian Hospital Northeast Discharge Summary, and October 2016 Ischemic Heart Disease Disability Benefits Questionnaire. Therefore, no alternative or additional diagnostic codes are for application. See Horowitz v. Brown, 5 Vet. App. 217, 224 (1993) ("The lack of reasons or bases for the Board's decision favoring one diagnostic code over others 'frustrates effective judicial review.'" Lendenmann v. Principi, 3 Vet. App. 345, 350 (1992) quoting Camp v. Pitts, 411 U.S. 138, 142, 93 S.Ct. 1241, 1244, 36 L.Ed.2d 106 (1973)). Extraschedular evaluation under 38 C.F.R. § 3.321(b), which is not raised by the Veteran or by the record, is not for application. To reasonably raise the issue of entitlement to an extraschedular consideration referral, the record must suggest, at a minimum, that the Veteran's service-connected disability is of an exceptional nature in some respect. Exceptionality is assessed by comparing the severity of symptoms of a claimant's service-connected disability with the relevant rating criteria to determine whether the Veteran's disability picture is contemplated in the criteria. See Long v. Wilkie, 33 Vet. App. 167 (2020). Extraschedular ratings are not an alternative path to compensation. They are only available where a disability is incapable of evaluation under the rating schedule. Whether the full scope of a disability is contemplated by applicable rating criteria in the diagnostic codes does not hinge on the mere comparison of documented symptoms and rating criteria: "The governing norm in these exceptional cases is a finding by the Director of Compensation Service or delegate that application of the regular schedular standards is impractical because the disability is so exceptional or unusual due to such related factors as marked interference with employment or frequent periods of hospitalization." See 38 C.F.R. § 3.321(b)(1). The Veteran has been unemployed since 1992. Prior to his July 2016 hospitalization for a blood clot-induced myocardial infarction, the Veteran had angioplasty procedures performed in 1992 and again in 2011. See March 2012 VA Heart Conditions examination report. The Board does not find such an unusual disability picture as to render the applicable rating criteria impractical due to such factors as marked interference with employment or frequent periods of hospitalization. Further, the Board finds that the symptoms of the Veteran's coronary artery disease are adequately reflected by the current rating schedule. Conclusion In summary, the Veteran is competent to report on factual matters of which he has firsthand knowledge, e.g., chest pain and dizziness. The Board has not overlooked the Veteran's statements regarding the severity of his condition. The Veteran provided lay evidence through private treatment, VA treatment, and VA examinations throughout the course of his appeal with respect to the presence of coronary artery disease-related symptoms. However, where the disability Rating Schedule is concerned, the criteria set forth therein generally require medical expertise where the types of findings required are not readily observable by a lay person. The evidence persuasively weighs against a finding that the Veteran is entitled to a rating greater than 10 percent for coronary artery disease prior to January 18, 2013, and greater than 30 percent prior to July 24, 2016. There is no factually ascertainable evidence in the record to satisfy the evaluation criteria for an increased rating. Medical evidence, including the September 2010, March 2012, and October 2013 VA examinations, is the most probative evidence of record on the question of entitlement to an increased rating. The examination reports were based on a review of the evidence, including lay statements from the Veteran, were supported by a detailed rationale, provided data to support any conclusions, and they provided a clear and reasoned analysis, the source of the most probative value in a medical report. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The VA examiner reports are consistent with the evidence of record, including a report by the Veteran of the ability to push mow the lawn, rake leaves, wash his truck, and chest pain due to high levels of activity, described as several hundred yards of walking to his mailbox. The medical evidence provides a compelling basis against the Veteran's claim for increase. There is no competent, credible evidence to refute the historical record. See 38 C.F.R. § 3.159(a)(1) (competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). The weight of the probative evidence of record is against a finding that the Veteran is entitled to an increased rating for coronary artery disease. Requirements for increased ratings due to coronary artery disease are not based on subjective criteria, including the Veteran's belief about what may be appropriate. Conclusory, generalized lay statements in favor of a claimed increase are insufficient to substantiate the relevant evaluation criteria. The relevant legal authority governing the evaluation of mental disorder ratings is clear and unambiguous, and the Board is bound by such authority. Consequently, an increase is not warranted. In conclusion, the evidence persuasively weighs against a finding that the Veteran meets the relevant diagnostic criteria under 38 C.F.R. § 4.104 for entitlement to a disability rating greater than 10 percent for coronary artery disease prior to January 18, 2013, and greater than 30 percent prior to July 24, 2016. Therefore, his claim must be denied. In reaching the conclusions stated above, the Board has considered the applicability of the benefit of the doubt doctrine. The rule does not apply when the Board finds that the evidence persuasively weighs against the claim. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to a TDIU, to include referral on an extraschedular basis. The Veteran contends that he is entitled to a total rating from January 18, 2011, to July 24, 2016, "because [Veteran's] service-connected coronary artery disease made him unable to secure and follow substantially gainful employment." See January 2022 Chisholm Appellate Brief. TDIU Eligibility VA will grant a TDIU when the evidence shows that a veteran is precluded, by reason of his service-connected disabilities, from securing and following "substantially gainful employment" consistent with his education and occupational experience. See 38 C.F.R. §§ 3.340, 3.341, 4.16; VAOPGCPREC 75-91; 57 Fed. Reg. 2317 (1992). The central inquiry is "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). In determining unemployability for VA purposes, consideration may be given to a veteran's level of education, special training, and previous work experience, but not to age or any impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; Hersey v. Derwinski, 2 Vet. App. 91, 94 (1992); Faust v. West, 13 Vet. App. 342 (2000). The sole fact that a veteran is unemployed or has difficulty obtaining employment is not enough, given that a high VA disability rating is in and of itself a recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (citing 38 C.F.R. §§ 4.1, 4.15, 4.16(a)). Medical evaluations are probative to understanding the level of functional impairment; however, the ultimate determination of unemployability is a legal question, not a medical one. See Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). In Ray v. Wilkie, 31 Vet. App. 58 (2019), the CAVC defined the term "unable to secure and follow a substantially gainful occupation" in § 4.16(b) to include two components: one economic and one noneconomic. The economic component means an occupation earning more than marginal income (outside of a protected environment) as determined by the United States Department of Commerce as the poverty threshold for one person. The non-economic component includes consideration of: the Veteran's history, education, skill, and training; whether the veteran has the physical ability to perform the type of activities required by the occupation at issue; and whether the veteran has the mental ability to perform the activities required by the occupation at issue. The Board recognizes the Court's findings in Cantrell v. Shulkin, 28 Vet. App. 382 (2000) concerning the meaning of the term "in a protected environment" under 38 C.F.R. § 4.16(a). In Cantrell, the Court held that the meaning of "employment in a protected environment" is not clear from the regulation's plain language and noted that the list of examples in the regulation "suggests that VA may have intended employment 'in a protected environment' to be a term of art that differs from the ordinary, accommodation-based dictionary definition proffered by the [V]eteran." Id. The Board takes note of the examples of "protected environment" used in the text of 38 C.F.R. § 4.16(a), "family business or sheltered workshop." In the case of a family business, it is common for an employer to hire a relative to fill a position, not because the relative is necessarily the most capable or efficient prospective employee, but for reasons of affection or obligation. The term "sheltered workshop" is not defined in Title 38 of the Code of Federal Regulations. Title 20 of the Code of Federal Regulations, 20 C.F.R. § 404.1574 (a)(3), which the Code describes as an evaluation guide for (Social Security Administration) employees for determining whether a worker is involved in substantially gainful activity, states: "If you are working in a sheltered workshop, you may or may not be earning the amounts you are being paid. The fact that the sheltered workshop or similar facility is operating at a loss or is receiving some charitable contributions or government aid does not establish that you are not earning all you are being paid." The Board recognizes that the Secretary, as of this decision, has not defined "protected environment." Therefore, said determinations must be made on a case-by-case basis, evaluating the information and evidence in the record. TDIU may be assigned where the schedular rating is less than total and it is found that the Veteran is unable to secure or follow a substantially gainful occupation as a result of either (1) a single service-connected disability ratable at 60 percent or more, or (2) 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. See 38 C.F.R. §§ 3.340, 3.341, 4.16(a). If the Veteran does not meet the required percentage standards set forth in 38 C.F.R. § 4.16(a), he still may receive a TDIU on an extraschedular basis if it is determined that he is unable to secure or follow a substantially gainful occupation by reason of his service-connected disabilities. See 38 C.F.R. § 4.16(b). In cases where extraschedular consideration is warranted, referral to the Director of Compensation Service is necessary prior to a determination on eligibility. See Bowling v. Principi, 15 Vet. App. 1 (2001). In Snider v. McDonough, Vet. App., No. 19-6707, (Nov. 19, 2021), the Court of Appeals for Veterans Claims (CAVC) addressed the issue of referrals to the Director of Compensation Service for extraschedular TDIU consideration. In so doing, the Court held that the Board, if it denies a referral, "will be making two determinations in its decision: (1) that a referral for extraschedular TDIU consideration is not warranted because there is insufficient evidence to substantiate a reasonable possibility that a veteran is unemployable because of service-connected disabilities; and (2) that TDIU benefits are not warranted because service-connected disabilities did not render the veteran unemployable." Evidence concerning a referral to the Director of Compensation Service must be considered under the "reasonable possibility" standard outlined in Ray. See Ray, supra at 66. When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of doubt shall be given to the claimant. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Period Prior to July 24, 2016 To the extent that a TDIU may be warranted, the Veteran is in receipt of a total 100 percent rating from July 24, 2016, and the issue of a total rating based on individual unemployability from July 24, 2016, is moot. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16(a). Prior to July 24, 2016, the Veteran's combined overall disability rating was 30 percent, including a 10 percent evaluation for coronary artery disease prior January 18, 2013, and a 30 percent evaluation for coronary artery disease thereafter. See May 2017 VA Rating Decision Codesheet. The Board finds that the Veteran does not meet the schedular criteria for consideration of a TDIU prior to July 24, 2016. See 38 C.F.R. § 4.16(a). Applying the first prong of Snider, the evidence persuasively weighs against a finding of sufficient evidence to substantiate a reasonable possibility that the Veteran is unemployable because of his service-connected disability prior to July 24, 2016. The Veteran's only service-connected disability is coronary artery disease, rated as 10 percent disabling under 38 C.F.R. § 4.104, Diagnostic Code 7005, prior to January 18, 2013, and 30 percent disabling under 38 C.F.R. § 4.104, Diagnostic Code 7005, prior to July 24, 2016. See May 2017 VA Rating Decision Codesheet. Service personnel records indicate that the Veteran was a "Cook" in the U.S. Army. See June 1966 DD Form 14, Certificate of Release or Discharge from Active Duty. However, the Veteran reported in VA treatment that he was a "Cook, Mechanic, Truck Driver" in the U.S. Army. See February 2010 VA Multi-Specialty Program Note. The Veteran reported work as a "Mechanic" from 1966 to 1967, and from 1967 to 1992, the Veteran reported work as an industrial fire fighter at "Olin Corp." See February 2010 VA Multi-Specialty Program Note and March 2010 VA Geriatric Psychiatry Consult. In addition, the Veteran reported that he "used to own a rental property...used to love working on automobiles and machinery [] used to do projects for my neighbors." See January 2022 Veteran Lay Statement. The Veteran obtained a GED equivalent. See March 2010 VA Geriatric Psychiatry Consult and January 2022 VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability. The Veteran received 8 weeks of training as a cook in the U.S. Army. See June 1966 DD Form 14, Certificate of Release or Discharge from Active Duty. While the Veteran reported a work history as a mechanic both in-service, post-service, and as a hobby, he did not indicate how or when he was trained. See February 2010 VA Multi-Specialty Program Note, March 2010 VA Geriatric Psychiatry Consult, and January 2022 Veteran Lay Statement. Further, the Veteran did not indicate training as a firefighter, despite having reported a 25-year work history as an industrial firefighter at Olin Corp. See January 2022 VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability. Past medical history for the Veteran includes: "hypertension; GERD; depression; alcoholism; degenerative joint disease; coronary artery disease; dyslipidemia; jaw fracture age 17; left 3rd finger traumatic injury; knee skin boil excision; left cataract removal; angioplasty right foot degenerative changes first metatarsal joint." See March 2010 VA Geriatric Psychiatry Consult. He endorsed "a longstanding history of pain in his lower back and now in his upper back...started at the age of 30." See November 1987 Alton Memorial Hospital History and Physical. The Veteran also stated that, "[H]e had had midback pain for 35 years. [A]wakens him in [the] middle of [the] night." See September 2013 VA Primary Care Nurse Practitioner / Physician Assistant Scheduled Visit. In September 2010, the Veteran reported that he was "[a]ble to lift 10 lbs...do laundry, rake leaves, use push lawn mower, limited by back pain / knee pain." See September 2010 VA Heart Conditions examination report. At January 2012 treatment, he detailed "back and chest pain while washing his truck." See January 2012 VA Primary Care Nurse Practitioner / Physician Assistant Scheduled Visit. In January 2013, he reported "chest tightness...attributed to back spasms." See January 2013 VA Cardiology Progress Note. The Veteran reported that he chose to retire in December 1992 when, "[H]e was told that he could no longer drive an ambulance due to his heart condition." See September 2010 VA Heart Conditions examination report, March 2012 VA Heart Conditions examination report, and January 2022 Veteran Lay Statement. The record does not identify the person with whom the Veteran spoke about being unable to "drive an ambulance due to his heart condition." However, the March 2012 VA medical examination describes the Veteran's employment as a firefighter as "very stressful." See March 2012 VA Heart Conditions examination report. In 2010, the Veteran expressed having "anxious feelings nearly all his life [] attributes some measure of anxiety to his occupation as a firefighter." See March 2010 VA Geriatric Psychiatry Consult. Prior to July 24, 2016, the evidence persuasively weighs against a finding that a there is sufficient evidence to substantiate a reasonable possibility that the Veteran is unemployable due to his service-connected disability, to include referral to the Director of Compensation Service for consideration on an extraschedular basis. Addressing the second prong of Snider, whether the Veteran is unemployable due to his service-connected disability prior to July 24, 2016, the Board finds that he is not. In June 2019 correspondence, VA requested that the Veteran complete "VA Form 21-4192, Request for Employment Information in Connection with Claim for Disability Benefit, [] by each of the employers identified on VA Form 21-8940. See June 2019 VA Subsequent Development Letter. While the Veteran completed and returned VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability, in January 2022, the Veteran did not provide VA Form 21-4192 for his former employer, the Olin Corporation. VA has a duty to assist the Veteran is substantiating his claim. However, that duty is not a one-way street. See Woods v. Gober, 14 Vet. App. 214, 224 (2000); see also Hurd v. West, 13 Vet. App. 449, 452 (2000) (the veteran cannot passively wait for help from VA). Consequently, evidence of the Veteran's employment history, his training history, his income history, and his reason(s) for leaving is not in the record. The Board considers the January 2022 lay statement from the Veteran to be an assessment of his current health and not a statement of his health prior to July 24, 2016. See January 2022 Veteran Lay Statement ("I had daily fatigue after walking around the house or completing a chore or task...I had to stop and take up to 8-minute breaks...weakness throughout my entire body."). Assuming arguendo that the Veteran's January 2022 lay statement is describing symptoms before July 24, 2016, statements provided during medical treatment are usually afforded greater probative weight, particularly if close in time to the onset thereof. See Buchanan, supra. Further, contemporaneous medical evidence has greater probative value than the Veteran's reports of history. See Curry, supra. As noted previously, the contemporaneous medical evidence demonstrates: 1) that the Veteran was more limited by "back pain / knee pain" than by "shortness of breath or chest pain;" 2) that the Veteran attributed "chest tightness" to "back spasms" three times in six months; 3) that the Veteran's congestive heart failure was not considered chronic, and he did not experience more than one episode of acute congestive heart failure in the previous year; 4) that the Veteran reported angina only at "high levels of activity;" 5) that the Veteran regularly denied "dizziness, fainting, headaches, blurred vision, weakness, fatigue, chest pain" at VA treatment; 6) that a February 2013 nuclear stress test measured left ventricle ejection fraction at 61 percent; 7) that the Veteran reported "short pains in his left chest with exertion...primarily when he went to the mailbox and back" and "has to go several hundred yards to get to the mailbox;" 8) that the Veteran reported "chest discomfort with some association with food, occurring every 2 weeks;" 9) that the Veteran reported "occasional chest pains and shortness of breath" only with "exertion;" 10) that the Veteran regularly reported feeling "well;" and 11) that the Veteran reported "very rare episodes of exertional angina, which resolve very quickly with rest" and "[n]o worsening" of symptoms or functioning prior to his June 2016 blood clot-based myocardial infarction. At the October 2013 VA medical examination, the Veteran denied a functional impact on his ability to work due to a heart condition. See October 2013 VA Heart Conditions examination report. The Veteran reported "[f]atigue" in October 2014, but the examining cardiologist ruled out "angina equivalent" and attributed the fatigue to "depressed mood." See October 2014 VA Cardiology Progress Note. In September 2013, the Veteran endorsed a "history of alcoholism and complains of insurance premiums going up if he sees psychiatry, so he will not pursue mental health treatment. See September 2013 VA Primary Care Nurse Practitioner / Physician Assistant Scheduled Visit. Diagnostic exercise testing in August 2011 measured METs at 8.5, which is consistent, which is consistent with activities such as climbing stairs quickly, moderate bicycling, sawing wood, and jogging at 6 mph. See March 2012 VA Heart Conditions examination report and VA Form 21-0960A-1, Ischemic Heart Disease Disability Benefits Questionnaire. Exercise stress testing in February 2013 measured METs at 5.8, but the examining cardiologist noted a "suboptimal" effort on the part of the Veteran. A February 2013 nuclear stress test, performed 10 days prior to the exercise stress test, measured left ventricle ejection fraction at 61 percent, which is normal. See October 2013 VA Heart Conditions examination report. The Board finds the August 2011 exercise stress test result of 8.5 METs, consistent with activities such as climbing stairs quickly, moderate bicycling, sawing wood, and jogging at 6 mph, to be more in line with the February 2013 normal left ventricle ejection fraction results. Meanwhile, the February 2015 exercise stress test result of 5.8 METs, characterized as a "suboptimal" effort from the Veteran by the examining cardiologist, is considered an outlier result by the Board. Notwithstanding the medical evidence to the contrary, the Board must still consider the statements of the Veteran's representative from May 2014: "Veteran states that he...is unable to complete simple tasks, i.e., mowing the lawn, walking distances of 40' or more, climbing staircases," and the Veteran's statements from January 2022: "I had daily fatigue after walking around the house or completing a chore or task." See May 2014 VA Form 21-0958, Notice of Disagreement, and January 2022 Veteran Lay Statement. The activities described by the Veteran's representative and the Veteran pertain to activities that require physical exertion, e.g., push mowing, walking, climbing stairs, and performing household chores. The Board finds that the Veteran was capable of substantially gainful and sedentary employment that did not require standing, walking, or physical exertion comparable to household chores, including sitting, answering telephones, taking messages, transferring calls, data entry, and general clerical and administrative work. Despite evidence of any formal training, other than training as a cook, the Veteran endorsed a knowledge of cooking, automobiles and engines, truck driving, firefighting, property management, and handiwork. Any number of industries, including food service, restaurant supply, automobile service, automotive parts and supply, tool manufacturing and supply, trucking, shipping, emergency dispatch, fire investigation, protection, prevention, and equipment, real estate, and lumber, hardware, and do-it-yourself, would allow the Veteran to utilize his work history, training, knowledge, and skills in a sedentary capacity as clerical and / or administrative employee. The Board finds that, prior to July 24, 2016, the evidence persuasively weighs against a finding that the Veteran's service-connected disability rendered him unable to secure or follow a substantially gainful occupation. Therefore, entitlement to a TDIU, including referral for extraschedular consideration under 38 C.F.R. § 4.16(b), is not warranted. Conclusion As previously noted, the standard in awarding a TDIU is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose, supra. The central inquiry is "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad, supra. Based upon the foregoing evidence, the Board concludes that the Veteran's service-connected condition does not prevent him from securing or following a substantially gainful occupation, consistent with his work history, training, knowledge, and skills. While the Veteran's service-connected conditions has the potential to functionally impact his employment, the standard under 38 C.F.R. § 4.16(a) is whether the disabled person is unable to secure or follow a substantially gainful occupation. The standard under § 4.16(b), pursuant to Snider, is: 1) whether there is sufficient evidence to substantiate a reasonable possibility that a veteran is unemployable because of service-connected disabilities; and 2) whether TDIU benefits are warranted because service-connected disabilities render the Veteran unemployable. The Board has responded to both of these inquiries in the negative. The Veteran chose to retire in December 1992, after 25 years as a corporate firefighter, because he was told by someone, not necessarily his employer, that he could no longer drive an ambulance. The Veteran disclosed in treatment that his job as a corporate firefighter made him anxious. Despite lay evidence from the Veteran's representative in 2014 and lay evidence from the Veteran in January 2022, the medical evidence of record consistently indicates that the Veteran felt "well," performed yard work that included raking leaves and push mowing the lawn, washed his truck, and walked several hundred yards to his mailbox, limited only by his back and knee problems, for which the Veteran is not service connected. In October 2013, the Veteran denied functional limitations on his ability to work due to a heart condition. A single reference to feeling "lightheaded" while crossing the street in June 2012 is considered an outlier when compared to the numerous statements made by the Veteran during treatment in which he consistently denied dyspnea, fatigue, angina, dizziness, syncope, and weakness. Based on the available evidence in the record, the Veteran cannot be found unable to secure or follow a substantially gainful occupation due to his service- connected disability. There is no evidence from the Veteran or in the record that the Veteran required or was otherwise employed in a protected work environment or was physically or mentally unable to perform sedentary work, including administrative or clerical duties, in any of the related fields for which the Veteran possesses the work history, knowledge, training, and skills to perform. There is no evidence from the Veteran or in the record that any of the Veteran's employers made accommodations to protect or shelter the Veteran in consideration of his service-connected disability. Therefore, there is no evidence that his service-connected condition limited his work to the degree required for a TDIU prior to July 24, 2016. A referral to the Director, Compensation Service, for extra-schedular consideration under 38 C.F.R. § 4.16(b) is not warranted. The Board finds that the current evaluation ratings accurately reflect the elements of the Veteran's disability picture. Therefore, the evidence persuasively weighs against a finding that the service-connected condition precludes all forms of substantially gainful employment, considering work history, knowledge, training, and skills. Accordingly, the Veteran's claim for a TDIU is denied. Because the evidence persuasively weighs against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. J. Kirby Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Small, Attorney Advisor 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.