Citation Nr: 1806022 Decision Date: 01/31/18 Archive Date: 02/07/18 DOCKET NO. 11-14 749 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to a rating higher than 50 percent for posttraumatic stress disorder (PTSD), prior to January 11, 2016, and rating higher than 70 percent thereafter. 2. Entitlement to a rating in excess of 20 percent for diabetes mellitus, type II. 3. Entitlement a compensable disability rating for hypertension prior to December 16, 2015. 4. Entitlement a rating higher than 80 percent for diabetic renal involvement with hypertension after December 16, 2015. 5. Entitlement to an initial compensable rating for erectile dysfunction. 6. Entitlement to a total disability rating based on individual unemployability (TDIU) due to the service-connected disabilities. 7. Entitlement to special monthly compensation (SMC) based on the need for regular aid and attendance of another person or on account of being housebound. REPRESENTATION Appellant represented by: Christopher L. Loiacono, Agent ATTORNEY FOR THE BOARD T. Azizi-Barcelo, Counsel INTRODUCTION The Veteran served on active duty from December 1966 to November 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions in April 2010 and May 2015 of a Department of Veterans Affairs (VA) Regional Office (RO). In a rating decision in April 2017 the RO granted a single rating of 80 percent for renal involvement in diabetes mellitus type II with hypertension, effective December 16, 2015. The separate evaluation for hypertension was discontinued effective that same date. See 38 C.F.R. § 4.14 (evaluation of a single manifestation of disability under separate diagnoses is to be avoided as pyramiding). Thus, the issues involving hypertension and diabetic renal involvement with hypertension have been recharacterized as reflected on the title page. That rating decision also increased the Veteran's disability rating for PTSD to 70 percent effective January 11, 2016. Because the increased ratings do not represent a grant of the maximum benefits allowable, the issues remain in appellate status. AB v. Brown, 6 Vet. App. 35, 38 (1993). In September 2017 the Veteran submitted a private medical statement without a waiver of initial RO consideration of the evidence. However, the Board notes that the automatic waiver provision applies in this case, as the appeal was certified after February 2, 2013. See Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Public Law No. 112-154, 126 Stat. 1165 (amending 38 U.S.C. § 7105 to provide for an automatic waiver of initial agency of original jurisdiction (AOJ ) review of evidence submitted to the AOJ or to the Board at the time of or subsequent to the submission of a substantive appeal filed on or after February 2, 2013, unless the claimant or claimant's representative requests in writing that the AOJ initially review such evidence). VA treatment records were also added to the claims file since the issuance of the most recent supplemental statement of the case. The additional evidence is duplicative of evidence already of record, and it does not have a bearing on the issues herein decided. Therefore, the Board finds that referral of the additional evidence to the AOJ for initial consideration is not warranted. 38 C.F.R. § 20.1304 (c) (2017). The Veteran was scheduled for a Board hearing in June 2017; however, in correspondence submitted that month, he withdrew his request. His hearing request is deemed withdrawn. See 38 C.F.R. § 20.702 (d). FINDINGS OF FACT 1. Affording the Veteran the benefit of the doubt, the Board finds that for the period of the claim prior to January 11, 2016, the Veteran's PTSD resulted in functional limitation most closely approximating occupational and social impairment with deficiencies in most areas. 2. The Veteran's PTSD has not been productive of total social and occupational impairment. 3. Throughout the appeal, the Veteran's diabetes mellitus type II has required an oral hypoglycemic agent, insulin, and a restricted diet, but not restriction of activity. 4. Prior to December 16, 2015, hypertension was not shown to be productive of diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more. 5. Effective December 16, 2015, the Veteran's diabetic renal involvement with hypertension has not been characterized by requiring regular dialysis, or preclusion of more than sedentary activity from one of the following: persistent edema and albuminuria; or BUN more than 80 mg percent; or creatinine more than 8 mg percent; or markedly decreased function of kidney or other organ systems, especially cardiovascular. 6. The most probative evidence of record does not show that the Veteran has a deformed penis. 7. Prior to December 15, 2016, the Veteran was unemployable due to service-connected disabilities. 8. Since December 15, 2016, VA has assigned a combined 100 percent rating for the Veteran's multiple service-connected disabilities. 9. The Veteran's service-connected disabilities themselves do not cause the need for regular aid and attendance of another person. CONCLUSIONS OF LAW 1. Prior to January 11, 2016, the criteria for an evaluation of 70 percent, but no higher, for PTSD were met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017). 2. The criteria for an evaluation in excess of 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017). 3. The criteria for rating higher than 20 percent for diabetes mellitus type II have not been met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. § 4.119, Diagnostic Code 7913 (2017). 4. Prior to December 16, 2015, the criteria for a compensable rating for hypertension have not been met. 38 U.S.C. §§ 1155, 5107(West 2012); 38 C.F.R. § 4.104, Diagnostic Code 7101 (2017). 5. Effective December 16, 2015, the criteria for a rating higher than 80 percent for diabetic renal involvement with hypertension have not been met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. § 4.104, Diagnostic Codes 7101, 7541 (2017). 6. The criteria for a compensable evaluation for erectile dysfunction have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.20, 4.31, 4.115b, Diagnostic Code 7522 (2017). 7. Prior to December 15, 2016 (i.e., prior to the award of the combined 100 percent evaluation), the criteria for a TDIU were met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 3.340, 4.16 (2017). 8. The criteria for entitlement to SMC for aid and attendance have not been met. 38 U.S.C. §§ 1114 (l), 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.350, 3.352(a) (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duty to Notify and Assist 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 duty to assist argument). Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 1. PTSD The Veteran's psychiatric disability is rated under Diagnostic Code 9411 which utilizes General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. Under that Formula, a 50 percent rating is assigned when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks (more than once a week); difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted 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); and the inability to establish and maintain effective relationships. A 100 percent rating is assigned for 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 ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closest relatives, own occupation, or own name. As the United States Court of Appeals for the Federal Circuit recently explained, evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed.Cir.2013). The symptoms listed are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms[,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas" - i.e., "the regulation... requires an ultimate factual conclusion as to the Veteran's level of impairment in 'most areas.'" Vazquez-Claudio, 713 F.3d at 117-18; 38 C.F.R. § 4.130, Diagnostic Code 9411. Further, when evaluating a mental disorder, the Board must consider the "frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission," and must also "assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination." 38 C.F.R. § 4.126(a). Global Assessment of Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) [citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), p. 32]. GAF scores ranging between 71 and 80 reflect that if symptoms are present they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument; no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). GAF scores ranging from 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but is generally able to function "pretty well," and has some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). See 38 C.F.R. § 4.130 [incorporating by reference the VA's adoption of the DSM-IV, for rating purposes]. VA implemented DSM-5, effective August 4, 2014, and the Secretary, VA, determined that DSM-5 applies to claims certified to the Board after August 4, 2014. See 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). As the Veteran's increased rating claim was originally certified to the Board after August 4, 2014, the DSM-5 is applicable to this case. Effective August 4, 2014, VA also amended the regulations regarding the evaluation of mental disorders by removing outdated references to DSM-IV. The amendments replace those references with references to the recently updated DSM-5. However, according to DSM-5, clinicians do not typically assess GAF scores. The DSM-5 introduction states that it was recommended that the GAF be dropped from DSM-5 for several reasons, including its conceptual lack of clarity (i.e., including symptoms, the suicide risk, and disabilities in its descriptors) and questionable psychometrics in routine practice. On VA examination in August 2008, the examiner noted no history of inpatient psychiatric hospitalization. Treatment consisted of outpatient mental health visits and medication. He denied suicidal or homicidal ideation. The Veteran reported being divorced for over 15 years. He had three children. He remained in contact with his daughter and one son, who occasionally visited. While he remained in touch with his adult children and grandchildren, the examiner noted that the Veteran appeared to be something of a social recluse. As for employment, the Veteran reported working for a school district for over 12 years in maintenance service, until reportedly he was dismissed for abusing the sick leave. The Veteran explained that he just wanted to stay home. Prior to that, he was employed for approximately eight years with a different school district. His employment was also terminated due to abusing sick leave and not obeying orders. The Veteran reported that he enjoyed staying home and working on his garden. He also enjoyed playing with his grandson and taking him boating and swimming on a nearby lake. Objectively, the Veteran was alert and oriented times four. His mood was neutral and his affect congruent and stable. There were no abnormal motor movements noted. He tended to speak in a clearly, audible, and well-modulated voice. Eye contact was socially appropriate. His thought processes seemed linear and logical and there was no evidence of any delusions or hallucinations. Attention and memory appeared impaired. Cognitive functions, as measured by the MOCA appeared impaired across most spheres. The Veteran showed difficulties with problem solving, abstract reasoning, eye-hand coordination, attention, concentration, and short-term memory. The examiner assigned a GAF score of 50, indicative of significant impairment regarding social and occupational functioning. VA treatment records showed that in March 2009 the Veteran's mood was stable to irritable. His affect was constricted. The Veteran denied suicidal or homicidal ideation, or hallucinations. His insight was good, and thought process was goal directed. His cognition was grossly intact. His GAF in 2009 was 54. On VA examination in February 2010 the Veteran endorsed panic attacks once a month, problems sleeping, loss of interest, self-isolation, irritability, depression, distressing memories, nightmares, flashbacks, feelings of detachment, hypervigilance, and exaggerated startle response. He denied any psychiatric hospitalizations or inpatient treatment. He saw a psychiatrist once a month through the VA and was taking medications, which were helpful. He indicated that he was last employed a few years earlier. He reported that he was single and lived alone. He had three adult children with whom he had contact with them on a daily or weekly basis. Generally, his relationship with his children was good. He also cared for his grandson and enjoyed gardening and caring for his dog. He reported having two very close friends, one who often visited him. The Veteran stated that he did not enjoy being around other people and even though he had a good relationship with his children, he did not like them to be around too long either. Occupationally, the Veteran reported he was fired from his maintenance job at a school due to difficulty performing job tasks. He described mild problems with attention and concentration that affected productivity. He denied problems on-the-job other than diabetic neuropathy which impeded his ability to complete job tasks. He reported a good relationship with coworkers and supervisors. The Veteran was described as appropriately dressed with good eye contact. He was alert and oriented. His behavior was within normal limits. Psychomotor activity was unremarkable. His speech, rate, volume, and tone were unremarkable, and his communication was good. His mood was mildly anxious. His affect was congruent and appropriate. His thought process and thought content were unremarkable. There were no signs of delusions or hallucinations. The Veteran denied suicidal or homicidal ideation, plan, or intent. He was noted to be a good historian. There was no inappropriate behavior displayed during the evaluation. The examiner determined that the Veteran's PTSD appeared to be productive of moderate social and occupational impairment as reflected by his GAF of 55. The examiner noted that the Veteran's GAF scores from 2009 to 2010 his GAF score has ranged from 55, 52, to 54. The examiner determined that the Veteran's PTSD alone was not completely disabling and did not render him unemployable. The Veteran's avoidance of others and irritability appeared to have a moderate impact on his relationships. A VA clinician in March 2010 noted that the Veteran's speech was normal. His mood was stable and affect was restricted. The Veteran's thought process was goal directed and his judgment was intact for self-preservation. His cognition was grossly intact. The Veteran denied suicidal or homicidal ideation or hallucinations. His GAF score was 54. In September 2012 the Veteran was seen for complaints of occasional nightmares. He also related avoidance of stimuli, feelings of numbness and detached from others, a sense of foreshortened future, loss of interest in activities, difficulty staying asleep, irritability, poor concentration, hypervigilance and exaggerated startle response. He related a history of panic attacks in the past, but none recently. The clinician noted that his symptoms had remained constant in severity for many years. There was no history of psychiatric hospitalizations. Objectively, the Veteran was alert and attentive and oriented time three. He was cooperative and reasonably groomed. His speech was normal. His mood was euthymic and affect congruent. There were no perceptual disturbances, such as hallucinations or illusions. Thought process and associations were normal and coherent, with no unusual thought content, suicidal or violent ideation. Insight and judgment were good. His memory was intact. He posed no danger to himself or others. On VA examination in November 2016 the Veteran endorsed flashbacks, anger outbursts, irritability, avoidance of stimuli, nightmares, exaggerated startle response, problems with concentration, sleep disturbance, depressed mood, anxiety, and suspiciousness. The Veteran reported that he was living with and caring for his 13 year old grandson, whom he had raised since infancy until about age eight, when his son took over due to the Veteran's health issues. Although he had a relationship with his son, he denied having much contact with his adult daughters, who reportedly had problems of that led to strained relationship with their father. He also denied any contact with his first ex-wife, the mother of his children. He did not have a partner or girlfriend. The Veteran indicated that he did not like being around other people. He stated that he was terminated from employment in 2008 due to abusing sick leave. He reported he was also written up for forgetfulness when performing his duties. He denied any issues or conflicts with his coworkers or his boss. The Veteran did not report irritability as an issue at work, as he generally kept to himself. He was able to do some limited public activities, like grocery shop with his son, or attend some of his grandson's sports activities with his son and daughter in law. Objectively, the Veteran was alert and oriented. He was neat and cleanly dressed. He was pleasant and cooperative. His mood was mildly anxious and his affect somewhat constricted. His thought content was concrete. The Veteran's judgment and insight were fair, impacted by his mental health issues. There were no motor behavior abnormalities. He walked slowly with a cane. His attention, concentration, and memory were broadly within normal limits. The examiner noted near-continuous panic or depression affecting the ability to function; mild memory loss, such as forgetting names, directions or recent events; difficulty in understanding complex commands; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships, and; difficulty in adapting to stressful circumstances, including work or a work like setting. The examiner noted that the Veteran's PTSD remained productive of functional impairment. The examiner concluded that the Veteran's symptoms had remained constant in severity, at the same level as noted in previous examinations. The examiner opined that from a mental health standpoint, the Veteran's exhaustion from lack of sleep, poor focus, poor concentration, inattention to detail, avoidance of issues interpersonally, irritability, were mildly to moderately impairing. The examiner determined that the Veteran's symptoms were productive of occupational and social impairment with reduced reliability and productivity. In August 2017 the Veteran underwent a private psychological evaluation. The Veteran endorsed depression, flashbacks, anxiety, avoidance of stimuli, hypervigilance, exaggerated startle response, sleep disturbance, irritability, intrusive thoughts, and a history of panic attacks when not taking medication. The Veteran reported that he continued to receive outpatient mental health treatment at VA and was also treated with medication. The Veteran denied suicidal ideation. He denied a history of inpatient treatment. The Veteran reported working for a brewing company for approximately eight years, before he became employed the school district for approximately 14 years. He last worked for a school district as a maintenance person for about eight years. He reported that he got terminated because he was unable to physically perform his job duties. He last worked in 2009. The Veteran graduated from high school. He was a special education student. He worked primarily as a janitor/maintenance person. The Veteran sought jobs that were solitary in nature, such as working the nightshift, but encountered legal difficulties for alcohol-related problems. The Veteran rented his home from his son. His teenage grandson often stayed with him. He spent his time watching television and doing yardwork. The Veteran denied having any friends. A visiting nurse helped him manage his medication. He was capable of tending to his own grooming and hygiene, and performed light household chores. He had assistance managing his medication, but was capable of handling his own finances. He did not drive far from home. The Veteran was described as dressed casually, but appropriately. His grooming and hygiene were adequate. He displayed no loose associations, flight of ideas or delusional beliefs. Speech was normal. Mood was depressed and affect was somewhat flat. The Veteran was alert, responsive, and oriented to all spheres. There was no evidence of obsessions, compulsions, excessively religiosity, paranoid ideations, psychosis, delusions or hallucinations. The clinician opined that within a reasonable degree of psychological certainty, the Veteran suffered from occupational and social, impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking or mood due to such symptoms as panic, depression, and impaired impulse control, difficulty adapting to stressful circumstances and inability to establish and maintain effective relationships. From a historical perspective, his medical records consistently recorded GAF scores falling in the low and mid 50's dating back to 2009. These ratings corresponded to a moderate degree of impairment in social and occupational functioning. The clinician further found that the Veteran's PTSD was not productive of total occupational and social impairment. Nonetheless, symptomatology was sufficiently severe to impact interpersonal functioning in the workplace. As such, he was disabled secondary to psychiatric impairment. Resolving all reasonable doubt in favor of the Veteran, the Board finds that the evidence shows occupational and social impairment with deficiencies in most areas such as family relations, judgment, thinking, and mood, were met prior to January 11, 2016. Throughout the appeal VA treatment records and examination reports consistently recorded GAF scores in the low to mid 50's, indicative of more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). The evidence also shows that symptoms reported prior to January 11, 2016, are consistent with those reported after his disability rating was increased to 70 percent. In this regard, the Veteran consistently reported nightmares, insomnia, memory problems, nightmares, anxiety, and depression. He endorsed panic attacks without medication. Although he had a good relationship with his son and grandson, his relationship with his daughters was strained. He occasionally endorsed having close friendships, although he reported that he preferred to be alone. The Veteran had been divorced twice and stated that he did not get along with his ex-wives. Throughout the appeal the Veteran denied being romantically involved or having a partner. Moreover, clinicians who have examined the Veteran throughout the appeal, both VA and private, indicated that the severity of the Veteran's symptoms remained constant throughout the period on appeal. On the other hand, the Board finds that the evidence of record does not support a higher disability rating of 100 percent at any time during the appeal. The evidence does not support a finding that such symptomatology occurred with such frequency, duration, or severity as contemplated for the assignment of a 100 percent disability rating. For example, the Veteran denied suicidal or homicidal ideation and no history of inpatient treatment. There is no evidence that he was in danger of hurting self or others as contemplated in the 100 percent rating. Additionally, while the evidence undeniably shows that the Veteran's PTSD is productive of social impairment, it is apparent from the evidence of record, to include the Veteran's reports, the Veteran has been able to establish friendships in recent years, to include two close friends, one whom at least at one point he saw on a regular basis. Although he did not like prolonged visits from friends or family, he was very involved in caring for his grandson and he visited with a friend and children at least on a weekly basis. He took his grandson fishing and attended his sporting events. He enjoyed caring for his dog and working in the garden. Significantly, when the Veteran was most recently evaluated in 2016 and 2017, the clinicians opined that the Veteran's PTSD was not productive of total occupational and social impairment. In absence of evidence of 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 ability to perform activities of daily living (including maintenance of minimal personal hygiene); and disorientation to time or place, the Board finds that the criteria for the next higher rating, 100 percent, have not been demonstrated. There is no evidence of memory loss for names of close relatives, or his own name. The Veteran has not been found to be disoriented. The evidence does not show persistent delusions or hallucinations. The evidence does not show gross inappropriate behavior or gross impairment in communication. His thought processes have not demonstrated gross impairment. Therefore, the Board finds that the evidence does not more nearly approximate the criteria for a rating of 100 percent and a rating greater than 70 percent is denied. Accordingly, prior to January 11, 2016, the Board resolves reasonable doubt in favor of the Veteran and finds that the criteria for a 70 percent rating for PTSD, but not higher, are met. A rating in excess of 70 percent for the entire period on appeal is denied. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert, 1 Vet. App. at 55-56. 2. Diabetes Mellitus Diabetes mellitus is currently rated 20 percent disabling under 38 C.F.R. § 4.119, Diagnostic Code 7913. The 20 percent evaluation encompasses requiring insulin and restricted diet, or; oral hypoglycemic agent and a restricted diet. The criteria for 40 percent under Diagnostic Code 7913 are insulin dependence, restricted diet, and regulation of activities. The criteria for 60 percent are that the Veteran requires insulin, a restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. Note (1) to Diagnostic Code 7913 provides that compensable complications of diabetes are rated separately unless they are part of the criteria used to support a 100 percent evaluation. Note 2 provides that when diabetes mellitus has been conclusively diagnosed, do not request a glucose tolerance test solely for rating purposes. Competent medical evidence is required to establish "regulation of activities," namely, avoidance of strenuous occupational and recreational activities, for a 40 percent rating under Diagnostic Code 7913. Camacho v. Nicholson, 21 Vet. App. 360, 364 (2007). The Veteran contends that he is entitled to a rating higher than 20 percent for diabetes mellitus. On VA examination in August 2008 the examiner noted that the Veteran required daily oral medication and a restricted diet to treat his diabetes. There was no restriction of activities. The Veteran denied problems with hypoglycemia or ketoacidosis and had no history of hospitalizations. He also denied weight loss. The Veteran's diabetes was productive of peripheral neuropathy to which he attributed his inability to work. He was unable to perform strenuous activities. No complications were noted. On VA examination in February 2010, the examiner noted that the Veteran required daily oral medication and insulin to treat his diabetes. He had minor hypoglycemic reactions that were promptly cleared by taking glucose. There was no history of hospitalizations for hypoglycemic reactions or ketoacidosis. The Veteran saw his diabetic care provider every month or two. He also thought he had lost about five pounds since his last visit. The Veteran was under no activity restriction on account of the diabetes mellitus. He had not been hospitalized for his diabetes mellitus. Regarding effects of the condition on his occupational functioning and daily activities, the Veteran had to retire in 2002 at age 53. He simply could not do the walking, lifting, etc., that his job in maintenance required. The examiner noted that the Veteran's employability, both active and sedentary, was not restricted due to service-connected disabilities. On VA examination in December 2015, the examiner noted that the Veteran required daily oral medication and insulin to treat his diabetes, along with a restricted diet. He did not require regulation of activities as part of medical management of diabetes mellitus. He visited his diabetic care provider less than two times per month. There were no episodes of ketoacidosis that required hospitalization over the past 12 months. He stated that he had lost 20 percent of body weight. VA treatment records during the period on appeal showed that the Veteran's diabetes continued to be managed with insulin, oral medication and restricted diet. He was also encouraged to exercise. Accordingly, the Board finds that the evidence shows diabetes mellitus requiring oral hypoglycemic, daily insulin injections, and a restricted diet. However, the Board finds that the evidence does not demonstrate that the Veteran's diabetes has required regulation of activities. There is no evidence in the clinical treatment notes consistent with regulation of activities due to diabetes, and none was noted on examination in 2008, 2012 and 2015. Additionally, the Veteran has denied episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year, or twice a month visits to a diabetic care provider. Since there is no medical evidence of regulation of activities, the Board finds that the criteria for the next higher rating have not been met. 38 C.F.R. § 4.119, Diagnostic Code 7913 (2017). To the extent that the Veteran complained of symptoms associated with the upper and lower extremities, renal involvement with hypertension, and erectile dysfunction, the RO has rated separately these complications of diabetes mellitus. The Board notes that the rating of the same disability under various diagnoses is to be avoided. The rating of the same manifestation under different diagnoses, a practice known as "pyramiding," is to be avoided. 38 C.F.R. § 4.14 (2017). The critical inquiry in making such a determination is whether any of the symptomatology is duplicative or overlapping. Esteban v. Brown, 6 Vet. App. 259 (1994). In sum, the Board finds that the claim for a rating in excess of 20 percent for diabetes mellitus must be denied. The preponderance of the evidence is against the Veteran's claim, and that claim must be denied. See 38 U.S.C.A. § 5107(b); Ortiz, 274 F.3d at 1364; Gilbert, 1 Vet. App. at 55-56. 3. Hypertension and Diabetic Renal Involvement As noted in the Introduction of this decision, prior to December 16, 2015, the Veteran's service connected hypertension associated with the service-connected diabetes mellitus type II was separately rated as noncompensably disabling under Diagnostic Code 7101, which rates hypertensive vascular disease, including hypertension and isolated systolic hypertension. See 38 C.F.R. § 4.104. Diagnostic Code 7101 provides for a 10 percent rating when diastolic pressure is predominantly 100 or more, or when systolic pressure is predominantly 160 or more, or as a minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is provided if diastolic pressure is predominantly 110 or more, or if systolic pressure is predominantly 200 or more. A 40 percent rating is provided if diastolic pressure is predominantly 120 or more. A 60 percent rating is provided if diastolic pressure is predominantly 130 or more. 38 C.F.R. § 4.104, Diagnostic Code 7101 (2017). A noncompensable rating is assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31 (2017). As of December 16, 2015, the RO rated the Veteran's hypertension as part of diabetic renal involvement with hypertension at 80 percent under Diagnostic Code 7101-7541. Under Diagnostic Code 7541, renal involvement in diabetes mellitus is rated as renal dysfunction. Under renal dysfunction, albumin and casts with history of acute nephritis; or, hypertension non-compensable under diagnostic code 7101warrants a noncompensable rating. Renal dysfunction is rated at 30 percent for albumin constant or recurring with hyaline and granular casts or red blood cells; or, transient or slight edema or hypertension at least 10 percent disabling under diagnostic code 7101. A 60 percent rating is warranted for constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension at least 40 percent disabling under diagnostic code 7101. An 80 percent rating is warranted for persistent edema and albuminuria with BUN 40 to 80mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. A 100 percent rating is warranted where regular dialysis is required, or more than sedentary activity is precluded from one of the following: persistent edema and albuminuria; or, BUN more than 80mg%; or, creatinine more than 8mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular. VA treatment notes in May 2008 recorded blood pressure readings of 124/64 and 120/64. Reportedly, his average blood pressure reading at home was 152/74. Other readings in 2008 were 151/85, 144/78, 140/76, 130/80, 140/90, 131/67, 185/87, 164/74, 139/71, and 180/92. On VA examination in August 2008, the Veteran reported that he treated his hypertension with antihypertensive medication. There was no history of hospitalization. There was no history of cardiac neoplasm, hypertensive renal disease, epistaxis, headaches, stroke, hypertensive cardiovascular disease, or hypertensive related disease. His blood pressure readings were 110/68, 112/70, and 108/68. The examiner diagnosed essential hypertension that was productive of o significant occupational impairment. Blood pressure readings in 2009 included 138/61, 21/62, 139/89, 161/79, and 109/47. His hypertension was noted as stable with medication. VA treatment laboratory studies in January 2010 revealed microalbumin elevated to 61, BUN of 23 and creatinine was 0.09. On VA examination in February 2010, the examiner noted renal disease stage 2, asymptomatic. On VA examination in February 2010 it was noted that the Veteran had hypertension for a long time, predating the onset of his diabetes mellitus. He denied syncope, headaches, blindness, or strokes. The Veteran took daily hypertensive medication with good control and no side effects from his medications. The Veteran's blood pressure was 150/70 in the left arm sitting and 160/82 in the right arm sitting. The examiner noted that the Veteran's hypertension was aggravated by diabetes mellitus. It was noted that Veteran's employability, both active and sedentary, was not restricted due to service connected disabilities. Blood pressure readings in 2011 included 124/60, 102/54, 105/60, and 130/54, and 110/68. His hypertension was noted as stable with medication. The Veteran's hypertension was noted as stable on medication. A December 2012 Examination for Housebound Status or permanent Need for Aid and Attendance recorded a blood pressure reading of 160/80. VA and private treatment notes after 2013 recorded blood pressure readings of 157/94, 132/70, 120/60, 110/70, 139/89, 160/80, 142/70, and 156/80. Private treatment records in August 2011 documented BUN as high as 40 mg/dl and creatinine as high as 2.0. No edema was noted. He was admitted for symptoms of weakness and treated for acute renal failure that resolved by the time he was discharged the following day. While the evidence shows that prior to December 16, 2015 the Veteran required continuous use of medication to control his hypertension, and there were systolic readings at 160 or higher, the evidence does not show that his systolic readings were predominantly 160 or higher or diastolic blood pressure readings predominantly 100 or higher. In the absence of diastolic readings predominantly 100 or higher or systolic readings predominantly 160 or higher, the criteria for a compensable rating are not met because the rating criteria for hypertension explicitly contemplate the effects of medication. Cf. Jones v. Shinseki, 26 Vet. App. 56, 61 (2012). As such, a compensable rating for hypertension prior to December 16, 2015, is not warranted. Further, the evidence does not support a rating in excess of 80 percent as of December 16, 2015 for diabetic renal involvement with hypertension. On VA kidney examination in December 2015, the Veteran complained of polydipsia and frequent nocturia. The examiner noted impaired renal function with elevated BUN and creatinine initially thought to be due to dehydration. His most recent studies in October 2015 revealed a BUN of 42 and a creatinine of 1.3. He continued to be treated with hypertensive medications. There was no evidence of renal dysfunction at that time. There was no history of a cardiovascular disorder associated with the service-connected renal condition. There was no history of urolithiasis. The condition had no impact on his ability to work. After careful review of the clinical findings, the Board finds that the above evidence reflects that during the course of the appeal the Veteran did not have symptoms more nearly approximating regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or BUN more than 80 mg percent; or creatinine more than 8 mg percent; or markedly decreased function of kidney or other organ systems, especially cardiovascular. In light of the foregoing, the Board concludes that the preponderance of the evidence is against a compensable rating prior to December 16, 2015, or a rating in excess of 80 percent thereafter, for diabetic renal involvement with hypertension and the claims must be denied. See 38 U.S.C.A. § 5107(b); Ortiz, 274 F.3d at 1364; Gilbert, 1 Vet. App. at 55-56. 5. Erectile Dysfunction The Veteran's service-connected erectile dysfunction is currently rated as noncompensable. He contends that a compensable rating is warranted. The Board notes that the Veteran is already in receipt of special monthly compensation for loss of use of a creative organ for this disability. Initially, the Board notes that the Veteran's erectile dysfunction is rated by analogy under 38 C.F.R. § 4.115b, Diagnostic Code 7522, for penile deformity. See 38 C.F.R. §§ 4.20, 4.27. Diagnostic Code 7522 provides for a 20 percent rating for deformity of the penis with loss of erectile power. 38 C.F.R. § 4.115b. Based on the Veteran's diagnosis and symptoms, which relate to the penis and include loss of erectile power, the Board finds Diagnostic Code 7522 to be the most appropriate diagnostic code. The Board finds no other applicable rating criteria, and the Veteran has not requested evaluation under any alternative rating criteria. Where, as here, the rating schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. On VA examination in February 2010 the Veteran's penis and testes were of normal size and consistency without deformity, swelling, or tenderness. On VA examination in December 2015 the examiner noted onset erectile dysfunction in 2012. The examiner noted no abnormalities of the penis, testes or epidymis. The condition had no occupational impact. Following a review of the record, the Board finds that a higher 20 percent rating is not warranted. Here, although the Veteran has loss of erectile power, the record is negative for evidence of penis deformity, which is necessary for a compensable rating under 38 C.F.R. § 4.115b, Diagnostic Code 7522. In this regard, the Veteran has not asserted, nor does the evidence show, that he has penile deformity. As such, there is no lay or medical support for a compensable disability rating for the Veteran's erectile dysfunction under Diagnostic Code 7522. The Board has also considered the compensable evaluation of 20 percent for atrophy of both testes under Diagnostic Code 7523; however, no such findings were made in this case. See 38 C.F.R. § 4.115b. Specifically, the VA examiner in 2015 noted clinical evaluation of the Veteran's testicles was normal. Moreover, as noted above the Veteran is already in receipt of special monthly compensation for loss of use of a creative organ. Therefore, a separate compensable rating for erectile dysfunction is not warranted. In sum, the weight of the credible evidence demonstrates that the Veteran is not entitled to a compensable rating for erectile dysfunction. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107(b); Ortiz, 274 F.3d at 1364; Gilbert, 1 Vet. App. at 55-56. 6. TDIU and SMC In order to establish a total rating based upon individual unemployability due to service-connected disabilities, there must be impairment so severe that it is impossible for the average person to follow a substantially gainful occupation. See 38 U.S.C. § 1155; 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). Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). Under the applicable criteria, total disability ratings based on individual unemployability may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more service-connected disabilities, provided that one of those disabilities is ratable 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16. In determining whether the veteran is entitled to a TDIU rating, neither his non-service-connected disabilities nor his advancing age may be considered. Van Hoose v. Brown, 4 Vet. App. 361 (1993). The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough for an award of TDIU. A high rating in itself is a recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. Id. Substantially gainful employment must be reviewed in a practical manner, and mere theoretical ability to engage in substantial gainful employment is not a sufficient basis to deny benefits. The test is whether a particular job is realistically within the physical and mental capabilities of the claimant. Moore v. Derwinski, 1 Vet. App. 356 (1991), Timmerman v. Weinberger, 510 F.2d 439 (8th Cir. 1975). The Board notes that the regulations do not provide a definition of "substantially gainful employment," but VA Adjudication Procedure Manual defines the term as "that which is ordinarily followed by the nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the Veteran resides." See also Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). Although the Board is not bound by VBA's manual, it can be useful when deciding claims such as this. Marginal employment, as a self-employed worker or at odd jobs or while employed at less than half of the usual remuneration, shall not be considered "substantially gainful employment." 38 C.F.R. § 4.16(a); see Moore. Marginal employment generally shall be deemed to exist when a Veteran's earned annual income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. 38 C.F.R. § 4.16(a). Moreover, the manual contains a note that for self-employed individuals, low net earnings in conjunction with gross income should be considered, and thus may be considered marginal employment. A veteran's service-connected disabilities, alone, must be sufficiently severe to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524 (1993). In determining whether unemployability exists, consideration may be given to the veteran's level of education, special training and previous work experience, but not to his age or to any impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. The Veteran's current claim for a TDIU was received in December 2009. In essence, he contends his service-connected disabilities render him unemployable. Effective December 2009, the service connection is in effect for PTSD, rated 70 percent disabling; diabetes mellitus, rated at 20 percent disabling; peripheral neuropathy of the left upper extremity, rated 10 percent disabling; peripheral neuropathy of the right upper extremity, rated 10 percent disabling; peripheral neuropathy of the left lower extremity, rated 10 percent disabling; peripheral neuropathy of the right lower extremity, rated 10 percent disabling; diabetic kidney disease, rated as noncompensable; hypertension, rated as noncompensable, and; erectile dysfunction, also rated as noncompensable. As such, he meets the criteria of 38 C.F.R. § 4.16(a) as of such date. As previously noted, as of December 16, 2015, the RO rated the Veteran's diabetic renal involvement with hypertension at 80 percent, and as such, as of that date his combined disability rating is 100 percent. Generally, to grant a TDIU, the Veteran cannot be in receipt of a total disability evaluation either for a single disorder or based on a combined evaluation. 38 C.F.R. § 4.16. Thus, as of December 16, 2015, the Veteran is not eligible under the terms of the regulation for a TDIU rating. See Vettese v. Brown, 7 Vet. App. 31, 34-35 (1994) ("claim for TDIU presupposes that the rating for the condition is less than 100%"); see also Holland v. Brown, 6 Vet. App. 443, 446 (1994) (100 percent schedular rating "means that a Veteran is totally disabled"). However, the Court has noted 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 Vet. 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 to SMC under 38 U.S.C.A § 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"). 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. In this regard, such statute states that, if a veteran has a service-connected disability rated as total and has additional service-connected disability or disabilities independently ratable at 60 percent or more, he may be paid at the housebound rate. Thus, 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 Bradley, the Court held that SMC might be warranted when a separate award of a TDIU rating, predicated on a single disability (perhaps not ratable at the schedular 100 percent level), is considered together with another disability separately rated at 60 percent or more. See Buie at 251; see also Bradley at 293. Work records from the Veteran's last employer show that he was terminated in 2008 due to neglect of duty, nonfeasance, insubordination, absenteeism, abusing the sick leave policy and inability to perform assigned work. Specific to his service-connected PTSD, on VA examination in August 2008, the Veteran reported working for a school district for over 12 years in maintenance service, until reportedly he was dismissed for abusing the sick leave. The Veteran explained that he just wanted to stay home. Prior to that, he was employed for approximately eight years with a different school district. His employment there was also terminated due to abusing sick leave and not obeying orders. The examiner found that the Veteran's PTSD was productive of significant social and occupational impairment. On VA examination in February 2010 the Veteran reported he was fired from his maintenance job at a school due to difficulty performing job tasks. He described mild problems with attention and concentration that affected productivity. He denied problems on-the-job other than diabetic neuropathy which impeded his ability to complete job tasks. He reported a good relationship with coworkers and supervisors. The examiner determined that the Veteran's PTSD alone was not completely disabling and did not render him unemployable. Nonetheless, the Veteran's avoidance of others and irritability appeared to have a moderate impact on his relationships. On VA examination in November 2016 the Veteran indicated that he did not like being around other people. He stated that he was terminated from employment in 2008 due to abusing sick leave. He reported he was also written up for forgetfulness when performing his duties. He denied any issues or conflicts with his coworkers or his boss. He did not report irritability as an issue at work, as he generally kept to himself. The examiner determined that the Veteran's symptoms were productive of occupational and social impairment with reduced reliability and productivity. However, there was evidence in the record review, including the Veteran's own statements, that he was capable of being successful at his last position. As such, the examiner opined that the Veteran's unempoyability was attributable to a combination of his mental and physical disabilities, to specifically include neuropathies that affected his ability to lift heavy objects or work in cold weather. From a from a mental health standpoint, his exhaustion from lack of sleep, poor focus/concentration, inattention to detail, avoidance of issues interpersonally, and irritability, mildly to moderately impaired his ability to work. An August 2017 private psychological evaluation report noted that the Veteran worked for a brewing company for approximately eight years, before he became employed by the school district for approximately 14 years. He reported that he got terminated because he was unable to physically perform his job duties. The Veteran graduated from high school as a special education student. His work history consisted primarily of work as a janitor/maintenance person. He sought jobs that were solitary in nature, such as working the nightshift, but encountered legal difficulties for alcohol-related problems. The clinician opined that within a reasonable degree of psychological certainty, the Veteran suffered from occupational and social, impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking or mood due to such symptoms as panic, depression, and impaired impulse control, difficulty adapting to stressful circumstances and inability to establish and maintain effective relationships. The clinician further found that while the Veteran's PTSD was not productive of total occupational and social impairment, his symptomatology was sufficiently severe to impact interpersonal functioning in the workplace. As such, he was disabled secondary to psychiatric impairment. Concerning the Veteran's service-connected physical disabilities, in August 2008 the Veteran attributed his unemployment to neuropathies of the upper and lower extremities. Specifically, he reported problems with lifting and carrying, pain, as well as numbness and burning in his feet after prolonged walking or standing. Similarly, on VA examination in February 2010 the Veteran reported that he quit his employment in maintenance because he could not meet the physical demands of his job, including walking, lifting, etc., due to his medical problems. The evidence shows that the Veteran is unable to secure or follow a substantially gainful occupation as a result of multiple service-connected disabilities. The Veteran, a former janitor/maintenance worker, experiences considerable occupational limitations due to his service connected disabilities. His mobility is restricted and he requires assistive devices for ambulation. He reported difficulty lifting and problems with prolonged standing or walking. He also endorsed numbness, pain and burning in the upper and lower extremities. His service-connected musculoskeletal disorders preclude heavy lifting, prolonged standing and walking, and preclude work in a physically demanding capacity, which accounts for most, if not all, of the Veteran's work experience. The Board also finds the Veteran's psychiatric symptoms precludes him from maintaining sedentary employment involving work with the public or coworkers or work that is detail oriented. His psychiatric disorder is productive of social isolation, irritability, exhaustion from lack of sleep, poor focus/concentration, inattention to detail, as well as problems relating to others. As such, the Veteran's PTSD further complicates his ability to engage in effective interpersonal communication. Accordingly, the Board finds that the combined effects of the Veteran's service-connected disabilities preclude employment. In light of these symptoms, the Veteran would not be capable of more than marginal employment in any type of work setting, whether physical or sedentary. Ortiz-Valles v. McDonald, 28 Vet. App. 65, 72 (2016). Thus, resolving reasonable doubt in his favor and find that prior to December 15, 2016, he has been unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. A TDIU is granted. See Gilbert, supra. Now, the Board must consider whether the Veteran is entitled to SMC. Compensation at the aid and attendance rate is payable when a Veteran's service-connected disability or disabilities cause the anatomical loss or loss of use of both feet or one hand and one foot, cause the Veteran to be blind in both eyes, or render him permanently bedridden or so helpless as to be in need of regular aid and attendance. 38 U.S.C.A. § 1114 (l); 38 C.F.R. § 3.350 (b). Determinations as to the need for regular aid and attendance are factual and must be based upon the actual requirements for personal assistance from others. In making such determinations, consideration is given to such conditions as: the inability of the claimant to dress or undress himself, or to keep himself 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 assistance; the inability of the claimant to feed himself through loss of coordination of upper extremities or through extreme weakness; the inability to attend to the wants of nature; or incapacity, either physical or mental, which requires care or assistance on a regular basis to protect a claimant from hazards or dangers incident to one's daily environment. It is not required that all of the disabling conditions enumerated be present before a favorable rating is made. The particular personal functions that the claimant is unable to perform should be considered in connection with his condition as a whole. It is only necessary that the claimant be so helpless as to be in need of regular aid and attendance, not that there is a constant need. "Bedridden" constitutes a condition which, through its essential character, actually requires that an individual remain in bed. The fact that a claimant has voluntarily taken to bed, or that a physician has prescribed bed rest for a lesser or greater portion of the day, will not suffice. 38 C.F.R. § 3.352 (a). In Turco v. Brown, 9 Vet. App. 222, 224 (1996), the Court held that eligibility for SMC by reason of regular need for aid and attendance requires that at least one of the factors set forth in VA regulation is met. In addition, determinations that the claimant is so helpless as to be in need of regular aid and attendance will not be based solely upon an opinion that the claimant's condition is such as would require him or her to be in bed. They must be based on the actual requirement of personal assistance from others. See Turco, 9 Vet. App. at 224. The evidence must show that the claimant is so helpless as to need regular and attendance; constant need for aid and attendance is not required. 38 C.F.R. § 3.352 (a). A VA Forms 21-2680 Examination for Housebound Status or Permanent Need for Regular Aid and Attendance, completed by a physician in January 2015, noted that the Veteran was able to feed himself and manage own finances. He was unable to prepare meals, bathe unassisted due to the non-service connected low back pain and bilateral lower extremity pain. The Veteran required a cane for ambulation. He was able to walk 20 to 30 feet with an unsteady gait or poor balance due to low back pain. The Veteran was not legally blind and did not require nursing home care or medication management. He was able to leave his home or immediate premises as needed. The clinician further noted that the Veteran was independent in his activities of daily living, being able to complete them without assistance. Consistent with these findings, VA treatment notes reflect that for most of the period on appeal the Veteran lived alone. Not only was he is independent with his personal care, but he also helped raise and cared for his grandson. The Veteran was also able to drive. The evidence shows the Veteran's service-connected disabilities impair his mobility, however, it is not clear that the assistance of another person is necessary solely as a result of the service-connected disabilities. Functionally, the Veteran could ambulate with assistive devices, as well as feed himself and does not require help bathing and dressing, or tending to the wants of nature. He was not legally blind, did not require assistance with any prosthetic or orthopedic appliances, and did not require nursing home care. He was also able to manage his own financial affairs. He has multiple nonservice-connected disabilities that contribute to his overall problem with the performance of activities of daily living, to specifically include low back pain. The record does not contain any competent medical evidence that the Veteran's service-connected disabilities, alone, render him physically helpless in the performance of the activities of daily living or in protecting himself from the everyday hazards and dangers incident to his environment. The preponderance of the evidence is against a finding that his service-connected disabilities alone result in his needing the regular aid and attendance of another person within the meaning of the cited legal authority. Accordingly, the evidence is against the claim for entitlement to special monthly compensation based upon the need for aid and attendance, and the claim is denied. The regulations also provide additional compensation on the basis of being housebound where the Veteran has, in addition to a single, permanent service-connected disability rated 100 percent disabling, additional service-connected disability or disabilities independently evaluated as 60 percent or more disabling which are separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems, or is permanently housebound by reason of service-connected disability or disabilities. A Veteran will be considered housebound where the evidence shows that, as a direct result of his service-connected disability or disabilities, he is substantially confined to his 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 lifetime. 38 U.S.C.A. § 1114 (s); 38 C.F.R. § 3.350. Regarding the criteria necessary for housebound status, the Veteran does not have a single, permanent service-connected disability rated 100 percent disabling, nor was the Veteran's TDIU predicated on a single disability; therefore, he does not meet the legal criteria for payment of compensation at the housebound rate under that criterion. See 38 U.S.C.A. § 1114 (s); 38 C.F.R. § 3.350. As the preponderance of the evidence is against the claim for special monthly compensation based on being housebound or needing the regular aid and attendance of another person, the benefit of the doubt doctrine is not for application and the claim must be denied. See 38 U.S.C.A. § 5107 (b) (West 2014); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert, 1 Vet. App. at 55-56. ORDER Prior to January 11, 2016, an evaluation of 70 percent, but no higher, for posttraumatic stress disorder is granted, subject to the rules and regulations governing the payment of VA monetary benefits. A disability rating higher than 70 percent for posttraumatic stress disorder is denied. A disability rating higher than 20 percent for diabetes mellitus type II is denied. Prior to December 16, 2015, a compensable disability rating for hypertension is denied. A rating higher than 80 percent for diabetic renal involvement with hypertension is denied. A compensable rating for erectile dysfunction is denied. Prior to December 15, 2016, a total disability rating based on individual unemployability due to service-connected disabilities is granted, subject to rules and regulations governing the payment of monetary awards. Entitlement to a TDIU after December 15, 2016, is dismissed. Special monthly compensation based on being housebound or needing the regular aid and attendance of another person is denied. ____________________________________________ D. JOHNSON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs