Citation Nr: 1644991 Decision Date: 11/30/16 Archive Date: 12/09/16 DOCKET NO. 04-25 185 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. What rating is warranted for posttraumatic stress disorder (PTSD) from March 24, 2003 through January 24, 2005? 2. What rating is warranted for PTSD from January 25, 2005 through August 10, 2009? 3. What rating is warranted for PTSD from August 11, 2009 through December 13, 2011? 4. Entitlement to an effective date prior to December 14, 2011 for an award of special monthly compensation under 38 U.S.C.A. § 1114(s). REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD M. Carsten, Counsel INTRODUCTION The Veteran served on active duty from July 1967 to July 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. The appeal has a lengthy procedural history. In October 2003, VA granted entitlement to service connection for PTSD and assigned a 10 percent rating effective March 31, 2003. The Veteran disagreed with the decision and perfected this appeal. In April 2007, the Board remanded the appeal for additional development. In December 2008, VA increased the rating for PTSD to 30 percent effective March 31, 2003 and to 50 percent effective September 16, 2008. In July 2009, the Board denied an initial rating in excess of 30 percent for PTSD for the period from March 31, 2003 through January 24, 2005; granted a 50 percent rating for PTSD for the period from January 25, 2005 through September 15, 2008; and denied a rating greater than 50 percent. The Veteran appealed this decision to the United States Court of Appeals for Veterans Claims (Court). In December 2010, the Court granted a Joint Motion for Remand and remanded the matter for further proceedings. A May 2011 rating decision found a clear and unmistakable error in the initial rating and the Veteran was assigned an earlier effective date of March 24, 2003 for the initial 30 percent rating for PTSD. In November 2011, the Board remanded the issue for further development. In April 2012, the RO increased the rating for PTSD to 70 percent effective August 11, 2009 and to 100 percent effective December 14, 2011. The rating also awarded entitlement to special monthly compensation at the (s) rate from December 14, 2011. In July 2012, the Board denied entitlement to initial ratings greater than 30 percent for the period from March 24, 2003 through January 24, 2005, greater than 50 percent for the period from January 25, 2005 through August 10, 2009, and greater than 70 percent for the period from August 11, 2009 through December 13, 2011. The Veteran appealed the July 2012 Board decision to the Court. His initial brief suggested he was appealing that portion of the decision that denied entitlement to an initial rating greater than 50 percent for the period from January 24, 2005 through August 10, 2009. The brief specifically stated "[a]ppellant does not wish to disturb the remainder of the Board's decision, which denied entitlement to an initial disability rating in excess of 30 percent for service-connected PTSD, from March 31, 2003 through January 24, 2005, and which denied entitlement to an initial schedular disability rating in excess of 70 percent for service-connected PTSD from August 11, 2009 through December 13, 2011." See Brief for Appellant, p. 2, n.1. Significantly, by Memorandum Decision dated in March 2014, the Court set aside the July 2012 Board decision and did not limit the issues as requested. The Court further determined that the issue of whether the Veteran's PTSD caused complete unemployment and entitled him to special monthly compensation was within the Board's authority to address. In January 2015, the Board determined that the issue of entitlement to special monthly compensation prior to December 14, 2011 was for consideration. That issue, as well as the PTSD rating issues, was remanded for further development. Following substantial compliance with the remand directives, the case was returned to the Board. This is a paperless appeal and the Veterans Benefits Management System (VBMS) and Virtual VA folders have been reviewed. FINDINGS OF FACT 1. For the period from March 24, 2003 through January 24, 2005, the Veteran's PTSD was not manifested by occupational and social impairment with reduced reliability and productivity. 2. For the period from January 25, 2005 through August 10, 2009, the disability picture associated with the Veteran's PTSD more nearly approximated occupational and social impairment with deficiencies in most areas. 3. For the period from August 11, 2009 through December 13, 2011, the Veteran's PTSD was not manifested by total occupational and social impairment. 4. Effective December 14, 2011, the Veteran was assigned a schedular 100 percent rating for PTSD and had additional disability independently ratable at 60 percent or more. Prior to December 14, 2011, the appellant did not have a single service-connected disability rated as 100 percent and his PTSD, standing alone, was not of sufficient severity to produce unemployability. CONCLUSIONS OF LAW 1. For the period from March 24, 2003 through January 24, 2005, the criteria for an initial disability rating in excess of 30 percent for PTSD were not met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2015). 2. For the period from January 25, 2005 through August 10, 2009, the criteria for an initial 70 percent disability rating, and no more, were met. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.130, Diagnostic Code 9411. 3. For the period from August 11, 2009 through December 13, 2011, the criteria for an initial disability rating in excess of 70 percent for PTSD were not met. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.130, Diagnostic Code 9411. 4. The criteria for an effective date prior to December 14, 2011 for an award of special monthly compensation at the (s) rate are not met. 38 U.S.C.A. §§ 1114(s), 1155 (West 2014); 38 C.F.R. §§ 3.350, 3.400 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claim herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2015); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Factual Background A November 2002 State of Georgia Department of Labor Separation Notice indicates the Veteran was separated due to lack of work. During a September 2003 VA contract examination the Veteran reported flashbacks, recurrent dreams, nightmares, and disturbances of sleep. On examination, he was well-oriented in time and place, displayed no deficit in cognitive functions and was able to do the serial seven subtractions quickly and well. He confirmed that he filed for Social Security benefits because the bottom of his feet felt like he was walking on hot asphalt and he tended to stumble in the dark. His affective responses were congruent at all times, and there was no indication of excessive anxiety and no suspected mood disorder. His thought processes were organized and his speech was well-articulated. The examiner diagnosed chronic, moderate PTSD, and assigned a Global Assessment of Functioning scale score of 53. The examiner commented that the Veteran had experienced more difficulty in the last three years, when he was laid off from his job. An exaggerated startle response and hypervigilance were suggested by his history and he appeared to need a high level of physical activity to suppress his symptoms. In his October 2003 VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, the Veteran indicated he could not work because of his diabetes and lower extremity neuropathy. An October 2003 statement from the Veteran's private physician, Dr. J.C., indicates that his main diagnoses were coronary atherosclerotic heart disease, status post atrial fibrillation converted to regular sinus rhythm, hypertension, hyperlipidemia, diabetes with peripheral neuropathy and retinopathy, gastroesophageal reflux disease and exogenous obesity. The physician noted that the Veteran experienced severe bilateral lower extremity pain due to peripheral neuropathy and he had not responded to several treatments. His prognosis was judged to be poor. A July 2004 statement from Dr. J.C. indicates that the Veteran's main problems consist of coronary atherosclerotic heart disease, hypertension, hyperlipidemia, diabetes, gastroesophageal reflux disease, peripheral neuropathy and degenerative joint disease. Because of these diseases the physician considered him disabled for his usual and/or any occupations. An October 2004 letter from the Social Security Administration notes the Veteran's contentions that he was disabled because of diabetes and neuropathy. While he was initially denied benefits, a fully favorable decision was issued in February 2005. On January 25, 2005, a VA staff physician, Dr. G.-B. indicated that the Veteran carried a diagnosis of PTSD, and suffered with most of the symptomatology associated with this disorder. The physician indicated that the Veteran had severe social and occupational impairment due to his illness; and that he was unemployable and considered 100 percent disabled secondary to the severity of his mental and physical problems. Correspondence received in June 2007 from the Veteran's wife, children, and former spouse indicates that he had panic attacks and flashbacks throughout the years, and had become reclusive and depressed. In his April 2008 application for unemployability the Veteran reported that he could not work due to his diabetes. During a September 2008 VA examination, the Veteran reported increasing problems with panic attacks, and nightmares occurring three or four times weekly which centered on Vietnam-related themes. The Veteran reported feelings of guilt that he survived, and that a friend of his from the same unit died. The Veteran reported that he startled easily, and that his doctor had increased his medications. He reportedly disliked crowds, and avoided things that reminded him of Vietnam. The Veteran reported memory problems and that his wife kept his calendar. He denied episodes of rage or irritability. He denied ever attempting suicide. On examination, the Veteran was alert and fully oriented. He was able to register three words immediately, but could recall only one without assistance after about three minutes. The other two he easily recalled when given a clue. He could not recall who served as President prior to Bill Clinton. He offered somewhat concrete interpretations to two proverbs. His speech was normal in rate, rhythm, and volume, but occasionally had a somewhat tremulous quality. His thought process was logical and linear. The Veteran denied auditory hallucinations, but indicated that he sometimes thought he would see something "out of the corner of his eye." He denied active suicidal or homicidal thoughts. No delusions were elicited. His mood was depressed at times, but predominantly anxious. His affect was nervous and jittery. His insight and judgment were fairly good. It was also noted that the Veteran sometimes drove a couple of miles to a hardware store to walk around, and that he and his wife would go out to dinner about twice per week. He also reported that two times each year they would go on some kind of vacation. For example, they went with others in the recent past to an antiques car show. He said that he would not be able to go on such a trip without having his brother and wife present. He reported having a good relationship with his brothers and talked to them fairly regularly. He was also in regular contact with his children. The examiner noted that the Veteran's memory and concentration were each impaired to some extent. The Veteran also tended to isolate himself with music or to talk to certain supportive family members in order to reduce symptoms. The Veteran did report solid relationships with others, but reported an inability to work or take part in almost any activity outside of his home without the comforting presence of a trusted individual. The examiner opined that the Veteran's limitations may be related more closely to his panic disorder than to PTSD, and that one could argue that the panic disorder is secondary to PTSD. A Global Assessment of Functioning scale score of 45 was assigned. The examiner opined that the PTSD signs and symptoms resulted in deficiencies in most of the following areas: work, school, family relations, judgment, thinking and mood. A VA treatment record from January 29, 2009 reflected that the Veteran showed for a scheduled appointment. He updated the examiner on his psychosocial stressors. The Veteran continued to report experiencing panic attacks about once or twice a week. He had impaired judgment and experienced disturbances of motivation and mood, unprovoked irritability, impaired impulse control, deficiencies at work and in family relations, judgment, thinking and mood. He had hypervigilance, hyperarousal, and flashbacks. He also had recurring dreams of events from combat in Vietnam. He had good insight into his illness and was willing to follow suggestions. He was also compliant with his medications. The appellant was glad the holiday season was over, and he reported enjoying talking with another veteran but admitted that his symptoms were triggered by what he heard. He complained of exacerbation of his PTSD symptoms in the area of re-experiencing, avoidance/isolative behavior, and hyperarousal. He reported waxing and waning of depressive symptoms. He discussed the possibility of increasing or augmenting his treatment with another medication to help reduce his mood symptoms. The examiner stated the Veteran had severe social and occupational impairments secondary to PTSD. He was described as unemployable and totally and permanently disabled. The Veteran was seen on April 10, 2009 for follow up of his PTSD. He reported an increase in panic attacks (2-3) per week, hypervigilance, hyperarousal, memory issues, spatial disorientation, deficiencies in social relations, distrubances of mood, mood swings, unprovoked irritability, neglect of personal appearance, difficulty adapting and impaired judgment. The social worker noted that these symptoms had been ongoing and continued at a very high level for this Veteran. The Veteran's PTSD was described as prolonged and severe. He had good insight into his illness and followed suggestions. He was unemployable and appeared totally and permanently disabled. In his April 2009 application for unemployability the Veteran reported that he was unable to work because of his diabetes and peripheral neuropathy. A June 17, 2009 VA record reflects that the panic attacks were now reported to occur between 2-5 times per week. His other symptoms (as noted above) remained active. At an August 2009 VA examination the Veteran noted that he felt distant or cut off from others, irritable and that he had anger outbursts. He reported flashbacks, avoiding thinking or talking about his military experiences, sleep impairment and was jumpy and easily startled. He reported continuing disturbing dreams about his military experiences. There was loss of interest and difficulty concentrating. The Veteran no longer hunted since coming back from Vietnam and related some paranoia regarding others who he said looked at him strangely because he was a veteran. The Veteran endorsed a restricted affect and numbing as moderately problematic. He denied suicidal ideation but when asked about hallucinations, he reported seeing things in his peripheral vision, but when he turned to look, there was nothing there. He loved his siblings but had visited them less in the last five years or so. He also endorsed numbing of his emotions. He was depressed and felt pressure. He lived with his wife and did not work having not worked in about six years due to problems with his feet and legs. He reported spending about 60 percent of his time sitting on his porch. He helped his wife with housework (vacuuming) and occasionally ventured out of his house for social activities, although this was somewhat limited due to panic attacks when alone. On mental status examination, the Veteran was alert, and his grooming was fairly good. He seemed to have a fine general tremor which was most pronounced in the upper extremities. He often jiggled his feet restlessly, increasingly so when asked to perform cognitive tasks. He was oriented to the year and month. He was able to register three words immediately, but recalled only one independently after three minutes. His level of physical agitation was markedly increased. His speech had a halting, almost stammering quality, and was punctuated with exasperated sighs or shrugs when he had trouble recalling something. He denied suicidal or homicidal thoughts. His mood was depressed and anxious. Affect was overall guarded and markedly anxious at times. Insight and judgment seemed fairly good. Global Assessment of Functioning scale score was 50. He was able to manage his own funds. Regarding the extent of psychosocial impairment, the examiner stated that the Veteran appeared unable to work due to a combination of physical and mental problems. He was able to maintain reasonably meaningful relationships and visits with family members. He was also able to enjoy some social activities outside the home although his anxiety and panic limit his ability to engage in solo activities. The examiner continued to opine that signs and symptoms of PTSD result in deficiencies in most areas. The Veteran was reexamined by VA in December 2011. He was noted to have occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. He reported that, while he had what he described as good relationships with his current wife and children, he admitted that he did not share all his struggles with his mental health issues with them. He denied having friends, noting that he did most of his socializing with family. He reported experiencing nightmares twice a week that have Vietnam-related scenes. He would have flashbacks, triggered by helicopters or war-related news; he tended to avoid triggers when possible. He described being easily agitated and hypervigilant, with feelings of anxiety and panic, particularly when alone or when driving. He disliked crowds, had poor concentration, and loss of memory. Objective examination noted that the Veteran had a depressed mood; anxiety; panic attacks occurring more than once a week; near-continuous panic attacks that adversely affected his ability to function independently; mild memory loss; a flattened affect; disturbances in in motivation and mood; an inability to establish and maintain effective relationships; and persistent delusions or hallucinations. The Veteran showed a restricted affect and he was extremely anxious during the examination. He displayed difficulty with memory, being unable to recall the names of past teachers or the name of the street he grew up on, which the examiner commented demonstrated impairment with long-term memory. His thought processes were lucid. He indicated that he sometimes got "a glimpse" of something moving out of the corner of his eye, accompanied by the screams of a soldier who had stepped on a land mine. He denied suicidal or homicidal ideation at present. The Veteran was noted to rarely leave his home, expect when accompanied by his wife. His involvement in activities had decreased due to his anxiety and lack of motivation (he also had several medical problems that interfered with functioning). He had frequent panic attacks in crowds, as well as flashbacks that would adversely impact any work productivity. The examiner opined that the Veteran's PTSD was severe and consistent with a Global Assessment Functioning scale score of 50. The examiner also stated that it was at least as likely as not that the Veteran's PTSD causes marked interference with employment. Analysis Increased initial ratings for PTSD At the outset, the Board observes that the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) remains for application in this case. See 80 Fed. Reg. 14308-09 (March 19, 2015); 79 Fed. Reg. 45093-99 (August 4, 2014). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C.A. § 1155. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). When a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. If there is a question as to which evaluation to apply, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. PTSD is evaluated pursuant to the General Rating Formula for Mental Disorders. A 30 percent evaluation is assigned when there is 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, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent evaluation is warranted when there is 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; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted when there is 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); and the inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted if there is 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. Id. As the United States Court of Appeals for the Federal Circuit (Federal Circuit) recently explained, evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed.Cir.2013). The symptoms listed under the referenced diagnostic code are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The Global Assessment of Functioning scale reflects the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). Scores of 41-50 reflect serious symptoms or serious impairment in social, occupational or school functioning. i. For the period from March 24, 2003 through January 24, 2005 Evidence during this period shows that the Veteran's PTSD was manifested, primarily, by chronic sleep impairment, flashbacks, and anxiety. While these symptoms seemed to occur frequently, they are, nonetheless, reflective of overall moderate social impairment with intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with routine behavior and self-care. Such level of impairment warrants an initial 30 percent disability rating. While the September 2003 examiner noted that an exaggerated startle response and hypervigilance were suggested by the history at times, those factors alone do not provide a sufficient basis for assignment of an initial 50 percent disability rating. Significantly, during this period, the Veteran's posttraumatic stress disorder was not found to be manifested by a flattened affect, circumlocutory or stereotyped speech, frequent panic attacks, difficulty in understanding complex commands, impaired memory, impaired judgment, or impaired abstract thinking - all symptoms which would warrant an initial 50 percent rating. The September 2003 examiner assigned a Global Assessment of Functioning scale score of 53 during the applicable period, reflective of moderate symptoms or moderate difficulty in social or occupational functioning. In light of the evidence of record, the Board finds that the preponderance of the evidence is against entitlement to an increased rating for posttraumatic stress disorder from March 24, 2003 to January 25, 2005. ii. For the period from January 25, 2005 through August 10, 2009 In the April 2013 Brief for Appellant, the then representative argued that the Veteran met the criteria for a 70 percent rating for the period from January 25, 2005 through August 10, 2009. The evidence during this period shows the Veteran was suffering from multiple PTSD symptoms to include panic attacks, chronic sleep impairment, flashbacks, depression, impaired memory and concentration, disturbances of motivation and mood, anxiety, and some isolation. The Board acknowledges that most of these symptoms are not listed within the rating criteria for a 70 percent rating. Notwithstanding, the Veteran's symptoms were described as productive of severe occupational and social impairment by his treating physician and VA examiner. The September 2008 VA examiner stated that his symptoms resulted in deficiencies in most areas. Additionally, Global Assessment of Functioning scores during this period were consistent with severe impairment. Resolving reasonable doubt in his favor, the Veteran's disability picture during this time period more nearly approximated occupational and social impairment with deficiencies in most areas and a 70 percent rating, and no more, was warranted. Total occupational and social impairment due to PTSD alone was not shown during this period. There was no evidence that the appellant was in persistent danger of hurting self or others, and there was no evidence of persistent delusions, memory loss for names of close relatives, or his own name. To the extent that examiners found the appellant unemployable it is clear that opinion was based on consideration of posttraumatic stress disorder plus other disorders, and the Board notes that the appellant was in receipt of a total disability evaluation based on individual unemployability due to service connected disorders between March 24, 2003 and August 11, 2009. iii. For the period from August 11, 2009 through December 13, 2011 Evidence during this period shows the Veteran's PTSD was manifested primarily by panic attacks, flashbacks, avoidance of thinking or talking about inservice stressful events, sleep impairment, loss of concentration, exaggerated startle response, irritability and anger. There was restriction of affect and numbing of his emotions. These symptoms are reflective of deficiencies in most areas, to include work, school, family relations, judgment, thinking and mood and are consistent with a 70 percent disability rating. The preponderance of the evidence shows that the Veteran was not entitled to a schedular 100 percent rating during this period. Evidence of record shows that the Veteran was oriented and he did not demonstrate grossly inappropriate behavior or an intermittent inability to perform activities of daily living. There was no evidence that the appellant was in persistent danger of hurting self or others, and there was no evidence of persistent delusions, memory loss for names of close relatives, or his own name. Without question psychiatric symptoms due to posttraumatic stress disorder caused impaired social and occupational functioning; however, the evidence shows that such symptoms did not standing alone result in total impairment for the period in question. He helped his wife with housework and occasionally ventured out of his house for social activities, although this was somewhat limited due to panic attacks when alone. Essentially, the Board finds that, while confirming impaired/strained functioning, the evidence of record, medical and lay, preponderates against finding that the Veteran's psychiatric symptomatology alone resulted in total occupational and social impairment prior to December 14, 2011. Thus, there is insufficient evidence as to warrant assignment of a 100 percent schedular disability evaluation for posttraumatic stress disorder prior to that date. iv. Extraschedular consideration The Board has considered whether the Veteran may be entitled to an extraschedular rating pursuant to 38 C.F.R. § 3.321 (2015). On review, the referenced diagnostic code contemplates the Veteran's occupational and social impairment based on PTSD symptoms. As the rating criteria are considered adequate, referral for consideration of an extraschedular rating is not warranted. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Veteran has not asserted entitlement to referral based on consideration of the collective impact of his service-connected disabilities. Yancy v. McDonald, 27 Vet. App. 484, 494 (2016). Entitlement to an earlier effective date for special monthly compensation Special monthly compensation is payable under the 38 U.S.C.A. § 1114(s) rate if a Veteran has a single service-connected disability rated as 100 percent and (1) has additional service-connected disability or disabilities independently evaluated as 60 percent or more 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. See 38 U.S.C.A. § 1114(s); 38 C.F.R. § 3.350(i). In April 2012, the RO granted entitlement to special monthly compensation at the (s) rate effective December 14, 2011. The award was based on PTSD rated as 100 percent disabling as of that date and additional service-connected disabilities independently ratable at 60 percent or more. The Veteran did not appeal the effective date assigned and this issue was not addressed in the Board's July 2012 decision. Nonetheless, in the March 2014 Memorandum Decision, the Court stated that the Board failed to determine whether the Veteran's PTSD caused complete unemployability, such that it would have alone caused individual unemployability and therefore demonstrated entitlement to special monthly compensation. See Bradley v. Peake, 22 Vet. App. 280, 293 (2008). The Court explained that in Bradley, it was determined that a grant of individual unemployability based on a single disability constituted a service-connected disability rated as total for the purposes of 38 U.S.C.A. § 1114(s). A review of the claims folder shows that in September 2009, the RO granted entitlement to individual unemployability effective from September 16, 2008. The rating decision noted that the Veteran last worked in February 2001 and was unable to secure and maintain gainful employment due to his service-connected disabilities of PTSD and diabetes with complications of peripheral neuropathy and peripheral vascular disease. In May 2011, the RO determined that a clear and unmistakable error had been made and that an effective date of March 24, 2003 was warranted for the grant of individual unemployability benefits. Considering the Memorandum Decision, the pertinent question appears to be whether the Veteran's PTSD alone was sufficient to support the award of individual unemployability benefits. If so, the criteria for the award of special monthly compensation benefits would arguably be met from an earlier date. In this regard, the effective date of an increase in a veteran's disability compensation shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefore. See 38 U.S.C.A. § 5110; 38 C.F.R. § 3.400. The Veteran is arguing entitlement under 38 C.F.R. § 3.350(i)(1) (total plus 60 percent) and is not asserting entitlement under 38 C.F.R. § 3.350(i)(2) (housebound in fact). On review, the preponderance of the evidence is against finding that prior to December 14, 2011, the Veteran's PTSD alone was of such severity so as to preclude gainful employment. In making this determination, the Board acknowledges that the Veteran's PTSD is clearly productive of occupational impairment and this is reflected in the schedular ratings assigned. Evidence of record shows the Veteran had long-term employment until approximately 2002. By his own statements, including the applications submitted for individual unemployability benefits, the Veteran reported that he was too old to be retrained and that because of his diabetes and neuropathy, no one would hire him. He applied for Social Security benefits based on those conditions. The appellant did not assert unemployability due to PTSD in and of itself. The Board acknowledges there are some medical statements suggesting he is unemployable due to PTSD. As set forth, there are also statements indicating he is unemployable due to his physical conditions or due to a combination of his physical and mental conditions. The evidence shows that at best, PTSD contributed to the Veteran's inability to obtain and maintain employment, but it was not the sole basis for awarding the benefit. Review of the rating decisions makes clear the award was granted based on the combined effect of his disabilities. See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993) (In considering entitlement to individual unemployability, the pertinent inquiry is whether service-connected disabilities individually or in combination are of sufficient severity to produce unemployability - not whether a veteran is unemployable solely due to his service-connected disabilities.) In summary, the most probative evidence preponderates against finding that PTSD, standing alone, was of sufficient severity to produce unemployability prior to December 14, 2011. Accordingly, the criteria for special monthly compensation were not met until he was awarded a schedular 100 percent for PTSD effective December 14, 2011. ORDER For the period from March 24, 2005 through January 24, 2005, entitlement to a disability rating greater than 30 percent for PTSD is denied. For the period from January 25, 2005 through August 10, 2009, entitlement to a 70 percent disability rating, and no more, for PTSD is granted, subject to the laws and regulations governing the award of monetary benefits. For the period from August 11, 2009 through December 13, 2009, entitlement to a disability rating in excess of 70 percent for PTSD is denied. Entitlement to an effective date prior to December 14, 2011 for the award of special monthly compensation under 38 U.S.C.A. § 1114(s) is denied. ____________________________________________ DEREK R. BROWN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs