Citation Nr: 1325631 Decision Date: 08/13/13 Archive Date: 08/16/13 DOCKET NO. 11-06 415 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUES 1. Entitlement to an increased evaluation for a duodenal ulcer with gastrointestinal neurosis, currently rated as 10 percent disabling. 2. Entitlement to special monthly compensation based upon the need for aid and attendance and/or housebound status. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD P. Olson, Counsel INTRODUCTION The Veteran had active service from July 1943 until February 1946. This matter came before the Board of Veterans' Appeals (Board) on appeal from a rating decision dated in December 2009 from the Department of Veterans Affairs (VA), Regional Office (RO), in Cleveland, Ohio. The case was certified to the Board by the VA RO in Pittsburgh, Pennsylvania. The Board remanded this appeal in September 2011 and January 2013. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The Veteran's duodenal ulcer with gastrointestinal neurosis has not been manifested by moderate ulcer disease with recurring episodes of severe symptoms two or three times a year averaging 10 days in duration; or with continuous moderate manifestations. 2. The Veteran has no single service-connected disability that is currently rated as 100 percent disabling; and the evidence preponderates against finding that, as a result of his service-connected disabilities alone, he is permanently bedridden or so helpless as to be in need of the regular aid and attendance of another person. 3. The Veteran's service-connected disabilities alone do not preclude him from obtaining and maintaining substantially gainful employment. CONCLUSIONS OF LAW 1. For the entire appeal period, the criteria for an evaluation in excess of 10 percent for a duodenal ulcer with gastrointestinal neurosis have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.114 Diagnostic Code 7305 (2012). 2. The criteria for an award of special monthly compensation based on the need for the regular aid and attendance or due to being housebound have not been met. 38 U.S.C.A. §§ 1114 (West 2002), 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.350, 3.352 (2012). 3. The criteria for a total disability evaluation based on individual unemployability due to service connected disorders, including for referral of this claim for extra-schedular consideration, have not been met. 38 U.S.C.A. §§ 5103, 5103A, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16, 4.18, 4.19 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The requirements of 38 U.S.C.A. §§ 5103 and 5103A have been met. There is no issue as to providing an appropriate application form or completeness of the application. VA notified the Veteran in September 2009 of the information and evidence needed to substantiate and complete a claim, to include notice of what part of that evidence is to be provided by the claimant, what part VA will attempt to obtain, and how disability ratings and effective dates are determined. VA fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate a claim, and as warranted by law, affording VA examinations. There is no evidence that additional records have yet to be requested, or that additional examinations are in order. Pursuant to the Board's remands the Veteran's medical records were secured and he was afforded VA examinations to determine the nature and extent of his service connected gastrointestinal disorder, whether or not his service-connected disabilities render him housebound or otherwise require the regular aid and attendance by another person. Hence, there has been substantial compliance with the Board's remands. Stegall v. West, 11 Vet. App. 268 (1998). Increased Rating Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When, as here, the Veteran is requesting a higher rating for an already established service-connected disability, the present disability level is the primary concern and past medical reports do not take precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, "staged" ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). A March 1946 rating decision established entitlement to service connection for mixed neurosis - gastrointestinal "psomatization" (sic). In June 1948, the Veteran's service-connected disability was recharacterized as a duodenal ulcer with gastrointestinal neurosis. In February 2009, the Veteran submitted a claim for an increased evaluation for his duodenal ulcer. A 10 percent rating has been in effect since 1946. The Veteran's duodenal ulcer with gastrointestinal neurosis has been evaluated pursuant to 38 C.F.R. § 4.114, Diagnostic Code 7305. Diagnostic Code 7305 provides a 20 percent evaluation for moderate ulcer disease with recurring episodes of severe symptoms two or three times a year averaging 10 days in duration; or with continuous moderate manifestations. VA medical records indicate that in March 2008, the Veteran weighed 125 pounds, and that his baseline weight was 135. A complete blood count was noted to be "OK." The examiner opined that a hiatal hernia may account for the appellant's early satiety. The Veteran was assessed with resolved iron deficiency anemia, weight loss, and malnutrition. The provider noted that hiatal hernia could account for early satiety. The Veteran's weight was 127 in August 2008. An August 2008 Primary Care Note indicates that the Veteran was suffering from malnutrition and weight loss. The provider again noted that a hiatal hernia might be causing continued weight loss and early satiety. A September 2008 endocrinology note indicates that the Veteran had a significant past medical history of polymyalgia rheumatic, unintentional weight loss, and thyroid nodules. The note indicates that the Veteran was initially seen in September 2007 where he had an 18-month history of weight loss of approximately 15 pounds. He was on chronic prednisone therapy for three years secondary to polymyalgia rheumatic. In 2006, steroids were stopped due to osteoporosis, and the appellant was started on alendronate and calcium and vitamin D supplements. At the time of his initial visit, the Veteran complained that in the intervening 18 months since his steroid use was discontinued, he had fatigue and unintentional weight loss of 15 pounds. The provider noted that since that time, he had gained approximately 15 pounds and said that his weight had stabilized reasonably well. The Veteran stated that his appetite was better and that his fatigue was not as bad. The Veteran denied any nausea, vomiting, diarrhea, chills, or other systemic complaints. Physical examination of the Veteran indicated that he weighed 132.2 pounds with a body mass index of 20.14. In September 2009, the Veteran underwent VA examination for housebound status or permanent need for regular aid and attendance. He weighed 120 pounds. The Veteran reported occasional nausea every other day and daily upper abdominal quadrant pain. The pain lasted 20 minutes or more, and rated a 1 or 2 on the pain level scale. The Veteran denied vomiting, red or black bowel movements, side effects from gastrointestinal medications, gastrointestinal tract surgeries, diarrhea, constipation, hospitalization for gastrointestinal problems, incapacitating periods due to the stomach or any type of duodenal disease, and gastrointestinal trauma. The examiner noted that the Veteran was malnourished, on Ensure supplements, on protein supplements, and that he had been having some difficulty with using the supplements. The Veteran was diagnosed as having, inter alia, iron deficiency anemia. In March 2010, the Veteran underwent VA examination for housebound status or permanent need for regular aid and attendance at which time he weighed 123 pounds. In May 2010, the Veteran underwent VA examination for housebound status or permanent need for regular aid and attendance at which time the appellant weighed 116 pounds with a body mass index of 17.5. The examiner noted that the Veteran looked emaciated with no muscle mass and that he looked drawn in the face. The examiner noted that the Veteran had lost his appetite and that his wife provided meals and encouraged him to eat, all due to diagnosis of duodenal ulcer and chronic gastrointestinal symptoms and "nervous stomach." The examiner noted that the Veteran continued to deteriorate physically, but that he did eat a solid diet although he limited himself to specific foods due to his stomach condition. The examiner noted that the Veteran experienced gastroesophageal reflux disease and stomach upset daily but that he was being treated with numerous gastrointestinal medications. The examiner also noted that the Veteran had chronic anemia requiring daily iron supplementation and that the anemia caused lightheadedness and dizziness contributing to fall risk and history. The Veteran had physical limitations related to his anemia secondary to his duodenal ulcer, gastrointestinal neurosis and bilateral hearing loss with tinnitus with dizziness. The examiner noted that the Veteran's service-connected medical conditions resulted in impaired appetite, weight loss, and weakness. The Veteran underwent VA examination in November 2011 at which time the examiner stated that the duodenal ulcer and acid reflux symptoms were controlled with his current medication regime, that the appellant took continuous medication for his gastrointestinal condition, that his recurring episodes of symptoms which occurred four or more times per year were not severe, that abdominal pain occurred at least monthly, and that the pain was relieved by standard ulcer therapy. The examiner also noted that the Veteran suffered four or more episodes of mild nausea per year and three episodes of mild vomiting per year. The Veteran denied hematemesis, melena, and incapacitating episodes. A VA medical opinion was obtained in January 2013. The examiner stated that the duodenal ulcer and acid reflux symptoms were controlled with his current medication regime. The examiner indicated that the Veteran had recurring episodes of symptoms that were not severe with a frequency of four or more times per year. The examiner noted that pain occurred at least monthly but it was relieved by standard ulcer therapy. The Veteran was noted to report mild nausea and vomiting three times a year. The January 2013 VA examiner found no melena, hematemesis, weight loss, anemia, and no indication of either severe episodes or incapacitating episodes. The appellant's less severe episodes were judged to last a day or less. The Veteran was in frail health with numerous medical issues affecting his health. Significantly, the examiner opined that the service connected duodenal ulcer was not one of them according to the most recent examination. The appellant's weight loss was found to be minimal over the prior six months with the evidence showing only a one pound weight loss. A June 2007 esophagastroduodenoscopy showed a normal esophagus, but a large paraesophageal hernia. (The appellant is not service connected for a paraesophageal hernia.) The examiner opined that the Veteran had numerous nonservice connected medical issues which could contribute to anemia including chronic obstructive pulmonary disease, hypertension, osteoarthritis, polymyalgia rheumatica, coronary artery disease status post myocardial infarction, and diverticulitis. The examiner concluded that the Veteran's bleeding was not a result of any ulceration to contribute to anemia. Given the above information, anemia and weight loss were attributed to a nonservice connected disorder. The large paraesophageal hernia was opined to be due to a hiatal hernia, and the examiner found that a hiatal hernia was not secondary to a duodenal ulcer. The record in this case indicates that the Veteran experienced symptoms of anemia and weight loss during the pendency of this appeal. The question, however, is whether these symptoms are due to the service connected duodenal ulcer with gastrointestinal neurosis, or due to a nonservice-connected disorder. Here, the preponderance of the evidence clearly shows that these symptoms are due to nonservice connected factors. In this regard, both a March and an August 2008 VA records attribute the appellant's early satiety to a nonservice connected hiatal hernia. The August 2008 examiner further found that the hiatal hernia may be causing continued weight loss. The January 2013 examiner was even more definitive in finding that the Veteran had numerous nonservice connected medical issues which could contribute to anemia including chronic obstructive pulmonary disease, hypertension, osteoarthritis, polymyalgia rheumatica, coronary artery disease status post myocardial infarction, and diverticulitis. The January 2013 examiner specifically concluded that the Veteran's bleeding was not a result of any ulceration to contribute to anemia, and that anemia and weight loss were best attributed to a nonservice connected disorder. Moreover, the examiner opined that the large paraesophageal hernia was due to a hiatal hernia, and that the hiatal hernia was not secondary to a duodenal ulcer. The preponderance of the most probative evidence is against finding that weight loss and anemia are due to the service connected duodenal ulcer, and there is no competent evidence showing that the hernias are caused or aggravated by the duodenal ulcer with gastrointestinal neurosis. Accordingly, the Board finds that the competent medical evidence of record preponderates against entitlement to an increased rating. Hence, the benefit sought on appeal is denied. With respect to the appellant's entitlement to an extraschedular rating the law provides that such a rating may be assigned when the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability at issue are inadequate. Thun v. Peake, 22 Vet. App. 111 (2008); see Fisher v. Principi, 4 Vet. App. 57, 60 (1993); 38 C.F.R. § 3.321(b)(1). If so, factors for consideration in determining whether referral for an extraschedular rating is warranted include marked interference with employment or frequent periods of hospitalization that indicate that application of the regular schedular standards would be impracticable. Thun, citing 38 C.F.R. § 3.321(b)(1) (2008). In the present case, there is no evidence that the Veteran's duodenal ulcer with gastrointestinal neurosis presented such an unusual or exceptional disability picture at any time so as to require consideration of an extra-schedular evaluation pursuant to the provisions of 38 C.F.R. § 3.321(b)(1). The criteria pertaining to duodenal ulcers in the Rating Schedule focus on recurring gastrointestinal symptoms and whether they are relieved by medication, incapacitating episodes, as well as the absence or presence of anemia, weight loss, hematemesis or melena. As discussed above, such symptomatology describes some of the Veteran's current disability picture; however, as noted those symptoms are due to nonservice connected disorders. Thus, the schedular criteria adequately compensate for any loss in earning capacity, and referral for extraschedular consideration is not warranted. Id. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the appellant's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet.App. 49 (1990). Special Monthly Compensation Special monthly compensation is payable to individuals who are permanently bedridden or are so helpless as a result of service-connected disability as to be in need of the regular aid and attendance of another person under the criteria set forth in 38 C.F.R. § 3.352(a). 38 U.S.C.A. § 1114(l); 38 C.F.R. § 3.350(b)(3). The regulations also provide additional compensation on the basis of being housebound where a veteran has, in addition to a single, permanent service-connected disability rated 100 percent disabling, (1) additional service-connected disability or disabilities independently evaluated as 60 percent or more disabling which are separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems; or, (2) is permanently housebound by reason of service-connected disability or disabilities. A veteran will be considered housebound where the evidence shows that, as a direct result of his service-connected disability or disabilities, he is substantially confined to his dwelling and the immediate premises or, if institutionalized, to the ward or clinical areas, and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his lifetime. 38 U.S.C.A. § 1114(s); 38 C.F.R. § 3.350(i). A finding that the veteran is "bedridden" will provide a proper basis for the determination. Bedridden will be that condition which, through its essential character, actually requires that the veteran remain in bed. The fact that a veteran has voluntarily taken to bed or that a physician has prescribed rest in bed for the greater or lesser part of the day to promote convalescence or cure will not suffice. It is not required that all of the disabling conditions enumerated in this paragraph be found to exist before a favorable rating may be made. Id. The following factors will be accorded consideration in determining the need for regular aid and attendance: inability of a claimant to dress or undress himself, or to keep himself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid (this will not include the adjustments of appliances which normal persons would be unable to adjust without aid, such as supports, belts, lacing at the back, etc.); inability of a claimant to feed himself through loss of coordination of upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, either physical or mental, which requires care or assistance on a regular basis to protect the claimant from hazards or dangers incident to his daily environment. 38 C.F.R. § 3.352(a). The particular personal functions that a veteran is unable to perform should be considered in connection with his condition as a whole. It is only necessary that the evidence establish that a veteran is so helpless as to need regular aid and attendance, not that there be a constant need. Determinations that a veteran is so helpless as to be in need of regular aid and attendance will not be based solely upon an opinion that the claimant's condition is such as would require him to be in bed. They must be based on the actual requirement of personal assistance from others. Id. In this case, service connection has been established for posttraumatic stress disorder, evaluated as 50 percent disabling; a duodenal ulcer with gastrointestinal neurosis, evaluated as 10 percent disabling; a bilateral hearing loss, evaluated as 10 percent disabling; and for left ear tinnitus, evaluated as 10 percent disabling. The VA examination reports and treatment records reflects that the Veteran is not, as a result of his service-connected disabilities alone, permanently bedridden or so helpless as to be in need of the regular aid and attendance of another person. Turning first to whether the appellant is permanently bedridden, the September 2009 aid and attendance examiner noted that the Veteran was not permanently bedridden. The March 2010 aid and attendance examiner noted that the Veteran was able to feed himself, that he did not need assistance in bathing, and that he did not require nursing home care. The Veteran was able to leave his home for doctors' appointments and family functions with some assistance. Finally, it must be noted that this examiner considered the impact of the appellant's nonservice connected coronary artery disease, osteoporosis, severe chronic obstructive pulmonary disease, and thyroid disorder in addition to the service connected disorders. Hence, while this opinion does not favor the appellant's claim, even if it did, the consideration of nonservice connected factors diminishes its probative value. The May 2010 aid and attendance examiner noted that the Veteran retired to his bed for the majority of the day attempting to sleep eight hours throughout the night and additionally rest for a two-hour nap throughout the day. As was the situation above, this examiner considered the impact of nonservice connected disorders to include coronary artery disease, arteriosclerotic heart disease, angina, chronic obstructive pulmonary disease. Again, the examiner's consideration of nonservice connected factors diminishes its probative value. The October 2011 aid and attendance examiner noted that the Veteran was not permanently bedridden and that he was not confined to his dwelling. The examiner opined that the appellant's service-connected disabilities alone did not render him bedridden, that he left the house three times a week, and that he reported driving a motor vehicle safely. The November 2011 aid and attendance examiner noted that although the Veteran could not leave unaccompanied, he was not permanently bedridden and that he was not confined to his dwelling and was able to leave his home at least one to two times a week. The examiner noted that the Veteran reported that he drove occasionally with his wife's supervision. While this examiner concluded that the Veteran needed daily personal health care services, in offering that opinion, the examiner did not limit his consideration to strictly service connected disorders, but considered non service connected disorders to include chronic obstructive pulmonary disease, hypertension, coronary atherosclerosis, polymyalgia rheumatic, thoracic compression fractures, osteoporosis of the pelvis and hips, and hip degenerative joint disease. To the extent that this examination arguably supports the claim, the examiner's consideration of nonservice connected factors diminishes its probative value. In January 2013, the October 2011 examiner provided an addendum opinion which reiterated that the Veteran was not "permanently bedridden" as the appellant regularly left his home and that he reported occasionally driving a motor vehicle in a safe manner. That same month, the November 2011 examiner provided an addendum opinion which reiterated that the Veteran's duodenal ulcer alone with gastroneurosis did not render him "permanently bedridden". A January 2013 VA examiner did opine that due to the appellant's overall health, the Veteran did require the daily personal services of a skilled provider without which he would require nursing home care. In so doing, however, the examiner considered the impact of the appellant's nonservice connected chronic obstructive pulmonary disease, coronary atherosclerosis, hypertension, prostatic hypertrophy, polymyalgia rheumatic, thoracic compression fractures, extensive osteoporosis of the pelvis and hips, and hip degenerative joint disease. As was the case above, the consideration of the impact of nonservice connected disorders diminishes any probative value this opinion may warrant. An addendum opinion was obtained regarding the Veteran's hearing loss and tinnitus. The VA audiologist opined that the conditions of hearing loss and tinnitus were less likely than not to render him bedridden. As such, the preponderance of the evidence indicates that the Veteran is not bedridden. As to whether the appellant is so helpless as to be in need of the regular aid and attendance of another person, as noted above, the March 2010, May 2010, November 2011, and January 2013 examiners while, in part, concluding that the Veteran did require the daily personal services of a skilled provider, did so only after considering numerous nonservice connected disorders. Hence, the probative value of these favorable opinions is greatly diminished by the examiners consideration of the impact of nonservice connected disorders. The September 2009 examiner found that the Veteran did not require the daily personal healthcare services of a skilled provider without which he would require hospital, nursing home, or other institutional care. The examiner noted that the Veteran stated that he drove to that day's examination. The October 2011 VA examiner noted the Veteran's posttraumatic stress disorder was of only moderate severity, and that despite the disorder he continued to function safely and independently with the exception of needing assistance with reminders for taking his medication, help stepping over the side of the bathtub to take a shower, shopping, meal preparation, an household tasks. The Veteran reported that he was able to feed himself, undress, bathe, dress, and care for other personal needs. The January 2013 audiologist noted that hearing loss and tinnitus were less likely than not to prevent the Veteran from protecting himself from the hazards incident to his environment, keeping himself clean and presentable, feeding himself due to loss of coordination of the upper extremities or extreme weakness, attending to the wants of nature, or otherwise requiring the regular aid and attendance by another person. Given that the only favorable opinions included consideration of nonservice connected disorders, and given that the October 2011 VA examiner opined that the Veteran's service-connected disabilities alone did not prevent him from protecting himself from the hazards incident to his environment, keeping himself clean and presentable, feeding himself due to loss of coordination of the upper extremities or extreme weakness, attending to the wants of nature, or otherwise requiring the regular aid and attendance by another person, the Board concludes that the preponderance of the evidence is against the appellant's claim. The Board has considered the assertions of the Veteran and his spouse that he needs the aid and attendance of another person. The pertinent evidence, that is, the evidence which considers only the impact of the appellant's service connected disorders preponderates against these assertions. Moreover, given that the evidence relied upon by the Board is offered by medical personnel, and given the appellant's lack of medical training, the Board assigns greater weight to the medical opinions. Regarding the criteria necessary for housebound status, the Veteran does not have a single, permanent service-connected disability rated or ratable at 100 percent disabling and additional service-connected disability or disabilities independently valued as 60 percent or more disabling. Therefore, he does not meet the legal criteria for payment of compensation at the housebound rate under that criterion. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Accordingly, the preponderance of the evidence reveals that the Veteran is not, as a result of his service-connected disabilities alone, bedridden or so helpless as to be in need of the regular aid and attendance of another person. As the preponderance of the evidence is against the claim of entitlement to special monthly compensation based on the need for regular aid and attendance or for being housebound, the benefit-of- the-doubt rule does not apply, and the Board has no other recourse but to deny the claim. 38 U.S.C.A. § 5107(b). Total disability evaluation based on individual unemployability due to service connected disorders The Veteran alleges that his service-connected disabilities render him unemployable and that he is, therefore, entitled to a total disability evaluation based on individual unemployability due to service connected disorders. Total disability ratings for compensation may be assigned, where the schedular rating is less than 100 percent, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of one or more service-connected disabilities without regard to advancing age or disabilities that have not been service connected. See 38 C.F.R. §§ 3.341(a), 4.16(a). Total disability will be considered to exist when there is present any impairment of mind or body that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 4.15; see also 38 C.F.R. § 3.340(a) (providing that to establish entitlement to a TDIU, there must be impairment so severe that it is impossible for the average person to follow a substantially gainful occupation). In determining entitlement to a total disability evaluation based on individual unemployability due to service connected disorders, the central inquiry is whether the Veteran's service-connected disabilities alone are of sufficient severity to cause unemployability, without regard to advancing age or disabilities for which service connection has not been established. See 38 C.F.R. §§ 3.341(a), 4.16(a). In a pertinent precedent decision, VA's General Counsel concluded that the controlling VA regulations generally provide that veterans who, in light of their individual circumstances, but without regard to age, are unable to secure and follow a substantially gainful occupation as the result of service-connected disability shall be rated totally disabled, without regard to whether an average person would be rendered unemployable by the circumstances. VAOPGCPREC 75-91. Thus, the criteria include a subjective (not just objective) standard. See Id. In order to satisfy the criteria for schedular consideration of entitlement to a total disability evaluation based on individual unemployability due to service connected disorders, if unemployability is the result of only one service-connected disability, this disability must be ratable at 60 percent or more. See 38 C.F.R. § 4.16(a). If it is the result of two or more service-connected disabilities, at least one must be ratable at 40 percent or more, with the others sufficient to bring the combined rating to 70 percent or more. Id. As noted, service connection is in effect for PTSD evaluated as 50 percent disabling, duodenal ulcer with gastrointestinal neurosis evaluated as 10 percent disabling, bilateral hearing loss evaluated as 10 percent disabling, and tinnitus evaluated as 10 percent disabling. Accordingly, because the Veteran does not have a single service-connected disability rated at 60 percent or more, or a combined disability rating of 70 percent or more, he does not meet the percentage requirements for a total disability evaluation based on individual unemployability due to service connected disorders under 38 C.F.R. § 4.16(a) . Nevertheless, a total disability evaluation based on individual unemployability due to service connected disorders still may be awarded on an extra-schedular basis under the alternative provisions of 38 C.F.R. § 4.16(b) if it is shown he is indeed unable to secure and follow a substantially gainful occupation because of his service-connected disabilities. The November 2008 VA examiner noted that the Veteran's PTSD symptoms would impact the productivity and efficiency of any employment but would not render him totally unemployable. The September 2009 VA examiner noted that the Veteran's psychiatric symptoms were moderate and did not render him totally unemployable. The October 2011 VA examiner noted that based on symptoms of PTSD alone, the Veteran was fully employable as he would be able to tolerate the schedule requirement, stress, and interpersonal interactions required to maintain gainful employment without experiencing an exacerbation of psychiatric symptoms and need for hospitalization. The examiner concluded that the Veteran's PTSD alone did not preclude gainful employment consistent with his education and occupational experience. The November 2011 VA examiner noted that the Veteran's stomach or duodenum conditions did not impact his ability to work. The January 2013 VA addendum opinions noted that the duodenal ulcer on its own would not preclude the Veteran from being employable and that he would not be hindered from physical or sedentary employment. In addition, with respect to the Veteran's hearing loss and tinnitus, the January 2013 examiner noted that the Veteran should be able to communicate with others and participate in various settings. In light of the foregoing evidence the Board finds that a total disability evaluation based on individual unemployability due to service connected disorders is not warranted, even on the alternative extra-schedular basis mentioned provided by 38 C.F.R. § 4.16(b). Thus, the Board finds that the Veteran is not entitled to a total disability evaluation based on individual unemployability due to service connected disorders either on a schedular or extra-schedular basis. 38 C.F.R. § 4.3. ORDER Entitlement to an increased evaluation for a duodenal ulcer with gastrointestinal neurosis is denied. Entitlement to special monthly compensation based upon the need for aid and attendance and/or housebound status is denied. Entitlement to a total disability evaluation based on individual unemployability due to service connected disorders is denied. ` ______________________________________________ DEREK R. BROWN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs