Citation Nr: 18103139 Decision Date: 05/17/18 Archive Date: 05/17/18 DOCKET NO. 13-15 927 DATE: May 17, 2018 ORDER The reduction of the rating for the Veteran's bilateral hearing loss from 50 percent to 40 percent, effective January 1, 2013, was improper; the 50 percent rating is restored. An initial disability rating in excess of 10 percent for a traumatic brain injury (TBI) is denied. A disability rating in excess of 10 percent for tinnitus, a TBI residual, is denied. A disability rating in excess of 50 percent for headaches, a TBI residual, is denied. A disability rating in excess of 50 percent for bilateral hearing loss, a TBI residual, is denied. A disability rating of 100 percent for PTSD is granted. Special monthly compensation at the housebound rate is granted. Entitlement to a total disability rating based on individual unemployability (TDIU) is dismissed as moot. FINDINGS OF FACT 1. The Veteran's service-connected bilateral hearing loss was rated 50 percent disabling for less than five years when the RO, in an April 2012 rating decision, proposed to reduce the rating. The reduction to a 40 percent rating was implemented in an October 2012 decision, effective January 1, 2013. 2. When the October 2012 rating decision reduced the rating for the Veteran's bilateral hearing loss, the evidence did not show improvement in the service-connected disability, including an actual improvement in the Veteran’s ability to function under the ordinary conditions of life and work. 3. The Veteran’s TBI is not manifested by any facet equating to higher than a level “1” under the Table of Facets of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified. 4. Tinnitus, a TBI residual, has been assigned a 10 percent rating throughout the entire appeal period, which is the maximum schedular rating authorized under the applicable diagnostic code. 5. Headaches, a TBI residual, have been assigned a 50 percent rating throughout the entire appeal period, which is the maximum schedular rating authorized under the applicable diagnostic code. 6. The audiometry data for bilateral hearing loss, a TBI residual, has yielded, at most, a 50 percent rating under Table VII throughout the appeal period. 7. The Veteran’s PTSD is manifested by total occupational and social impairment with such symptoms as a gross impairment in thought processes or communication, persistent hallucinations or delusions, a persistent danger of the Veteran hurting himself or others, and disorientation. 8. In addition to the 100 percent schedular rating for PTSD awarded herein, throughout the appeal period the Veteran has had other separate and distinct ratings involving different anatomical segments or bodily systems, which, under the combined ratings table, combine to at least 60 percent. 9. As a 100 percent rating for PTSD and entitlement to SMC are being assigned for the entirety of the period on appeal, there remain no questions of law or fact to be decided regarding entitlement to a TDIU. CONCLUSIONS OF LAW 1. The 50 percent rating for bilateral hearing loss from January 1, 2013 is restored. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.105(e), 3.344, 4.85, 4.86, Diagnostic Code (DC) 6100. 2. The criteria for an initial disability rating in excess of 10 percent for residuals of TBI are not met. 38 U.S.C. §§ 1154 (a), 1155, 5107(b); 38 C.F.R. § 3.102, 4.124a, DC 8045. 3. The criteria for a rating in excess of 10 percent for tinnitus, a TBI residual, have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.102, 4.87, DC 6260. 4. The criteria for a disability rating in excess of 50 percent for headaches, a TBI residual, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.124a, DC 8100. 5. The criteria for a rating in excess of 50 percent for bilateral hearing loss, a TBI residual, have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.102, 4.85, 4.86, DC 6100. 6. The criteria for a rating of 100 percent for PTSD are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.130, Diagnostic Code 9411. 7. The criteria for special monthly compensation at the housebound rate are met. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). 8. The appeal for entitlement to a TDIU is dismissed as moot. 38 U.S.C. § 7105(d)(5); 38 C.F.R. § 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1961 to August 1975 in the United States Army. He and his spouse testified before the undersigned during a February 2018 hearing. This matter is on appeal from April 2012 and October 2012 rating decisions. In reaching the decisions below, the Board considered the Veteran’s claims and decided entitlement based on the evidence. Neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record, with respect to his claims. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Rating Reduction A disability rating may be reduced, however, the circumstances under which rating reductions can occur are specifically limited and carefully circumscribed by regulations promulgated by the Secretary. Dofflemyer v. Derwinski, 2 Vet. App. 277, 280 (1992). In Brown v. Brown, 5 Vet. App. 413 (1993), the Court interpreted the provisions of 38 C.F.R. § 4.13 to require that in any rating reduction case, it must be ascertained, based upon a review of the entire recorded history of the condition, whether the evidence reflects an actual change in the disability and whether the examination reports reflecting such change are based upon thorough examinations. Moreover, 38 C.F.R. §§ 4.2 and 4.10 provide that in any rating reduction case, not only must it be determined that an improvement in a disability has actually occurred, but also that that improvement in a disability actually reflects an improvement in the Veteran's ability to function under the ordinary conditions of life and work. Brown, 5 Vet. App. at 421. The Court additionally held that several general regulations are applicable to all rating reduction cases, without regard for how long a particular rating has been in effect. The Court stated that certain regulations “impose a clear requirement that VA rating reductions, as with all VA rating decisions, be based upon a review of the entire history of the Veteran's disability.” Brown, 5 Vet. App. at 420 (referring to 38 C.F.R. §§ 4.1, 4.2, 4.13) (1993). 38 C.F.R. § 3.344(c), applicable to ratings such as these, in effect for less than 5 years, requires improvement before an evaluation is reduced. Implicit in the regulations is that any improvement must be of such a nature as to warrant a change in the evaluation. In considering the propriety of a reduction, the Board must focus on the evidence available to the RO when the reduction was effectuated, although post-reduction medical evidence may be considered for the limited purpose of determining whether the condition had demonstrated actual improvement. Dofflemyer, 2 Vet. App. at 281-282. It should be emphasized, however, that such after-the-fact evidence may not be used to justify an improper reduction. Under the criteria for rating hearing loss, disability ratings are determined by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are performed. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). Hearing loss disability evaluations range from 0 percent to 100 percent based on organic impairment of hearing acuity, as measured by controlled speech discrimination tests in conjunction with the average hearing threshold, as measured by puretone audiometric tests in the frequencies 1000, 2000, 3000 and 4000 Hertz. The rating schedule establishes 11 auditory acuity levels designated from Level I for essentially normal hearing acuity, through Level XI for profound deafness. VA audiometric examinations are conducted using a controlled speech discrimination test together with the results of a puretone audiometry test. The vertical lines in Table VI represent nine categories of the percentage of discrimination based on the controlled speech discrimination test. See 38 C.F.R. § 4.85. The horizontal columns in Table VI represent nine categories of decibel loss based on the pure tone audiometry test. The numeric designation of impaired hearing (Levels I through XI) is determined for each ear by intersecting the vertical row appropriate for the percentage of discrimination and the horizontal column appropriate to the puretone decibel loss. The percentage evaluation is found from Table VII by intersecting the vertical column appropriate for the numeric designation for the ear having the better hearing acuity and the horizontal row appropriate to the numeric designation level for the ear having the poorer hearing acuity. 38 C.F.R. § 4.85. In addition, 38 C.F.R. § 4.86 applies where there are exceptional patterns of hearing impairment. When the puretone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86 (a). When the puretone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. That numeral will then be elevated to the next higher Roman numeral. 38 C.F.R. § 4.86 (b). The Veteran was granted service connection for bilateral hearing loss in a September 1984 rating decision, and assigned a noncompensable rating. The noncompensable rating was continued in an August 2007 rating decision. In a November 2010 rating decision, a higher rating of 50 percent was granted, effective July 14, 2010. This rating was based on the results of a September 2010 VA examination. On examination, the following pure tone thresholds, in decibels, were obtained: HERTZ 1000 2000 3000 4000 RIGHT 65 80 85 85 LEFT 70 100 100 100 The pure tone threshold average was 78.75 decibels for the right ear, with a speech discrimination score of 96 percent, yielding Level II hearing according to Table VI. The provisions of 38 C.F.R. § 4.86 apply to the right ear, and as Table VIA yields Level VII hearing, those results will be applied as this is more favorable to the Veteran. On the left, the pure tone threshold average was 92.5 decibels, with a speech discrimination score of 72 percent, yielding Level VII hearing. The provisions of 38 C.F.R. § 4.86 apply to the left ear, and as Table VIA yields Level IX hearing, those results will be applied as this is more favorable to the Veteran. Combining these, according to Table VII, reveals a 50 percent rating. At the conclusion of the report, the examiner opined that the bilateral hearing loss caused no significant effects on occupation, and no effects on the usual activities of daily living. In January 2011, the Veteran filed a claim for a TDIU, which the RO construed as a claim for higher ratings for his service-connected disabilities. He was scheduled for VA examinations to assess the severity of his service-connected conditions and their impact on his ability to work. On VA examination in April 2011, the following pure tone thresholds, in decibels, were obtained: HERTZ 1000 2000 3000 4000 RIGHT 50 60 70 75 LEFT 40 80 80 80 The pure tone threshold average was 63.75 decibels on the right, with a speech discrimination score of 94 percent, yielding Level II hearing according to Table VI. On the left, the pure tone threshold average was 70 decibels, with a speech discrimination score of 94 percent, yielding Level II hearing. The provisions of 38 C.F.R. § 4.86 do not apply to either ear. Combining these, according to Table VII, reveals a noncompensable rating. At the conclusion of the report, the examiner stated that the Veteran would have significant difficulty in a noisy work environment, even wearing his issued amplification. While hearing loss would not preclude employment, he would need to work in an area where constant communication with other people was not required or where contact with the public was limited. With proper accommodations, employability would be minimally affected. In an April 2012 rating decision, the RO proposed to reduce the rating to a noncompensable level (0 percent), based on the April 2011 report. In a September 2012 Disability Benefits Questionnaire (DBQ), the following pure tone thresholds, in decibels, were obtained: HERTZ 1000 2000 3000 4000 RIGHT 60 80 85 80 LEFT 75 95 100 95 The pure tone threshold average was 76.25 decibels on the right, with a speech discrimination score of 88 percent, yielding Level III hearing according to Table VI. The provisions of 38 C.F.R. § 4.86 apply to the right ear, and as Table VIA yields Level VI hearing, those results will be applied as this is more favorable to the Veteran. On the left, the pure tone threshold average was 91.25 decibels, with a speech discrimination score of 76 percent, yielding Level V hearing. The provisions of 38 C.F.R. § 4.86 apply to the left ear, and as Table VIA yields Level IX hearing, those results will be applied as this is more favorable to the Veteran. Combining these, according to Table VII, reveals a 40 percent rating. The Board notes that in using Table VIA for the right ear, it is arguable which category applies. A score of 70-76 yields Level VI hearing, but a score of 77-83 yields Level VII hearing. As the Veteran’s score of 76.25 is in excess of the 70-76 category, and the 38 C.F.R. § 4.85(d) does not contain rounding rules, it is arguable that his score could result in Level VII hearing, which yields a 50 percent rating when combined with the left ear. At the conclusion of the report, the examiner opined that the hearing loss impacted ordinary conditions of life, including the ability to work. The Veteran withdrew from social activities because he could not hear. It was hard for him to communicate. He has great difficulty hearing speech in the presence of background noise, and required loud volumes for the television and phone. In October 2012, the rating reduction was implemented, effective January 1, 2013. In that decision, the RO reduced the rating from 50 percent to 40 percent. The evidence cited by the RO in the October 2012 rating decision included private medical reports, statements from the Veteran, VA treatment records, and the September 2012 DBQ. Applying the facts to the criteria discussed above, the Board finds the evidence before the RO in October 2012 did not indicate overall improvement in the appellant's service-connected hearing loss, including an actual improvement in the Veteran’s ability to function under the ordinary conditions of life and work. Significantly, in contrast to the September 2010 examiner’s finding of no impact of the disability on occupational activities or activities of daily living, both the April 2011 and September 2012 examiners described various impacts in both areas. The 2011 examiner specifically stated the Veteran would have “significant” difficulty in a noisy environment, even with hearing aids, and that work accommodations would be required. Further, as described above, it is arguable that the criteria for a 50 percent rating were met by the September 2012 report. Regardless, however, the September 2012 scores depict worse scores in every pure tone threshold for each ear, and worse speech recognition scores bilaterally, compared to the 2011 report. In fact, the averages were close to those obtained on VA examination in September 2010 (78.75 on the right in 2010, 76.25 on the right in 2012; 92.5 on the left in 2010, 91.25 on the left in 2012). This does not illustrate actual improvement. Moreover, the April 2011 VA examination report is of reduced probative value as the examiner did not indicate that the entire claims file was reviewed. See Tucker v. Derwinski, 2 Vet. App. 201 (1992) (holding that the failure of the examiner in that case to review the claims file rendered the reduction decision void ab initio). It cannot be stated with any certainty that there has been actual improvement of the Veteran’s service-connected bilateral hearing loss since the time the 50 percent rating was established. Thus, the 50 percent rating is restored, effective January 1, 2013. Claims for Higher Ratings Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disability specified is considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. TBI In the October 2012 rating decision on appeal, service connection for a TBI was granted, and a 10 percent rating was assigned effective May 29, 2012, under 38 C.F.R. §4.124a, Diagnostic Code 8045. Diagnostic Code 8045 states that there are three main areas of dysfunction that may result from TBIs 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. 38 C.F.R. § 4.124a, Diagnostic Code 8045 (2016). 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. Cognitive impairment is to be evaluated under the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." Subjective symptoms may be the only residual of a TBI or may be associated with cognitive impairment or other areas of dysfunction. Subjective symptoms that are residuals of a TBI, whether or not they are part of cognitive impairment, are to be evaluated under the subjective symptoms facet in the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." However, any residual with a distinct diagnosis that may be evaluated under another diagnostic code, such as migraine headache or Meniere's disease, should be evaluated separately rather than under the "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" table, even if that diagnosis is based on subjective symptoms. Emotional/behavioral dysfunction should be evaluated 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, emotional/behavioral symptoms should be evaluated under the criteria in the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." Physical (including neurological) dysfunction is to be evaluated 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. Diagnostic Code 8045 stipulates that the preceding list of types of physical dysfunction does not encompass all possible residuals of a TBI. Residuals not listed here that are reported on an examination are to be evaluated under the most appropriate diagnostic code. Each condition should be evaluated separately as long as the same signs and symptoms are not used to support more than one evaluation, and the evaluations for each separately rated condition should be combined under § 4.25. 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. Diagnostic Code 8045 also stipulates that 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., must be considered. Diagnostic Code 8045 also states that the table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified” contains 10 important facets of a 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. A 100-percent evaluation is to be assigned if "total" is the level of evaluation for one or more facets. If no facet is evaluated as "total," the overall percentage evaluation based on the level of the highest facet is to be assigned as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent. The regulation provides the following example: assign a 70 percent evaluation if 3 is the highest level of evaluation for any facet. There are five notes that accompany the current version of Diagnostic Code 8045. Four apply to the instant case. 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. On VA examination in October 2012, the Veteran described his in-service TBI, which occurred when he was struck in the head by a solid steel bar, requiring prolonged hospitalization and reconstructive facial surgery. His TBI was also the result of exposure to frequent blasts that knocked him down. On testing, the examiner found there was a complaint of mild memory loss (such as having difficulty following a conversation, recalling recent conversations, remembering names of new acquaintances, or finding words, or often misplacing items), attention, concentration, or executive functions, but without objective evidence on testing, corresponding to level “1” impairment. Judgement was mildly impaired, corresponding to level “1” impairment. Social interaction was occasionally inappropriate, corresponding to level “1” impairment. The Veteran was always oriented to person, time, place, and situation, corresponding to level “0” impairment. Motor activity was normal, corresponding to level “0” impairment. Visual spatial orientation was normal, corresponding to level “0” impairment. There were three or more subjective symptoms that mildly interfered with work, instrumental activities of daily living, family, or other close relationships, corresponding to level “1” impairment. Neurobehavioral effects included one or more effects that did not interfere with workplace interaction or social interaction, corresponding to level “0” impairment. Communication was manifested by the ability to communicate through spoken and written language, and comprehend spoken and written language, corresponding to level “0” impairment. Consciousness was normal. The Veteran had a scar related to his TBI which was not painful and/or unstable, and was less than 39 square centimeters (6 square inches). Residuals of the TBI were identified, and included a mental disorder, tinnitus, headaches, and bilateral hearing loss. On VA examination in August 2017, motor activity was normal, corresponding to level “0” impairment. Visual spatial orientation was normal, corresponding to level “0” impairment. There were no subjective symptoms, corresponding to level “0” impairment. Communication was manifested by the ability to communicate through spoken and written language, and comprehend spoken and written language, corresponding to level “0” impairment. Consciousness was normal. There were no other pertinent physical findings, complications, conditions, signs, or symptoms. The examiner found that the neurological effects of the TBI were stable. In a separate August 2017 VA examination report addressing the other facets of the TBI, the examiner diagnosed a mild neurocognitive disorder that was unrelated to the TBI or any service-connected condition. Rather, it was due to cognitive decline resulting from two transient ischemic attacks and Parkinson’s disease, which began four decades after the TBI. There were no cognitive or mental residuals of the TBI itself. With regard to the TBI alone, the examiner found memory, attention, concentration, and executive functions were normal, corresponding to level “0” impairment. Judgement was normal, corresponding to level “0” impairment. Social interaction was routinely appropriate, corresponding to level “0” impairment. The Veteran was always oriented to person, time, place, and situation, corresponding to level “0” impairment. Visual spatial orientation was normal, corresponding to level “0” impairment. Neurobehavioral effects included one or more effects that did not interfere with workplace interaction or social interaction, corresponding to level “0” impairment. The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for the Veteran’s TBI at any portion of the appeal period. On VA examinations, the highest level of impairment found was a level “1,” which corresponds to a 10 percent rating. Level “0” impairment was found in all other parameters, corresponding to a noncompensable evaluation. The Board has considered the need for special monthly compensation based on the TBI, but finds that discussion in this regard is not warranted, as the evidence does not raise issues such as loss of use of an extremity, 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), or housebound status due to the TBI. Residuals of the TBI The October 2012 VA examiner identified the following residuals of the TBI: tinnitus, bilateral hearing loss, headaches, and a mental disorder. Service connection has been in effect for each of these residuals for the duration of the appeal period. The matter of a higher rating for the separately-service connected mental disorder has been developed as a claim in its own right, and is addressed in the next section of the decision. As for tinnitus and headaches, the Veteran has been awarded the maximum schedular ratings of 10 percent and 50 percent, respectively, for the duration of the appeal period. As there is no legal basis upon which to award a higher schedular rating, higher ratings cannot be assigned. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). As for bilateral hearing loss, the section above addressing the Veteran’s rating reduction illustrates that VA examination reports of September 2010, April 2011, and September 2012 do not support a rating in excess of 50 percent. Additionally, on VA examination in October 2014, the following pure tone thresholds, in decibels, were obtained: HERTZ 1000 2000 3000 4000 RIGHT 60 75 90 85 LEFT 65 85 100 90 The pure tone threshold average was 77.50 decibels on the right, with a speech discrimination score of 80 percent, yielding Level V hearing according to Table VI. The provisions of 38 C.F.R. § 4.86 apply to the right ear, but as Table VIA yields Level VII hearing, the results from Table VI will be applied as this is more favorable to the Veteran. On the left, the pure tone threshold average was 85 decibels, with a speech discrimination score of 60 percent, yielding Level VIII hearing. The provisions of 38 C.F.R. § 4.86 also yield Level VIII hearing. Combining these, according to Table VII, reveals a 40 percent rating. On VA examination in August 2017, the following pure tone thresholds, in decibels, were obtained: HERTZ 1000 2000 3000 4000 RIGHT 70 75 85 80 LEFT 70 90 95 90 The pure tone threshold average was 77.50 decibels on the right, with a speech discrimination score of 76 percent, yielding Level V hearing according to Table VI. The provisions of 38 C.F.R. § 4.86 apply to the right ear, but as Table VIA yields Level VII hearing, the results from Table VI will be applied as this is more favorable to the Veteran. On the left, the pure tone threshold average was 86.25 decibels, with a speech discrimination score of 60 percent, yielding Level VIII hearing. The provisions of 38 C.F.R. § 4.86 also yield Level VIII hearing. Combining these, according to Table VII, reveals a 40 percent rating. The record also contains a May 2012 private audiogram and a March 2014 VA audiogram, but these records cannot be used to rate the disability because the testing conducted does not comply with 38 C.F.R. § 4.85. Regardless, even if both were supportive of the claim, the preponderance of the remaining audiometric data from September 2010, April 2011, September 2012, October 2014, and August 2017, is against the claim. In short, the preponderance of the evidence is against the assignment of a rating higher than 50 percent for bilateral hearing loss based on the audiometric data of record. The Board is bound by the applicable law and regulations to mechanically apply the rating schedule to the numeric designations from audiometric test results. 38 U.S.C. § 7104 (c); 38 C.F.R. § 20.101 (a). Finally, the preponderance of the evidence is also against the assignment of a separate rating for the Veteran’s TBI scar, as the scar does not involve visible or palpable tissue loss, gross distortion or asymmetry of features, or characteristics of disfigurement. The scar is also not of the requisite size for a compensable rating, is not painful or unstable, and is not shown to have any disabling effects. In sum, the preponderance of the evidence is against the assignment of a rating in excess of 10 percent for the TBI, in excess of 50 percent for headaches or hearing loss, or in excess of 10 percent for tinnitus. In reaching this decision the Board considered the doctrine of reasonable doubt, however, to the extent the preponderance of the evidence is against ratings higher than or separate from those already assigned, the doctrine is not for application. PTSD Once a veteran has been diagnosed with a service-connected psychiatric disability, VA reviews his medical history to determine how significantly the disorder has disrupted the veteran's social and occupational functioning. The level of disability is rated according to a General Rating Formula for Mental Disorders, codified at 38 C.F.R. § 4.130 (“General Rating Formula”), which provides for ratings of zero, 10, 30, 50, 70, or 100 percent. VA compensates Veterans beginning at 10 percent disability, and compensation increases at each level. Pursuant to 38 C.F.R. § 4.130, a 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent 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. When determining the appropriate disability evaluation to assign, the Board's primary consideration is the veteran's symptoms, but it must also make findings as to how those symptoms impact the veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because the use of the term “such as” in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran's impairment must be “due to” those symptoms, a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. In determining the appropriateness of the evaluations assigned to the Veteran’s disability, the GAF scores assigned by medical providers will be discussed. A GAF score of 31 to 40 indicates some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). A GAF score of 41-50 contemplates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). See DSM-IV at 44-47. A GAF score of 51-60 contemplates moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). Id. A GAF score of 61-70 contemplates some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. Id. In November 2010, the RO granted service connection for PTSD with a mood disorder, and assigned a 50 percent rating. In January 2011, the Veteran filed a claim for a TDIU, which the RO construed as a claim for higher ratings for his service-connected disabilities. In the April 2012 rating decision on appeal, the 50 percent rating was continued. In January 2016, the Veteran was assigned a temporary total rating from August 27, 2015 to November 1, 2015 when the 50 percent rating was resumed. Evidence dated from this period will not be considered in adjudicating the claim since the Veteran was already receiving the maximum evaluation possible at that time. Considering the evidence under the laws and regulations as set forth above, and resolving all reasonable doubt in his favor, the Board finds that a 100 percent rating is warranted for the Veteran’s PTSD throughout the appeal period. Initially, throughout the entire appeal period, the Veteran’s GAF scores have consistently ranged between 40 and 50, which indicates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). For example, the record reflects the following scores: 45 (July 2010), 45 (November 2010), 45 (September 2010), 45 (February 2011), 45 (May 2011), 45 (August 2011), 45 (January 2012), 45 (May 2012), 45 (August 2012), 42 (October 2012), 42 (January 2013), 45 (April 2013), 45 (July 2013), 43 (January 2014), 43 (April 2014), 41-50 (December 2014), 41-50 (March 2015), and 41-50 (June 2015). On the matter of total occupational impairment, in an October 2011 letter, his treating VA psychiatrist opined that the Veteran had a poor prognosis, and was unable to work due to his problems with PTSD, TBI, sleep apnea, and the side effects of his medications. In a May 2012 letter, his psychiatrist submitted a letter stating that while he worked as a truck driver in the past and was effective because it did not require social interaction, he had several instances of aggression behind the wheel. He had become unable to work in his job due to his required medications, and the psychiatrist opined that he was overall incapable of working due to his PTSD. On VA examination in February 2016, the examiner opined there was total occupational impairment due to PTSD. The examiner stated he was emotionally unfit to work with the public, take instruction, or work in an enclosed space. As for total social impairment, On VA examination in September 2010, the Veteran could not name any close friends. In the October 2011 letter, the Veteran’s treating VA psychiatrist stated he was seclusive, stayed home most of the time, and had major problems from the PTSD that have greatly affected his personal life. In the May 2012 letter, his psychiatrist stated his PTSD has caused him to struggle in relationships, with both marriages ending in divorce. His daughter no longer spoke to him due to his anger and aggressive behaviors, and he had been violent toward his former spouses. In July 2013, his VA psychiatrist submitted a letter stating his PTSD was severe and caused many social problems. He had altercations with other people in Walmart, and pulled a man out of his car to fight. On VA examination in February 2016, the examiner opined there was total social impairment due to PTSD. The record also demonstrates many of the symptoms contemplated by a 100 percent rating. Persistent hallucinations and delusions were identified as a symptom of the Veteran’s PTSD on VA examination in February 2016. Grossly inappropriate behavior was documented on VA examination in September 2010; the examiner described a “long history of trouble with his temper.” The examiner stated there has been inappropriate behavior, consisting of verbal explosions and fights. A March 2011 VA examiner documented that the Veteran had been fired once for “beating the hell out of somebody.” He reported homicidal ideation with no intended victim. He stated sometimes he chased people down on the road and exited his car to confront them. In a February 2016 VA treatment record, it was documented that he had gotten in a road rage incident while traveling to the VAMC for his appointment. He and the other driver pulled over, and the Veteran struck the other person with his cane during the altercation. A persistent danger of the Veteran hurting himself is shown by suicidal ideation documented on a number of occasions. On VA examinations in September 2010 and March 2011, a past suicide attempt with asphyxiation from an exhaust pipe into a car was documented. This attempt required medical revival and resulted in hospitalization. He reported to the March 2011 examiner that he had experienced suicidal thoughts 4 months prior. His plan was death by carbon monoxide, although he reported he had no intention on acting on those thoughts. In May 2012, his psychiatrist documented a long history of suicidal ideation. Disorientation was documented in May 2013 and February 2016 VA treatment records. To the extent there is inconsistent evidence, doubt is resolved in favor of the Veteran. For all the above reasons, the Board finds the Veteran’s disability picture has most closely approximated that contemplated by a 100 percent rating throughout the appeal period. SMC VA has a "well-established" duty to maximize a claimant's benefits. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011). This duty to maximize benefits requires VA to assess all a claimant's disabilities to determine whether any combination of disabilities establishes entitlement to SMC under 38 U.S.C. § 1114. See Bradley v. Peake, 22 Vet. App. 280 (2008). The Veteran's PTSD is now 100 percent disabling, and his other compensable service-connected disabilities consist of headaches (50 percent disabling), hearing loss (50 percent disabling), tinnitus (10 percent disabling), and a TBI (10 percent disabling). These ratings are separate and distinct from the 100 percent rating for PTSD, involve different anatomical segments or bodily systems, and, under the combined ratings table, result in a combined rating of at least 60 percent. 38 C.F.R. §§ 3.350(i)(1), 4.25. While the Veteran has been awarded SMC(s), it has not been for the entirety of the appeal period; his award was limited to the period of a temporary total rating from August 27, 2015 to November 1, 2015. As such, SMC at the housebound rate for the remainder of the appeal period is warranted. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). TDIU As the Veteran now has a 100 percent schedular rating and SMC for the entire appeal period, the appeal for a TDIU is dismissed as moot. Bradley v. Peake, 22 Vet. App. 280 (2008). M. TENNER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Smith, Counsel