Citation Nr: 24006458 Decision Date: 02/06/24 Archive Date: 02/06/24 DOCKET NO. 17-07 487 DATE: February 6, 2024 ORDER Entitlement to an initial rating in excess of 70 percent for posttraumatic stress disorder (PTSD) is denied. Entitlement to a compensable rating for bilateral hearing loss prior to March 26, 2021, and in excess of 20 percent thereafter, is denied. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is granted. REMANDED Entitlement to service connection for an undiagnosed illness or a diagnosed medically unexplained chronic multi-symptom illness (MUCMI), to include fibromyalgia and/or chronic fatigue syndrome, is remanded. FINDINGS OF FACT 1. The Veteran's PTSD does not result in total occupational and social impairment. 2. Prior to March 26, 2021, the Veteran's bilateral hearing loss manifested by no more than Level I hearing impairment in the right ear and Level I hearing impairment in the left ear, which corresponds to a noncompensable rating. 3. From March 26, 2021, the Veteran's bilateral hearing loss manifests by no more than Level VI hearing impairment in the right ear and Level IV hearing impairment in the left ear, which corresponds to a 20 percent rating. 4. The Veteran's service-connected PTSD prevents him from securing and following a substantially gainful occupation consistent with his education, training, and work history. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 2. The criteria for entitlement to a compensable rating for bilateral hearing loss prior to March 26, 2021, and in excess of 20 percent thereafter, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.85, 4.86, Diagnostic Code 6100. 3. The criteria for entitlement to a TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 3.340, 3.341, 4.15, 4.16, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from July 1985 to September 1992. These matters are before the Board of Veterans' Appeals (Board) on appeal from a July 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In August 2022, the Veteran testified before the undersigned Veterans Law Judge at a virtual hearing. The Board remanded these matters in December 2022 for additional development. The case is now returned to the Board for further appellate consideration. Increased Rating Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; see generally 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating applies. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. The veteran's entire history is to be considered when making disability determinations. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the question for consideration is the propriety of the initial rating assigned, evaluation of the evidence since the effective date of the grant of service connection is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the current level of disability that is of primary concern, and VA must only address the evidence concerning the state of the disability from the time period one year before the claim for an increase was filed until VA makes a final decision on the claim. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, in all increased rating claims, when the factual findings show distinct time periods during which the veteran exhibited symptoms of disability and such symptoms warrant different disability ratings, staged ratings may also be assigned. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107(b); Lynch v. McDonough, 21 F.4th 776, 780-81 (Fed. Cir. 2021). 1. Entitlement to an initial rating in excess of 70 percent for PTSD The Veteran seeks an initial increased rating for PTSD, which is currently rated 70 percent disabling from May 17, 2013. He generally contends that his symptoms are more severe than reflected by his currently-assigned rating. The Veteran's PTSD is rated under Diagnostic Code 9411. Pursuant to a General Rating Formula for Mental Disorders, specified in 38 C.F.R. § 4.130, in relevant part, a 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals that interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting ability to function independently, appropriately, and effectively; impaired impulse control (e.g., unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (e.g., work or work like setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted for total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411, General Rating Formula for Mental Disorders. The symptoms associated with each rating under the General Rating Formula do not constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Thus, the evidence considered in determining the appropriate rating of a psychiatric disorder is not restricted to the symptoms set forth in the General Rating Formula. Id. When rating a mental disorder, VA must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126; Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). VA shall assign a rating based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). When rating the level of disability from a mental disorder, VA will consider the extent of social impairment, but shall not assign a rating based solely on social impairment. 38 C.F.R. § 4.126(b). In other words, VA must engage in a holistic analysis that: assesses the severity, frequency, and duration of the signs and symptoms of the psychiatric disability; quantifies the level of occupational and social impairment caused by those symptoms; and assigns an evaluation that most nearly approximates the level of occupational and social impairment. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017). Turning to the relevant evidence, the Veteran underwent a VA examination in May 2013. Upon examination, the Veteran reported symptoms of depressed mood, anxiety, suspiciousness, near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a worklike setting. He also reported irritability, intrusive thoughts, and hypervigilance; he stated that he keeps a gun in every room of the house. The Veteran reported being close to his siblings and having a good relationship with his girlfriend of 10 years. However, he prefers to isolate himself and does not engage socially on a consistent basis. He has not worked since 2008 when he became disabled due to a motor vehicle accident. The examiner determined that his PTSD causes occupational and social impairment with reduced reliability and productivity. In a February 2014 statement, the Veteran wrote that his PTSD has caused significant issues in his life, including a divorce, drinking problems, constant nightmares, and social problems. He reported that he does not sleep at night out of fear that something will happen to his family and he obsessively checks the locks on the doors to his home. He is anxious, irritable, and angry, which creates tension with his family and makes others not want to be around him. He socially isolates. He feels that he cannot function in society for fear of getting angry and causing physical harm to someone. In a March 2021 statement, the Veteran's wife described how the Veteran's PTSD impacts his life. The Veteran regularly experiences nightmares that cause him to awaken with a racing heartbeat and heavy breathing. The nightmares leave him confused, disoriented, and angry. The Veteran does not leave the house often. When he does, he has to perform a lengthy ritual of checking rooms and the locks on the doors several times; he also surveys the neighborhood for unknown vehicles. He packs of bag of miscellaneous items, such as first-aid items, cleaning supplies, and a change of clothing, just in case something happens while he is out. He is always on guard; a strange person or vehicle in the neighborhood will put him on high alert. Any strange noise invokes a perimeter search of the house and yard. The Veteran constantly watches the news on the television in case something catastrophic happens in the country or the world. News events, such as mass shootings, cause him intense worry and fear that the same thing will happen in his own community. The Veteran has frequent angry outbursts at benign things, such as the dog barking. He does not have any friends or social relationships outside of his own family. The Veteran's wife reported that she is often on eggshells around the Veteran and that life with him can be very difficult. At his August 2022 Board hearing, the Veteran testified that his PTSD causes suicidal ideation, anger, nightmares and flashbacks, brain fog and lack of concentration, paranoia, and hypervigilance. He no longer attends family functions or social events because he cannot be around people. However, he maintains contact with his siblings through video chats; they are supportive of his mental health issues. The Veteran reported that he prefers to be by himself, and stays home all day with his dogs. He will occasionally take a ride by himself to the beach. He is unemployed; he testified that he would not be able to work due to his PTSD because it prevents him from interacting with people and concentrating on tasks. He struggles with his memory and focus; he often cannot finish a sentence once he starts speaking because he gets distracted and loses focus. The Veteran was afforded a VA examination in March 2023. Upon examination, he endorsed symptoms of depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationship, difficulty in adapting to stressful circumstances, including work or a worklike setting, and inability to establish and maintain effective relationships. The Veteran reported that his marriage to his wife of nine years is going great and that she is very supportive of his struggles, despite him being moody and argumentative at times. He angers easily. At times he has suicidal thoughts but has never acted upon them. Behaviorally, the examiner noted that the Veteran was cooperative and pleasant. His affect was consistent with the subject matter discussed. The examiner determined that the Veteran's PTSD causes occupational and social impairment with reduced reliability and productivity. The Veteran was afforded another VA examination in June 2023. Upon examination, he endorsed symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationship, difficulty in adapting to stressful circumstances, including work or a worklike setting, and obsessional rituals which interfere with routine activities. On behavioral observation, the examiner found the Veteran to be cooperative, with good insight and judgment. His social skills were adequate. His thought processes were coherent and goal-directed. The examiner determined that his PTSD causes occupational and social impairment with reduced reliability and productivity. VA treatment records throughout the appeal period reflect that the Veteran has always been observed by his health care providers to be oriented to person, place, time, and situation with appropriate behavior, appearance, thoughts, and judgment. He received mental health treatment from VA briefly in 2013; however, he has not pursued formal treatment or medication management for PTSD since then. After careful review of the above medical and lay evidence, the Board finds that the evidence is persuasively against assigning an initial rating in excess of 70 percent for the Veteran's PTSD at any time during the appeal period. In making this finding, the Board has considered the rating criteria in the General Rating Formula for Mental Disorders not as an exhaustive list of symptoms, but as examples of the type and degree of the symptoms, or effects, that would justify a particular rating. The Board has not required the presence of a specified quantity of symptoms in the rating schedule to warrant the assignment of a higher rating. Mauerhan, 16 Vet. App. at 436. The evidence of record indicates that the Veteran's PTSD primarily manifests by symptoms of the type and degree as suicidal ideation, obsessional rituals which interfere with routine activities, near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively, impaired impulse control, such as unprovoked irritability and anger with periods of violence, memory impairment, disturbance of motivation and mood, difficulty in adapting to stressful circumstances, including work or a work-like setting, and inability to establish and maintain effective relationships. The Board finds such symptomatology results in no more than occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, which corresponds to a 70 percent rating. The Board notes that the next higher rating of 100 percent requires a finding of total occupational and social impairment. However, at no time has the Veteran exhibited symptoms of the type and degree required for a 100 percent rating, such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name, or more severe symptomatology such as to warrant a finding of total occupational and social impairment. Because the evidence does not indicate the Veteran's psychiatric symptoms are so severe as to result in signs and symptoms indicative of total occupational and social impairment, the Board finds that a 100 percent disability rating is not warranted. To the extent the Veteran believes his symptoms of PTSD are worse than reflected by a 70 percent rating, Board acknowledges that he is competent to report on factual matters of which he has first-hand knowledge, such as experiencing a heightened level of psychiatric symptomatology. Washington v. Nicholson, 19 Vet. App. 362, 368 (2005); see also Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). However, he is not competent to report that his PTSD is of sufficient severity to warrant a higher rating under the rating schedule, as such an opinion requires specialized medical expertise which falls outside the realm of the common knowledge of a layperson. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Board must rely on the cumulative medical vidence of record to assign the appropriate disability rating, and therefore, accords the objective medical findings greater weight than any subjective complaints of increased symptomatology. Accordingly, for the above reasons, the Board finds the evidence persuasively weighs against finding that an initial rating in excess of 70 percent for PTSD is warranted. As such, the benefit-of-the-doubt doctrine is inapplicable, and the claim must be denied. 38 U.S.C. § 5107(b); Lynch, 21 F.4th at 780-81. 2. Entitlement to a compensable rating for bilateral hearing loss prior to March 26, 2021, and in excess of 20 percent thereafter The Veteran seeks an increased rating for bilateral hearing loss, which is currently rated noncompensable (zero percent) prior to March 26, 2021, and 20 percent thereafter. He generally contends that his symptoms are more severe than reflected by his currently-assigned rating. The Veteran filed his claim for an increased rating on May 17, 2013; as such, the Board must consider the relevant evidence of record from one year prior to the date of the claim. In evaluating hearing loss, disability ratings are derived by a mechanical application of the ratings schedule to the numeric designations assigned after audiometric evaluations are rendered. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). Hearing loss disability evaluations range from noncompensable (0 percent) to 100 percent based on organic impairment of hearing acuity. Audiological examinations used to measure impairment must be conducted by a state-licensed audiologist and must include both a controlled speech discrimination test (Maryland CNC) and a puretone audiometric test. 38 C.F.R. § 4.85(a). The ratings schedule provides a table for ratings purposes (Table VI) to determine a Roman numeral designation (I for essentially normal acuity through XI for profound deafness) for hearing impairment, based upon a combination of the percent of speech discrimination and the puretone threshold average, which is the sum of the puretone thresholds at 1000, 2000, 3000 and 4000 hertz, divided by four. 38 C.F.R. § 4.85, Diagnostic Code 6100. Table VII is then used to determine the percentage evaluation by intersecting the Roman numeral designations from Table VI for hearing impairment of each ear. The horizontal row represents the ear having the poorer hearing and the vertical column represents the ear having the better hearing. Id. Exceptional patterns of hearing impairment are evaluated under the provisions of 38 C.F.R. § 4.86. When the puretone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86(a). When the puretone threshold is 30 decibels or less at 1000 hertz, and 70 decibels or more at 2000 hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. That numeral will then be elevated to the next higher Roman numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86(b). Turning to the relevant evidence, the Veteran underwent a VA audiology examination in May 2013. Upon examination, the Veteran did not report any functional impacts of his hearing loss on the ordinary conditions of daily life. See 38 C.F.R. § 4.10; Martinak v. Nicholson, 21 Vet. App. 447 (2007). Upon audiometric testing, pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 20 15 60 75 43 LEFT 15 15 65 60 39 Speech discrimination scores on the Maryland CNC word list were 96 percent in the right ear and 96 percent in the left ear. The average puretone threshold was 43 decibels in the right ear and 39 decibels in the left ear. The May 2013 audiology examination findings, applied to Table VI, yield a numeric designation of Roman numeral I in the right ear on the basis of a 43 decibel puretone threshold average and 96 percent speech discrimination, and a numeric designation of Roman numeral I in the left ear on the basis of a 39 decibel puretone threshold average and 96 percent speech discrimination. The numeric designation for the right ear, I, along with the numeric designation for the left ear, I, entered into Table VII, corresponds to a noncompensable rating for hearing impairment. 38 C.F.R. § 4.85. Next, the Veteran underwent another VA audiology examination in November 2021. Upon examination, the Veteran reported that his hearing loss causes frustration between him and his wife because sometimes he does not hear what she says and he gets tired of asking her to repeat herself. He also has difficulty hearing in the presence of background noise. He has to watch the television at a high volume. See 38 C.F.R. § 4.10; Martinak, 21 Vet. App. at 447. Upon audiometric testing, pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 20 80 75 80 64 LEFT 20 40 75 75 53 Speech discrimination scores on the Maryland CNC word list were 80 percent in the right ear and 82 percent in the left ear. The average puretone threshold was 64 decibels in the right ear and 53 decibels in the left ear. The Board notes that exceptional patterns of hearing impairment are present in the right ear, as the puretone threshold is 30 decibels or less at 1000 hertz, and 70 decibels or more at 2000 hertz. As such, the Board will determine the Roman numeral designation for hearing impairment of the right ear from Table VIa, as this table results in the higher numeral. That numeral will then be elevated to the next higher Roman numeral. 38 C.F.R. § 4.86(b). The November 2021 audiology examination findings, applied to Table VIa for the right ear, yield a numeric designation of Roman numeral V, which is elevated to the next higher numeral of VI; the findings applied to Table VI for the left ear yield a numeric designation of Roman numeral IV. The numeric designation for the right ear, VI, along with the numeric designation for the left ear, IV, entered into Table VII, corresponds to a 20 percent rating for hearing impairment. 38 C.F.R. § 4.85. The Veteran underwent another VA audiology examination in March 2023. Upon examination, the Veteran reported that his hearing loss disability impacts the ordinary conditions of daily life, but he did not provide any specific examples. See 38 C.F.R. § 4.10; Martinak, 21 Vet. App. at 447. Upon audiometric testing, pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 20 60 65 70 54 LEFT 20 30 70 75 49 Speech discrimination scores on the Maryland CNC word list were 80 percent in the right ear and 80 percent in the left ear. The average puretone threshold was 54 decibels in the right ear and 49 decibels in the left ear. The March 2023 audiology examination findings, applied to Table VI, yield a numeric designation of Roman numeral IV in the right ear on the basis of a 54 decibel puretone threshold average and 80 percent speech discrimination, and a numeric designation of Roman numeral III in the left ear on the basis of a 49 decibel puretone threshold average and 80 percent speech discrimination. The numeric designation for the right ear, IV, along with the numeric designation for the left ear, III, entered into Table VII, corresponds to a 10 percent rating for hearing impairment. 38 C.F.R. § 4.85. Based on the above evidence, the Board finds that a compensable rating for bilateral hearing loss prior to March 26, 2021, and in excess of 20 percent thereafter, is not warranted. In making this finding, the Board is sympathetic to the Veteran's contention that he has difficulty hearing conversations or the television due to his hearing loss disability. However, the Board must consider the Veteran's description of his service-connected disability in conjunction with the clinical evidence of record and the pertinent rating criteria. In this regard, the Board emphasizes that disability ratings for hearing loss are derived by a mechanical application of the rating schedule. See Lendenmann, 3 Vet. App. at 349. Thus, the Board has no discretion in this matter and must predicate its determination on the basis of the results of the audiological testing of record. As described above, for the rating period prior to March 26, 2021, the May 2013 VA audiological testing results, which is the only audiometric test of record, when applied to the rating criteria, show that the Veteran's bilateral hearing loss disability did not rise to the level of severity required for the assignment of a higher rating. Those examination findings demonstrate that prior to March 26, 2021, the Veteran's bilateral hearing loss manifested by no more than Level I hearing impairment in the right ear and Level I hearing impairment in the left ear, which corresponds to a noncompensable rating under Diagnostic Code 6100. Next, for the rating period from March 26, 2021, the Board notes that the November 2021 VA examination report reflects more severe hearing loss than that shown on the March 2023 examination and, thus, it will be used to evaluate the Veteran's disability during this period. The November 2021 VA audiological testing results show that the Veteran's bilateral hearing loss disability did not rise to the level of severity required for the assignment of a higher rating. As previously discussed, those examination findings demonstrate that from March 26, 2021, the Veteran's bilateral hearing loss manifests by no more than Level VI hearing impairment in the right ear and Level IV hearing impairment in the left ear, which corresponds to a 20 percent rating under Diagnostic Code 6100. The Board notes that in addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in the final report. See Martinak, 21 Vet. App. at 447. In this case, the Veteran reported on examination that he has difficulty hearing speech or the television, especially in this presence of background noise. This is frustrating for him and sometimes causes problems with his wife. The Board acknowledges the Veteran's reported functional impairments and has given them appropriate consideration. However, the probative medical evidence, as previously discussed, fails to support the assignment of an increased rating at any time. The Board further notes that the Veteran's reported functional limitations are manifestations of decreased hearing acuity, which is already contemplated by the schedular rating criteria for hearing loss. A comparison between the level of severity and symptomatology of the Veteran's assigned rating with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology, including his difficulty hearing speech or the television. The Board notes that this conclusion is consistent with the Court's holding in Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) ("[W]hen a claimant's hearing loss results in an inability to hear or understand speech or to hear other sounds in various contexts, those effects are contemplated by the schedular rating criteria."). The Board further finds that other than difficulty hearing or understanding speech or other environmental sounds, the record contains no evidence of other symptoms attributable to service-connected bilateral hearing loss. For the above reasons, the evidence is neither evenly balanced nor approximately so with regard to whether a compensable rating for bilateral hearing loss prior to March 26, 2021, and in excess of 20 percent thereafter, is warranted. Rather, the evidence persuasively weighs against the claim. As such, the benefit-of-the-doubt doctrine is inapplicable, and the claim must be denied. 38 U.S.C. § 5107(b); Lynch, 21 F.4th at 780-81. 3. Entitlement to a TDIU The Veteran contends that his service-connected PTSD prevents him from securing and following a substantially gainful occupation. It is established VA policy that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16. Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. §§ 3.340(a), 4.15. If the total rating is based on a disability or combination of disabilities for which the rating schedule provides an evaluation of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability. 38 C.F.R. § 3.341(a). A total disability evaluation can be assigned based on individual unemployability if the veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disability, provided that the veteran has one service-connected disability rated at 60 percent or higher; or two or more service-connected disabilities, with one disability rated at 40 percent or higher and the combined rating is 70 percent or higher. 38 C.F.R. § 4.16(a). Substantially gainful employment is defined as work that is more than marginal and permits the individual to earn a living wage. 38 C.F.R. § 4.16(a); Moore v. Derwinski, 1 Vet. App. 356 (1991). In determining whether unemployability exists, consideration may be given to the veteran's level of education, special training, and previous work experience, but it may not be given to age or any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. The sole fact that a veteran is unemployed or has difficulty obtaining employment is not enough to prove unemployability. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate 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). The Board notes that the ultimate question of whether a veteran is capable of substantially gainful employment is not a medical one; that determination is for the adjudicator. Geib v. Shinseki, 773 F.3d 1350, 1354 (Fed. Cir. 2013). Thus, the conclusions of VA examiners are not dispositive. However, the observations of the examiners regarding functional impairment due to service-connected disability go to the question of physical or mental limitations that may impact the veteran's ability to obtain and maintain employment. From May 17, 2013, the Veteran is in receipt of service connection for PTSD (rated 70 percent disabling) and tinnitus (rated 10 percent disabling). From this date, he meets the percentage requirements for consideration of a schedular TDIU under 38 C.F.R. § 4.16(a). From March 26, 2021, the Veteran is also in receipt of service connection for bilateral hearing loss (rated 20 percent disabling), diverticulosis (rated 10 percent disabling), chronic bronchitis (rated noncompensable), and kidney cyst (rated noncompensable). Therefore, the question before the Board is whether the Veteran is precluded from obtaining or maintaining a substantially gainful occupation as a result of his service-connected disabilities. In June 2023, the Veteran submitted VA Form 21-8940 Veteran's Application for Increased Compensation Based on Unemployability. He reported that he last worked fulltime in 2008 as a grocery store manager. His prior work experience also includes positions as a restaurant manager. He reported that he stopped working due to his service-connected PTSD and bilateral hearing loss, as well as nonservice-connected sleep apnea. At his Board hearing, the Veteran testified that he would not be able to sustain fulltime employment due to his anxiety and lack of focus. His prior work as a manager/supervisor is no longer possible due to memory issues and becoming easily distracted. In the prior section of this decision in which the Board evaluated the severity of the Veteran's PTSD, the Board took note of his more severe symptoms of PTSD, to include paranoid, suicidal ideation, obsessional rituals which interfere with routine activities, near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively, and impaired impulse control, such as unprovoked irritability and anger with periods of violence. These symptoms are well-documented by the lay and medical evidence of record. At an April 2023 VA examination, an examiner noted that the Veteran's PTSD causes symptoms such as depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a work-like setting, and inability to establish and maintain effective relationships. The examiner remarked that in an employment setting, the Veteran would have difficulty attending to tasks at hand because he is easily distracted; he has difficulty maintaining concentration and focus on work over a period of time and tends to skip from one task to another without completing the prior task. The Veteran also has significant problems remembering instructions and details of work assignments, as well as functioning around other people or as a member of a team due to feeling uncomfortable around others. Finally, the Veteran's sleep is so disrupted that he would be easily fatigue at work, making concentrating and focusing on work assignments difficult. In light of the foregoing evidence, the Board finds that the evidence is at least in approximate balance that the Veteran is unable to secure and follow a substantially gainful occupation consistent with his education, training, and work history by reason of his service-connected PTSD. In this regard, the Veteran has not participated in fulltime, gainful employment since 2008 when he last worked as a grocery store manager. The competent and credible lay and medical evidence of record clearly documents that the Veteran's PTSD causes social anxiety, paranoia and hypervigilance, especially around other people or public settings, compulsive behaviors, chronic sleep impairment, lack of focus and concentration, memory problems, low motivation, irritability and anger, difficulty working around others, and difficulty adapting to stressful environments. These symptoms of PTSD would significantly impede the Veteran's ability to maintain his prior employment as a manager/supervisor in public, social, and fast-paced settings such as a grocery store or restaurant. As such, in light of the foregoing, the Board finds that the evidence is at least in approximate balance that his service-connected PTSD renders him unemployable. Accordingly, after resolving all reasonable doubt in the Veteran's favor, the appeal as to entitlement to a TDIU is granted. 38 U.S.C. § 5107(b); Lynch, 21 F.4th at 780-81. REASONS FOR REMAND Unfortunately, the issue remaining on appeal must be remanded for additional evidentiary development. Although the Board regrets the delay, this development is necessary to ensure there is a complete record upon which to decide this claim so that the Veteran is afforded every possible consideration. Entitlement to service connection for an undiagnosed illness or a medically unexplained chronic multi-symptom illness (MUCMI), to include fibromyalgia and/or chronic fatigue syndrome, is remanded. The Veteran asserts that he suffers from chronic disability, characterized by signs and symptoms such as fatigue, joint/bone pain, and headaches, due to his Persian Gulf service. The Board notes that service connection may be established on a presumptive basis for a Persian Gulf War veteran who exhibits objective indications of chronic disability resulting from undiagnosed illness that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2026, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). The Veteran had service in the Southwest Asia theatre of operations, specifically, Saudi Arabia, from December 1990 to May 1991, and is therefore considered a Persian Gulf War veteran pursuant to 38 C.F.R. § 3.317. A "qualifying chronic disability" for purposes of 38 U.S.C. § 1117 is a chronic disability resulting from (a) an undiagnosed illness or (b) a medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, or irritable bowel syndrome) that is defined by a cluster of signs or symptoms. 38 U.S.C. § 1117(a)(2); 38 C.F.R. § 3.317 (a)(2)(i). Objective indications of chronic disability include both signs, in the medical sense of objective evidence perceptible to a physician, and other, non-medical indicators that are capable of independent verification. To fulfill the requirement of chronicity, the illness must have persisted for a period of six months. 38 C.F.R. § 3.317(a)(2), (3). Signs or symptoms that may be manifestations of undiagnosed illness include, but are not limited to: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system; (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). Pursuant to the December 2022 Board remand, the Veteran was afforded a Gulf War examination in March 2023. Based on the Veteran's reported symptoms during the examination, he underwent further examination for chronic fatigue syndrome. On the examination report, the examiner marked that the Veteran has the following symptoms of chronic fatigue syndrome: debilitating fatigue and daily fatigue. However, later in the examination report, the examiner stated that the Veteran did not meet the diagnostic criteria for chronic fatigue syndrome. The examiner did not reconcile this finding with the Veteran's symptoms of fatigue, nor did the examiner provide any other etiology for the Veteran's fatigue. The examination report is therefore inadequate and remand is warranted to afford the Veteran a new VA examination and medical opinion. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Moreover, as to the Veteran's reported symptoms of joint and bone pain, at a September 2023 VA examination, the Veteran was diagnosed with rheumatoid arthritis, which the examiner noted is a diagnosable illness with an unknown etiology. The examiner opined that the Veteran's rheumatoid arthritis is less likely than not related to his Persian Gulf service, but did not provide any rationale for this opinion specific to the individual facts of the Veteran's case. Rather, the examiner only noted that rheumatoid arthritis is a chronic inflammatory disorder caused in many cases by the interaction between genes and "environmental factors, such as tobacco." The examiner did not appear to consider the environmental factors present in the Veteran's case, namely, his specific toxic exposures during service in Southwest Asia. The Board notes that on August 10, 2022, the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxins Act of 2022 ("PACT Act") was enacted. Section 303 of this law provides that, if a Veteran submits a claim for service connection with evidence of disability and evidence of participation in a toxic exposure risk activity ("TERA"), then VA shall obtain a medical opinion as to whether it is at least as likely as not that there is a nexus between the claimed disability and the toxic exposure risk activities during service. 38 U.S.C. § 1168. In September 2023, pursuant to the PACT Act, VA associated with the record the Veteran's Individual Longitudinal Exposure Record (ILER), which outlines the Veteran's individual exposures associated with burn pits and other toxins (BPOT) during his deployment in Saudi Arabia. Given the foregoing, the Board finds that remand is also warranted to afford the Veteran a TERA examination and medical opinion to assess whether his rheumatoid arthritis, chronic fatigue syndrome (if diagnosed), and other reported conditions, such as headaches, is related to exposure to BPOT during service in Southwest Asia. Accordingly, the matter is REMANDED for the following action: Schedule the Veteran for a VA TERA examination with an examiner of appropriate expertise to fully assess the nature and etiology of his claimed conditions related to service in Southwest Asia. The claims file, to include a copy of this REMAND, must be made available to and reviewed by the examiner. Thereafter, the examiner must provide a fully-articulated medical opinion addressing the following: (a) Is it at least as likely as not (i.e., the likelihood is at least approximately balanced or nearly equal, if not higher) that the pattern of signs and symptoms reported by the Veteran, to include fatigue, joint/bone pain, insomnia, dizziness, memory problem, and headaches, result from (i) an undiagnosed illness or (ii) a medically unexplained chronic multi-system illness (MUCMI) (i.e., fibromyalgia, chronic fatigue syndrome) that is related to service in Southwest Asia? If the examiner determines that the Veteran does not have a current diagnosis of chronic fatigue syndrome, this finding must be reconciled with the March 2023 finding that he suffers from debilitating fatigue and daily fatigue. (b) If any of the Veteran's claimed symptoms can be ascribed to a known clinical diagnosis the examiner is asked to opine whether it is at least as likely as not (i.e., the likelihood is at least approximately balanced or nearly equal, if not higher) that the diagnosed condition was incurred in or caused by military service, to include the Veteran's period of active duty in Southwest Asia and confirmed exposure to BPOT? (c) Is it at least as likely as not (i.e., the likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's rheumatoid arthritis was incurred in or caused by military service, to include the Veteran's period of active duty in Southwest Asia and confirmed exposure to BPOT? The requested opinions must specifically consider and address the synergistic, combined effect of all of the Veteran's TERAs, including his conceded burn pit/fine particulate matter exposures during his deployment to Saudi Arabia and any other potential toxic exposures from his MOS duties. In doing so, the examiner should review the Veteran's Individual Longitudinal Exposure Record. The Veteran is considered competent to report his medical history, including when and under what circumstances his symptoms began, and such reports must be acknowledged and considered in formulating any opinion. The examiner must provide a complete rationale for any opinions offered, citing to the examiner's own expertise, medical principals, and/or evidence in the Veteran's claim file, when necessary, to support the conclusion reached. If an opinion cannot be reached without resorting to speculation, the examiner must fully explain why that is so. J. NICHOLS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Melissa Barbee, 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.