Citation Nr: A25035175 Decision Date: 04/16/25 Archive Date: 04/16/25 DOCKET NO. 211021-193555 DATE: April 16, 2025 ORDER Entitlement to a rating in excess of 50 percent for tension headaches is denied. Entitlement to a 60 percent rating, and no higher, for residuals of gallbladder surgery is granted. Entitlement to a 10 percent rating, and no higher, for residual scar, status post gallbladder surgery, is granted. Entitlement to a total rating based on individual unemployability (TDIU) is granted. FINDINGS OF FACT 1. The Veteran is in receipt of the maximum schedular rating for tension headaches, and symptoms have not been identified that are not contemplated by the schedular rating criteria. 2. Resolving any doubt in the Veteran's favor, her residuals of gallbladder surgery caused other symptom combinations productive of severe impairment of health. 3. Resolving any doubt in the Veteran's favor, her residual scar from gallbladder surgery has been painful. 4. The Veteran's service-connected disabilities preclude her from securing or maintaining substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating in excess of 50 percent for tension headaches have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.124a, Diagnostic Code 8100. 2. The criteria for a 60 percent rating, and no higher, for residuals of gallbladder surgery have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.114, Diagnostic Codes 7318, 7346. 3. The criteria for a 10 percent rating, and no higher, for residual scar, status post gallbladder surgery, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7804. 4. The criteria for entitlement to a TDIU have been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.400, 4.15, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from January 1987 to September 2008. The rating decision on appeal was issued in October 2020 and constitutes an initial decision; therefore, the modernized review system, also known as the Appeals Modernization Act (AMA), applies. In the October 2021 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the October 2020 agency of original jurisdiction (AOJ) decision on appeal. 38 C.F.R. § 20.301. Any evidence submitted after the AOJ decision on appeal cannot be considered by the Board. 38 C.F.R. §§ 20.300, 20.301, 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. 1. Entitlement to a rating in excess of 50 percent for tension headaches is denied. During the pendency of the appeal, the Board granted a 50 percent rating from October 1, 2008 for tension headaches in another AMA decision. See December 2024 Board decision (Docket No. 210428-156398). By way of background, in a December 2018 Board legacy decision, service connection for headaches was remanded for additional development. In an April 2020 rating decision, the AOJ granted service connection for tension headaches with a 30 percent evaluation effective March 19, 2012. In April 2021, the Veteran submitted a VA Form 10182, seeking a higher initial rating and an earlier effective date. In the December 2024 AMA decision, the Board granted an initial 50 percent rating from October 1, 2008. The AOJ effectuated it a January 2025 rating decision. This AMA appeal arose from a claim for a TDIU submitted on August 27, 2020. The AOJ construed it as an increased rating claim for tension headaches, and it continued the 30 percent rating in the October 2020 AOJ decision on appeal. The Veteran appealed the AOJ decision by submitting the October 2021 VA Form 10182. The appeal period for this appeal begins on August 27, 2020, plus one-year look back period. Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010). The December 2024 AMA decision encompasses the appeal period of this appeal, and the 50 percent rating assigned is the maximum schedular rating under 38 C.F.R. § 4.124a, Diagnostic Code 8100. As the Veteran is in receipt of the maximum schedular rating for her tension headaches, there is no legal basis upon which to award a higher schedular rating. Sabonis v. Brown, 6 Vet. App. 426 (1994). 2. Entitlement to a 60 percent rating, and no higher, for residuals of gallbladder surgery is granted. The Board initially notes that effective May 19, 2024, VA amended the rating criteria for the digestive system. The revised rating criteria apply to all claims received by VA or that are pending before the AOJ on or after May 19, 2024. Generally, where the rating criteria are amended during the course of the appeal, both the former and the current schedular criteria are considered. Should an increased rating be warranted under the revised criteria, that award may not be made effective before the effective date of the change. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, because the most recent rating schedule change occurred after the evidentiary window closed in this case, there is no evidence to consider under the newest criteria. The Board will therefore evaluate residuals of bladder surgery under the prior rating criteria. Prior to May 19, 2024, Diagnostic Code 7318, for removal of gallbladder provides that a noncompensable evaluation is warranted for asymptomatic gallbladder removal. A 10 percent evaluation is warranted for gallbladder removal with mild symptoms. A maximum 30 percent evaluation is warranted for gallbladder removal with severe symptoms. Prior to May 19, 2024, Diagnostic Code 7346, for hiatal hernia provides that a 30 percent rating is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A maximum 60 percent rating is warranted for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 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) (stating that disabilities rated by analogy will not show all objective criteria of the analogous rating). During the pendency of the appeal, the Board granted an initial 30 percent rating for residuals of gallbladder surgery in a legacy decision. See February 2023 legacy decision (Docket No. 15-38 257). By way of background, in September 2013, the AOJ granted service connection for residuals of gallbladder surgery with a 10 percent evaluation effective May 22, 2012. In September 2014, the Veteran submitted a notice of disagreement (NOD), seeking a higher initial rating. The appeal was certified to the Board in a legacy appeal. In December 2018, the Board remanded the claim for further development. In February 2023, the Board granted an initial 30 percent rating for residuals of gallbladder surgery, and it also granted service connection for gastroesophageal reflux disease (GERD) as secondary to the residuals. The AOJ effectuated the decision in a March 2023 rating decision by assigning a 30 percent evaluation for residuals of gallbladder surgery with GERD effective May 22, 2012 under 38 C.F.R. § 4.114, Diagnostic Codes 7318. This AMA appeal arose from the August 2020 TDIU claim. The AOJ has construed it as a claim for an increased rating for residuals of gallbladder surgery, and it continued the 10 percent rating in the October 2020 AOJ decision on appeal. The appeal period under review begins from August 27, 2020, plus one-year look back period. Gaston, 605 F.3d at 982. The February 2023 Board decision encompasses the appeal period of this AMA appeal, and the 30 percent rating assigned is the maximum schedular rating under 38 C.F.R. § 4.114, Diagnostic Codes 7318. The Board has considered whether other diagnostic codes would provide a higher rating for the Veteran's residuals of gallbladder surgery. As noted above, the Veteran was granted service connection for GERD as secondary to residuals of gallbladder surgery, and the AOJ combined the two disorders into a single rating in March 2023. Regardless, the evidence of record at the time of the October 2020 AOJ decision on appeal consistently noted GERD as one of the symptoms of the residuals of gallbladder surgery. As such, the Board has considered whether the Veteran would be entitled to a higher rating under the diagnostic criteria for GERD. Prior to May 19, 2024, there was no specific diagnostic code for GERD; it was typically rated by analogy to hiatal hernia under Diagnostic Code 7346. Turning to the record, at a December 2019 VA examination for gallbladder and pancreas conditions, the Veteran was diagnosed with cholecystectomy (removal of gallbladder). She reported symptoms of GERD, pain, extreme gas, and diarrhea. She also reported feeling as if she is "having a heart attack" 3-4 times a month. She stated she has taken Ranitidine for years but has stopped due to warnings of cancer with long-term use. She reported she was in emergency room on that week for difficulty swallowing and chest/heart pain and was told they were from her untreated GERD. The examiner noted that the Veteran had cholecystectomy post-operative residuals with severe symptoms. The examiner noted that the Veteran had reproducible epigastric tenderness to palpation. The examiner noted the Veteran had cholecystectomy surgical scars that were intact, well-healed, stable, and non-tender. The examiner noted that the Veteran's gallbladder condition did not impact on her ability to work. In an August 2020 correspondence, the Veteran stated that her service-connected gastrointestinal disabilities cause her tremendous amount of discomfort and pain. She stated that she has terrible reflux, and without medication, she vomits 2-3 times a week; with medication, she still vomits once a week. She stated her reflux is so bad that she has to use a special wedge pillow to sleep. She stated she keeps her head up to prevent throwing up while sleeping. She stated that normally before vomiting, she gets a knot in her throat and a large buildup of gas in her stomach; when this happens, she gets severe, debilitating chest and arm pain. She stated that she literally feels like she is having a heart attack. She stated that after she vomits, her voice gets very hoarse, and she sometimes cannot even speak. She stated that even with medication, her gastrointestinal problems cause her to have regular, periodic non-fecal anal leakage that soil her underpants, and 1-2 fecal accidents a year. She stated that since December 2019, when she stopped taking Ranitidine, she had very frequent, sometimes daily fecal accidents. She stated that she spends a minimum of eight hours a week dealing or coping with her reflux and bowel issues, which includes time coping with pain, vomiting or toileting, and recovery. At an October 2020 VA examination, the Veteran was diagnosed with residuals of bladder surgery. She reported GERD, regurgitation, feeling of fullness and vomiting, abdominal pain, burping, and occasional diarrhea. She reported she was taking Ranitidine and her symptoms were under control, but since it has been recalled, she had to stop and was tried on different medications without any relief. She stated she currently takes Omeprazole 40 mg twice a day and Gaviscon 2 tablespoon every 2 hours as needed. The examiner noted the Veteran has gallbladder dyspepsia confirmed by X-ray 4 episodes or more per year. The examiner noted she has additional symptoms of GERD, regurgitation, feeling of fullness and vomiting, abdominal pain, burping, occasional diarrhea. The examiner did not mark the severity of cholecystectomy post-operative residuals, whether they were asymptomatic, mild, or severe. The examiner noted the Veteran had 3 scars from gallbladder removal located in the right upper abdomen: first one measured 0.5 centimeter (cm) x 0.2 cm; the other two measured 1 cm x 0.1 cm. They were not painful or unstable. A March 2020 imaging study showed 3 cm hiatal hernia; diffuse mild hemorrhagic gastritis; and 6 millimeter (mm) duodenal polyp. The examiner noted that the Veteran's gallbladder condition impacts her ability to work in that "Due to residuals of gallbladder surgery frequent heart burns, burping, vomiting which makes it difficult to sleep and she is unable to do any household work." The Veteran's VA records intermittently show treatments for her gastrointestinal condition. Notably, in an April 2020 VA record, the Veteran reported Ranitidine was recalled and switched to famotidine, but she did not any relief with her acid reflux. She stated she switched to omeprazole, but that it was still not controlling her reflux and was waking up 3 times a week with reflux, having to vomit to have a sense of relief. She stated that after her esophagogastroduodenoscopy (EGD), she was switched back to Ranitidine and feels this has worked better to decrease the severity of symptoms. She stated she is still having reflux 2-3 times a week at night that lasts about an hour, compared to 2-3 hours in the past without Ranitidine. She stated she is still not able to rest at night. In a May 2020 VA record, the Veteran reported that since coming off Ranitidine and with taking pantoprazole twice daily for the past 1 week, there was no improvement in reflux and continues to have daily episodes of reflux, mostly in the evening after dinner or in the middle of the night. He stated that just this past weekend, she felt her throat was "raw." She stated she has been sleeping in the recliner. She stated she is taking Tums to compensate. In a June 2020 VA record, she stated that she is feeling "at least 75% improved." She stated she has been taking Nexium 40 milligrams (mg) once daily and Gas-X as needed. She stated her episodes of reflux are less than once a week. She stated she continues to avoid beans, fried foods, tomatoes, and oranges, and cut down on coffee intake to less than 2 cups a day and mostly drinks water. She stated she is sleeping with the head of bed elevated with 3 pillows, but if she rolls off, then she has reflux. After careful review, resolving all doubt in the Veteran's favor, the Board finds that her residual of gallbladder surgery results in symptom combinations productive of severe impairment of health. The December 2019 VA examination report shows that she has GERD, pain, extreme gas, diarrhea, difficulty swallowing, epigastric tenderness, and feeling as if she is "having a heart attack" 3-4 times a month. The examiner stated that the Veteran had severe post-operative residual symptoms from her cholecystectomy. The October 2020 VA examination report shows that the Veteran has GERD, regurgitation, vomiting, abdominal pain, occasional diarrhea, and gallbladder dyspepsia. The examiner also noted the Veteran has difficulty sleeping and is unable to do any household work. Although the October 2020 VA examiner did not indicate the severity of post-operative cholecystectomy symptoms, the overall assessment of the October 2020 VA examination appears similar to the December 2019 VA examination. Further, in assigning a rating under Diagnostic Code 7346, the Board may not consider the ameliorative effects of medication. Jones, 26 Vet. App. at 63. The record shows the Veteran used to use Ranitidine before its recall, which appears to have controlled her symptoms well compared to other medicines. She stated in the April and May 2020 VA treatment records that new medications were not as effective as Ranitidine, and that she had 2-3 times a week to daily episodes of reflux, feelings of her throat "raw," likely due to reflux or vomiting, and that she slept in a recliner. Her June 2020 VA record noted that new medications of Nexium and Gas-X somehow worked very well and improved her symptoms "at least 75%." The Veteran also stated in the August 2020 correspondence that with medication, she had regular non-fecal leakage and 1-2 fecal accidents a year; when she stopped Ranitidine, she had very frequent, sometimes daily fecal accidents. These suggest that without the ameliorative effects of her medication, the Veteran's residuals of bladder surgery and GERD more likely than not appear to cause severe impairment of health. Resolving any doubt in the Veteran's favor, the Board finds that during the appeal period under review, her residuals of gallbladder surgery, which includes GERD, caused other symptom combinations productive of severe impairment of health. Accordingly, a 60 percent rating is warranted from August 27, 2019. Sixty percent is the maximum schedular rating under Diagnostic Code 7346. The Diagnostic Codes 7138 and 7346 adequately contemplate the severity and symptomatology of the Veteran's residuals of gallbladder surgery. The Board has considered whether any other Diagnostic Codes related to disabilities of the digestive system would provide for a higher disability rating; however, the evidence does not reflect that the Veteran's residuals of gallbladder surgery would warrant a higher rating under a different diagnostic code. 38 C.F.R. § 4.114. In conclusion, resolving any doubt in the Veteran's favor, a 60 percent rating is warranted for the residuals of gallbladder surgery. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7; Lynch v. McDonough, 21 F.4th 776, 781-82 (Fed. Cir. 2021). 3. Entitlement to a 10 percent rating, and no higher, for residual scar, status post gallbladder surgery, is granted. The Veteran is seeking a higher rating for residual scar, status post gallbladder surgery. See October 2021 VA Form 10182. The Veteran's VA Form 21-8940 was construed as a claim for higher rating for the residual scar. Thus, the appeal period under review begins on August 27, 2020, with one-year look back period. Gaston, 605 F.3d at 982. The Veteran's residual scar is rated under Diagnostic Code 7805 for other scars (including linear scars) and other effects of scars evaluated under Diagnostic Codes 7800, 7801, 7802, and 7804. Diagnostic Code 7805 instructs that any disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-04 under an appropriate diagnostic code. Diagnostic Code 7800 is for burn scar(s) of the head, face, or neck; scar(s) of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck. The Veteran's scars are in the upper abdomen and right middle abdomen. Thus, a compensable rating is not warranted under this code. Diagnostic Code 7801 is for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are associated with underlying soft tissue damage. The Veteran's scars are not associated with underlying soft tissue damage. Thus, a compensable rating is not warranted under this code. Diagnostic Code 7802 is for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are not associated with underlying soft tissue damage. Under this code, a scar with an area or areas of 144 square inches (929 sq. cm.) or greater warrants a 10 percent rating. The Veteran's scars had approximate total area of 0.3 sq. cm. Thus, a compensable rating is not warranted under Diagnostic Code 7802. Under Diagnostic Code 7804, one or two scars that are unstable or painful scars warrants a 10 percent rating. Three or four scars that are unstable or painful scars warrants a 20 percent rating. Five or more scars that are unstable or painful warrants a 30 percent rating. For the reasons explained below, resolving any doubt int the Veteran's favor, the Board finds that a 10 percent rating is warranted under Diagnostic Code 7804. At the December 2019 VA examination for gallbladder and pancreas conditions, the examiner noted that the Veteran had old scars from cholecystectomy that are well-healed, stable, and non-tender. In an August 2020 letter, the Veteran stated that her gallbladder removal scar becomes dry and flaky. She stated that when it is dry and flaky, the skin on the scar will crack and hurt. She stated this occurs at least once every 2-3 months, and worse in the summer. She stated that her scar has been like this since service. At the October 2020 VA examination for gallbladder and pancreas conditions, the examiner noted the Veteran had 3 scars from gallbladder removal in the right upper abdomen: the first measured 0.5 centimeter (cm) x 0.2 cm; the other two measured 1 cm x 0.1 cm. The examiner noted that the scars were not painful or unstable. At an October 2020 VA examination for scars, the examiner noted the Veteran had three scars status post gallbladder surgery in 1997. The examiner noted that the first one was in the upper abdomen and it measured 0.5 cm x 0.2 cm; it was itching. The second scar was in the right middle abdomen and it measured 1 cm x 0.1 cm; it was healed and closed. The third one was in the right lower abdomen and it measured 1 cm x 0.1cm; it was healed and closed. The three scars had approximate total area of 0.3 sq. cm. The examiner noted that the scars were not painful or unstable, and that they were without underlying tissue damage. The examiner noted that the scars did not result in limitation of function. The scars did not impact the Veteran's ability to work. The Board find that a 10 percent rating, and no higher, is warranted under Diagnostic Code 7804. The VA examinations consistently indicated that the Veteran's scars were not painful or unstable. However, the Veteran stated in the August 2020 letter that her scar, identifying it in singular form, becomes dry and flaky, and the skin on the scar will crack and hurt. She stated that it has been like this since service. The October 2020 VA examination noted that two of the three scars were healed and closed; one was itching. Thus, it appears one of the three scars sometimes cracks and causes pain. Lay persons are competent to report symptoms that are observable, including pain. Layno v. Brown, 6 Vet. App. 465 (1994). Given the foregoing, resolving any doubt in the Veteran's favor, the Board finds that the Veteran has a scar that has sometimes been painful during the appeal period under review. Accordingly, a 10 percent rating is granted from August 27, 2019. As the October 2020 VA examination which was conducted in-person found that two of the three scars were closed and healed, and only one was itching, and as the Veteran reported a single scar to be painful, a rating higher than 10 percent is not warranted under Diagnostic Code 7804. 38 C.F.R. § 4.118. The Board notes that the evidence of record shows there are no other disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-04. In conclusion, resolving any doubt in the Veteran's favor, a 10 percent rating is warranted for the Veteran's residual scar from gallbladder surgery. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7; Lynch, 21 F.4th at 781-82. 4. Entitlement to a TDIU is granted. The Board initially notes that entitlement to a TDIU is on appeal before the Board in legacy and another AMA appeal. See December 2018 and February 2023 legacy appeal decisions; December 2024 AMA appeal decision. The December 2024 AMA decision considered entitlement to a TDIU based on tension headaches only. Although the Board initially did not find that a TDIU claim was raised in the December 2018 decision; it later found in the February 2023 decision that it was raised under Rice?v. Shinseki, 22?Vet. App. 447 (2009), and remanded the claim for further development. The AOJ denied it in a December 2024 supplemental statement of the case (SSOC), and it is pending final adjudication by the Board in the legacy appeal. At the time of the October 2021 VA Form 10182, entitlement to a TDIU was not raised in the legacy appeal. As such, the claim for a TDIU is properly before the Board in this AMA appeal. Further, as the Board is granting entitlement to a TDIU, this decision does not prejudice the Veteran while the issue is in remand status in the legacy appeal system. The Veteran contends that her service-connected disabilities preclude her from securing or following substantially gainful employment. See August 2020 VA Form 21-8940. The appeal period begins on August 27, 2020, with a one-year look back period. Gaston, 605 F.3d at 982. Total disability ratings for compensation may be assigned when a veteran is unable to secure and follow a substantially gainful occupation. 38 U.S.C. § 1155; 38 C.F.R. § 4.16. Section 4.16(a) provides a rating hurdle for schedular consideration of a TDIU. Where the schedular rating is less than total, if there is only one such disability, this disability shall be ratable at 60 percent or more; 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. To meet the requirement of the 60 percent disability or the 40 percent disability, the following will be considered as one disability: (1) disability of one or both lower extremities, including the bilateral factor, if applicable; (2) disabilities resulting from one common etiology; (3) disabilities affecting a single body system; (4) multiple injuries incurred in action; and (5) multiple disabilities incurred as a prisoner of war. Id. The phrase "unable to secure and follow a substantially gainful occupation" contains both economic and noneconomic components. Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). The economic component simply means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. Id. The noneconomic component requires a determination as to a veteran's ability to secure and follow such employment. Id. Attention should be given to the veteran's history, education, skills, and training; whether the veteran has the physical ability (both exertional and non-exertional) to perform the types of activities required by the occupation at issue (e.g., lifting, bending, sitting, standing, walking, climbing, as well as auditory and visual limitations); and whether the veteran has the mental ability to perform the activities required by the occupation at issue (e.g., memory, concentration, ability to adapt to change, handle work place stress, get along with coworkers, and demonstrate reliability and productivity). Id. Factors such as age or impairment by non-service-connected disabilities are not to be considered. 38 C.F.R. §§ 3.341, 4.16, 4.19. The fact that a Veteran is unemployed or has difficulty obtaining employment is not enough, as a schedular rating provides recognition of such. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The schedular criteria contemplate compensating a Veteran for considerable loss of working time from exacerbations proportionate to the severity of the disability. 38 C.F.R. § 4.1. The ultimate question is whether the Veteran, because of service-connected disabilities, is incapable of performing the physical and mental acts required by employment, not whether he or she can find employment. See Van Hoose, 4 Vet. App. at 363. In this case, the Veteran is service-connected for: tension headaches (50 percent from October 1, 2008); residuals of gall bladder surgery with GERD (30 percent from May 22, 2012; 60 percent from August 27, 2019); neck scar, disfigurement (30 percent from August 26, 2015); painful scar, associated with melanoma removal (10 percent from August 26, 2015); hypertension (0 percent from March 19, 2012); uterine fibroids (0 percent from March 19, 2012); residual scar, status post left knee meniscal tear surgery (0 percent from March 19, 2012); residual scar, status post gallbladder surgery (0 percent from May 22, 2012; 10 percent from August 27, 2019). As pertinent to this appeal, the Veteran's combined rating is 90 percent from August 27, 2019. Thus, the Veteran meets the schedular criteria during the appeal period under review. 38 C.F.R. § 4.16(a). The Veteran's DD Form 214 shows that her military occupational specialty (MOS) was Security Forces Craftsman. In the August 2020 VA Form 21-8940, the Veteran noted that her service-connected disabilities prevent her from securing or following any substantially gainful occupation. She noted that the date her disability affected full-time employment was October 1, 2008: the date she last worked full-time was June 30, 2008; and the date she became disabled to work was October 1, 2008. The most she has ever earned in one year was $50,596 in 2007 in the Air Force. For employment history, she noted she worked full-time in the Air Force from January 1987 to September 2008 in the security forces. She had two years of college education. She noted in the remarks that she has not worked since she retired from service in 2008. The VA examination reports and treatment records above pertaining to residuals of gallbladder surgery are incorporated herein by reference. The Veteran underwent VA examinations for headaches in December 2019 and October 2020. At the December 2019 VA examination, the Veteran was diagnosed with migraine and tension headaches. She reported she had 2-4 debilitating headaches monthly. She took Aleve as needed. The examiner noted that the Veteran's symptoms were pulsating or throbbing head pain on both sides of the head that worsened with physical activity; it lasted 1-2 days. The examiner noted associated symptoms of nausea, vomiting, sensitivity to light and sound, and change in vision. The examiner noted that the Veteran had prostrating attacks of headache pain once a month, and that she had very prostrating and prolonged attacks headache pain productive of severe economic inadaptability. The examiner indicated that the Veteran's headache condition does not impacts her ability to work. At the October 2020 VA examination for headaches, the Veteran was diagnosed with tension headaches. She reported 2-3 migraine attacks every month, accompanied by nausea or vomiting. She preferred to rest in dark, quite area during her headache. She reported she sleeps with a wet rag on her face. She took Aleve or Midol as needed. The examiner noted the Veteran has pulsating or throbbing head pain on both sides of the head that worsened with physical activity; it lasted less than 1 day. The examiner noted associated symptoms of nausea, vomiting, sensitivity to light and sound, and changes in vision. The examiner noted that the Veteran has characteristic prostrating attacks of headache pain once every month, but that she did not have very prostrating and prolonged attacks of headache pain productive of severe economic inadaptability. The examiner noted her headache condition impacts her ability to work in that due to her headaches, she has "difficulty functioning." The VA headache examinations show that the Veteran's symptoms included headache pain, nausea, vomiting, light sensitivity, and sound sensitivity. The disability was characterized as prostrating attacks that occur once per month; the attacks were found to be productive of severe economic inadaptability in the December 2019 examination report, but not in the October 2020 examination report. She treated her headaches by taking over-the-counter Aleve or Midol medications. There is no evidence of headaches requiring emergency treatment or hospitalizations. In October 2020, a private counselor Z.F. provided a vocational assessment of the Veteran. Z.F. noted that the Veteran obtained an associate's degree in security administration in 2005 through the Community College of the Air Force. He noted that the Veteran has not worked in any capacity since her discharge from service. He noted that her job title in service was Superintendent of Operations and Trainings; her duties were clerical in nature, overseeing 10 individuals within an office and facilitating the regional training for individuals preparing to enter hostile areas. He noted that the Veteran's residuals of gallbladder surgery cause her to vomit 1-2 days per week due to "acid build up." She experienced dyspnea and constant abdominal discomfort where she "live off of Tums and Gas-X." She reported she does not obtain any sleep 2-3 nights a week due to abdominal discomfort and the need to vomit, and has daytime somnolence and difficulty concentrating. She stated her voice becomes hoarse due to the vomiting. She was irritable due to constant symptoms and severe difficulty in remaining asleep. She experiences diarrhea several days a month, and sometimes up to 4-5 times a day. Z.F. noted that the Veteran's tension headaches occurred at least once a week. She reported she takes a shower during the onset of symptoms; if the symptoms persist, she lies down for at least 4-5 hours in a dark, quiet, and secluded room. She experienced headaches that last 10 hours or more every two weeks; during the prolonged headaches, she has to lie down in a dark, quiet room with a washcloth until her symptoms subside. She was sensitive to sound and light. She reported inability to multi-task and severe difficulty completing household tasks due to her abdominal discomfort, headaches, and overall fatigue. Z.F. opined that it is at least as likely as not that the Veteran has been incapable of meeting the standard requirements of pace, productivity, and reliability, even in a sedentary unskilled work role due to her service-connected gallbladder surgery residuals and headaches, considered alone and in combination, since March 2008. He noted parts of VA examination reports and VA treatment records to support his opinion. He stated that the Veteran's gallbladder surgery residuals and headaches would contribute to her inability to sustain concentration for two consecutive hours, and that such would impair her ability to follow instructions and complete tasks in a timely and accurate manner. He also stated that due to the unpredictable and severe nature of her symptoms including abdominal discomfort, vomiting, restroom use, and headache pain, her disabilities will negatively impact her productivity, require significant time off task, and/or prevent her from completing tasks. He noted that the Veteran's past work while enlisted was specific to the military and would not generate skills readily transferable to alternative civilian employment. He also noted that her marked impairments in concentration, pace, productivity, and reliability would render her unable to meet the demands of even simple, unskilled sedentary employment with accuracy, efficiency, and consistency, rendering her unemployable in the competitive workforce regardless of her education and vocational history. In October 2020, a VA contract examiner stated that the Veteran's service-connected hypertension, scars, and headaches did not result in any restriction for job activities. The examiner noted that due to the residuals of gallbladder surgery, the Veteran can perform "sedentary" work; the examiner described there term "sedentary work" as "[E]xerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time." Based on a review of the record, resolving any reasonable doubt in the Veteran's favor, the Board finds that her service-connected disabilities in combination reasonably preclude her from securing and maintaining substantially gainful employment consistent with her education and work experience. In reaching this determination, the Board has considered both the economic and non-economic components that pertain to a determination as to whether the Veteran in this case is capable of securing or following substantially gainful employment that is consistent with her history, education, skill, and training. The evidence of record does not reveal any income during the appeal period. Thus, the economic component of Ray has been met. Regarding the non-economic component, the evidence demonstrates the Veteran's service-connected disabilities result in physical limitations. Due to her residuals of gallbladder surgery, she experiences GERD; abdominal pain and discomfort; vomiting and hoarse voice; extreme gas; diarrhea; epigastric tenderness; chest pain that feels like "having a heart attack"; difficulty sleeping and daytime somnolence; and non-fecal and fecal incontinence. These symptoms will likely limit her from performing any strenuous tasks that triggers abdominal/chest pain, vomiting, or fecal/non-fecal accidents, and require her to take unpredictable breaks and absences. These would likely reduce her work productivity. Due to her tension headaches, she experiences throbbing head pain on both sides of the head, including prostrating attacks of headache pain once a month. Her headaches are accompanied by nausea, vomiting, sensitivity to light and sound, and/or change in vision, and she needs to rest in a dark, secluded area to mitigate her symptoms. Her headache symptoms would also require her to take unpredictable breaks and absences and reduce her work productivity. It does not appear that her residuals of gallbladder surgery alone or tension headaches alone would result in physical limitations that prevent her from securing or maintaining substantially gainful employment. Each would reduce her work productivity. However, if she has severe gastrointestinal symptoms such as abdominal pain, vomiting, and fecal/non-fecal accidents, along with throbbing head pain with nausea, sensitivity to light and sound, and change in vision, she would be very difficult to perform jobs that even consist of only light physical work. She would be an unreliable employee that cannot complete tasks, or has significant difficulty performing tasks. The Veteran is not service-connected for a mental disorder. However, Z.F. stated that she has concentration problems and daytime somnolence due to lack of sleep from her gallbladder surgery residuals, and irritability due to constant symptoms and severe difficulty in remaining asleep. These symptoms appear to cause some mental limitations in her ability to follow instructions and complete tasks in a timely and accurate manner. The Board finds that none of the Veteran's service-connected disabilities alone preclude substantially gainful employment. The combined effect, however, of her service-connected disabilities on her physical and mental functioning would reasonably appear to preclude her ability to be able to secure and follow substantially gainful employment consistent with her education, skills, and limited work experience. (Continued on the next page) ? Accordingly, resolving all reasonable doubt in the Veteran's favor, the Board finds that the criteria for TDIU have been met. Entitlement to a TDIU is granted. D. JOHNSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Jake Choi, Attorney Advisor The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.