Citation Nr: 1810810 Decision Date: 02/20/18 Archive Date: 03/01/18 DOCKET NO. 11-05 327 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Buffalo, New York THE ISSUES 1. Entitlement to service connection for ischemic heart disease. 2. Propriety of the reduction in rating for schizophrenic reaction (currently characterized as posttraumatic stress disorder (PTSD)) from 50 percent to noncompensable, effective from March 1, 1977. 3. Entitlement to a rating in excess of 50 percent for PTSD prior to June 8, 2010. 4. Entitlement to a rating in excess of 70 percent for PTSD from February 9, 2011 through November 21, 2014. 5. Entitlement to an initial rating in excess of 10 percent for residuals of a traumatic brain injury (TBI). 6. Entitlement to an initial rating in excess of 10 percent for gastroesophageal reflux disease (GERD). 7. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) prior to November 11, 2010. 8. Entitlement to special monthly compensation (SMC) based on the need for aid and attendance or housebound status. REPRESENTATION Appellant represented by: Robert V. Chisholm, Attorney ATTORNEY FOR THE BOARD Jarrette A. Marley, Counsel INTRODUCTION The Veteran served on active duty in the United States Army from August 1967 to May 1969, including service in the Republic of Vietnam, and his decorations include the Combat Infantryman Badge. These matters come before the Board of Veterans' Appeals (Board) on appeal from December 1976, August 2010, June 2012, August 2012, and March 2015 rating decisions by the Buffalo, New York Department of Veterans Affairs (VA) Regional Office (RO). For clarity, the Board notes that the December 1976 rating decision reduced the rating for the Veteran's schizophrenic reaction from 50 percent to 0 percent, effective March 1, 1977. The August 2010 rating decision granted an increased rating of 50 percent for PTSD, effective April 27, 2010. The June 2012 rating decision, in part, denied service connection for ischemic heart disease. The August 2012 rating decision granted service connection for residuals of a TBI, rated 10 percent effective from June 14, 2011, and granted service connection for GERD, effective from June 14, 2011. And the March 2015 rating decision granted entitlement to a TDIU rating, effective from November 11, 2010 through November 21, 2014. The claims for an increased rating for PTSD were previously before the Board in August 2011 when the Board denied entitlement to a rating in excess of 50 percent for the period prior to June 8, 2010, granted an increased 70 percent rating for the period from June 8, 2010 through February 8, 2011, and remanded entitlement to a rating in excess of 70 percent since February 9, 2011. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In May 2012, the Court vacated the August 2011 Board decision to the extent it denied entitlement to a rating in excess of 50 percent for PTSD prior to June 8, 2010, and remanded the matter to the Board for further action consistent with a Joint Motion for Partial Remand (Joint Motion) by the parties. The Veteran did not appeal the award of a 70 percent rating for the period from June 8, 2010 through February 8, 2011, and thus this period is not on appeal, and the issues have been characterized accordingly. In addition, a March 2015 rating decision granted an increased (100 percent) rating for PTSD, effective November 22, 2014. Accordingly, the matter has been characterized as being limited to a rating in excess of 70 percent from February 9, 2011 through November 21, 2014. Also, a separate March 2015 rating decision granted entitlement to TDIU, effective from November 11, 2010 through November 21, 2014 (after which the Veteran has a schedular 100 percent rating). The Veteran continued to express disagreement with the effective dates assigned in May 2015 correspondence, and the matter remains on appeal. The case was most recently before the Board in June 2016 when, in part, it was remanded for additional development. FINDINGS OF FACT 1. Hypertension and right bundle branch block were not manifested during service or within one year of separation from service, and are not shown to be etiologically related to service, including conceded herbicide exposure in the Republic of Vietnam; no chronic heart disorder other than hypertension is shown. 2. A November 1974 rating decision increased the rating for the Veteran's schizophrenic reaction to 50 percent, effective October 9, 1974. 3. On December 1, 1976, the RO notified the Veteran of a proposal to reduce the rating for his schizophrenic reaction to 0 percent, effective March 1, 1977. 4. A May 1977 rating decision restored a 30 percent rating for the Veteran's schizophrenic reaction, effective March 1, 1977. 5. An April 1979 rating decision notified the Veteran of a proposal to reduce the rating for his schizophrenic reaction to 10 percent, effective July 1, 1979. 6. At the time of the reductions in 1977 and 1979, the Veteran's schizophrenic reaction did not show improvement in ability to function under the ordinary conditions of life and work. 7. From February 5, 2010 through June 7, 2010, the Veteran's PTSD has been productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 8. For the period from February 9, 2011 through November 21, 2014, the Veteran's PTSD has not been productive of total psychiatric impairment. 9. The Veteran's TBI equates to a level of severity of "1" with respect to memory, attention, concentration, and executive function facets of traumatic brain injury. The remaining facets equate to a level of severity of "0". 10. At no time during the appeal period has the Veteran's GERD been manifested by symptoms or impairment that may reasonably be characterized as productive of considerable impairment of health. 11. Prior to November 11, 2010, the Veteran's service-connected disabilities do not preclude substantially gainful employment. 12. The Veteran's service-connected disabilities have not resulted in the Veteran being blind or so nearly blind as to have corrected visual acuity of 5/200 or less, in both eyes, or concentric contraction of the visual field to 5 degrees or less; or is a patient in a nursing home because of mental or physical incapacity; or require the regular aid and attendance of another person; or rendered the Veteran permanently housebound. CONCLUSIONS OF LAW 1. The criteria for service connection for ischemic heart disease are not met. 38 U.S.C. §§ 1110, 1112, 1113, 5107 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2017). 2. The criteria for restoration of a 50 percent rating for schizophrenic reaction, effective October 9, 1974, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.105, 3.159, 3.344, 4.1, 4.2, 4.3, 4.7, 4.130 (2017). 3. The criteria for a rating of 70 percent, but no higher, for PTSD, effective February 5, 2010 through June 7, 2010, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.7, 4.130, Diagnostic Code 9411 (2017). 4. The criteria for a rating in excess of 70 percent for PTSD from February 9, 2011 through November 21, 2014, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.7, 4.130, Diagnostic Code 9411 (2017). 5. The criteria for an initial rating in excess of 10 percent for TBI have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.10, 4.124a, Diagnostic Code 8045 (2017). 6. The criteria for an initial rating in excess of 10 percent for GERD have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.114, Diagnostic Code 7346 (2017). 7. Prior to November 11, 2010, the criteria for TDIU have not been met. 38 U.S.C.A. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16 (2017) 8. The criteria for SMC based on the need for aid and attendance and/or housebound allowance are not met. 38 U.S.C. §§ 1114, 5107 (2012); 38 C.F.R. §§ 3.350, 3.351, 3.352 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection Ischemic Heart Disease Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304. Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999). Certain chronic diseases, including cardiovascular disease (which includes hypertension), may be service-connected on a presumptive basis if manifested to a compensable degree in a specified period of time post-service (one year for cardiovascular disease). 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. A veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. The last date on which such a veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he or she served in the Republic of Vietnam during the period on January 9, 1972, and ending on May 7, 1975. In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Veteran contends that he is entitled to service connection for ischemic heart disease as being related to his active service. As noted above in the Introduction, the Veteran served in the Republic of Vietnam, and it is conceded that he was exposed to herbicides. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). The Board notes that the Veteran has a current diagnosis of hypertension and right bundle branch block, neither of which are recognized as a disease presumptive to veterans who were exposed to an herbicide agent during active service. 38 C.F.R. § 3.309(e) (noting ischemic heart disease does not include hypertension); see also June 2015 VA heart conditions examination (opining that the Veteran's right bundle branch block is not ischemic heart disease). When the evidence of record is reviewed under the laws and regulations as set forth above, the Board finds that there is no basis for granting service connection for hypertension or for right bundle branch block. At the outset, the Board notes that the Veteran's medical records do not show that his hypertension was manifested during service, or within one year of separation from service. See, e.g., March 1969 Medical Board report of medical examination (finding the heart normal on clinical evaluation, and showing a blood pressure reading of 124/78). The Veteran does not contend otherwise. The first evidence of record of a diagnosis of hypertension is approximately 1998, approximately 29 years after active service. See April 2008 VA Agent Orange report (noting his medical history included hypertension for about 10 years). The first evidence of record of a diagnosis of right bundle branch block is January 2011, approximately 40 years after active service. See January 2011 VA treatment record (noting baseline EKG revealed right bundle branch block). See also Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (stating that evidence of a prolonged period without complaint is proper to consider); Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (indicating that "negative evidence" was relevant to a proximate cause determination). As noted above, it is not in dispute the Veteran had active service in Vietnam and had herbicide exposure therein. As hypertension and right bundle branch block are not recognized as diseases entitled to the presumptive provisions regarding service connection based on herbicide exposure, such regulations are not applicable to the Veteran's claim for service connection for hypertension and right bundle branch block. Therefore, the claim of service connection for hypertension and right bundle branch block must be denied on a presumptive basis. 38 C.F.R. § 3.307(a)(6)(iii). Inasmuch as the Veteran does not contend service connection for hypertension or right bundle branch block based on post-service recurrence of symptomatology, entitlement to service connection on such basis must be denied. 38 C.F.R. § 3.303(b). As for service connection based on the initial documentation of the disability after service under 38 C.F.R. § 3.303(d), the Board notes that the record is negative for a competent and credible opinion finding a causal association or link between the Veteran's current hypertension and right bundle branch block and an established injury, disease, or event in service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303; Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992) (establishing service connection requires finding a relationship between a current disability and events in service or an injury or disease incurred therein). See also June 2015 VA heart conditions examination (opining that the Veteran's right bundle branch block is not ischemic heart disease and that it was not due to service). To the extent the Veteran contends his hypertension and right bundle branch block are caused by his service, to include herbicide exposure, the Board finds that the diagnosis of hypertension and right bundle branch block may not be made by a layperson because special medical training and testing is required to diagnose each disability. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Therefore, the Board finds that the presence of the disability is a determination "medical in nature" and not capable of lay observation. Id. As such, since laypersons are not capable of opining on matters requiring medical knowledge, the Board finds that the Veteran's opinion that his hypertension and/or right bundle branch block were caused by service are not competent evidence. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Based on the discussion above, the Board finds that the record is negative for a competent and credible medical opinion finding a causal association or link between the Veteran's current hypertension and right bundle branch block and an established injury, disease, or event of service origin, including his conceded herbicide exposure. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303(d); Rabideau, 2 Vet. App. at 143. Therefore, the Board also finds that service connection for hypertension and right bundle branch block is not warranted based on the initial documentation of the disabilities after service. Propriety of Reduction of Schizophrenic Reaction The provisions of 38 C.F.R. § 3.105(e) allow for the reduction in evaluation of a service-connected disability when warranted by the evidence, but only after following certain procedural guidelines. The RO must issue a rating action proposing the reduction and setting forth all material facts and reasons for the reduction. The veteran must then be given 60 days to submit additional evidence and to request a predetermination hearing. Then a rating action will be taken to effectuate the reduction. 38 C.F.R. § 3.105(e). The effective date of the reduction will be the last day of the month in which a 60-day period from the date of notice to the veteran of the final action expires. 38 C.F.R. § 3.105(e), (i)(2)(i). 38 C.F.R. § 3.344 provides that rating agencies will handle cases affected by change of medical findings or diagnosis, so as to produce the greatest degree of stability of disability evaluations consistent with the laws and VA regulations governing disability compensation. It is essential that the entire record of examination and the medical-industry history be reviewed to ascertain whether the recent examination is full and complete, including all special examinations indicated as a result of general examination and the entire case history. Examinations which are less thorough than those on which payments were originally based will not be used as a basis for reduction. Ratings for diseases subject to temporary or episodic improvement (e.g., manic depressive or other psychotic reaction), will not be reduced on the basis of any one examination, except in those instances where all of the evidence of record clearly warrants the conclusion that sustained improvement has been demonstrated. Moreover, where material improvement in the physical or mental condition is clearly reflected, the rating agency will consider whether the evidence makes it reasonably certain that the improvement will be maintained under the ordinary conditions of life and work. 38 C.F.R. § 3.344(a); Brown v. Brown, 5 Vet. App. 413, 421 (1993). Historically, a November 1974 rating decision granted an increased 50 percent rating for the Veteran's service-connected schizophrenic reaction, effective October 9, 1974. In a December 1976 rating decision, the RO notified the Veteran of contemplated reduction from 50 percent to 0 percent for the Veteran's schizophrenic reaction, effective March 1, 1977. A May 1977 rating decision was issued 60 days after the proposed action in December 1976, and the effective date of the reduction was March 1, 1977, after the 60-day period had passed. In addition, the May 1977 rating decision restored the rating for the schizophrenic reaction to 30 percent (rather than the previously proposed 0 percent rating). Thus, the Board finds that the RO satisfied the requirement of allowing at least a 60-day period to expire before assigning the effective date of reduction. Nevertheless, the Board finds that based on the evidence of record the reduction was not proper. In considering the propriety of a reduction, the Board must focus on the evidence available to the RO at the time the reduction was effectuated, although post-reduction medical evidence may be considered in the context of evaluating whether the disability had demonstrated actual improvement. Dofflemyer v. Derwinski, 2 Vet. App. 277, 281-82 (1992). In order for a rating reduction to be sustained, it must be shown by a preponderance of the evidence that the reduction was warranted. Sorakubo v. Principi, 16 Vet. App. 120 (2002). As noted above, a November 1974 rating decision granted an increased 50 percent rating for the Veteran's schizophrenic reaction. An October 1974 VA Social Survey report noted the Veteran was unable to hold a job due to impulsivity, difficulty with authority figures, suspiciousness, and an inability to settle down. It was also indicated the Veteran physically assaulted his spouse on occasion. The Veteran's spouse reported he was irritable and distrustful. His symptoms include sleep impairment, poor memory, no close friends, and he isolates himself. The Veteran stated he believed his psychiatric condition was becoming progressively worse but he is not willing to accept treatment. The October 1974 VA Social Survey report was the basis for the grant of the 50 percent rating in the November 1974 rating decision. On October 1976 VA examination, the Veteran reported he has held a number of jobs for short periods of time post-service. He also reported a history of losing his temper at various jobs and arguments with supervisors, resulting in being terminated from employment. He denied being a patient at a VA hospital. The Veteran indicated he last visited a VA outpatient clinic about four years ago. On mental status evaluation, the Veteran was neat and clean in appearance. He answered questions relevantly and coherently. The Veteran denied hallucinations and delusional ideas. There was no evidence of any paranoid state. The diagnosis was schizophrenic reaction, chronic undifferentiated type, now in social remission. The examiner indicated there was no overt evidence of a psychosis or active neurosis, and very little evidence of social or economic disability at the present time. An April 1977 VA Social Survey report noted the Veteran had difficulty holding a job due to a nervous condition. He was presently working part-time as a bus driver for a charter service. During the three years before the most recent employment, the Veteran was self-employed as a TV repairman, and that he functioned well in the situation. The Veteran and his wife reported he changed jobs approximately 50 times in the past three year period. He had past irritability and arguments at prior places of employment that caused him to lose jobs. On mental status evaluation, the Veteran's affect was appropriate. He was clear in his thoughts and speech, was adequate in concentration and memory and appeared to have good insight into his situation. The Veteran denied hallucinations and delusions. He described images of experiences in Vietnam when daydreaming, approximately every other day. He also described a tendency to be suspicious, not trusting anyone, since service. However, he did recently begin to trust his parents and wife more than in the past. He had little awareness of sleep difficulties which were reported by his wife and other bus drivers. It was also noted the Veteran's heavy drinking problem has been controlled since November 1976. Social activities were somewhat limited due to living in a rural area, but visits parents' houses on a regular basis. It was opined that the Veteran's present functioning, at home and work situations, appears influenced by his "feeling hyper" nervous condition. In the home, he appears restless and continually active with some sleep difficulties. In a job situation, he experiences pressure from demands of being around other people and worries about "blowing up" as in the past and losing his job. It was opined he was marginally employable at the present time. After a review of the record, the Board finds that the evidence does not show that the Veteran's schizophrenic reaction clearly materially improved and that the improvement would be maintained under the ordinary conditions of life and work. See Murphy v. Shinseki, 26 Vet. App. 510, 517 (2014); Faust v. West, 13 Vet. App. 342, 349 (2000); Brown v. Brown, 5 Vet. App. 413, 421 (1993) (citing 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.13 (1992)). The Board notes that the findings have been relatively consistent throughout the appeal, and the Veteran consistently complained of an inability to hold a job, impulsivity, irritability, difficulty with authority figures, suspiciousness, distrust of others, and sleep impairment. The Board also finds significant that the April 1977 Social Survey noted the Veteran had a heavy drinking problem that resolved as of November 1976 (i.e., after the October 1976 VA examination). Based on the above, the question before the Board is whether the October 1976 VA examination and April 1977 VA Social Survey report reflect improvement in the Veteran's ability to function under the ordinary conditions of life and work. Based on the consistency of the Veteran's psychiatric symptoms since the October 1974 VA Social Survey report, the basis for the award of a 50 percent rating for the Veteran's schizophrenic reaction, as reflected in the October 1976 VA examination and April 1977 VA Social Survey report, the Board finds that the preponderance of the evidence does not show improvement in the Veteran's schizophrenic reaction that will be maintained. Under the circumstances, the reduction will not be sustained, and the 50 percent rating for schizophrenic reaction is restored effective October 9, 1974, as though the reduction had not occurred. See Kitchens v. Brown, 7 Vet. App. 320 (1995); Brown v. Brown, 5 Vet. App. 413 (1993); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Significantly, an interim rating decision in April 1979 reduced the rating for the Veteran's schizophrenic reaction to 10 percent (from 30 percent), effective July 1, 1979. The above decision restored the 50 percent rating for schizophrenic reaction, effective October 9, 1974, changing the legal and factual background against which the subsequent April 1979 rating decision was made. Accordingly, the Board finds that it must consider the effects of the restoration of the 50 percent rating for schizophrenic reaction on the legal and factual basis of the subsequent April 1979 rating decision. See Pirkl v. Shinseki, 718 F.3d 1379, 1984-85 (Fed. Cir. 2013). On March 1979 VA psychiatric examination, the Veteran indicated he was employed as a driver. His affect appeared little blunted. It was noted he was friendly and cooperative, his speech was logical, relevant and coherent, and his dress was appropriate, neat and clean. The Veteran reported several odd jobs after service and drinking heavily, but that he was no longer drinking heavily. He complained that his sleep was impaired. His concentration was noted to be pretty good. He stated he felt comfortable working alone by himself. However, he also sometimes gets irritable and loses his temper. The Veteran's memory for recent and remote events was adequate, and his reasoning, insight, and judgment were found to be adequate in regards to daily activities. His thought processes were organized, without evidence of any hallucinations or delusions. The diagnosis was chronic schizophrenia, undifferentiated, in remission. The question before the Board is whether the March 1979 VA psychiatric examination reflects improvement in the Veteran's ability to function under the ordinary conditions of life and work. Comparing the Veteran's psychiatric symptoms since the October 1974 VA Social Survey report, the basis for the award of a 50 percent rating for the Veteran's schizophrenic reaction, and in the October 1976 VA examination and April 1977 VA Social Survey report, the Board finds that the preponderance of the evidence does not show improvement in the Veteran's schizophrenic reaction that will be maintained. The March 1979 VA examination still noted irritability, sleep impairment, and based on the examination it is not clear if other symptomatology had resolved or if it was simply not asked of the Veteran (e.g., recollections of Vietnam, suspiciousness, distrustfulness). Under the circumstances, the reduction will not be sustained, and the 50 percent rating for schizophrenic reaction is restored, as though the reduction had not occurred. See Kitchens v. Brown, 7 Vet. App. 320 (1995); Brown v. Brown, 5 Vet. App. 413 (1993); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Increased Rating Claims Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. The percentage ratings in VA's Schedule for Rating Disabilities (Rating Schedule) represent as far as can practicably be determined the average impairment in earning capacity resulting from such disabilities and their residual conditions in civil occupations. 38 C.F.R. § 4.1. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more closely approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Where entitlement to compensation has already been established and increase in disability is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, "staged" ratings are appropriate where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); see also Fenderson v. West, 12 Vet. App. 119 (1999). PTSD The Veteran's PTSD is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411 (the General Rating Formula for Mental Disorders (General Formula)), which provides for a 50 percent rating is warranted when the evidence shows occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted when the evidence shows 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 worklike setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted when the evidence shows total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). When determining the appropriate disability evaluation to assign, however, the Board's "primary consideration" is the Veteran's symptoms. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). For the period prior to June 8, 2010, the Board notes that when the evidence demonstrates that a factually ascertainable increase in disability occurred within the one-year period preceding the date of receipt of a claim for increased compensation, if an increase in disability occurred within the one year prior to the claim, the increase is effective as of the date the increase was "factually ascertainable." 38 U.S.C. § 5110(b)(2); Dalton v. Nicholson, 21 Vet. App. 23, 31-32 (2007); Harper v. Brown, 10 Vet. App. 125 (1997); 38 C.F.R. § 3.400(o)(l)(2); VAOPGCPREC 12-98 (1998). The United States Court of Appeals for the Federal Circuit has explained that the provisions of 38 U.S.C. § 5110 governing the effective date to be assigned for an increased rating require "that a veteran's claim for increased disability compensation must be filed within one year of an increase in the disability, as shown by the evidence, in order to obtain an effective date earlier than the date of the claim." Gaston v. Shinseki, 605 F.3d 979, 984 (Fed. Cir. 2010) (explaining the legislative intent to provide veterans with a one-year grace period for filing their claims). In this case, for the period prior to June 8, 2010, the evidence shows that a February 5, 2010, VA treatment record notes the Veteran had slowly been noticing increased symptoms the last couple of years; he denied suicidal or homicidal ideation. The Board finds that such constitutes an informal claim for an increased rating for the Veteran's PTSD, and the pertinent period on appeal constitutes February 5, 2009 through June 8, 2010. See also May 2012 Court Joint Motion for Partial Remand (finding the August 2011 Board Decision did not consider whether the February 2010 treatment record constituted the date of claim). Nonetheless, the Board notes that prior to February 5, 2010, there is no evidence to suggest an increased rating for the Veteran's PTSD was factually ascertainable. The Board notes that a March 2010 VA treatment record included the Veteran's denial of suicidal ideation, but also included the notation that the Veteran often wondered why he was here and what was the purpose. The Court has held that suicidal ideation generally rises to the level contemplated in a 70 percent rating. See Bankhead v. Shulkin, 29 Vet. App. 10, 19-20 (2017). The Court specified that VA must not require "more than thought or thoughts to establish the symptom of suicidal ideation," and may not require that the Veteran have been "hospitalized or treated on an inpatient basis" to establish suicidal ideation because that imposes a higher standard than the criteria in the Diagnostic Code for mental disorder. Id. at 20-21. Moreover, the Court cautioned VA not to conflate the risk of "suicidal ideation, which VA generally considers indicative of a 70 [percent] evaluation, and his risk of self-harm, the persistent danger of which VA generally considers indicative of a 100 [percent] evaluation." Id. at 21. As applied, the Board finds that the March 2010 VA treatment record is sufficient to establish the suicidal ideation symptom consistent with a 70 percent rating in the General Rating Formula for Mental Disorders, and inasmuch as the Board finds that the February 5, 2010 VA treatment record constitutes an informal claim, effective from February 5, 2010, the Board finds that the Veteran is entitled to a 70 percent rating effective from said date, but no earlier, as there is no evidence prior to such date to suggest an increased rating for the Veteran's PTSD was factually ascertainable. For the period from February 5, 2010 through June 7, 2010, the preponderance of the evidence is against a finding the Veteran's PTSD shows total occupational and social impairment, so as to warrant a rating of 100 percent. In this regard, the evidence does not show symptomatology such 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, disorientation to time or place, memory loss for names of close relatives, own occupation, or own name, or any symptomatology otherwise consistent with total occupational and social impairment. Therefore, for the period from February 5, 2010 through June 7, 2010, the Board finds that a rating in excess of 70 percent is not warranted. For the period from February 9, 2011 through November 21, 2014, the Veteran's PTSD is rated 70 percent disabling. The Board finds that the preponderance of the evidence is against a finding in excess of 70 percent during this period. As provided above, in order to warrant a 100 percent rating, the Veteran's PTSD should be manifested by total occupational and social impairment. The Board acknowledges that on September 2011 VA PTSD examination, it was opined that the Veteran was socially and totally occupationally impaired and individually unemployable. However, at no time during the period from February 9, 2011 through November 21, 2014, was the Veteran's PTSD shown to have been manifested by any of the criteria provided for a 100 percent rating. During this period, the evidence shows irritability, anger, difficulty getting out of bed, mildly restricted affect, at worst moderate depression, at worst mild to moderate anxiety, sleep impairment. Gross impairment in thought process, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living, and memory loss for names of close relatives, own occupation, or own name, are not shown. While there is evidence of occasional suicidal ideation, there is no evidence of suicidal intent, such as to be consistent with a persistent danger of hurting himself. The Board also finds significant that the only reasoning for the September 2011 VA PTSD examiner's opinion that the Veteran was socially and totally occupationally impaired and individually unemployable was mainly the examiner's clinical experience. In light of the conclusory nature of the September 2011 VA PTSD examination, the Board finds that the opinion is not entitled to any probative value. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions). Accordingly, based on the evidence of record, the Board finds that for the period from February 9, 2011 through November 21, 2014, the preponderance of the evidence is against a finding that the Veteran's PTSD was manifested by total occupational and social impairment, and a 100 percent rating is not warranted for the Veteran's PTSD at any period during the period from February 9, 2011 through November 21, 2014. Residuals of TBI Revised Code 8045 states that there are three main areas of dysfunction that may result from TBI and have profound effects on functioning: cognitive (which is common in varying degrees after TBI), emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation. "Cognitive impairment" is defined as decreased memory, concentration, attention, and executive functions of the brain. "Executive functions" are goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive. Not all of these brain functions may be affected in a given individual with cognitive impairment, and some functions may be affected more severely than others. In a given individual, symptoms may fluctuate in severity from day-to-day. Evaluate cognitive impairment under the table titled Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified. Subjective symptoms may be the only residual of TBI or may be associated with cognitive impairment or other areas of dysfunction. Evaluate subjective symptoms that are residuals of TBI, whether or not they are part of cognitive impairment, under the subjective symptoms facet in the table titled Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified. However, separately evaluate any residual with a distinct diagnosis that may be evaluated under another diagnostic code, such as migraine headache or Meniere's disease, even if that diagnosis is based on subjective symptoms, rather than under the Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified table. Evaluate emotional/behavioral dysfunction under § 4.130 (Schedule of ratings - mental disorders) when there is a diagnosis of a mental disorder. When there is no diagnosis of a mental disorder, evaluate emotional/behavioral symptoms under the criteria in the table titled Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified. Evaluate physical (including neurological) dysfunction based on the following list, under an appropriate diagnostic code: Motor and sensory dysfunction, including pain, of the extremities and face; visual impairment; hearing loss and tinnitus; loss of sense of smell and taste; seizures; gait, coordination, and balance problems; speech and other communication difficulties, including aphasia and related disorders, and dysarthria; neurogenic bladder; neurogenic bowel; cranial nerve dysfunctions; autonomic nerve dysfunctions; and endocrine dysfunctions. The preceding list of types of physical dysfunction does not encompass all possible residuals of TBI. For residuals not listed here that are reported on an examination, evaluate under the most appropriate diagnostic code. Evaluate each condition separately, as long as the same signs and symptoms are not used to support more than one evaluation, and combine under § 4.25 the evaluations for each separately rated condition. The evaluation assigned based on the Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified table will be considered the evaluation for a single condition for purposes of combining with other disability evaluations. Consider the need for Special Monthly Compensation (SMC) for such problems as loss of use of an extremity, certain sensory impairments, erectile dysfunction, the need for aid and attendance (including for protection from hazards or dangers incident to the daily environment due to cognitive impairment), being housebound, etc. Evaluation of Cognitive Impairment and Subjective Symptoms: The table titled Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified contains 10 important facets of TBI related to cognitive impairment and subjective symptoms. It provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and a 5th level, the highest level of impairment, and labeled "total." However, not every facet has every level of severity. The Consciousness facet, for example, does not provide for an impairment level other than "total," since any level of impaired consciousness would be totally disabling. Assign a 100- percent evaluation if "total" is the level of evaluation for one or more facets. If no facet is evaluated as "total," assign the overall percentage evaluation based on the level of the highest facet as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent. For example, assign a 70 percent evaluation if 3 is the highest level of evaluation for any facet. For the facet memory, attention, concentration, executive functions a "0" level of impairment is assigned with no complaints of impairment. A "1" level is assigned with complaint of mild memory loss (such as having difficulty following a conversation, recalling recent conversations, remembering names of new acquaintances, finding words or often misplacing items), attention, concentration or executive functions, but without objective evidence on testing. A "2" level is assigned with objective evidence on testing of mild impairment. A "3" level is assigned with objective evidence on testing of moderate impairment. A "total" level is assigned with objective evidence on testing of severe impairment. For the facet judgment a "0" level of impairment is assigned for normal judgment. A "1" level is assigned with mildly impaired judgment; for complex or unfamiliar decisions, occasionally unable to identify, understand and weigh the alternatives, understand the consequences of choices, and make a reasonable decision. A "2" level is assigned with moderately impaired judgment; for complex or unfamiliar decisions, usually unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision, although has little difficulty with simple decisions. A "3" level is assigned with moderately severely impaired judgment; for even routine and familiar decisions, occasionally unable to identify, understand, weigh the alternatives, and make a reasonable decision. A "total" level is assigned with severely impaired judgment; for even routine and familiar decisions, usually unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision; for example, unable to determine appropriate clothing for current weather conditions or judge when to avoid dangerous situations and activities. For the facet social interaction a "0" level of impairment is assigned when social interaction is routinely appropriate. A "1" level is assigned when social interaction is occasionally inappropriate. A "2" level is assigned when social interaction is frequently inappropriate. A "3" level of impairment is assigned when social interaction is inappropriate most or all of the time. For the facet orientation a "0" level of impairment is assigned when always oriented to person, time, place and situation. A "1" level is assigned when occasionally disoriented to one of the four aspects of orientation. A "2" level is assigned when occasionally disoriented to one of the four aspects of orientation or often disoriented to one aspect of orientation. A "3" level is assigned when often disoriented to two or more of the four aspects of orientation. A "total" level is assigned when constantly disoriented to two or more of the four aspects of orientation. For the facet motor activity (with intact motor and sensory system) a "0" level of impairment is assigned for normal motor activity. A "1" level is assigned for motor activity that is normal most of the time but mildly slowed at times due to apraxia (inability to perform previously-learned motor activities despite normal motor function). A "2" level is assigned for motor activity mildly decreased or with moderate slowing due to apraxia. A "3" level is assigned for motor activity moderately decreased due to apraxia. A "total" level is assigned for motor activity severely decreased due to apraxia. For the facet visual spatial orientation a "0" level of impairment is assigned when normal. A "1" level is assigned when mildly impaired: occasionally gets lost in unfamiliar surroundings; has difficulty reading maps or following directions; is able to use assistive devices such as GPS (global positioning system). A "2" level is assigned when moderately impaired: usually gets lost in unfamiliar surroundings; has difficulty reading maps, following directions and judging distance; has difficulty using assistive devices such as GPS. A "3" level is assigned when moderately severely impaired: gets lost even in familiar surroundings; unable to use assistive devices such as GPS. A "total" level is assigned when severely impaired: may be unable to touch or name own body parts when asked by the examiner, identify the relative position in space of two different objects, or find the way from one room to another in a familiar environment. For the facet subjective symptoms a "0" level of impairment is assigned for subjective symptoms that do not interfere with work; instrumental activities of daily living; or work, family of other close relationships (examples are mild or occasional headaches or mild anxiety). A "1" level is assigned with three or more subjective symptoms that mildly interfere with work; instrumental activities of daily living; or work, family of other close relationships (examples of findings that might be seen at this level of impairment are intermittent dizziness, daily mild-to-moderate headaches, tinnitus, frequent insomnia, hypersensitivity to sound, hypersensitivity to light). A "2" level is assigned with three or more subjective symptoms that moderately interfere with work; instrumental activities of daily living; or, work, family of other close relationships (examples of findings that might be seen at this level of impairment are marked fatigability, blurred or double vision, headaches requiring rest periods during most days). For the facet neurobehavioral effects a "0" level of impairment is assigned for one or more neurobehavioral effects that do not interfere with workplace interaction or social interaction. Examples of neurobehavioral effects are: irritability, impulsivity, unpredictability, lack of motivation, verbal aggression, physical aggression, belligerence, apathy, lack of empathy, moodiness, lack of cooperation, inflexibility, and impaired awareness of disability. Any of these effects may range from slight to severe, although verbal and physical aggression are more likely to have a more serious impact on workplace interaction and social interaction than some other effects. A "1" level is assigned with one or more neurobehavioral effects that occasionally interfere with workplace interaction, social interaction, or both but do not preclude them. A "2" level is assigned with one or more neurobehavioral effects that frequently interfere with workplace interaction, social interaction, or both but do not preclude them. A "3" level is assigned with one or more neurobehavioral effects that interfere with or preclude workplace interaction, social interaction, or both on most days or that occasionally require supervision for safety of self or others. For the facet communication a "0" level of impairment is assigned when able to communicate by spoken or written language (expressive communication) and to comprehend spoken and written language. A "1" level is assigned when comprehension or expression, or both, of either spoken or written language is only occasionally impaired; can communicate complex ideas. A "2" level is assigned with inability to communicate either by spoken language, written language, or both, more than occasionally but less than half the time, or to comprehend spoken language, written language, or both, more than occasionally but less than half the time; can generally communicate complex ideas. A "3" level is assigned with inability to communicate either by spoken language, written language, or both, at least half the time but not all the time, or to comprehend spoken language, written language, or both, at least half the time but not all the time; may rely on gestures or other alternative modes of communication; able to communicate basic needs. A "total" level is assigned for complete inability to communicate either by spoken language, written language, or both, or to comprehend spoken language, written language, or both; unable to communicate basic needs. For the facet consciousness a "total" level of impairment is assigned for persistently altered state of consciousness, such as vegetative state, minimally responsive state, and coma. Note (1): There may be an overlap of manifestations of conditions evaluated under the table titled Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified with manifestations of a comorbid mental or neurologic or other physical disorder that can be separately evaluated under another diagnostic code. In such cases, do not assign more than one evaluation based on the same manifestations. If the manifestations of two or more conditions cannot be clearly separated, assign a single evaluation under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning due to both conditions. However, if the manifestations are clearly separable, assign a separate evaluation for each condition. Note (2): Symptoms listed as examples at certain evaluation levels in the table are only examples and are not symptoms that must be present in order to assign a particular evaluation. Note (3): "Instrumental activities of daily living" refers to activities other than self-care that are needed for independent living, such as meal preparation, doing housework and other chores, shopping, traveling, doing laundry, being responsible for one's own medications, and using a telephone. These activities are distinguished from "Activities of daily living," which refers to basic self-care and includes bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet. Note (4): The terms "mild," "moderate" and "severe" TBI, which may appear in medical records, refer to a classification of TBI made at, or close to, the time of injury rather than to the current level of functioning. This classification does not affect the rating assigned under diagnostic code 8045. Note (5): A veteran whose residuals of TBI are rated under a version of § 4.124a, diagnostic code 8045, in effect before October 23, 2008 may request review under diagnostic code 8045, irrespective of whether his or her disability has worsened since the last review. As this Veteran was not service-connected until June 2011, Note (5) does not apply. The Veteran is separately service-connected for posttraumatic stress disorder (PTSD), rated as 70 percent disabling under 38 C.F.R. § 4.130, Code 9411, since the Veteran was awarded service connection for residuals of TBI. Certain impairments cited in the rating criteria for TBI, such as memory loss, are also specifically incorporated into the rating criteria for PTSD. The evaluation of the same manifestation under various different diagnoses is to be avoided; see 38 C.F.R. § 4.14; see also Brady v. Brown, 4 Vet. App. 203, 206 (1993), holding that the rating schedule may not be employed as a vehicle for compensating a claimant twice or more for the same symptomology because such a result would overcompensate the claimant for the actual impairment of his earning capacity and would constitute pyramiding. The Board finds that a rating in excess of 10 percent is not warranted. For the facet memory, attention, concentration, executive functions, a level "1" impairment is appropriate. See June 2012 VA TBI examination. The memory loss is a symptom that is incorporated into the Veteran's 70 percent rating for PTSD, and may not be considered as a basis for evaluation under another Code. Brady, 4 Vet. App. at 206. For the facet judgment a "0" level of impairment is appropriate. The June 2012 and February 2017 VA TBI examinations found the Veteran's judgment to be normal. There is no clinical evidence of record showing impaired judgment. For the facet social interaction a "0" level of impairment is appropriate. The June 2012 and February 2017 VA TBI examinations found the Veteran's social interaction to be normal. There is no clinical evidence of record showing impaired social interaction. For the facet orientation a "0" level of impairment is appropriate. The June 2012 and February 2017 VA TBI examinations found the Veteran was consistently oriented in all four aspects. There is no clinical evidence of record showing impaired orientation. For the facet motor activity a "0" level of impairment is appropriate since the Veteran's motor and sensory systems are consistently shown to be intact on examination. See June 2012, February 2017 VA TBI examinations. For the facet visual spatial orientation a "0" level of impairment is appropriate as the Veteran is not shown to have any impairment in this area. See June 2012, February 2017 VA TBI examinations. For the facet subjective symptoms a "0" level of impairment is appropriate. At no time has the Veteran indicated that he suffers from symptoms that interfere with his ability to work. See June 2012, February 2017 VA TBI examinations. For the facets neurobehavioral effects, communication and consciousness a "0" level of impairment is assigned because the Veteran demonstrates no impairment in these areas. See June 2012, February 2017 VA TBI examinations. Thus, the Veteran's highest level of impairment in any facet is "1" in the memory, attention, concentration, executive functions facet. An initial rating of 10 percent is warranted under Code 8045. In assessing the severity of this disability, the Board has considered the Veteran's assertions regarding his symptoms. However, the criteria needed to support higher ratings are the required clinical findings that are within the province of trained medical and mental health professionals. As such, the Veteran's lay assertions are not considered more persuasive than the objective clinical findings which do not support assignment of a higher rating for his TBI pursuant to any applicable criteria at any point pertinent to this appeal. The Board has found no discrete time period during the period under review in which the criteria for evaluation higher than 10 percent were met. Accordingly, a "staged" initial rating is not warranted. Fenderson v. West, 12 Vet. App. 119 (1999). The Board finds that during the period under review the disability picture associated with the Veteran's TBI residuals has approximated the criteria for a rating of 10 percent and no higher. As a preponderance of the evidence is against the award of an increased rating, the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1991). GERD The Veteran contends that he is entitled to an initial rating in excess of 10 percent for his service-connected GERD. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Diagnostic Code 7346 provides a 10 percent rating if the GERD's adverse symptomatology equates to a hiatal hernia with two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent rating is warranted if adverse symptomatology equates to a hiatal hernia with persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 60 percent rating is warranted for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114. After a review of the evidence of record, the Board finds the preponderance of the evidence is against a rating in excess of 10 percent throughout the appeal period for the Veteran's GERD. On June 2012 VA esophageal conditions examination, the Veteran's symptoms were noted to include infrequent episodes of epigastric distress, pyrosis (i.e., heartburn), reflux, regurgitation, sleep disturbance caused by reflux (recurrence 4 or more times per year), and nausea (recurrence 4 or more times per year, average 1 to 0 days in duration). It was noted the disability had no impact on the Veteran's ability to work, but that it did make him very uncomfortable due to the reflux and dry heaving from the reflux. And on February 2017 VA examination, it was noted that the Veteran's GERD symptoms were stable, and there were no pertinent physical findings, complications, conditions, signs or symptoms related to the GERD. VA treatment records routinely note stable dyspepsia (i.e., indigestion), and no nausea, vomiting, diarrhea, or constipation. See, e.g., December 2011, August 2013, March 2014, October 2014, June 2015, July 2016 VA treatment records. The Board acknowledges that there are occasional periods of complaints of abdominal pain and diarrhea and/or constipation. See, e.g., January 2013, May 2013, October 2015 VA treatment records. There is also a complaint of some blood with bowel movements and constipation in October 2015, but such is noted to be related to a hemorrhoidectomy 6 weeks prior. Nonetheless, the Veteran's symptoms associated with his service-connected GERD are consistent with the currently assigned 10 percent rating as the preponderance of the evidence is against a finding his GERD is consistent with, or approximates, considerable impairment of health as required for an increased (30 percent) rating. In summary, the Board finds that most probative evidence of record shows that the criteria for a rating in excess of 10 percent GERD are not met because it does not cause at least persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. In addition, because the Veteran's symptomatology was substantially the same throughout the appeal period, the Board finds that consideration of a staged rating is not warranted. TDIU Prior to November 11, 2010 A total disability rating 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 the result of service-connected disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. Consideration may be given to a veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Todd v. McDonald, 27 Vet. App. 79, 85-86 (2014). To qualify for a total rating for compensation purposes, the evidence must show: (1) a single disability rated as 100 percent disabling; or (2) that the veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities and there is one disability ratable at 60 percent or more, or, if more than one disability, at least one disability ratable at 40 percent or more and a combined disability rating of 70 percent. 38 C.F.R. § 4.16(a). For the purpose of establishing one 60 percent disability, or one 40 percent disability in combination, disabilities affecting a single body system are considered as one disability. Id. Disabilities that are not service connected cannot serve as a basis for a total disability rating. 38 C.F.R. §§ 3.341, 4.19. Unlike the regular disability rating schedule, which is based on the average work-related impairment caused by a disability, "entitlement to TDIU is based on an individual's particular circumstance." Rice v. Shinseki, 22 Vet. App. 447, 452 (2009) (quoting Thun v. Peake, 22 Vet. App. 111, 116 (2008)); see also Todd, 27 Vet. App. at 85-86. Therefore, in adjudicating a TDIU claim, VA must take into account the individual veteran's education, training, and work history. Hatlestad v. Derwinski, 1 Vet. App. 164, 168 (1991) (level of education is a factor in deciding employability); see Friscia v. Brown, 7 Vet. App. 294 (1994) (considering veteran's experience as a pilot, his training in business administration and computer programming, and his history of obtaining and losing 19 jobs in the previous 18 years); Beaty v. Brown, 6 Vet. App. 532 (1994) (considering veteran's 8th grade education and sole occupation as a farmer); Moore v. Derwinski, 1 Vet. App. 356 (1991) (considering veteran's master degree in education and his part-time work as a tutor). Marginal employment shall not be considered substantially gainful employment. For purposes of this section, 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. Marginal employment may also be held to exist, on a facts found basis (includes but is not limited to employment in a protected environment such as a family business or sheltered workshop), when earned annual income exceeds the poverty threshold. Consideration shall be given in all claims to the nature of the employment and the reason for termination. 38 C.F.R. § 4.16(a). The Veteran has been awarded TDIU effective from November 21, 2010. See March 2015 rating decision. The Veteran contends that he is entitled to a TDIU rating prior to November 21, 2010 based on his service-connected disabilities. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Based on the above decision, the Veteran met the schedular criteria for TDIU pursuant to 38 C.F.R. § 4.16(a), effective from February 5, 2010. The evidence of record shows that the Veteran was employed until November 11, 2010. See October 2011 VA Form 21-8940; see also April 2013 Social Security Administration (SSA) Form 831 (listing the Veteran's disability began on November 11, 2010). The pertinent question in this case is whether prior to November 11, 2010, the Veteran's employment was substantially gainful employment. The Veteran's attorney has contended that the employment was below the poverty threshold, and therefore his employment should be characterized as marginal employment. See June 2013 C.B. vocational consult report (stating the Veteran's earnings were substantially below the poverty threshold for two people from 1999 through 2010). Initially, the Board notes that even were the assertions of C.B. correct in that the Veteran's income in 2010 was below the poverty threshold for two people, the relevant inquiry is whether the Veteran's income in 2010 was below the poverty threshold for one person. 38 C.F.R. § 4.16(a). In addition, SSA earnings from 1964 through 2011 show that the Veteran's earnings in 2010 were $26,849. Such is significantly above the poverty threshold for a single person. See http://livingwage.mit.edu/counties/36029 (showing the poverty threshold in Erie County, New York for 2010 for a single person was $10,400). Thus, the evidence does not show that prior to November 2010 the Veteran's employment was marginal employment. Inasmuch as there is no evidence supporting the Veteran was unable to secure and follow a substantially gainful occupation by reason of his service-connected disabilities prior to November 11, 2010, entitlement to TDIU prior to November 11, 2010 is not warranted. SMC SMC is payable where a veteran suffers from service-connected disability that renders him permanently bedridden or so helpless as to be in need of regular aid and attendance. 38 U.S.C. § 1114(l); 38 C.F.R. § 3.350(b). A veteran shall be considered to be in need of regular aid and attendance if he or she is blind or so nearly blind as to have corrected visual acuity of 5/200 or less, in both eyes, or concentric/contraction of the visual field to 5 degrees or less; or is a patient in a nursing home because of mental or physical incapacity; or establishes a factual need for aid and attendance under the criteria set forth in 38 C.F.R. § 3.352(a). See also 38 C.F.R. § 3.351(c). Determinations as to the need for aid and attendance are based on the actual requirements of personal assistance from others. Pursuant to 38 C.F.R. § 3.352(a), the following criteria are to be considered for determining whether a claimant is in need of the regular aid and attendance of another person: (1) the inability of the claimant to dress himself or to keep himself ordinarily clean and presentable; (2) frequent need of adjustment of any special prosthetic or orthopedic appliance which, by reason of the particular disability, cannot be done without aid; (3) the inability of the claimant to feed himself through the loss of coordination of the upper extremities or through extreme weakness; (4) the inability to attend to the wants of nature; or, (5) a physical or mental incapacity that requires care and assistance on a regular basis to protect the claimant from the hazards or dangers incident to his or her daily environment. Bedridden will be that condition which, through its essential character, actually requires that the claimant remain in bed. It is mandatory for VA to consider the enumerated factors within the regulation, and at least one of the enumerated factors be present. Turco v. Brown, 9 Vet. App. 222 (1996). In order for the Veteran to prevail in the claim, the evidence must show that it is a service-connected disability that has resulted in the need for regular aid and attendance. Prejean v. West, 13 Vet. App. 444 (2000). The regulations also provide additional compensation on the basis of being housebound where a veteran has, in addition to a single, permanent service-connected disability rated 100 percent disabling, (1) 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, (2) 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. § 1114(s); 38 C.F.R. § 3.350(i). The Veteran contends that he is entitled to SMC because he has difficulty attending to the basic needs of life. See July 2015 attorney correspondence (stating that based on the December 2010 SSA function report it can be inferred the Veteran needs assistance and reminders to take care of his personal needs and grooming and taking his medications); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Initially, the Board notes that the service-connected disabilities have not resulted in the Veteran being blind or so nearly blind as to have corrected visual acuity of 5/200 or less, in both eyes, or concentric contraction of the visual field to 5 degrees or less. He is not service-connected for any eye disability. The March 2017 VA examination found the Veteran's best corrected vision was not 5/200 or worse in both eyes. Moreover, the record does not reflect he is a patient in a nursing home because of mental or physical incapacity. Based on the evidence, the Board finds that the preponderance of the evidence is against a finding the Veteran requires the regular aid and attendance of another person. In this regard, the Board notes that the December 2010 SSA function report referenced by his attorney states that his wife cuts his hair, but also states that he only needs reminders to shave and bathe, and occasional reminders to take his medicine. It did state that the Veteran's wife prepares his meals. However, the Veteran also reported therein that he could do most household chores, but that it takes longer to complete. The evidence also includes a January 2011 SSA K.D. psychiatric evaluation report, wherein it was found the Veteran was able to dress, bathe, and groom himself. It was also noted the Veteran cooks and prepares food, although his wife does the laundry and shopping. The Veteran was noted to still drive. K.D. found the Veteran could follow and understand simple directions and instructions, and could perform simple tasks independently. Based on the evaluation, it was opined that it was not clear that the Veteran's psychiatric problems were significant enough to interfere with his ability to function on a daily basis. In addition, on March 2017 VA examination, it was found that the Veteran has some difficulty with the ability for self-feeding, to dress and undress, self bathe, self-groom, and with his toileting ability. However, it was also found that the Veteran could perform all functions of self-care, and possessed the ability to protect himself from his daily environment. Thus, based on the evidence, the Board finds that the preponderance of the competent evidence of record is against a finding the Veteran requires the regular aid and attendance of another person. As to the issue of whether the Veteran is entitled to SMC at the housebound rate, the current TDIU rating in effect from November 11, 2010 is based on multiple service-connected disabilities. See March 2015 rating decision (awarding TDIU based on the Veteran's service-connected disabilities). The Board acknowledges that effective from November 22, 2014, the Veteran's PTSD is rated as 100 percent disabling. However, the Veteran has not established 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 PTSD. 38 C.F.R. § 3.350(i). Further, the record does not reflect he has been rendered permanently housebound by reason of his service-connected disabilities. The evidence of record demonstrates that the Veteran has unrestricted circumstances he can leave his home, and on January 2011 SSA K.D. psychiatric evaluation report, it was noted the Veteran drove himself to the evaluation, a distance of approximately 16 miles from his home. See March 2017 VA examination. In view of the foregoing, the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to SMC based on the need for regular aid and attendance or by reason of being housebound. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application in the instant case. Consequently, the benefit sought on appeal regarding this claim must be denied. ORDER Service connection for ischemic heart disease is denied. The rating reduction for the Veteran's schizophrenic reaction from 50 percent to 30 and 10 percent, effective October 9, 1974, was improper, and the 50 percent rating is restored. Subject to the laws and regulations governing monetary benefits, a 70 percent rating, and no more, is granted for PTSD from February 5, 2010. A rating in excess of 70 percent for PTSD from February 9, 2011 through November 21, 2014 is denied. An initial rating in excess of 10 percent for TBI is denied. An initial rating in excess of 10 percent for GERD is denied. Entitlement to TDIU prior to November 11, 2010, is denied. SMC based on the need for regular aid and attendance or by reason of being housebound is denied. ____________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs