Citation Nr: 18141513 Decision Date: 10/10/18 Archive Date: 10/10/18 DOCKET NO. 13-24 820 DATE: October 10, 2018 ORDER Entitlement to service connection for lumbar spondylosis and degenerative disc disease is granted. Entitlement to an initial disability rating of 70 percent for posttraumatic stress disorder (PTSD) is granted prior to January 26, 2010, subject to the laws and regulations governing the payment of monetary benefits. From September 29, 2006 to June 30, 2009, entitlement to special monthly compensation based on statutory housebound status is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a total disability rating based upon individual unemployability due to service-connected disability (TDIU) prior to July 1, 2009 is dismissed. Entitlement to a TDIU from July 1, 2009 to January 25, 2010 is denied. REMANDED Entitlement to an initial evaluation in excess of 10 percent for coronary artery disease associated with herbicide exposure is remanded. FINDINGS OF FACT 1. The evidence is at least in equipoise as to whether the Veteran’s lumbar spondylosis and degenerative disc disease are etiologically related to service. 2. Prior to January 26, 2010, the Veteran’s PTSD symptoms showed social and occupational impairment with deficiencies in most areas, but not total impairment. 3. From September 29, 2006 to June 30, 2009, the Veteran was in receipt of a disability rating of 100 percent for prostate cancer and had additional service-connected disabilities independently rated at more than 60 percent, separate and distinct from the 100 percent service-connected prostate cancer and involving different anatomical segments or bodily systems. 4. The Veteran is in receipt of the maximum benefits available prior to July 1, 2009; therefore, entitlement to TDIU for this period is dismissed as moot. 5. The evidence does not show that the Veteran’s service-connected disabilities preclude him from maintaining substantially gainful employment consistent with his educational and occupational background from July 1, 2009 to January 25, 2010. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for lumbar spondylosis and degenerative disc disease have been met. 38 U.S.C. §§ 1110, 1131, 1154 (a), 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for entitlement to an initial disability rating of 70 percent for PTSD prior to January 26, 2010 have been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code (DC) 9411. 3. From September 29, 2006 to June 30, 2009, the criteria for SMC at the statutory housebound rate have been met. 38 U.S.C. § 1114 (s); 38 C.F.R. § 3.350 (i)(1). 4. The criteria for entitlement to a TDIU prior to July 1, 2009 have not been met. 38 U.S.C. § 7105; Bradley v. Peake, 22 Vet. App. 280. 5. The criteria for entitlement to a TDIU from July 1, 2009 to January 25, 2010 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19, 4.25. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably on active duty with the United States Army from August 1967 to June 1969, including a tour of duty in Vietnam. These matters come before the Board of Veterans’ Appeals (Board) on appeal from June 2011 and July 2013 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. The June 2011 decision addressed the Veteran’s claims for PTSD and TDIU, and the July 2013 rating decision concerned the Veteran’s claims for a low back disability and coronary artery disease. The detailed procedural history of this case is set forth in the Board’s March 2016 decision, which reopened the Veteran’s claim of entitlement to service connection for a low back disability and remanded the reopened claim, as well as the increased rating and TDIU claims, for further development. The Veteran’s claims were again remanded in July 2017 to schedule the Veteran for a Board hearing. The Veteran testified at a travel board hearing before the undersigned Veterans Law Judge in July 2018. A copy of the transcript has been associated with the claims file. The Veteran’s claims were most recently adjudicated by the agency of original jurisdiction (AOJ) in an April 2017 supplemental statement of the case (SSOC). Subsequently, the Veteran submitted new evidence in the form of written statements and a letter from a private doctor concerning his claimed low back disability. The Veteran did not submit a signed waiver of initial AOJ review. Nevertheless, under 38 U.S.C. § 7105(e), for cases in which substantive appeals are received on or after February 2, 2013, if the claimant or the claimant’s representative submits evidence to the AOJ or the Board for consideration in connection with the issues on appeal, the Board may consider such evidence in the first instance unless the claimant or representative requests in writing that the AOJ initially review such evidence. See 38 C.F.R. §§ 19.31, 19.37, 20.1304. As the Veteran’s substantive appeal was received in August 2013, and as he generated and submitted the evidence without a request for initial AOJ review, explicit waiver of initial AOJ consideration is not required. 1. Entitlement to service connection for a low back disability Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Generally, in order to establish service connection, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical, or in certain circumstances, lay evidence of a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Spondylosis (as arthritis) is a “chronic disease” listed under 38 C.F.R. § 3.309 (a); therefore, the presumptive service connection provisions based on “chronic” in-service symptoms and “continuous” post-service symptoms under 38 C.F.R. § 3.303 (b) apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159 (a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a layperson. 38 C.F.R. § 3.159 (a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). 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 the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In this case, the evidence shows the Veteran has been diagnosed with multiple back disabilities, including intervertebral disc syndrome, degenerative disc disease of the lumbar spine, lumbar spondylosis, and congenital spinal stenosis. Therefore, the Veteran meets the first requirement of service connection, a current disability. The evidence is at least in equipoise on the question of whether the Veteran’s current lumbar spondylosis is etiologically related to active service. STRs show the Veteran sought treatment for low back pain in August 1967. In May 2016 correspondence, the Veteran wrote that he injured his back during bayonet training in August 1967 and was treated with pain pills and sleeping on a flat surface. The Veteran also described in detail how he had suffered back pain ever since his in-service injury. Private medical treatment records show the Veteran reported chronic low back pain since August of 1967, when he initially hurt his back during in-service bayonet training. During his June 2016 VA examination, the Veteran again reported that he injured his back during bayonet training, but also reported that he later re-injured his back carrying heavy artillery rounds while serving in combat in Vietnam. The Veteran reiterated this contention during his July 2018 Board hearing. The Veteran’s friend, J.S., submitted a lay statement noting that he has known the Veteran for more than 50 years and he has complained of back pain on many occasions during that time. J.S. wrote that the Veteran told him he injured his back during bayonet training, and then again while carrying heavy artillery in combat. J.S. also wrote that in 1970, the Veteran took short term disability from a job because of his back. The Veteran was afforded VA examinations in connection with his claim in June 2013 and June 2016. The June 2013 examiner stated he could not find evidence of a back injury in service and essentially determined that the Veteran did not seek treatment for a low back disability until 2010. In accordance with the Board’s March 2016 remand instructions, the Veteran was afforded another VA examination in June 2016. The Veteran reported extreme low back pain that had been continuous since service. The examiner noted that “[h]eavy lifting over time can cause pathological problems in the back” but determined that the Veteran’s current back conditions were unrelated to service because he complained of back pain only once in service (August 1967), and in any case, his spinal stenosis was congenital. In reaching a nexus opinion, the examiner did not specifically address the Veteran’s other diagnosed back disabilities, nor did he address the Veteran’s lay testimony that he has suffered back pain chronically and continuously since service. Of record is a February 2018 letter from Dr. G.K., who wrote that the Veteran has had a 50-year history of pain in the cervical area, as well as in the upper lumbar and lower lumbar area, which he attributed to the strain of walking long distances carrying heavy artillery in combat. Dr. G.K. also reviewed a note from a VA neurosurgeon who reportedly indicated that the Veteran has degenerative disease “as part of the normal aging process exacerbated/accelerated by his duties while in the military.” In a March 2018 treatment note, Dr. G.K. wrote that the Veteran was exposed to significant trauma in the war on a repetitive basis that he describes and certainly it is possible that the significant changes in the [lumbar] region are a result of the repetitive basis that he describes and certainly it is possible that the significant changes in the [lumbar] region are a result of the repetitive and consistent strain and trauma that the spine experienced during the war. In an undated note, Dr. K. opined that the Veteran’s current back issues “could have arisen” from heavy carrying and trauma to the spine that he experienced during the Vietnam War. The rationale was that he had no pain prior to this, but subsequent pain. Overall, the Board finds that the evidence, both positive and negative, is at least in equipoise on the question of whether the Veteran’s degenerative disc disease and spondylosis are etiologically related to service. The Veteran’s DD Form 214 shows that his military occupational specialty was artillery. The Veteran is competent to report the circumstances of his in-service injury and symptoms, and his account of what happened is consistent with circumstances, conditions, or hardships of such service. The Veteran is also competent to report that he has suffered low back pain chronically and continuously since service. The VA nexus opinions are unfavorable, but also not probative due to inadequate rationales. The medical opinions from Dr. G.K. are favorable, but generally speculative in nature and thus of lessened weight. In short, the evidence pertaining to causal nexus is in relative equipoise. Affording the Veteran the benefit of reasonable doubt in this matter, the Board concludes that he has also met the second and third requirements of service connection—an in-service occurrence and a nexus between the occurrence and the currently diagnosed lumbar spondylosis and degenerative disc disease. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Moreover, lumbar spondylosis is a chronic disease and the Veteran reports back pain symptoms have been continuous since service separation; therefore, service connection is warranted under theory of chronicity and continuity. See 38 C.F.R. § 3.303. 2. Entitlement to an initial rating in excess of 30 percent for PTSD prior to January 26, 2010 The Veteran asserts that his PTSD during the period prior to January 26, 2010 was more severely disabling that currently evaluated. Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by the applicable Diagnostic Code (DC). Generally, the degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. Where the question for consideration is the propriety of the initial ratings assigned, evaluation of the evidence since the effective date of the grant of service connection is required. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Under the general rating formula for mental disorders, a 30 percent rating is assigned when a veteran’s PTSD causes occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating is assigned when a veteran’s PTSD causes 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-term 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; or difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is assigned when a veteran’s PTSD causes 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); or an inability to establish and maintain effective relationships. A 100 percent rating is assigned when a veteran’s PTSD causes total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal hygiene); disorientation to time or place; or, memory loss for names of close relatives, occupation, or own name. The use of the term “such as” in the general rating formula for mental disorders in 38 C.F.R. § 4.130 demonstrates that the symptoms listed after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). VA is not required to find the presence of all, most, or even some of the enumerated symptoms recited for particular ratings. The use of the phrase “such symptoms as,” followed by a list of examples, provides guidance as to the severity of the symptoms contemplated for each rating and permits consideration of other symptoms particular to each veteran and disorder and the effect of those symptoms on the Veteran’s social and work situation. Indeed, § 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). For the period prior to January 26, 2010, the evidence shows that the Veteran’s PTSD more nearly approximates a 70 percent rating, based on occupational and social impairment with deficiencies in most areas such as work, family relations, mood, due to such symptoms as: daily sleep disturbances, frequent hypervigilance, frequent nightmares, obsessive rituals, difficulty concentrating, problems with memory, occasional 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. VA treatment records from the period show the Veteran was referred for mental health treatment at the Houston VA Medical Center (VAMC) in November 2006. The Veteran stated that he had noticed paranoia and hypervigilance since he was in Vietnam, locking doors and “building sand bag walls in my backyard.” He described chronic nightmares associated with restlessness and movement noted by bedmates. The Veteran described these episodes as “seizure-like” in that he would stop breathing at times and feel paralyzed. He reported physical violence during such episodes, such as trying to choke his wife. The Veteran denied difficulty with concentration but endorsed intense anger about certain social situations and trouble keeping jobs because of his intensity and inability to work with others. The Veteran also noted experiencing periodic depressive episodes, at times associated with suicidal ideation. During a December 2006 VA mental health initial evaluation note, the Veteran noted that he was currently married but had been divorced twice previously. He noted problems with his family relations secondary to his alcohol abuse and difficulties with communication and understanding. He reported that he was on probation following a drunk driving conviction. The Veteran noted that he had been told he was like “Jekyll and Hyde.” The Veteran reported working full time as an accountant. In a subsequent December 2006 treatment note, the Veteran reported chronic sleep trouble and recurring nightmares involving dreams of being trapped in a combat situation and unable to move. He reported experiencing these dreams two to three times per month. He reported a long history of heavy alcohol use that worsened after Vietnam. He also reported regular use of marijuana. The Veteran reported a legal history involving multiple drunk driving convictions and several arrests for drunk and disorderly conduct, but no legal problems at present. The Veteran reported depressive symptoms of decreased interest in pleasurable activities, difficulty staying asleep, excessive guilt, feelings of worthlessness, fatigue or loss of energy, overeating, decreased libido, irritability, isolation and social withdrawal. He denied manic symptoms but endorsed excessive anxiety and worry, difficulty controlling worry, restlessness, feeling “keyed up” or on edge, muscle tension, sleep disturbance, and inability to relax. He reported frequent nightmares of his Vietnam experiences, recurrent intrusive thoughts, and physiological reactivity to reminders of the trauma. He also reported avoiding thoughts, feelings, or talks about the trauma, as well as feelings of detachment or estrangement from others; hypervigilance, and an exaggerated startle reflex. He denied psychotic or cognitive symptoms, and denied panic attacks. His mental status examination was largely normal—he was well-groomed; speech was normal; thought process was logical and goal-directed; he reported no delusions, paranoid ideation, suicidal or homicidal ideation, and no obsessions; long-term, short-term, and immediate-recall memory were all intact; insight and judgment were fair. In a May 2007 letter, the Veteran wrote that as a result of his experiences, in what he described as combat, he has developed behavioral disorders and fears that have caused deficiencies in family relations, career development, and social judgments involving alcohol and drugs. He endorsed periodic delusions of being surrounded and helpless and exhibiting a “seizure-like” response to haunting dreams and sleepless nights “which can happen months at a time.” The Veteran further wrote that “[a]t severe moments, I have contemplated suicide about my dysfunctional life style.” In a July 2007 VA treatment note, the Veteran reported having a “real bad” episode while sleeping, during which he had a nightmare that dead people were chasing him around. The Veteran said his wife told him he was having “something like a seizure,” was grinding his teeth, and was speaking in an unknown language that he suspects was Vietnamese. The Veteran reported having a lot of flashbacks. He noted he was still employed as an accountant despite undergoing treatment for prostate cancer. In a subsequent July 2007 treatment note, the Veteran reported, “[e]very day is a [good] day. I am a cancer survivor.” The Veteran also inquired about medication to deal with his anxiety and nightmares. In yet another July 2007 VA treatment note, the Veteran reported symptoms of acting out dreams and nightmares, which he believed to be related to his anxiety. The Veteran reported loud snoring, choking, and gasping for breath. Otherwise, he denied any other anxiety symptoms. Mental health examination was largely normal. In a September 2007 VA treatment note, the Veteran was advised to get involved in the PTSD treatment program. He was found to still be smoking marijuana, though he reported ceasing alcohol use. He reported occasional “meltdowns.” Mental status examination was largely normal. The treating physician determined the Veteran was not a danger to himself or others. In a January 2008 treatment note, the Veteran reported increased stress related to difficult family relations, including fights with his sister that would become physical at times. He noted he was still working as an accountant and reported being employed by one of the largest investment management firms in the state. He was noted to have finished a PTSD treatment course and was starting another; he stated that the education allowed him to better manage the disabling side of PTSD and noted that the psychological tools he learned helped him negotiate difficult family situations. Mental status examination was normal. In February 2008, the Veteran reported to the emergency room at the Erie, Pennsylvania VAMC. He reported increased stress related to the recent death of his mother in Erie. He reported feeling significant anger and even homicidal thoughts toward his sister, whom he felt had abused and neglected his mother. He also admitted to suicidal thoughts and was positive on a suicide screen. However, he denied current plans or intent for suicide or homicide. He reported increased marijuana and alcohol use and indicated he reported to the VAMC “for safety.” With regard to attempting suicide, the Veteran stated that he had attempted suicide before, noting that he “does a lot of risky things, so suicide is always on the table.” In an April 2008 VA treatment note, the Veteran reported still having fights with his sister but pledged that he would not harm himself or her. He stated that he relapsed into heavy drinking and marijuana after the recent death of his mother but had recently stopped and was getting more involved at church. He reported occasional feelings of guilt, hopelessness, and worthlessness. He reported poor energy, and also denied suicidal ideation while endorsing occasional homicidal ideation. Mental status examination was largely normal. In a June 2008 letter, private counselor G.B. wrote that he had interviewed the Veteran, whom he found to be tense and nervous. He noted that “while things on the surface look okay, underneath [the Veteran] has been suffering for years without knowing what was going on.” G.B. noted the Veteran’s drug and alcohol abuse and wrote that the Veteran has struggled to control his anger and let go of the “homicidal urge” he felt in Vietnam. G.B. also wrote that the Veteran “has felt both anxious and depressed most of the time, including suicidal ideation and, on occasion, suicidal plans.” He noted the Veteran’s reports of being unable to sleep due to nightmares and flashbacks. He noted that the Veteran also endorsed decreased ability to concentrate and focus, which made keeping his job as an accountant harder and harder. He quoted the Veteran as saying, “[t]his invisible enemy inside my head has caused me to construct a mental barrier which no one is allowed to penetrate. I cannot trust anything or anyone. I pray to God to help get my life back together.” In a November 2009 VA treatment note, the Veteran reported current struggles of difficulty trusting others. He also reported an increase in recurring nightmares—two to three per week instead of per month—which tended to come and go with stress. However, he reported less hopelessness than before. Nevertheless, he reported being “tired” of everyday struggles and reported difficulty seeing other’s perspective. He endorsed increased anger and irritability. He reported recent bouts of depression but denied suicidal or homicidal ideations and was found to be functioning well occupationally. The examining physician noted that he spoke with a doctor familiar with the Veteran, who referred to the Veteran as one of the most high functioning patients in her groups currently. Mental status examination was largely normal. The doctors concurred that referral for an inpatient treatment program did not seem appropriate at that time. Subsequent VA treatment records show the Veteran was later admitted to an inpatient PTSD treatment program at the Little Rock VAMC in late January, 2010. At the time of admission, the Veteran was found to have extreme reexperiencing symptoms, extreme avoidance symptoms, extreme arousal symptoms, and severe depression. During a February 2010 session, the Veteran endorsed having had suicidal ideations as recently as September 2009, though he stated it was a “bad reaction to morphine” and indicated that his grandchildren were barriers to suicide. During his July 2018 Board hearing, the Veteran reported that he experienced hallucinations and nightmares on a nightly basis from 2006 to 2010. He said he could be physically violent during these times, especially toward his wives (the most recent of which had recently divorced him). The Veteran also stated that he had thoughts of harming himself and others dating back to 2006 and noted “constant” episodes of violence outside of his marital situation. However, the Veteran reported that his memory loss had worsened only recently and noted that he had been able to hold down a job as an accountant until 2010. Overall, the Board finds that the Veteran’s PTSD symptoms for the period prior to January 26, 2010 warrant a rating higher than the currently assigned 30 percent rating, though the evidence of record for the period makes it difficult to determine whether a 50 percent rating or an even higher 70 percent rating would be appropriate. VA treatment notes seem to suggest that although the Veteran endorsed vivid nightmares and resulting chronic sleep impairment, he was generally found to be high functioning, with normal mental status examinations and no occupational impairment. However, VA treatment records, private medical evidence, and lay evidence chronicle significant problems due to increased anger and irritability and resultant decreased impulse control—especially related to the Veteran’s family. The record also suggests numerous instances in which the Veteran showed poor judgment by turning to alcohol and marijuana and behaving in a physically violent manner. Moreover, on at least several occasions, the Veteran acknowledged suicidal and homicidal ideations, albeit on a passive basis. As previously discussed, where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. In this case, resolving doubt in favor of the Veteran, the Board finds that the Veteran’s PTSD symptoms more nearly approximated the criteria for a 70 percent disability rating for the period prior to January 26, 2010. However, a higher disability rating of 100 percent is not warranted. As previously discussed, a maximum 100 percent rating requires total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. Based on the evidence set forth above, the Board does not find that these criteria have been met, and finds that a 70 percent rating more appropriately captures the Veteran’s disability picture for the period. The evidence shows that the Veteran was capable of working during this period and was able to maintain some relationships—albeit in a limited fashion at times. Nonetheless, the evidence demonstrates that the Veteran is not “totally” impaired occupationally and socially. In making its determinations in this case, the Board has carefully considered the Veteran’s contentions with respect to the nature of his PTSD and notes that his lay testimony is competent to describe certain associated symptomatology. The Veteran’s history and symptom reports have been considered, including as presented in the medical evidence discussed above. Ultimately, the competent medical evidence offering detailed specific findings pertinent to the rating criteria is the most probative evidence with regard to evaluating the pertinent symptoms of the Veteran’s PTSD. As such, while the Board accepts the Veteran’s testimony with regard to the matters he is competent to address, the Board relies upon the competent medical evidence with regard to the specialized evaluation of functional impairment, symptom severity, and details of clinical features of the service-connected conditions at issue. Based on the foregoing, the Board finds that an initial disability rating of 70 percent, and no higher, is warranted for the Veteran’s service-connected PTSD for the period prior to January 26, 2010. 3. Entitlement to SMC from September 29, 2006 to June 30, 2009 A veteran is presumed to be seeking the maximum benefit allowed by law or regulation, and such a claim remains in controversy, even if partially granted, where less than the maximum benefit available is awarded. A.B. v. Brown, 6 Vet. App. 35, 38 (1993). Moreover, VA has a duty to fully and sympathetically develop a veteran’s claim to its optimum, which includes determining all potential claims raised by the evidence and applying all relevant laws and regulations. Moody v. Principi, 360 F.3d 1306, 1310 (Fed. Cir. 2004). Relevant to this appeal, a claim for increased disability compensation may include the “inferred issue” of entitlement to SMC, even where the veteran has not expressly placed entitlement to SMC at issue. Akles v. Derwinski, 1 Vet. App. 118, 121 (1991); see Buie v. Shinseki, 24 Vet. App. 242 (2010) (requiring VA to assess all of the claimant’s disabilities to determine whether entitlement to SMC under 38 U.S.C. § 1114 (s) is established whenever a veteran with a total disability rating is subsequently awarded service connection for any additional disability or disabilities even in the absence of an express claim for SMC). Special monthly compensation at the housebound rate is payable where a 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. 38 U.S.C. § 1114 (s) (2012); 38 C.F.R. § 3.350 (i) (2016). Here, the Veteran was in receipt of a 100 percent disability rating for prostate cancer from September 29, 2006 to June 30, 2009. Moreover, pursuant to this decision, he is now in receipt of a 70 percent disability rating for his PTSD from September 29, 2006 to January 25, 2010. As such, SMC at the housebound rate is warranted for the period from September 29, 2006 to June 30, 2009. SMC is not warranted from June 30, 2009 as the Veteran does not have a single disability rated as total along with additional disabilities that total 60 percent. 4. Entitlement to a TDIU prior to July 1, 2009 As noted above, the Veteran was in receipt of a 100 percent disability rating for his service-connected prostate cancer prior to July 1, 2009. The receipt of a 100 percent schedular rating for a service-connected disability does not necessarily render moot a claim for a total disability based on individual employability (TDIU), see Bradley v. Peake, 22 Vet. App. 280, 293 (2008). However, entitlement to a TDIU only survived for the purpose of SMC consideration. As the Board has now awarded SMC for this period, which constitutes the maximum benefits available under the circumstances, the Veteran’s claim of entitlement to TDIU prior to July 1, 2009 is rendered moot and dismissed. 5. Entitlement to a TDIU from July 1, 2009 to January 25, 2010 A TDIU may be assigned where the combined schedular evaluation for service-connected disabilities is less than total and the disabled Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disability or disabilities, provided that, if there is only one such disability, the disability shall be ratable at 60 percent or more, and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. 3.340, 3.341, 4.16 (a). The central inquiry is whether service-connected disabilities alone are of sufficient severity to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524 (1993). Neither nonservice-connected disabilities nor advancing age may be considered in the determination. 38 C.F.R. 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Consideration shall be given to the Veteran’s level of education, special training, and previous work experience. Therefore, the Board must evaluate whether there are circumstances in the Veteran’s case, apart from any non-service-connected conditions and advancing age, which would justify a TDIU rating. 38 C.F.R. 3.341 (a), 4.16 (a), 4.19. In order to establish an inability to maintain a substantially gainful occupation, as required for a TDIU award pursuant to 38 C.F.R. § 3.340 (a), a veteran is not required to submit proof that he is 100 percent unemployable. See Roberson v. Principi, 251 F.3d 1378, 1385 (2001). Instead, the regulations contemplate more flexibility in the employability determination. Whether a TDIU should be awarded is a determination for the adjudicator. Although VA must give full consideration, per 38 C.F.R. § 4.15, to “the effect of combinations of disability,” VA regulations place responsibility for the ultimate TDIU determination on VA, not a medical examiner’s opinion. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013); 38 C.F.R. § 4.16 (a); see also Smith v. Shinseki, 647 F.3d 1380, 1385-86 (Fed. Cir. 2011) (VA is not required to obtain an industrial survey from a vocational expert before making a TDIU determination but may choose to do so in an appropriate case). The Veteran seeks a TDIU for the period between July 1, 2009 to January 25, 2010 based on PTSD, now rated as 70 percent disabling, and prostate cancer, rated as 40 percent disabling. Initially, the Board notes that the Veteran’s service-connected disabilities meet the schedular rating requirements of 38 C.F.R. § 4.16 (a) for consideration of TDIU. Turning to the evidence of record, VA treatment records from 2006-2009 show the Veteran consistently reported working as an accountant. However, in November 2006, the Veteran noted having had trouble keeping jobs because of his intensity and lack of ability to work with others. In January 2008 he reported that he was still employed as an accountant, and in November 2009 he indicated that he had been “functioning well occupationally.” During that same treatment, the Veteran’s psychiatrist noted that the Veteran had been able to maintain a moderate level of social and occupational functioning while simultaneously seeking treatment. The June 2008 letter from counselor G.B. indicates the Veteran’s PTSD negatively impacted his ability to concentrate and focus, which made it harder for him to keep his job as an accountant. A November 2009 letter from the Veteran’s former employer notified the Veteran that his job was being eliminated due to corporate restructuring and that his scheduled termination date was January 25, 2010. The letter made no mention of the Veteran’s service-connected disabilities. In his August 2010 formal application for TDIU, the Veteran provided that he completed a Master’s in Public Administration and had worked as an accountant over the past five years, earning as much as $80,000 in 2008. He noted that he lost about four weeks of time from 2006-2010 due to his prostate cancer and PTSD. He also indicated that he became too disabled to work as of January 25, 2010. During an October 2010 VA examination concerning his prostate cancer, the examiner noted that the Veteran’s condition caused difficulty climbing stairs, doing prolonged walking or standing, squatting, kneeling or bending, or heavy lifting. The examiner did not opine as to whether the Veteran’s prostate cancer would affect his work as an accountant, as the Veteran was not working at the time of the examination. The Veteran’s Social Security Administration (SSA) records were obtained and associated with the claims file and show that he was found to be disabled under SSA regulations as of January 25, 2010. In his application for SSA disability benefits, the Veteran indicated he stopped working for reasons other than his claimed disability; that he was “let go by the company.” The Veteran also provided that he had worked one job in the 15 years before he became unable to work, and that his disabilities did not cause him to make changes in his work activities. During his July 2018 Board hearing, the Veteran testified that he had previously been employed as an accountant by a CPA audit and accounting firm, specializing in tax. The Veteran also indicated he had at one time been a professor of taxation. He testified that he was making “about 100 plus thousand” per year before he retired in 2010. However, later in the hearing, he stated that he “had to quit” because of his “mental capacity to be functional.” Overall, the Board finds that the weight of the evidence is against a finding that the Veteran’s service-connected disabilities render unable to obtain and maintain substantially gainful employment. As previously discussed, while the Veteran’s PTSD symptoms show impairment in most areas—especially social impairment, they have not been found to cause total occupational impairment. Indeed, no examiner has commented that the Veteran is precluded from functioning in an occupational environment consistent with his eduction and prior work history due to any service-connected disability or disabilities. Significantly, the available evidence shows the Veteran was gainfully employed as an accountant for the entire period on appeal, at times making as much as $80,000 (or, by his account at his Board hearing, in excess of $100,000) per year. Ultimately, the Veteran stopped working in January 2010, but the evidence indicates that this was because his job was terminated as part of corporate restructuring. There is no evidence the Veteran sought employment after that. For these reasons, the Board finds that the weight of the evidence demonstrates that the criteria for TDIU have not been met or more nearly approximated for any period. As the preponderance of the evidence is against this claim, the benefit of the doubt rule is not for application, and the Board must deny the claim. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. REASONS FOR REMAND Entitlement to an initial evaluation in excess of 10 percent for coronary artery disease associated with herbicide exposure is remanded. During his July 2018 Board hearing, the Veteran testified that his coronary artery disease has worsened since his last VA examination in 2013. Therefore, the Board finds that remand is necessary in order to afford the Veteran a new VA examination to determine the current severity of his service-connected coronary artery disease. Accordingly, the matter is remanded for the following actions: Schedule the Veteran for an appropriate VA examination to determine the current nature and severity of his service-connected coronary artery disease. The record, to include a copy of this remand, must be made available to and be reviewed by the examiner, and the examination report should note that review. Any indicated evaluations, studies, and tests should be conducted. The examiner should describe all symptoms caused by the Veteran’s service-connected coronary artery disease artery disease, as well as the severity of each symptom. The examiner should assess the Veteran’s workload of metabolic equivalents (METs) and left ventricular ejection fraction. With respect to METs testing, if a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. If METs testing is medically contraindicated, the examiner must state this. Also, if the examiner finds that other testing results were more representative of the Veteran’s overall cardiac functioning, the examiner should explain why. A rationale should be given for each opinion expressed. D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD G. T. Raftery, Associate Counsel