Citation Nr: 1803964 Decision Date: 01/23/18 Archive Date: 01/31/18 DOCKET NO. 14-07 371 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to an effective date earlier than April 8, 2012, for the grant of service connection for coronary artery disease (CAD). 2. Entitlement to service connection, including on a secondary basis, for bilateral upper extremity peripheral neuropathy. 3. Entitlement to service connection, including on a secondary basis, for bilateral lower extremity peripheral neuropathy. 4. Entitlement to service connection, including on a secondary basis, for obstructive sleep apnea (OSA). 5. Entitlement to an initial increased rating in excess of 30 percent prior to April 6, 2013, and in excess of 50 percent from April 6, 2013, for posttraumatic stress disorder (PTSD) with major depressive disorder and panic disorder without agoraphobia. 6. Entitlement to an initial increased rating in excess of 60 percent for CAD. 7. Entitlement to an initial compensable rating for tinea pedis. 8. Entitlement to a total disability rating based on individual unemployability, due to service-connected disabilities (TDIU). 9. Entitlement to special monthly compensation (SMC) based on aid and attendance/housebound. REPRESENTATION Veteran represented by: Polly Murphy, Attorney WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD J. Cheng, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1964 to October 1966. This case comes to the Board of Veterans' Appeals (Board) on appeal from March 2012, August 2012, March 2014, and March 2016 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. In February 2017, the Veteran and his spouse testified during a hearing before the undersigned that was conducted via videoconference. A transcript of the hearing is of record. FINDINGS OF FACT 1. At the Board hearing on February 9, 2017, the Veteran withdrew his perfected appeal of the issue of entitlement to an initial increased rating for CAD. 2. At the Board hearing on February 9, 2017, the Veteran withdrew his perfected appeal of the issue of entitlement to an initial increased rating for tinea pedis. 3. The Veteran first filed a claim seeking service connection for a heart disorder on April 8, 2013, more than one year after the effective date that CAD was included as a presumptive Agent Orange disease under 38 C.F.R. § 3.309(e) . 4. There is no other statement or communication from the Veteran, or other document, prior to the April 8, 2013, that constitutes a claim of entitlement to service connection for CAD. 5. Resolving reasonable doubt in the Veteran's favor, his current peripheral neuropathy of the bilateral upper extremities is etiologically related to his service-connected diabetes mellitus. 6. Resolving reasonable doubt in the Veteran's favor, his current peripheral neuropathy of the bilateral lower extremities is etiologically related to his service-connected diabetes mellitus. 7. Resolving reasonable doubt in the Veteran's favor, his current OSA is etiologically related to his service-connected PTSD. 8. Resolving reasonable doubt in the Veteran's favor, his PTSD has been manifested, at worst, by symptoms productive of occupational and social impairment with deficiencies in most areas. 9. From November 8, 2010, the Veteran's service-connected PTSD rendered him unable to secure or follow substantially gainful employment. 10. The Veteran was not permanently substantially confined to his home as a result of his service-connected disabilities. 11. The Veteran was not unable to protect himself from the hazards and dangers incident to his daily environment due to service-connected disabilities, nor was he unable to perform self-care activities without the aid and assistance of another. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the appeal of the issue of entitlement to an initial increased rating for CAD have been met. 38 U.S.C. § 7105(b)(2), (d)(5) (2012); 38 C.F.R. § 20.204 (2017). 2. The criteria for withdrawal of the appeal of the issue of entitlement to an initial increased rating for tinea pedis have been met. 38 U.S.C. § 7105(b)(2), (d)(5) (2012); 38 C.F.R. § 20.204 (2017). 3. The criteria for assignment of an effective date prior to April 8, 2012, for the grant of service connection for CAD have not been met. 38 U.S.C. § 5110 (2012); 38 C.F.R. § 3.400 (2017). 4. The criteria to establish service connection for peripheral neuropathy of bilateral upper extremities are met. 38 U.S.C. §§ 1101, 1110, 1112, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309(a) (2017). 5. The criteria to establish service connection for peripheral neuropathy of bilateral lower extremities are met. 38 U.S.C. §§ 1101, 1110, 1112, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309(a) (2017). 6. The criteria to establish service connection for OSA are met. 38 U.S.C. §§ 1101, 1110, 1112, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309(a) (2017). 7. The criteria for an initial rating of 70 percent for the entire appeal period for PTSD have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.7, 4.130, Diagnostic Code 9411 (2017). 8. The criteria for entitlement to TDIU have been met from November 8, 2010. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.340, 3.341, 4.1, 4.3, 4.16, 4.19, 4.25, 4.26 (2017). 9. The criteria for SMC based on the need for regular aid and attendance or based on being housebound have not been met. 38 U.S.C. §§ 1114, 5107 (2012); 38 C.F.R. §§ 3.350, 3.352 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA is granting the entitlement sought for the Veteran's claims of entitlement to service connection for peripheral neuropathy of his bilateral upper and lower extremities and OSA, as well as entitlement to a TDIU. Therefore, any deficiency in VA's duties to notify and assist the Veteran for those issues is harmless. The Veteran is challenging the evaluation assigned in connection with the grant of service connection for PTSD. Similarly, the Veteran's claim of entitlement to an earlier effective date arises from the initial grant of service connection of CAD. Once service connection is granted, the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is required with respect to this claim. The record also shows that VA has fulfilled its obligation to assist the Veteran in developing the claim, including with respect to VA examination of the Veteran. Neither the Veteran nor his representative has identified any deficiency in VA's notice or assistance duties. See Scott v. McDonald, 789 F.3rd 1375 (Fed. Cir. 2015). Withdrawal of Appeal Legal Requirements The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204. Withdrawal may be made by an appellant or by his authorized representative. Id. Analysis At the February 2017 Board hearing in the present case, the Veteran withdrew his perfected appeal of the issues of entitlement to increased ratings for coronary artery disease and tinea pedis. Hence, there remains no allegation of errors of fact or law for appellate consideration concerning those issues. Accordingly, the Board does not have jurisdiction to review the appeal of those issues, and they are dismissed in the Order portion of this decision. Earlier Effective Date The Veteran seeks an earlier effective date for the award of service connection for his CAD. Generally, the effective date of an award of disability compensation, i.e., service connection, is the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. If a claim for service connection is received within one year after separation from service, the effective date of entitlement is the day following separation or the date entitlement arose. 38 C.F.R. § 3.400(b)(2)(i). In this context, it should be noted that the provisions of 38 U.S.C. § 5110 refer to the date an "application" is received; and "date of receipt" means the date on which a claim, information or evidence was received by VA. 38 C.F.R. § 3.1(r). The regulations use the terms "claim" and "application" interchangeably, and they are defined broadly to include "a formal or informal communication in writing requesting a determination of entitlement, or evidencing a belief in entitlement, to a benefit." 38 C.F.R. § 3.1(p). See also Rodriguez v. West, 189 F.3d. 1352 (Fed. Cir. 1999), cert. denied, 529 U.S. 1004 (2000). The benefit sought must be identified, but need not be specific. See Stewart v. Brown, 10 Vet. App. 15, 18 (1997); Servello v. Derwinski, 3 Vet. App. 196, 199 (1992). While VA must interpret a claimant's submissions broadly, VA is not required to conjure up issues not raised by claimant. VA is not required to anticipate any potential claim for a particular benefit where no intention to raise it was expressed. Brannon v. West, 12 Vet. App. 32, 35 (1998); Talbert v. Brown, 7 Vet. App. 352, 356-57 (1995). Moreover, the effective date of an award of service connection is not based upon the date of the earliest medical evidence demonstrating entitlement, but on the date that the application upon which service connection was eventually awarded was received by VA. See Lalonde v. West, 12 Vet. App. 377 (1999); see also MacPhee v. Nicholson, 459 F.3d 1323, 1327 (Fed. Cir. 2006). In this case, service connection for the Veteran's CAD was granted pursuant to the principles of presumptive service connection due to herbicide exposure, based upon a liberalizing law. Generally, the effective date of an award of service connection granted pursuant to a liberalizing law or VA administrative issue is the effective date of the liberalizing law or administrative issue, only if the claim is received within one year after such date. Thus, under the provisions for liberalizing laws, awards based on presumptive service connection established under the Agent Orange Act of 1991ordinarily cannot be made effective earlier than the date VA issued the regulation authorizing the presumption. Id. In this case, CAD was included as a presumptive Agent Orange disease under 38 C.F.R. § 3.309(e), which was made effective by VA as of August 31, 2010. District court orders have created an exception to the generally applicable rules in 38 U.S.C. § 5110(g) and 38 C.F.R. § 3.114, which were later incorporated into a final regulation, 38 C.F.R. § 3.816, that became effective on September 24, 2003. See Nehmer v. United States Veterans Admin., 712 F. Supp. 1404, 1409 (N.D. Cal. 1989) (Nehmer I). That regulation defines a "Nehmer class member" to include a Veteran who has, or died from, a covered herbicide disease. 38 C.F.R. § 3.816(b)(1)(i), (b)(2)(i). The regulation provides for situations where the effective date can be earlier than the date of the liberalizing law, assuming a "Nehmer class member" has been granted compensation from a covered herbicide disease. Either (1) VA denied compensation for the same covered herbicide disease in a decision issued between September 25, 1985 and May 3, 1989; or (2) the class member's claim for disability compensation for the covered herbicide disease was either pending before VA on May 3, 1989, or was received by VA between May 3, 1989 and the effective date of the statute or regulations establishing a presumption of service connection for the covered disease. In these situations, the effective date of the award will be the later of the date such claim was received by VA or the date the disability arose. 38 C.F.R. § 3.816(c)(1), (c)(2). As defined in the current regulations, the term "covered herbicide disease" means a disease for which the Secretary of VA has established a presumption of service connection pursuant to the Agent Orange Act of 1991, Public Law 102-4, other than chloracne. 38 C.F.R. § 3.816(b)(2)(i). The Board acknowledges the Veteran's representative's arguments that the Veteran's service-connected CAD should have an earlier effective date of November 2010. Specifically, the Veteran's representative argued that the Veteran filed compensation claims for several unrelated disabilities prior to his April 2013 CAD claim, specifically in November 2010 and at that time, the claims file included evidence that the Veteran had a diagnosis of CAD or any other ischemic heart disease stemming back to 2007. See February 2017 Board hearing; see also July 2010 Neuropsychological Evaluation from Texoma. The Veteran's representative's argument was presumably based on a February 2011 VA issued Training Letter with an attached "Nehmer Training Guide," which stipulated that if medical records are received by VA, documenting a diagnosis of a now-covered presumptive disease, then the first rating decision issued after receipt of those records is deemed to have denied service connection for that disability, and the claim denied by that decision is deemed to have included a claim for the now-covered disease. See VA Training Letter 10-04 (Feb. 10, 2011). However, the Board notes that during the pendency of the appeal, all VA Fast and Training Letters, including the training letter cited above, were rescinded and summaries incorporated into VA's Adjudication Manual, M21-1. The manual currently contains provisions similar to those in the training letter cited above. See M21-1, IV.ii.2.C.4.d. (updated June 2, 2017). Nevertheless, the Board notes that VBA materials, to include VA's Adjudication Manual, M21-1MR, are not binding on the Board, except where the provisions have been determined by appropriate legal authority to constitute "substantive" rules. Neither the Fast Letters nor the resulting M21-1MR changes have been determined to constitute "substantive" rules. As such, those provisions are not for application with respect to the Board's decision. In this case, the Veteran is a Nehmer class member as he is a Vietnam Veteran with a covered herbicide disease, i.e., CAD. In a March 2014 rating decision, he was awarded service connection for CAD, as a disease presumptively related to herbicide exposure. In connection with this award, he had filed a claim for service connection for an ischemic heart disease (IHD) on April 8, 2013. This was his first claim for compensation benefits for an ischemic heart disease. Moreover, there is no indication that VA denied compensation for CAD in any decision issued between September 25, 1985 and May 3, 1989. Additionally, there is no indication in the record that the Veteran filed a claim, formal or otherwise, for his heart condition prior to or within the one year period following August 31, 2010, the effective date that IHD/CAD was added as a presumptive Agent Orange disease. There is, furthermore, no evidence that the Veteran filed any claim for VA benefits based on a heart disorder prior to his original claim for service connection for a heart condition which was received by VA on April 8, 2013. As for the representative's argument concerning the record showing evidence of CAD at the time of earlier claims for other disorders, the Board finds that, even with the liberal review of the record required by caselaw, this did not raise any informal claim for service connection for CAD. Thus, based on applicable laws and regulations, the effective date for service connection for CAD was properly assigned as April 8, 2012, exactly one year prior to the date of receipt of his original claim, as the evidence clearly establishes that the his heart disease was present as of the August 31, 2010, effective date of the liberalizing law at issue, and has continued since. Cf. 38 C.F.R. § 3.114(a). For the above reasons, the Board finds that entitlement to an effective date earlier than April 8, 2012, for the grant of service connection for CAD is not warranted, as the Veteran did not provide any communication to VA indicative of a desire to file a heart-related claim prior to the date of receipt of his original claim for a heart disability which was received on April 8, 2013. Therefore, the earlier effective date claim for his service-connected CAD must be denied. Service Connection Service connection may be granted for a disability resulting from disease or injury that is incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. To establish service connection for the claimed disorder, the three following criteria must be met: (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical, or in certain circumstances, lay evidence of a nexus between the claimed in-service disease or injury and the current disability. See 38 C.F.R. § 3.303; see also Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999). For the first criterion of a service connection claim, a disability is considered current so long as it exists at the time the claim is filed or during the pendency of the appeal. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). But see Romanowsky v. Shinseki, 26 Vet. App. 289, 293-94 (2013) (explaining that in certain circumstances evidence of a disability prior to the filing of the claim may be considered if it is sufficiently proximate so as to constitute a "current" disability). Additionally, for certain diseases designated as chronic, medical nexus may be presumed under certain circumstances. 38 C.F.R. §§ 3.303(a), (b), 3.309(a). Service connection may be granted for disability which is proximately due to or the result of service-connected disability. 38 C.F.R. § 3.310(a). Additional disability resulting from the aggravation of a nonservice-connected disability by a service-connected disability is also service-connected. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995). As to the second and third criteria requiring proof of in-service incurrence and medical nexus, a veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period starting on January 9, 1962, and ending on May 7, 1975, is presumed to have been exposed during such service to a herbicide agent, unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service. 38 U.S.C. § 1116; 38 C.F.R. § 3.307 (a)(6)(iii). "Service in the Republic of Vietnam" includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307(a)(6)(iii). VA has interpreted the term "service in Vietnam" and related regulations to mean that a Veteran must have actually been present at some point on the landmass or the inland waters of Vietnam during the Vietnam conflict to be found presumptively exposed to herbicides. See Haas v. Peake, 525 F.3d 1168 (Fed. Cir. 2008). Here, a review of the Veteran's personnel records reveals that he served on the landmass of the Republic of Vietnam from December 1965 to October 1966. As such, the Veteran is resumed to have been exposed to such herbicides. Additionally, the Board notes that early onset peripheral neuropathy and diabetes mellitus Type II are conditions for which medical nexus may be presumed if the Veteran is presumed to have been exposed to herbicide. 38 C.F.R. § 3.309(e). For early-onset peripheral neuropathy, the condition must have first manifested to a compensable degree within one year of the last exposure to herbicides. 38 C.F.R. § 3.307(a)(6)(ii). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. The Board notes that it has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting its decision, there is no requirement that the Board discuss every piece of evidence in the record. The Board will summarize the relevant evidence, as deemed appropriate, and the Board's analysis will focus on what the evidence shows, or fails to show, as to the claim. See Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The Board must determine whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. Peripheral Neuropathy of Bilateral Upper and Lower Extremities Factual Background and Analysis The Veteran first contended that his peripheral neuropathy of his bilateral upper and lower extremities was due to his presumed in-service herbicide exposure. However, the Veteran has since been service-connected for type II diabetes mellitus in a September 2016 rating decision. The Veteran now contends his peripheral neuropathy of his bilateral upper and lower extremities is secondary to his service-connected type II diabetes mellitus. The Board notes that the Veteran has a current diagnosis of peripheral neuropathy in his bilateral upper and lower extremities. See April 2013 Texoma Neurology Progress Notes. The Board further acknowledges that there are opinions of record noting the Veteran's peripheral neuropathy of his bilateral upper and lower extremities may be due to his in-service Agent Orange exposure. However, the Veteran was not diagnosed with peripheral neuropathy until 2013, certainly after the one year mark from separation of active service. Thus, medical nexus for the bilateral upper and lower peripheral neuropathy is not presumed under 38 C.F.R. § 3.309(e) due to herbicide exposure. Nevertheless, the Board notes that since the Veteran has been service-connected for type II diabetes mellitus, the Veteran's treating providers have provided opinions that the Veteran's peripheral neuropathy in his bilateral upper and lower extremities is secondary to the service-connected disability. A November 2016 Texoma Foot and Ankle Specialists PA treatment record noted the Veteran's type II diabetes mellitus with diabetic polyneuropathy. A February 2017 letter from the Veteran's private treating neurologist, Dr. Sundaram, noted that the Veteran's neuropathy involved both his hands and feet and that it was more than likely than not related to the service-connected diabetes. The provider noted the Veteran was a borderline diabetic for many years and now had a full diagnosis and was treated with Metformin. A February 2017 letter from Dr. Landrum, from Texoma Care, noted the Veteran had prediabetes with onset in 2014 and that his peripheral neuropathy of hands and feet was more than likely secondary to his service-connected type II diabetes. There is no contrary medical opinion in the record. Thus, the November 2016 and February 2017 opinions stand unchallenged as competent and probative medical evidence on the crucial question of medical nexus. Given the only record of opinions are in favor of service connection, a remand for another VA examination could be construed as obtaining additional evidence for the sole purpose of denying a claim, which is impermissible. 