Citation Nr: 1746933 Decision Date: 10/20/17 Archive Date: 10/31/17 DOCKET NO. 13-33 429 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to an initial disability rating in excess of 70 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a disability rating in excess of 60 percent for gastroesophageal reflux disorder (GERD)/hiatal hernia. 3. Entitlement to special monthly compensation (SMC) based on a need for the regular aid and attendance of another person. 4. Entitlement to SMC based on housebound status. REPRESENTATION Veteran represented by: J. Michael Woods, Attorney ATTORNEY FOR THE BOARD J.A. Gelber, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1984 to June 1991. These matters come before the Board of Veterans' Appeals (Board) on appeal from an October 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. In a November 2016 VA Form 21-0958, the Veteran, via his attorney, raised the issue of entitlement to SMC based on aid and attendance and based on housebound status. These claims are under the Board's jurisdiction as part and parcel of his increased rating claims. See Akles v. Derwinski, 1 Vet. App 118, 121 (1991); 38 C.F.R. § 3.155(d)(2) (2016). FINDINGS OF FACT 1. The weight of the competent and probative evidence is against finding total occupational and social impairment due to PTSD-related symptoms. 2. The Veteran's service-connected GERD/hiatal hernia has been assigned the maximum schedular rating under 38 C.F.R. 4.114, Diagnostic Code 7346. 3. The weight of the competent and probative evidence is against finding that the Veteran's service-connected disabilities render him so incapable of performing the activities of daily living that he requires care or assistance on a regular basis to protect him from hazards or dangers incident to his daily environment. 4. The Veteran does not have a single permanent disability warranting a 100 percent rating. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating in excess of 70 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code (DC) 9411 (2016). 2. The criteria for a disability rating in excess of 60 percent for GERD/hiatal hernia have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.114, DC 7346 (2016). 3. The criteria for SMC based on the need for regular aid and attendance have not been met. 38 U.S.C.A. §§ 1114, 5107 (West 2014); 38 C.F.R. §§ 3.350, 3.352 (2016). 4. The criteria for SMC based on housebound status have not been met. 38 U.S.C.A. §§ 1114, 5107; 38 C.F.R. § 3.350. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. VA sent a letter to the Veteran in July 2010, prior to adjudication of his claims. No further notice is required regarding the downstream issue of a higher initial rating for PTSD as it stems from the grant of service connection, and no prejudice has been alleged. Next, VA has a duty to assist the Veteran in the development of his claims. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159 (2016). The Veteran's military personnel and treatment records, as well as all available, identified medical records, have been associated with the virtual file and considered. The Board has also reviewed 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. The Veteran was afforded relevant VA examinations in June 2010, October 2010, January 2012, October 2012, November 2012, and November 2015. In light of the foregoing, the Board will proceed to the merits of the appeal. II. Initial Increased Rating Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. 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 disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where, as in the instant case, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Staged ratings are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods during the course of the appeal. Id. at 126-27; Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Rating Schedule. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3; see Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the disorder. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath, 1 Vet. App. at 593. The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one disorder is not duplicative of the symptomatology of the other disorder. 38 C.F.R. § 4.14 (2016); Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The Veteran is competent to report symptoms and experiences observable by his senses. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). The Veteran contends he is entitled to an initial disability rating in excess of 70 percent for PTSD, evaluated under Diagnostic Code 9411. Psychiatric disabilities are rated based on the General Rating Formula codified in 38 C.F.R. § 4.130, which provides disability ratings based on a spectrum of symptoms. "A veteran may qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of a similar severity, frequency, and duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV) and (5th ed. 2013) (DSM-5). See Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). Indeed, "VA must engage in a holistic analysis" that assess the severity, frequency, and duration of the signs and symptoms of the veteran's service-connected mental disorder; quantifies the level of occupational and social impairment caused by those symptoms; and assigns an evaluation that most nearly approximates the level of occupational and social impairment. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017). Under the General Rating Formula, in pertinent part, the criteria for a 100 percent rating are as follows: 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; and memory loss for names of close relatives, own occupation, own name. 38 C.F.R. § 4.130. The criteria for a 70 percent rating, the Veteran's current one, are for application with occupational and social impairment, with deficiencies in most area, 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 work like setting); inability to establish and maintain effective relationships. After reviewing the relevant medical and lay evidence and applying the above laws and regulations, the Board finds that an initial disability rating in excess of 70 percent for PTSD is not warranted. Initially, the Board notes that the Veteran was employed by a landscaping company on a seasonal basis from 2007 to 2011, with other previous employment, but has not been employed since October 2011. 11/05/2011 VBMS, VA 21-8940. The Veteran's ability to maintain even part-time employment weighs against finding total social and occupational impairment prior to October 2011. In October 2010, a VA examiner conducted a mental status examination with the following results: cooperative; mildly anxious; normal speech; organized thought processes; appropriate eye contact; no inappropriate behavior; not currently suicidal or homicidal; in control of his impulses; maintains minimal personal hygiene and other basic activities of daily living (ADLs); no obsessive or ritualistic behavior; restricted affect; oriented to person, time, and place. The Veteran denied panic attacks and hallucinations, but admitted to sometimes hearing his own voice saying "watch out" or "be alert." The Veteran was not currently delusional, but did describe significant hypervigilance. The Veteran knew the current United States president and the two previous presidents, but made errors on simple calculations. The examiner concluded that the Veteran's PTSD-related signs and symptoms result in decreased reliability and productivity, citing to the Veteran's difficulties with anxiety, irritability, being in crowds, and concentration. The examiner assigned a Global Assessment of Functioning (GAF) score of 50. 10/27/2010 VBMS, VA Exam, pp. 4-9. A GAF score between 41 and 50 indicates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or serious impairment in social, occupational, or school functioning. See DSM-IV (emphasis added). A January 2012 VA examination noted symptoms such as depressed mood, anxiety, suspiciousness, and chronic sleep impairment. The examiner did not indicate the presence of such symptoms as near continuous panic or depression, memory or cognitive impairment, hallucinations, grossly inappropriate behavior, or inability to perform ADLs. The examiner noted that he lives with his spouse and they get along fairly well. The examiner concluded that the Veteran's PTSD-related symptoms result in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The examiner also opined that the Veteran's PTSD does not render him unable to secure and maintain gainful employment. 01/07/2012 VBMS, VA Exam, pp. 4-9. An October 2012 VA examination indicates symptoms such as depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The examiner did not find the presence of such symptoms as near continuous panic or depression, memory or cognitive impairment, hallucinations, grossly inappropriate behavior, or inability to perform ADLs, but noted that the Veteran will sometimes neglect personal hygiene and grooming while depressed. The examiner noted passive suicidal intent, but stated that there have been no hospitalizations due to psychiatric symptoms at any time. A mental status examination demonstrated normal speech; organized and goal-directed thought processes; no hallucinations; and alert and oriented to person, time, place, and situation. Some cognitive impairment was shown: the Veteran was able to spell "world" forwards and backward; he was able to interpret proverbs; he had difficulty with concentration; he was able to perform simple calculations but had difficulty performing serial 7s; he was able to name the three most recent United States presidents; immediate recall was intact; and he recalled one of three objects after three minutes. The examiner found that the Veteran had fair insight and that his judgment was not impaired. The Veteran reported that he fights a lot with his spouse and that he does not like to be around people. The examiner concluded that the Veteran's PTSD-related symptoms result in occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, and/or mood. 10/17/2012 VBMS, VA Exam, pp. 5-11. The Veteran was afforded a VA examination in November 2015, at which time the following symptoms were indicated: depressed mood; anxiety; suspiciousness; panic attacks more than once a week; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a worklike setting; suicidal ideation; and problems with concentration. The Veteran reported having problems with his spouse and not having any close friends. Based on a mental status examination, the examiner found that the Veteran was alert and oriented, cooperative, mildly anxious, had normal speech, and recalled two of three words with prompting. The Veteran had never been hospitalized for mental health problems. The examiner concluded that the Veteran's PTSD-related symptoms result in severe occupational and social impairment with deficits in most areas such as work, school, family relations, judgment, thinking, and/or mood. 11/16/2015 VBMS, C&P Exam. The record reflects over two dozen mental status examinations conducted by VA mental health experts during the period on appeal. None of the mental status examinations demonstrated symptoms such 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 ADLs; disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. The mental status examinations all reflected GAF scores between 41 and 50, which, as previously noted, indicate serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or serious impairment in social, occupational, or school functioning. See DSM-IV (emphasis added). A GAF score of 30 or less would be more indicative of total and social occupational impairment. See id. The Board finds the October 2010, January 2012, October 2012, and November 2015 VA examinations to be competent, credible, and highly probative, as they are supported by in-person examinations, review of the relevant medical records, mental health expertise, and adequate rationales. The probative value of the examinations is bolstered by the consistent findings contained in the numerous mental status examinations conducted throughout the period on appeal. Accordingly, the Board finds that the weight of the competent and probative evidence is against finding that the Veteran's disability picture more closely approximates a 100 percent rating for PTSD. Indeed, the Veteran had some seasonal employment prior to October 2011. Regarding social impairment, it was noted that he got along with this spouse fairly well at the January 2012 VA examination. Additionally, the 2015 VA examiner found that the Veteran had difficulty in establishing and maintaining effective work and social relationship. The foregoing competent medical and lay evidence, along with that described in more detail above, weighs against a finding of total social and occupational impairment. All possible applicable diagnostic codes have been considered, but the Veteran could not receive a higher disability rating for PTSD. See 38 C.F.R. § 4.130. Indeed, when a disorder is listed in the schedule, rating by analogy is not appropriate. Copeland v. McDonald, 27 Vet. App. 333, 336-37 (2015). III. Non-Initial Increased Rating 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 disability. Schafrath, 1 Vet. App. at 594. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Id. Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505, 510 (2007). The Veteran is competent to report symptoms and experiences observable by his senses. See Jandreau, 492 F.3d at 1377; 38 C.F.R. § 3.159(a). The Veteran contends he is entitled to a disability rating in excess of 60 percent for GERD, evaluated, by analogy, under Diagnostic Code 7346 for hiatal hernia. 38 C.FR. § 4.114, DC 7346. A 10 percent rating is applicable to conditions with two or more of the symptoms listed in the 30 percent criteria of less severity. A 30 percent rating is warranted for persistently recurrent epigastric distress with dysphagia (difficulty swallowing), pyrosis (heartburn), and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. Finally, the maximum, 60 percent disability rating requires pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of serious impairment of health. 38 C.F.R. § 4.114, DC 7346. As previously noted, the Veteran is currently assigned the maximum 60 percent schedular rating under Diagnostic Code 7346 throughout the entire rating period on appeal stretching from June 2010 to the present. The Veteran was afforded a VA examination in June 2010, at which time he denied any limitations in his ability to perform ADLs due to his GERD. The examiner noted symptoms such as hematemesis, reflux, regurgitation, nausea, headaches, and trouble sleeping, but no history of hospitalizations. The examiner also noted functional limitations such as occasional light headedness and an inability to participate in activities such as basketball and running, and that the Veteran missed work six to seven times over the past year. 06/26/2010 VBMS, VA Exam. In July 2010 and October 2010, VA received statements from the Veteran in which he reported that issues such as trouble keeping food down, indigestion, light headedness, headaches, vomiting, fatigue, anxiety, and weight fluctuations cause him to miss work. 07/21/2010 VBMS, VA 21-4138; 10/12/2012 VBMS, VA 21-4138. A January 2012 VA examination indicates the presence of symptoms such as persistently recurrent epigastric distress, dysphagia, heartburn, reflux, regurgitation, substernal arm or shoulder pain, sleep disturbance, transient episodes of nausea lasting less than one day, and transient episodes of vomiting lasting less than one day. The examiner opined that the Veteran's GERD-related symptoms do not impact his ability to work. 01/06/2012 VBMS, VA Exam, pp. 12-15. In November 2012, a VA examiner noted symptoms such as persistently recurrent epigastric distress, dysphagia, heartburn, reflux, regurgitation, substernal arm or shoulder pain, sleep disturbance, recurrent episodes of nausea lasting less than one day, recurrent episodes of vomiting lasting less than one day, episodes of hematemesis lasting less than one day, and recurrent episodes of melena lasting less than one day. The examiner concluded that the Veteran's GERD-related symptoms do not impact his ability to work. 11/05/2012 VBMS, VA Exam, pp. 3-8. A November 2015 VA examiner noted the presence of dysphagia, and opined that the Veteran's GERD does not impact his ability to work. 11/20/2015 VBMS, C&P Exam. The Board finds the June 2010, January 2012, November 2012, and November 2015 VA examinations to be competent, credible, and highly probative, as they are supported by in-person examinations, review of the relevant medical records, and medical expertise. The Board considered all potentially applicable diagnostic codes in accordance with Schafrath, 1 Vet. App. 589; however, the evidence does not show symptoms that could be rated higher under another diagnostic code. See 38 C.F.R. § 4.114. In any event, the 60 percent rating under Diagnostic Code 7346 effectively accounts for all GERD/hiatal hernia-related symptoms that combine to cause a serious impairment of health. Thus, the Board finds that the Veteran is not entitled to a rating in excess of 60 percent for GERD/hiatal hernia. IV. SMC "SMC is available when, 'as the result of service-connected disability,' a veteran suffers additional hardships above and beyond those contemplated by VA's schedule for rating disabilities." Breniser v. Shinseki, 25 Vet. App. 64, 68 (2011) (citing 38 U.S.C.A. §1114(k)-(s)). Section 1114(l) provides five distinct ways for a veteran, "as the result of service-connected disability," to qualify for this rate of SMC: (1) anatomical loss or loss of use of both feet; (2) anatomical loss or loss of use of one hand and one foot; (3) blindness in both eyes with 5/200 visual acuity or less; (4) being permanently bedridden; or (5) having "such significant disabilities as to be in need of regular aid and attendance." 38 U.S.C.A. § 1114(l). The following basic considerations are critical in determining the need for the regular aid and attendance of another person: inability of the Veteran to dress or undress him or herself, or to keep him or herself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid (this will not include the adjustment of appliances which normal persons would be unable to adjust without aid, such as supports, belts, lacing at the back, etc.); inability of claimant to feed him or herself through loss of coordination of upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect the claimant from hazards or dangers incident to his or her daily environment. 38 C.F.R. § 3.352(a). Determinations as to the need for aid and attendance must be based on actual requirements of personal assistance from others. Id. It is not required that all of the disabling conditions enumerated in 38 C.F.R. § 3.352(a) be found to exist before a favorable rating may be made. The particular personal functions which a veteran is unable to perform should be considered in connection with his or her condition as a whole. It is only necessary that the evidence establish that a veteran is so helpless as to need regular aid and attendance, not that there is a constant need. Id. "Bedridden" will be a proper basis for the determination for the need for aid and attendance. "Bedridden" will be that condition which, through its essential character, actually requires that the claimant remain in bed. The fact that a claimant has voluntarily taken to bed or that a physician has prescribed rest in bed for the greater or lesser part of the day to promote convalescence or cure will not suffice. 38 C.F.R. § 3.352(a). In Turco v. Brown, 9 Vet. App. 222, 224-25 (1996), the United States Court of Appeals for Veterans Claims (Court) held that it was not required that all of the disabling conditions enumerated in the provisions of 38 C.F.R. § 3.352 (a) be found to exist to establish eligibility for aid and attendance and that such eligibility required at least one of the enumerated factors be present. If the Veteran does not qualify for increased benefits for aid and attendance, increased compensation benefits may still be payable if the Veteran is able to establish entitlement to SMC based on housebound status under 38 U.S.C.A. § 1114(s). Under 38 U.S.C.A. § 1114(s), SMC is payable at the housebound rate if the Veteran has a single service-connected disability rated as 100 percent and either of the following are met: (1) there is 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) he or she 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). The requirement of "permanently housebound" will be considered to have been met when the veteran is substantially confined to his or her house (ward or clinical areas, if institutionalized) or immediate premises due to a service-connected disability or disabilities which it is reasonably certain will remain throughout his or her lifetime. Id. In Bradley v. Peake, the United States Court of Appeals for Veterans Claims (Court) held that if the evidence supports a finding of TDIU based solely upon a single service-connected disability, then such a TDIU rating may serve as the factual predicate for an award of SMC pursuant to 38 U.S.C.A. § 1114(s). 22 Vet. App. 280, 293 (2008). Initially, the Board notes that the Veteran does not have a service-connected disability rated at 100 percent. The Board acknowledges that the Veteran is in receipt of a 100 percent rating based on TDIU; however, the Board finds that TDIU is not based solely on a single service-connected disability. The May 2016 rating decision granting TDIU stated that the award was based on the Veteran's inability to maintain gainful employment due to both his PTSD and GERD. Additionally, for the reasons set forth in Sections II and III above, the Board finds that neither the Veteran's PTSD nor his GERD/hiatal hernia by itself renders the Veteran unable to secure and maintain gainful employment. Accordingly, Bradley is inapplicable, and the Veteran does not have a single service-connected disability warranting a 100 percent rating. Thus, SMC based on housebound status is not warranted. The Board next considers whether the evidence demonstrates the need for aid and attendance of another person on a facts found basis. The evidence, as set forth more fully above, does not indicate that the Veteran is unable to undress himself, keep himself ordinarily clean and presentable, feed himself, or attend to the wants or nature, or that he has a physical or mental disorder which requires care or assistance on a regular basis to protect him from hazards or dangers incident to his daily environment. Nor is there any indication that the Veteran is bedridden. The Veteran's GERD/hiatal hernia symptoms do not impact his ability to take care of himself. The VA examinations and voluminous mental health records all indicate that the Veteran is capable of attending to his activities of daily living. For example, the November 2010 VA examination for PTSD noted that the Veteran was casually dressed and he was able to maintain his minimal personal hygience and other basic activities of daily living. Similarly, the October 2012 VA PTSD examination report reflects that the box for neglect of personal appearance and hygiene was not checked. Accordingly, the Board finds that the weight of the competent and probative evidence is against finding that the Veteran's service-connected disabilities render him so incapable of performing the activities of daily living that he requires care or assistance on a regular basis to protect him from hazards or dangers incident to his daily environment. ORDER An initial disability rating in excess of 70 percent for PTSD is denied. A disability rating in excess of 60 percent for GERD/hiatal hernia is denied. SMC based on the need for aid and attendance is denied. SMC based on housebound status is denied. ____________________________________________ Paul Sorisio Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs