Citation Nr: 1736088 Decision Date: 08/30/17 Archive Date: 09/06/17 DOCKET NO. 13-20 112 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to an initial evaluation in excess of 20 percent for low back pain lumbago prior to July 31, 2015, and to a 40 percent rating thereafter. 2. Entitlement to an initial evaluation in excess of 30 percent for posttraumatic stress disorder (PTSD) prior to August 10, 2015 and to a 50 percent rating thereafter. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). 4. Entitlement to special monthly compensation (SMC) based on the need for aid and attendance. 5. Entitlement to SMC based on housebound status. 6. Whether new and material evidence has been submitted to reopen a claim for service connection for feet pain and if so whether service connection for a chronic disability manifested by feet pain is warranted; or in the alternative, whether service connection for feet conditions to include pes planus, plantar fascial fibromatosis, hallux valgus, hammer toes, and metarsalgia is warranted. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD Jason George, Associate Counsel INTRODUCTION The Veteran had active service from April 1980 to December 1980, from August 2001 to April 2002, from January 2003 to June 2003, and from August 2004 to December 2005, to include service in Iraq. These matters come before the Board of Veterans' Appeals (Board) on appeal from March 2011 (PTSD), August 2012 (bilateral knee disability, low back disability, and disability manifested by bilateral foot pain) and September 2014 (SMC based on the need for aid and attendance and/or housebound status) rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran's May 2013 and April 2014 VA Form 9s, substantive appeals, submitted specific to entitlement to an initial evaluation in excess of 20 percent for low back pain lumbago, entitlement to an initial evaluation in excess of 30 percent for PTSD, and entitlement to service connection for bilateral knee disability, reflected his desire to participate in a hearing before a member of the Board. However, in June 2014 correspondence, the Veteran withdrew this hearing request. In a subsequent appeal to the Board, the Veteran again requested a hearing, but again withdrew this request in correspondence in May 2017. Accordingly, the Board considers the Veteran's request for a hearing to be withdrawn. 38 C.F.R. § 20.704(e). Pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009), when last on appeal, the Board took jurisdiction of a TDIU claim is part of the increased rating claims on appeal. The Board further acknowledges that the grant of TDIU, effective April 11, 2014 does not moot the issue. First, the Veteran may be entitled to TDIU prior to April 11, 2014. Further, the Veteran may be entitled to TDIU on less than all of his service-connected disabilities, which may help him establish entitlement to SMC at the housebound rate prior to September 23, 2014. 38 U.S.C.A. § 1114(s); 38 C.F.R. § 3.350(i); Bradley v. Peake, 22 Vet. App. 280, 293 (2008). Thus, the issue of entitlement to TDIU remains on appeal. The following diagnoses of feet disorders has been raised by the record: pes planus, plantar fascial fibromatosis, hallux valgus, hammer toes, and metarsalgia. Given the various diagnoses and claimed conditions the Board will recharacterize the claim as service connection for a bilateral foot disorder, to include all of the listed conditions. Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that when a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled); see also Brokowski v. Shinseki, 23 Vet. App. 79 (2009). When last on appeal, the Board remanded the appeal so that additional medical records could be obtained and the Veteran could be afforded VA examinations. To the extent decided herein, such development conducted on remand was sufficient to resolve the claims as decided below. Additional evidence relevant to the Veteran's increased rating claim for PTSD has been associated with the claims file since the most recent supplemental SOC issued in September 2015. However, such is redundant of that which was considered by the RO in the SSOC. The issue of entitlement to service connection for memory loss was raised by the record in a September 2014 statement. This issue has not been adjudicated by the RO because the RO determined that it was intertwined with issues on appeal. Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b). In February 2012 correspondence from the Veteran, he requested that VA "make a decision as quick as possible" because he was experiencing hardship with his financial status. In support of the claim, the Veteran submitted various financial documents. 38 C.F.R. § 20.900(c) allows for advancement on the docket where a Veteran is experiencing "severe financial hardship." Based on the evidence, the Board finds that the motion to advance on the docket is denied. The issues of entitlement to service connection for a bilateral foot disorder; entitlement to TDIU prior to September 23, 2014; SMC housebound prior to September 23, 2014; and SMC aid and attendance are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. For the entire claims period, the Veteran's low back disability has been manifested by forward flexion to less than 30 degrees, but not unfavorable ankylosis of the thoracolumbar spine or entire spine. 2. Prior to May 21, 2014, the Veteran's PTSD has been manifested by suicidal ideation, panic attacks, irritability, hypervigilance, sleep impairment, and GAF scores in the 50s and 60s, which are productive of occupational and social impairment with deficiencies in most areas, but not total occupational and social impairment. 3. Since May 21, 2014, the Veteran has had non-differentiated psychological symptoms which resulted in total occupational and social impairment which, at times, have included agoraphobia (fear of leaving the house), suicidal ideation, irritability, anger, chronic sleep impairment, panic attacks, and a GAF score of less than 40. 4. Since September 23, 2014, the Veteran has a 100 percent rating for PTSD and additional separate and distinct service-connected disabilities independently ratable at 60 percent or greater. 5. The Veteran did not note disagreement with the August 2012 rating decision denying service connection for feet pain or submit additional evidence pertaining to the claim within one year, and the denial of the claim became final. 6. Since then, the Veteran new and material evidence has been added to the claims file pertaining to his claim for service connection for feet pain. CONCLUSIONS OF LAW 1. Prior to July 31, 2015, the criteria for a rating of 40 percent, but no higher, for chronic low back pain lumbago have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, DC 5242, General Rating Criteria for Diseases and Injuries of the Spine (2016). 2. Since July 31, 2015, the criteria for an initial rating in excess of 40 percent for chronic low back pain lumbago have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, DC 5242, General Rating Criteria for Diseases and Injuries of the Spine (2016). 3. Prior to May 21, 2014, the criteria for an initial 70 percent rating, but no higher, for PTSD were met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.14, 4.130, Diagnostic Code (DC) 9411 (2016). 4. Since May 21, 2014, the criteria for an initial 100 percent rating for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.14, 4.130, Diagnostic Code (DC) 9411 (2016). 5. Since September 23, 2014, the criteria for SMC at the housebound rate have been met. 38 U.S.C.A. § 1114 (West 2014); 38 C.F.R. § 3.350 (2016). 6. Evidence received since the August 2012 rating decision became final is new and material; the claim of entitlement to service connection for feet pain is reopened. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. §§ 3.156(a) (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Increased Rating Claims Ratings are based on a schedule of reductions in earning capacity from specific injuries or combination of injuries. The ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civil occupations. 38 U.S.C.A. § 1155. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 U.S.C.A. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3. The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided, 38 C.F.R. § 4.14, however, the ratings under more than one diagnostic code will be assigned when that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Chronic Low Back Pain Lumbago Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all of these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective enervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45. The United States Court of Appeals for Veterans Claims (Court) has held that VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss under 38 C.F.R. § 4.40, which requires VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45. Furthermore, the intent of the rating schedule is to recognize painful motion with joint or particular pathology as productive of disability. Thus, actually painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. The joints should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. In Burton v. Shinseki, 25 Vet. App. 1, 5 (2011), the Court found that, when 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis context, the Board should address its applicability. Staged ratings are appropriate whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran claims that the rating assigned for his low back disability does not reflect the severity of his symptomatology. August 2012 and July 2014 VA medical reports regarding the Veteran's low back disability are of record. There reports to not include range of motion measurements, which are necessary to adjudicate the increased rating claim for the period prior to July 31, 2015. Therefore, it is necessary to obtain a medical opinion regarding range of motion for the low back and associated medical findings on remand. At the August 2012 examination, the Veteran was reported to be unable to lift more than 2 pounds, take out the trash, tie his shoes, or pickup objects from the floor, though the Veteran had previously been very active. He also had difficulty picking up his grandchildren. As a result of these limitations, the Veteran could not keep jobs in housekeeping or a saw mill. He experienced flare-ups upon sitting or driving more than 30 minutes, or walk more than 3-4 blocks. Dressing caused shooting pain. Though range of motion measurements were not recorded, it was reported that the Veteran was able to perform repetitive-use testing, but experienced functional loss due to less movement than normal, weakened movement, excess fatigability, and pain on movement. Muscle spasm, tenderness, or pain to palpation was noted as absent, muscle strength was normal without muscle atrophy. The prior remand in this case found this examination inadequate to rate the disability. At the July 2014 examination, the Veteran reported that he sometimes cannot move, that such episodes last 4 hours 2-3 time per week, sometimes at night. He also reported that it hurts to sit and stand and that his balance is getting worse. He reported being unable to sit or stand for any extended period of time, needing help to tie his shoes, get out of bed, and get in and out of the shower. However, upon later examinations, the Veteran was found not to have ankylosis. His 40 percent rating since July 31, 2015 for his low back disability was based on a July 2015 VA examination, during which resulted in forward flexion to 15 degrees, extension to 0 degrees, right lateral flexion to 10 degrees, left lateral flexion to 10 degrees, right lateral rotation to 5 degrees, and left lateral rotation to 5 degrees. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine note (4) (directing range of motion measurement to be rounded to the nearest 5 degrees). Pain was noted on each range of motion measurement, to include with weight bearing, and the Veteran was unable to perform repetitive testing. Limited range of motion was reported to affect prolonged sitting, standing, walking, bending, lifting, pushing, pulling, twisting, and turning. Pain was said to limit functional ability during flare-ups. Muscle spasm, localized tenderness, and guarding resulting in abnormal gait or abnormal spinal contour were noted. Muscle strength in was noted as active movement against some resistance for all tests conducted. No muscle atrophy was reported. The Veteran did not have ankylosis of the spine or intervertebral disc syndrome (IVDS). In May 2017 correspondence, the Veteran requested that his hearing be cancelled because he had difficulty sitting in certain types of chairs for a long time. For the period prior to July 31, 2015, a 40 percent rating is granted. The examination conducted in August 2012, and subsequent disability benefit questionnaire (DBQ) from July 2014, do not provide adequate information upon which to assign a rating. Indeed, in the July 2015 remand, the Board specifically found that the August 2012 VA back conditions examination was not adequate, and the Board likewise finds that the July 2014 DBQ not adequate because it contains no range of motion findings. Thus, the only adequate VA examination report is the July 2015 VA examination report. However, both show significant function limitation as a result of the low back disability. The next best evidence of the severity of the Veteran's disability during this period is the July 2015 examination report. As noted above, at the July 2015 examination the Veteran's range of motion for forward flexion was to 15 degrees, for which a 40 percent rating is warranted. Therefore, a 40 percent rating will be assigned for the period prior to July 31, 2015. A rating in excess of 40 percent since July 31, 2015 for chronic low back pain lumbago is not warranted as the examination reports show that the Veteran does not experience unfavorable ankylosis of the spine. Further, while the VA examination conducted in September 2015 does not include all of the range of motion testing required by Correia v. McDonald, 28 Vet. App. 158 (2016), as the Veteran's 40 percent rating is the maximum schedular rating available based on limitation of range of motion, such testing is unnecessary to determine that a rating in excess of 40 percent is not warranted. The rating criteria also have considered the Veteran's muscle spasm, localized tenderness, and guarding resulting in abnormal gait or abnormal spinal contour, pain, inability to perform repetitive testing, use of a brace and cane, and additional functional impact during flare-ups and after repetitive use. 38 C.F.R. § 4.40, 4.45, 4.59, 4.71a, DC 5272, General Rating Formula for Diseases and Injuries of the Spine. Such rating also contemplates difficulty sitting in certain types of chairs for long periods of time because of pain. Therefore, a rating in excess of 40 percent since July 31, 2015 is denied. The Board also notes that there is no indication of incapacitating episodes due to IVDS that require bed rest prescribed by a physician to warrant a higher rating under 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. The Board acknowledges that the Veteran is service connected for right and left lower muscle rigidity with stiffness with radiculopathy, and that the Veteran had neurological abnormalities reported on the September 2015 thoracolumbar examination. When adjudicating an increased rating claim for the spine, the rating code directs the Board to rate "any associated objective neurologic abnormalities." 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine; see also Esteban v. Brown, 6 Vet. App. 259, 262 (1994) (holding that multiple rating codes can be used to rate the same disability where there is no overlapping symptomatology considered by the rating codes under which ratings for the disability have been assigned). However, it has been stated that the Veteran's muscle rigidity in each leg was related to Parkinson's disease, for which the Veteran appears to be rated under several different DCs. This is the most definitive statement as to the etiology of the Veteran's service-connected muscle rigidity with stiffness in the lower extremities. There is no indication that these radicular disabilities are related to the low back. Thus, the Board finds that the Veteran's muscle rigidity in each leg is related to Parkinson's disease, not the low back disability for which he now seeks a higher rating. Therefore, the Board is not in a position to exercise jurisdiction over these ratings. In summary, a rating in excess of 40 percent for chronic low back pain lumbago since July 31, 2015 is denied. PTSD The Veteran's PTSD has been evaluated under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, DC 9411. A 10 percent evaluation is warranted for PTSD where 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. A 30 percent evaluation is warranted for PTSD where there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, 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). A 50 percent evaluation is warranted for PTSD where 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. A 70 percent evaluation is warranted where there is objective evidence demonstrating 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, or 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. A 100 percent disability evaluation is warranted when 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 and place; and memory loss for names of close relatives, own occupation, or own name. Id. The symptoms listed in Diagnostic Code 9411 are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002); see also Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013) (explaining that the symptoms that could give rise to a given rating are those in like kind, i.e., of similar duration, severity, and frequency, to those provided in the non-exhaustive lists). Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). An assigned GAF score, like an examiner's assessment of the severity of a condition, is not dispositive of the percentage rating issue; rather, it must be considered in light of the actual symptoms of a psychiatric disorder (which provide the primary basis for the rating assigned). See 38 C.F.R. § 4.126(a). Accordingly, an examiner's classification of the level of psychiatric impairment, by word or by a GAF score, is to be considered but is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. Carpenter, 8 Vet. App. 242; see also 38 C.F.R. § 4.126, VAOPGCPREC 10-95, 60 Fed. Reg. 43186 (1995). GAF scores were historically used to reflect the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health, and were also useful indicators of the severity of a mental disorder. See DSM-IV. A GAF of 21 to 30 is defined as behavior considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriate, suicidal preoccupation) or an inability to function in almost all areas (e.g., stays in bed all day, no job, home or friends). A GAF of 31 to 40 is indicative of some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or any major impairment in several areas, such as work or school, family relations, judgment, thinking or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). A GAF score of 51 to 60 indicates the examiner's assessment of moderate symptoms (e.g., a flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF score of 61 to 70 indicates the examiner's assessment of some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well and having some meaningful interpersonal relationships. The December 2010 VA examination reports that the Veteran was cooperative, friendly, and relaxed with normal affect. He had a good mood. However, he reported sleep impairment, resulting in only five hours of sleep per night that caused exhaustion and interfered with daytime activities. Lack of panic attacks and suicidal and homicidal ideation was reported. Recurrent and intrusive recollections resulting in avoidance behavior was noted. He also had hypervigilance, and startled response. His PTSD was reported to be mild, and a GAF score of 61 was assigned. Treatment records from May 2011 note a GAF score of 50, from September 2011, a GAF score of 55, and from October 2011, and a GAF score of 60. In April 2013, a GAF score of 65 was reported. As noted in March 2014, the Veteran, in addition to experiencing PTSD symptoms, was grieving the loss of his son. He reported having had a panic attack on the way to the appointment. In May 2014 VA examination report, the Veteran was said to have PTSD, panic disorder with agoraphobia, and depression. Psychosocial and environmental problems were described to be severe, and a GAF score under 40 was assigned. Total occupational and social impairment was endorsed by the examiner. The Veteran had not worked in several years and did not appear to be capable of working. Anxiety, near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively, memory impairment, flattened affect, difficulty understanding complex commands, disturbances of motivation and mood, suicidal ideation, and intermittent inability to perform activities of daily living was reported. The Veteran reported sleeping only 2-3 hours for the last 2-3 weeks. Similarly, in December 2014, the Veteran reported being groggy because of lack of sleep, and feeling more depressed. In February 2015, the Veteran's mood was noted to be irritable, dysphoric initially, and quite reticent. Throughout the claims period, there appear to be records directed at controlling anger and irritability. In addition, there are inconsistent indications of suicidal ideation, though without plan or intent throughout the record, without a definitive demarcation indicating onset of this symptom. In June 2015, the Veteran appeared at an appointment with his wife and gave only hostile, one-word answers. At the July 2015 VA thoracolumbar back examination, the examiner reported that the Veteran presented initially with poor eye contact, accompanied by spouse. Spouse was tearful, and the Veteran expressed frustration with VA and depression. After intervention by a mental health clinician, and taking medication, the Veteran presented with brighter affect. At an August 2015 examination, the Veteran was said to have PTSD and panic disorder, and the examiner concluded it was not possible to attribute definitively symptoms to each disorder. The Veteran experienced depressed mood, panic attacks less than weekly, chronic sleep impairment, mild memory loss, and difficulty in establishing and maintaining effective work and social relationships. The Veteran's PTSD and panic disorder was said to impede his ability to engage in physical and sedentary work. Overall, PTSD was said to be frequent, chronic, and moderate in nature. The Board notes that the Veteran's presentation at the July 2015 VA thoracolumbar back examination is indicative of a very severe level of social and occupational impairment. However, his condition improved with medication. As the rating criteria applied contemplate "continuous medication" at the 10 percent level, the Board finds that the rating criteria contemplates the ameliorative effects of medication. See McCarroll v. McDonald, 28 Vet. App. 26 (2016) (holding that the Board did not err in failing to discount the ameliorative effects of blood pressure medication as the plain language of DC 7101 contemplates the effects of medications). Cf. Jones v. Shinseki, 26 Vet. App. 56, 63 (2012), (holding that, "[a]bsent a clear statement [in the diagnostic code] setting out whether or how the Board should address the effects of medication . . . the Board may not deny entitlement to a higher disability rating on the basis of relief provided by medication"). Therefore, the Board may consider that the Veteran had a sufficient level of social and occupational function so that the back examination could be conducted with the use of medication. Prior to May 21, 2014, the Veteran's PTSD was conductive of occupational and social impairment in most areas, for which a 70 percent rating is warranted. This is supported by the Veteran's suicidal ideation, irritability, panic attacks, sleep impairment, intrusive thoughts, avoidance behavior, hypervigilance, and startled response. Nonetheless, as of May 21, 2014, the date of the May 2014 VA examination report, the Veteran's PTSD warrants a 100 percent rating. The examiner therein noted agoraphobia-fear of leaving the house. This strongly implicates that the Veteran experienced total occupational and social impairment. He has also had on-going suicidal ideation and irritability. A GAF score of less than 40, indicative of rather severe impairment was also reported on the May 2014 examination report. Though appearing with brighter affect after medication, the Veteran's distraught emotional state at the July 2015 back examination also weighs in favor of finding that PTSD symptoms after May 21, 2014 most nearly approximate those listed in the 100 percent rating. Though the Veteran's symptoms recorded in the May 2014 examination may have existed prior to the examination date, this is the date on which those symptoms warranting a 100 percent rating were first ascertainable, and therefore, this is the appropriate date for the increase. Swain v. McDonald, 27 Vet. App. 219, 224 (2015). Further, though the Veteran was reported to have more than one psychological disorder contributing to the reported symptoms in the examination reports of record, the examiner have not, or could not, distinguish the effects of the disorders, and so all symptoms must be attributed to service-connected PTSD. See Mittleider v. West, 11 Vet. App. 181 (1998) (regulations require that when examiners are not able to distinguish the symptoms and/or degree of impairment due to a service-connected versus a non-service-connected disorder, VA must consider all of the symptoms in the adjudication of the claim). Special Monthly Compensation-Housebound SMC provided by 38 U.S.C. § 1114(s) is payable where a veteran has a single service-connected disability rated as total and either (1) has additional service-connected disability or disabilities independently ratable at 60 percent or more, 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. 38 U.S.C.A. § 1114(s); 38 C.F.R. § 3.350(i). Given the 100 percent rating for PTSD assigned herein, the Veteran is entitled to schedular SMC at the housebound rate as of September 23, 2014, because he has additional ratings with a combined rating of at least 60 percent. 38 C.F.R. § 3.350(i)(1). Though the Veteran had yet not met the schedular requirement's for SMC at the housebound rate, the Veteran's agoraphobia, as reported on the May 21, 2014 examination report, which is presumed to be attributed to service-connected PTSD under Mittleider, based on the well-known nature of the disorder and reports that the Veteran rarely left his home. The above intermediary adjudication of benefits herein will not prejudice the Veteran. In particular, though the Veteran is still seeking SMC aid and attendance, which is a greater benefit than SMC housebound, this grant will not prejudice the Veteran. If SMC aid and attendance is later awarded for a period when the Veteran was in receipt of SMC housebound, the RO will ensure the Veteran is in receipt of the proper benefit allowed by law. Because of the grant of SMC at the housebound rate as of September 23, 2014, the issue of entitlement to TDIU after September 23, 2014 has become moot. Claim to Reopen Service Connection for Feet Pain Generally, a VA decision becomes final if a notice of disagreement (NOD) is not filed, unless new evidence is submitted by the Veteran or associated with the file by VA. 38 U.S.C.A. § 7105; 38 C.F.R. §§ 20.1100, 20.1103. To reopen and review a claim that has been previously denied, new and material evidence must be submitted by or on behalf of a claimant. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a); see also Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). The question of whether to reopen a claim should be considered under the standard of 38 C.F.R. § 3.159(c)(4)(iii), consistent with McLendon v. Nicholson, 20 Vet. App. 79 (2006), for determining whether a VA examination is necessary. See Shade v. Shinseki, 24 Vet. App. 110, 118-19, 123 (2010). If the McLendon standard is met, the claim should be reopened. See id. In August 2012, service connection for feet pain was denied. There was no note of a current diagnosis for the claimed disability or explain as to why service connection was denied, other than citation to the record. The Veteran was given notice of the decision in August 2012. Thereafter, the Veteran noted disagreement with other claims, but not the denial of service connection for feet pain. Since then, additional medical records pertaining to treatment for and diagnosis of feet conditions have been submitted, including a disability benefits questionnaire (DBQ) completed by the Veteran's physician. Specifically, the DBQ reports that the Veteran has flare-ups, his limited ambulation during flare-ups, and diagnoses for feet pain. Therefore, new and material evidence has been received such that the Board can reopen the claim for service connection for feet pain. See 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a). In summary, the Board is assigning a rating of 40 percent for the low back for the entire rating period on appeal; granting a 70 percent rating for PTSD prior to May 21, 2014 and a 100 percent rating thereafter; and granting SMC at the housebound rate as of September 23, 2014. The claim of service connection for feet pain is also reopened. ORDER Prior to July 31, 2015, an initial rating of 40 percent, but no higher, for chronic low back pain lumbago is granted, subject to the laws and regulations governing the payment of monetary benefits. Since July 31, 2015, an initial rating in excess of 40 percent for chronic low back pain lumbago is denied. Prior to May 21, 2014, an initial rating of 70 percent for PTSD is granted, subject to the laws and regulations governing the payment of monetary benefits. Since May 21, 2014, an initial rating of 100 percent for PTSD is granted, subject to the laws and regulations governing the payment of monetary benefits. Since September 23, 2014 SMC at the housebound rate is granted, subject to the laws and regulations governing the payment of monetary benefits. New and material evidence having been submitted, the claim for entitlement to service connection for feet pain is reopened, the appeal is granted to this extent only. REMAND It is necessary to remand the Veteran's claim for service connection for chronic bilateral foot pain to afford him with a VA examination and obtain a medical opinion. In this regard, VA is obliged to provide an examination or obtain a medical opinion in a claim of service connection when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service, and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C.A. § 5103A (d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran claims that his chronic bilateral foot pain is related to service, and no examination of the feet has yet been conducted. Because the Veteran served in the Southwestern Theater of Operation, there is no need for a current diagnosis under McLendon. The McLendon criteria having been met, it is necessary to determine whether the Veteran's chronic bilateral foot pain is attributable to any particular disorder. If so, the question is whether that disorder is at least as likely related to service. If the Veteran's chronic bilateral foot pain is of an unknown etiology, then service connection should be granted under 38 C.F.R. § 3.317. Accordingly, the case is REMANDED for the following action: 1. Thereafter, arrange for the Veteran to undergo a VA examination to determine the nature and etiology of his bilateral foot pain, also claimed as pes planus, plantar fascial fibromatosis, hallux valgus, hammer toes, and metarsalgia. The entire claims file should be reviewed by the examiner and all indicated tests should be conducted. The examiner is requested to opine as to the following: (A) Confirm whether the Veteran's chronic bilateral foot pain is attributable to any known clinical diagnoses with a clear and specific etiology, including include pes planus, plantar fascial fibromatosis, hallux valgus, hammer toes, and metarsalgia. (B) If the Veteran's chronic bilateral foot pain is attributable to one or more known clinical diagnoses with a clear and specific etiology, whether it is at least as likely as not that one or more diagnosable foot conditions are related to service, to include service in Southwest Asia. (C) The functional limitations of all of the Veteran's service-connected disabilities prior to September 23, 2014, which, at that time, included only PTSD, chronic low back pain lumbago, and right and left knee arthritis, to include the impact of these disabilities on employability. A complete rationale for all opinions should be provided. 2. Schedule the Veteran for a VA aid and attendance examination. The entire claims file should be reviewed by the examiner and all indicated tests should be conducted. The examiner is to comment on the effects of the Veteran's service-connected disabilities on his possible need of regular aid and attendance. The examiner should comment on whether the following factors are present as a result of the disabilities, including consideration of the statements of the Veteran: inability of the Veteran to dress himself or to keep himself ordinarily clean and presentable; inability of the Veteran to feed himself through the loss of coordination of the upper extremities or through extreme weakness; or inability to tend to the wants of nature; and the incapacity, physical or mental, which requires care or assistance on a regular basis to protect the Veteran from hazards or dangers incident to his daily environment. A rationale for all opinions expressed should be provided. 3. Finally, readjudicate the appeal. If any of the benefits sought remain denied, issue a supplemental statement of the case and return the case to the Board. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs