Citation Nr: A24029710 Decision Date: 06/06/24 Archive Date: 06/06/24 DOCKET NO. 191119-49194 DATE: June 6, 2024 ORDER Entitlement to an initial rating of 30 percent, but no higher, for gastroesophageal reflux disease with a hiatal hernia is granted. Entitlement to a total rating based on individual unemployability (TDIU) due to service connected disabilities for the appeal period beginning September 11, 2012 is granted. Entitlement to a TDIU for the appeal period prior to September 11, 2012 is denied. REMANDED Entitlement to a higher rating for degenerative disc lumbar spine, rated as 10 percent disabling for the appeal period prior to March 26, 2020 and 20 percent thereafter, is remanded. FINDINGS OF FACT 1. Throughout the period on appeal, the Veteran's gastroesophageal reflux disease with a hiatal hernia manifested as persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain productive of considerable impairment of health without symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia or other symptom combinations productive of severe impairment of health. 2. For the appeal period beginning on September 11, 2012, the combined effects of the Veteran's service connected disabilities have rendered him unable to obtain and maintain substantially gainful employment. 3. For the appeal period prior to September 11, 2012, the combined effects of the Veteran's service connected gastroesophageal reflux disease with a hiatal hernia, degenerative disc lumbar spine, and bilateral hearing loss have not rendered him unable to obtain and maintain substantially gainful employment consistent with his education, training, and experience. CONCLUSIONS OF LAW 1. The criteria for an initial 30 percent rating for gastroesophageal reflux disease with a hiatal hernia have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.27, 4.114, Diagnostic Code 7346. 2. The criteria for entitlement to a TDIU based upon the combined effects of the Veteran's service connected disabilities for the appeal period beginning September 11, 2012 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. 3. The criteria for entitlement to a TDIU for the appeal period prior to September 11, 2012 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1968 to November 1970. These matters are before the Board of Veterans' Appeals (Board) on appeal from a rating decision dated in January 2019 and issued in March 2019 by a Department of Veterans Affairs (VA) Regional Office (RO). The rating decision on appeal constitutes an initial decision; therefore, the modernized review system, also known as the Appeals Modernization Act (AMA), applies. In the November 2019 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket. A Board hearing was held in January 2024. A copy of the transcript has been associated with the claims file. Therefore, the Board may only consider the evidence of record at the time of the March 2019 agency of original jurisdiction (AOJ) decision on appeal, as well as any evidence submitted by the Veteran at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(a), 20.801. If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claims, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. However, because the Board is remanding the claim of increased rating for degenerative disc lumbar spine, any evidence the Board could not consider will be considered by the AOJ in the adjudication of the claim. 38 C.F.R. § 3.103(c)(2)(ii). The Board notes that in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court of Appeals for Veterans Claims (Court) held that a claim for a TDIU due to a service-connected disability is part and parcel of an increased rating claim for that disability when raised by the record. In the present case, the Veteran contends that his service-connected gastroesophageal reflux disease with a hiatal hernia and degenerative disc lumbar spine render him unable to obtain and maintain substantially gainful employment. See October 2017 VA examination. Accordingly, the issue of entitlement to a TDIU is before the Board. See Roberson v. Principi, 251 F.3d 1378, 1384 (2001) ("[O]nce a veteran submits evidence of a medical disability and makes a claim for the highest rating possible, and additionally submits evidence of unemployability, the VA must consider... TDIU."). The Veteran is currently unrepresented. The Board notes that the Privacy Act request from the Veteran's former representative was fulfilled in January 2021. The Privacy Act request from the Veteran was fulfilled in December 2019. 1. Entitlement to an initial rating of 30 percent, but no higher, for gastroesophageal reflux disease with a hiatal hernia is granted. The Veteran contends that he is entitled to a higher rating for gastroesophageal reflux disease with a hiatal hernia as his symptoms are more severe than as assigned by the current rating. See January 2024 Hearing Transcript. Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. Separate evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the appeal, a practice known as "staged" ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). 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. Hart v. Mansfield, supra. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). However, the Board must also consider staged ratings. Hart v. Mansfield, supra. The veteran's entire history is considered when assigning disability ratings. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). A review of the recorded history of a disability is necessary to make an accurate rating. 38 C.F.R. §§ 4.2, 4.41. The regulations do not give past medical reports precedence over current findings where such current findings are adequate and relevant to the rating issue. Francisco v. Brown, 7 Vet. App. 55 (1994); Powell v. West, 13 Vet. App. 31 (1999). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, supra. The assignment of a particular diagnostic code is dependent on the facts of a particular case. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. In reviewing the claim for a higher rating, the Board must consider which diagnostic code or codes are most appropriate for application in the veteran's case and provide an explanation for the conclusion. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran's service-connected disability. 38 C.F.R. § 4.14. It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no obligation to discuss, in detail, the extensive evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as it relates to the Veteran's claim. When there is an approximate balance of positive and negative evidence as to any issue material to the determination of a matter, VA will resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc). Gastroesophageal reflux disease with a hiatal hernia is not specifically listed in the Rating Schedule. The most analogous diagnostic code for gastroesophageal reflux disease with a hiatal hernia is Diagnostic Code 7346, which applies to hiatal hernia. 38 C.F.R. § 4.20 (providing for rating by analogy). 38 C.F.R. § 4.114 provides that ratings under Diagnostic Codes 7301 through 7329, 7331, 7342, and 7345 to 7348, inclusive, will not be combined with each other. Rather, a single rating will be assigned under the diagnostic code that reflects the predominant disability picture, with elevation to the next higher rating where the severity of the overall disability warrants such elevation. Under Diagnostic Code 7346, a 10 percent rating is assigned where there are two or more of the symptoms listed in the criteria for the 30 percent rating of less severity. A 30 percent rating is assigned where there is persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain productive of considerable impairment of health. A 60 percent rating is assigned where there are symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia, or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114, Diagnostic Code 7346. The terms "severe impairment of health", "material weight loss", and "considerable impairment of health" are not defined in the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. In assigning a rating under Diagnostic Code 7346, the Board may not consider the ameliorative effects of medication. See Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). The rating criteria are not successive or cumulative with that of the lower rating. See Tatum v. Shinseki, 23 Vet. App. 152, 155 (2009); see also Stankevich v. Nicholson, 19 Vet. App. 470, 472 (2006) (The Court recognized that disabilities rated by analogy will not show all objective criteria of the analogous rating). The Board notes that the Schedule for Rating Disabilities of the digestive system was amended effective May 19, 2024. As the rating decision on appeal was issued in March 2019, the rating period on appeal predates the effective date of the amendment. Therefore, in this case the Board will only apply the pre-May 2024 version of the Schedule for Rating Disabilities of the digestive system. Turning to the evidence of record, in a June 2010 VA treatment record the Veteran reported a burning sensation and regurgitation of food for approximately 30 years. In a November 2014 VA treatment record, the Veteran complained of chronic recurrent episodes of vomiting and diarrhea since the 1970s. In a March 2017 VA treatment record the Veteran reported a history of chronic nausea/vomiting and watery diarrhea. The Veteran was afforded a VA examination in October 2017, at which time he reported that his heartburn and diarrhea were related to his deployment to Vietnam. The Veteran reported that for 50 years he had liquid stools with abdominal distress three or four times per week just after eating certain foods. On other days of the week the Veteran reported maintaining soft stools and no constipation. The Veteran reported episodes of heartburn and feeling of nausea and vomiting liquids. The Veteran indicated that he did not sleep before eating and had to sleep on at least two pillows. The examiner indicated that the Veteran reported his weight had remained stable for most of his life at around 230 pounds. The examiner found that the Veteran had persistently recurrent epigastric distress, reflux, sleep disturbance caused by esophageal reflux of four or more times per year lasting less than one day, nausea of four or more times per year lasting less than one day, and vomiting of four or more times per year lasting less than one day. The examiner indicated that the Veteran did not have an esophageal stricture, spasm of the esophagus or an acquired diverticulum of the esophagus. An August 2019 private treatment record indicated that the Veteran had a history of dysphagia. In a September 2019 private treatment record, the Veteran reported heartburn. In a May 2020 Statement in Support of Claim (VA Form 21-4138), the Veteran reported chronic episodes of vomiting, diarrhea, choking, and recent hospitalization. In a January 2024 VA treatment record the Veteran reported avoidance of spicy food and alcohol, sleeping on several pillows at night, and regurgitation one to three times per month. During a January 2024 Board hearing, the Veteran testified that he experienced regurgitation since 2021 and was hospitalized. He reported that he lost over 40 pounds as a result of his diet, propped up pillows for sleeping, drank less alcohol, was having bowel movements more frequently, had a burning sensation, nausea, and reflux four days per week. The Veteran indicated that he could not eat certain foods or ate less of them. The Veteran's wife testified at the hearing that he had difficulty with breathing due to the regurgitation. The Veteran reported pain that traveled to his left side approximately four times per month and vomiting from the acid reflux approximately five times per year. The Veteran reported that his stools were a little darker than normal but his physician did not find blood in the stool. A February 2024 VA treatment record received during the post-hearing evidentiary submission window indicated that the Veteran was on medication for anemia. Based on the evidence, the Board finds that an initial 30 percent rating, but no higher, is warranted for the appeal period. In this regard, the October 2017 VA examiner found that the Veteran had persistently recurrent epigastric distress. An August 2019 VA treatment record noted the Veteran's history of dysphagia. The Veteran reported pyrosis and regurgitation consistently during the appeal period. During the January 2024 Board hearing, the Veteran reported pain traveling to his left side. The clinical evidence establishes that the Veteran reported acid reflux during this time. These symptoms are productive of considerable impairment of health. However, the Board finds that a rating in excess of 30 percent for gastroesophageal reflux disease with a hiatal hernia is not warranted. To warrant a 60 percent rating the evidence must show symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia, or other symptom combinations productive of severe impairment of health. While the evidence shows some symptoms of pain, vomiting, and treatment for anemia, there is no evidence that the Veteran exhibits melena with moderate anemia. The evidence also does not show hematemesis. In addition, the Veteran reported weight-loss at the Board hearing in January 2024 and that his weight at the time was 222 pounds. However, the October 2017 VA examiner noted that the Veteran's weight was stable and around 230 pounds for most of his life. Therefore, material weight loss is not shown. For these reasons, a higher 60 percent rating is not appropriate. The Board has also considered whether a higher or separate rating is warranted under an alternative diagnostic code. The record does not establish, and the Veteran has not alleged, stricture, spasm or diverticulum of the esophagus. Therefore, a higher or separate rating under Diagnostic Codes 7203, 7204 or 7205 is not warranted. To the extent that the Veteran has been diagnosed with gastritis, a separate or higher rating cannot be awarded on that basis. The Schedule of Ratings-Digestive System indicates that ratings under Diagnostic Codes 7301 to 7329 inclusive, 7331, 7342 and 7345 to 7348 inclusive will not be combined with each other and that a single rating will be assigned under the diagnostic code which reflects the predominant disability picture. The Veteran's gastroesophageal reflux disease with a hiatal hernia is rated under Diagnostic Code 7346 and gastritis is rated under Diagnostic Code 7307. Moreover, there is no evidence or allegation that the Veteran experienced chronic gastritis with severe hemorrhages or large ulcerated or eroded areas which could potentially warrant a rating higher than 30 percent. Moreover, the Board finds that based on the Veteran's symptomatology a rating under Diagnostic Code 7346 reflects the predominant disability picture. In reaching its conclusions, the Board acknowledges the Veteran's belief that his gastroesophageal reflux disease with a hiatal hernia is more severe than as reflected by the currently assigned rating. The Board must consider the entire evidence of record when analyzing the criteria laid out in the rating schedule. While the Board recognizes that the Veteran is competent to provide evidence regarding his symptomatology, he is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Ultimately, the Board finds the medical evidence in which professionals with medical expertise examined the Veteran, acknowledged his reported symptoms, and described the manifestations of such disability in light of the rating criteria to be more persuasive than his reports regarding the severity of his gastroesophageal reflux disease with a hiatal hernia. The Board has also considered whether a staged rating under Fenderson v. West, supra is appropriate for the Veteran's service-connected gastroesophageal reflux disease with a hiatal hernia; however, the Board finds that his symptomatology has been stable throughout the period on appeal. Therefore, assigning a staged rating for such disability is not warranted. Further, the Veteran has neither raised any other issues, nor have any other issues been reasonably raised by the record, with regard to the initial rating claim adjudicated herein. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Accordingly, the Board finds that an initial rating of 30 percent, but no higher, for gastroesophageal reflux disease with a hiatal hernia is warranted for the appeal period. To that extent, the appeal is granted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, supra. 2. Entitlement to a TDIU due to service connected disabilities for the appeal period beginning September 11, 2012 is granted. The Veteran contends that he is unable to obtain and maintain employment as a result of his service connected disabilities. See October 2017 VA examination. Specifically, the Veteran asserts that his service connected gastroesophageal reflux disease with a hiatal hernia, degenerative disc lumbar spine, and bilateral hearing loss have prevented him from working gainfully since September 11, 2012. Id.; see also May 2014 Veteran's Application for Increased Compensation Based on Unemployability (VA Form 21-8940). Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability, such disability shall be ratable as 60 percent or more, and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Rating boards should submit to the Director of Compensation Service for extraschedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities but who fail to meet the percentage standards set forth in 38 C.F.R. § 4.16(a). See 38 C.F.R. § 4.16(b). Unlike the regular disability rating schedule, which is based on the average work-related impairment caused by a disability, "entitlement to a TDIU is based on an individual's particular circumstances." Rice v. Shinseki, supra. Therefore, when adjudicating a TDIU claim, VA must take into account the individual veteran's education, training, and work history. Hatlestad v. Derwinski, 1 Vet. App. 164 (1991) (level of education is a factor in deciding employability); see Friscia v. Brown, 7 Vet. App. 294 (1994) (considering a veteran's experience as a pilot, his training in business administration and computer programming, and his history of obtaining and losing 19 jobs in the previous 18 years); Beaty v. Brown, 6 Vet. App. 532 (1994) (considering a veteran's 8th grade education and sole occupation as a farmer); Moore v. Derwinski, 1 Vet. App. 356 (1991) (considering a veteran's master's degree in education and his part-time work as a tutor). Age may not be considered as a factor when evaluating unemployability or intercurrent disability, and it may not be used as a basis for a total disability rating. 38 C.F.R. § 4.19. There must be a determination that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age or a non-service-connected disability. 38 C.F.R. §§ 3.340, 3.341, 4.16. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question, however, 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 v. Brown, 4 Vet. App. 361, 363 (1993). A claim for TDIU may be filed as a freestanding claim. In addition, TDIU may be an element of a claim for an increased disability rating when unemployability is raised by the record. See Rice v. Shinseki, supra. In the instant case, and as of the date of this decision, service connection is in effect for posttraumatic stress disorder, major depressive disorder, insomnia and alcohol dependence (PTSD), rated as 30 percent disabling prior to April 9, 2008 and as 50 percent disabling thereafter; bilateral hearing loss, rated as noncompensable prior to June 22, 2015 and as 50 percent disabling thereafter; diabetes mellitus type II, rated as 20 percent disabling from April 8, 2016; left lower extremity (sciatic nerve) peripheral neuropathy, rated as 20 percent disabling from April 13, 2017; left lower extremity (femoral nerve) peripheral neuropathy, rated as 20 percent disabling from August 22, 2018; degenerative disc lumbar spine, rated as 10 percent disabling prior to March 26, 2020 and as 20 percent disabling thereafter; tinnitus, rated as 10 percent disabling from August 11, 2004; gastroesophageal reflux disease with a hiatal hernia, rated as 30 percent disabling from April 8, 2009; right lower extremity (sciatic nerve) peripheral neuropathy, rated as 10 percent disabling from April 13, 2017; right lower extremity (femoral nerve) peripheral neuropathy, rated as 10 percent disabling from August 22, 2018; and malaria, rated as noncompensable from November 18, 1970. The Veteran's combined rating for compensation was at minimum 70 percent from April 8, 2009. Thus, the schedular criteria for a TDIU have been met throughout the period on appeal. The Board finds a claim of TDIU was raised by the record pursuant to the Veteran's claim for an increased rating for his service connected gastroesophageal reflux disease with a hiatal hernia and degenerative disc lumbar spine. See Rice v. Shinseki, supra. The Veteran contends that his gastroesophageal reflux disease with a hiatal hernia and degenerative disc lumbar spine render him unable to obtain and maintain substantially gainful employment. See October 2017 VA examination. Therefore, the Board may proceed with adjudicating a TDIU claim. To the extent that the Veteran's functional impact of his service-connected gastroesophageal reflux disease with a hiatal hernia is discussed in the preceding section, the Board incorporates such herein. A review of the record demonstrates that the combined effects of the Veteran's service connected gastroesophageal reflux disease with a hiatal hernia, degenerative disc lumbar spine, and bilateral hearing loss render him unable to secure and maintain substantially gainful employment. In an August 2018 VA Form 21-8940, the Veteran indicated that he last worked full-time on September 11, 2012, the date that he became too disabled to work. He reported that he worked as a chemical operator from September 1982 to September 2012 at over 50 hours per week. He indicated that he left his last job because of his disabilities. The Veteran indicated that he completed two years of college. Turning to the evidence of record, in October 2012 the Veteran was afforded a VA examination for his degenerative disc lumbar spine. He reported that repetitive bending aggravates his back. In January 2015 the Veteran was afforded a VA examination for his PTSD. The Veteran reported that he retired from his position as a chemical operator because he was having problems with his back, had pain, and could not take prescription medications because of drug testing at work. In October 2015 the Veteran was afforded a VA examination for his bilateral hearing loss. He indicated that he found it difficult to understand speech when there was competing noise, if he did not see the speaker's face or was not close to the speaking source, the lighting was not good, or if he was at a distance. In October 2017, the Veteran was afforded a VA examination for his service connected gastroesophageal reflux disease with a hiatal hernia. The Veteran reported that he worked in chemical plants for over 30 years and retired five years previously as he could not function due to his service connected gastroesophageal reflux disease with a hiatal hernia and degenerative disc lumbar spine. In October 2017, the Veteran was afforded a VA examination for his service connected degenerative disc lumbar spine. The examiner indicated that the Veteran's degenerative disc lumbar spine impacted his ability to work. The Veteran described his former position as a chemical operator requiring him to read open valves and check pump steam. The Veteran reported that the pain would leave him unable to climb to the top of the towers. The Veteran reported that he was unable to fully perform his job responsibilities and chose to retire. Based on the evidence of record, the Board finds that the combined effects of the Veteran's service-connected gastroesophageal reflux disease with a hiatal hernia, degenerative disc lumbar spine, and bilateral hearing loss prevented him from maintaining substantially gainful employment that is consistent with his education and occupational experience for the period on appeal beginning September 11, 2012, the date the Veteran reported that he became too disabled to work due to service connected disabilities. In this regard, the Veteran worked as a chemical operator in his post-service career. The Veteran's physical limitations due to his service connected gastroesophageal reflux disease with a hiatal hernia, and degenerative disc lumbar spine, to include difficulty with climbing, bending, acid reflux, nausea, vomiting, regurgitation, frequent bowel movements, left side pain, and anemia would impact his ability to work as a chemical operator as the occupation would require climbing, bending, and frequent periods of time without close proximity to a restroom. See Ray v. Wilkie, 31 Vet. App. 58 (2019). Furthermore, the October 2017 VA examiner indicated that the Veteran's degenerative disc lumbar spine would impact his ability to work. The Veteran's difficulty with understanding speech when there was competing noise associated with his service connected bilateral hearing loss would impact his ability to understand directions from co-workers while serving as a chemical operator. Thus, the Board finds that the impairment caused by the Veteran's combined effects of his various service-connected gastroesophageal reflux disease with a hiatal hernia, degenerative disc lumbar spine, and bilateral hearing loss prevented him from securing and maintaining employment consistent with his industrial background and education beginning September 11, 2012. VA's duty to maximize benefits requires it to assess all of a claimant's service connected disabilities to determine whether any combination of the disabilities establishes eligibility for special monthly compensation under 38 U.S.C. § 1114(s). See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); Bradley v. Peake, 22 Vet. App. 280, 294 (2008). In Bradley, the Court held that 38 U.S.C. § 1114(s) permits a TDIU rating based on a single disability to satisfy the statutory requirement of a "total" rating. When a veteran is awarded TDIU based on a single disability and receives schedular disability ratings for other conditions, special monthly compensation based on the statutory housebound criteria may be awarded so long as the same disability is not counted twice, i.e., as a basis for TDIU and as a separate disability rated 60 percent or more disabling. See 75 Fed. Reg. 11,229, 11,230; Summary of Precedent Opinions of the VA General Counsel (March 10, 2010) (withdrawing VAOPGCPREC 6-1999 in light of Bradley, 22 Vet. App. at 280). A veteran with a 100 percent schedular rating for a single service-connected disability could also obtain a TDIU on a single separate disability (though not on multiple service-connected disabilities), in order to meet the special monthly compensation requirements (100 percent rating plus 60 percent rating). A TDIU could meet the special monthly compensation requirements by either: a) increasing a single disability rating of less than 60 percent to at least 60 percent (in a case where a separate 100 percent rating is already established), or b) increasing a single disability that is less than 100 percent to a "total" (100 percent) rating, in a case where there is already established a combination of other ratings that meet the separate 60 percent rating requirement for special monthly compensation. See Buie at 249-50. The Veteran is being awarded a TDIU based on the combined effects of his service connected disabilities herein and he does not have service connected disabilities that are separately rated as 60 percent disabling. Therefore, special monthly compensation under 38 U.S.C. § 1114(s) for statutory housebound benefits is not warranted. Therefore, based on the foregoing, the Board finds that the combined effects of the Veteran's service-connected disabilities have rendered him unable to secure and follow a substantially gainful occupation and entitlement to a TDIU is warranted for the appeal period beginning on September 11, 2012. To that extent, the appeal is granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch v. McDonough, supra. 3. Entitlement to a TDIU for the appeal period prior to September 11, 2012 is denied. With regard to the period on appeal prior to September 11, 2012, the Board finds that entitlement to a TDIU is not warranted. In this regard, the Veteran indicated that he worked full-time until September 11, 2012 and that his service connected disabilities forced him to stop working on September 11, 2012. See August 2018 VA Form 21-8940. The determination as to whether a veteran can secure or follow a substantially gainful occupation includes an economic component and a noneconomic component. The economic component means that a veteran must not receive income from employment outside of a protected environment that exceeds the poverty threshold for one person. The noneconomic component requires consideration of a veteran's ability to secure or follow substantially gainful employment, including factors such as the veteran's history of education, skill, and training, as well as his or her ability to perform the physical and mental activities required by the occupation in question. See Ray v. Wilkie, supra. In addition, a September 2018 Request for Employment Information in Connection with Claim for Disability Benefits (VA Form 21-4192) completed by the Veteran's last employer indicated that he earned $88,111.67 during the 12 months preceding September 2012, which would support that the Veteran was working and earning income above the poverty threshold through September 11, 2012. There is no evidence or allegation that the Veteran's employment was in a protected environment. Accordingly, the Board finds that prior to September 11, 2012 the combined effects of the Veteran's service-connected disabilities did not render him unable to secure and follow a substantially gainful occupation. To that extent, the appeal is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, supra. REASONS FOR REMAND Entitlement to an increased rating for degenerative disc lumbar spine, rated as 10 percent disabling for the appeal period prior to March 26, 2020 and 20 percent thereafter, is remanded. The Veteran asserts that his degenerative disc lumbar spine symptoms are worse than currently rated. See January 2024 Hearing Transcript. Specifically, the Veteran states that his back problem causes him pain and that he has a bladder impairment. Id. The Veteran was afforded a VA examination in October 2012. The Board finds the October 2012 VA examination report incomplete to decide the claim. Specifically, the Board notes that the October 2012 VA examination is not compliant with the Court's holding in Correia. See Correia v. McDonald, 28 Vet. App. 158 (2016) (holding that "to be adequate, a VA examination of the joints must, wherever possible, include the results of range of motion testing" for active range of motion, passive range of motion, weight bearing range of motion, and nonweight bearing range of motion). Here, the VA examiner did not conduct passive range of motion testing or range of motion in weight bearing and in nonweight bearing. In addition, the examiner indicated that the Veteran did not report flare-ups, even though the Veteran reported his pain worsened with repetitive bending. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (an opinion that does not consider all relevant evidence, including lay statements, is inadequate); see also Sharp v. Shulkin, 29 Vet. App. 26 (2017). Subsequently, the Veteran was afforded a VA examination in October 2017. The Board finds the October 2017 VA examination report incomplete to decide the claim. Specifically, the Board notes that the October 2017 VA examination is not compliant with the Court's holding in Correia as the examiner did not conduct passive range of motion testing. See Correia v. McDonald, supra. In addition, the VA examiner indicated that the Veteran did not report flare-ups, despite the Veteran reporting that his back symptoms had worsened since the October 2012 VA examination. See Nieves-Rodriguez v. Peake, supra; Sharp v. Shulkin, supra. Accordingly, the Board concludes that addendum opinions should be obtained to determine the severity of the Veteran's degenerative disc lumbar spine. Where VA provides a veteran with an examination in a claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The failure to provide an adequate VA examination is a pre-decisional duty to assist error. The matter is REMANDED for the following action: Return the claim file to the October 2012 and October 2017 examiners, or an examiner with appropriate expertise, to obtain retrospective opinions regarding the severity of the Veteran's service connected degenerative disc lumbar spine. After reviewing the record, including this Remand, the examiner should provide an estimate, if at all possible, as to the Veteran's range of motion of the lumbar spine, to specifically include range of motion during flare-ups. In doing so, the examiner should discuss the historical severity of the Veteran's range of motion with both active and passive motions as well as in weight-bearing and nonweight-bearing, to include during any flare-up episodes or with repeated use over time. If factors, such as pain, weakness, fatigability or incoordination limited range of motion or functional ability, discuss its impact in terms of the severity, frequency and duration thereof. If possible, the examiner should provide an estimate of his or her range of motion in degrees. A rationale should be provided for all opinions offered. The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resorting to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Kuhn, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.