BVA9503474 DOCKET NO. 90-48 156 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for a psychiatric disability. 2. Entitlement to an increased (extraschedular) rating for post gastrectomy syndrome, currently assigned a 60 percent evaluation. 3. Entitlement to an increased rating for right shoulder tendon transplant, currently assigned a 20 percent evaluation. 4. Entitlement to an increased rating for left shoulder bursitis, currently assigned a 10 percent evaluation. 5. Entitlement to an increased (compensable) rating for pulmonary tuberculosis. 6. Entitlement to a total rating for compensation purposes based upon individual unemployability. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD R. P. Harris, Counsel INTRODUCTION The appellant had active service from May 1952 to December 1954 and June 1958 to May 1975. This matter came before the Board of Veterans' Appeals (Board) on appeal from an October 1989 rating decision of the Nashville, Tennessee, Regional Office (RO), which denied increased evaluations for post gastrectomy syndrome, right shoulder tendon transplant, left shoulder bursitis, and pulmonary tuberculosis. Subsequently, the appellant appealed rating decisions dated in January and July 1990, which respectively denied the issues of service connection for a psychiatric disability and a total rating based upon individual unemployability. In July 1991, February 1993, and March 1994, the Board remanded the case for evidentiary and procedural development. That development has largely been accomplished and the case returned to the Board for further appellate review. CONTENTIONS OF APPELLANT ON APPEAL The appellant contends, in essence, that his psychiatric disability had its onset in service, or alternatively, is secondary to his service-connected post gastrectomy syndrome. He argues that he was treated with Valium for nervousness during his second period of service, after the gastrectomy was performed, and continued to received said treatment post service. Reference is made to a recent Department of Veterans Affairs (VA) psychiatric examination report dated in March 1994, wherein the examiner diagnosed a current anxiety disorder as related to anxiety symptomatology exhibited in service. He contends that his post gastrectomy syndrome is manifested by episodes of nausea, vomiting, and diarrhea; and that as a result, he needs to lie down after eating meals. His disabilities of the shoulders are manifested by pain and limitation of motion. It is contended that a 1991 VA general medical examination report is incomplete. He asserts that his service-connected disabilities, in particular, post gastrectomy syndrome, preclude employability. It is requested that applicable statutory and regulatory provisions be considered, including 38 C.F.R. §§ 3.303 and 4.7, pertaining to service connection principles and the higher of two evaluations, respectively. Additionally, it is requested that the benefit of the doubt doctrine be applied. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the appellant's claims files. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the evidence is in equipoise to grant service connection for a psychiatric disability, classified as anxiety disorder, an increased rating of 30 percent for right shoulder tendon transplant, an increased rating of 20 percent for left shoulder bursitis, and a total rating based upon individual unemployability. However, the preponderance of the evidence is against allowance of an increased (extraschedular) evaluation in excess of 60 percent for post gastrectomy syndrome, a rating in excess of 30 percent for right shoulder tendon transplant, an evaluation in excess of 20 percent for left shoulder bursitis, or a compensable rating for pulmonary tuberculosis. FINDINGS OF FACT 1. All available, relevant evidence necessary for disposition of the appeal has been obtained by the RO. 2. The appellant has achieved a high school equivalency certificate. 3. He reportedly has not been gainfully employed since service. 4. It is probable that the appellant has a chronic acquired psychiatric disability, classified as an anxiety disorder, and that it was initially manifested during military service. 5. The appellant's service-connected post gastrectomy syndrome is manifested primarily by complaints of "dumping syndrome" with episodes of nausea, vomiting, bloating, and diarrhea. There is no recent clinical evidence of gastric ulceration or material weight loss. The gastric disability does not represent an exceptional or unusual disability picture as to render the regular schedular standards inadequate. 6. The appellant's service-connected right shoulder disability (major upper extremity) is manifested primarily by complaints of pain and limitation of motion. The recent clinical evidence reflects that he is able to abduct the right arm approximately 60 degrees, which more nearly approximates a position midway between the side of his body and shoulder level, not a position at shoulder level. However, that degree of abduction manifested does not more nearly approximate a position 25 degrees from the side of the body. 7. The appellant's service-connected left shoulder disability is manifested primarily by complaints of pain and limitation of motion. The recent clinical evidence reflects that he is able to abduct the left arm to 100 degrees. That degree of abduction manifested more nearly approximates a position at shoulder level, but not a position midway between the side of his body and shoulder level. 8. The appellant's service-connected pulmonary tuberculosis was completely arrested at a moderately advanced stage, and has been inactive since the mid-1950's. The recent clinical evidence shows radiographic findings of a few small, calcified granulomas scattered in the lungs consistent with pulmonary fibrosis. However, definite symptomatology from pulmonary tuberculosis, such as dyspnea on exertion, has not been recently shown. 9. In addition to the aforementioned service-connected disabilities, service connection is in effect for left ear hearing loss, and residuals of malaria, each currently rated as noncompensable. When combined, the service-connected disabilities were evaluated by the RO as 70 percent disabling; a minimum combined rating of 80 percent will result from action taken in this decision. 10. It is more likely that the appellant's service-connected disabilities are of sufficient severity as would prevent him from engaging in some form of substantially gainful employment, even of a sedentary nature, consistent with his education and occupational experience. CONCLUSIONS OF LAW 1. The appellant's chronic acquired psychiatric disability, classified as an anxiety disorder, was incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5107(a) (West 1991); 38 C.F.R. §§ 3.303, 3.304 (1994). 2. The criteria for an increased (extraschedular) evaluation in excess of 60 percent for post gastrectomy syndrome have not been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.2, 4.7, 4.10, 4.110-4.114, Codes 7304, 7308 (1994). 3. The criteria for a 30 percent evaluation for right shoulder tendon transplant have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 1991); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.2, 4.7, 4.10, 4.20, 4.40, 4.71a, Code 5201 (1994). 4. The criteria for an evaluation in excess of 30 percent for right shoulder tendon transplant have not been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.2, 4.7, 4.10, 4.20, 4.40, 4.71a, Code 5201 (1994). 5. The criteria for a 20 percent evaluation for left shoulder bursitis have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 1991); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.2, 4.7, 4.10, 4.20, 4.40, 4.71a, Codes 5019, 5201 (1994). 6. The criteria for an evaluation in excess of 20 percent evaluation for left shoulder bursitis have not been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.2, 4.7, 4.10, 4.20, 4.40, 4.71a, Codes 5019, 5201 (1994). 7. The criteria for a compensable evaluation for pulmonary tuberculosis have not been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.2, 4.7, 4.10, 4.96, 4.97, Codes 6722, 6731 (1994). 8. It is more probable that the appellant has service-connected disabilities that are sufficient to produce unemployability. 38 U.S.C.A. §§ 1155, 5107(b) (West 1991); 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16(a), 4.18 (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Given the Board's favorable decision granting service connection for a chronic acquired psychiatric disability, classified as an anxiety disorder, 30 percent and 20 percent evaluations, respectively, for right shoulder tendon transplant and left shoulder bursitis, and a total rating based on individual unemployability, these claims are "well grounded" within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). Additionally, the Board finds the claims for an increased (extraschedular) evaluation in excess of 60 percent for post gastrectomy syndrome and a compensable evaluation for pulmonary tuberculosis arguably "well grounded." 38 U.S.C.A. § 5107(a). After reviewing the record, the Board is satisfied that all relevant facts have been properly developed and that no useful purpose would be served by again remanding the case with directions to provide further assistance to the appellant. The Board would be remiss in not pointing out that, in deciding the issues on appeal, it has relied upon the existing evidence of record, without remanding again for additional evidentiary development. While the examinations on file are, in part, somewhat dated, those exams, with subsequent outpatient records provide sufficient basis to proceed without additional delay. Contrary to the appellant's assertions, the September 1991 general medical examination report appears complete, and includes detailed findings with respect to the service-connected pulmonary disability, including chest x-ray study, and a diagnosis for pulmonary tuberculosis by history. Neither that examination nor more recent clinical evidence indicates that his pulmonary tuberculosis is active or symptomatic, or that the other service- connected disabilities are more severe than shown on the September 1991 examinations. With respect to the service connection issue, the Board remanded the case again in March 1994 for a psychiatric examination to determine the current diagnosis and etiology of any psychiatric disability manifested. The psychiatric examiner's conclusions appear to be somewhat ambiguously worded, however; but the Board has construed their meaning in a manner most beneficial to the appellant. Furthermore, pursuant to the Board's February 1993 remand, the RO requested information from the appellant as to relevant VA treatment records and records associated with a Social Security Administration (SSA) administrative law decision; and these records were obtained and associated with the claims folder. However, in particular, the SSA administrative law decision rendered in November 1982 was based upon early 1980's medical evidence. There is a relative lack of recent medical evidence or opinion as to the impact the appellant's service-connected disabilities have upon employability. It would have been of considerable benefit if the RO had afforded the appellant a social and industrial survey, or provided him more recent examinations, in order for the examiners to elaborate upon the impact the service-connected disabilities have upon his employability. Nevertheless, in view of the favorable action taken, the record is adequate for entering a decision. The Board has balanced these evidentiary concerns with the fact that the issues on appeal have been in appellate status for nearly five and a half years. A delay of justice is troubling to the Board, and to order another remand for the RO to more appropriately develop the evidentiary record would likely significantly add to the delay. Therefore, based upon the evidence in the claims folders, the Board has applied the relevant laws and regulations, and decided these issues. Thus, the Board concludes that the evidence is sufficient for purposes of reaching a fair and well-reasoned decision of the issues on appeal, and that the duty to assist the appellant as contemplated by 38 U.S.C.A. § 5107(a) has been satisfied. I. Service Connection for a Psychiatric Disability Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131. In pertinent part, for the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. § 3.303(d). In pertinent part, satisfactory lay or other evidence that an injury or disease was incurred or aggravated in combat will be accepted as sufficient proof of service connection if the evidence is consistent with the circumstances, conditions or hardships of such service even though there is no official record of such incurrence or aggravation. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). The appellant alleges that he has a psychiatric disability which had its onset in service, or alternatively, is secondary to his service-connected post gastrectomy syndrome. He argues that he was treated with Valium for nervousness during his second period of service, after the gastrectomy was performed, and continued to received said treatment post service. Initially, the Board observes that the service records reflect he served during the Korean War and received a Combat Infantryman Badge; and that he was medically discharged from service in 1954 on account of pulmonary tuberculosis. Additionally, he re-enlisted in the late 1950's and served for approximately a decade and a half, including as an administrative specialist in Vietnam. The Board recognizes his approximate 20 years of active service, and the circumstances, conditions, or hardships inherent in said military activities, and has kept this in mind in deciding this appeal, in particular the service connection issue. 38 U.S.C.A. §§ 1110, 1131, 1154(b); 38 C.F.R. §§ 3.303, 3.304. The appellant's service medical records during the initial period of service reflect no complaints, findings, or diagnosis of an acquired psychiatric disorder on examination for entry into service in May 1952. In late 1953, he complained of back pain, and some objective back symptomatology was clinically noted. However, in November 1953, a neuropsychiatric evaluation was conducted, and his symptoms were considered of emotional origin. Additionally, the examiner noted that the appellant was an insecure and quite immature individual; and conversion reaction manifested by persistent back pain was diagnosed. Conversion disorder is a psychoneurosis. See 38 C.F.R. § 4.132 and Part 4, Code 9402, (1994). This in-service diagnosis of a psychoneurosis represents positive evidence for the proposition that he had a psychiatric disability related to service. However, on examination for service retirement in November 1954, his psychiatric status was clinically normal. Therefore, this latter piece of evidence is negative evidence, suggesting that any psychiatric symptoms in service were acute and transitory, and resolved in service. After the initial period of service, neither his January 1955 application for disability benefits nor private and VA medical reports dated in 1955 and early 1956 reflect a chronic acquired psychiatric disability. However, in a medical questionnaire accompanying a military periodic examination report dated in June 1956, he reported having or having had nervous trouble. This constitutes positive evidence suggesting continuity of psychiatric symptomatology since service. On the other hand, the June 1956 examination report constitutes negative evidence, since a psychiatric disability was not clinically noted thereon. On a medical questionnaire accompanying the report of the appellant's examination for re-enlistment into service dated in June 1958, he complained of having or having had nervous trouble. However, clinically his psychiatric status was normal. During the second period of service, a neuropsychiatric evaluation was conducted in September 1958. Significantly, he reported no history of interpersonal difficulties with parents, siblings, or others. However, clinically he appeared extremely nervous; and he stated that he felt uneasy in being evaluated by a psychiatrist for the first time. This piece of evidence regarding nervousness is positive evidence, suggesting continuity of psychiatric symptomatology since the initial period of service. The examiner noted that the appellant occasionally showed signs of anger. However, the examiner stated that the "main psychopathology noted in this individual is marked passive- aggressive behavior which is demonstrated by his impulsive actions when he is frustrated and is unable to accept controls from his external environment....Again, his irrational responses of anger during the interview also demonstrate the patient's aggressive core". The impression was passive-aggressive reaction. It should be pointed out that the provisions of 38 C.F.R. § 3.303(c) (1994) preclude a grant of service connection for personality disorders. During the remainder of the appellant's second period of service, there were no complaints, findings, or diagnosis of an acquired psychiatric disorder, except that on a medical questionnaire accompanying the report of examination in June 1965, he complained of having or having had nervous trouble. In 1974, a partial gastrectomy with subsequent surgical revision were performed, and in early 1975, he was found unfit for service due to physical disabilities. There was no mention of psychiatric disability. See March 1975 reports of military Medical Board examination and Physical Evaluation Board proceedings. A significant positive piece of evidence is his statement dated and received by the RO in August 1975, a few months after service, divulging that he had a "nervous condition", that he did not know whether it was caused by his post gastrectomy syndrome, that he had been prescribed "nerve" medicine apparently by the VA, and that he "stayed very nervous." Again, this evidence suggests continuity of psychiatric symptomatology since service. Moreover, on a September 1975 general medical examination, the appellant complained of nervousness. The examiner noted that the appellant felt his nervousness "is due to stomach trouble and vomiting. At times gets real nervous, shakes and eats something and goes away and could be hypoglycemia (note always with empty stomach)." Clinically, his psychiatric status was noted as "negative", although it does not appear that a comprehensive psychiatric assessment was done. Subsequent medical records reflect that in a May 1982 statement, Gary C. Salk, Ph.D., a private psychologist, concluded that the appellant had a neurotic personality; and a neurosis was diagnosed. See record accompanying SSA administrative law decision dated in November 1982. A November 1989 VA outpatient treatment report referred to neuropsychiatric side effects from Reglan, a prescribed medicine for his gastric disorder. There is no indication in the record that these side effects were chronic. In any event, this is moot since the Board's favorable decision with respect to the service connection issue is based upon direct, not secondary, service connection. On VA psychiatric examination in November 1991, the appellant gave a history of Valium having been prescribed in service after his gastric surgery, and continuously thereafter. The examiner referred to the claims folder as not showing complaints or treatment for a psychiatric disability in the service medical records; and stated that while he may have had some occasional anxiety symptoms according to his history, there was no evidence for a formal psychiatric diagnosis. However, the examiner on subsequent VA psychiatric examination in March 1994 reached a contrary conclusion. The report of that examination reflects that examiner's opinion that the appellant: "notes that the prominent symptoms of anxiety began after the stomach operations; however, on further questioning it appears that he has always been somewhat of an anxious gentleman....I do agree that he has some somatization of psychological issues and may have some passive aggressive traits....he does not meet the criteria of PTSD. There is further no evidence of panic disorder. He does not meet the full criteria for generalized anxiety disorder. However, due to the longstanding nature of his problem that was exhibited in the military prior to the surgery as well as markedly after the surgery, I believe that he does meet the criteria for anxiety disorder...." With resolution of reasonable doubt in the appellant's favor, a reasonable reading of the March 1994 psychiatric examination report is that the examiner related the appellant's anxiety disorder to psychiatric symptoms he had in service, prior and subsequent to the in-service surgeries for the service-connected gastric disability. Weighing the negative and positive evidence as contained in the entire evidentiary record on the question of whether a chronic acquired psychiatric disorder currently exists, and if so, whether in-service symptoms represented the initial onset of that disability, the Board finds the evidence in relative equipoise. Accordingly, service connection for a psychiatric disability, classified as anxiety disorder, is granted. 38 U.S.C.A. §§ 1110, 1131, 1154(b), 5107(a); 38 C.F.R. §§ 3.303, 3.304. II. An Increased (Extraschedular) Evaluation in Excess of 60 Percent for Post Gastrectomy Syndrome Disability evaluations are determined by application of a schedule of ratings which is based on average impairment of earning capacity under the VA's Schedule for Rating Disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. The appellant is currently receiving the maximum evaluation assignable for the service- connected gastric disability under Diagnostic Code 7308 for severe post gastrectomy syndrome. The issue for resolution is whether the post gastrectomy syndrome represents an exceptional or unusual disability picture as to render the regular schedular standards inadequate. The Board will consider the appellant's service-connected post gastrectomy syndrome in the context of the total history of that disability, particularly as it affects the ordinary conditions of daily life, including employment, as required by the provisions of 38 C.F.R. §§ 4.1, 4.2, 4.10 and other applicable provisions. Schafrath v. Derwinski, 1 Vet.App. 589 (1991). However, as the Court stated in Francisco v. Brown, 7 Vet.App. 55 (1994), "Where...an increase in the disability rating is at issue, the present level of disability is of primary concern." Francisco, 7 Vet.App. at 58. The appellant's service medical records during his second period of service reflect that in September1973, he had abdominal complaints and a history of excessive alcohol use. An upper gastrointestinal x-ray study was negative except for an ulcer crater in the distal antrum-pyloric channel. His weight was 140 pounds. See May 1952 examination for entry into service, which recorded his height as 66 inches and weight 132 pounds. An upper gastrointestinal x-ray study in November 1973 revealed marked ulcer improvement. However, a November 1974 hospital report reflects that in early 1974, recurrence of the ulcer was noted, and a partial gastrectomy with vagotomy, antrectomy, and Billroth I anastomosis was performed. Due to symptoms of vomiting and postcibal symptoms, corrective gastric surgery (Roux-en-Y gastrojejunostomy) was performed for post gastrectomy syndrome. However, post gastrectomy syndrome with recurrent episodes of vomiting, postprandial pain, nausea, and bloating was reported; and he was considered unfit for military service retention. A VA examination report in September 1975 reflects that the appellant complained of vomiting and abdominal pain, but that it occurred less frequently. Significantly, there was no evidence of material weight loss, since his weight was 128 and a half pounds; and an upper gastrointestinal x-ray study revealed no ulcer or obstruction. During VA hospitalization from April to May 1981, he reported occasional episodes of diarrhea, abdominal bloating, and postprandial vomiting. His weight was 125 pounds. An upper endoscopic examination revealed the stomach was unremarkable. He was placed on a "dumping diet", and did not experience diarrhea. He was considered able to engage in slight, but nonstrenuous, employment. In an SSA administrative law decision rendered in November 1982, the judge referred to the appellant's testimony alleging gastric complaints including nausea, diarrhea, and cramping, and alluded to his rather thin appearance; and held that that disability, in combination with shoulder and emotional problems, precluded employment. However, subsequent VA outpatient treatment reports reflect that the appellant's weight remained steady at 141 pounds in November 1989, an upper endoscopic examination revealed no ulcer or significant gastric pathology in March 1990, and mild gastroparesis with mild episodic regurgitation was assessed in May 1990. A VA gastrointestinal examination report in September 1991 noted a stable weight of 138. He complained of occasional vomiting and diarrhea, in addition to constant abdominal pain and bloating. However, clinical findings were unremarkable. More recent VA outpatient treatment reports reflect that in July 1992, he complained of occasional postprandial diarrhea and mild bloating. However, his weight was 149 pounds, and his post gastrectomy syndrome was assessed as "doing well." In January 1993, he reported slight diarrhea and some postprandial bloating, but no nausea or vomiting; and there was no evidence of weight loss, since he weighed 154 pounds. In conclusion, the appellant's service-connected post gastrectomy syndrome, manifested by occasional postprandial bloating, diarrhea, and vomiting, is adequately compensated for by the 60 percent evaluation for the degree of functional loss resulting therefrom. There is no recent clinical evidence of gastric ulceration or material weight loss. Complaints of occasional postprandial bloating, diarrhea, and vomiting are contemplated in the rating that is assigned. He has not been frequently hospitalized for that disability, and the gastric disability in and of itself has not been shown to markedly interfere with all forms of gainful employment. 38 C.F.R. § 3.321(b)(1). See also April to May 1981 VA hospital report, the SSA administrative law decision rendered in November 1982, and the more recent clinical evidence, which does not reflect significant worsening of that disability to indicate that the regular schedular standards are inadequate. Since the preponderance of the evidence is against allowance of this issue on appeal, the benefit of the doubt doctrine is inapplicable. 38 U.S.C.A. § 5107(b) (West 1991). III and IV. Evaluations in Excess of 20 Percent and 10 Percent, Respectively, for Right Shoulder and Left Shoulder Disabilities Disability evaluations are determined by application of a schedule of ratings which is based on average impairment of earning capacity under the VA's Schedule for Rating Disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. The Board will consider the appellant's service-connected right and left shoulder disabilities in the context of the total history of those disabilities, particularly as each affects the ordinary conditions of daily life, including employment. It should be pointed out that the only upper extremity disabilities for which service connection is in effect involve the shoulders. The appellant's right shoulder disability is rated by analogy on the basis of limitation of motion under Diagnostic Code 5201. 38 C.F.R. § 4.20. With respect to the right shoulder, Diagnostic Code 5201 provides that: A 20 percent evaluation may be assigned for limitation of motion of the major arm when motion is possible to the shoulder level. A 30 percent evaluation requires that motion be limited to midway between the side and shoulder level. A 40 percent evaluation requires that motion be limited to 25 degrees from the side. With respect to the service-connected left shoulder bursitis, Diagnostic Code 5019 provides that bursitis is rated as degenerative arthritis (Diagnostic Code 5003) on the basis of limitation of motion of the affected part. It appears that the RO rated the left shoulder bursitis as 10 percent disabling under Diagnostic Code 5003, on the basis that a 10 percent rating is applied for limitation of motion of that joint when noncompensable under the appropriate diagnostic code (Under Diagnostic Code 5201, assignment of a compensable (20 percent) rating requires limitation of motion of the minor arm when motion is possible to the shoulder level or to midway between the side and shoulder level). A 30 percent evaluation requires that motion be limited to 25 degrees from the side. The Board will evaluate the left shoulder disability under the appropriate diagnostic codes including Code 5201. The appellant's service medical records during the second period of service reflect that he was treated for tendonitis or bursitis of the shoulders in the mid-1960's. With respect to the right shoulder, a biceptal tendon transfer and surgical removal of calcific deposits from the rotator cuff were performed in August 1968, with some postoperative complications. In March 1975, he was determined unfit for service retention, in part, due to limitation of motion at shoulder level of the right arm (major upper extremity). A VA examination report in September 1975 revealed right upper extremity impairment. However, with respect to the shoulders, the right arm had 85 degrees abduction and the left arm had 120 degrees abduction. For informational purposes, without reliance thereon, to abduct is defined as "To draw away from the median line or from a neighboring part or limb." Dorland's Illustrated Medical Dictionary, 2 (24th ed. 1965). Under Code 5201, the schedular criteria are based upon the degree of abduction exhibited. However, ranges of other motions of the shoulders on that examination (flexion, internal and external rotation) were no more than moderately limited on the right and mildly limited on the left. See Plate I, 38 C.F.R. § 4.71 (1994). On more recent VA orthopedic examination in September 1991, the appellant complained of right shoulder stiffness and difficulty with strenuous use of the left arm. Significantly, the right arm had approximately 60 degrees abduction and the left arm had 100 degrees abduction. Ranges of other motions of the shoulders on that examination were no more than moderately limited on the right and mildly limited on the left. See Plate I, 38 C.F.R. § 4.71 (1994); and the examiner's impression reported on that examination. The more recent September 1991 examination indicates that the degree of abduction of each of the appellant's shoulders has decreased somewhat. With resolution of reasonable doubt, the Board finds that the recent clinical evidence reflects that he is able to abduct the right arm approximately 60 degrees, which more nearly approximates a position midway between the side of his body and shoulder level (45 degrees), not a position at shoulder level (90 degrees). 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.7, Code 5201. Therefore, an increased rating of 30 percent is warranted for the right shoulder disability. However, that degree of abduction manifested does not more nearly approximate a position 25 degrees from the side of the body as to warrant an evaluation in excess of 30 percent for that disability. With respect to the left shoulder, the recent clinical evidence reflects that the appellant is able to abduct the left arm to 100 degrees. Resolving reasonable doubt in his favor, the Board concludes that that degree of abduction manifested more nearly approximates a position at shoulder level (90 degrees). Therefore, an increased rating of 20 percent is warranted for the left shoulder disability. However, that degree of abduction manifested does not more nearly approximate a position 25 degrees from the side of the body as to warrant an evaluation in excess of 20 percent for that left shoulder disability. The Board has considered more recent VA outpatient reports, but these do not indicate that either shoulder disability has significantly worsened since that September 1991 examination. Additionally, an extraschedular evaluation is not warranted, since the evidence does not show that the service-connected bilateral shoulder disability presents such an unusual or exceptional disability picture as to render the regular schedular standards impractical. 38 C.F.R. § 3.321(b)(1). The appellant has not been frequently hospitalized for the bilateral shoulder disability, and the bilateral shoulder disability in and of itself has not been shown to markedly interfere with all forms of gainful employment. 38 C.F.R. § 3.321(b)(1). See September 1991 VA orthopedic examination, reflecting examiner's impression that shoulder impairment was no more than mild to moderate. V. A Compensable Evaluation for Pulmonary Tuberculosis Disability evaluations are determined by application of a schedule of ratings which is based on average impairment of earning capacity under the VA's Schedule for Rating Disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. The Board will consider the appellant's pulmonary tuberculosis in the context of the total history of that disability, particularly as it affects the ordinary conditions of daily life, including employment. The appellant's service medical records reflect that during his initial period of service, he was hospitalized in 1954 for pulmonary tuberculosis involving the right upper lobe, which was diagnosed as moderately advanced and active. After treatment with anti-tuberculin medications, the respiratory symptomatology became quiescent, and he was retired from service in late 1954 on account thereof. Medical records after service reveal that during VA hospitalization from January to March 1955, chest x- rays were interpreted as suspicious for [tuberculotic] cavitation in the right upper lobe, although a sputum smear was negative. Moderately advanced pulmonary tuberculosis, active for six months, with mild symptomatology, was diagnosed. He was again treated with anti-tuberculin medication. By a March 1955 rating decision, service connection was granted and a 100 percent rating was assigned, effective January 1, 1955, for active, moderately advanced pulmonary tuberculosis. A March 1956 VA examination report reflects that a chest x-ray was interpreted as showing a very small amount of haziness having an appearance of fibrosis, but without activity, in the right lung field; and the radiographic impression was minimal, inactive pulmonary tuberculosis of the right apical lung. Based upon this evidence of inactivity, the RO, in an April 1956 rating decision, determined that pulmonary tuberculosis had been completely arrested as of March 16, 1956, and applied the graduated rating provisions for inactive pulmonary tuberculosis under Diagnostic Codes 6721-6724. The appellant's service medical records during the second period of service reflect that a June 1958 re-enlistment examination revealed radiographic findings of some scarring with increased [broncho-vascular markings] in the right apical lung; but no evidence of active pulmonary tuberculosis. During hospitalization from August to October 1958, a chest x-ray was interpreted as showing minimal scarring in the right lung, without evidence of active pulmonary tuberculosis. Significantly, the remainder of his service medical records, including those in the 1960's and 1970's, and post-service clinical records do not reveal complaints, symptoms, or treatment for pulmonary tuberculosis. In particular, during VA examination in September 1975, he had no pertinent complaints or symptoms; and a tuberculin smear and chest x-ray study were negative. A VA examination in September 1991 noted no recurrence of pulmonary tuberculosis since mid-1950's treatment with anti-tuberculin medications. Clinically, his lungs were clear, and a chest x-ray was interpreted as unremarkable, except for a few small, calcified granulomas scattered in the lungs. Recent VA outpatient treatment reports dated in the 1990's do not reveal respiratory symptoms or treatment for pulmonary tuberculosis. Even the appellant's testimony at a hearing in April 1990 did not allege current respiratory symptomatology or treatment therefor. See April 1990 hearing transcript, at T.3. It should be pointed out that the graduated rating provisions for inactive pulmonary tuberculosis under 38 C.F.R. §§ 4.96(b), 4.97, Diagnostic Codes 6721-6724 are applicable, since the appellant was receiving or entitled to receive compensation for pulmonary tuberculosis as of August 19, 1968. Additionally, the graduated rating provisions as well as the provisions of Diagnostic Code 6731 (which applies to veterans initially entitled to receive compensation for pulmonary tuberculosis after August 19, 1968) will be considered, whichever is most beneficial to the appellant. In pertinent part, Diagnostic Code 6722 provides: Inactive, chronic, pulmonary tuberculosis warrants a 100 percent evaluation for 2 years after the date of inactivity, following active pulmonary tuberculosis which was clinically identified during active service or subsequently thereto. A 50 percent evaluation is assigned during the period from the third through the sixth years after the date of inactivity and a 30 percent evaluation is assigned during the period from the seventh through the eleventh years after the date of inactivity. Thereafter, a 20 percent evaluation is warranted following moderately advanced lesions provided there is continued disability, emphysema, dyspnea on exertion, impairment of health, etc. In other cases, a noncompensable evaluation is appropriate after the end of the eleventh year following the date of inactivity. In pertinent part, Diagnostic Code 6731 provides: Chronic, inactive pulmonary tuberculosis warrants a 100 percent evaluation for 1 year after the date of attainment of inactivity. Thereafter, the evaluation is based upon the residuals attributable to tuberculosis. A 100 percent evaluation based on residuals requires pronounced residuals with advanced fibrosis with a severe ventilatory deficit manifested by dyspnea at rest, a marked restriction of chest expansion, and a pronounced impairment of bodily vigor. A 60 percent evaluation is warranted for severe residuals with extensive fibrosis and severe dyspnea on slight exertion with a corresponding ventilatory deficit confirmed by pulmonary function tests and with a marked impairment of health. A 30 percent evaluation is warranted for moderate residuals with considerable pulmonary fibrosis and moderate dyspnea on slight exertion, confirmed by pulmonary function tests. A 10 percent evaluation based on residuals requires definite symptomatology with pulmonary fibrosis and moderate dyspnea on extended exertion. If those residuals consist of healed lesions with minimal or no symptoms, a noncompensable evaluation is warranted. The Board finds that the appellant's service-connected pulmonary tuberculosis was completely arrested at a moderately advanced stage, and has been inactive since the mid-1950's. The recent clinical evidence shows radiographic findings of a few small, calcified granulomas scattered in the lungs consistent with pulmonary fibrosis. For informational purposes, without reliance thereon, a medical text states: "The granulomas seen in tuberculosis are characterized by a form of tissue necrosis known as caseation,....Prior to the time of necrosis the lesion may heal completely by resolution, but once necrosis and caseation have occurred it heals by fibrosis,...." Emanuel Wolinsky, Tuberculosis in 2 Cecil, Textbook of Medicine, 1682 (James B. Wyngaarden, M.D., et al. eds., 18th ed. 1988). However, definite symptomatology from pulmonary tuberculosis, such as dyspnea on exertion, has not been recently shown. Since the residuals of his pulmonary tuberculosis consist of healed granulomatous lesions without any respiratory symptoms, a compensable evaluation for inactive, moderately advanced pulmonary tuberculosis is not warranted under either Diagnostic Code 6722 or 6731. 38 C.F.R. § 4.97, Codes 6722, 6731. The fact that respiratory symptomatology resulting from that disability has not been recently shown persuasively shows that the disability does not more nearly approximate the criteria for a compensable rating under these diagnostic codes. 38 C.F.R. § 4.7. Additionally, an extraschedular evaluation is not warranted, since the evidence does not show that the inactive pulmonary tuberculosis presents such an unusual or exceptional disability picture as to render the regular schedular standards impractical. 38 C.F.R. § 3.321(b)(1). The appellant has not been frequently hospitalized for that disability in recent years, and the absence of respiratory symptomatology clearly shows that that disability, in and of itself, does not markedly impair his employability. Since the preponderance of the evidence is against allowance of this issue on appeal, the benefit of the doubt doctrine is inapplicable. 38 U.S.C.A. § 5107(b). VI. A Total Rating Based on Individual Unemployability Total disability ratings for compensation may be assigned where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities; provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, and that if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). The RO rated the service-connected disabilities as combined 70 percent disabling. However, since the Board has granted increased ratings for the right and left shoulder disabilities, the appellant's service-connected disabilities are now rated a combined 80 percent disabling, even without rating the severity of his anxiety disorder which the Board in this decision has granted service connection for. See 38 C.F.R. § 4.25, Combined Ratings Table. The majority of the appellant's service-connected disabilities, namely post gastrectomy syndrome, right shoulder tendon transplant, left shoulder bursitis, and pulmonary tuberculosis, have been discussed in detail as to their severity, in the prior sections of this decision. In addition, he has left ear hearing loss and residuals of malaria, each rated noncompensable, which have not been shown or alleged to significantly impact upon his employability. His anxiety disorder, for which the Board has herein granted service connection, was diagnosed as mild on recent VA psychiatric examination in March 1994. Since the service-connected disabilities are at least a combined 80 percent, he is eligible under 38 C.F.R. § 4.16(a) for assignment of a total disability rating for compensation purposes based on individual unemployability. A total disability rating is based primarily on the average impairment of earning capacity, that is, upon the economic or industrial handicap which must be overcome and not from individual success in overcoming it. However, full consideration must be given to unusual physical or mental effects in individual cases, to particular effects of occupational activities, to defects in physical or mental endowment preventing the usual amount of success in overcoming the handicap of disability, and to the effect of combinations of disability. A total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 4.15. The Board concedes that the appellant may be unable to engage in some positions of a heavy manual labor nature, since he has some limitation of motion of either shoulder. The right upper extremity is the major extremity, as the clinical evidence indicates, and is more limited in function than the left shoulder. His testimony as well as other evidence indicate he considers himself totally disabled primarily on account of his post gastrectomy syndrome and upper extremities dysfunction. The negative evidence includes the fact that neither his written statements nor his testimony suggest that he has recently attempted to seek employment of a light manual nature. The issue for resolution is whether nonstrenuous, sedentary positions would be precluded by his service-connected disabilities. The negative evidence includes the fact that the appellant has some disabilities, including a cervical spine disability, for which service connection is not in effect, and which impact upon employability. See November 1982 SSA administrative law decision. Additionally, it is not entirely clear whether his post gastrectomy syndrome and bilateral shoulder disability are of such severity, either singularly or in combination, as would preclude all nonstrenuous, sedentary positions consistent with his educational background and military occupational experiences, i.e., administrative type positions. He reportedly completed 10th grade and achieved a high school equivalency certificate. See April 1990 hearing transcript. However, the positive evidence includes the impact the appellant's mild anxiety disorder may have upon employability, in combination with his post gastrectomy syndrome and bilateral shoulder disability. In fact, the November 1982 SSA administrative law decision primarily was based upon the impact these disabilities had upon employability, and the judge decided that the appellant was precluded from even sedentary employment. While this decision by another governmental agency is not binding upon the VA, it is a probative piece of evidence considered in the entire framework of this case. Of course, that administrative law decision was based upon clinical evidence dated in the 1980's, not evidence reflecting current level of disability. On the other hand, the evidentiary record does not clearly reflect material improvement in these disabilities since that decision. Unfortunately, the record is devoid of recent medical opinion as to his employability. Additionally, the record indicates that he has not been gainfully employed since service separation, approximately two decades ago. In conclusion, the evidence is in relative equipoise regarding the question of whether the appellant's service-connected disabilities, either singularly or in combination, preclude all forms of substantially gainful employment. For the foregoing reasons, and without any clear or direct medical opinion or evidence of the appellant's ability to work, a total rating based on individual unemployability is granted. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16(a). ORDER An increased (extraschedular) rating for post gastrectomy syndrome, and an increased (compensable) rating for pulmonary tuberculosis are denied. To that extent, the appeal is denied. Service connection for a psychiatric disability, classified as anxiety disorder, is granted. Increased ratings of 30 percent for right shoulder tendon transplant, and 20 percent for left shoulder bursitis, and a total rating for compensation purposes based upon individual unemployability are granted, subject to the applicable regulatory provisions governing monetary awards. To that extent, the appeal is allowed. MICHAEL D. LYON Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.