Citation Nr: 1804272 Decision Date: 01/23/18 Archive Date: 01/31/18 DOCKET NO. 14-11 443 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for hypertension as secondary to the service-connected cervical spine and/or his service-connected anxiety disorder disabilities. 2. Entitlement to an increased rating in excess of 20 percent for the cervical spine disability. 3. Entitlement to a rating in excess of 30 percent for the period prior to February 27, 2013 for anxiety disorder, not otherwise specified. 4. Entitlement to special monthly compensation (SMC) pursuant to 38 U.S.C.A. § 1114 (s). REPRESENTATION Appellant represented by: American Red Cross ATTORNEY FOR THE BOARD R. Casadei, Counsel INTRODUCTION The Veteran served on active duty from July 1974 to July 1976. This appeal comes before the Board of Veterans' Appeals (Board) from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, the Commonwealth of Puerto Rico. The issue of (1) entitlement to service connection for hypertension as secondary to the service-connected cervical spine disability; and (2) entitlement to an increased rating in excess of 20 percent for the cervical spine disability were previously remanded by the Board in September 2016. Procedural Issues By way of procedural background, the Board notes that in a May 2011 rating decision, the RO granted service connection for anxiety disorder and assigned a 30 percent evaluation effective October 26, 2010. In July 2011, the Veteran filed a Notice of Disagreement (NOD) with all determinations made in the May 2011 rating decision, which would include the rating and effective date assigned. In a subsequent March 2013 rating decision, the RO granted a 100 percent rating for anxiety disorder effective February 27, 2013. In April 2013, the Veteran indicated that he agreed with the 100 percent rating, but requested reconsideration as to the effective date for the grant of a 100 percent evaluation. Specifically, the Veteran indicated that the effective date of the 100 percent rating should have been October 2010. In a June 2014 rating decision, the RO found that clear and unmistakable error was made in the assignment of a 100 percent disability rating and the Veteran's rating was reduced to 30 percent effective August 1, 2014. However, in an August 2015 rating decision, the RO found clear and unmistakable error had been committed and restored the 100 percent rating effective February 27, 2013. In November 2017, the RO issued a Statement of the Case (SOC) which denied the issue of entitlement to an earlier effective dated prior to February 27, 2013 for the evaluation of 100 percent disabling for service-connected anxiety disorder. A substantive appeal was timely filed in November 2017. As such, the Board will consider whether a rating in excess of 30 percent for the period prior to February 27, 2013 for anxiety disorder is warranted. Regarding the issue for a higher rating and earlier effective date for a low back disorder, the Board notes that in September 2016, the issue of whether new and material evidence had been received to reopen the claim for service connection for a low back disorder was remanded. Thereafter, in a June 2017 rating decision, the RO granted service connection for a low back disorder and assigned a 10 percent rating effective November 22, 2010, and a 40 percent rating effective April 26, 2016. The RO also granted special monthly compensation based on housebound criteria from February 27, 2013 to March 1, 2014. In July 2017, the Veteran filed a Notice of Disagreement (NOD) with ratings and effective dates assigned in the June 2017 rating decision. In July 2017, the RO acknowledged receipt of the NOD and is taking additional action. As such, this situation is distinguishable from Manlicon v. West, 12 Vet. App. 238 (1999), where a NOD had not been recognized. As such, the Board finds that a remand for the issuance of a statement of the case for these issues in not necessary at this time. FINDINGS OF FACT 1. The Veteran's hypertension is not caused by, the result of, or aggravated by the service-connected cervical spine and/or psychiatric disabilities. 2. For the rating period prior to February 27, 2013, the Veteran's cervical spine disability did not more nearly approximated forward flexion of the cervical spine to 15 degrees or less or favorable ankylosis of the entire cervical spine. 3. For the rating period beginning February 27, 2013, the Veteran's cervical spine disability was manifested by forward flexion of the cervical spine limited to 20 degrees with objective evidence of pain starting at 10 degrees. 4. For the entire rating period prior to February 27, 2013, the evidence is in equipoise as to whether the Veteran's anxiety disorder was manifested by symptoms resulting in total occupational and social impairment. 5. For the rating period beginning June 3, 2011, the Veteran's service-connected anxiety disorder is a service-connected disability rated as total, and his other service-connected disabilities are rated as at least 60 percent disabling. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension as secondary to a service-connected disability have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 2. For the rating period prior to February 27, 2013, the criteria for a disability rating in excess of 20 percent for the cervical spine disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237 (2017). 3. For the rating period beginning February 27, 2013, the criteria for a disability rating of 30 percent, but no higher, for the cervical spine disability have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237 (2017). 4. For the rating period prior to February 27, 2013, the criteria for a 100 percent rating for anxiety disorder have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9413 (2017). 5. The criteria for special monthly compensation at the housebound rate have been met beginning June 3, 2011. 38 U.S.C. §§ 1114 (s), 5103, 5107; 38 C.F.R. §§ 3.102, 3.350 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist In this case, neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Service Connection Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Only chronic diseases listed under 38 C.F.R. § 3.309(a) (2017) are entitled to the presumptive service connection provisions of 38 C.F.R. § 3.303(b). Walker v. Shinseki, 708 F.3d 1331 Fed. Cir. 2013). Establishing service connection generally requires (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 evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The U.S. Court of Appeals for Veterans Claims (Court) has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310 (a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See 38 C.F.R. § 3.310 (a); Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In rendering a decision on appeal the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57(1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382(1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment, including by a veteran. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner's opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102 . Service Connection Analysis for Hypertension The Veteran maintains that his hypertension is secondary to his service-connected cervical spine and/or psychiatric disability. See December 2010 statement from Veteran. The evidence does not suggest, and the Veteran has not otherwise contended, that his hypertension is directly related to service. As such, the Board will only consider whether secondary service connection is warranted. Initially, the Board finds that the Veteran has a current diagnosis of hypertension. See April 2011 VA examination report. Next, the Board finds that the preponderance of the evidence weighs against a finding that the Veteran's hypertension is either caused or permanently aggravated by a service-connected disability. The evidence includes an April 2011 VA examination. The examiner diagnosed the Veteran with hypertension and opined that it was not secondary to the Veteran's service-connected cervical spine disability. In support of this opinion, the examiner indicated that medical literature had been reviewed; however there was no pathophysical relationship between a cervical spine strain and arterial hypertension. Pursuant to the Board's remand directive, the Veteran was afforded another VA examination in January 2017. The examiner opined that that Veteran's hypertension was not caused or aggravated by a service-connected disability. The examiner explained that although mental diseases and stress could temporarily elevate blood pressure during an acute phase of the disease, the medical literature did not substantiate a claim that anxiety caused or permanently elevated blood pressure. Moreover, the examiner agreed with the April 2011 VA examiner in that hypertension and the cervical spine had different pathophyscial mechanism. In other words, hypertension was caused by the hardening of the arteries with aging due to family and dietary factors, whereas the cervical spine condition was a result of trauma or wear and tear factors. The Veteran has argued that his hypertension is worse during periods of stress, and therefore they could be aggravated by his anxiety disorder. However, temporary or intermittent flare-ups of symptoms of a condition, alone, do not constitute sufficient evidence aggravation unless the underlying condition worsened. See Davis v. Principi, 276 F. 3d 1341, 1346-47 (Fed. Cir. 2002). In other words, there must be a permanent worsening beyond natural progression rather than temporary or intermittent flare-ups. Id. This is not shown here. The Board has also considered the Veteran's lay statements purporting to relate his hypertension to his service-connected cervical spine and psychiatric disabilities. However, as a lay person, the Veteran does not have the requisite medical knowledge, training, or experience to be able to render a competent medical opinion regarding the cause of the medically complex hypertension disorder. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011) (recognizing an anterior cruciate ligament injury is a medically complex disorder that required a medical opinion to diagnose and to relate to service). Hypertension is a medically complex disease process because of its multiple possible etiologies. Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (holding that rheumatic fever is not a condition capable of lay diagnosis); see also 38 C.F.R. § 4.104, Diagnostic Code 7101 (setting forth the types of diagnostic findings upon which a diagnosis of hypertension may be predicated). The remaining evidence of record does not include an opinion relating the Veteran's hypertension to a service-connected disability. For these reasons, the Board finds that the preponderance of the competent and probative evidence of record weighs against the Veteran's claim for service connection for hypertension as secondary to his service-connected disabilities. As such, the Board finds that service connection is not warranted, and the claim must be denied. Laws and Analysis for Cervical Spine Disability Rating The Veteran maintains that his cervical spine disability is more severe that what is contemplated by the currently assigned 20 percent disability rating. Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in a veteran's condition. Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. See 38 C.F.R. § 4.1. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Nevertheless, where a veteran is appealing the rating for an already established service-connected condition, his present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. Staged ratings are 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 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection of parts of the musculoskeletal system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. The functional loss may be due to absence of part, or all, of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). The General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula) encompasses such disabling symptoms as pain, ankylosis, limitation of motion, muscle spasm, and tenderness. Diagnostic codes 5235-5243 are included under the General Rating Formula. Under the General Rating Formula, the following ratings are either currently assigned or available: 100% Unfavorable ankylosis of the entire spine; 40% Unfavorable ankylosis of the entire cervical spine; 30% Forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine; 20 % Forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (5). The evidence includes a March 2010 VA spine examination. During the evaluation, the Veteran reported pain in the cervical area radiating to the upper extremities. Upon range of motion testing forward flexion of the cervical spine was limited to 45 degrees, with pain starting at 35 degrees. The Veteran was able to repeatedly flex the cervical are and had pain at the paravertebral, but no weakness or fatigue was noted. The Veteran denied any incapacitating episode. The examiner also did not diagnose the Veteran with radiculopathy and the sensory examination was intact to pinprick in the upper extremities. In a February 27, 2013, VA cervical spine examination, the Veteran denied flare-ups. Range of motion testing revealed forward flexion limited to 20 degrees, with objective evidence of painful motion starting at 10 degrees. After repetitive use testing, there was no additional loss of motion in flexion. The examiner further indicated that the Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. The Veteran was not diagnosed with IVDS. The Veteran was most recently afforded a VA spine examination in April 2017. At that time, the Veteran complained of constant upper back pain and stiffness. The Veteran denied flare-ups. Upon range of motion testing, flexion was limited to 35 degrees with pain however, the examiner did not indicate where pain began. After repetitive use testing, there was no additional loss of motion in flexion. The examiner further indicated that the Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. There was also no ankylosis of the spine. The examiner further indicated that the Veteran had IVDS with episodes of bed rest having a total duration of at least one week but less than two weeks during the past 12 months. These episodes were noted to be described by the Veteran only without documentation. Based on the clinical findings regarding range of motion of the cervical spine, the Board finds that, for the rating period prior to February 27, 2013, a rating in excess of 20 percent is not warranted as the forward flexion has never been reduced to 15 degrees or less, and as there has never been a finding of favorable ankylosis of the entire cervical spine. The Board has specifically considered the functional impairment caused by the service-connected cervical spine disability. The March 2010 VA examiner reported that there was no additional limitation of motion or functional impairment during flare-ups. There was no additional loss of motion after repetitive use testing. The clinical evidence reflects that, despite the Veteran's pain, which the Board finds is present with all motion of the cervical spine, the Veteran was able to attain the reported ranges of motion. The Board emphasizes that the presence of pain, even with all motion, is not itself probative of entitlement to a rating higher than 20 percent for the cervical spine disability. While it is clear from the record that there is limited motion and painful motion, evaluations in excess of the minimum compensable rating (10 percent) must be based on demonstrated functional impairment to the appropriate degree. Unlike the assignment of a minimum compensable rating, which can be based on painful motion to any degree, the question for resolution here is not whether pain limits motion of the cervical spine, but whether that limitation would decrease motion to the degrees specified for a higher rating. Here, the evidence simply does not demonstrate impairment to the level necessary for the next higher 30 percent rating regarding the cervical spine prior to February 27, 2013. For the reasons discussed above, the Board concludes that a rating higher than 20 percent under the General Rating Formula is not warranted for the cervical spine disability for the rating period prior to February 27, 2013. The Board further finds that, for the rating period beginning February 27, 2013, the evidence is in equipoise as to whether the Veteran's cervical spine disability more nearly approximates a 30 percent rating. As noted by the February 2013 VA examiner, the Veteran first experienced pain when testing forward flexion of the cervical spine at 10 degrees. See VAOPGCPREC 9-98 (recognizing the motion effectively ends where pain begins). For these reasons, and resolving reasonable doubt in the Veteran's favor, the Board finds that a 30 percent rating is warranted for the Veteran's cervical spine disability effective February 27, 2013, the first evidence of forward flexion of the cervical spine at less than 15 degrees. As there is no evidence of ankylosis of the cervical spine, a rating in excess of 30 percent is not warranted. The Board may also consider whether higher ratings based upon the Formula for Rating IVDS Based on Incapacitating Episodes are warranted. At his April 2017 VA examination, the examiner noted a diagnosis of IVDS. However, the record does not reflect any prescribed periods of bed rest for cervical spine IVDS during the appeal period which would meet the criteria for a higher rating in excess of 30 percent. Thus, the Board finds that this alternative rating method likewise provides no basis for any higher rating. The Board has considered whether a separate neurological rating is warranted for the cervical spine disability, as contemplated by the regulations. However, as noted above, the evidence is against the finding of a current diagnosis of a neurological disability of the upper extremities associated with his cervical spine disability. There is no evidence of any other neurological manifestations. The VA examinations discussed above all indicated that the Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. Further, a June 2011 statement from Dr. M. F. indicated that the Veteran complained of upper extremity radiculopathy; however, the objective evidence of record does not demonstrate a diagnosis of radiculopathy. An imaging report dated in November 2010 from Dr. M. D. did not diagnosed radiculopathy despite providing various other diagnoses pertaining to the spine. VA treatment records are also absent for any documented diagnosis of radiculopathy of the upper extremities. The Board notes that ratings for radiculopathy are based on the objective results of testing administered by, and findings rendered by, trained medical professionals. Hence, the Veteran's assertions are not competent in this regard. See 38 C.F.R. § 3.159(a)(1) (competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). As indicated, here, such testing results and findings do not support the assignment of a rating for separate rating for radiculopathy. Thus, while the assertions of the Veteran have been considered, such assertions are not considered more persuasive than the objective testing results and medical findings which, as indicated above, do not support a separate rating for radiculopathy. Laws and Analysis for Anxiety Disorder Disability Rating As noted above, the Veteran is currently in receipt of a 100 percent disability rating for his anxiety disorder effective February 27, 2013. The Veteran maintains that his disability more nearly approximated a 100 percent rating for the entire initial rating period on appeal. The Veteran is in receipt of a 30 percent disability rating for anxiety disorder for the rating period prior to February 27, 2013 under Diagnostic Code 9413. A higher 50 percent rating is assigned 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; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130. A 70 percent disability rating is assigned 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 that is intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Id. A 100 percent disability rating is assigned 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, or for the veteran's own occupation or name. Id. In applying the above criteria, the Board notes that, when it is not possible to separate the effects of the service-connected disability from a nonservice-connected disability, such signs and symptoms shall be attributed to the service-connected disability. See 38 C.F.R. § 3.102; Mittleider v. West, 11 Vet. App. 181 (1998) citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996) (the Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence which does so). The evidence prior to February 27, 2013, includes the February 2013 VA examination. During the evaluation, the examiner specifically indicate that the evaluation would cover the time period from the date of the rating decision (May 2011) to the present. As such, the Board finds that the February 2013 examination is relevant to the rating period currently on appeal. The examiner diagnosed the Veteran with anxiety disorder, continuous alcohol abuse, and alcohol induced mood disorder, depressed. Importantly, the examiner indicated that it was not possible to differentiate what symptoms were attributable to each diagnosis. Although these were noted to be separate diagnoses, the examiner stated that alcohol abuse was a risk factor for, and could exacerbate, both anxiety and depressive disorders. During the evaluation, the Veteran indicated that he had ongoing alcohol dependence for at least 3 years and retired in 2010 as a police officer so as to not have problems at work due to his drinking. After performing a mental status examination, a review of the claims file, and an interview with the Veteran, the examiner indicated that the Veteran's psychiatric disorders resulted in total occupational and social impairment. The Board finds that a 100 percent rating is warranted for the Veteran's anxiety disorder with alcohol abuse, and alcohol induced mood disorder for the entire rating period from October 26, 2010, (date of claim) to February 26, 2013. Although the Veteran was afforded a VA psychiatric examination in April 2011, the examiner did not address the Veteran's alcohol abuse disorders. As such, the Board finds the April 2011 VA examination to be of little probative value. For these reasons, and resolving reasonable doubt in the Veteran's favor, the Board finds that a rating of 100 percent for anxiety disorder with alcohol abuse, and alcohol induced mood disorder is warranted for the rating period on appeal prior to February 27, 2013. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. SMC The Court has held that VA has a "well-established" duty to maximize a claimant's benefits. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); AB v. Brown, 6 Vet. App. 35, 38 (1993); see also Bradley v. Peake, 22 V et. App. 280 (2008). This duty to maximize benefits requires VA to assess all of a claimant's disabilities to determine whether any combination of disabilities establishes entitlement SMC under 38 U.S.C. § 1114. See Bradley, 22 Vet. App. 280, 294 (2008) (finding that SMC "benefits are to be accorded when a Veteran becomes eligible without need for a separate claim"). Special monthly compensation is payable where the Veteran has a single service-connected disability rated as 100 percent and (1) has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. This requirement is met when the Veteran is substantially confined as a direct result of service-connected disabilities to his or her dwelling and the immediate premises, or if institutionalized, to the ward or clinical areas and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his or her lifetime. 38 U.S.C.A. § 1114 (s); 38 C.F.R. § 3.350 (i). Subsection 1114(s) requires that a disabled Veteran whose disability level is determined by the ratings schedule must have at least one disability that is rated at 100 percent in order to qualify for the special monthly compensation provided by that statute. Under the law, subsection 1114(s) benefits are not available to a Veteran whose 100 percent disability rating is based on multiple disabilities, none of which is rated at 100 percent disabling. In this case, the Board notes that as a result of this decision, a 100 percent rating has been assigned for the service-connected psychiatric disability beginning October 26, 2010. Thus, for SMC purposes, this disability satisfied the requirement of a "service-connected disability rated as total." See Buie v. Shinseki, 24 Vet. App. 242, 251 (2011); see also Bradley v. Peake, 22 Vet. App. 280, 293 (2008). Further, and because the Veteran has a single service-connected disability rated as total (i.e., anxiety disorder with alcohol abuse, and alcohol induced mood disorder), and has additional service-connected disabilities (i.e., headaches, rated as 50 percent disabling; cervical strain, rated as 20 percent disabling; and tinnitus, rated as 10 percent disabling) that are independently rated at over 60 percent beginning June 3, 2011, the criteria for SMC at the housebound rate have been met beginning June 3, 2011. Thus, in light of the Court's decisions in Bradley and in Buie, entitlement to SMC at the housebound rate under 38 U.S.C. § 1114 (s) is granted effective June 3, 2011. Finally, the Board notes that neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). [CONTINUED ON NEXT PAGE] ORDER Service connection for hypertension as secondary to the service-connected cervical spine and/or his service-connected anxiety disorder disability is denied. For the rating period prior to February 27, 2013, a disability rating in excess of 20 percent for the cervical spine disability is denied. For the rating period beginning February 27, 2013, a disability rating of 30 percent, but no higher, for the cervical spine disability is granted, subject to the law and regulations governing the payment of monetary benefits. For the rating period prior to February 27, 2013, a 100 percent rating for anxiety disorder is granted, subject to the law and regulations governing the payment of monetary benefits. Beginning June 3, 2011, SMC at the housebound rate under 38 U.S.C. § 1114 (s) is granted, subject to the law and regulations governing the payment of monetary benefits. ______________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs