DIABETES MELLITUS

D. JOHNSON · 2026 · Case ID: A26008821

GRANTED

Summary

The Veteran, an Army Veteran who served from August 1982 to December 1985, was granted service connection for diabetes mellitus type II, bilateral lower extremity peripheral neuropathy, obstructive sleep apnea, MDD with anxious distress, headaches, and entitlement to TDIU. The Board found that the Veteran's diabetes mellitus type II was secondary to his service-connected left knee disability, with obesity serving as an intermediate step. While VA examiners opined that the diabetes was less likely than not related to the knee condition, the Board found their opinions inadequate for failing to address aggravation. A private medical opinion from Dr. M.B. provided a favorable nexus, stating it was at least as likely as not that the knee disability contributed to weight gain, obesity, and subsequently the diabetes. The Board found this opinion probative and resolved doubt in the Veteran's favor. Similarly, the Veteran's bilateral lower extremity peripheral neuropathy was granted secondary to diabetes mellitus type II, supported by both VA and private medical opinions. Obstructive sleep apnea was also granted secondary to the left knee disability, with the Board finding approximate balance of evidence and resolving doubt in the Veteran's favor, relying on a private opinion that linked the knee condition to sleep impairment and obesity, which in turn contributed to sleep apnea. Service connection for MDD with anxious distress was granted secondary to the left knee disability, based on the Board finding that the knee pain contributed to the Veteran's mental health condition. Headaches were granted service connection, with the Board finding a private opinion linking them to diabetes mellitus type II to be competent and probative, overriding a VA opinion that found no nexus. Finally, entitlement to TDIU was granted, as the Board found that the cumulative effect of the Veteran's service-connected disabilities, including the newly granted mental health and sleep apnea conditions, precluded him from securing and following substantially gainful employment.

Rationale

VA examiners opined diabetes less likely than not related to knee disability, but failed to address aggravation.; Private opinion found it at least as likely as not that knee disability contributed to weight gain, obesity, and diabetes.; Board found evidence in approximate balance and resolved doubt in Veteran's favor.

Service Branch

ARMY

Special Benefit

TDIU

Docket No.

240730-460525

Full Decision Text

Citation Nr: A26008821
Decision Date: 01/29/26 Archive Date: 01/29/26

DOCKET NO. 240730-460525
DATE: January 29, 2026

ORDER

Service connection for diabetes mellitus type II is granted.

Service connection for left lower extremity peripheral neuropathy is granted.

Service connection for right lower extremity peripheral neuropathy is granted.

Service connection for obstructive sleep apnea is granted.

Service connection for a psychiatric disorder, to include major depressive disorder (MDD) with anxious distress, is granted.

Service connection for headaches is granted.

Entitlement to a total disability rating based on individual unemployability (TDIU) is granted.

FINDINGS OF FACT

1. The Veteran's diabetes mellitus type II was caused by his service-connected left knee instability and arthritis status post (s/p) meniscectomy, with obesity serving as an intermediate step.

2. The Veeran's bilateral lower extremity peripheral neuropathy is a complication of his diabetes mellitus type II.

3. The Veteran's obstructive sleep apnea was caused by his service-connected left knee instability and arthritis s/p meniscectomy, with obesity serving as an intermediate step.

4. The Veteran's MDD with anxious distress was caused by his service-connected left knee instability and arthritis s/p meniscectomy.

5. The Veteran's headaches are related to his now service-connected diabetes.

6. The Veteran's combined service-connected disabilities reasonably preclude substantially gainful employment.

CONCLUSIONS OF LAW

1. The criteria for service connection for diabetes mellitus type II have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

2. The criteria for service connection for left lower extremity peripheral neuropathy have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

3. The criteria for service connection for right lower extremity peripheral neuropathy have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

4. The criteria for service connection for obstructive sleep apnea have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

5. The criteria for service connection for an acquired psychiatric disorder, to include MDD with anxious distress, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

6. The criteria for service connection for headaches have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

7. The criteria for entitlement to a TDIU have 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 in the United States Army from August 1982 to December 1985.

In June 2023, the Veteran submitted a VA Form 20-0996, Decision Review Request: Higher-Level Review (HLR), and requested review of an August 2022 rating decision that denied service connection for bilateral lower extremity peripheral neuropathy and entitlement to a TDIU. In September 2023, the agency of original jurisdiction (AOJ) issued the HLR decision on appeal, which considered the evidence of record at the time of the prior August 2022 rating decision. Therefore, the Board may only consider the evidence of record at the time of the August 2022 rating decision and any evidence submitted during an applicable evidentiary window.

In June 2023, the Veteran submitted a VA Form 20-0995, Decision Review Request: Supplemental Claim, and requested readjudication of service connection for diabetes mellitus type II, posttraumatic stress disorder (PTSD), sleep apnea syndromes, and migraines most recently addressed in June 2019 and March 2020 rating decisions. In November 2023, the AOJ issued the supplemental claim decision on appeal, which found that new and relevant evidence had
at the time of the prior August 2022 rating decision. Therefore, the Board may only consider the evidence of record at the time of the August 2022 rating decision and any evidence submitted during an applicable evidentiary window.

In June 2023, the Veteran submitted a VA Form 20-0995, Decision Review Request: Supplemental Claim, and requested readjudication of service connection for diabetes mellitus type II, posttraumatic stress disorder (PTSD), sleep apnea syndromes, and migraines most recently addressed in June 2019 and March 2020 rating decisions. In November 2023, the AOJ issued the supplemental claim decision on appeal, which found that new and relevant evidence had been received and denied the claim based on the evidence of record at the time of that decision. Therefore, the Board may only consider the evidence of record at the time of the decision on appeal and any evidence submitted during an applicable evidentiary window.

In the July 2024 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Evidence Submission docket. Therefore, the Board may only consider the evidence of record at the time of the August 2022 AOJ decision for service connection for bilateral lower extremity peripheral neuropathy and entitlement to a TDIU, which was subsequently subject to higher-level review, and at the time of the June 2023 rating decision for service connection for diabetes mellitus type II, PTSD, sleep apnea syndromes, and migraines, as well as any evidence submitted by the Veteran or his representative with, or within 90 days from receipt of, the VA Form 10182. 38 C.F.R. § 20.303. If evidence was submitted either (1) during the period after the AOJ issued the decision, which was subsequently subject to higher-level review and prior to the date the Board received the VA Form 10182, or (2) more than 90 days following the date the Board received the VA Form 10182, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.303, 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.

Service Connection

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004).

Service connection for PTSD requires medical evidence diagnosing the condition in accordance with the requirements in 38 C.F.R. § 4.125 (a) (currently, that the diagnosis conform to the criteria in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)); a link supported by medical evidence between the current symptoms and a stressor (traumatic event) during service; and credible supporting evidence that the alleged stressor occurred. 38 C.F.R. § 3.304(f).

Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc).

Obesity is not a "disease" or "disability" for VA purposes and, therefore, obesity is not eligible for service connection on a direct or secondary basis. See VAOPGCPREC 1-2017 (Jan. 6, 2017). However, obesity can serve as an "intermediate step" between a current disability and a service-connected disability for purposes of secondary service connection if it is found that (1) a service-connected disability caused or aggravated the veteran to become obese; (2) this obesity was a substantial factor in causing the current disability; and (3) the current disability would not have occurred but for the obesity caused or aggravated by a service-connected disability. See Walsh v. Wilkie, 32 Vet. App. 300, 305-07 (2020). Stated another way, obesity can constitute an "intermediate step" in showing secondary service connection, i.e., that service connection is warranted when a service-connected disability causes or aggravates obesity, which in turn causes the claimed disability. Id.

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see Lynch v. McDonough, 999 F.3d 1391, 1395 (Fed. Cir. 2021) (holding that if the positive and negative evidence is in approximate balance, which includes but is not limited to equipoise, the claimant receives the benefit of the doubt).

Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the veteran).

1. Service connection for diabetes mellitus type II is granted.

2. Service connection for left lower extremity peripheral neuropathy is granted.

3. Service connection for right lower extremity peripheral neuropathy is granted.

The Veteran contends that he had limited physical activity and exercise due to pain from his service-connected left knee instability and arthritis s/p meniscectomy, which resulted in obesity, and that his obesity caused his diabetes mellitus type II. See July 2024 Argument Brief.

Because the Veteran has not raised, and the record does not reasonably raise, entitlement to direct service connection, the Board's adjudication will consider only entitlement to secondary service connection.

The AOJ has favorably found that the Veteran has a diagnosis of diabetes mellitus type II, and that he has been service-connected for left knee arthritis with limitation of flexion of the leg. See November 2023 rating decision; 38 C.F.R. § 3.104(c).

The question for the Board is whether the Veteran's diabetes mellitus type II resulted from his service-connected left knee disability. Resolving any doubt in the Veteran's favor, the Board finds that his diabetes was caused by his left knee disability, with obesity serving as an intermediate step.

The Veteran's service treatment records (STRs) are silent for any complaints, diagnosis, or treatment for diabetes; they show treatment for left knee condition and weight gain at separation. His June 1982 enlistment Report of Medical Examination (RME) noted normal endocrine system; his weight at entrance was 157 pounds. An April 1984 record noted a complaint of left knee pain from knee twist; the assessment was internal derangement of left knee. A September 1984 profile record noted no running, jumping, or crawling for three months due to "sprain knee ligament." A November 1984 profile record noted no running, jumping, or crawling for a month due to "Post op knee surgery." A February 1985 record noted "s/p L [left] meniscectomy." An April 1985 record noted complaints of left knee stiffness and swelling; the assessment was arthralgia. Another April 1985 record noted complaints of left knee pain and
his weight at entrance was 157 pounds. An April 1984 record noted a complaint of left knee pain from knee twist; the assessment was internal derangement of left knee. A September 1984 profile record noted no running, jumping, or crawling for three months due to "sprain knee ligament." A November 1984 profile record noted no running, jumping, or crawling for a month due to "Post op knee surgery." A February 1985 record noted "s/p L [left] meniscectomy." An April 1985 record noted complaints of left knee stiffness and swelling; the assessment was arthralgia. Another April 1985 record noted complaints of left knee pain and effusion; the assessment was left knee effusion s/p meniscectomy. An April 1985 profile record noted no running, jumping, or crawling for a month due to "sprain knee ligament." A May 1985 profile record noted no running, jumping, or crawling for two months due to "left knee sprain." A July 1985 RME noted normal endocrine system; his weight was 194 pounds. His December 1985 separation RME noted normal endocrine system; the summary of defects noted s/p left knee medial meniscectomy; his weight was 198 pounds. The corresponding December 1985 Report of Medical History (RMH) noted left knee medial meniscectomy in November 1984. He was service-connected for left knee lateral meniscectomy effective December 24, 1985, the date after discharge from service, in an October 1986 rating decision

After service, the Veteran's VA treatment records show a diagnosis of diabetes in 2003; they intermittently show complaints of left knee pain. In an August 2003 record, he stated he had a drug screen done three months ago at his church and was told he had elevated blood sugar (BS) level and wanted to recheck his BS level. The assessment was diabetes mellitus type II, and he was to be put on metformin and glyburide. His VA records thereafter continue to show diagnosis of mellitus type II. A September 2007 VA record noted history of left medial partial meniscectomy in 1984. It noted he had chronic bilateral knee pain that was worse in the left, and that the pain was worse with climbing up and down the stairs. He was diagnosed with bilateral knee pain and early degenerative joint disease in the left knee. An April 2010 record noted a diagnosis of bilateral knee osteoarthritis and use knee braces and a cane. An August 2011 record noted he ambulates with a cane and wears knee braces. An August 2016 record noted he ambulates with a cane. A February 2018 VA record noted that his gait was slow, and that he was assisted with a cane for stability due to knee pain. A February 2020 record noted he stopped walking because it increased pain. An October 2022 record noted when he goes to a store, he uses his cane and hangs onto the basket for leverage. His VA records show that he has remained at the elevated weight level or gained more weight after discharge from service, except for temporary decrease in 2017 due to diabetic ketoacidosis.

His VA examinations for knee conditions indicate that he has had pain in his left knee since around 1983. During an October 2007 VA contract examination for knee conditions, the Veteran was diagnosed with left knee s/p lateral meniscectomy. He reported his left knee condition has existed since 1983, and that he has had in the knee for 24 years. He reported left knee pain is elicited by physical activity, and relieved by rest. Examination showed limping gait with tenderness diffusely over the knee and a surgical scar. There was pain, fatigue, weakness, and lack of endurance in the knee. The effect of the diagnosed condition was difficulty with prolonged walking, standing, climbing stairs and ladders, and getting up from a chair.

During an April 2011 VA contract examination, the Veteran was diagnosed with degenerative joint disease of the left knee associated with s/p lateral left knee meniscectomy with scar. He reported left knee meniscectomy in November 1984, and residuals of pain, discomfort, and swelling. He reported weakness, stiffness, swelling, pain, giving way, lack of endurance, locking, fatigability, and tenderness. The effect of the diagnosed condition was difficulty standing or walking for long periods of time, and that he must use knee braces and a cane to get around.

During a March 2019 VA examination, the Veteran was diagnosed with
standing, climbing stairs and ladders, and getting up from a chair.

During a March 2019 VA examination, the Veteran was diagnosed with left knee meniscal tear in 1984 and left knee degenerative arthritis. He reported history of left knee meniscectomy, and use of a knee brace and a cane. He also reported continuing issues with hip and back pain. He stated his mobility has worsened in the last year and a half. He stated that pain in his hip, back, and knees are constant. The examiner noted that the use of the knee brace, cane, and walker was for left knee pain, and that the use of the cane and walker was for hip and lower back pain.

During a September 2019 VA contract examination, his diagnosis was unchanged. The examiner noted that a 2019 x-ray of the left knee showed advanced arthritis. The Veteran reported he takes Tylenol for pain relief, and wears a hard knee brace for support. He reported left knee pain, swelling, buckling, popping, and cracking. He reported difficulty walking, standing, and bending his knees. The examiner noted that the Veteran uses a brace and cane for left knee arthritis. The examiner noted that the diagnosed condition impacts his ability to work in that he is unable to ambulate without cane; and limited in running, kneeling, crawling, squatting, prolonged standing, prolonged walking, and high impact activities.

During a June 2021 VA contract examination, the Veteran was diagnosed with left knee arthritis and instability s/p meniscectomy. He reported he tore his left meniscus in 1984, which led to his current knee condition. He reported left knee stiffness, constant ache, and giving out. The examiner noted that the Veteran uses a brace and cane for left knee arthritis and instability. The examiner noted that the diagnosed condition impacts his ability to work in that he is limited in running, kneeling, crawling, squatting, prolonged standing, prolonged walking, and high impact activities.

During a February 2022 VA contract examination, the Veteran's diagnosis was unchanged. He reported he injured his left knee in service and had arthroscopy in 1984. He stated he continued to have pain, and his condition has worsened. He reported constant aching pain, and that climbing and prolonged standing/walking caused increased pain and limitations. The examiner noted that the Veteran uses a left knee brace and cane for his left knee condition. The examiner noted that the Veteran's diagnosed condition impacts his ability to work in that he has inability to stand/ambulate for extended periods due to pain; limited ability to climb due to pain and decreased range of motion; and inability to squat due to pain.

The Veteran underwent a VA examination for diabetes mellitus in March 2019. The examiner noted that the Veteran had a diagnosis of diabetes mellitus type II, and that he also had diabetic peripheral neuropathy, which was a complication of his diabetes. Referring to parts of the March 2019 VA knee examination, the examiner noted that the Veteran has been diagnosed with diabetes mellitus since 2004 and has a history of poor control, including admission in 2017 for diabetic ketoacidosis. The examiner noted that the Veteran wears a knee brace and walks with a cane constantly. The examiner opined that the Veteran's diabetes is less likely than not due to or the result of his service-connected left knee disability. The examiner noted that after reviewing records, there is no evidence that the Veteran was ever given oral or injected steroids for treatment of his knee. The examiner stated that there is no pathology to link his left knee condition to the development of his diabetes. The examiner also stated that the literature does not support a relationship between the two conditions.

During a July 2023 VA examination for diabetes, the examiner noted that the Veteran had a diagnosis of diabetes mellitus type II, and that he also had diabetic peripheral neuropathy, which was a complication of his diabetes. The examiner opined that the Veteran's diabetes is less likely than not due to or the result of his service-connected left knee disability. The examiner noted that the Veteran's diabetes and his service-connected left knee disability are not medically related. The examiner noted that the Veteran's diabetes is a separate entity entirely from his service-connected left knee disability, and unrelated to it. The examiner further noted that the records are silent for the treatment of steroids for the Veteran's left knee condition that could have caused his diabetes mellitus type II. The examiner noted that a thorough review of medical literature failed to demonstrate a causal relationship. The examiner also opined that the Veteran's diabetes was less likely than not due to or the result of his service-connected right hand trigger fingers; the rationale was the same as the one for left knee disability.

In a June 2024, letter, Dr. M.B. opined that it is at least as likely as not that the Veteran's service-connected left knee instability and arthritis s/p meniscectomy contributed to his weight gain and obesity. She discussed extensively about the Veteran's medical history and explained that his left knee pain has resulted in chronic pain and limited movement, which have impacted his ability to exercise and get restorative sleep, thereby contributing to weight gain and obesity. She then opined that the Veteran's obesity, in turn, resulted in the development of his diabetes mellitus and associated diabetic peripheral neuropathy of the bilateral lower extremities. She stated that research shows that body mass index has a strong relationship to diabetes and insulin resistance. She noted that in obese individuals, the amount of nonesterified fatty acids, glycerol, hormones, cytokines, proinflammatory markers, and other substances that are involved in the development of insulin resistance, is increased. She stated that the pathogenesis in the development of diabetes is based on the fact that the cells of the pancreas are impaired, causing a lack of control of blood glucose. She noted that weight gain and body mass are central to the formation and rising incidence of diabetes. She stated that another medical article states that physical inactivity (and unhealthy nutrition) has distorted body composition and, in turn, reordered the proportions of myocyte and adipocyte insulin receptors. She stated that insulin acting on adipocyte receptors produces less glucose uptake than does comparable interaction with myocyte receptors. She noted that, accordingly, in individuals with disproportionate muscle/fat composition, any given glucose load requires greater-than-normal pancreatic insulin secretion for adequate disposal. She stated that this hyperinsulinemia then becomes the leading cause of diabetes mellitus type II, as insulin-sensitive tissues become desensitized. She noted that the Veteran's obesity predates his diagnosis of diabetes mellitus type II. She concluded that based on this research and the timeline concerning the Veteran's weight gain, obesity, and diagnosis with diabetes mellitus, it is at least as likely as not that the Veteran's obesity has caused or contributed to the development of his diabetes mellitus type II.

Resolving any doubt in the Veteran's favor, the Board finds that service connection for diabetes mellitus type II is warranted as secondary to his service-connected left knee disability.

The evidence of record includes opinions in favor of and against the claim. The VA examiners opined that the Veteran's diabetes was less likely than not resulted from his service-connected left knee disability because the two disabilities are not medically related, medical literature failed to demonstrate a causal relationship, and the evidence fails to show any chronic use of steroids for the Veteran's left knee disability that could have caused his diabetes. To this extent, the opinions appear adequate as they were provided by medical professionals, they were based on an accurate medical history, and they provide explanations for the conclusions and supporting data. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The examiners, however, failed to opine on aggravation, which renders the opinions inadequate. Findings of "not due to," "not caused by," and "not related to" a service-connected disability are insufficient to address the question of aggravation under 38 C.F.R. § 3.310(b); El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013).

M
adequate as they were provided by medical professionals, they were based on an accurate medical history, and they provide explanations for the conclusions and supporting data. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The examiners, however, failed to opine on aggravation, which renders the opinions inadequate. Findings of "not due to," "not caused by," and "not related to" a service-connected disability are insufficient to address the question of aggravation under 38 C.F.R. § 3.310(b); El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013).

M.B. provided a favorable opinion. She first opined that it is at least as likely as not that the Veteran's service-connected left knee disability contributed to his weight gain and obesity. She referred to parts of the Veteran's STRs and post-service medical records to support her opinion. M.B.'s opinion appears consistent with the evidence of record. The record shows he was diagnosed with diabetes in 2003, and it appears that left knee disability contributed to his weight gain prior to the diagnosis. His STRs show that he weighed 157 pounds at enlistment and 198 pounds at separation. The STRs show he injured his left knee in April 1984 and was placed on profile in September 1984. He had a left meniscectomy in November 1984, but he reported again that he had pain and swelling, and he was put on profile. His finally weighed 198 pounds at separation. His VA records indicate that he has remained at that weight level, or higher, thereafter, except for 2017 when he had diabetic ketoacidosis. When he was first diagnosed with diabetes in 2003, he weighed 196 pounds. The October 2007 VA examination for knee conditions noted that his left knee condition existed since 1983, and that he has had 24 years of left knee pain. The April 2011 VA examination noted he had lateral left knee meniscectomy in November 1984, and that he had residuals of pain, discomfort, and swelling. Thus, it appears more likely than not that the Veteran's service-connected left knee disability contributed to his weight gain and obesity. M.B. then opined that the Veteran's obesity, in turn, resulted in the development of his diabetes mellitus and associated diabetic peripheral neuropathy of the bilateral lower extremities. She relied on a number of medical articles to support her opinion. She cited medical research that shows body mass index has a strong relationship to diabetes and insulin resistance. She noted that the Veteran's left knee disability have resulted in chronic limited and painful movement, exercise intolerance, and obesity, which in turn have resulted in the development of his diabetes mellitus type II and associated diabetic peripheral neuropathy of the bilateral lower extremity. The opinion was adequate because it was provided by a medical professional, it is based on an accurate medical history, and it provides a clear explanation for the conclusions and supporting data. See Nieves-Rodriguez, 22 Vet. App. at 304.

The Board finds the evidence to be at least in approximate balance as to whether the Veteran's diabetes mellitus type II is due to or aggravated by his service-connected left knee disability, with obesity as an intermediate step. Accordingly, after resolving all reasonable doubt in favor of the Veteran, the Board finds that service connection for diabetes mellitus type II, secondary to his service-connected left knee disability, is warranted. 38 C.F.R. §§ 3.102, 3.310; Lynch, 21 F.4th at 776.

The Veteran has asserted that his bilateral lower extremity peripheral neuropathy is associated with his diabetes mellitus type II. See July 2024 Argument Brief.

The AOJ has favorably found that the Veteran has been diagnosed with bilateral lower extremity diabetic peripheral neuropathy. See September 2023 rating decision. 38 C.F.R. § 3.104(c).

As noted above, the VA examiners indicated in the March 2019 and July 2023 diabetes examination reports that the Veteran's diabetic peripheral neuropathy was a complication of his diabetes mellitus type II.

During a July 2022 VA contract examination for peripheral nerves conditions, the Veteran was diagnosed with bilateral lower extremity diabetic peripheral neuropathy. He stated his nerve condition began in the 1990s as tingling and numbness in his feet. The examiner opined that the Veteran's bilateral lower extremity diabetic peripheral neuropathy was due to poorly controlled diabetes.

In the June 2024, letter, M.B. stated that it is well known in the
38 C.F.R. § 3.104(c).

In the June 2024, letter, M.B. stated that it is well known in the medical community that peripheral neuropathy is one of the most common risk factors of diabetes. She stated that in a cohort study, the prevalence of diabetic peripheral neuropathy was 40.3 percent, and that the risk increased with age. She concluded that it is at least as likely as not that the Veteran's diabetic peripheral neuropathy of the bilateral lower extremity is a complication of his uncontrolled diabetes mellitus type II.

The VA examiners and M.B. are competent to provide opinions on the etiology of the Veteran's bilateral lower extremity peripheral neuropathy. They reviewed his medical history, and they provided cogent rationale and clear conclusions. Nieves-Rodriguez, 22 Vet. App. at 304. Given the foregoing, the Board finds that service connection for bilateral lower extremity peripheral neuropathy as secondary to his diabetes mellitus type II is warranted. 38 C.F.R. §§ 3.102, 3.310; Lynch, 21 F.4th at 776.

4. Service connection for obstructive sleep apnea is granted.

The Veteran contends that his obstructive sleep apnea is due to obesity caused by his service-connected left knee disability, and chronic sleep impairment from an in-service trauma of seeing a fellow servicemember getting shot near him. See July 2024 Argument Brief. The Board has recharacterized the issue on appeal as shown above in accordance with the evidence of record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009).

The AOJ has favorably found that he has been diagnosed with obstructive sleep apnea, and that he is service-connected for left knee arthritis. See November 2023 rating decision; 38 C.F.R. § 3.104(c).

The question for the Board is whether the Veteran's obstructive sleep apnea resulted from his service-connected left knee disability. Resolving any doubt in the Veteran's favor, the Board finds that his obstructive sleep apnea was caused by his left knee disability, with obesity serving as an intermediate step.

There are conflicting medical records regarding whether the Veteran's obstructive sleep apnea is secondary to his service-connected left knee disability.

During a July 2023 VA examination for sleep apnea, the Veteran was diagnosed with obstructive sleep apnea. He reported his sleep apnea began in 2014; he was "waking up with a cold sweat, heart palpitations, difficulty falling/staying asleep." He stated he underwent a sleep study in January 2020 and was diagnosed with obstructive sleep apnea and was prescribed a continuous positive airway pressure (CPAP) machine. The examiner opined that the Veteran's obstructive sleep apnea was less likely than not due to or the result of his service-connected left knee or right hand disability or tinnitus. The examiner explained that the Veteran's obstructive sleep apnea and his service-connected disabilities are separate entities. The examiner noted that although arthritis of a joint or a trigger finger can cause sleep disturbance due to pain during sleep, it does not cause obstructive sleep apnea. The examiner noted that obstructive sleep apnea is a respiratory disorder that causes breathing interruption due to an upper airway blockage of air flow, not due to arthritis or a trigger finger. The examiner further stated that a thorough review of medical literature failed to demonstrate a causal relationship.

During a June 2024 private evaluation for sleep apnea by M.B., the Veteran was diagnosed with obstructive sleep apnea. M.B. noted that a January 2020 sleep study showed a diagnosis of obstructive sleep apnea, and that he uses a CPAP machine for treatment. In the June 2024 letter, M.B. stated that medical research showed that chronic pain and disrupted sleep are commonly associated, and they share a clear cause and effect relationship. She noted that pain produces a state of shallow
breathing interruption due to an upper airway blockage of air flow, not due to arthritis or a trigger finger. The examiner further stated that a thorough review of medical literature failed to demonstrate a causal relationship.

During a June 2024 private evaluation for sleep apnea by M.B., the Veteran was diagnosed with obstructive sleep apnea. M.B. noted that a January 2020 sleep study showed a diagnosis of obstructive sleep apnea, and that he uses a CPAP machine for treatment. In the June 2024 letter, M.B. stated that medical research showed that chronic pain and disrupted sleep are commonly associated, and they share a clear cause and effect relationship. She noted that pain produces a state of shallow sleep while disrupting restorative slow-wave sleep, resulting in increased apneas. She noted that it is at least as likely as not that the Veteran's service-connected left knee caused chronic pain that impairs sleep, and this chronic nonrestorative sleep has caused or contributed to the development of obstructive sleep apnea.

M.B. also stated that Veteran's obesity resulted in the development of his sleep apnea. She reiterated that the Veteran's left knee disability has resulted in chronic pain and limited movement, which have impacted his ability to exercise and get restorative sleep, thereby contributing to weight gain and obesity. She stated that obesity is a well-known risk factor for the development of OSA because, as a body gains weight, tissue builds up in the neck and airway passages. She stated this makes them more vulnerable to collapse as the muscles relax when the Veteran is asleep. She noted that based on this research and the timeline concerning the Veteran's weight gain and obesity and the diagnosis of obstructive sleep apnea, it is at least as likely as not that his obesity has caused or contributed to the development of his obstructive sleep apnea.

Upon review of the record, resolving any doubt in the Veteran's favor, the Board finds that service connection for obstructive sleep apnea is warranted as secondary to his service-connected left knee disability.

The Board addressed above that the Veteran's left knee disability likely contributed to his weight gain and obesity. The Board finds M.B.'s opinion probative, as it was provided by a medical professional, it is based on an accurate medical history, and it provides a clear explanation for the conclusions and supporting data. Nieves-Rodriguez, 22 Vet. App. at 304.

The VA examiner opined that while pain from the Veteran's service-connected left knee disability or right hand disability can cause sleep disturbance due to pain, it does not cause obstructive sleep apnea as obstructive sleep apnea is a respiratory disorder that causes breathing interruption due to an upper airway blockage of air flow, and not due to arthritis or a trigger finger condition. To this extent, this opinion was adequate as it was provided by a medical professional, based on an accurate medical history, and provides a clear explanation for the conclusion. Nieves-Rodriguez, 22 Vet. App. at 304. The examiner, however, failed to opine on aggravation. El-Amin, 26 Vet. App. at 140.

Given the foregoing, the Board finds the evidence to be at least in approximate balance as to whether the Veteran's obstructive sleep apnea is due to or aggravated by his service-connected left knee disability. Accordingly, after resolving all reasonable doubt in favor of the Veteran, the Board finds that service connection for obstructive sleep apnea, secondary to his service-connected left knee disability, is warranted. 38 C.F.R. §§ 3.102, 3.310; Lynch, 21 F.4th at 776.

5. Service connection for an acquired psychiatric disorder, to include MDD with anxious distress, is granted.

The Veteran contends that he has PTSD due to witnessing a fellow servicemember getting shot 11 times by her estranged husband while exiting the dining hall in September 1985. See February 2019, November 2019, June 2021, and June 2023 VA Form 21-0781s. He also asserts that racial discriminations during active service and chronic pain from his service-connected left knee disability contributed to his mental condition. See November 2019 and June 2023 VA Form 21-0781s; July 2024 Argument Brief. The Board has recharacterized the issue on appeal as shown above in accordance with the evidence of record. See Clemons, 23 Vet. App. at 1.

The Veteran's STRs are generally silent for any complaints or treatment for his psychiatric condition. A July 1985 STR noted that he presented for a command referral for mental health evaluation, and that he was psychiatrically cleared. A December 198
Form 21-0781s. He also asserts that racial discriminations during active service and chronic pain from his service-connected left knee disability contributed to his mental condition. See November 2019 and June 2023 VA Form 21-0781s; July 2024 Argument Brief. The Board has recharacterized the issue on appeal as shown above in accordance with the evidence of record. See Clemons, 23 Vet. App. at 1.

The Veteran's STRs are generally silent for any complaints or treatment for his psychiatric condition. A July 1985 STR noted that he presented for a command referral for mental health evaluation, and that he was psychiatrically cleared. A December 1985 Report of Mental Status Evaluation (RMSE) noted that he was cleared psychiatrically for any administrative proceedings. His June 1982 enlistment RME, July 1985 RME, and December 1985 RME noted normal evaluation of his psychiatric system.

An October 2023 report from Records Research Center noted that it has completed comprehensive research on the Veteran's claimed stressor event of a female soldier being shot and killed by her estranged husband outside the mess hall around September 1985 while he was assigned to the 331st Transportation Company in Ft. Story, Virginia. It noted that the following source was reviewed to substantiate the claimed incident: the National Archives and Records Administration (NARA) and Official Military Activities Report (OMAR) casualty databases. It noted that these reveal the death of S.S.C. who died [REDACTED], due to homicide in Virginia. It noted that No DD Form 1300 was available. It noted that it requested records from NARA, the custodian of Army unit records for 1985, but NARA was unable to locate the 1985 unit history or daily journals for the 331st Transportation Company or 11th Transportation Battalion higher headquarters.

After service, the Veteran's VA records are generally silent for any complaints of a psychiatric condition until filing of the claim for PTSD in 2019.

During a February 2020 VA mental health initial evaluation for PTSD, the Veteran reported in-service trauma of witnessing a fellow servicemember getting killed. He stated he was leaving the mess hall at Ft. Steward when a female solider was shot 11 times by her husband. He stated he was 30 feet away and ran to her aid, but it was too late. He stated the military police apprehended her husband. He stated he thinks about the incident every day and has nightmares about it 3 times a week. He also reported there was a lot of racism in the Army. He stated some members would whisper in his ear "we are going to hang you." He stated that "I have withdrawn from society," and that he does not like being in a crowd. He stated he will attend church then wait in the car so his family can enjoy the social time afterwards. He stated he does not like being "anywhere where I am not in control." He worries about his family when they are out and if they will make it home. He stated he feels depressed. He reported chronic pain in his back, knees, and foot and can no longer do the things he enjoyed in the past. He reported bilateral knee injuries with surgery on the left. He stated he stopped walking because it increased pain. He stated the pain prevents him from enjoying things he did in the past. He stated he does not feel worthless but he does wish he could contribute more than what he does. He feels "I am living on the sidelines as life goes by." He stated he last worked 2 years ago. He reported he was recently diagnosed with sleep apnea and uses a machine every night, but he cannot sleep despite treatment. He stated he will sit up some nights until 5AM for the last few years. He stated the pain, nightmare, and thoughts about the female soldier being shot keep him awake.

For assessment, the clinician noted that the Veteran is a patient with chronic pain who experiences depression and anxiety symptoms. She noted that he supervised 35 people in a high street corporate environment and had to stop working after he was not able to tolerate the noise and large crowds. She noted that he has chronic pain in his back, knees, and foot, and can no longer do the things he enjoyed in the past. She noted that he was at Ft. Steward when a female acquaintance walked out of the mess hall and was shot by her husband 11 times, and he is no longer able to tolerate crowds and thinks of the incident daily. For impression, she noted the following DSM-5 diagnoses: "MDD, anxiety, r/o [rule out] PTSD."
a patient with chronic pain who experiences depression and anxiety symptoms. She noted that he supervised 35 people in a high street corporate environment and had to stop working after he was not able to tolerate the noise and large crowds. She noted that he has chronic pain in his back, knees, and foot, and can no longer do the things he enjoyed in the past. She noted that he was at Ft. Steward when a female acquaintance walked out of the mess hall and was shot by her husband 11 times, and he is no longer able to tolerate crowds and thinks of the incident daily. For impression, she noted the following DSM-5 diagnoses: "MDD, anxiety, r/o [rule out] PTSD." The contributing factors were "medical, social, employment."

During an April 2021 private evaluation, the Veteran reported PTSD symptoms from trauma that occurred while he was in the service. He stated that he was on base coming from the mess hall when an individual stopped him outside the building. He claimed he heard gunfire and when he turned, he saw his colleague shot 11 times and murdered by her husband, the perpetrator. He reported frequent nightmares and difficulties with concentration. He stated he cannot handle being in crowds and was fearful of his wife being hurt. He stated he is easily agitated, has mood swings, dislikes others, does not feel safe, is anxious, and has difficulties trusting his daughters when not around him. He stated that if he ever sees a woman hurt, it triggers flashbacks of the incident and he relives it like he was just there and "even smells the actual carbon from the weapon." He stated that his children became his "security blanket" and when he lost his mother, he felt out of control. He reported he tries to be a good father and a good husband, but he is lonely. He described his current feelings as "isolate and antisocial." He reported panic attacks with symptoms including sweating, difficulty breathing, facing heart, feeling of the need to escape, and ringing in his ears. His current medical concerns included diabetes, glaucoma, high cholesterol, arthritis, neuropathy, planter fasciitis, heart issues, and sleep apnea. On a pain scale of one to ten with ten being the most severe pain, he reported a level of nine. His previous surgeries included left knee surgery, emergency removal of infection due to diabetes, tonsillectomy, four eye surgeries, and surgery on his left hand. He stated functional limitations include frequent falls due to neuropathy and weakened joints. He sleeps two hours per night with early and mid-cycle insomnia, nightmares, and night sweats five times per week. The clinician noted that based on the current examination, the most appropriate diagnosis under DSM-5 was PTSD and panic disorder. The clinician noted that prognosis is fair at this time.

During a June 2024 private evaluation by psychologist K.G., the Veteran was diagnosed with MDD with anxious distress and alcohol use disorder in sustained remission. He reported that during his time in service, he witnessed the murder of a fellow servicemember by gunshot. He stated he began drinking heavily in attempt to self-numb. He also reported he endured pain and attempted repeated rehabilitation following a knee injury, which failed to heal properly. He stated that the recovery was "horrible" in large part because his platoon sergeant apparently would not honor the "doctor profile" or "no duty" status and had to walk in sand and climb flights of stairs. He also experienced racial discrimination and harassment where some soldiers hung nooses on his door and left threatening notes. He stated that following these incidents, he experienced insomnia, anxiety, and paranoia, and started drinking to cope.

In a concluding opinion, K.S. stated that the Veteran did not have any mental health issues prior to the service. She noted that while in the service, he witnessed the shooting death of a friend and fellow servicemember, injured his left knee that did not recover, experienced harassment and racial discrimination, and learned that his father had a stroke. She noted that the collective stress led him to drink excessively and develop anger, mood, and motivation problems. She noted that these issues have persisted to the present day, and have only been made worse by his service-connected disabilities. She stated that it is more likely than not that the Veteran's MDD with anxious distress and alcohol use disorder in sustained remission are related to the service. She stated that it is more likely than not that his service-connected left knee disability contributed to the progression of his MDD. She noted that his knee pain has caused ongoing frustration, low mood, poor sleep, and renders him unable to participate in hobbies and family activities. She stated that such physical limitations also contribute to low motivation,
. She noted that the collective stress led him to drink excessively and develop anger, mood, and motivation problems. She noted that these issues have persisted to the present day, and have only been made worse by his service-connected disabilities. She stated that it is more likely than not that the Veteran's MDD with anxious distress and alcohol use disorder in sustained remission are related to the service. She stated that it is more likely than not that his service-connected left knee disability contributed to the progression of his MDD. She noted that his knee pain has caused ongoing frustration, low mood, poor sleep, and renders him unable to participate in hobbies and family activities. She stated that such physical limitations also contribute to low motivation, social isolation, and difficulty with concentration. She further stated that the Veteran tends to underreport his symptoms and that they were previously masked by his alcohol use (from military service until 2004) as a means of self-medication.

Upon review of the record, resolving any doubt in the Veteran's favor, the Board finds that his MDD with anxious distress is secondary to his service-connected left knee disability.

The evidence of record appears to support that the Veteran's MDD with anxious distress was caused by his service-connected left knee disability. The VA clinician noted in the February 2020 VA evaluation that the contributing factors to the Veteran's MDD and anxiety included "medical, social, employment" reasons, and she stated that the Veteran has chronic pain in his back, knees, and foot, and can no longer do the things he enjoyed in the past. Thus it appears that his left knee pain was a contributing factor to his MDD with anxious distress. K.G. opined in her June 2024 letter that it is more likely than not that his service-connected left knee disability has contributed to the progression of his MDD. She stated that the knee pain has caused ongoing frustration, low mood, poor sleep, and renders him unable to participate in hobbies and family activities. Overall, the evidence appears to indicate that the Veteran's service-connected left knee disability likely contributed to the development of his MDD with anxious distress. Accordingly, service connection for MDD with anxious distress as secondary to service-connected left knee disability is granted. All reasonable doubt has been resolved in the Veteran's favor. 38 C.F.R. § 3.102; Lynch, 21 F.4th at 776.

The Board finds that service connection for PTSD is not warranted. Although the Veteran has repeatedly stated about in-service trauma regarding the death of a female servicemember, the incident was not verified. The October 2023 response from the Records Research Center noted that a female person named S.S.C. died on [REDACTED] due to homicide in Virginia, but no further records were available. However, no further details could not be found. Moreover, the Veteran does not remember the name of the servicemember, and his reports regarding the location of the incident, whether at Fr. Story or Ft. Stewart, is mixed. As the in-service trauma has not been verified, service connection for PTSD is not warranted. 38 C.F.R. § 3.304(f).

However, the Veteran is being granted service connection for MDD with anxious distress in this instant decision. The Board notes for informational purposes that a veteran with multiple mental disorders bearing the same symptomatology only receives one psychiatric disorder rating under the General Rating Formula for Mental Disorders for 38 C.F.R. § 4.130, under the guidance set forth at 38 C.F.R. § 4.126, and the avoidance of pyramiding rule set forth at 38 C.F.R. § 4.14.

6. Service connection for headaches is granted.

The Veteran contends that his headaches are due to his service-connected tinnitus. See June 2023 VA Form 20-0995. He also asserted that his headaches are manifestations of his diabetes mellitus type II. See July 2024 Argument Brief.

The AOJ has favorably found that the Veteran has a current diagnosis of acute/intermittent tension headache. See November 2023 rating decision; 38 C.F.R. § 3.104(c).

The Veteran's STRs are generally silent for any complaints of headaches except for a complaint of frequent headaches in the December 1985 RMH. After service, the Veteran's treatment records are generally silent for any complaints or treatment for headaches until filing of the claim in 2019.

During a July 2023 VA examination for headaches, the Veteran was diagnosed with acute intermittent tension headache. He reported onset of "pounding with a tight band" type of headache that began in the 1970s, and that their frequency increased around 1983-1984. The examiner opined that the claimed condition is less likely than not due to or the result of the Veteran's service-connected tinnitus. The examiner noted that the Veteran has a diagnosis of acute intermittent tension headache, but no diagnosis of migraines. She noted that the claims file is silent for a migraine diagnosis or treatment throughout years of service and post-separation. She stated that without a current diagnosis of migraines, a nexus cannot be established.

The Board finds that the July 2023 VA opinion was inadequate. The Veteran was diagnosed with intermittent tension headaches, and she had to opine whether his headaches were related to service, or was caused or aggravated by his service-connected tinnitus, as asserted in the VA Form 20-0995 and the attached medical article. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993).

Dr. M.B. provided an opinion regarding the Veteran's headaches in her June 2024 letter. Dr. M.B. opined that it is at least as likely as not that the Veteran's frequent headaches (tension headaches) are a manifestation of his diabetes mellitus type II.

Because the only competent and probative medical nexus opinion addressing whether the Veteran's headaches were either caused or aggravated by his now service-connected diabetes is favorable, the Board finds service connection for headaches is warranted.

7. Entitlement to a TDIU is granted.

The Veteran asserts that his chronic arthritis, PTSD, and sleep disorder preclude his ability to work.

A TDIU may be assigned, where the schedular rating is less than total, where a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16(a). To qualify for schedular consideration of a TDIU, if there is only one such disability, this disability shall be ratable at 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. Id.

For the purposes of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) Disabilities of one or both upper extremities, one or both lower extremities, including the bilateral factor, if applicable; (2) disabilities resulting from common etiology or a single accident; (3) disabilities affecting a single body system, e.g., orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric; (4) multiple injuries incurred in action; or (5) multiple disabilities incurred as a prisoner of war. 38 C.F.R. § 4.16(a); see Moody v. Wilkie, 30 Vet. App. 329, 339 (2018) (combining disabilities as "one disability" to meet the rating threshold of § 4.16(a) requires the use of the combined rating table).

The phrase "unable to secure and follow a substantially gainful occupation" contains both economic and noneconomic components. See Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). The economic component refers to 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 nonexertional) 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
. 58, 73 (2019). The economic component refers to 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 nonexertional) 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. Neither nonservice-connected disabilities nor advancing age may be considered in the determination. 38 C.F.R. § 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993).

An award of TDIU is an individualized determination, specific to a veteran's particular circumstances, e.g., his or her history, education, skills, and training. See Todd v. McDonald, 27 Vet. App. 79, 85 (2014). It does not require a showing of 100 percent unemployability. Roberson v. Principi, 251 F.3d 1378, 1385 (Fed. Cir. 2001). The ultimate question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993).

Analysis

In the August 2022 rating decision on appeal, the AOJ made favorable findings that the Veteran was not working and had reported on his TDIU application that he had not worked since 2017. The AOJ also found that his service-connected disabilities meet the schedular criteria for entitlement to individual unemployability because his overall combined evaluation is 70 percent. The AOJ denied entitlement to a TDIU on the basis that while the Veteran's service-connected disabilities may impact his ability to engage in certain employment; the evidence does not support a finding that his disabilities prevent him from obtaining or sustaining any kind of employment. The AOJ stated,

[E]vidence does not reflect that your service connected conditions preclude you from doing sedentary work. Sedentary work is defined as light duty work that involves lifting less than 10 pounds of weight at one time. This usually involves carrying or lifting smaller items such as files, smaller tools, etc. Given your work history, education, and the nature of your service connected disabilities, the evidence suggests that you would be capable of performing the acts required for sedentary employment.

Consistent with the AOJ's rating decision, a February 2022 VA examination report shows the Veteran's left knee causes functional loss of unable to stand longer than "a couple minutes max" or walk further than 25 yards. This functional loss is caused by pain, weakness, and lack of endurance which causes interference with standing, disturbance of locomotion and weakened movement. He has the inability to stand/ambulate for extended periods.

Also, records from the Social Security Administration (SSA) reflect that the Veteran earned a bachelor's degree in business administration. In a June 2020 cover letter from his attorney, it was asserted that the Veteran has worked as a health care advisor, director of sales, and territory manager for two companies. He asserted that he was unable to work due to his diabetes, lumbosacral sprain, and arthritis in his knees and hips. Other information in the SSA file shows he last worked in April 2018; his work history included sales rep and field agent as well as those previously noted. In a March 2020 decision, SSA determined that the Veteran was not disabled although he had severe impairments: degenerative joint disease of the left and right knee; mild osteoarthritis of the hips, insulin dependent diabetes mellitus and neuropathy that significantly limit the ability to perform basic work activities. SSA's vocational expert determined that the Veteran's past relevant work as sales representative of motor vehicles and supplies and sales representative of petroleum products qualified as skilled labor. The vocational expert also determined that occupations exist which could be performed by an individual with the same education, past relevant work experience, and residual functional capacity as the Veteran, and which require skills acquired in his past relevant work experience. The vocational expert indicated that
as those previously noted. In a March 2020 decision, SSA determined that the Veteran was not disabled although he had severe impairments: degenerative joint disease of the left and right knee; mild osteoarthritis of the hips, insulin dependent diabetes mellitus and neuropathy that significantly limit the ability to perform basic work activities. SSA's vocational expert determined that the Veteran's past relevant work as sales representative of motor vehicles and supplies and sales representative of petroleum products qualified as skilled labor. The vocational expert also determined that occupations exist which could be performed by an individual with the same education, past relevant work experience, and residual functional capacity as the Veteran, and which require skills acquired in his past relevant work experience. The vocational expert indicated that the Veteran could perform work as a sales person of trailers and mobile homes.

In the rating decision on appeal, the Board has granted service connection for additional disabilities - obstructive sleep apnea, diabetes with peripheral neuropathy of the bilateral lower extremities, and MDD with anxious distress.

Within 90 days of his NOD, the Veteran submitted relevant medical evidence addressing the impact of his now service-connected psychiatric disorder and OSA on his occupational functioning.

In a June 2024 private psychiatric assessment by Dr. K.D., the Veteran's now service-connected psychiatric disorder was found to cause difficulty in establishing and maintaining effective work and social relationships and difficulties adapting to stressful circumstances including work or work-like settings. The Veteran also submitted private medical evidence showing the significant and deleterious affect that his now service-connected OSA had on his ability to achieve and maintain restorative sleep.

The Board has reviewed the cumulative lay and medical evidence of record receiving prior to the August 2022 rating decision and during the open evidentiary window. The Board finds that there is sufficiently probative evidence to demonstrate that the Veteran would be unable to secure unable to secure and follow a substantially gainful occupation due to a combination of his now service-connected mental health and physical disabilities. That is, while his service-connected disabilities left knee and right hand disabilities may only preclude employment that his physically strenuous (i.e., the physical ability to perform the activities required by the occupations at issue), with the additional consideration of the significant effect the sleep impairment caused by his OSA and the limitations he has in establishing and maintaining effective work and social relationships and difficulties adapting to stressful circumstances including work or work-like settings from the service-connected psychiatric disorder, the Board finds the Veteran also reasonably lacks the mental ability to perform the activities required by the occupation at issue. For this reason, and resolving reasonable doubt in favor of the Veteran, entitlement to TDIU is warranted.

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.

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