38 C.F.R. § 3.304(c) ("The development of evidence in connection with claims for service connection will be accomplished when deemed necessary but it should not be undertaken when evidence present is sufficient for this determination"); Mariano v. Principi, 17 Vet. App. 305, 312 (2003) (VA may not order additional development for the sole purpose of obtaining evidence unfavorable to a claimant). As such, resolving reasonable doubt in favor of the Veteran, the Board finds that the record shows that it is at least as likely as not that the Veteran's peripheral neuropathy in his bilateral upper and lower extremities is secondary to, related to and/or aggravated by his service-connected type II diabetes mellitus. Therefore, service connection is warranted for the Veteran's peripheral neuropathy in his bilateral upper and lower extremities. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). II. OSA Factual Background and Analysis The Veteran contends that his sleep apnea was caused by or aggravated by his service-connected PTSD and/or his service-connected CAD. The Veteran's outpatient VA treatment records and private treatment records show the Veteran has a current diagnosis of obstructive sleep apnea and is receiving treatment for the disability. See also February 2016 VA examination. During the February 2016 VA examination, the Veteran stated that his OSA began five years ago and reported he was having loud snoring. The VA examiner noted that in an April 2010 sleepy study, the study found obstructive sleep apnea and the Veteran was placed on a CPAP machine. The examiner noted the current symptom was intermittent daytime sleepiness and the Veteran was switched form a CPAP to VPAP six months ago. After examination, the examiner opined that the Veteran's OSA was less likely than not proximately due to or the result of the Veteran's service connected disabilities. The examiner's noted the Veteran was in Vietnam for 11 months in 1965 and that he developed essential vascular hypertension in 1975, cardiac arrhythmia in 1975, with cholesterol elevation since 1975. The examiner noted OSA means that the airway gets blocked by soft tissue from nose to trachea and that this had nothing to do with the heart or PTSD. The examiner noted that in terminal cases of heart disease, there can be agonal breathing. In the February 2017 Board hearing, the Veteran reported that his sleep apnea began approximately five or six years ago and that he received his CPAP through his private provider. In a February 2017 letter by a Dr. Brady, the provider opined, after a review of the Veteran's medical records and claims file, that the Veteran's OSA is a direct result of his service connected PTSD. The provider based the opinion on medical treatises that detailed the causal connection between PTSD and OSA. After evaluating the probative value of the opinions both for and against the claim, the Board is unable to assign greater probative value to any particular opinion. Board notes that the February 2017 provider provided multiple substantial medical treatises that supported the causal connection between PTSD and OSA which contradicted the February 2016 VA examiner's finding that OSA has nothing to do with PTSD. The Board finds this lowers the probative value of the February 2016 VA examiner's opinion. The evidence in this case therefore is at least in equipoise. Thus, service connection for obstructive sleep apnea is warranted. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher rating 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. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. The Court has held that separate ratings may be assigned for separate periods of time based on the facts found, a practice known as "staged" rating. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999) (the Court noted a distinction between claims stemming from an original rating versus increased rating); see also Hart v. Mansfield, 21 Vet. App. 505 (2007) (staged ratings are appropriate for an increased rating claim whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. PTSD The Veteran's PTSD with major depressive disorder and panic disorder without agoraphobia is evaluated as 30 percent disabling prior to April 6, 2013, and 50 percent disabling from April 6, 2013 under DC 9411. Under the General Rating Formula for Mental Disorders, a 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, DC 9411. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating 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. When determining the appropriate disability evaluation under the general rating formula, the Board's primary consideration is the Veteran's symptoms, but it must also make findings as to how those symptoms impact the Veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because the use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; Sellers v. Principi, 372 F. 3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, as all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran's impairment must be due to those symptoms, a veteran may only qualify for a given disability rating under the general rating formula by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d 112. The classification outlined in the portion of VA's Schedule for Rating Disabilities that addresses service-connected psychiatric disabilities is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, of the American Psychiatric Association (DSM-V). 38 C.F.R. § 4.130. VA implemented DSM-V, effective August 4, 2014. The Secretary of VA, however, has determined that DSM-V does not apply to claims certified to the Board prior to August 4, 2014. See 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). The AOJ initially certified the Veteran's appeal for his PTSD increased rating claim to the Board in September 2016. Factual Background The Veteran was provided a neuropsychological evaluation from the Applied Psychology Group of Texoma in November 2010. The evaluator noted the Veteran's concerns regarding his memory. The Veteran reported his short-term memory loss began suddenly between two and three years ago, and that his memory problems caused trouble for him in keeping track of appointments. The Veteran reported severe headaches, depression, anxiety, panic attacks, and posttraumatic stress symptoms. The Veteran reported he first experienced panic attacks in 1985 and has since experienced approximately one panic attack per month, with his most recent panic attack in 1985. The Veteran reported he experienced flashbacks, nightmares, hypervigilance, and intrusive recollections. The Veteran reported mild feelings of depression and anxiety within the past two weeks and denied experiencing any manic symptoms. The evaluator noted the Veteran's that current test results showed mild deficits in neurocognitive functioning, including impairment of immediate memory encoding and cognitive inhibition, with decrements from presumed premorbid functioning in delayed memory and executive processing skills. The evaluator noted that test results indicate the Veteran suffers from chronic posttraumatic stress, panic attacks, depression, and a prolonged history of alcohol dependence that may have influenced his performance. The evaluator noted the Veteran was prone to anxiety and may be particularly sensitive to cognitive decline, further interfering with his ability to concentrate and attend to assigned attacks. The evaluator noted the Veteran demonstrated a history of chronic emotional difficulties that interfered with his current function as well as significant concern regarding physical problems. The evaluator diagnosed cognitive disorder not otherwise specified (NOS), chronic PTSD, panic disorder without agoraphobia, recurrent mild major depressive disorder, and alcohol dependence without physiological dependence on sustained full remission. The evaluator assigned a GAF score of 55. The Veteran was provided a VA examination in January 2011. During examination, the Veteran reported experiencing symptoms of intrusive recollections, avoidance behaviors, and sympathetic nervous system arousal secondary to exposure to trauma and with constant, continuous, or ongoing severe symptoms lasting more than three months. The Veteran indicated that his symptoms affected total daily functioning which resulted in decreased energy and concentration. The Veteran reported he was no longer engaging in activities that were previously enjoyed, with poor task completion at work and home, and with less physical activity which contributed to decline in overall health. The Veteran reported he had trouble sleeping for 43 years which included prolonged sleep onset latencies, fragile sleep with multiple prolonged awakenings, nightmares, and profound daytime sleepiness. The Veteran stated a history of violent behavior which resulted in his employment termination. He did not indicate a history of suicide attempts. The Veteran reported symptoms of depressed and irritable mood, reduced interests, feelings of guiltiness and worthlessness, reduced energy and concentration, variable appetites, and psychomotor retardation/agitation. He reported his panic disorder symptoms included overwhelming panic attacks with racing heart rate, excessive sweating, and hyperventilation, with constant fear of having another panic attack and avoidance of perceived triggers of panic attacks. The examiner noted the severe symptoms were constant, continuous, or ongoing and the Veteran indicated the symptoms affected total daily function which resulted in social withdrawal, irritability, conflicts with others, social anxiety, and avoidance behaviors. The Veteran reported a good relationship with his wife, five siblings, and his children. The Veteran reported that post-service, he had a poor relationship with his supervisor but that his relationship with his co-workers was fair. The examiner noted the Veteran had not worked since 1997 and that he was previously employed in construction for 27 years. The Veteran contended that his unemployment was due, primarily, to the effects of his panic disorder making it too difficult to function around others. On examination, the examiner noted the Veteran was a reliable historian with orientation within normal limits. The examiner noted the Veteran's appearance, hygiene, and behavior was appropriate. He maintained good eye contact during examination but that his affect and mood showed findings of PTSD. The examiner noted the Veteran's depressed mood impacted all facets of work and home life due to social withdrawal, suspiciousness, persistent anxiety, sleep disturbances with nightmares, intrusive recollections, avoidance behaviors, exaggerated startle response, and symptomatic nervous system arousal. The examiner noted the Veteran's communication and speech was within normal limits but that there was impaired attention and/or focus. The examiner noted it interfered with work performance and daily task completion, since the Veteran often forgot what the task at hand was. The examiner noted panic attacks were present and occurred less than once per week. The examiner noted the Veteran's sense of foreshortened future, feelings of detachment or estrangement from others, exaggerated startle response, difficulty concentrating, and that his hypervigilance continued to persist. The examiner also noted the Veteran's irritability or outbursts of anger continued to persist. The Veteran stated he became angry at insignificant events with emotional outburst, and general irritability and impatience with others. The examiner noted examples of the Veteran's suspiciousness included an inability to open up to others or share experiences and feelings, he felt a need to be on guard, had extreme discomfort in public settings, and he felt that his capacity for trust was gone forever. The examiner noted there was no report of a history of delusions or hallucinations. The examiner noted obsessive compulsive behavior was absent. The examiner found that the Veteran's unemployment was caused by the impact of his PTSD, depression, and panic disorder making functioning in a working environment too difficult to sustain. The examiner noted the effects of PTSD symptoms on Veteran's employment an overall quality of life included heightened arousal, hypervigilance, and readiness to combat others despite no longer being in a combat situation. The examiner noted this interfered significantly with maintaining viable working relationships with others. The examiner also noted the Veteran had difficulty establishing and maintaining effective work/school and social relationships because of social withdrawal and that he had difficulty maintaining effective family role functioning because of irritability. After examination, the examiner diagnosed PTSD, major depressive disorder, and panic disorder without agoraphobia. The examiner assigned a GAF score of 55. A July 2011 VA examination addendum opinion clarified that the Veteran had "total interference" in performing activities of daily living because of poor energy and concentration, leading to poor task completion at work and home. VA treatment records noted the Veteran's continued participation in group and individual counseling for his PTSD. VA treatment records from 2010 to 2016 noted the Veteran's reports of his struggle with his PTSD symptoms that included continued problems with irritability, nightmares, sleep impairment, anxiety, hypervigilance, and anger. The Veteran also reported his frustration with his increasing memory loss and his intermittent panic attacks. A July 2011 VA treatment record noted he had nightmares of trauma, was hypervigilant, avoided crowds, and was irritable most of the time. The Veteran also complained of terrible short term memory and that he felt better when he was left alone. The July 2011 VA provider assigned a GAF score of 45. The Veteran was provided another VA examination in May 2013. The examiner noted the Veteran's thought process and communication skills appeared within normal limits and the Veteran had denied any symptoms of delusions or hallucinations. The Veteran was noted as cooperative, had maintained good eye contact, and exhibited no inappropriate behavior. The Veteran acknowledged occasional passive suicidal ideation but he denied any current suicidal or homicidal ideation, plan, or intent. The Veteran appeared able to maintain personal hygiene and basic activities of daily living. The Veteran's short and long term memory appeared to be without gross deficits. However, the Veteran reported mild difficulty with attention span and concentration, as well as mild dysfunction with short-term memory in routine day-to-day functioning. The examiner noted the Veteran had occupational and social impairment with reduced reliability and productivity. The Veteran reported he continued in his marriage of 38 years, maintained regular contact with his son and two granddaughters, and reported he enjoyed spending time with his granddaughters. The Veteran continued to be retired with his last employment approximately 10 years ago performing construction/concrete finishing work. On examination, the examiner noted the Veteran experienced recurrent and distressing recollections and dreams of the traumatic event. The examiner noted the Veteran also experienced intense psychological distress as well as physiological reactivity on exposure to internal or external cues that symbolized or resembled an aspect of the traumatic event. The examiner noted the Veteran made efforts to avoid thoughts, feelings, or conversations associated with the trauma and also made efforts to avoid activities, places or people that aroused recollections of the trauma. The Veteran was noted to have feelings of detachment or estrangement from others. The examiner noted the Veteran had difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hypervigilance, and exaggerated startle response. The examiner noted the Veteran's PTSD symptoms caused clinically significant distress or impairment in social, occupational, or other important areas of functioning. The examiner noted PTSD symptoms of depressed mood, anxiety, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The examiner noted the Veteran's symptoms of PTSD appeared to have increased slightly in frequency, duration, and intensity since the January 2011 VA examination. However, the examiner noted the Veteran's PTSD symptoms failed to be of such severity as to require the aid and attendance of another since the Veteran was able to perform all activities of daily living and was alert and fully oriented. The Veteran had reported he was able to make meals for himself and his granddaughters. The examiner also noted the Veteran failed to exhibit any significant cognitive impairment at the time of examination. The examiner assigned a GAF score of 52. In a June 2013 letter from the Veteran's treating provider, Dr. Landrum, the provider noted the Veteran had numerous complicating medical conditions but that the most impacting was his PTSD. The provider noted that due to the PTSD, the Veteran suffered from severe anxiety, short term memory loss, poor cognition, and processing disorder. The provider noted the Veteran had difficulty maintaining focus and concentration and had extreme difficulty with cognitive processing, as he was unable to find the correct words to say. The provider also noted the veteran had difficulty with simple one step order processing. Based on these PTSD symptoms, the provider found the Veteran was unable to be gainfully employed. In a January 2017 letter from the Veteran's spouse, J.P., she reported she had a difficult marriage with the Veteran. J.P. reported the Veteran was always aggressive and unable to focus on instructions which led to him being fired and laid off from his jobs. She indicated that when they were both working and living in California, they were doing okay. She indicated that after they moved to Oklahoma in 2002 to be with her elderly mother, the Veteran's behavior worsened. She reported the Veteran could not work due to his inability to stay focused or his inability to follow simple directions and instructions. She indicated the Veteran could not attend doctor appointments without her assistance since he did not comprehend a lot of what the doctors were telling him. She indicated their lives have been and is almost nonexistent. She stated they have no close or good friends due to the Veteran's "attitude illnesses." She stated that the only joy they had in their lives were their son and grandchildren. During the February 2017 Board hearing, the Veteran reported that when he worked in California, he got into arguments with his coworkers all the time and got into fights with them. He also reported that he had physically attacked a supervisor in a work confrontation. He was subsequently fired. The Veteran also reported he got into fights outside of work. The Veteran reported that after he came to Oklahoma, he started counseling through the VA in the mid 2000s. The Veteran reported the constant feeling of being overwhelmed, anxious, and angry. The Veteran reported he was drinking all the time until his pacemaker was put in in 2007. He reported that after he quit drinking, his mental problems caused him to not want to be around the family and that that was still the case but that he tried to hold back as best as possible. The Veteran's spouse reported they had no close friends and did not socialize due to the Veteran's mental problems and that he did not like crowds. The Veteran's spouse also reported the Veteran did not like to be around people, was not talkative, and sometimes was offensive in his interactions with others. She reported the Veteran had gotten in physical and verbal confrontations with neighbors and family members, as well as strangers. The Veteran's spouse indicated he was very negative and that she had to drive him to his appointments to make sure he attended and to make sure of any change in medications or any additional medical issues. She also reported the Veteran had terrible nightmares where he would fight, yell, and was sometimes "swinging" in his sleep, accidently hitting her. Analysis For the entirety of the appeal, many of the Veteran's abilities and behaviors do not approximate particulars for a disability rating in excess of 50 percent. For example, his orientation, alertness, speech, and linear thought process was mostly described to be within normal limits and the Veteran consistently denied suicidal or homicidal ideation, intent, or plan, as demonstrated throughout the record, weigh against finding that the Veteran's psychiatric symptoms result in deficiencies in most areas. However, the Veteran's continued complaints regarding his impaired attention and/or focus, his poor memory, his irritability and violent outbursts, his ongoing sleep impairment, his persistent hypervigilance, and his intrusive thoughts supports entitlement to a 70 percent rating for PTSD. The mandate to accord the Veteran the benefit of the doubt is triggered when the evidence is in equipoise, as is the case here. Because a state of relative equipoise has been reached as to the issue of an increased rating for PTSD, the benefit of the doubt rule applies and a 70 percent rating is granted. See Alemany v. Brown, 9 Vet. App. 518 (1996); Brown v. Brown, 5 Vet. App. 413 (1993). For the entirety of the appeal, the Veteran is not entitled to a disability rating in excess of 70 percent. The medical and lay evidence does not indicate that the Veteran is a persistent harm to himself or others, that he experienced delusions or hallucinations, had grossly inappropriate behavior, or was disoriented to time or place. The Board also notes the Veteran maintains close relationships with his wife, son, and grandchildren. The Veteran's ability to make meals and help care for his grandchildren also weighs heavily against a 100 percent rating that is applicable only when there is total occupational and social impairment. The Board also notes numerous medical evaluations that have noted the Veteran's adequate appearance and grooming, thus showing an ability to maintain personal hygiene. The Veteran's GAF scores during the appeal period have ranged from 45 to 55, reflecting serious symptoms (in the 40's) to moderate symptoms (in the 50's). Lower GAF scores are available for individuals exhibiting some impairment in reality testing or communication, or any major impairment in several areas (see, e.g., GAF range of 31 to 40), and have not been assigned to this Veteran, indicating that he has not been regarded as exhibiting the most severe categories of functional impairments. Considering the evidence clearly does not show the Veteran has total occupational and social impairment due to his PTSD, the Veteran's PTSD does not warrant a higher rating of 100 percent. The evidence is in relative equipoise. The benefit-of-the-doubt rule applies and entitlement to a 70 percent disability rating (but no more) for PTSD for the entire period on appeal is granted. See 38 C.F.R. §§ 3.102; 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Extraschedular Consideration Since the Veteran has raised the matter of extraschedular consideration, the Board has also considered the provisions of 38 C.F.R. § 3.321(b)(1). See Doucette v. Shulkin, 28 Vet. App. 366, 368 (2017); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008). However, in this case, the Board finds that the record does not show that the Veteran's psychiatric disability is so exceptional or unusual as to warrant the assignment of a higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321 (b)(1). The threshold factor for extra-schedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, there must be a comparison between the level of severity and symptomatology of the claimant's service- connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and no extra-schedular referral is required. Thun, 22 Vet. App. 111; VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those marked interference with employment and frequent periods of hospitalization. 38 C.F.R. § 3.321(b)(1). The evidence in this case does not show such an exceptional disability picture that the assigned schedular evaluations for the service-connected disability are inadequate. Here, as with all increased rating claims for psychiatric disorders, all psychiatric symptoms are contemplated by the rating criteria, because the criteria consider all psychiatric symptoms that impact occupational and social functioning. Thus, consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required and referral for an extra-schedular rating is unnecessary. As such, the Board concludes that referral for extraschedular consideration is not warranted here. The Board notes that in Johnson v. McDonald, 762 F.3d 1362, 1365-66 (Fed. Cir. 2014), the U.S. Court of Appeals for the Federal Circuit held that a veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. Effective January 8, 2018 for all cases pending before VA, VA amended 38 C.F.R. § 3.321 to clarify that an extraschedular evaluation may not be based on the combined effect of multiple service-connected disabilities. TDIU Law and Analysis A request for a total disability rating based on individual unemployability (TDIU), whether expressly raised by a veteran or reasonably raised by the record, is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability as part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). In other words, if the claimant or the evidence of record reasonably raises the question of whether the Veteran is unemployable due to a disability for which an increased rating is sought, then part and parcel with the increased rating claim is the issue of whether TDIU is warranted as a result of that disability. Id. TDIU may be assigned when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16(a). If there is only one such disability, it must be rated at 60 percent or more; if there are two or more disabilities, at least one disability must be rated at 40 percent or more, with sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Entitlement to a total rating must be based solely on the impact of the veteran's service-connected disabilities on his ability to keep and maintain substantially gainful employment. 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is "whether the veteran's service connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). "Unemployability" is synonymous with an inability to secure and follow a substantially gainful occupation. VAOPGPREC 75-91; 57 Fed. Reg. 2317 (1992). Individual unemployability must be determined without regard to any nonservice-connected disabilities or the veteran's advancing age. 38 C.F.R. §§ 3.341(a), 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). The sole fact that a veteran is unemployed or has difficulty obtaining employment is not enough to prove unemployability. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose, 4 Vet. App. at 363. A veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed. 38 C.F.R. § 4.16(b). The ability to work sporadically or obtain marginal employment is not substantially gainful employment. 38 C.F.R. § 4.16(a); Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). Marginal employment, i.e., earned annual income that does not exceed the poverty threshold for one person, is not considered substantially gainful employment. 38 C.F.R. § 4.16(a). For the entire appeal period, the Veteran met the schedular criteria for a TDIU, even before the new service connection grants for sleep apnea and peripheral neuropathy of his bilateral upper and lower extremities. 38 C.F.R. § 4.16(a). For the entire appeal, he was in receipt of the following ratings: a 70 percent rating for PTSD; a 60 percent rating for CAD effective April 8, 2012; a 20 percent rating for type II diabetes mellitus effective April 20, 2016; noncompensable ratings for tinea pedis and scar status post cardiac pacemaker surgery associated with CAD. Therefore, for the entire appeal period, the Veteran met the schedular criteria for a TDIU. 38 C.F.R. § 4.16(a). The only remaining question is whether the Veteran was unable to secure or follow a substantially gainful occupation as a result of any of his service-connected disabilities. The Board resolves reasonable doubt in the appellant's favor and finds that a TDIU is warranted. The Veteran submitted a claim for a TDIU in April 2013. He cited to his disabilities of PTSD and neuropathy prevented him from securing or following any substantially gainful occupation. SSA records show the Veteran last worked in 1995. An October 1996 SSA disability decision granted the Veteran's claim for disability based on his physical and mental impairments. The decision noted the Veteran's ability to perform the full range of sedentary work was reduced by nonexertional limitations and restrictions involving complex and detailed instructions and interaction with coworkers, supervisors, and the public. The decision further noted the Veteran's education was limited, and he had no acquired no skills readily transferable to the skilled or semi-skilled work activities of other work performable within the range of his residual functional capacity. A review of the record does not show the Veteran has since received further occupational or educational training. In the January 2011 VA examination, the examiner specifically found that the Veteran's unemployment was caused by the impact of his PTSD, depression, and panic disorder making functioning in a working environment too difficult to sustain. In the July 2011 VA examination addendum opinion, the examiner further clarified that the Veteran had "total interference" in performing activities of daily living because of poor energy and concentration, leading to poor task completion at work and home. The Board notes that although the May 2013 VA examiner found the Veteran had occupational and social impairment with reduced reliability and productivity, the examiner also noted his PTSD symptoms had worsened since July 2011, albeit not to the degree necessitating aid and attendance. Furthermore, the May 2013 VA examiner did not specifically find either way whether the Veteran was unemployable. Thus, the Board will not afford the opinion significant probative weight for or against the TDIU claim. In a June 2013 letter from the Veteran's treating provider, Dr. Landrum, the provider noted the Veteran had numerous complicating medical conditions but that the most impacting was his PTSD. The provider noted that due to the PTSD, the Veteran suffered from severe anxiety, short term memory loss, poor cognition, and processing disorder. The provider noted the Veteran had difficulty maintaining focus and concentration and had extreme difficulty with cognitive processing, as he was unable to find the correct words to say. The provider also noted the veteran had difficulty with simple one step order processing. Based on these PTSD symptoms, the provider found the Veteran was unable to be gainfully employed. As indicated above, the Veteran's spouse has also indicated in her January 2017 letter that the Veteran could not work due to his inability to stay focused or his inability to follow simple directions and instructions. She further indicated the Veteran could not attend doctor appointments without her assistance since he did not comprehend a lot of what the doctors were telling him. The Board accords significant probative weight to the January 2011 VA examiner's and Dr. Landrum's opinions, who both found that the Veteran's PTSD symptoms rendered the Veteran unemployable. There is no adequate contrary opinion of record. Corroborating this opinion, the Veteran and his spouse has consistently and credibly described PTSD symptoms that prevented him from working. Thus, the Board finds that that the Veteran's service-connected PTSD has rendered him unable to secure and follow substantially gainful employment. As such, a TDIU is warranted. Entitlement to TDIU prior to date of TDIU claim In a March 2012 rating decision, the Veteran was granted service connection for PTSD. The Veteran has since been granted in this decision a 70 percent disability rating effective November 8, 2010, the date of claim. Based on that 70 percent rating, the Veteran was found to be unable to secure and maintain substantially gainful employment due solely to his service-connected PTSD and the Board has granted TDIU. The earliest date of the Veteran's claim for TDIU is April 6, 2013. The Veteran contends that he is entitled to an earlier effective date for TDIU back to November 8, 2010, the date of claim for service connection for PTSD. Given that the Veteran has been subsequently granted TDIU based on the 70 percent disability rating for PTSD, the Board finds that an earlier effective date of November 8, 2010, is warranted for the grant of entitlement to TDIU as well. The record does not support establishment of a TDIU to an even earlier date. The Veteran does not have any rated service-connected disability prior to November 8, 2010 of which a claim for TDIU can be based upon. SMC The Veteran and record has also asserted the matter of SMC based aid and attendance. "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. §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. § 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. § 1114(s). Under 38 U.S.C. § 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. 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. § 1114(s). 22 Vet. App. 280, 293 (2008). The Board has considered 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 or housebound. 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 May 2013 VA examination for PTSD specifically noted the Veteran's PTSD symptoms failed to be of such severity as to require the aid and attendance of another since the Veteran was able to perform all activities of daily living and was alert and fully oriented. The examiner also noted the Veteran was able to make meals for himself and his granddaughters. VA treatment records have also consistently noted from 2010 to 2016 that the Veteran has been casually dressed during all appointments and did not indicate the Veteran had inappropriate grooming or hygiene. The Veteran and his spouse also failed to indicate the Veteran was unable to undress himself, keep himself ordinarily clean and presentable, feed himself, attend to the wants or nature, or was housebound. 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 The appeal of the issue of entitlement to an initial increased rating for CAD is dismissed. The appeal of the issue of entitlement to an initial increased rating for tinea pedis is dismissed. An effective date prior to April 8, 2012, for the grant of service connection for CAD is denied. Service connection for peripheral neuropathy of the bilateral upper extremities is granted. Service connection for peripheral neuropathy of the bilateral lower extremities is granted. Service connection for obstructive sleep apnea is granted. Entitlement to an initial disability rating of 70 percent for the entire appeal period for PTSD is granted. Entitlement to TDIU from November 8, 2010 is granted. SMC based on the need for aid and attendance or on housebound status is denied. ______________________________________________ THOMAS H. O'SHAY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs