Citation Nr: 21001027 Decision Date: 01/06/21 Archive Date: 01/06/21 DOCKET NO. 09-34 839 DATE: January 6, 2021 ORDER Prior to August 18, 2016, an initial disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is denied. Since August 18, 2016, a disability rating in excess of 70 percent for PTSD is denied. Prior to August 18, 2016, a total disability rating based on individual unemployability (TDIU) is denied. FINDINGS OF FACT 1. Prior to August 18, 2016, the Veteran’s PTSD was not manifested by occupational and social impairment, with deficiencies in most areas, such as school, family relations, judgment, or thinking due to such symptoms as: 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); inability to establish and maintain effective relationships. 2. Since August 18, 2016, the Veteran’s PTSD has not been manifested by total occupational and social impairment, due to such symptoms as: a gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. 3. Prior to August 18, 2016, the Veteran’s service-connected PTSD did not render him unable to secure or follow substantially gainful employment. CONCLUSIONS OF LAW 1. Prior to August 18, 2016, the criteria for a disability rating in excess of 50 percent for PTSD were not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411. 2. Since August 18, 2016, the criteria for a disability rating of 70 percent have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. § 4.130, DC 9411. 3. Prior to August 18, 2016, the criteria for entitlement to a TDIU were not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1966 to June 1969 in the United States Army, with service in the Republic of Vietnam. These matters come before the Board of Veterans' Appeals (Board) on appeal from a March 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In April 2011, the Veteran testified before the undersigned during a during a hearing in Washington, DC. A transcript of the hearing is included in the electronic claims file. 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. Once a Veteran has been diagnosed with service-connected psychiatric disability, VA reviews his/her medical history to determine how significantly the disorder has disrupted 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. Pursuant to 38 C.F.R. § 4.130, DC 9411, a 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- 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 for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. 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). The ratings in the General Rating Formula are 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 Global Assessment of Functioning (GAF) scores assigned by medical providers will be discussed. While the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (5th Ed.) (DSM-5) does not incorporate the use of GAF scores, the Secretary of VA has specifically indicated that DSM-5 is to be applied to claims certified to the Board on or after August 4, 2014. 79 Fed. Reg. 45094 (Aug. 4, 2014). As the claim here was certified prior to that date, GAF scores, which are part of the DSM-IV, are applicable. 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). 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). A GAF score of 61-70 contemplates 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 that the individual is generally functioning well has some meaningful interpersonal relationships. In the March 2008 rating decision on appeal, service connection for PTSD was granted, and a 30 percent rating was assigned, effective November 22, 2006. In an August 2009 rating decision, a higher rating of 50 percent was assigned, effective November 22, 2006. In April 2012, the Board denied the claim for an initial rating in excess of 50 percent. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In an April 2013 Memorandum Decision, the Court vacated the April 2012 Board decision and remanded the matter to the Board for development. The Board’s decision was vacated because the Board had failed to consider an October 2006 private medical report of Dr. M., which supported the claim. Additionally, in the decision, the Board assigned little probative weight to several GAF scores, finding they were inconsistent with the accompanying clinical findings. The Court found the Board’s determination violated Colvin v. Derwinski, 1 Vet. App. 171 (1991) and directed the Board to obtain medical findings reconciling the GAF scores from February 2008, July 2008, and May 2009 with the associated clinical findings. In October 2013 and May 2014, the Board remanded the claim for further development. In January 2015, the Board denied the claim. The Veteran again appealed the Board’s decision to the Court. In November 2016, the RO granted a higher rating of 70 percent for the Veteran’s PTSD, effective August 18, 2016. In a November 2016 Memorandum Decision, the Court vacated the Board’s January 2015 decision due to its failure to obtain the Veteran’s vocational rehabilitation records. The Court additionally found that the Board failed to ensure substantial compliance with the previous April 2013 Memorandum Decision regarding reconciliation of the February 2008, July 2008, and May 2009 GAF scores with the associated clinical findings. In March 2020, the Board remanded the matters of a rating in excess of 50 percent prior to August 18, 2016, and a rating in excess of 70 percent since that date, for further development. There has been substantial compliance with the Board's remand directives and appellate adjudication may proceed. Stegall v. West, 11 Vet. App. 268 (1998); see also Dyment v. West, 13 Vet. App. 141, 147 (1999) (requiring substantial compliance with Board remand directives). Specifically, as discussed below, the Veteran’s vocational rehabilitation records have been obtained and considered, the October 2006 report of Dr. M. has been considered, and clarification of the 2008 and 2009 GAF scores has been obtained. As such, the Board finds that the concerns of the Court have been addressed. 1. Prior to August 18, 2016, an initial disability rating in excess of 50 percent for PTSD is denied. In an October 2006 private medical report of Dr. M., the Veteran was noted to experience chronic tension, with disturbing and intrusive memories and nightmares. He had been married to his wife for 40 years and they were raising a grandson together. He had worked as an independent business owner in the floor covering business since 1979. Dr. M. opined that his psychiatric symptoms substantially interfered with and disturbed his previous level of adjustment. In a January 2007 private medical report, the Veteran’s treating physician, Dr. E., stated he had completed an annual physical examination of the Veteran. The Veteran reported increased difficulty in performing his job due to back and knee pain. Dr. E. opined that it would be very difficult for the Veteran to continue making a living in his profession due to his low back and knee disabilities. In a July 2007 determination, the Social Security Agency (SSA) determined that the Veteran was disabled due to degenerative disc disease, effective February 1, 2007. On VA psychiatric examination in January 2008, the Veteran reported being haunted by the sights and sounds of his experiences in Vietnam. He reported having significant trouble with nightmares and sleeping generally. He had been married to his wife for 41 years, and reported that they had their ups and downs but got along fairly well. He sold carpet and tile for a living. He occasionally visited a friend and a nephew, and attended church. A mental status examination revealed normal speech, a depressed mood, and appropriate affect. Thought processes and memory were normal. The examiner found no hallucinations or delusions. Judgment was adequate. There was no suicidal or homicidal ideation. He was oriented and casually groomed. The examiner characterized the psychiatric symptoms as “mild” and opined that his PTSD did not preclude employment. The examiner assigned a GAF score of 57. In a VA treatment record of February 2008, the Veteran reported having intrusive memories while trying to fall asleep, startling easily, and feeling anxious. His speech was normal and thought processes were linear and goal-oriented. There was no suicidal or homicidal ideation, delusions, or hallucinations. The examiner characterized the PTSD as “mild” and assigned a GAF score of 45. In a VA treatment record of July 2008, the Veteran’s speech was normal and thought processes were linear and goal-oriented. There was no suicidal or homicidal ideation, delusions, hallucinations, or obsessions. The Veteran reported having trouble sleeping, and experiencing low energy and difficulty concentrating. He reported spending time with his grandson and attending church. He was assigned a GAF score of 49. On VA psychiatric examination in May 2009, the Veteran reported ongoing dreams and visions related to his Vietnam experiences, with significant trouble sleeping. He was not getting along with his wife as well as before. He reported that he stopped working in the carpet business when he was no longer able to physically perform the work. On examination, thought processes were normal and the Veteran was oriented. Memory was intact. As for the hallucinations/visions from Vietnam, the examiner opined that these constituted flashback-like experiences. Insight and judgment were adequate. There was no suicidal or homicidal ideation. The examiner assigned a GAF score of 45. At the April 2011 hearing, the Veteran testified that he hardly ever slept, and got just over two hours of sleep on a good night. He reported having no social interaction with anyone besides his grandson. He testified that he struggled with eating compulsively. He felt that his PTSD symptoms rendered him unemployable. On VA psychiatric examination in August 2012, the Veteran had been married for 46 years but did not think his wife loved him anymore. He was no longer working. His symptoms of PTSD included a depressed mood, chronic sleep impairment, disturbances in motivation and mood, and difficulty establishing and maintaining effective work and social relationships. The examiner opined that his symptoms were moderate, and did not preclude employment. The examiner characterized the severity of the disability as causing occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication, the symptoms contemplated by a 10 percent rating. He was assigned a GAF score of 50. In an December 2012 addendum opinion, August 2012 examiner clarified that the claims file had been reviewed in providing the requested opinion. On VA psychiatric examination in November 2013, the Veteran reported he had been married for 47 years but had a “conflictual” relationship with his wife. He was not working. His symptoms included anxiety and chronic sleep impairment. The examiner characterized the severity of the disability as causing occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication, the symptoms contemplated by a 10 percent rating. He was assigned a GAF score of 51. The examiner further found that despite the low GAF scores noted in February 2008, July 2008, and May 2009, his PTSD symptoms had been stable, and it was less likely than not that psychiatric symptoms precluded physical or sedentary employment. In November 2013, the Veteran’s request for vocational rehabilitation services was denied as it was determined that he did not have a service-connected disability contributing to his difficulty in obtaining and maintaining a job. In an June 2014 addendum opinion, the November 2013 examiner opined that from 2006 to 2013, the Veteran’s psychiatric symptoms ranged from mild to moderate. He had maintained a long-term marriage, assisted in the care of his grandson, and displayed stability. The examiner stated that the low GAF scores in 2008 to 2009 reflected fluctuations of mild to moderate psychiatric symptoms. She further opined that his symptoms had not precluded him from working in a substantially gainful occupation consistent with his work and educational background. Rather, his knee and back problems were primary contributors to his employment difficulties. In a June 2014 private medical report of Dr. M., the Veteran’s ability to understand, remember, and follow simple instructions was mildly impaired, and moderately impaired with complex instructions. His abilities to interact appropriately with others was moderately impaired, and his abilities to respond appropriately to work changes or work routines was mildly impaired. In a February 2015 private medical report of Dr. R., the Veteran reported ongoing insomnia and nightmares. He had problems with chronic low back pain and knee pain. Dr. R. found that when working, the Veteran required assistance due to his physical problems. Also, he could only work while the homeowner was not present because of difficulties with relating and conversing with others. In an April 2015 private medical report of Dr. R., the Veteran reported occasional suicidal ideation. He self-medicated with alcohol. In an August 2015 private medical report of Dr. R., the veteran reported avoidant behaviors, chronic tension, social withdrawal, and ongoing and chronic distress. Dr. R. opined that his symptoms caused clinically significant impairment in occupational adjustment and functioning, as well as social impairment. In an September 2015 private medical report of Dr. M., the Veteran’s ability to understand, remember, and follow simple instructions was mildly impaired, and moderately impaired with complex instructions. His abilities to interact appropriately with others was moderately impaired, and his abilities to respond appropriately to work changes or work routines was mildly impaired. On VA psychiatric examination in April 2020, the examiner, reflecting on the low GAF scores from 2008 and 2009, stated that GAF scores represented an antiquated way of measuring functional impairment. In September 2020, the April 2020 examiner provided addendum opinions. As for the GAF score of 45 in February 2008, the PTSD was characterized as “mild” and the social and occupational activities documented in the report indicated adequate functioning. His symptoms did not appear to be “serious” as reflected by the GAF score. As for the GAF score of 49 in July 2008, the examiner again noted that Veteran’s PTSD symptoms were only “mild.” As for the May 2009 GAF score of 45, the Veteran had no impairment in several areas of functioning. His symptoms ranged from mild to moderate, but there was no evidence to support the assigned score of 45. The examiner concluded that the more appropriate GAF score on each occasion would have been between 61 and 70, indicating mild symptoms. GAF determinations were known to have poor interrater reliability. The assigned scores were not consistent with contemporary documentation which showed less severe symptomatology. Considering the pertinent evidence in light of the governing legal authority, the Board finds that the preponderance of the evidence is against a rating higher than the 50 percent rating currently assigned for the portion of the appeal dated prior to August 18, 2016. In assessing the severity of the Veteran’s PTSD, the January 2008 VA examiner and February 2008 VA provider both characterized the disability as “mild.” VA examiners in both August 2012 and November 2013 characterized the severity of the disability as causing occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication, the symptoms contemplated by a 10 percent rating. To the extent that Dr. M. found in October 2006 that the Veteran’s psychiatric symptoms “substantially interfered” with functioning, this finding is isolated and the preponderance of the evidence indicates otherwise. Further, his GAF scores of 57 (January 2008) and 51 (November 2013) are reflective of only moderate symptomatology. Additionally, deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, are not shown by the record for this portion of the appeal period. Deficiencies in school were not shown. There are few deficiencies in family because although some marital discord was documented in the treatment notes, the record does not indicate any significant problems with the Veteran’s marriage at the time and the VA examiners made no such finding. Rather, he was shown to have maintained a long-term marriage and was helping to raise his grandson. There were no deficiencies in judgment or thinking, as both were intact when assessed on multiple examinations throughout the pertinent appeal period. Further, few of the symptoms typically associated with a 70 percent rating are shown by the record for this period of the appeal. The record contains no indication that it resulted in obsessional rituals, issues with speech or content of speech. Additionally, the disability did not result in near-continuous panic or depression affecting the ability to function independently, any impaired impulse control, spatial disorientation or neglect of personal appearance and hygiene. Rather, the Veteran’s PTSD was shown to be manifested by a depressed mood, anxiety, irritability, avoidant behaviors, chronic sleep impairment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. All of these symptoms correspond to those contemplated by the currently-assigned 50 percent rating. In accordance with the concerns of the Court, the Board has considered the low GAF scores of 45 (February 2008), 49 (July 2008), and 45 (May 2009). However, the Board assigns little probative weight to these scores given the September 2020 VA examiner’s explanation as to why they were not reflective of his clinical symptomatology, and the examiner’s finding that scores ranging from 61 to 70 would have more accurately reflected the severity of his psychiatric symptomatology at the time. The Board has also carefully considered the April 2015 report of Dr. R. documenting occasional suicidal ideation. See Bankhead v. Shulkin, 29 Vet. App. 10 (2017) (holding that the language of the regulation indicates that the presence of suicidal ideation alone may cause occupational and social impairment with deficiencies in most areas, as contemplated by a 70 percent rating) (emphasis added). Here, the Veteran was assessed for suicidal ideation throughout the appeal period, and numerous other examiners found no indication in this regard, including in January 2008, February 2008, July 2008, May 2009, August 2012, or November 2013. When viewing this isolated report in the context of the entire disability picture, spanning over the course of 12 years, combined with the absence of other symptomology contemplated by a 70 percent rating and the specific severity findings of the VA examiners, the Board finds the preponderance of the evidence is against a rating in excess of 50 percent. In sum, the overall symptomatology attributable to the Veteran’s PTSD prior to August 18, 2016 most closely approximated the level of severity contemplated by a 50 percent rating. In reaching this decision, the Board considered the doctrine of reasonable doubt. 2. Since August 18, 2016, a disability rating in excess of 70 percent for PTSD is denied. On VA examination in September 2016, the Veteran reported having a good relationship with his living sisters, but a poor one with his brother. He had been married to his wife since 1966, but reported that the relationship was strained and they were separated. Their son died, and they were raising his child. He had a few friends he saw occasionally. He was no longer working. His socialization activities were limited. On examination, his symptoms included a depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, mild memory loss, a flattened affect, difficulty understanding complex commands, impaired judgment, impaired abstract thinking, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, suicidal ideation, neglect of appearance and hygiene, and an intermittent inability to perform activities of daily living. The examiner found the Veteran was retired and unable to work due to physical and mental disabilities. His psychiatric symptoms would seriously interfere with his ability to function in an occupational environment. The examiner opined that the disability caused occupational and social impairment, with deficiencies in most areas, the level of severity contemplated by a 70 percent rating. On VA examination in March 2018, the Veteran had been married for 51 years, but was having difficulty in the marriage. He participated in fellowship activities with his church. He was no longer working. On examination, his symptoms included chronic sleep impairment and disturbances of motivation and mood. The examiner opined that the PTSD was mild and did not preclude employment. He characterized the severity of the disability as causing occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication, the symptoms contemplated by a 10 percent rating. On VA examination in April 2020, the Veteran reported that he and his wife had been separated for two years. He felt his wife was mean, evil, and hated him. He was close with his brother-in-law and loved his grandson. He reported keeping in touch with a few friends occasionally. On examination, his symptoms included a depressed mood, anxiety, chronic sleep impairment, mild memory loss, and neglect of personal appearance and hygiene. The examiner stated that it appeared the Veteran was intoxicated during the examination based on the odor of alcohol, unsteady gait, and unlikely answers. However, based on the Veteran’s medical records and the totality of the evidence, the examiner estimated that the Veteran’s PTSD caused occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication, the symptoms contemplated by a 10 percent rating. Considering the pertinent evidence in light of the governing legal authority, the Board finds that the preponderance of the evidence is against the assignment of a 100 percent rating for the Veteran’s PTSD since August 18, 2016. Significantly, in determining the overall severity of the Veteran’s psychiatric disability, the September 2016 VA examiner selected the severity statement corresponding to a 70 percent rating, and March 2018 and April 2020 VA examiners selected the severity statement corresponding to a 10 percent rating, at the exclusion of selecting severity statements corresponding to higher ratings. Their selection of the severity statement corresponding with their findings upon examination. Specifically, none of the examiners found that the disability is manifested by total occupational and social impairment. While total occupational impairment is implicated by the RO’s award of a TDIU for this time period, a 100 percent rating under Diagnostic Code 9411 requires the presence of total occupational and total social impairment. Total social impairment is not shown by the record. While separated from his wife, the Veteran reported having positive relationships with his sisters, grandson, and brother-in-law. He saw friends occasionally, and participated in fellowship activities with his church. Further, nearly none of the symptoms typically associated with a 100 percent rating are shown by the record. The record does not indicate that during the pertinent time frame the Veteran’s PTSD was manifested by a gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. While the September 2016 VA examiner found an intermittent inability to perform activities of daily living, this symptom, in isolation, does not support the assignment of a 100 percent disability rating. In sum, the overall symptomatology attributable to the Veteran’s service-connected PTSD has most closely approximated the level of severity contemplated by a 70 percent rating since August 18, 2016, and the preponderance of the evidence is against a higher rating. In reaching this decision the Board considered the doctrine of reasonable doubt. TDIU 3. Prior to August 18, 2016, TDIU is denied. In a footnote attached to the Court’s April 2013 Memorandum Decision, the Court found that a claim for a TDIU had been raised by the and was properly in remand status. See Rice v. Shinseki, 22 Vet. App. 447 (2009) In January 2015, the Board denied the claim for a TDIU. The Veteran appealed the Board’s decision to the Court. In November 2016, the RO granted a TDIU, effective August 18, 2016. The matter of a TDIU prior to August 18, 2016, however, remained on appeal. See Harper v. Wilkie, 30 Vet. App. 356 (2018) (holding that where a Rice TDIU claim has been raised, and the grant of TDIU does not encompass the entire disability rating period on appeal, it serves as a partial grant and the remaining period for which TDIU was not granted or considered, remains in appellate status.) In a November 2016 Memorandum Decision, the Court vacated the Board’s January decision due to its failure to obtain the Veteran’s vocational rehabilitation records. As discussed, these records have been obtained and considered. In March 2020, the Board remanded the claim for a higher rating for PTSD prior to August 18, 2016 for further development. The claim for a TDIU was remanded as inextricably intertwined. VA will grant disability compensation based upon individual unemployability (TDIU) when the evidence shows that the Veteran is precluded, by reason of his service-connected disabilities, from obtaining or maintaining “substantially gainful employment” consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16; VAOPGCPREC 75-91; 57 Fed. Reg. 2317 (1992). The Court has defined “substantially gainful employment” as encompassing both an economic and a noneconomic component. The economic component means “an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person,” while the noneconomic component requires consideration of a veteran’s ability to secure or follow that type of employment. Ray v. Wilkie, 31 Vet. App. 58 (2019). The Court set forth a number of factors to consider in making the latter determination, including the following: the veteran’s history, education, skill, and training; his or her physical abilities, including any audio or visual limitations, as well as limitations in lifting, bending, sitting, standing, walking, climbing, grasping, typing, reaching; and his or her mental ability, including limitations in memory, concentration, ability to adapt to change, handle workplace stress, get along with coworkers, and demonstrate reliability and productivity. Id. A threshold requirement for eligibility for a TDIU under 38 C.F.R. § 4.16(a) is that if there is only one such disability, it must be rated at 60 percent or more; if there are two or more disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. Here, the minimum schedular criteria have not been met. Prior to August 18, 2016 the Veteran was service-connected only for PTSD (50 percent disabling). His combined disability rating was 50 percent prior to August 18, 2016. See November 2016 rating decision codesheet (most recent codesheet). Nonetheless, it is VA's policy that all Veterans who are unable to secure a substantially gainful occupation by reason of service-connected disabilities “shall be rated totally disabled.” See 38 C.F.R. § 4.16(b). The Court has held that the Board has no power to award a TDIU under 38 C.F.R. § 4.16(b) in the first instance without ensuring that the claim is referred to VA's Director, Compensation Service (Director) for consideration of an “extraschedular rating”. Bowling v. Principi, 15 Vet. App. 1, 10 (2001). While there has been no referral to VA's Director, Compensation Service, the Board will consider whether a remand for such referral is warranted. The Board must determine whether the Veteran's service-connected disability precluded him from engaging in substantially gainful employment prior to August 18, 2016 (work that is more than marginal, which permits the individual to earn a “living wage.”) Moore v. Derwinski, 1 Vet. App. 356 (1991). The record shows that the Veteran completed high school and three years of college. Following discharge, he was self-employed as a floor installer. In Applications for Increased Compensation Based on Unemployability (VA Form 21-8940), he reported that he last worked full-time in 2006. He has not had other education or training since becoming too disabled to work. The remainder of the pertinent evidence has been summarized in the section above addressing the Veteran’s entitlement to a rating in excess of 50 percent for PTSD prior to August 18, 2016, and additional recitation is not necessary. In considering the evidence under the laws and regulations as set forth above, the Board finds that his service-connected PTSD did not prevent him from securing or following substantially gainful employment prior to August 18, 2016. For the portion of the appeal prior to August 18, 2016, the economic component of Ray was met because the Veteran was not employed. To the extent it is mentioned in treatment records that the Veteran performed any work during this time period, the record indicates that such work was occasional and marginal. As for the noneconomic component, the Veteran is vocationally-limited to the extent that he has not obtained a college degree. However, he did not have any service-connected disability causing an audiological limitation. He did not have any service-connected disability causing a visual limitation. He did not have any service-connected disability causing a physical limitation, including any limitation in lifting, bending, sitting, standing, walking, climbing, grasping, typing, or reaching. As for his mental ability, in January 2007, Dr. E. found that the Veteran would have difficulty continuing in his profession due to non-service connected physical disabilities. The SSA reached a similar determination in July 2007. The January 2008 VA psychiatric examiner opined that PTSD did not preclude employment. The February 2008 VA provider characterized the disability as “mild.” The August 2012 VA examiner found that PTSD did not preclude employment. The November 2013 VA examiner opined that the Veteran’s PTSD was not likely to preclude physical or non-physical employment. In November 2013, the Veteran’s request for vocational rehabilitation services was denied as he did not have a service-connected disability contributing to his difficulty in obtaining and maintaining a job. In the June 2014 addendum opinion, the November 2013 examiner found PTSD had not precluded him from working in a substantially gainful occupation consistent with his work and educational background. In 2014 and 2015 private medical records from Dr. M., psychiatric symptoms caused only mild to moderate impairment. The September 2020 VA examiner, reflecting on the low GAF scores of 2008 to 2009, opined that the disability would have more accurately been reflected by a GAF score of 61 to 70. In short, while the Veteran underwent psychiatric evaluations and treatment prior to August 18, 2016, no provider or examiner opined that that he was unable to secure or follow substantially gainful employment due to his PTSD. To the extent that the October 2006 report of Dr. M. indicates that the Veteran’s psychiatric symptoms substantially interfered with functioning, this finding is isolated among a large volume of contrary evidence. When assessing the Veteran’s disability picture as a whole, which included no visual limitations, no audiological limitations, no physical limitations, and minimal mental limitations, the preponderance of the evidence is against a referral for an extraschedular TDIU for the portion of the appeal period prior to August 18, 2016. Rather, the rating assigned for his PTSD during this time frame is recognition of the occupational impairment it caused. The benefit-of-the-doubt doctrine is therefore not for application, and the claim must be denied. As a final matter, VA's duty to maximize a claimant's benefits requires consideration of whether his disabilities establish entitlement to special monthly compensation (SMC) under 38 U.S.C. § 1114 since August 18, 2016. SMC(s) is available to veterans who have a single disability rated as total, and a separate disability(ies) that amount to 60 percent. 38 U.S.C. § 1114(s). Here however, while the Veteran has been service-connected for hearing loss since August 18, 2016 in addition to his PTSD, his hearing loss has been assigned a noncompensable evaluation. As such, he does not have separate disabilities that could combine to 60 percent, and the concerns addressed in Bradley are not present. The Board need not further address whether SMC(s) is warranted since August 18, 2016. M. Tenner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Smith, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.