Citation Nr: 1337119 Decision Date: 11/14/13 Archive Date: 11/26/13 DOCKET NO. 10-25 606 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manchester, New Hampshire THE ISSUES 1. Entitlement to an increased rating for posttraumatic stress disorder (PTSD), currently evaluated as 50 percent disabling. 2. Entitlement to an initial rating in excess of 10 percent for ischemic heart disease. 3. Entitlement to special monthly compensation (SMC) based on housebound status. 4. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Christopher Loiacono, Agent INTRODUCTION The Veteran had active military service from January 1968 to November 1970 and from November 1973 to August 1976. These matters come before the Board of Veterans' Appeals (Board) from August 2008 and December 2010 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO) in Manchester, New Hampshire. In September 2009, the Veteran testified before a Decision Review Officer in Manchester, New Hampshire. A transcript of that hearing is of record. In July 2011, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. These matters were previously before the Board in March 2012 and were remanded for further development. They have now returned to the Board for further appellate consideration. The Board finds that there has been substantial compliance with the mandates of the remand and will proceed to adjudicate the appeal. See Dyment v. West, 13 Vet. App. 141 (1999) (noting that a remand is not required under Stegall v. West, 11 Vet. App. 268 (1998) where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). FINDINGS OF FACT 1. Prior to January 25, 2011, the Veteran's PTSD was manifested by complaints of road rage, occasional suicidal and/or homicidal ideation without plans, preoccupation with where his life was going, and difficulty with concentration; however, he had friends, enjoyed being on his boat, maintained hygiene, did not have obsessional rituals which interfered with routine activities, had no acts of violence, and could live independently, and he was assigned a GAF score of 50, demonstrating no more than occupational and social impairment with reduced reliability and productivity. 2. From January 25, 2011, the Veteran's PTSD has been manifested by complaints of road rage, and difficulty concentration, and with evidence of threatening behavior towards others, with continued evidence that he has friends, enjoys being on his boat, and can live independently, and he has been assigned a GAF score of 40, demonstrating no more than occupational and social impairment with deficiencies in most areas, and not total occupational and social impairment. 3. The evidence of record does not reflect that prior to November 12, 2009, the Veteran's heart disability was manifested by coronary artery disease with a workload of 7 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or X-ray, or more severe findings. 4. The evidence of record reflects that from March 1, 2010 to November 2, 2010, the Veteran's heart disability was manifested by an ejection fraction of only 40-45 percent, but the coronary artery disease did not result in chronic congestive heart failure; or workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent. 5. From November 2, 2010, the Veteran's heart disability was manifested by an ejection fraction of 55 percent or greater, a METs level greater than 7, and a normal EKG. 6. The Veteran is not in receipt of a 100 percent rating and a additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems for any time period on appeal, other than November 12, 2009 to March 1, 2010, for which he is already in receipt of SMC. 7. There has been no demonstration by competent medical evidence, or competent and credible lay evidence, that the Veteran is housebound due to his service-connected disabilities. 8. The competent clinical evidence of record is against a finding that the Veteran's service-connected disabilities precluded him from maintaining substantially gainful employment prior to July 27, 2011. 9. Resolving doubt in favor of the Veteran, his service-connected disabilities preclude him from maintaining substantially gainful employment from July 27, 2011. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating in excess of 50 percent for PTSD prior to January 25, 2011 have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.126, 4.130, Diagnostic Code 9411 (2013). 2. The criteria for entitlement to a rating of 70 percent, and no higher, for PTSD from January 25, 2011, have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.126, 4.130, Diagnostic Code 9411 (2013). . 3. The criteria for a rating of 60 percent, and no higher, for ischemic heart disease, from March 1, 2010 to November 2, 2010 have been met. 38 U.S.C.A. §§ 1115, 5107 (West 2002); 38 C.F.R. § 4.104, Diagnostic Code 7005 (2013). 4. The criteria for a rating in excess of 10 percent prior to March 1, 2010, and from November 2, 2010 for ischemic heart disease have not been met. 38 U.S.C.A. §§ 1115, 5107 (West 2002); 38 C.F.R. § 4.104, Diagnostic Code 7005 (2013). 5. The requirements for special monthly compensation based on the need for aid and attendance or housebound status have not been met. 38 U.S.C.A. §§ 1114, 1134, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.350, 3.352 (2013). 6. The criteria for the award of TDIU benefits prior to July 27, 2011 have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2013). 7. The criteria for the award of TDIU benefits from July 27, 2011 have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Notice was provided to the Veteran in December 2007, June 2009, March 2010, and December 2012. VA has a duty to assist the Veteran in the development of the claims. The claim file includes service treatment records (STRs), post service medical records, Social Security Administration (SSA) records, and the statements of the Veteran in support of his claims. The Board has considered the statements and perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims for which VA has a duty to obtain. In its March 2012 remand, the Board directed that VA attempt to obtain Vet Center records. In December 2012 correspondence, VA requested the Veteran to provide records or authorization for VA to obtain them. An April 2013 report of contact (VA Form 27-080) reflects that the Veteran stated that he has not been to the Vet Center "in a long time" and did not intend to return a 21-4142 authorizing VA to obtain records from the Vet Center or provide records with regard to his claim for SMC. The duty to assist is not a one-way street. If a Veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Based on the Veteran's actions, and lack of providing authorization, the Board finds that VA does not have a further duty to assist the Veteran in obtaining records. Numerous VA examinations have been provided and the opinions and records are associated with the claims file. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the examination/opinions are adequate as they are predicated on consideration of the Veteran's symptoms, and diagnostic testing, to include electrocardiograms. Adequate rationale has been provided. In addition, the reports of the examination contain findings necessary to evaluate the Veteran's service-connected disabilities under the applicable diagnostic code rating criteria. Nieves-Rodriguez v. Peake, 22 Vet App 295 (2008). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issues on appeal has been met. 38 C.F.R. § 3.159(c) (4). The Veteran's agent has repeatedly stated that January 27, 2010 VA EKG results are not associated with the claims file. The Board finds that the record is associated with the claims file, and appears, by its physically location in the claims file and by reference to the results in the December 2010 rating decision, to have been in the claims file when the file was reviewed by the agent. The Board find that the agent was provided with the opportunity to review the EKG report when he reviewed the entire claims file. Thus, VA does not have a further duty to assist. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to the claims. Essentially, all available evidence that could substantiate the claims has been obtained. Rating Disabilities - in general Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2013). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. Id. § 4.3. In determining whether a claimed benefit is warranted, VA must determine whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107(a); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Moreover, an appeal from the initial assignment of a disability rating, such as the appeal in this case, requires consideration of the entire time period involved, and contemplates staged ratings where warranted. Specific schedular criteria for rating mental disorders PTSD is rated by applying the criteria in 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411 (2013). The VA Schedule rating formula for mental disorders reads in pertinent part as follows: 100 percent rating (the maximum schedular rating) - Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. 70 percent - Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. 50 percent -- Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 30 percent-- Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). 10 percent -- Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Global Assessment of Functioning (GAF) GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 32 (4th ed. 1994)). According to the pertinent sections of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (1994) (DSM-IV), a GAF score of 71 to 80 indicates that if symptoms are present, they are transient and expectable reactions so psychosocial stressors and there is no more than slight impairment in social, occupational, or school functioning. A GAF score of 61 to 70 indicates some mild symptoms or some difficulty social occupational or school functioning but that an examinee is generally functioning pretty well, has some meaningful interpersonal relationships. A GAF score of 51 to 60 indicates the examinee has moderate symptoms or moderate difficulty in social, occupational, or school functioning. A GAF score of 41 to 50 indicates the examinee has serious symptoms or a serious impairment in social, occupational, or school functioning. A GAF score of 31 to 40 indicates that the examinee has some impairment in reality testing or communication such as speech is illogical, obscure, or irrelevant, or that the examinee has major impairment in several areas. See Quick Reference to the Diagnostic Criteria from DSM-IV, 46-47 (1994). Diagnostic Code (DC) 7005 Under DC 7005, a 10 percent rating is warranted when there is a workload greater than 7 METs but not greater than 10 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or when continuous medication required. A 30 percent rating is warranted for coronary artery disease with a workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or X-ray. The next higher rating of 60 percent requires more than one episode of acute congestive heart failure in the past year, or workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Finally, a 100 percent rating is warranted for coronary artery disease resulting in chronic congestive heart failure; or workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104, DC 7005. SMC based on housebound status Under 38 U.S.C.A. § 1114(s), special monthly compensation is payable if the veteran has a single service-connected disability rated as 100 percent and, (1) has additional service-connected disability or disabilities independently ratable at 60 percent, 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. The term "permanently housebound" will be considered to have been met when the Veteran is substantially confined to such Veteran's house (ward or clinical areas, if institutionalized) or immediate premises due to a service connection disability which it is reasonably certain will remain throughout such Veteran's lifetime. TDIU Total disability ratings for compensation may be assigned where the schedular rating is less than total, 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 a 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 service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Substantially gainful employment is defined as work which is more than marginal and which permits the individual to earn a living wage. Moore v. Derwinski, 1 Vet. App. 356 (1991). To establish a total disability rating based on individual unemployability, there must be impairment so severe that it is impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. In reaching such a determination, 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). In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training and previous work experience, but not to his age or any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19 (2011); Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). 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; provided that permanent total disability shall be taken to exist when the impairment is reasonably certain to continue throughout the life of the disabled person. 38 C.F.R. § 4.15. It is the established policy of VA that all Veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16(b). Rating boards should refer to the Director of the Compensation and Pension Service for extra-schedular consideration all cases of Veterans who are unemployable by reason of service-connected disabilities but who fail to meet the percentage requirements set forth in 38 C.F.R. § 4.16(a). The Veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed. 38 C.F.R. § 4.16(b). Analysis The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the medical evidence for the rating period on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Increased rating for PTSD, currently evaluated as 50 percent disabling In order to be assigned a particular rating, a Veteran need not demonstrate the presence of all, most, or even some, of the symptoms listed as examples in the rating criteria. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The key element for a rating under the General Formula for Mental Disorders is the degree of social and occupational impairment caused by those symptoms. The Veteran's claim for an increased rating for PTSD was received by VA in December 2007. A 70 percent or higher rating is warranted where the Veteran has occupational and social impairment, with deficiencies in most areas. As noted above, examples of such deficiencies would include suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. A July 14, 2008 VA examination report reflects that the Veteran was not on any psychiatric medication nor in counseling. The Veteran reported that he had last been to the Vet Center four or five years earlier. He reported that he was not working, and spends "most of his day watching television, visiting friends, and drinking with those friends." It was noted that he lived alone because his 19-year-old son joined the Air Force. The Veteran did his own cooking, cleaning, and grocery shopping. He had his driver's license but reportedly experienced some road rage. It was noted that the Veteran had not had any legal problems since his last examination. The Veteran reported that he last worked in 2007 and "was getting along with everybody at work except for one coworker." The Veteran reported that he has one or two close friends, does not visit family at all, and has a poor relationship with three of his four children. He reported no assaultive behavior since 1995 and no suicide attempt since 1995. The examiner found that the Veteran's behavior indicated a lot of overt gestures. His speech was rapid and sometimes pressured. His mood was at times expansive, but there were hints of anxiety and depression. His affect was broad and expansive. There was no evidence of depersonalization or derealization. The Veteran denied hallucinations and delusions. The Veteran's thought process was circumstantial and sometimes tangential, but he was easily redirected. There were no preoccupations or obsessions. The Veteran had suicidal ideation of a passive nature, and no homicidal ideation. He was oriented times three, and had mild problems with attention and concentration, resulting in mild short term memory problems. His ability for abstract and insightful thinking was within normal range. The Veteran's commonsense reasoning and judgment, as well as moral and ethical thinking, was noted to be dependent upon his stress level. The July 14, 2008 VA examiner assigned a GAF score of 50. The examiner noted that this was because the Veteran is "having difficulty keeping a job. He has some passive suicidal ideation. Also, he really does not know what to do with his life." The examiner also stated as follows: In summary, the patient's psychiatric symptoms are of a serious nature. The frequency is ongoing. There have been no periods of remission. He is currently not in any treatment at all. He has been unemployed now for at least since February 2008. His psychiatric symptoms do not render him unemployable. His psychiatric symptoms seriously to moderately interfere with social functioning. He does have problems with alcohol dependence. His marijuana dependence is in remission right now. There is no impairment in thought process or communication. He is able to maintain his personal hygiene and his daily responsibilities. All of the mental disorders are listed above and they are all secondary to PTSD, except for the cyclothymic disorder. The patient is competent to manage his VA benefits, according to VA guidelines. . . . The patient is able to get along with people, for the most part. He does have a hot temper and has a tendency to be "mouthy." However, his psychiatric symptoms do not render him unemployable. There is occasional decrease in work efficiency and there are intermittent periods of inability to perform occupation tasks due to symptoms of PTSD, but he is generally satisfactorily functioning in routine behavior, self-care and normal conversations. His PTSD symptoms certainly would be best treated with psychotherapy and medication. A July 22, 2008 VA mental health medication management note reflects that the Veteran requested medication to "keep him happy" and wanted something that would make him "less wound up and hyper". The Veteran reported that he was doing well until he was laid off from work in the fall (November 2007). The Veteran reported that he lost his job due to lack of work. The Veteran reported symptoms of anxiety, depression, moods which were up and down, very bored, wound up "tighter than a clock", positive for panic attacks, constantly feels like under pressure, where is my life going, hot temper, road rage, sleeping okay, stable appetite, okay concentration and attention, memory fair, no suicidal or homicidal ideation, and no auditory or visual hallucinations. The July 2008 clinician noted that the Veteran was casually dressed, oriented to all spheres, and talkative with normal speech. His insight and judgment were within normal limits. A GAF score of 60/65 was assigned. An April 2009 mental health evaluation from Dr. J.S. (psychologist) is of record. It reflects that the Veteran is a "chatterbox", very hard to interrupt, has poor boundaries, makes inappropriate comments at times, and is grandiose. His speech was pressured, constant, and loud. His mood was elevated, and his affect was congruent with his mood. He denied hallucinations, but thinks people are out to get him, and is very preoccupied with his financial situation and where his life was going. He had homicidal ideation on occasion and gets very confrontational when he feels threatened or slighted. He had occasional suicidal ideation. The Veteran was oriented times three, his memory was 3.1, and his attention and concentration were good. The Veteran reported that on a normal day, he would be at friend's house talking, or watching television. If it was a nice day, he would go outside. He reported that his personal hygiene and appetite varies. He reported that he can go days without taking a shower because he does not do anything to get dirty. He reported that he keeps his house neat, and drives himself, but struggles to control road rage. He reported that he hates going shopping and does not crowds. Dr. J.S. made the following findings: 1. The Veteran's ability with ADL's is limited, but not precluded. 2. The Veteran's social functioning was limited but not precluded. He spends his time with two friends and he gets along well with them. 3. The Veteran's understanding and remembering instructions was limited but not precluded. 4. The Veteran's racing thoughts make it hard for him to concentrate and limited his ability to concentrate and complete tasks, but did not preclude it. 5. The Veteran's judgment and insight were poor in that he has a poor sense of boundaries and was thus limited, but not precluded. 6. The Veteran is not capable of managing funds on his own behalf, but this does not imply competency. Dr. J.S. recommended that the Veteran obtain medication and counseling. September 2009 correspondence from R.C., Operations Manager of S. Mechanical reflects that the Veteran had been project coordinator. R.C. stated, in pertinent part, as follows: We hear [sic] at [S.] mechanical had quite a difficult time working with [the Veteran]. His job title was project coordinator. His role was to help in the planning and scheduling of material deliveries. On several accounts he had purchased material numerous times for the same project. Such as purchasing and having two boilers delivered when only one was required. He was also required to attend weekly project meetings to review manpower and project deadlines. We have found that he had a very hard time grasping the time lines and following along with the meeting. He would seem to just drift off into his own space. Quite frequently speaking very loudly about irrelevant topics as you can image this was quite destructive to our day-to-day operations. Which had therefore led to the fact that we could no longer work with him? The Veteran testified at a September 2009 DRO hearing. He reported that his symptoms included general irritability, restlessness, sleeplessness, and a "blank attitude". He reported that he does not want to be around people and does not want to work. He described his attitude as "laissez-faire ". He reported that he does a "little bit" of fishing and boating but that it is predominantly by himself. He reported that he has a friend with whom he hangs out. He described a difficult relationship with family members and problems with road rage. He also testified that the company for whom he worked liked his personality but not his work habits. (See DRO transcript page 4.) An October 2009 VA examination report is of record. It reflects that the Veteran reported that he was laid off from his most recent job for poor performance, to include memory problems and irritability. The record reflects that the Veteran remained married to his second wife of 25 years but they have an open marriage in that she has her own apartment, although she frequently visits the Veteran. The Veteran reported that he did not have a current girlfriend and did not "like having to go outside the house for girlfriends." The Veteran reported maintaining a relationship with two of his sons, having two close friends, and that he spends much of his time drinking and socializing with one friend. The Veteran reported no assaultiveness and road rage since his last examination in 2008. The Veteran was casually dressed, had mildly pressured speech which was replete with curses, was friendly and relaxed, had expansive mood, was oriented times three, had unremarkable thought process and content, no delusions, and understands the outcome of his behavior. He had no hallucinations, no inappropriate behavior, no obsessive ritualistic behavior, and no panic attacks. The Veteran reported frequent irritability, coupled with passive thoughts of harming the irritant, but indicated that he works hard to control his anger and has not been physically violent in several years. He reported occasional passive suicide ideation without plan or intent. He reported impulsivity and poor judgment when he is manic. He also reported that if he were given money, he would "go to the track, get some hookers and weed and blow through it all with no idea how I had spent it." He had mild impairment of recent and immediate memory, intrusive thoughts two to five times a week, and nightmares two to three times a month. The October 2009 examiner assigned the Veteran a GAF score of 50. The examiner stated that the Veteran's functioning had not changed significantly since his last evaluation, when he was determined not to be unemployable due to his PTSD. The examiner noted that the Veteran's current "mindset is that he no longer wants to work and since he currently receives Social Security disability, work is not viewed as a necessarily to him." The examiner also stated that the "veteran's complaints regarding work seem better accounted for by his Bipolar Disorder than his PTSD. His impulsivity, poor judgment, loud talking, pressured speech, sexual inappropriateness towards female coworkers are best accounted for by Bipolar disorder. Irritability, distractibility, and poor memory are symptoms of both disorders making it impossible to state which diagnoses accounts for them" The examiner found that the Veteran did not have total occupation and social impairment due to PTSD signs and symptoms. The October 2009 VA examiner also stated in pertinent part, as follows: Although veteran's irritability and difficulty getting along with others impacts his work, they do not render him incapable of gainful employment. Veteran currently performs all his ADLs and maintains his household by himself, although he noted his son, who recently moved in, occasionally performs chores when vet asks. . . .veteran's PTSD and Bipolar Disorder preclude neither sedentary nor physical labor. . . [The Veteran] stated he is not currently, nor does he have any intention of looking for work. He made this decision when he was diagnosed with severe heart conditions requiring surgery this past spring. . . . His Bipolar and PTSD more likely than not reduce the quality of his work, but do not preclude work. It is more likely than not that his bipolar disorder, which is not service-connected, impairs his ability to function well more so than his SC PTSD. However, there is considerable symptoms overlap between the two, making a clear distinction impossible. March 2010 correspondence from A.P, readjustment counseling therapist, reflects that the Veteran attended his last Vet Center session in October 2009. A.P. stated that his last contact with the Veteran was a home visit in December 2009, at which he was doing well, and had quit smoking and drinking after his heart surgery. A.P. stated that given the duration of the Veteran's symptoms and his unwillingness/inability to maintaining a counseling relationship, his prognosis for improvement is poor. His PTSD was noted to have had a significant negative impact on his occupational and social spheres of life. A January 2011 report of general information by a VA employee (field examiner) reflects that during a discussion with the Veteran, the Veteran was loud, adversarial, difficult to keep on track, and used profanity. However, he was also friendly to the field examiner. A February 2011 VA Form 21-4138 completed by a field examiner states that the Veteran reported that he agreed to being rated incompetent because he thought it would aid his claim for TDIU. The examiner stated that the examiner did not have the time or resources to "monitor a veteran that is using an incompetency rating to further his access to increased benefits from the VA." February 2011 correspondence from Dr. R.F. reflects that the Veteran has been his patient since August 2008 and Dr. R.F. has never found him to be incompetent. In correspondence received by VA in February 2011, the Veteran stated that he is not incompetent. He reported that he had access to his bank accounts and has never totally cleaned them out. He indicated that he pays his bills and manages his home, to include having his son live with him without requesting compensation from his son. A February 2011 VA clinical record reflects that the Veteran was doing "all of the publicity of a band and must have the ability to function adequately" and he did not feel that he was getting any benefit from his current dosage of Depakote. The Veteran reported that his sleep is good. He was alert, his speech was clear and fluent with somewhat rapid rate, and some push of speech. His mood was expansive and animated. His affect was congruent, and his thoughts were rapid. There was no psychosis, and no suicidal or homicidal ideation. He was oriented, his memory was intact, his insight and judgment were fair, and he reported that his sleep, appetite, and energy were okay or adequate. A March 14, 2011 report of general information by a VA employee reflects that during a telephone conversation, the Veteran was irate, yelling, and made threats to harm another VA employee. However, a March 14, 2011 VA clinical record reflects that the Veteran denied any plans of harm to himself or others. A March 2011 VA cardiology consultation record reflects that the Veteran reported that he has been exercising on average twice a week at a local Planet Fitness for the last three months and uses different pieces of equipment as part of his program. (The Board notes that Planet Fitness is a chain of fitness centers with exercise equipment.) A March 2011 VA mental health medication note reflects that the Veteran reported that his medication was not helping. He reported irritability and hyperactivity. He stated that the medication made him sleepy. It was noted that flashbacks and nightmares are "rare". The Veteran was neatly groomed with fair eye contact, normal speech in note. Logical thinking and logical thought process, no delusions, no auditory or visual hallucinations, constricted affect, neutral mood, oriented in all spheres, intact judgment and insight. The Veteran denied suicidal or homicidal ideation. A March 2011 VA examination report is of record. The Veteran reported current psychiatric symptoms of "angry irritability, compulsive behavior, suicidal thoughts, depression, sleeplessness, boredom, restlessness." It was noted that he reported that he had gone back to the Vet Center about a month previously. The report reflects that the Veteran was banned from the RO because of making a threat to somebody there. He reported that his relationship with his two sons is up and down, and he has no contact with his children from his first marriage. He drinks daily and smokes marijuana once a week. He reported that he assaulted somebody three to four weeks earlier at a bar. The March 2011 VA examiner found that the Veteran's behavior was tense, his speech was normal, his mood was anxious and depressed. There were no indications of depersonalization or hallucinations. His thought process tended to be circumstantial, but he was easily redirected to the topic at hand. There were no preoccupations or obsessions or delusions. He reported suicidal ideation of a passive nature. He had no homicidal ideation. He was oriented times three. There were mild problems with attention and concentration resulting in mild short-term memory problems; his long term memory appeared to be intact. His appetite was "halfway decent", his energy level was "lethargic", sex drive was "average", reported depression most of the time which depression being a 5 out of 10. And anxiety most of the time. Nightmares only occur once a month. Symptoms of hypervigilance, emotionally detached, prefers to be alone, startles easily were noted. The examiner did not see any signs of bipolar disorder. It was noted that the Veteran could work with one or two other co-workers and it would be best if he worked with an employer who was sympathetic and knowledgeable about PTSD. The examiner stated in pertinent part as follows: His psychiatric symptoms do not render him unemployable. His psychiatric symptoms moderately to seriously interfere with social functioning. He currently doesn't have a problem with alcohol or substance abuse or dependence by his report. There is no impairment of thought process or communication unless he is under severe stress, and then he talks impulsively or says things impulsively, and also does things impulsively. He got into that bar fight. He got himself banned from the regional office. He is able to maintain his personal hygiene and his daily responsibilities. It was further noted that the Veteran reported that he "spends his time watching television, doing things around the house, he does his own cooking and cleaning, his wife does the grocery shipping. He has his driver's license, but he has to be careful on the road because he gets very angry. His PTSD symptoms require continuous medication. There is reduced reliability and productivity due to PTSD signs and symptoms." A March 2011 VA audiology report is of record which also reflects that he has friends, and has reduced going out because of his hearing loss. Thus, the record again reflects that the Veteran's PTSD does not prevent friends and going out. The Veteran testified at the July 2011 hearing that he has gotten into physical altercations with his sons; however, he did not state when this occurred. He further testified that he had been providing them with some financial assistance. He testified that he has two decent friends and a "bunch of acquaintances." He reported suicidal ideation, anxiety, flashbacks, and attention trouble. He testified that he can get out of the house and go to the grocery store and things of "that nature." An August 2011 VA primary care note reflects that the Veteran reported that he remains active and is going to the gym. He was living with his son. The claim file includes an August 2011 examination report from a July 2011 examination by D.G., licensed psychologist. It reflects that the Veteran was "quite personable and talkative. It was difficult for him to remain on one topic long enough for the evaluator to gather information needed without redirecting him several times and often repeating the question." He reported flashbacks and hypervigilance. He reported limited friends as he does not readily trust others and he has historically struggled with maintaining relationships. It was noted that he lived with his two sons, which caused stress. The Veteran reported that he enjoys his house on a lake and is often relaxing on his boat. The examiner noted that the Veteran had appropriate hygiene, well-groomed appearance, generally calm motor activity with frequent emphasis gesturing during explanation of his behaviors and history. He was able to participate in a 90 minute interview without complaints, although several times he stated that the examiner should just "write that he was crazy to speed up the process and then we could hang out on his boat." His attitude was cooperative. According to the examiner he "had a very quick wit and often tried to use humor though he did not seem aware that he had poor boundaries. Just a few examples include offering to spend time with the examiner on his boat, several times referenced the physical appearance of the examiner and how lucky her husband was to have her." D.G. found that the Veteran's speech was loud and somewhat pressured with no articulation problems noted. Prosody, fluency and tone were normal. Language comprehension appeared intact. His mood was bright and expansive at times. His affect was full in range. He smiled and laughed throughout the interview. His thought processes were logical and directed though he was often tangential and would spontaneously interject his opinion about various issues somewhat related to the evaluation. He had to be redirected to the evaluation's purposes and present question. Thought content was normal. There was no evidence of psychosis and he denied current suicidal or homicidal ideation. Judgment and insight were limited. He was oriented times three, able to recall three words on registration and one from memory after interference. He was able to spell "earth" forwards and backwards with no errors. A typical day for the Veteran included sometimes going for a ride with his neighbor on his boat, going for a walk or "hanging out" on his deck, watching television, doing household chores and handling simple needs. He did not require assistance or direction to properly care for personal affairs, do shopping, cook, obtain transportation, maintaining his residence, and care for grooming and hygiene. He was unable to interact appropriately and communicated effectively with family members, neighbors, friends, landlord, fellow employees, and supervisors. (The Board notes that the record is against a finding that the Veteran had a landlord, employees, and supervisors at the time of the examination; he owned his own home and had been unemployed for several years. Moreover, he had two close friends.) The examiner found that the Veteran was unable to remember detailed work-like procedures and instruction due to poor concentration and distractibility. He also had racing thoughts and was unable to tolerate stresses common to a work environment. D.G. also submitted a Psychiatric/Psychological Impairment Questionnaire in which she assigned a GAF score of 40 and noted that the Veteran had deficiencies in family relations, tangential speech, deficiencies in work or school, inappropriate remarks and boundaries, deficiencies in mood, difficulty in adapting to stressful circumstances, intrusive recollections of traumatic experiences, grossly inappropriate behavior, unprovoked hostility and irritability, inability to establish and maintain effective relations, and deficiencies in judgment. She also found that the Veteran was effectively precluded from the ability to work in proximately to others without being distracted by them, the ability to complete a normal workweek, the ability to accept instructions and respond appropriately to criticism from supervisors, ability to get along with co-workers or peer without distracting them or exhibiting behavior extremes. However, he was not precluded from ability to remember work-like procedures, maintaining attention and concentration for extended periods of time, ability to perform activities within a schedule maintain regular attendance, and be punctual within customary tolerance, ability to interact appropriately with the general public, ability to maintain social appropriate behavior and to adhere to basic standards of neatness and cleanliness, ability to respond appropriately to changes in work setting, and ability to set realistic goals or make plans independently. She did not find that he had memorably loss for names of close relatives, own occupation, or own name, obsessional rituals which interfere with routine activities, persistent irrational fears, persistent delusions or hallucinations, persistent danger of hurting self or others, depression affectively the ability to function independently, appropriately, and effectively, neglect of personal appearance and hygiene, intermittent inability to perform activities of daily living, spatial disorientation, disorientation to time or place, or suicidal ideation. The Board finds that D.G.'s finding of the Veteran's inability to establish and maintain effective relationships is not supported by the evidence because the evidence reflects that he has friends with whom he relaxes and goes boating. October 2011 record reflects that the Veteran reported that he was no longer taking his medication, divalproex, because he did not think it helped his mood as much as relaxation and beer helped. The probative value of a medical opinion is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. As is true with any piece of evidence, the credibility and weight to be attached to these opinions are within the province of the adjudicator. Guarneri v. Brown, 4 Vet. App. 467, 470-71 (1993). There is no requirement that additional evidentiary weight be given to the opinion of a medical provider who treats a veteran; courts have repeatedly declined to adopt the "treating physician rule." See White v. Principe, 243 F.3d 1378, 1381 (Fed. Cir. 2001); Van Slack v. Brown, 5 Vet. App. 499, 502 (1993) The Board finds based on the evidence noted above, that the Veteran's PTSD symptoms do not warrant a 100 percent rating for any period on appeal. Again, the Board is mindful that in order to be assigned a particular rating, a Veteran need not demonstrate the presence of all, most, or even some, of the symptoms listed as examples in the rating criteria. The Board has considered the examples in the rating criteria for a 100 percent evaluation and notes that the Veteran does not have persistent delusions or hallucinations, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, memory loss for names of close relatives, own occupation or own name, persistent danger of hurting self or others. In addition, although he had exhibited inappropriate behavior as evidenced by a bar fight, making inappropriate comments to an examiner, and using excessive profanity, the Board finds that it does not rise to the level of grossly inappropriate behavior. The Board has also considered that his communication has been described as mouthy and a chatterbox that needs redirection; however, again, the Board finds that this does not rise to the level of gross impairment in thought processes or communication. The Board has also considered whether the Veteran has other symptoms which reflect that he has total occupational and social impairment, but finds he does not. The Board notes that the Veteran has not had a job in many years, does not live with his wife, and prefers to avoid crowds; however, he has two close friends, has a boat which he likes to enjoy, maintains his own home to include many chores, goes to Planet Fitness weekly for exercise, enjoys fishing on occasion, and has one or two of his sons live with him when they are in the area. Such evidence reflects that he can maintain relationships, and can function independently. The Board also notes that the evidence reflects that when the Veteran being evaluated for competency, it was apparently due to his desire to have a higher rating and/or his "mouthy" statement as to what he would do with funds (e.g. he would spend money on prostitutes, gambling, alcohol, and drugs.) However, he has also stated that he provides a home for his sons, as well as food for them. He has also been able to live alone. In February 2011 correspondence, the Veteran noted that he "joking" told the VA examiner that "water and money are alike to me, they both flow freely out of my hands." He further stated that the words were taking out of context, and should not be evidence that he was incompetent. He also reported that his bank accounts were not in arrears, that he knew current market value of his home, that he knows the mortgage company of his home. The Board has considered the private and VA clinical reports and the opinions of the examiners, and the GAF scores. As a whole, the opinions and GAF scores do not reflect that the Veteran has a total occupational and social impairment. The Board finds that the evidence is against a finding that the Veteran's PTSD symptoms caused total social and occupational impairment. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Next, the Board will discuss whether the Veteran's PTSD warrants a 70 percent rating for any period on appeal. The Board has considered the examples in the rating criteria for a 70 percent. The evidence is against a finding that the Veteran has obsessional rituals which interfere with routine activities, near continuous panic or depression affecting the ability to function independently, appropriately and effectively, and spatial disorientation; neglect of personal appearance and hygiene, and inability to establish and maintain effective relationships. The evidence reflects that the Veteran's symptoms fall between the 50 percent rating and the 70 percent rating. However, the Board finds, that prior to January 25, 2011, they more closely resemble the 50 percent rating. As noted above, when a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. The Veteran was able to function without medication or counseling prior to March 2009. In addition, and importantly, he was able to control aggression prior to February 2011. The July 2008 and October 2009 records reflect that he had not had assaultive behavior and/or physically violent since 1995. During the rating period on appeal, he was able to maintain friends, leave his home to socialize, enjoy his time on his boat, take care of his home, maintain personal hygiene, and do occasional fishing. Although, he was prescribed medication for psychiatric symptoms in March 2009, he was able to function without it and did not begin taking it until April 2009 or after. An October 2009 record reflects that the Veteran felt that the medication had stabilized his mood somewhat and reduced his irritability. Both before and after the medication, he maintained a GAF score of 50; thus, indicating that either the medication made no substantial effect or that his symptoms had increased and needed medication to remain at a GAF score of 50. Regardless, the evidence does not reflect that his symptoms rose to the level which would warrant a 70 percent rating prior to January 2011. As noted above a January 25, 2011 report of general information reflects that during a discussion with the a field examiner, the Veteran was adversarial and used profanity. However, he also was pleasant to the examiner and according to the field examiner, the Veteran appeared to be trying to get information from him to circumvent the VA process or to use against someone. A March 2011 report of general information reflects that during a telephone conversation, the Veteran was irate, yelling, and made threats to harm a VA employee. However, a VA clinical note from that same date reflects that the Veteran denied being a harm to himself or others. A March 2011 VA examination report notes that the Veteran, approximately one month earlier, had begun to go back to the Vet Center for PTSD sessions. It also reflects that the Veteran had been banned from the RO because of making a threat to somebody there, and had reported that he had assaulted somebody three to four weeks earlier at a bar. These records reflect that the Veteran was no longer able to control his anger. After careful consideration of the evidence, the Board will resolve reasonable doubt in favor of the Veteran and assign a 70 percent rating from January 25, 2011. Such a rating reflects the Veteran's complaints of increased depression, ineffectiveness of medication, his threatening behavior, and his belief that his symptoms were severe enough to warrant a return to counseling. The Board notes that prior to that time, the evidence does not reflect that the Veteran was physically or verbally threatening and, although he was mouthy, he had been able to control any rage. The Board finds that his actions do not rise to the level of a 100 percent evaluation, as he was still able to maintain friendships, and thus, did not have total social impairment. The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107 (West 2002), and 38 C.F.R. § 3.102 (2013). Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990) in assigning a rating of 70 percent and assigning an effective date of that rating as January 25, 2011. Initial rating in excess of 10 percent for ischemic heart disease The Veteran is service connected for ischemic heart disease, evaluated, under DC 7005, as 10 percent from September 29, 2009, 100 percent from November 12, 2009 to March 1, 2010, and 10 percent from March 1, 2010. A September 2009 VA clinical record reflects that the Veteran denied any chest discomfort. He reported occasional episodes of dyspnea which are limited in duration and do not seem to be related to exertion. He had not had any palpations. He had not had any syncope. The Veteran was noted to have mitral valve prolapse and severe mitral regurgitation which was currently asymptomatic. It was noted that the Veteran's ejection fraction had been 60 to 65 percent in February 2009. The October 2009 VA examination report reflects that the Veteran reported that he does not have "any cardiac symptoms except 'occasional twinges' of chest pain with some shortness of breath associated with exertion. He has a METS rating greater than 7 but less than 10. The examiner noted that the Veteran's heart condition has mild to moderate effect on physical labor. The Veteran had surgery for his heart on November 12, 2009. A December 22, 2009 private record from New England Heart Institute reflects that the Veteran had an ejection fraction of 40-45 percent. A January 2010 VA ECG report reflects that the Veteran had normal sinus rhythm and a normal ECG. It was noted that the ejection fraction can be evaluated in "1 - 2 months". A January 27, 2010 UC note reflects that the EKG showed normal sinus rhythm and 80 beats per minute. An April 2010 VA clinical record reflects that the Veteran's ejection fraction as preserved going into surgery, however, "ejection fraction tends to be overestimated due to the high degree of mitral insufficiency that was present. His ejection fraction has reduced to 40 to 45 percent after the valve has been repaired." He reports non exertional chest discomfort, is able to perform his daily activities and currently tolerating metoprolol. A September 2010 VA clinical note reflects that the Veteran called and requested a letter stating that he should not fly due to his heart function. The Veteran was informed that the cardiology department would not write such a letter as the Veteran did not have physical restrictions. November 2010 clinical records reflect that the Veteran's ejection fraction was normal, the mitral insufficiency is no longer present, and his heart disease does not impact his ability to work. A November 2010 VA examination report reflects that the Veteran does not have congested heart failure. He had a METs level of greater than 7. He did not have cardiac hypertrophy or dilation. The Veteran's heart disability did not impact his ability to work. A November echocardiogram report reflects that the ejection fraction was estimated to be 55 percent without any regional wall motion abnormalities. A March 2011 VA record reflects that the Veteran reported that he has been exercising on average of twice a week at the local Planet Fitness for the last three months. His METs were 10.1. The stress EKG was without diagnostic evidence for ischemia. The April 2011 VA record notes that the Veteran has no signs of any ischemia on recent treadmill testing. A March 2011 echocardiogram revealed an ejection fraction of 55 to 60 percent with normal wall motion. It was noted that the degree of mitral insufficiency remains "trace-mild". An April 2011 VA record reflects a normal EKG. An August 2011 VA clinical record reflects that the Veteran's heart disability appeared stable without any ongoing ischemia and had remained stable off of beta blockades. He was noted to have occasional chest pain which was not worsened with activity. An October 2011 VA clinical record reflects that the Veteran reported occasional fleeting episodes of chest discomfort in the right side which was atypical in nature and is not brought on by exertion or his exercise. On the day of the exam, he denied chest discomfort, palpitations, and shortness of breath. An April 2012 VA clinical record reflects that after bypass surgery, the Veteran's "subsequent echocardiogram showing an improvement in the ejection fraction left within normal limits, 55 to 60%. There is no significant mitral insufficiency. Trace to mild. I did not detect this murmur on examination today. His shortness of breath is with moderate activity and has not reported any changes in functional capacity, particularly with his aerobic activity at the gym, for instance. . . . . His last echocardiogram shows a marked improvement which he is reassured." An April 2013 VA ECG report reflects normal sinus rhythm, normal ECG, premature ventricular complexes are not longer present. The Board finds that prior to December 22, 2009, an increased rating is not warranted as the evidence does not support a higher rating (e.g. February 2009 ejection fraction of 60 to 65 percent, September 2009 evidence of no chest discomfort and only occasional dyspnea unrelated to exertion, and October 2009 METS greater than 7.) From March 1, 2010 to November 2, 2010, a rating of 60 percent, and no higher is warranted because his ejection fraction was reduced to 40 to 45 percent. A higher rating is not warranted as the evidence does not support a finding of chronic congestive heart failure; or workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104, DC 7005. From November 2, 2010, a rating in excess of 10 percent is not warranted. In sum, the record reflects an ejection fraction of 55 percent (November 2010), METs greater than 7 (November 2010), METs of at least 10 (March 2011), ejection fraction of 55 - 60 percent (March 2011), normal EKG (April 2011), ejection fraction of 55 - 60 percent (April 2012), and normal ECG (April 2013), The evidence is against a finding that from November 2, 2010, the Veteran's service-connected heart disability has resulted in a workload of 7 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or X-ray. While the Veteran has reported some fatigue, the clinical evidence does not reflect a METs level of 7 or less. The Board acknowledges that the claims file includes correspondence from Dr. S. Hanlon in which he states that the Veteran underwent an echocardiography on December 22, 2010 which reflected an ejection fraction of 40-45 percent. The Board finds that this is incorrect date for the test. The evidence reflects that the test was actually performed on December 22, 2009. In addition, as the correspondence from Dr. S. Hanlon was originally dated February 2010, the test could have taken place in December 2010, a date which had not yet occurred. The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107 (West 2002), and 38 C.F.R. § 3.102 (2013), but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Extraschedular(PTSD and Heart Disability) Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). An extra-schedular disability rating would be warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). The Board has reviewed the evidence of record and finds that it does not show such an exceptional disability picture. The effects of the Veteran's disabilities have been fully considered and are contemplated in the rating schedule; hence, an extraschedular rating is not warranted. The rating formula for mental disorders allows for them to be rated based on the level of occupational and social impairment. While the code lists examples to be considered, the Veteran's PTSD-related symptoms have been considered, whether or not they are listed as an example. The evaluations are based on the severity of the Veteran's symptoms and the code allows for various evaluations based on levels of symptoms from mild or transient to those causing total impairment. Thus, regardless if the actual related symptom is listed in any criteria, it is still considered based on its severity. With regard to the heart, the rating formula allows for consideration of dyspnea, fatigue, angina, dizziness, syncope, continuous use of medication, workload (METs), as well as diagnostic testing results. The Veteran avers that because he has a heart disability, he is not authorized to have a commercial driver's license. The rating criteria is based on symptoms and physical limitations, and the extraschedular ratings are based on symptoms and physical limitations, to include frequent hospitalization or marked interference with work. The mere fact that the Veteran's heart disability may, as he alleges, legally or by contract interfere with his ability to obtain a commercial driver's license, is not in and of itself sufficient to find that the rating criteria impractical. License regulations which may disqualify the Veteran from having a commercial driver's license are not synonymous with physical limitations due to his disability. Importantly, the Veteran does not have a long employment history as a truck driver or commercial driver. While the Veteran has stated that he cannot be employed as such a driver due to his heart, he has not provided competent objective evidence of such. The July 2008 VA Form 21-4192 by his employer reflects that he was no longer employed as driver because of lack of work and job performance, not because of his heart disability. Thus, the situation is not one wherein the Veteran's service-connected disabilities cause marked interference with employment. The Board finds that the Veteran does not experience any chronic symptomatology not contemplated by the rating schedule. Referral for extraschedular consideration is not warranted. Thun v. Peake, 22 Vet. App. 111 (2008). SMC In a decision dated in December 2010, the RO granted the Veteran SMC from November 12, 2009 to March 1, 2010 because he had been granted a temporary 100 percent evaluation for his service-connected heart disease, and he had other disabilities of PTSD and tinnitus rated as 60 percent disabling. 38 C.F.R. § 3.350 (i). As the Veteran does not have a 100 percent disability rating after March 1, 2010, SMC is no longer warranted. The Board has also considered whether the Veteran is entitled to SMC on the basis of being housebound, but finds that he is not. The term "permanently housebound" will be considered to have been met when the Veteran is substantially confined to such Veteran's house (ward or clinical areas, if institutionalized) or immediate premises due to a service connection disability which it is reasonably certain will remain throughout such Veteran's lifetime. See 38 C.F.R. § 3.350i)(2). In the Veteran's case, the record reflects that during the rating period on appeal, he has been shopping, boating, to visit friends, to Planet Fitness regularly for exercise, and to a bar on at least one occasion. The Veteran stated at the July 2011 Board hearing that he is "not really housebound". (See Board hearing transcript page 11.). In addition, an April 2013 report of general information (VA Form 27-0820) reflects that the Veteran stated that he was "not an invalid" and would not be sending in any information for housebound status. TDIU The Veteran was most recently employed in 2007. The Veteran's ratings are recognition that the impairment may make it difficult to obtain and keep employment. The question is whether the Veteran is capable of performing the physical and mental acts required by employment consistent with his education and occupational experience. See Van Hoose v. Brown, 4 Vet. App. 361 (1993). The mere fact that the Veteran has not sustained long-term employment since 2007 is not synonymous with an inability to maintain substantial gainful employment at other occupations. The issue is whether the Veteran is unable to follow a substantially gainful occupation as a result of a service-connected disabilities, not whether the Veteran can find employment. See Van Hoose v. Brown, 4 Vet. App. 361 (1993). SSA records are associated with the claims file; however SSA determinations are not binding on the Veteran but are for consideration. SSA records reflect disability due to PTSD and Bipolar disorder effective from December 2008. The evidence reflects that the Veteran has an education level of four years of college with an emphasis on business. He has experience employed in construction work, in sales, and in boat detailing. He has worked for companies specializing in construction, geo-technical lab testing, lumber distribution, heating and air condition, and dry wall. He worked as a driver for approximately seven months in 2007 and was terminated due to a lack of work. He was subsequently rehired for four days but was terminated due to his job performance. Despite the contentions of the Veteran, the evidence of record does not support a finding that the Veteran was incapable of substantial gainful employment prior to July 27, 2011. The July 2008 VA examiner noted above assigned a GAF score of 50. The examiner noted that the Veteran is able to get along with people "for the most part. He does have a hot temper and has a tendency to be "mouthy." However, his psychiatric symptoms do not render him unemployable. The April 2009 mental health evaluation by Dr. J.S. (psychologist) reflects that the Veteran is able to understand and remember instructions, and complete tasks. The Board has also considered the September 2009 correspondence from R.C., Operations Manager of S. Mechanical which reflects that the Veteran had been project coordinator with that company. R.C. stated, in pertinent part, that the Veteran had a very hard time grasping the time lines and following along with the meeting. He would seem to just drift off into his own space. Quite frequently speaking very loudly about irrelevant topics as you can image this was quite destructive to our day-to-day operations. Which had therefore led to the fact that we could no longer work with him?" The Veteran testified at a September 2009 DRO hearing that the company for whom he worked liked his personality but not his work habits. (See DRO transcript page 4.) He reported that he had worked as a construction project manager for 7-9 months, had been unemployed for a year prior to that, and had approximately four jobs the year prior to that. He testified that he had been granted SSA benefits based on unemployability due to his mental health. An October 2009 VA examination report is of record. The examiner stated that the Veteran's functioning had not change significant since his last evaluation, which was that he was not unemployable due to his PTSD. The examiner noted that the Veteran current "mindset is that he no longer wants to work and since he currently received social security disability, work is not viewed as a necessity to him." The October 2009 VA examiner also stated in pertinent part, as follows: Although veteran's irritability and difficulty getting along with others impacts his work, they do not render him incapable of gainful employment. Veteran currently performs all his ADLs and maintains his household by himself, although he noted his son, who recently moved in, occasionally performs chores when vet asks. . . .veteran's PTSD and Bipolar Disorder preclude neither sedentary nor physical labor. . . [The Veteran] stated he is not currently, nor does he have any intention of looking for work. He made this decision when he was diagnosed with severe heart conditions requiring surgery this past spring. . . . His Bipolar and PTSD more likely than not reduce the quality of his work, but do not preclude work. An October 2009 VA examination TDIU report reflects that the Veteran's heart disability has only a mild to moderate effect on physical labor. It was noted that coronary artery disease would limit heavy lifting. However, this condition would not affect sedentary employment. A February 2011 VA clinical record reflects that the Veteran was doing "all of the publicity of a band and wanted to ensure he had the correct medication to be able to function adequately. A March 2011 VA examination report is of record. The examiner found that the Veteran could work with one or two other co-workers and it would be best if he worked with an employer who was sympathetic and knowledgeable about PTSD. The examiner stated that the Veteran's psychiatric symptoms do not render him unemployable. The August 2011 evaluation report reflects the opinion of the examiner that the Veteran was unable to remember detailed work-like procedures and instruction due to poor concentration and distractibility. He also had racing thoughts and was unable to tolerate stresses common to a work environment. She assigned a GAF score of 40. D.G. found that the Veteran was effectively precluded from the ability to work in coordination with or proximity to others without being distracted by them, the ability to complete a normal workweek, the ability to accept instructions and respond appropriately to criticism from supervisors, ability to get along with co-workers or peer without distracting them or exhibiting behavior extremes. Thus, the Board finds, based on the record as a whole, that the Veteran is unemployable as of the July 27, 2011 evaluation which referenced in the August 2011 mental health report. The Board finds that, prior to July 27, 2011, the evidence is against a finding that the Veteran's service-connected disabilities rendered him unemployable. The July 2008, August 2009, October 2009, and March 2011 clinical records all reflect that he was not unemployable due to his PTSD symptoms. In addition, the evidence does not reflect that his PTSD symptoms, in combination with his other service-connected disabilities, rendered him unemployable. The Veteran is service connected for PTSD, tinnitus, ischemic heart disease, and bilateral hearing loss. Despite his contentions, the evidence of record does not reflect that such disabilities, taken together, rendered him unable to sustain substantial gainful employment prior to July 27, 2011. The October 2009 VA examination report reflects that the Veteran reported that he does not have "any cardiac symptoms except 'occasional twinges' of chest pain with some shortness of breath associated with exertion. He has a METS rating greater than 7 but less than 10. The examiner noted that the Veteran's heart condition has mild to moderate effect on physical labor. November 2010 clinical records reflect that the Veteran's ejection fraction was normal, the mitral insufficiency is no longer present, and his heart disease does not impact his ability to work. A March 2011 VA record reflects that the Veteran reported that he has been exercising on average of twice a week at the local Planet Fitness for the last three months. His Mets were 10.1. The stress EKG was without diagnostic evidence for ischemia. The April 2011 VA record notes that the Veteran has no signs of any ischemia on recent treadmill testing. The Board finds that the Veteran's July 2011 testimony as to his symptoms, such as shortness of breath and pain upon exertion (e.g. that he cannot use a crank when working with trucks), are less than credible given the clinical records, to include his treadmill testing. An August 2011 VA record reflects that the Veteran remains active and goes to the gym. He reported one episode of shortness of breath without chest pains when he was bringing in his boating dock without the assistance from his sons. The Board also acknowledges the Veteran's April 2013 statement (See VA Form 27-0820) that his heart disability causes him to be unable to work, but finds that this is less than credible given the clinical records. In determining that the Veteran is unemployable as of July 27, 2011, the Board acknowledges that he is not physically precluded from driving a truck; however, the record reflects that he has continually reported having road rage. In addition, while the Veteran is not physically precluded from sedentary work, his mental symptoms now make working with groups of more than two individuals difficult and he has a GAF score of 40, indicative of more than serious symptoms or a serious impairment in social, occupational, or school functioning. The Board notes that the Veteran meets the schedular criteria for TDIU on, and after, January 25, 2011 based on his 70 percent rating for PTSD. Prior to January 25, 2011, the Board finds, based on the discussion above, that referral for TDIU on an extraschedular basis is not warranted. See 38 U.S.C.A. § 5107(b); Gilbert . v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to a rating in excess of 50 percent for PTSD prior to January 25, 2011 is denied. Entitlement to a rating of 70 percent, and no higher, for PTSD from January 25, 2011, is granted, subject to the laws and regulations controlling the award of monetary benefits Entitlement to a rating of 60 percent, and no higher, for ischemic heart disease, from March 1, 2010 to November 2, 2010 is granted, subject to the laws and regulations controlling the award of monetary benefits Entitlement to a rating in excess of 10 percent prior to November 12, 2009 and from November 2, 2010 for ischemic heart disease is denied. Entitlement to special monthly compensation (SMC) is denied. Entitlement to a total rating for compensation purposes based on individual unemployability (TDIU) prior to July 27, 2011 is denied. Entitlement to a total rating for compensation purposes based on individual unemployability (TDIU) from July 27, 2011 is granted, subject to the laws and regulations controlling the award of monetary benefits. ______________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs