Citation Nr: 25004642 Decision Date: 04/04/25 Archive Date: 04/04/25 DOCKET NO. 14-31 455A DATE: April 4, 2025 ORDER From December 1, 2011, entitlement to a rating in excess of 10 percent for status-post laryngeal squamous cell carcinoma of the left true vocal cord (vocal cord cancer residuals) is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) is denied. FINDINGS OF FACT 1. Throughout the period on appeal, the Veteran's vocal cord cancer residuals have been manifested by hoarseness; they were not manifested by thickening or nodules of vocal cords, polyps, submucous infiltration, or pre-malignant changes on biopsy and did not prevent him from speaking above a whisper or communicating by speech. 2. The evidence of record does not reflect that the Veteran was unable to secure or follow substantially gainful employment as a result of his service-connected disabilities. CONCLUSIONS OF LAW 1. From December 1, 2011, the criteria for a rating in excess of 10 percent for vocal cord cancer residuals have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.97, Diagnostic Codes (DC) 6819-6516. 2. The criteria for a TDIU have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1965 to October 1967. These matters come before the Board of Veterans' Appeals (Board) on appeal from March 2011 and March 2016 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). By way of background, these matters were previously before the Board in July 2022, December 2022, October 2023, June 2024, and November 2024, when they were remanded for additional development. Lastly, in the March 2025 informal hearing presentation (IHP), the Veteran's representative noted that the Agency of Original Jurisdiction (AOJ) last contacted the Veteran via telephone in November 2024 but stated that he subsequently failed to attend scheduled VA examinations and had not received medical care through VA since November 2024. To the contrary, he emphasized that the Veterans Health Administration (VHA) sent an "Unable to Contact" letter to the Veteran in January 2025. In this regard, the Veteran's representative acknowledged that it was the Veteran's responsibility to communicate with VA and to attend scheduled appointments but stated that a welfare check may be in order due to his lack of communication. See March 2025 Appellate Brief (VSO IHP; Post remand Brief; Attorney Brief); see also February 2025 CAPRI. The Board cannot direct such development at this time. However, the Veterans representative can request a welfare check through VHA. In addition, if the Veteran is in need of any immediate attention, he should contact VA's Veterans Crisis Line by dialing 988 and pressing 1 or by calling 1-800-273-8255 (1-800-273-TALK). Increased Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability ratings is the ability of the body as a whole, or of the psyche, or of a system or organ of the body, to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more nearly approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When a reasonable doubt arises regarding the degree of disability, that reasonable doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 1. From December 1, 2011, entitlement to a rating in excess of 10 percent for vocal cord cancer residuals As an initial matter, the Veteran filed his claim for entitlement to service connection for vocal cord cancer in April 2011, and in an August 2012 rating decision, the AOJ granted service connection for vocal cord cancer residuals and assigned a 100 percent rating, effective from April 1, 2011 to December 1, 2011, and a noncompensable rating thereafter. See April 2011 VA Form 21-526b, Veteran Supplemental Claim; August 2012 Rating Decision - Narrative; August 2012 Notification Letter (e.g., VA Form 20-8993, VA Form 21-0290, PCGL). A March 2016 rating decision granted an increased 10 percent rating for vocal cord cancer residuals, effective December 1, 2011. See March 2016 Rating Decision - Narrative. Throughout the period on appeal, the Veteran's service-connected vocal cord cancer residuals have been rated pursuant to 38 C.F.R. § 4.97, DC 6819-6516. Hyphenated diagnostic codes are utilized when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. Here, the hyphenated diagnostic code indicates that the Veteran's service-connected vocal cord cancer residuals are manifested by malignant neoplasms of any specified part of the respiratory system exclusive of skin growths under DC 6819, to be rated as chronic laryngitis pursuant to DC 6516. See November 2024 Rating Decision - Codesheet. Pursuant to DC 6516, a 10 percent rating is assigned for hoarseness, with inflammation of cords or mucous membrane, and a maximum 30 percent rating is assigned for hoarseness with thickening or nodules of cords, polyps, submucous infiltration, or pre-malignant changes on biopsy. 38 C.F.R. § 4.97. In addition, under DC 6819, malignant neoplasms of any specified part of the respiratory system exclusive of skin growths are to be rated on the residuals thereof absent any local recurrence or metastasis. See 38 C.F.R. § 4.97, DC 6819, Note (1). Turning to the evidence of record, the Veteran underwent direct microlaryngobronchoscopy with biopsy and esophagoscopy procedures for a left vocal cord mass and hoarseness in March 2011. Following the procedures, the Veteran was diagnosed with a superficially invasive well-differentiated squamous cell carcinoma and subsequently completed radiation therapy in June 2011. See May 2011 Medical Treatment Record - Non-Government Facility; February 2025 CAPRI. In support of his claim, the Veteran submitted a disability benefits questionnaire (DBQ) for sinusitis, rhinitis, and other conditions of the nose, throat, larynx, and pharynx from Dr. J.P. dated in May 2012. Dr. J.P. noted that the Veteran had been diagnosed with laryngeal squamous cell carcinoma of the left true vocal cord but indicated that he underwent a rigid tracheoscopy, laryngoscopy, and biopsy in March 2011 and completed radiation therapy in June 2011. During the examination, the Veteran reported sporadic hoarseness during the day but denied any dysphagia, odynophagia, globus, or ear pain, and Dr. J.P. listed daily hoarseness as the Veteran's only residual condition or complication of vocal cord cancer. In this regard, he found that the Veteran did not have inflammation of the vocal cords or mucus membrane, thickening or nodules of the vocal cords, submucous infiltration of the vocal cords, or vocal cord polyps. See May 2012 Disability Benefits Questionnaire (DBQ) - Veteran Provided. The Veteran was afforded a VA examination for sinusitis, rhinitis, and other conditions of the nose, throat, larynx, and pharynx in May 2014. The examiner noted that the Veteran had been diagnosed with vocal cord cancer in February 2011 but stated that he completed radiation treatment in June 2011 and had not experienced any recurrence of disease. During the examination, the Veteran reported that he had been plagued by dry throat and intermittent hoarseness since he underwent radiation therapy, and the examiner listed hoarseness and dry mouth as the only residuals or complications from the Veteran's vocal cord cancer. In this regard, the examiner stated that the Veteran's residual symptoms would likely never improve as more than three years had passed since his last radiation treatment. See May 2014 CAPRI. Otolaryngology notes dated in May 2014 and September 2014 show that the Veteran endorsed intermittent dry throat. However, he also indicated that he was able to hydrate and was otherwise doing well. In addition, the notes show that he communicated with good vocal quality and language, and fiberoptic flexible laryngoscopies performed in connection therewith were normal. See December 2016 CAPRI; February 2025 CAPRI. A March 2015 speech pathology note shows that the Veteran stated that his vocal cord cancer residuals, to include dysphonia and hoarseness, disrupted his career and the overall quality of his life. In this regard, the examiner indicated that the Veteran's vocal quality was slightly harsh. However, a fiberoptic flexible laryngoscopy was normal, and the examiner indicated that the Veteran's neck appearance and tracheal position were normal with no masses. In addition, the examiner indicated that the Veteran was following gastroesophageal reflux disease (GERD) precautions for intermittent reflux. The Veteran continued to report hoarseness in July 2015, but a February 2016 otolaryngology note shows that the Veteran's voice was strong and that he communicated with good vocal quality and language. See February 2025 CAPRI. In his May 2016 substantive appeal, the Veteran argued that his chronic laryngitis warranted a rating in excess of 10 percent. In this regard, he stated that he had not been able to pursue his vocation as a preacher since he was diagnosed with cancer. See May 2016 VA Form 9. In August 2016, the Veteran denied any complaints except for tightness and stiffness in his neck; however, a December 2016 otolaryngology note shows that he continued to report some hoarseness but continued to communicate with good vocal quality and language. See February 2025 CAPRI. In June 2017, September 2017, and January 2018, the Veteran reported some difficulty swallowing and throat clearing with food. However, fiberoptic flexible laryngoscopies were normal, and the examiners found that the Veteran's neck appearance and tracheal position were normal with no masses. See id. During a February 2018 physical medicine rehabilitation consultation, the Veteran reported neck pain, stiffness, and decreased range of motion, as well as difficulty swallowing with occasional coughing with dysregulation. On physical examination, the examiner found no evidence of skin changes, swelling, or erythema but noted decreased rotation and extension of the cervical spine and tenderness to palpation. The assessment was myofascial neck pain status-post vocal cord cancer. VA treatment records dated from July 2018 to June 2022 show that the Veteran continued to endorse fullness in his neck and in the folds of his cervical area. See id. In September 2019, the Veteran reported that he had been experiencing stiffness and spasms while laying down since he underwent radiation therapy for vocal cord cancer in 2011. On physical examination, the examiner noted rough, tight, and deformed skin on the front area of the Veteran's neck. The assessment included radiation scar of the neck, and the examiner advised the Veteran to apply coconut oil to his skin twice a day to increase flexibility and to return for an x-ray if his symptoms persisted. See id. A March 2020 primary care note shows that the Veteran reported that he had been experiencing neck pain, which manifested only while he was laying down, for more than a year and noted that he underwent radiation therapy for vocal cord cancer. He further explained that he tried using coconut oil for his skin with no improvement, and the examiner noted that he had scar tissue on his anterior neck. The assessment included neck pain, cervical spine versus radiation scar of the neck, and skin changes due to radiation. See id. In August 2021, the Veteran reported that he had been experiencing radiation dermatitis, which was manifested by pain that restricted movement of his neck, for years. On physical examination, the examiner noted erythematous scaly plaque with areas of atrophy on the Veteran's anterior neck. In this regard, the examiner diagnosed the Veteran with radiation dermatitis and recommended Silvadene cream, a topical antibiotic. See id. A February 2022 primary care note shows that the Veteran reported worsening neck pain and tightness. He further explained that his neck felt tight when he turned his head and noted that he took a long time to fall asleep due to pain. See id. Lastly, in October 2024, the Veteran reported decreased range of motion of the neck. However, he denied hoarseness or dysphasia, and the examiner noted that he communicated with good vocal quality and language. On physical examination, the examiner found that the Veteran had fibrosis of the neck and lymphedema, however, a fiberoptic flexible laryngoscopy showed no signs of pharyngeal or laryngeal lesions and excellent vocal cord mobility. The impression included laryngeal cancer, which had been treated with radiation therapy with no evidence of disease, and lymphedema/decreased range of motion/possible hypothyroidism. See id. After a review of the evidence of record, the Board finds that a rating in excess of 10 percent is not warranted for the Veteran's service-connected vocal cord cancer residuals. In this regard, the evidence of record does not show that the Veteran's vocal cord cancer residuals were manifested by thickening or nodules of cords, polyps, submucous infiltration, or pre-malignant changes on biopsy. To the contrary, although the evidence of record, to include the May 2012 DBQ from J.P. and the May 2014 VA examination report, shows that the Veteran consistently reported hoarseness, fiberoptic flexible laryngoscopies conducted throughout the period on appeal were normal with no signs of pharyngeal or laryngeal lesions and excellent vocal cord mobility. See May 2012 Disability Benefits Questionnaire (DBQ) - Veteran Provided; May 2014 CAPRI; February 2025 CAPRI. The Board has also considered whether a higher rating would be warranted under any other diagnostic codes. In this regard, the Board recognizes the Veteran's reports that his vocal cord cancer residuals were manifested by neck pain, stiffness, and decreased range of motion, which was most prevalent when he laid down and increased the amount of time it took him to fall asleep. See February 2025 CAPRI. However, the evidence of record does not show that the Veteran's neck pain causes or has caused functional impairment, and as such, the Board finds that a separate compensable rating for neck pain is not warranted at any time during the period on appeal. See 38 C.F.R. § 4.40, 4.45, 4.59, 4.71a. The Board has also considered whether separate compensable ratings are warranted for the Veteran's diagnosed radiation dermatitis. However, the Board finds that a separate compensable rating is not warranted under DC 7806 as the Veteran's radiation dermatitis was not manifested by characteristic lesions involving at least 5 percent of his entire body or of exposed areas affected and that he did not require intermittent systemic therapy any time during the period on appeal. See 38 C.F.R. § 4.118. In addition, the Board acknowledges and has considered the Veteran's reports that his service-connected vocal cord cancer residuals were manifested by difficulty swallowing and throat clearing with food. However, the Board concludes that the evidence of record does not show that such symptoms have been associated with the Veteran's vocal cord cancer residuals. To the contrary, although the Veteran endorsed some difficulty swallowing and throat clearing with food in June 2017, September 2017, and January 2018 and subsequently reported difficulty swallowing during his February 2018 physical medicine rehabilitation consultation, the examiners did not find that such symptoms were related to his vocal cord cancer residuals. Moreover, neither the May 2012 DBQ from Dr. J.P. nor the May 2014 VA examination report shows that the Veteran's vocal cord cancer residuals were manifested by either of the above symptoms and they have not otherwise been related to his service-connected vocal cord cancer. In this regard, the Board recognizes that the Veteran is considered competent to report the observable manifestations of his claimed disability. See Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). However, while a Veteran can competently report the onset and continuity of subjective symptoms, he is not competent to render a diagnosis or to determine the medical etiology of his reported symptoms. See Jandreau v. Nicholson, 492 F.3d 1372, 1376, 1377 (Fed. Cir. 2007). Thus, the Board finds that the Veteran is not entitled to a separate rating for difficulty swallowing or throat clearing. In reaching the above conclusions, the Board acknowledges that the Veteran last underwent a VA examination in relation to his claim of entitlement to a rating in excess of 10 percent for vocal cord cancer residuals in May 2014. In this regard, the Board remanded the Veteran's increased rating claim to obtain an examination to assess the current severity and manifestations of his disability in July 2022. See July 2022 BVA examination. Thereafter, in December 2022, October 2023, and June 2024 Remands, the Board, in pertinent part, noted that the Veteran failed to report for multiple scheduled VA examinations and remanded his increased rating claim to obtain an adequate examination. See December 2022 BVA Decision; October 2023 BVA Decision; June 2024 BVA Decision. The Board last remanded the Veteran's claim to confirm that his address and phone numbers were correct and current and to obtain an examination to determine the current nature and severity of his service-connected vocal cord cancer in November 2024. See November 2024 BVA Decision. Following the November 2024 Board remand, a November 2024 report of general information shows that the Veteran confirmed that the address and phone number of record were correct and current. See November 2024 VA Form 27-0820 Report of General Information. However, examination scheduling request contention cancellation forms show that the Veteran did not attend scheduled VA examinations to determine the current severity of his service-connected vocal cord cancer residuals in December 2024 and January 2025. See December 2024 Examination Request; January 2025 Examination Request. Thereafter, in a January 2025 letter, the organization contracted to perform VA examinations notified the Veteran that his VA examination would take place at a stand-alone clinic/doctor's office and was scheduled to occur in February 2025. See February 2025 C&P examination. However, an examination scheduling request contention cancellation form shows that the Veteran did not attend his scheduled appointment, and as a result, that his examination was cancelled. See February 2025 Examination Request. Thus, although no examinations were obtained pursuant to the July 2022, December 2022, October 2023, June 2024, and November 2024 Remands, the Board finds that there has been substantial compliance with the remand directives. It is the Veteran's obligation to actively participate in the retrieval of any information pertinent to his claim, to include attending scheduled VA examinations. The Veteran is expected to cooperate in the efforts to adjudicate the claim, and failure to do so could result in an adverse adjudication based on an incomplete and underdeveloped record. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991); Kowalski v. Nicholson, 19 Vet. App. 171, 178 (2005). Here, the Board finds that the AOJ made several attempts to re-schedule the Veteran for his examinations following the November 2022 Board remand, and that the Veteran failed to attend the VA examinations and has not presented good cause for his lack of attendance or otherwise requested to reschedule the examinations. Thus, the Board finds another remand to obtain an examination is not warranted. In sum, the Board finds that the evidence is persuasively against assignment of a rating greater than 10 percent under DC 6819-6516 for vocal cord cancer residuals at any time during the period on appeal. The claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.7, 4.88b, 4.97; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to a TDIU As an initial matter, the Board found that the issue of entitlement to a TDIU had been raised by the record in a July 2022 decision. See July 2022 BVA Decision. As such, pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009), the claim for entitlement to a TDIU is considered part and parcel to the Veteran's increased rating claims, including his claim for entitlement to an increased rating for his service-connected acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and other specified trauma and stressor related disorder. In this regard, the Board notes that the Veteran's increased rating claim arose from a March 2011 rating decision, which granted service connection for an acquired psychiatric disorder, to include PTSD, and assigned a 10 percent rating, effective November 30, 2005, the date VA received the Veteran's service connection claim. See March 2011 Rating Decision - Narrative. A TDIU may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16(a). A TDIU will be granted when the evidence shows that the veteran, due to service-connected disabilities, is precluded from obtaining or maintaining any gainful employment consistent with their education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. VA's policy is to grant a TDIU in all cases where a service-connected disability causes unemployability regardless of the percentage evaluations. 38 C.F.R. § 4.16(b). In situations where the percentage evaluations do not allow a TDIU under § 4.16(a), an extraschedular TDIU may be awarded under § 4.16(b). The Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 4.16 in the first instance. The Board, however, is not precluded from considering whether the case should be referred to the Director of VA's Compensation Service for consideration of an extraschedular TDIU rating. A decision by the Director of the Compensation Service is not evidence. Rather it is a decision or adjudication that is adopted by the RO and reviewed de novo by the Board. Wages v. McDonald, 27 Vet. App. 233 (2015). The determination of whether a case should be referred for an extraschedular TDIU determination under 38 C.F.R. § 4.16(b) is a lower standard than a determination on whether a TDIU is warranted. See Snider v. McDonough, No. 19-6707 (Vet. App. 2021). In determining whether a referral is warranted, the Board must address whether there is sufficient evidence to substantiate a "reasonable" possibility that a veteran is unemployable because of service-connected disabilities. See Ray, supra. If the Board concludes that there is no reasonable possibility that the veteran is unemployable, then it necessarily follows that the higher standard is not met. In the present case, the Veteran has been service connected for the following disabilities: an acquired psychiatric disability, to include PTSD and other specified trauma and stressor related disorder, rated as 30 percent disabling as of November 30, 2005; diabetes mellitus rated as 20 percent disabling as of April 22, 2004; tinnitus rated as 10 percent disabling as of April 22, 2004; vocal cord cancer residuals rated as 100 percent disabling from April 1, 2011 to December 1, 2012 and as 10 percent disabling thereafter; prostate cancer rated as 100 percent disabling from April 30, 2013 to April 1, 2015, and as 10 percent disabling thereafter; bilateral hearing loss rated as noncompensable from April 22, 2004; and erectile dysfunction rated as noncompensable from May 16, 2014. Thus, during the period on appeal, the Veteran's combined disability rating was 50 percent from November 30, 2005 to April 1, 2011 and 60 percent from December 1, 2011 to April 30, 2013 and from April 1, 2015. See 38 C.F.R. § 4.16(a). Thus, excluding the periods from April 1, 2011 to December 1, 2011 and from April 30, 2015 to April 1, 2015, during which the Veteran was in receipt of 100 percent ratings, he has not met the schedular criteria for a TDIU. However, the Board must still consider whether referral for extraschedular consideration is warranted. Turning to the evidence of record, the Veteran reported that he was working with a railroad in March 2004, however, a September 2005 primary care physician note shows that he left his job and had been enjoying retirement from employment. See December 2016 CAPRI. The Veteran endorsed difficulty hearing and intermittent tinnitus during a May 2005 VA audio examination. However, neither he nor the examiner indicated what effect, if any, his symptoms had on employment. See May 2005 VA examination. The Veteran initially underwent a VA examination for PTSD in August 2010. During the examination, the Veteran noted that he spent time with his children and grandchildren, occasionally went on camping trips, and was active in his church, and the examiner found that his acquired psychiatric disorder was manifested by transient or mild symptoms that did not have any effect on occupational functioning, as he was retired. He further stated that he dropped out of school in the 11th grade. However, the examiner indicated that the Veteran's psychiatric symptoms caused some degree of subjective distress, which could have a mildly adverse effect on his quality of life. See August 2010 VA examination. In March 2011, the Veteran reported hoarseness related to his service-connected vocal cord cancer residuals, but stated that he was working as a preacher. See May 2011 Medical Treatment Record - Non-Government Facility. The Veteran underwent a VA examination for diabetes mellitus in March 2012. Following the examination, the examiner found that the Veteran's diabetes mellitus did not impact his ability to work. See March 2012 VA examination. In support of his claim, the Veteran submitted a DBQ for sinusitis, rhinitis, and other conditions of the nose, throat, larynx, and pharynx from Dr. J.P. dated in May 2012. After performing an examination and reviewing the evidence of record, Dr. J.P. found that the Veteran's vocal cord cancer residuals impacted his ability to work. Specifically, he noted that the Veteran was working as a pastor and that his hoarseness intermittently affected his ability to deliver a sermon. See May 2012 Disability Benefits Questionnaire (DBQ) - Veteran Provided. Thereafter, during a May 2014 VA examination for sinusitis, rhinitis and other conditions of the nose, throat, larynx, and pharynx, the examiner noted that the Veteran's service-connected vocal cord cancer residuals affected his ability to work and explained that post-radiation changes, to include dry mouth and chronic hoarseness, prevented him from performing his job as preacher. See May 2014 CAPRI. The Veteran was also afforded a VA examination for PTSD in May 2014. During the examination, the Veteran acknowledged that he retired in 2006 but explained that he was active in his church and helped the elderly in his community by mowing lawns and by performing similar activities. In this regard, although the examiner diagnosed the Veteran with other specified trauma and stressor related disorder, he found that such was which was manifested by occupational and social impairment due to mild or transient symptoms that decreased work efficiency and ability to perform occupational tasks only during periods of significant stress or by symptoms controlled by medication. See May 2014 C&P examination. The Veteran also underwent VA examinations for prostate cancer in May 2014 and November 2014. Following the examinations, both examiners found that the Veteran's prostate cancer did not impact his ability to work. See May 2014 C&P examination; November 2014 C&P examination. A March 2015 speech pathology note shows that the Veteran stated that his vocal cord cancer residuals, to include dysphonia and hoarseness, disrupted his career and the overall quality of his life. In this regard, the examiner indicated that the Veteran's vocal quality was slightly harsh. See February 2025 CAPRI. In his May 2016 substantive appeal, the Veteran reported that he had not been able to pursue his vocation as a preacher since he was diagnosed with cancer. See May 2016 VA Form 9. On a November 2016 VA examination for hearing loss and tinnitus, the examiner noted the Veteran's diagnosis of bilateral sensorineural hearing loss in the frequency ranges of 500 Hz to 4000 Hz and 6000Hz or higher frequencies and tinnitus. After examining the Veteran, the examiner found that his bilateral hearing loss and tinnitus impacted the ordinary conditions of daily life, including his ability to work and noted the Veteran's reports that his hearing loss prevented him from hearing others speak, especially his wife, and that his tinnitus interfered with his ability to think. See November 2016 C&P examination. In April 2018, the Veteran reported that he previously worked as a welder at a railroad company. See February 2025 CAPRI. Lastly, during an August 2024 VA examination for mental disorders, the examiner diagnosed the Veteran with other specified trauma and stressor related disorder but found that his symptoms were not severe enough to interfere with his occupational and social functioning or to require continuous medication. In this regard, he noted that the Veteran reported periodic depressed mood, which typically occurred in response to notable psychosocial stressors like losses of friends or family, and occasional distressing memories and dreams of his service in the Republic of Vietnam, but found that such symptoms were typically mild and transitory. In addition, the Veteran reported that he had not worked since he retired in or around 2005 but indicated that he was occasionally asked to preside over funerals and other ceremonies at his church. See November 2024 C&P examination. Following a review of the evidence of record, the Board finds that the Veteran's service-connected disabilities do not render him unable to secure or follow a substantially gainful occupation consistent with his education and work history. In this regard, while it is clear that the Veteran has some occupational and functional impairment as a result of his service-connected acquired psychiatric disorder, to include PTSD and other specified trauma and stressor related disorder, the Board finds that it does not impose restrictions that, when considered collectively and independently, preclude him from obtaining or maintaining employment. To the contrary, although the August 2010 VA examiner found that the Veteran's psychiatric symptoms caused some degree of stress, he subsequently found that such could only have had a mildly adverse effect on his quality of life. In addition, the May 2014 and August 2024 VA examiners found that the Veteran's acquired psychiatric disorder was manifested by occupational and social impairment due to mild or transient symptoms that decreased work efficiency and ability to perform occupational tasks only during periods of significant stress and by symptoms that were not severe enough to interfere with his occupational and social functioning or to require continuous medication, respectively. In addition, the Board finds it significant that the Veteran consistently reported that he was active in his church, to include presiding over funerals and other ceremonies, during his August 2010 and May 2014 VA examinations for PTSD and his August 2024 VA examination for mental disorders. Thus, the Board finds that the evidence of record does not show the Veteran's service-connected acquired psychiatric disorder rendered him unable to perform the mental tasks necessary to follow a substantially gainful occupation at any time during the period on appeal. In addition, the Board recognizes that the Veteran's service-connected vocal cord cancer residuals, to include hoarseness, caused functional impairment that impacted his ability to work as a preacher, and that his bilateral hearing loss prevented him from hearing others speak, especially his wife, and that his tinnitus interfered with his ability to think. Nevertheless, the Board finds that the Veteran's service-connected vocal cord cancer residuals, hearing loss, and tinnitus did not preclude him from performing employment, to include work that did not require constant speech and in environments where it is not necessary to have excellent hearing acuity. In this regard, the Board finds it significant that none of the VA examiners found that the Veteran's service-connected disabilities precluded him from working. Here, the Board affords significant probative weight to the VA examiners' opinions as such were based on physical and psychological examinations of the Veteran and a review of the record, to include his medical history, work history, and lay statements. Thus, although the record reflects that the Veteran dropped out of school in the 11th grade, there is no indication that his service-connected disabilities would prevent him from performing work consistent with his past employment as a welder at a railroad, or from employment activities that do not require constant speech and in environments where it is not necessary to have excellent hearing acuity. Further, the record reflects that the Veteran's diabetes mellitus and prostate cancer do not impact his ability to work either physically or mentally. Moreover, the Board notes that while the Veteran does not meet the percentage standards set forth in 38 C.F.R. § 4.16(a), referral to the Director, Compensation Service is not warranted. 38 C.F.R. § 4.16(b). As described in Ray v. Wilkie, the correct standard for referral is whether there is "sufficient evidence to substantiate a reasonable possibility that a veteran is unemployable by reason of his or her service-connected disabilities." 31 Vet. App. 58, 66 (2019). Here, there is not sufficient evidence to substantiate a reasonable possibility that the Veteran was unemployable solely by reason of his service-connected disabilities at any time during the period on appeal. Accordingly, referral of the claim for a TDIU is not warranted. As a final note, the Board notes that the Veteran was in receipt of a 100 percent rating for vocal cord cancer residuals from April 1, 2011 to December 1, 2011 and for prostate cancer from April 30, 2013 to April 1, 2015. In this regard, although the Veteran has not been awarded Special Monthly Compensation (SMC) during the period on appeal from April 1, 2011 to December 1, 2011, he was in receipt of SMC from April 30, 2013 to April 1, 2015, based on prostate cancer rated as 100 percent disabling and additional service-connected disabilities, to include vocal cord cancer residuals, an acquired psychiatric disorder, diabetes mellitus, and tinnitus, independently ratable at 60 percent or more. VA has a "well-established duty" to maximize a claimant's benefits. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); AB v. Brown, 6 Vet. App. 35, 38 (1993); Bradley, 22 Vet. App. at 280. This duty to maximize benefits requires VA to assess all of a claimant's disabilities to determine whether any combination of disabilities establishes entitlement to SMC under 38 U.S.C. § 1114. See Bradley, 22 Vet. App. at 294. In this regard, the Board notes that SMC is payable at the housebound rate where the Veteran has a single service-connected disability rated as 100 percent disabling and, in addition, (1) has a service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability, and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). For the purposes of this specific appeal, although the Veteran was in receipt of a 100 percent rating for vocal cord cancer residuals from April 1, 2011 to December 1, 2011, his other service-connected disabilities were not independently ratable at 60 percent disabling and he was not permanently housebound by reason of his service-connected disabilities during the relevant period. As such, the Veteran does not currently qualify for further consideration for SMC during the period on appeal from April 1, 2011 to December 1, 2011. A. Dean Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Justis, 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.