SLEEP APNEA SYNDROMES (OBSTRUCTIVE CENTRAL MIXED)

DAVID H. ROBERTSON · 2026 · Case ID: A26032152

DENIED

Summary

The Veteran served from April 1970 to November 1973. The Veteran appeals the denial of increased ratings for sleep apnea, coronary artery disease, left and right lower extremity peripheral neuropathy, and a surgical scar status post coronary artery bypass surgery. The Veteran also appeals the denial of service connection for interstitial lung disease, claimed as secondary to diabetes, and the denial of TDIU and an earlier effective date for housebound SMC. The Board denied the claim for a rating in excess of 50 percent for sleep apnea, finding no evidence of chronic respiratory failure, carbon dioxide retention, cor pulmonale, or need for tracheostomy. For coronary artery disease, the Board denied increased ratings, finding the evidence did not support ratings higher than those already assigned for the periods on appeal. The surgical scar was also denied a compensable rating as it did not meet the size criteria. Peripheral neuropathy claims were denied an increase as the evidence did not support ratings higher than 20 percent, with the Board finding only moderate incomplete paralysis. Service connection for interstitial lung disease was denied, with the Board finding the evidence weighed against a nexus to service or service-connected diabetes, and that Agent Orange exposure was not a causative factor. TDIU was denied as the Veteran's service-connected disabilities, while impacting employability, were not found to be solely sufficient to preclude substantially gainful employment, and VA examinations did not support the Veteran's claims of unemployability. The claim for an earlier effective date for housebound SMC was denied, as the Veteran did not meet the criteria for a 100 percent rating or the housebound status prior to the date on appeal.

Rationale

No evidence of chronic respiratory failure, carbon dioxide retention, or cor pulmonale.; No need for tracheostomy.; VA examinations and treatment records consistent with current rating.

Special Benefit

SMC - HOUSEBOUND; TDIU

Diagnostic Code

6847

Docket No.

260220-628380

Full Decision Text

Citation Nr: A26032152
Decision Date: 04/08/26 Archive Date: 04/08/26

DOCKET NO. 260220-628380
DATE: April 8, 2026

ORDER

Entitlement to an initial rating in excess of 50 percent for sleep apnea is denied.

Entitlement to a rating in excess of 10 percent prior to January 25, 2024, for coronary artery disease, and in excess of 30 percent from January 25, 2024, to June 25, 2025, is denied.

Entitlement to a compensable rating for a surgical scar status post coronary artery bypass surgery is denied.

Entitlement to an initial rating in excess of 20 percent for left lower extremity peripheral neuropathy is denied.

Entitlement to an initial rating in excess of 20 percent for right lower extremity peripheral neuropathy is denied.

Entitlement to service connection for interstitial lung disease, to include as secondary to service-connected diabetes, is denied.

Entitlement to a total disability rating based upon individual unemployability (TDIU) prior to January 25, 2024, is denied.

Entitlement to an effective date prior to June 26, 2025, for special monthly compensation (SMC) based on housebound status is denied.

FINDINGS OF FACT

1. Throughout the appeal period, the Veteran's service-connected sleep apnea manifested as requiring the use of a breathing assistance device such as a CPAP machine, but not as symptoms of chronic respiratory failure with carbon dioxide retention, cor pulmonale, or the need for a tracheostomy.

2. Prior to January 25, 2024, the Veteran's service-connected coronary artery disease was shown to be manifested by only the need for continuous medication for control; a workload of 5.1 to 7.0 METs resulting in heart failure symptoms was not shown, and neither was evidence of cardiac hypertrophy or dilatation confirmed by echocardiogram or equivalent.

3. From January 25, 2024, to June 25, 2025, the Veteran's service-connected coronary artery disease was shown to be manifested by a METS score of 5 to 7 METs; a workload of 3.1 to 5.0 METS resulting in heart failure symptoms was not shown.

4. The Veteran's surgical scar status post coronary artery bypass surgery does not measure 929 square centimeters (144 square inches).

5. The Veteran's left lower extremity peripheral neuropathy manifests by no more than moderate incomplete paralysis.

6. The Veteran's right lower extremity peripheral neuropathy manifests by no more than moderate incomplete paralysis.

7. The persuasive weight of the evidence is against a finding that the Veteran's interstitial lung disease is related to service or caused by a service-connected disability; aggravation by a service-connected disability has not been raised by the Veteran nor reasonably raised by the record.

8. The probative evidence of record does not show that the Veteran's service-connected disabilities prevented him from securing and following substantially gainful employment prior to January 25, 2024.

9. Prior to June 26, 2025, the Veteran did not have a single service-connected disability rated as 100 percent and additional service-connected disabilities ratable at 60 percent.

CONCLUSIONS OF LAW

1. The criteria for a rating in excess of 50 percent for sleep apnea have not been met. 38 U.S.C. §§ 1110, 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.97, Diagnostic Code 6847.

2. The criteria for a rating in excess of 10 percent prior to January 25, 2024, for coronary artery disease have not been met. 38 U.S.C. §§ 1110, 1155, 5107; 38 C.F.R. § 4.104, Diagnostic Codes 7005 - 7017.

3. The criteria for a rating in excess of 30 percent from January 25, 2024, to June 25, 2025, for coronary artery disease have not been met. 38 U.S.C. §§ 1110, 1155, 5107; 38 C.F.R. § 4.104, Diagnostic Codes 7005 - 7017.

4. The criteria for an initial compensable rating for a surgical scar status post coronary artery bypass surgery have not been met. 38 U.S.C. §§ 1110, 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.118, Diagnostic Code 7802.

for a rating in excess of 30 percent from January 25, 2024, to June 25, 2025, for coronary artery disease have not been met. 38 U.S.C. §§ 1110, 1155, 5107; 38 C.F.R. § 4.104, Diagnostic Codes 7005 - 7017.

5. The criteria for a rating in excess of 20 percent for left lower extremity peripheral neuropathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8526.

6. The criteria for a rating in excess of 20 percent for right lower extremity peripheral neuropathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8526.

7. The criteria for service connection for interstitial lung disease, to include as secondary to service-connected diabetes, have not been met. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310.

8. The criteria for entitlement to a TDIU prior to January 25, 2024, have not been met. 38 U.S.C. §§ 1155; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16, 4.18, 4.25.

9. The criteria for entitlement to SMC based on housebound status prior to January 26, 2025, have not been met. 38 U.S.C. §§ 1114, 5107; 38 C.F.R. §§ 3.102, 3.350.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from April 1970 to November 1973.

The rating decisions on appeal were issued on August 8 2025, and August 27, 2025, and constitute initial decisions; therefore, the modernized review system, also known as the Appeals Modernization Act (AMA), applies.

In the February 2026 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 two August 2025 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.

In adjudicating the Veteran's appeal, the Board acknowledges the recent United States Court of Appeals for Veterans Claims (Court) decision in Williams v. McDonough, 37 Vet. App. 305 (2024), which found that under 38 C.F.R. § 20.202(c)(2), the Board generally may not decide an appeal before the deadline for requesting an AMA docket switch has elapsed. 38 C.F.R. § 20.202(c) allows appellants to switch AMA dockets by completing and submitting a new VA Form 10182 within 60 days from when the Board receives the original VA Form 10182, or one year from the date the AOJ mails notice of the decision on appeal, whichever is later, unless: (1) an appellant has already submitted evidence or testimony as described in 38 C.F.R. §§ 20.
, 37 Vet. App. 305 (2024), which found that under 38 C.F.R. § 20.202(c)(2), the Board generally may not decide an appeal before the deadline for requesting an AMA docket switch has elapsed. 38 C.F.R. § 20.202(c) allows appellants to switch AMA dockets by completing and submitting a new VA Form 10182 within 60 days from when the Board receives the original VA Form 10182, or one year from the date the AOJ mails notice of the decision on appeal, whichever is later, unless: (1) an appellant has already submitted evidence or testimony as described in 38 C.F.R. §§ 20.302 and 20.303, or (2) the appellant or representative has requested a waiver of the ability to request to switch dockets during this timeframe. Williams, 37 Vet. App. 305.

In this case, the Veteran elected to waive his right to select a different review option. See January 2026 Waiver of Time to Select a Different Board Review Option. As such, the Board will proceed with adjudication.

By way of background, the Veteran filed his Application for Increased Compensation Based on Unemployability, VA Form 21-8940, in January 2024. Following a September 2025 rating decision denying the claim, the Veteran filed a Notice of Disagreement in January 2026. The Board subsequently dismissed the Veteran's claim of entitlement to TDIU prior to January 25, 2024, in a February 2026 decision, finding that the Veteran did not timely appeal any of the underlying evaluations for his claimed TDIU.

However, in the instant decision, the Veteran and his representative seek to rely on Rice v. Shinseki, 22 Vet. App. 447 (2009). In Rice, the United States Court of Appeals for Veterans Claims held that a TDIU claim may be part and parcel with an increased rating claim, when such a claim is expressly raised by a veteran or reasonably raised by the record. Id. at 453. Here, there is evidence that the service-connected disabilities on appeal in the instant decision affect the Veteran's employability. As such, the Board must conclude that TDIU appropriately before the Board for adjudication.

Increased Ratings

Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degrees of disability specified by the schedule are considered adequate to compensate veterans for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3.

In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in this decision is, therefore, undertaken with consideration of the possibility that different ratings may be warranted for different time periods.

Once the evidence has been assembled, it is the Board's responsibility to evaluate the evidence. 38 U.S.C. § 7104 (a). When there is an approximate balance of positive and negative evidence as to any issue material to the determination of a matter, VA will resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc).

Restrictive Lung Disease - Sleep Apnea

decision is, therefore, undertaken with consideration of the possibility that different ratings may be warranted for different time periods.

Restrictive Lung Disease - Sleep Apnea

The Veteran's sleep apnea has been rated as 50 percent disabling under Diagnostic Code 6847 for the entire period on appeal. Under Diagnostic Code 6847, a 50 percent rating is warranted for sleep apnea requiring use of breathing assistance device such as a CPAP machine; and a 100 percent rating is warranted for sleep apnea causing chronic respiratory failure with carbon dioxide retention or cor pulmonale; or that requires tracheostomy. 38 C.F.R. § 4.97, Diagnostic Code 6847.

Entitlement to an initial rating in excess of 50 percent for sleep apnea

In initial-rating cases, where the appeal stems from a granted claim of service connection with respect to the initial evaluation assigned, VA assesses the level of disability from the effective date of service connection. See Fenderson v. West, 12 Vet. App. 119, 125; 38 U.S.C. § 5110; 38 C.F.R. § 3.400. As this is an appeal as to the initial rating assigned, the relevant temporal focus is from August 10, 2022, the date of the award of service connection to present.

The Veteran received a VA examination in May 2023 and the examiner noted a diagnosis of obstructive sleep apnea. The Veteran reported using a prescribed continuous positive airway pressure (CPAP) machine every night while sleeping, and it reduced snoring and noisy breathing. There was no chronic respiratory failure, carbon dioxide retention or cor pulmonale, nor did his sleep apnea require a tracheostomy.

The Veteran received a VA examination in March 2024 and reported that "[a]s long as I use the CPAP its fine. He required the use of a CPAP machine, but there was still no chronic respiratory failure, carbon dioxide retention or cor pulmonale, nor did his sleep apnea require a tracheostomy.

D. B., the Veteran's spouse, submitted a statement in May 2025 noting that the Veteran had trouble sleeping at night. He always used a CPAP machine but still tossed and turned due to nightmares. They slept in separate bedrooms because the Veteran was so restless, but she could still hear him moaning in his sleep. He woke up several times a night, even when wearing the CPAP, and was tired and fatigued during the day.

The Veteran received a VA examination in June 2025 and reported using his CPAP nightly. However, he sometimes had trouble sleeping and awoke to his CPAP no longer on his face. There was still no chronic respiratory failure, carbon dioxide retention or cor pulmonale, nor did his sleep apnea require a tracheostomy.

The Veteran's VA treatment records are consistent with the Veteran's current 50 percent rating under Diagnostic Code 6847. The records indicate that there are no notations showing chronic respiratory failure with carbon dioxide retention or cor pulmonale; or the need for a tracheostomy. The Veteran has also not submitted any private treatment records regarding the presence of any chronic respiratory failure with carbon dioxide retention, cor pulmonale, or the need for a tracheostomy.

The evidence of record does not reveal the presence of any chronic respiratory failure with carbon dioxide retention, cor pulmonale, or the need for a tracheostomy, that would allow the Board to assign a rating more than what has already been assigned in this case. Consequently, the Board must deny the Veteran's claim for a rating in excess of 50 percent for his sleep apnea at this time based on the evidence of record in this case. See 38 C.F.R. §§ 4.7, 4.97, Diagnostic Code 6847. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107 (b); 38
tracheostomy, that would allow the Board to assign a rating more than what has already been assigned in this case. Consequently, the Board must deny the Veteran's claim for a rating in excess of 50 percent for his sleep apnea at this time based on the evidence of record in this case. See 38 C.F.R. §§ 4.7, 4.97, Diagnostic Code 6847. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Lynch, 21 F.4th 776 (Fed. Cir. 2021); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001)

Diseases of the Heart - Coronary Artery Disease

The Veteran's coronary artery disease has been rated as 10 percent disabling prior to January 25, 2024, under Diagnostic Code 7005-7017, and 30 percent disabling from January 25, 2024, to June 25, 2025. Beginning June 26, 2025, the Veteran was assigned a 100 percent rating.

Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the evaluation assigned. The additional code is shown after a hyphen. 38 C.F.R. § 4.2.

Under 38 C.F.R. § 4.104, Diagnostic Codes 7005 and 7017 are rated in accordance with the General Rating Formula for Diseases of the Heart. A 10 percent rating is warranted where a workload of 7.1 - 10 METs results in heart failure symptoms; or continuous medication required for control.

A 30 percent rating is warranted where a workload of 5.1-7.0 METs results in heart failure symptoms, or where there is cardiac hypertrophy or dilatation confirmed by echocardiogram or equivalent (e.g., multigated acquisition scan or magnetic resonance imaging).

A 60 percent rating is warranted where a workload of 3.1-5.0 METs results in heart failure symptoms.

A 100 percent rating is warranted where a workload of 3.0 METs or less results in heart failure symptoms.

One MET is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. 38 C.F.R. § 4.104, Note (2). When the level of METs at which breathlessness, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in those symptoms may be used. Id.

For purposes of the General Rating Formula for Diseases of the Heart, heart failure symptoms include, but are not limited to, breathlessness, fatigue, angina, dizziness, arrhythmia, palpitations, or syncope. 38 C.F.R. § 4.104, Note (3).

Entitlement to a rating in excess of 10 percent prior to January 25, 2024, for coronary artery disease, and in excess of 30 percent from January 25, 2024, to June 25, 2025

The relevant temporal focus for adjudicating a non-initial increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). Based on this procedural history, the Board finds that the relevant temporal focus for adjudicating this increased rating claim is from November 29, 2021, one year prior to the date the Veteran filed the present claim for an increased rating on November 29, 2022.

VA treatment records reflect that the Veteran's heart had a normal rate in rhythm in December 2021. See Primary Care Note. There were normal first and second heart sounds but no murmur, click, or thrill.

The Veteran received a VA examination in December 2022 and the examiner noted a diagnosis of coronary artery disease, status post coronary artery bypass surgery. The Veteran required continuous medication for his heart condition but there
(2007). Based on this procedural history, the Board finds that the relevant temporal focus for adjudicating this increased rating claim is from November 29, 2021, one year prior to the date the Veteran filed the present claim for an increased rating on November 29, 2022.

The Veteran received a VA examination in December 2022 and the examiner noted a diagnosis of coronary artery disease, status post coronary artery bypass surgery. The Veteran required continuous medication for his heart condition but there was no evidence of cardiac hypertrophy or cardiac dilatation. An interview-based stress test was performed in place of an exercise stress test but there were no symptoms reported; the Veteran denied experiencing symptoms attributable to a cardiac condition with any level of physical activity.

The Veteran received a VA examination in March 2024 but denied active cardiac symptoms. He required continuous medication for his heart condition but there was no evidence of cardiac hypertrophy or cardiac dilatation. An interview-based stress test was performed in place of an exercise stress test, and symptoms during activity included breathlessness and fatigue. As a result, the examiner estimated a level of greater than 5 to 7 METs due solely to the Veteran's coronary artery disease. Finally, the examiner noted that the Veteran had not had congestive heart failure.

Prior to January 25, 2024, the Veteran's service-connected coronary artery disease was shown to only require continuous medication. There was no evidence of cardiac hypertrophy or dilatation confirmed by echocardiogram or its equivalent. In the absence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray study; or a workload of not greater than 7.0 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, the Board finds that a rating in excess of 10 percent for service-connected coronary artery disease is not warranted prior to January 25, 2024.

From January 25, 2024, to June 25, 2025, the Veteran's service-connected coronary artery disease was shown to be manifested by a METs score of 5 to 7 METs and continuous medication required for control. Such findings do not merit a rating in excess of 30 percent for this period on appeal under Diagnostic Codes 7005-7017. In the absence of a workload of 3.1 to 5.0 METs that results in congestive heart failure, the Board finds that a rating in excess of 60 percent for the service-connected coronary artery disease from January 25, 2024, to June 25, 2025, is not warranted.

In sum, the Board concludes that the evidence is neither evenly balanced nor approximately so with regard to whether a rating in excess of 10 percent prior to January 25, 2024, and in excess of 30 percent from January 25, 2024, to June 25, 2025, for the Veteran's service-connected coronary artery disease is warranted. Rather, the evidence persuasively weighs against a rating increase for any period on appeal. The benefit of the doubt doctrine, see 38 U.S.C. § 5107(b), 38 C.F.R. § 4.3, is therefore not for application for this rating claim. Lynch, 21 F.4th 776 (Fed. Cir. 2021) (en banc).

The Skin - Scars

The Veteran's surgical scar status post coronary artery bypass surgery has been rated as noncompensable under Diagnostic Code 7802 for the entire period on appeal.

Under Diagnostic Code 7800, a 10 percent rating is warranted for disfigurement of the head, face or neck is rated on the basis of the Veteran having one characteristic of disfigurement as listed in Note (1). The 8 characteristics of disfigurement for purposes of evaluation under 38 C.F.R. § 4.118 are:

1. scar 5 or more inches in length;

2. scar at least one-quarter inch wide (0.6 cm.) at widest part;

3. surface contour of scar elevated or depressed on palpation;

4. scar adherent to underlying tissue;

5. skin hypo- or hyper-pigmented in an area exceeding six square inches (39 sq. cm.);

6. skin texture abnormal (irregular, atrophic, shiny, scaly etc.) in an area exceeding six square inches (39 sq. cm.);

7.
(1). The 8 characteristics of disfigurement for purposes of evaluation under 38 C.F.R. § 4.118 are:

1. scar 5 or more inches in length;

2. scar at least one-quarter inch wide (0.6 cm.) at widest part;

3. surface contour of scar elevated or depressed on palpation;

4. scar adherent to underlying tissue;

5. skin hypo- or hyper-pigmented in an area exceeding six square inches (39 sq. cm.);

6. skin texture abnormal (irregular, atrophic, shiny, scaly etc.) in an area exceeding six square inches (39 sq. cm.);

7. underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.), and;

8. skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.).

Diagnostic Code 7801 contemplates 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. 38 C.F.R. § 4.118, Diagnostic Code 7801. A 10 percent rating is awarded when the area of the scar(s) covers at least 6 square inches (39 square centimeters) but less than 12 square inches (77 square centimeters). A 20 percent rating is warranted when the area of the scar(s) covers at least 12 square inches (77 square centimeters) but less than 72 square inches (456 square centimeters). A 30 percent rating is warranted when the area of the scar(s) covers at least 72 square inches (456 square centimeters) but less than 144 square inches (929 square centimeters). A 40 percent rating is assigned when the area of the scar(s) covers at least 144 square inches (929 square centimeters) or greater. 38 C.F.R. § 4.118, Diagnostic Code 7801.

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. 38 C.F.R. § 4.118, Diagnostic Code 7802. A 10 percent disability rating is warranted when the area of the scar covers 144 square inches (929 square centimeters) or greater.

Diagnostic Code 7804 provides disability ratings for scars that are unstable or painful. A 10 percent rating is warranted for one or two scars that are unstable or painful. A 20 percent rating is warranted for three or four scars that are unstable or painful. A 30 percent rating is warranted for five or more scars that are unstable or painful. Note (1) states that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provides that if one or more scars are both unstable and painful, an additional 10 percent should be added to the evaluation based on the total number of unstable or painful scars. Note (3) states that scars evaluated under diagnostic codes 7800, 7801, 7802, or 7805 may also receive an evaluation under this Diagnostic Code, when applicable. 38 C.F.R. § 4.118, Diagnostic Code 7804.

Under Diagnostic Code 7805, scars with disabling effects other than those evaluated under Diagnostic Codes 7800 through 7804 are to be rated under an applicable Diagnostic Code. 38 C.F.R. § 4.118, Diagnostic Code 7805.

Diagnostic Codes 7806 and 7813 provide compensation for service-connected dermatophytoses, including ringworm of the body (tinea corporis), head (tinea capitis), feet (tinea pedis), beard area (tinea barbae), nails (tinea unguium, onychomycosis), and inguinal area (jock itch, tinea cruris), and for tinea versicolor. 38 C.F.R. § 4.118. Such disorders are to be evaluated under the General Rating Formula for the Skin.

Under the General Rating Formula for the Skin, a 0 percent rating is provided for no more than topical therapy required over the past 12-month period and at least one of the following: (i) characteristic lesions involving less than 5 percent of the entire body affected; or (ii) characteristic lesions involving less than 5 percent of exposed areas affected. Id.

A 10 percent rating is provided for at least one of the following: (i) characteristic lesions involving at least 5 percent, but less than 20 percent
, tinea cruris), and for tinea versicolor. 38 C.F.R. § 4.118. Such disorders are to be evaluated under the General Rating Formula for the Skin.

A 10 percent rating is provided for at least one of the following: (i) characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; (ii) at least 5 percent, but less than 20 percent, of exposed areas affected; or (iii) intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. Id.

Systemic therapy is defined as treatment that is administered through any route (orally, injection, suppository, intranasally) other than the skin, and topical therapy is treatment that is administered through the skin. 38 C.F.R. § 4.118.

Diagnostic Code 7819, pertinent to benign skin neoplasms, is rated as disfigurement of the head, face, or neck (Diagnostic Code 7800), scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), or impairment of function.

Entitlement to a compensable rating for a surgical scar status post coronary artery bypass surgery

The relevant temporal focus for adjudicating a non-initial increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). Based on the procedural history, the Board finds that the relevant temporal focus for adjudicating this increased rating claim is from January 25, 2023, one year prior to the date the Veteran filed the present claim for an increased rating on January 25, 2024.

The Veteran received a VA examination in March 2024 and the examiner noted a well-healed sternal surgical scar status post coronary artery bypass grafting. The scar was not painful or unstable and was not due to burns. It measured 23 centimeters by 1 centimeter; there was no underlying tissue damage, and the scar had an approximate total area of 23 square centimeters.

After a review of all the evidence, the Board finds that the Veteran's service-connected surgical scar status post coronary artery bypass surgery does not meet the criteria for a compensable rating at any point during the appeal period, as the scarring of the anterior trunk does not measure 929 square centimeters (144 square inches) or greater.

The Board has considered whether any other Diagnostic Codes related to disabilities of the skin would provide for a higher disability evaluation. However, the evidence does not reflect that he would warrant a higher rating under a different diagnostic code. See 38 C.F.R. § 4.118.

In so finding the above, the Board acknowledges the Veteran's contentions that his surgical scar status post coronary artery bypass surgery is more severe than contemplated by the current rating assigned. The Veteran is competent to report symptoms such as pain because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). However, he is not considered competent to medically attribute or assess the severity of his surgical scar status post coronary artery bypass surgery as required in the diagnostic codes. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Therefore, his statements do not constitute competent evidence, and the Board assigns more probative weight to the competent medical evidence of record.

In sum, the Board concludes that the evidence is neither evenly balanced nor approximately so with regard to whether a compensable rating for the Veteran's surgical scar status post coronary artery bypass surgery is warranted. Rather, the evidence persuasively weighs against a rating increase for any period on appeal
Vet. App. 303, 311 (2007). However, he is not considered competent to medically attribute or assess the severity of his surgical scar status post coronary artery bypass surgery as required in the diagnostic codes. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Therefore, his statements do not constitute competent evidence, and the Board assigns more probative weight to the competent medical evidence of record.

Diseases of the Peripheral Nerves - Anterior Crural Nerve (Femoral)

The Veteran's left lower extremity peripheral neuropathy and right lower extremity peripheral neuropathy have been rated as 20 percent disabling for the entire period on appeal under Diagnostic Code 8526 for impairment of the anterior crural nerve (femoral).

Incomplete paralysis of the anterior crural nerve warrants a 20 percent rating when moderate, and a 30 percent rating when severe. 38 C.F.R. § 4.124a.

The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124.

Neither the Rating Schedule nor the regulations provide definitions for descriptive words such as "mild," "moderate," "moderately severe," and "severe." Spellers v. Wilkie, 30 Vet. App. 211, 219 (2018) ("[Diagnostic Code] 8520 does not define 'mild,' 'moderate,' 'moderately severe,' or 'severe,' or generally associate those terms with specific symptoms"). Although the Board has at times attempted to define these terms using dictionary definitions, those definitions are problematic because they "do little to explain the Board's understanding of these terms and do not 'disclos[e] that benchmark it employed to reach [its] conclusion.'" Casey v. McDonough, No. 21-7569, 2023 U.S. App. Vet. Claims LEXIS 98, *5 (Jan. 24, 2023) (mem dec) (Falvey, J.) (quoting Johnson v. Wilkie, 30 Vet. App. 245, 255 (2018)) (discussing the Board's attempt to define the terms slight, mild, moderate, and severe in Diagnostic Code 8515). See also Bethea v. Derwinski, 2 Vet. App. 252, 254 (1992) (single judge decisions may be relied upon for any persuasiveness or reasoning they contain). With regard to Diagnostic Code 8520, although 38 C.F.R. § 4.120, 4.123, and 4.124 are "helpful in framing the analysis, [they] are not alone sufficient to explain the Board's decision absent an articulated connection to specific evidence." LeMon v. McDonough, No. 21-3949, 2022 U.S. App. Vet. Claims LEXIS 1998, *7 (Dec. 16, 2022) (mem dec) (Toth, J.). As explained in LeMon, these regulations leave gaps in defining the relevant terms that are filled by VA's Adjudication Manual, M21-1.

The Board "is required to discuss any relevant provisions contained in the M21-1 as part of its duty to provide adequate reasons or bases," Overton v. Wilkie, 30 Vet. 257, 264 (2018). Clearly relevant to this case are M21-1 provisions regarding evaluations of paralysis of the sciatic nerve.

The M21-1 describes mild incomplete paralysis as a disability "limited to sensory deficits that are lower graded, less persistent, or affecting a smaller area." Part V, sbpt. iii, ch. 12, sec. A.2.c.

Moderate incomplete paralysis should be "reserved for the most significant cases of sensory-only impairment," where the sensory
21-1.

The M21-1 describes mild incomplete paralysis as a disability "limited to sensory deficits that are lower graded, less persistent, or affecting a smaller area." Part V, sbpt. iii, ch. 12, sec. A.2.c.

Moderate incomplete paralysis should be "reserved for the most significant cases of sensory-only impairment," where the sensory involvement covers "a larger area in the nerve distribution." Id. M21-1 examples of a moderate disability include "motor and/or reflex impairment such as weakness or diminished or hyperactive reflexes (with or without sensory impairment) graded as medically moderate." Id.

A severe evaluation is warranted for "motor and/or reflex impairment (for example, atrophy, weakness, or diminished or hyperactive reflexes) at a grade reflecting a very high level of limitation or disability." In addition, "[t]rophic changes may be seen in severe longstanding neuropathy." Id.

Entitlement to an initial rating in excess of 20 percent for left lower extremity peripheral neuropathy

Entitlement to an initial rating in excess of 20 percent for right lower extremity peripheral neuropathy

The relevant temporal focus for adjudicating a non-initial increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). Based on this procedural history, the Board finds that the relevant temporal focus for adjudicating this increased rating claim is from January 25, 2023, one year prior to the date the Veteran filed the present claim for an increased rating on January 25, 2024.

The Veteran received a VA Diabetic Sensory - Motor Peripheral Neuropathy examination in March 2024 and the examiner noted diagnoses of left and right lower extremity diabetic peripheral neuropathy. There was no constant pain, mild intermittent pain, mild paresthesias and/or dysesthesias, and moderate numbness in the left and right lower extremities. Muscle strength testing was normal bilaterally, and there were decreased deep tendon reflexes in the left and right ankles. Light touch/monofilament testing results were decreased in the left and right foot/toes. Vibration sensation and cold sensation were absent in the left and right lower extremities. There was, however, no muscle atrophy and no trophic changes. Based on the results of the examination, the examiner found moderately severe incomplete paralysis of the anterior crural nerves of the left and right lower extremities.

In her May 2025 statement, D. B. noted that the Veteran was unable to walk or stand for long periods due to the numbness and tingling in his legs, as well as the pain in his feet. He could only take their dog on a walk halfway around their cul de sac before he needed to stop and he also needed to take breaks when walking to the mailbox.

The Veteran received a VA Back examination in June 2025 and the examiner noted normal muscle strength in the left and right lower extremities. There was also no muscle atrophy. The reflex examination revealed decreased deep tendon reflexes in the left and right ankles. Light touch (dermatome) testing results were decreased in the left lower leg/ankle (L4/L5/S1). There was no constant pain, moderate intermittent pain, moderate paresthesias and/or dysesthesias, and moderate numbness in the left and right lower extremities.

The Veteran received a VA Peripheral Nerves Conditions examination in June 2025 and the results were the same as the June 2025 VA Back examination. Based on these results, the examiner found moderate incomplete paralysis of the left and right sciatic nerves; the femoral nerve was noted as normal.

After careful review of the evidence, and with consideration of the benefit of the doubt doctrine, the Board finds that the evidence is not in approximate balance to support ratings in excess of 20 percent for the Veteran's left lower extremity peripheral neuropathy and right lower extremity peripheral neuropathy. The record does not show that the disabilities have been severe, as required for a 30 percent rating, the next highest available. As previously noted, severe incomplete paralysis, per the M21-1, is warranted for "motor and/or reflex impairment (for example, at
VA Back examination. Based on these results, the examiner found moderate incomplete paralysis of the left and right sciatic nerves; the femoral nerve was noted as normal.

After careful review of the evidence, and with consideration of the benefit of the doubt doctrine, the Board finds that the evidence is not in approximate balance to support ratings in excess of 20 percent for the Veteran's left lower extremity peripheral neuropathy and right lower extremity peripheral neuropathy. The record does not show that the disabilities have been severe, as required for a 30 percent rating, the next highest available. As previously noted, severe incomplete paralysis, per the M21-1, is warranted for "motor and/or reflex impairment (for example, atrophy, weakness, or diminished or hyperactive reflexes) at a grade reflecting a very high level of limitation or disability." Here, the medical evidence only notes decreased deep tendon reflexes in the bilateral ankles. There is also only evidence of, at worst, moderate intermittent pain, moderate paresthesias and/or dysesthesias, and moderate numbness in the bilateral lower extremities. Finally, there is no medical evidence of muscle atrophy.

Accordingly, while the Veteran has been shown to exhibit some neurological impairment of his left and right lower extremities, the record does not show, and the Board cannot conclude, that the Veteran's conditions more nearly approximated greater than moderate impairment. As such, the claims for ratings greater than 20 percent for the Veteran's left lower extremity peripheral neuropathy and right lower extremity peripheral neuropathy must be denied. See 38 C.F.R. § 38 C.F.R. § 4.124a, Diagnostic Code 8526. The benefit of the doubt doctrine, see 38 U.S.C. § 5107(b), 38 C.F.R. § 4.3, is therefore not for application for these rating claims. Lynch, 21 F.4th 776 (Fed. Cir. 2021) (en banc).

Service Connection

Generally, 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 may also be established on a secondary basis for a disability which is due to, or the result of, a service-connected disease or injury, or which has been aggravated beyond its natural progression by the same. 38 C.F.R. §3.310(a). Establishing service connection on a secondary basis requires evidence that is sufficient to show that (1) a current disability exists; and (2) the current disability was either (a) caused or (b) aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc); see also Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023) (invalidating the requirement of "proximate cause" and instead holding that a "but for" causation or aggravation is enough to show entitlement to secondary service connection).

In rendering this decision, the Board has reviewed all evidence of record whether discussed in detail. See Newhouse, 497 F.3d 1298, 1302 (Fed. Cir. 2007) (holding the Board must only discuss the evidence which is relevant to the issues on appeal). To the extent the evidence is found in "approximate balance," the Board will afford the benefit of the doubt in favor of the Veteran. Lynch, 21 F. 4th 776 (Fed, Cir. 2021) (holding that exact equipoise is not required for the benefit of the doubt to be applied, but rather the Veteran is entitled to the benefit of the doubt when the evidence is in approximate balance or "nearly equal").

Entitlement to service connection for interstitial lung disease, to include as secondary to service-connected diabetes

The Veteran filed his Fully Developed Claim, VA Form 21-526EZ, in November 2022 and asserted that his restrictive lung disease was caused by exposure to Agent Orange.

The Veteran received a VA examination in December 2022 and the examiner noted a diagnosis of interstitial lung disease that was first diagnosed in June
Lynch, 21 F. 4th 776 (Fed, Cir. 2021) (holding that exact equipoise is not required for the benefit of the doubt to be applied, but rather the Veteran is entitled to the benefit of the doubt when the evidence is in approximate balance or "nearly equal").

Entitlement to service connection for interstitial lung disease, to include as secondary to service-connected diabetes

The Veteran filed his Fully Developed Claim, VA Form 21-526EZ, in November 2022 and asserted that his restrictive lung disease was caused by exposure to Agent Orange.

The Veteran received a VA examination in December 2022 and the examiner noted a diagnosis of interstitial lung disease that was first diagnosed in June 2014. Based on the results of the examination, the examiner opined that the condition was less likely than not caused by service. The Veteran served from 1970 to 1973, and interstitial lung disease was diagnosed in 2014. While service treatment records showed that the Veteran had pre-existing bronchitis in 1966, no other records from service showed that he had any respiratory-related conditions. However, the Veteran was diabetic and medical literature showed that it was a known cause for micro/macrovascular complications which resulted in interstitial lung disease. This appeared to more likely be the underlying etiology of the Veteran's respiratory condition.

A Toxic Exposure Risk Activity (TERA) memorandum was obtained in April 2023 highlighting the Veteran's military personnel records showing service in the Republic of Vietnam. As such, the Veteran participated in a TERA during active military service.

The Veteran received a VA examination in May 2023 and a board-certified pulmonologist noted that the Veteran served in the Republic of Vietnam and, therefore, his exposure to Agent Orange was conceded. In 2014, he had recurrent dyspnea and a severe cough; a chest x-ray was consistent with interstitial lung disease. Based on the results of the examination, the pulmonologist opined that the condition was less likely than not proximately due to or the result of his service-connected diabetes. She highlighted treatment records from the Veteran's pulmonologist, in which he commented that the Veteran's CT scan was consistent with idiopathic pulmonary fibrosis (IPF). However, the CT scan was unavailable for review and the Veteran's course of treatment was not typical for the treatment for IPF. Diabetes was not considered to be a risk factor for interstitial lung disease, nor was it felt to be a causative condition. She noted an article from June 2022 suggesting the possibility of diabetes contributing to IPF but there was no evidence of the condition. Based on her review of the medical literature, combined with her 30 years of experience in the diagnosis and management of interstitial lung disease as a board-certified pulmonologist, she opined that the Veteran's interstitial lung disease was less likely than not due to his service-connected diabetes.

The pulmonologist also opined that the Veteran's interstitial lung disease was less likely than not caused by the indicated TERA, after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all TERA of the Veteran. Medical research showed that interstitial lung diseases were associated with asbestos exposure and autoimmune diseases, but the Veteran had neither. It was idiopathic, meaning the etiology was unclear other than a variety of occupational exposures and medications, but again the Veteran did not have these risks factors. Agent Orange had not been listed as a risk factor for the condition. While there was a medical article that suggested a possible relation, it was not definitive and was discussing IPF which the Veteran did not have. Based on her review of the medical literature, combined with her 30 years of experience in the diagnosis and management of interstitial lung disease as a board-certified pulmonologist, she opined that the Veteran's condition was less likely than not incurred in or due to his conceded herbicide exposure.

The Veteran received a VA examination in June 2025 and the examiner noted that the interstitial lung disease had worsened. Based on the results of the examination, the examiner opined that the condition was less likely than not caused by service. A review of medical literature failed to prove that exposure to Agent Orange caused the condition.

The Board finds the available VA examinations to be the most probative evidence of record and concludes that service connection for interstitial lung disease is not warranted. While the December 2022 VA examiner offered an opinion that the Veteran's service-connected diabetes was likely the etiology of his respiratory condition, its probative value is outweighed by the May 2023 medical opinion from a VA pulmonologist. The Board finds her expertise as a board-certified
and the examiner noted that the interstitial lung disease had worsened. Based on the results of the examination, the examiner opined that the condition was less likely than not caused by service. A review of medical literature failed to prove that exposure to Agent Orange caused the condition.

The Board finds the available VA examinations to be the most probative evidence of record and concludes that service connection for interstitial lung disease is not warranted. While the December 2022 VA examiner offered an opinion that the Veteran's service-connected diabetes was likely the etiology of his respiratory condition, its probative value is outweighed by the May 2023 medical opinion from a VA pulmonologist. The Board finds her expertise as a board-certified pulmonologist, as well as her rationale for her negative nexus opinion, highly probative. Furthermore, the December 2022 VA examiner failed to highlight which micro/macrovascular complications the Veteran experienced that could lead to interstitial lung disease.

The May 2023 VA pulmonologist's findings are credible and competent, as they were provided with thorough rationales with regards to the Veteran's interstitial lung disease and its lack of connection to conceded Agent Orange exposure or the service-connected diabetes. The Board notes that there is nothing in the record to link the Veteran's interstitial lung disease to his time in service and that his statements alone, while probative, are not competent to link a currently diagnosed interstitial lung disease to service. The May 2023 VA pulmonologist was able to conclude that the Veteran's claimed condition was less likely than not incurred in or caused by service following a thorough examination and review of medical literature. The benefit of the doubt doctrine, see 38 U.S.C. §5107(b), is therefore not for application as to this claim and entitlement to service connection for interstitial lung disease must be denied. Lynch, 21 F.4th 776 (Fed. Cir. 2021) (en banc).

TDIU

TDIU may be granted where a Veteran's service-connected disabilities are rated less than total, but they prevent him from obtaining or maintaining all gainful employment for which his education and occupational experience would otherwise qualify him. 38 C.F.R. § 4.16.

Where a Veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability, the requirement in 38 C.F.R. § 3.155(a) that an informal claim "identify the benefit sought" has been satisfied and VA must consider whether the Veteran is entitled to a total rating for compensation purposes based on individual unemployability (TDIU). Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). The central inquiry is, "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993).

The regulations provide that if there is only one such disability, it must be rated at 60 percent or more; and if there are two or more disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. Disabilities resulting from a common etiology or a single accident or disabilities affecting a single body system will be considered as one disability for the above purposes of one 60 percent disability or one 40 percent disability. 38 C.F.R. § 4.16(a).

A total disability rating may also be assigned on an extraschedular basis, pursuant to the procedures set forth in 38 C.F.R. § 4.16(b), for veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in § 4.16(a). Marginal employment shall not be considered as constituting substantially gainful employment. 38 C.F.R. § 4.16(a).

VA policy is to grant TDIU, regardless of the percentages, when service-connected disability actually renders a veteran unemployable. 38 C.F.R. § 4.16(b).

Pursuant to 38 C.F.R. § 4.16(a), marginal employment or the ability to work sporadically shall not be considered substantially gainful employment. Marginal employment generally shall be deemed to exist when a veteran's earned annual income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Marginal employment may also be held to exist, on a facts-found basis (includes but is not limited to employment in a protected environment such as a
to grant TDIU, regardless of the percentages, when service-connected disability actually renders a veteran unemployable. 38 C.F.R. § 4.16(b).

Pursuant to 38 C.F.R. § 4.16(a), marginal employment or the ability to work sporadically shall not be considered substantially gainful employment. Marginal employment generally shall be deemed to exist when a veteran's earned annual income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Marginal employment may also be held to exist, on a facts-found basis (includes but is not limited to employment in a protected environment such as a family business or sheltered workshop), when earned annual income exceeds the poverty threshold. Consideration shall be given in all claims to the nature of the employment and the reason for termination.

CAVC reiterated that TDIU is not a separate claim but is instead a rating option available whenever a claimant attempts to get service connection or a higher rating from VA and the record includes evidence of unemployability. Phillips v. McDonough, 37 Vet. App. 394, 397 (2024). CAVC also explained that consideration of entitlement to a TDIU is dependent upon when a veteran submits evidence of unemployability. If a veteran applies for service connection and VA learns the veteran cannot work, then VA must consider TDIU when assigning the appropriate rating. When a veteran already has service connection for a disability and applies for a higher rating, then VA needs to consider TDIU when it receives evidence of unemployability. Id. at 401.

Age may not be considered as a factor when evaluating unemployability or intercurrent disability, and it may not be used as a basis for a total disability rating. 38 C.F.R. § 4.19. There must be a determination that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age or a non-service-connected disability. 38 C.F.R. §§ 3.340, 3.341, 4.16.

The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question, however, is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993).

In Ray v. Wilkie, 31 Vet. App. 58 (2019), the Court of Appeals for Veterans Claims, held that "substantially gainful employment" has both an economic and non-economic component. 38 C.F.R. § 4.16(b). The economic component includes the Veteran's ability to earn more than a marginal income as evidenced by federal poverty thresholds. The non-economic component involves assessing the Veteran's actual ability to work. Factors to be discussed include (1) the Veteran's history, education, skill, and training; (2) whether the veteran has the physical ability to perform the type of activities required by the occupation at issue; and (3) whether the Veteran has the mental ability to perform the activities required by the occupation at issue.

In rendering this decision, the Board has reviewed all evidence of record whether discussed in detail. See Newhouse v. Nicholson, 497 F.3d 1298, 1302 (Fed. Cir. 2007) (holding the Board must only discuss the evidence which is relevant to the issues on appeal). To the extent the evidence is found in "approximate balance," the Board will afford the benefit of the doubt in favor of the Veteran. Lynch v. McDonough, 21 F. 4th 776 (Fed, Cir. 2021) (holding that exact equipoise is not required for the benefit of the doubt to be applied, but rather the Veteran is entitled to the benefit of the doubt when the evidence is in approximate balance or "nearly equal").

Entitlement to TDIU prior to January 25, 2024

Prior to January 25, 2024, the Veteran's service-connected disabilities included: (i) obstructive sleep apnea (50 percent); (ii) coronary artery disease (30 percent); (iii) diabetes mellitus type II (20 percent); (iv) left lower extremity diabetic peripheral neuropathy (10 percent); (v) right lower extremity diabetic peripheral neuropathy (10 percent); (vi) right foot Charcot arthropathy (10 percent); (vii) hypertension (0 percent); (viii) coronary artery bypass surgery surgical
entitled to the benefit of the doubt when the evidence is in approximate balance or "nearly equal").

Entitlement to TDIU prior to January 25, 2024

On his January 2024 Application for Increased Compensation Based on Unemployability, VA Form 21-8940, the Veteran reported that all of his service-connected disabilities prevented him from securing or following any substantially gainful occupation. He last worked full time in February 2012 but became too disabled to work in February 2016. The most he ever earned in one year was $143,000 in 2011 as a registered nurse. He had worked as a registered nurse from 1987 to 2016 but had not lost any time due to illness, making approximately $11,800 per month in gross earnings. The Veteran completed college but did not have any other education or training before becoming too disabled to work.

The December 2022 VA Heart Conditions examination found that the Veteran's coronary artery disease did not impact his ability to work. When the condition began, the Veteran had difficulty breathing but there were no current symptoms. Under "Impact," the examiner wrote "N/A."

The January 2023 VA Diabetes examination found that the Veteran's diabetes mellitus did not impact his ability to work. The peripheral pulses examination and findings were within normal limits, as were the motor and sensory examinations; gait, balance, cranial, and peripheral nerves were all normal.

The May 2023 VA Sleep Apnea examination found that the Veteran's sleep apnea did not impact his ability to work. He reported a prescription and nightly usage of a continuous positive airway pressure (CPAP) machine which decreased snoring and noisy breathing. The only signs and symptoms attributable to sleep apnea were mouth breathing without discomfort when he napped with his CPAP machine; he did not report persistent daytime hypersomnolence.

Dr. B. T. submitted a medical opinion in June 2025 as to the impact of the Veteran's service-connected impairments have on his ability to work. He noted the Veteran's service-connected disabilities and the available medical evidence. He also consulted with the Veteran who reported three associates degrees as a registered nurse. The Veteran reported that he retired in 2016 and still struggled with shortness of breath, pain and numbness in the lower extremities, and daytime fatigue. Based on his review, Dr. B. T. concluded that the Veteran would be unable to stand for 30 minutes without needing to lean on something, would only be able to walk for 30 minutes slowly and unassisted, and could sit for a total of 30 minutes at a time. As a result, he would need to be able to alternate between sitting and standing, as well as sitting and laying down, to alleviate pain and this would impact pace and productivity. This would require the Veteran to miss work or leave early three or more days per month due to pain and limitations. For more than three days per month, he would not be able to stay focused for at least seven hours of an eight-hour workday due to constant pain and extra needed breaks. All of these issues were inconsistent with an ability to sustain even sedentary employment, which at the very least required a person to be able to attend work reliably, sustain a steady pace and concentration, and work productively. As a result, Dr. B. T. concluded that the Veteran had been unable to maintain substantially gainful employment as a result of his service-connected disabilities since at least August 10, 2022.

The record shows that the Veteran has not worked full time since at least February 2016 when he worked as a registered nurse. See January 2024 VA Form 21-8940. The Board acknowledges that the Veteran was unemployed during the period on appeal, but the mere fact that a Veteran is unemployed, underemployed, or has difficulty obtaining employment is not enough to warrant a grant of TDIU. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). A high rating in itself is recognition that the impairment makes it difficult to obtain or maintain employment, but the ultimate question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. Ray, 31 Vet. App. 58, 72 (2019) (citing Van Hoose, 4 Vet. App. 361, 363 (1993)). Hence, while the Veteran may have had difficulty finding employment during this time period, that cannot be a factor in the Board's analysis.

In reviewing the record, although the Veteran maintains he was unable to maintain gainful employment due to his service-connected disabilities, VA records do not ascribe an inability to work due solely to them. In this regard, the Board finds the available VA examinations and their conclusions regarding the functional impact of the service-connected disabilities highly probative, as they are based on contemporaneous examinations of the Veteran and considered all lay statements made regarding his disabilities. The VA medical examinations competently concluded that the Veteran's disabilities did not impact his ability to work. Furthermore, Dr. B. T. found that the Veteran's service-connected disabilities would only "impact pace and productivity." The Board is cognizant of the limitations enumerated in his medical opinion, but they are not supported by the medical evidence. For example, Dr. B. T. noted that the Veteran would need to alternate between sitting, standing, and laying down to alleviate the pain in his lower extremities. However, the VA diabetes examination found that the Veteran's lower extremities were normal. Specifically, his gait, balance, and peripheral nerves were all normal after a motor and sensory examination.. Despite his conclusion that the Veteran had been unable to maintain substantially gainful employment as a result of his service-connected disabilities since at least August 10, 2022, neither the VA medical examinations nor his own conclusions in the June 2025 medical opinion support this finding.

In conclusion, while the Board does not wish to minimize the nature and extent of the Veteran's overall service-connected disabilities, the evidence of record simply does not support his claim that they are sufficient to produce unemployability. Although his disabilities exhibit a degree of impairment, the evidence does not reflect that gainful employment was precluded solely due to them. To the extent the Veteran is limited by his service-connected disabilities, any such limitation is contemplated in, and is being adequately compensated by the current disability rating assigned for these disorders.

Accordingly, the Board finds that entitlement to a TDIU prior to January 25, 2024, is not warranted. The appeal is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch, 21 F. 4th 776.

SMC - Housebound

SMC benefits by reason of being housebound are payable if the Veteran has a single permanent disability rated 100 percent disabling and has either (1) additional service-connected disability or disabilities independently ratable at 60 percent or more, or (2) is "permanently housebound" by reason of service-connected disability or disabilities. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). The disabilities independently ratable at 60 percent or more must be separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems. 38 C.F.R. § 3.350(i)(1).

For determining whether a disability is rated as total, the requirement may be met if TDIU is awarded based on the effects of one disability and the remaining disabilities total at least 60 percent. See Bradley v. Peake, 22 Vet. App. 280, 293 ("[38 U.S.C. § 1114(s)] does not limit 'a service-connected disability rated as total' to only a schedular rating of 100%, and the Secretary's current regulation permits a TDIU rating based on a single disability to satisfy the statutory requirement of a total rating.").

Entitlement to an effective date earlier than June 26, 2025, for SMC based on
3.350(i)(1).

Entitlement to an effective date earlier than June 26, 2025, for SMC based on housebound status

The Veteran contends he is entitled to an earlier effective date prior to June 26, 2025, for SMC at the housebound rate. After a review of the evidence, the Board finds that as earlier effective date for SMC is not warranted.

Again, the Board notes that SMC under subsection (s) may be awarded where a veteran is in receipt of service connection for a single disability rated as total and additional disabilities that are independently ratable at least 60 percent disabling that affect different bodily systems or anatomical units. The requirement for a single disability rated as total may be satisfied by a TDIU premised on a single disability. See Bradley v. Peake, 22 Vet. App. 280 (2008). However, the Federal Circuit has recently found that this requirement cannot be satisfied by a TDIU premised on multiple disabilities, including multiple disabilities that may be considered as a single disability for TDIU purposes as set forth at 38 C.F.R. § 4.16(a)(2) and (3). See Mackey v. Collins, No. 24-1854 (Fed. Cir. 2026).

Prior to June 26, 2025, the Veteran was not in receipt of a single permanent disability rated 100 percent disabling. In this regard, the Board notes that the Veteran was awarded TDIU from January 25, 2024, to June 26, 2025. However, the AOJ found that the Veteran was to be unable to secure or follow a substantially gainful occupation as a result of all of his service-connected disabilities. See September 2025 Rating Decision - Narrative.

Thus, the Veteran did not have a single service-connected disability rated as 100 percent and additional service-connected disability or disabilities ratable at 60 percent prior to June 26, 2025.

Moreover, the evidence does not establish that the Veteran was housebound on a factual basis, nor does it establish that he was bedridden. The June 2025 private opinion from Dr. B. T. highlighted that the Veteran walked approximately one mile daily for exercise, worked in his garden, and walked the dog twice per day. Thus, the Board concludes that the Veteran was not substantially confined to his home, or otherwise housebound. See 38 C.F.R. § 3.351(d). Therefore, an effective date prior to June 26, 2025, for SMC based on housebound status is not warranted.

(Continued on the next page)

In sum, the evidence is against an effective date prior to June 26, 2025, as the medical evidence did not demonstrate that entitlement to SMC based on the housebound rate arose prior to this date nor does the threshold requirements for entitlement to SMC been met. In denying an earlier effective date, the Board finds the benefit of the doubt doctrine is not applicable.

David Robertson

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board A. Daniels, Counsel

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.

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