Citation Nr: 18157152 Decision Date: 12/12/18 Archive Date: 12/11/18 DOCKET NO. 16-62 461 DATE: December 12, 2018 ORDER Entitlement to a 100 percent initial evaluation for cardiomyopathy is granted. Entitlement to an initial 50 percent disability rating for posttraumatic stress disorder (PTSD) is granted. The claim of entitlement to service connection for headaches, dizziness and lightheadedness as secondary to service-connected cardiomyopathy is dismissed. REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) as due to service-connected disability is remanded. FINDINGS OF FACT 1. From the December 7, 2009 effective date of service connection for cardiomyopathy, there is sufficient indication that the Veteran has manifested the signs and symptomatology consistent with a more or less consistent showing of chronic congestive heart failure. There also was more recently, indication of workload of three METs or less resulting in symptoms of dyspnea, fatigue, angina, dizziness, and syncope. 2. From the December 7, 2009 effective date of service connection for PTSD, the Veteran had reduced reliability and productivity due to his symptoms. 3. On June 7, 2018, prior to the promulgation of a decision in the appeal, the Board received notification from the Veteran through his authorized attorney that a withdrawal of this appeal is requested, with regard to the claim for entitlement to service connection for headaches, dizziness, and lightheadedness as secondary to service-connected cardiomyopathy. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran’s favor, the criteria are met to establish an initial 100 percent evaluation for cardiomyopathy. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.100; 4.104, Diagnostic Code 7020 (2018). 2. The criteria for an initial 50 percent disability rating for PTSD are met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10; 4.130, Diagnostic Code 9411 (2018). 3. The criteria for withdrawal of an appeal by Veteran (or his authorized representative) have been met, with regard to the issue of entitlement to service connection for headaches, dizziness, and lightheadedness as secondary to service-connected cardiomyopathy. 38 U.S.C. § 7105(b)(2), (d)(5) (2012); 38 C.F.R. § 20.204 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from November 1983 to March 1984, August 2001 to April 2002, and August 2004 to December 2005. The issues being considered and decided upon the merits, at present, are the claims of increased rating for cardiomyopathy, and PTSD. The issue of a TDIU is being remanded. Pursuant to the June 2018 request from the Veteran’s representative, the claim for service connection for headaches is being voluntarily withdrawn from appeal, discussed further below. Neither the Veteran nor his attorney have raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Increased Rating 1. Entitlement to an evaluation higher than 60 percent for cardiomyopathy. Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2018). Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. Where there is a question as to which of two evaluations shall be applied, the higher evaluations will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 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. The Veteran’s service-connected cardiomyopathy is currently rated at the 60 percent level, from the December 7, 2009 effective date of service connection onwards. Under Diagnostic Code 7020, pertaining to cardiomyopathy, the maximum 100 percent rating is assigned for chronic congestive heart failure; or, workload of three METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope; or, there is left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104, Diagnostic Code 7020 (2018). A MET (metabolic equivalent) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, a medical examiner’s estimation 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. 38 C.F.R. § 4.104, Note 2. Moreover, supplementing the above is section 4.100, providing in pertinent part that in all cases, whether or not cardiac hypertrophy or dilatation (documented by electrocardiogram, echocardiogram, or X-ray) is present and whether or not there is a need for continuous medication must be ascertained. In addition, even if the requirement for a 10 percent rating (based on the need for continuous medication) or a 30 percent rating (based on the presence of cardiac hypertrophy or dilatation) is met, MET testing is required except when there is a medical contraindication; when the left ventricular ejection fraction has been measured and is 50 percent or less; when chronic congestive heart failure is present or there has been more than one episode of congestive heart failure within the past year; and when a 100 percent evaluation can be assigned on another basis. In addition, if left ventricular ejection fraction (LVEF) testing is not of record, evaluation should be based on alternative criteria unless the examiner states that the LVEF test is needed in a particular case because the available medical information does not sufficiently reflect the severity of the Veteran’s cardiovascular disability. For the time period just prior to the effective date of service connection for cardiomyopathy, December 7, 2009, when evaluated back in September 2009, the Veteran was shown to have had an ejection fraction of 35 percent. The October 2009 report from Dr. A.S., private cardiologist, notated the following conditions as active problems: cardiomegaly, cardiomyopathy, chronic systolic congestive heart failure, premature ventricular contractions. Records pertaining to receipt of disability benefits from the Social Security Administration (SSA) include an April 2011 occupational health evaluation by a private physician, stating in part that a recent echocardiogram from 2009 had revealed an ejection fraction of 30 percent. Another such evaluation in 2010 during cardiac catheterization showed that his arteries were clear but ejection fraction was 40 percent. Upon VA examination of the heart and cardiovascular system in July 2010, it was indicated the diagnosis at outset of cardiomyopathy, date of onset September 2009. The examination findings indicated no history of myocardial infarction, rheumatic fever, hypertensive heart disease, valvular heart disease including prosthetic valve, congestive heart failure, angina, dizziness, syncope, fatigue, dyspnea. Continuous medication was required for control of hypertension and for control of heart disease. Additional findings were that by x-ray study heart size was larger than normal. Testing for left ventricular dysfunction was done which showed ejection fraction of 35 percent. The final diagnosis was indicated to have been nonischemic cardiomyopathy. A corresponding medical opinion stated further that cardiomyopathies caused irregular rhythms that were shown on EKG to include PVCs and Holter studies, and the Veteran was positive for irregular rhythms on both studies. The VA Medical Center (VAMC) records indicate objectively medical test results of in April 2010, the left ventricle was normal in size, ejection fracture was 40 percent. Then in July 2010, the left ventricular size and thickness were normal. Ejection fraction was 40 percent. The July 2011 VA treatment records further indicates, on testing there was an ejection fraction notated of 40 to 45 percent. A VA examination in October 2011 for a heart condition, indicated no ischemic heart disease, but continuous medication required for treatment of cardiomyopathy. He was further notated to have had chronic congestive heart failure. There were no episodes of acute CHF in the past year. An interview-based METS test indicated 5-7 estimated METS. Ejection fraction showed improved to 50 percent. A VA examination in July 2012 indicated this time apparently no finding of chronic congestive heart failure. There was cardiac arrhythmia, intermittent (paroxysmal). There was no evidence of cardiac hypertrophy. There was evidence of cardiac dilatation. Echocardiogram showed LVEF of 50 percent. Holter monitor showed abnormal results, frequent PVCs. Interview based METS test results were 5-7 METS, symptoms notated of dyspnea and fatigue. The heart condition impacted ability to work. He still had mild dilated cardiomyopathy. At a VA examination in April 2015, the diagnoses indicated at outset consisted of ventricular arrhythmia, and non-ischemic dilated cardiomyopathy. Continuous medication was required for control of the Veteran’s heart condition. There was no myocardial infarction or congestive heart failure. He did have a cardiac arrhythmia. There was no heart valve condition. There were no infectious heart conditions or pericardial adhesions. There was no evidence of cardiac hypertrophy, there was evidence of cardiac dilatation. On an echocardiogram, the LVEF reading was 40 to 45 percent. On an interview-based METS test the level estimated was 1-3 METS. There was dyspnea, fatigue, dizziness. It was further indicated that the METS level notated was not solely due to the heart condition. The limitation in METS level was due to multiple medical conditions including the heart conditions. It was not possible to accurately estimate the percent of METs limitation attributable to each medical condition. The Board finds in this case that on the whole, the criteria for the maximum 100 percent initial rating for cardiomyopathy are effectively met. This is based upon having resolved reasonable doubt in the Veteran’s favor with regard to severity of symptomatology. See 38 C.F.R. § 4.3. Whereas findings varied from time to time based on which VA examination, there were enough consistent notations of chronic congestive heart failure, as to raise reasonable likelihood that this was a long-term issue. Under the rating criteria, as applied, that correlates generally speaking to the 100 level. 38 C.F.R. § 4.104, Diagnostic Code 7020 (2018). There is a sufficient long-term history of the issue as to go back to the December 7, 2009 effective date of service connection when the condition was first indicated and documented. Significantly, also, the April 2015 most recent VA examination found 1-3 METS estimated. Though the VA examiner did not conclusively attribute the observed findings above to the Veteran’s service-connected cardiomyopathy, the examiner expressly stated that the exact cause and precipitating condition could not be clearly determined. Under these particular circumstances, where etiology of symptomatology cannot be determined by reasonable inquiry, the applicable law requires that said symptomatology is presumed due to service-connected disability. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). See also Howell v. Nicholson, 19 Vet. App. 535, 540 (2006). Accordingly, based upon these facts and having considered the complete applicable rating standard, the criteria for an initial 100 percent schedular evaluation are deemed met. 2. Entitlement to an increased evaluation for PTSD, initially rated at 30 percent from December 7, 2009, and at 50 percent from April 12, 2012 onwards. According to VA’s General Rating Formula for Mental Disorders, a 30 percent rating applies to 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, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-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; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating may be assigned where there is 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; obsessed rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted where there is total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. 38 C.F.R. § 4.130. The symptoms and manifestations listed under the above rating formula are not requirements for a particular evaluation, but are examples providing guidance as to the type and degree of severity of these symptoms. Consideration also must be given to factors outside the rating criteria in determining the level of occupational and social impairment. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). A veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). Additionally, while symptomatology should be the primary focus when deciding entitlement to a given disability rating, § 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused the requisite occupational and social impairment. Id. One factor for consideration is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the “psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness.” Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)). However, the American Psychiatric Association has determined that the GAF score has limited usefulness in the assessment of the level of disability. “Noted problems include lack of conceptual clarity and doubtful value of GAF psychometrics in clinical practice.” 79 Fed. Reg. 45,093, 45,097 (Aug. 4, 2014). Having reviewed the medical findings addressing the Veteran’s signs and regular symptomatology in association with his service-connected PTSD, an initial 50 percent rating is granted and a rating in excess of 50 percent is denied. The pertinent evidence is summarized below. At his VA examination in January 2010, there was notated a recent positive screen for depression. A suicide screen was negative as was a PTSD screen. There was no recent outpatient treatment, or ongoing treatment. As for routine activities the Veteran used to spend time with friends daily, now was limited by a legal problem. He stayed home mostly, but sometimes went outdoors for recreation or went to church about every other Sunday. There was no history of suicide attempts or violence. On mental status interview he was appropriately groomed, psychomotor activity was unremarkable, speech was spontaneous and coherent, attitude was cooperative and friendly, he had flat affect, his mood was dysphoric, he was easily distracted, he was well-oriented, his thought process was linear and appropriate to conversation, he had difficulty sleeping, and he had no delusions or hallucinations. His judgment and insight were intact. He interpreted proverbs appropriately, did have panic attacks briefly 2-3 times per week, denied suicidal or homicidal thoughts, his impulse control was good, he was able to maintain minimum personal hygiene, and had no problem with activities of daily living. His memory was good. There was irritability, hypervigilance, and other characteristic symptoms of PTSD. The diagnosis given was PTSD; chronic, moderate. Further indicated was that PTSD signs and symptoms resulted in deficiencies in key areas, those of judgment, thinking, family relations, work, mood or school. This is contemplated by the 70 percent criteria. Despite the examiner’s finding, the content of the examination report does not support a 70 percent rating. It does, however, support a 50 percent rating. The content of the examination report does not show that the frequency, severity, and duration of these symptoms rises to the level of causing deficiencies in most areas. At the examination, the Veteran reported being married to his wife since 1981. He described their relationship as “it’s fine now,” but noted that they used to argue before he stopped drinking. He had a 16 year old son and he described their relationship as “fine.” He did not see his brothers, but this was because they did not live nearby; he saw them on holidays. He had more frequent contact with his sisters. He has a “good connection” with his mother, whom he was in contact with nearly every other day. He did not spend time with his friends, but this was not due to PTSD symptoms. He explained that this was due to being on house arrest and the fact that they all drank alcohol and he was trying to make new friends who did not drink alcohol. His family relationships were good, and he was consciously avoiding his friends because he was also avoiding alcohol and they all drank. He attended church. These factors all support a finding that the symptoms are not severe enough to result in “inability” to form relationships, but instead are more accurately described as “difficulty.” Although the examiner stated that there was a deficiency in judgement, this was not consistent with the examination report, where it was noted that the Veteran understood the outcome of his behavior. Additionally, the examiner reported a deficiency of thinking because it was possible he minimized his symptoms, but had also specifically found that his thought processes were normal. Because his thought processes were normal, his impaired thinking is not of the severity to support a 70 percent rating. Although the 70 percent rating criteria contemplate deficiencies in “most areas,” including work, school, family relations, judgment, thinking, or mood, such deficiencies must be “due to” the symptoms listed for that rating level, “or others of similar severity, frequency, and duration.” Vazquez–Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). Because the Veteran has dysphoric and constricted mood, and because the 70 percent level contemplates a deficiency in “mood” among other areas, does not mean his PTSD rises to the 70 percent level. Indeed, the 30 percent, 50 percent, and 70 percent criteria each contemplate some form of mood impairment. The Board, instead, must look to the frequency, severity, and duration of the impairment. Id. Here, the Veteran’s depressed mood is expressly contemplated by at best, the 50 percent criteria, which contemplates “disturbances” in mood. 38 C.F.R. § 4.130. The Veteran is adequately compensated for that impairment with the assignment of a 50 percent rating. On re-examination in September 2011, it was indicated the Veteran “struggles with depression.” The symptoms of depression were encompassed by the diagnosis of PTSD. The psychiatric condition did not impair his ability to engage in physical and sedentary forms of employment. Substance abuse was not a factor. The prognosis for improvement and/or stabilization was guarded. The Veteran was competent to manage his own financial affairs without assistance. The overall level of impairment was estimated to have been occupational and social impairment due to mild or transient symptoms which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress; or symptoms controlled by medication. This level of impairment is contemplated by the 10 percent rating criteria. He had several characteristic symptoms of PTSD, those of difficulty sleeping, irritability, difficulty concentrating, hypervigilance, exaggerated startle response. Additional general symptoms were depressed mood, anxiety, suspiciousness, chronic sleep impairment, and suicidal ideation. According to the Veteran he had some insomnia, he sometimes felt helpless, there was low energy and low motivation, he had some passive suicidal thinking but was not then suicidal. Mental status exam indicated he was pleasant, cooperative, well-oriented, affect restricted, denied suicidal ideation, denied homicidal ideation, no paranoia or hallucinations, no overt evidence of psychoses, speech was appropriate, judgment and insight were intact, and there was no overt evidence of any cognitive deficits. On re-examination in June 2012, the diagnosis at outset was PTSD chronic and associated depression. Estimated level of the condition was occupational and social impairment with reduced reliability and productivity. Reported symptoms were sleep disturbance, intrusive thoughts, nightmares, avoiding trauma related stimuli, restricted range of affect, sense of foreshortened future, irritability, and hypervigilance. He denied suicidal thoughts, stated there were sleep difficulties, indicated feeling hopeless at times or crying, managed hygiene although was not always punctual doing so. The Veteran stated he was concerned about his health due to the heart condition. Further notated was markedly diminished interest or participation in significant activities, feeling of detachment or estrangement from others. Restricted range of affect. Irritability or outbursts of anger. Additional symptoms were indicated to have been depressed mood, anxiety, chronic sleep impairment, impaired judgment, disturbances of motivation and mood, inability to establish and maintain effective relationships. According to the VA examiner, the Veteran’s PTSD seemed somewhat worsened by his service-connected heart condition. He noted increased social withdrawal and sleep disturbance. However even with these worsened PTSD symptoms, he did not appear to be unemployable due to PTSD symptoms, and if anything it was likely due to other issues and circumstances. On subsequent VA examination in April 2015, the Veteran was indicated to have had, due to PTSD, “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation.” No other mental disorder had been diagnosed. As to recent history, the Veteran continued to reside with his spouse of about 30 years, stating that there was more arguing and he described himself as increasingly withdrawn. His adult son lived with him. No changes in immediate living situation. He spent time mostly around the house. He “could not do a lot” due to physical stamina, dizziness, balance problems and shortness of breath from medical issues. He enjoyed fishing to relax. He lacked motivation to follow up on some things. Social activity was limited lately. He had not gone to church in a couple of months. The Veteran took an antidepressant for mood symptoms. There was no history of group or individual psychotherapy. Sleep was limited, he had nightmares, reminders from service, hyperarousal, diminished concentration, mood consistently anxious. He denied suicidal or homicidal ideation, intent or plans. Additional symptoms indicated were depressed mood, anxiety, chronic sleep impairment, mild memory loss, circumstantial or otherwise affected speech, difficulty in establishing and maintaining effective work and social relationships. Behavioral observations were physical appearance with adequate grooming and hygiene, nonverbal behavior some consistent with anxiety, no hostile or unusual behaviors apparent during interview, mental status alert and oriented, speech normal, mood and affect slightly constricted congruent with dysphoric mood, thought process mildly circumstantial, denied current suicidal or homicidal ideation intent or plans, judgment and insight fair. The clinical presentation was prominently depressive. He was generally withdrawn but this avoidance was not trauma specific. Symptoms were mild to moderate based on his self-report during interview. There were no objectively measurable increases in symptom severity. Based on the foregoing, a 70 percent rating is being denied. For the initial timeframe under consideration from December 7, 2009 to April 11, 2012, the Board finds that the evidence is most consistent with the 50 percent rating granted above. To this effect, from reviewing the January 2010 whereas it is clearly shown and without question that the Veteran experienced characteristic symptoms of PTSD, overall any additional impairment was not close to more pronounced than that already recognized. The examination from 2011 notably, was more or less similar, showing characteristic signs of the denoted service-connected disability, from the outset, but other than that little further. Generally speaking, beyond what substantiated the PTSD diagnosis, and the Veteran was nearly asymptomatic. The examiner’s conclusion of “mild and transient” level of symptoms and impairment reflected that. There was at first some notation indicated of a reported finding of a suicidal ideation but more objective notation on interview of the Veteran, did apparently rule out that particular finding. Thus, the single notation of suicidal ideation over a time period of almost two years is not of the frequency, severity, or duration to result in deficiencies in most areas. As to the time period from April 12, 2012 onwards, to this effect, the Veteran did have signs of more consistent mood disturbances notated such as depression and anxiety, but nonetheless nothing at or approaching near-continuous panic or depression with consequent impact on functioning effectively. Otherwise, there was chronic sleep impairment. The Veteran reported some intermittent suicidal ideation, however, the record did not show that this was of the frequency, severity, or duration to interfere with his day to day life. The last examiner from 2015 had found that symptom severity had not increased. The examiner found difficulty, rather than inability to form relationships. Based on the record as a whole, which reflects strained, but existent interpersonal relationships, the Board finds that his overall ability to form and maintain relationships is more closely describe by “difficulty” instead of “inability,” even though the 2012 examiner stated that the Veteran’s PTSD caused inability. The majority of VA examiners did not find inability. Accordingly, the criteria for a 70 percent rating is not shown. VA’s benefit-of-the-doubt doctrine is not applicable whereas here, the preponderance of the evidence weighs against finding the rating criteria for the greater evaluation to have been met. Issue Withdrawn from Appeal The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105 (2012). An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204 (2018). Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204. In the present case, the Veteran through his authorized attorney has withdrawn the appeal with regard to the issue of service connection for headaches and associated vertigo, hence, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the appeal and it is dismissed. REASONS FOR REMAND 1. Entitlement to a TDIU as due to service-connected disability is remanded. The Board grants an initial 100 percent rating for the Veteran’s heart disability in this decision. As a result, his heart disability may not be considered when determining whether a TDIU is warranted. Without his 100 percent rating for his heart disability, the Veteran has one service-connected disability rated at 50 percent. The criteria for consideration of a schedular TDIU are not met. 38 C.F.R. § 4.16(a). Even though the Veteran has a 100 percent rating for a single disability, the grant of a TDIU based solely on PTSD could result in special monthly compensation based on 38 U.S.C. 1114(s), and therefore TDIU is still for consideration. See Bradley v Peake, 22 Vet. App. 280 (2008). When the applicable percentage standards set forth in 38 C.F.R. § 4.16(a) are not met, the issue of entitlement to a TDIU may be submitted to the Director of the Compensation Service for extraschedular consideration where the Veteran is unable to secure or follow a substantially gainful occupation by reason of service-connected disability. 38 C.F.R. § 4.16(b) (2018); Fanning v. Brown, 4 Vet. App. 225 (1993). The Board does not have the authority to assign an extraschedular TDIU rating in the first instance. Bowling v. Principi, 15 Vet. App. 1 (2001). An extraschedular rating is requested by the RO and approved by the Director of the Compensation Service. 38 C.F.R. § 4.16(b) (2018). The question before the Board is whether the Veteran’s PTSD alone results in unemployability. In his TDIU application, the Veteran reported working as a handyman, which is a physical occupation that his heart condition clearly prevents, but this cannot be considered in the Board’s TDIU analysis. He also stated that his PTSD caused unemployability. He reported having one year of high school and no additional training since that time. The Veteran’s attorney argued that the Veteran had limited transferrable skills and that a combination of his heart and psychiatric conditions precluded employment. Because of the limited education reported on the Veteran’s TDIU application (one year of high school), the Board finds that referral for extraschedular consideration is necessary to determine if the Veteran’s PTSD alone, without consideration of his heart disability, results in unemployability. 38 C.F.R. § 4.16(b) (2018). The matter is REMANDED for the following action: 1. Obtain the Veteran’s most recent VA outpatient records and associate them with the electronic claims folder. 2. Refer the claim to the Director of the Compensation Service for consideration of the issue of whether the Veteran’s PTSD alone makes him entitled to a TDIU on an extraschedular basis, pursuant to 38 C.F.R. § 4.16(b). 3. Then readjudicate the claim on appeal. If the benefit sought on appeal is not granted in full, the Veteran and his attorney should be furnished with a Supplemental Statement of the Case (SSOC) and afforded an opportunity to respond before the file is returned to the Board for further appellate consideration. D. Martz Ames Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Jason A. Lyons