Citation Nr: 21001801 Decision Date: 01/11/21 Archive Date: 01/11/21 DOCKET NO. 16-61 938 DATE: January 11, 2021 ORDER Entitlement to service connection for tinnitus has been dismissed. Entitlement to a rating greater than 60 percent for a heart disability has been dismissed. Entitlement to a rating greater than 60 percent for urinary leakage/frequency, residuals of prostate cancer, status-post prostatectomy has been dismissed. Entitlement to a compensable rating for erectile dysfunction associated with prostate cancer, status-post prostatectomy has been dismissed. Entitlement to a compensable rating for surgical scar, residual of prostatectomy associated with prostate cancer, status-post prostatectomy has been dismissed. Entitlement to service connection for a lumbar spine disability, to include lumbar degenerative disc disease (DDD) and degenerative joint disease (DJD) (claimed as chronic low back pain) is granted. Entitlement to an initial rating greater than 50 percent for posttraumatic stress disorder (PTSD) with mood disorder due to prostate cancer and non-Hodgkin’s lymphoma is granted. Entitlement to a total disability rating for individual unemployability (TDIU) due to service-connected urinary incontinence or due to PTSD is dismissed. Entitlement to special monthly compensation (SMC) is granted. REMANDED Entitlement to service connection for bilateral hearing loss disability is remanded. Entitlement to a rating greater than 10 percent for non-Hodgkin’s lymphoma, postoperative residuals, stomach injury is remanded. FINDINGS OF FACT 1. At his March 2020 hearing, prior to the promulgation of a decision on this appeal, the Board of Veterans’ Appeals (the Board) received notification from the Veteran that a withdrawal of his appeal for entitlement to service connection for tinnitus, and increased ratings for a heart disability, urinary leakage, erectile dysfunction, and scar associated with prostatectomy was requested. 2. Resolving reasonable doubt in the Veteran’s favor, his chronic back pain, later diagnosed as DDD and DJD began during active service. 3. Resolving reasonable doubt in the Veteran’s favor, the severity, frequency, and duration of the Veteran’s psychiatric symptoms more closely approximate total occupational and social impairment for the entire period on appeal. 4. The Veteran’s claim for TDIU is moot as the Veteran’s PTSD has been rated as 100 percent disabling. 5. The Veteran is entitled to SMC on the account of a rating of 100 percent for PTSD and independently ratable disorders of 60 percent. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the appeal for entitlement to service connection for tinnitus, and for increased ratings for a heart disability, urinary leakage, erectile dysfunction, and scar associated with prostatectomy by the appellant have been met. 38 U.S.C.§7105(b)(2), (d)(5) (2012); 38 C.F.R. §§ 19.55, 20.204 (2019). 2. The criteria for entitlement to service connection for a lumbar spine disability, to include lumbar DDD and DJD are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for entitlement to a 100 percent rating for PTSD with mood disorder due to prostate cancer and non-Hodgkin’s lymphoma are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 4. The criteria for entitlement to a TDIU is moot. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16 (2019). 5. For the entire period on appeal, the criteria for SMC is met at the housebound rate. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Navy from December 1964 to February 1966, to include service in the Republic of Vietnam. See Certificate of Release of Discharge From Active Duty DD Form 214. The Veteran was afforded a Travel Board hearing before the undersigned in March 2020, and a transcript has been associated with the record. See March 2020 Hearing Transcript. VA has a “well-established” duty to maximize a claimant’s benefits. See Buie v. Shinseki, 24 Vet. App. 242 (2011); see also Bradley v. Peake, 22 Vet. App. 280 (2008) (finding that SMC “benefits are to be accorded when a Veteran becomes eligible without need for a separate claim.)” Accordingly, the Board is considering a claim of entitlement to SMC. The appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.900(c) (2019). 38 U.S.C. § 7107(a)(2) (West 2014). Withdrawal 1. Entitlement to service connection for tinnitus 2. Entitlement to a rating greater than 60 percent for a heart disability 3. Entitlement to a rating greater than 60 percent for urinary leakage/frequency, residuals of prostate cancer, status-post prostatectomy 4. Entitlement to a compensable rating for erectile dysfunction associated with prostate cancer, stats-post prostatectomy 5. Entitlement to a compensable rating for surgical scar, residual of prostatectomy associated with prostate cancer, status-post prostatectomy The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204. Withdrawal may be made by the appellant or by his authorized representative. Id. At his March 2020 hearing, the appellant indicated that he wished to withdraw his appeal for service connection for tinnitus, and for increased ratings for a heart disability, urinary leakage, erectile dysfunction, and scar associated with prostatectomy. See March 2020 Hearing Transcript. He testified that he understood the consequences. 38 C.F.R. § 20.204(b)(3) (2019). Given such, the Board finds that the Veteran’s withdrawal is explicit, unambiguous, and done with a full understanding of the consequences of such action. See DeLisio v. Shinseki, 25 Vet. App. 45, 57 (2011). Thus, there remains no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the appeal concerning service connection for tinnitus, and increased ratings for a heart disability, urinary leakage, erectile dysfunction, and scar associated with prostatectomy, and it is dismissed. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection may be granted for certain chronic diseases listed at 38 C.F.R. § 3.309(a), to include arthritis, if manifested to a compensable degree within one year from the date of separation from service. See 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a), 3.309(a). The Board notes that “arthritis” is defined as inflammation of a joint and as such includes DJD. DORLAND’S ILLUSTRATED MEDICAL DICTIONARY 152 (31st ed. 2007). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 6. Entitlement to service connection for a lumbar spine disability The Veteran contends that he has chronic low back pain that is due to service. He has described falling from a transport vehicle in Vietnam, and receiving treatment for his back in Japan during service. See March 2020 Hearing Transcript; see April 2017 Dr. C. Nord/Clinical and Counseling Psychology. Here, there have been references in the record to the Veteran not being sound at entrance to service, for instance in the February 1966 Medical Board determination. See February 1966 STR-Medical. A veteran is presumed to have been sound upon entry into the military, except as to conditions noted at the time of the acceptance, examination, or enrollment, or where clear and unmistakable evidence demonstrates that the condition existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111 (2012); Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). Critical to determining whether a defect, infirmity, or disorder has been “noted” is whether the condition is “recorded” in an examination report. 38 C.F.R. § 3.304(b). Here, the enlistment examination did not note or record a lumbar spine disability. See November 1964 STR-Medical. In February 2013, the Veteran reported that he did not have back problems until he fell from the vehicle he was riding on in Vietnam, and was sent to the hospital in Japan for his back. See February 2013 Statement in Support of Claim. He indicates that in the hospital he was told that he “could have hurt [his] back in school” and that he “went along with what they told” him but he “never had back problems … until that incident [in Vietnam].” Id. June 2013 VA examiner provided a negative nexus reasoning the Veteran’s disability preexisted service and was not aggravated by service, based in large part on the Medical Board report which indicated “it is not felt that the service has aggravated his condition any more than a comparable period of civilian life.” See February 1966 Medical Board Report; see June 2013 VA Examination Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire. The Medical Board report also stated “[i]t is felt that this man is not fit nor was he ever fit for duty.” Id. The Board finds that the evidence does not rise to the level of clear and unmistakable, which requires that it “cannot be misinterpreted and misunderstood, i.e., it is undebatable.” Anderson v. West, 12 Vet. App. 254, 258-59 (1999) (citing definition of “clear and unmistakable error” in Russell v Principi, 3 Vet. App. 310, 313-14 (1992)). Rather, the Medical Board used wording such as “felt” which suggests they perceived their conclusions, but this is not undebatable. Then, the 2013 VA examiner based her opinion in large part on the Medical Board’s findings. See June 2013 VA Examination Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire. In this case, the Board finds a lumbar disability was not “noted” at service entrance, that the presumption of soundness applies, and that the evidence suggesting it arose prior to service and was not permanently aggravated by service does not amount to “clear and unmistakable” evidence. As such the presumption of soundness is not rebutted. 38 U.S.C. § 1111; Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). Therefore, the Board’s analysis must turn to the question of whether the Veteran currently suffers from a lumbar spine disability, and, if so, whether this disorder began in or is otherwise due to his military service. The Board concludes that the Veteran has a current lumbar spine disability, to include lumbar DJD that was incurred in service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a); see April 2020 Dr. R. Kaufmann/The Kaufmann Clinic Inc. A June 2013 VA examination report shows that the Veteran has a current diagnosis of DJD of the thoracolumbar spine, and July 2015 imaging shows multilevel DDD. See June 2013 VA Examination Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire; see July 2015 Northside Hospital Department of Radiology. During service, in July 1965, the Veteran was treated for continuous back pain for the previous month, with impression of back strain, and in August 1965 the Veteran was treated by the Naval Hospital for chronic lumbosacral strain and arthritis. See July 1965 STR-Medical; see August 1965 STR–Medical. In November 1965 the Veteran was admitted for chronic lumbar strain. See November 1965 STR-Medical. A Medical Board in February 1966 recommended discharge finding the Veteran had mild spasms in the lumbosacral area most likely mild early rheumatoid arthritis, and determined that it existed prior to entry and was not aggravated by service. See February 1966 STR-Medical. Thus, the question becomes whether the current disability is related to service. The evidence in favor of the claim includes the April 2020 private note from Dr. Kaufmann stating that he reviewed the records for the Veteran’s back pain, DDD of the lumbar spine, and considered it at least as likely as not that the Veteran’s duties contributed to his condition given the Medical Board’s finding that he had never been fit for service. See April 2020 Dr. R. Kaufmann/The Kaufmann Clinic. In August 2017, Dr. Kaufmann noted that having reviewed the Veteran’s records regarding back pain, he demonstrated significant DDD of the lumbar spine when he presented for treatment at their office in 2012. See August 2017 Dr. R. Kaufmann/The Kaufmann Clinic. Dr. Kaufmann concluded that in view of the Medical Board determining the Veteran had not been fit for service, it was at least as likely as not that his duties could have contributed to his condition. See August 2017 Dr. R. Kaufmann/The Kaufmann Clinic. At his June 2013 VA examination for the spine, the Veteran reported that his symptoms began in 1965 when he fell from one of the transportation vehicles, and his condition has since worsened. See June 2013 VA Examination Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire. The Veteran reported that when he was working he had to take off of work due to his back pain, and that he could not do any heavy lifting or sports, and his activities were limited due to his injury. Id. The evidence against the claim consists of the July 2013 VA examiner’s negative nexus opinion. See June 2013 VA Examination Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire. The examiner reviewed the medical records, and focused on service treatment records where the Veteran reported a history of back pain since a high school basketball injury, and on the Medical Board report concluding that the Veteran’s back condition was not incurred in service, and was not aggravated more than a comparable period of civilian life. Id. As determined above, however, the Board finds that the Veteran is presumed sound at entry, and the evidence does not rebut the presumption of soundness. As such, the Board finds the examiner’s conclusion is not based on sound reasoning. The Board does, however, consider the description of service treatment records detailing the Veteran’s multiple efforts to seek treatment for low back pain, variously assessed as low back strain, low back instability, and possible rheumatoid arthritis in service as revealing in-service incurrence. The Board finds Dr. Kaufmann’s favorable conclusion that the Veteran’s duties contributed to his condition, the June 2013 VA examiner’s summation of in-service back related treatment, in combination with the medical and lay evidence of record showing the Veteran has experienced back pain in and since service, and is diagnosed with DDD and DJD of the lumbar spine, to be compelling evidence for in-service incurrence of lumbar spine arthritis. See June 2013 VA Examination Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire; see April 2020 Dr. R. Kaufmann/The Kaufmann Clinic; see March 2020 Hearing Transcript. The Veteran is competent and credible in his reports of falling from a vehicle in service and injuring his back and reports of back pain since service, and the medical record shows diagnoses of DDD and DJD. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006); see April 2020 Dr. R. Kaufmann/The Kaufmann Clinic; see March 2020 Hearing Transcript. Upon review of the record, the Board finds the evidence to be at least in equipoise as to whether the Veteran’s current lumbar spine disability, to include lumbar DDD and DJD was incurred in service. Accordingly, after resolving reasonable doubt in favor of the Veteran, the Board finds that service connection for lumbar spine disability, to include DDD and DJD is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Increased Rating Disability ratings are determined by application of the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; see generally 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating applies. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran’s entire history is to be considered when making disability evaluations. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where, as here, the question for consideration is the propriety of the initial rating assigned, evaluation of the medical evidence since the effective date of the grant of service connection and consideration of the appropriateness of the assignment of different ratings for distinct periods of time, based on the facts found, is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999); Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). 7. Entitlement to a rating greater than 50 percent for PTSD with mood disorder due to prostate cancer and non-Hodgkin’s lymphoma The Veteran is in receipt of a 50 percent rating for his PTSD with mood disorder under Diagnostic Code 9411 since October 22, 2010, and has appealed this initial rating. See June 2013 Rating Decision-Narrative; see October 2013 NOD. Under DC 9411, a 50-percent rating is assigned when there is 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. 38 C.F.R. § 4.130, DC 9411. A 70-percent rating is assigned when the psychiatric condition produces occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships.). 38 C.F.R. § 4.130, DC 9411. A maximum 100-percent rating is assigned when there is total occupational or social impairment due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place, memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, DC 9411. When determining the appropriate disability evaluation to assign, the Board’s primary consideration is a veteran’s symptoms, but it must also make findings as to how those symptoms impact a veteran’s occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436 (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. Id. at 442; see also Sellers v. Principi, 372 F.3d 1318 (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 rating by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. The Board must conduct a “holistic analysis” that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. As such, the Board will consider both the Veteran’s specific symptomatology as well as the occupational and social impairment associated with the DC to determine whether an increased evaluation is warranted. In January 2011, the Veteran describes thoughts about Vietnam, feeling like he is reliving it, and seeing faces of young men (those his age at the time) that will never grow old or have a family. See January 2011 Correspondence. He reported difficulty falling asleep, and not wanting to wake and face the day once he eventually slept. Id. He reported experiencing nightmares and guilt, waking wet with sweat, his heart beating quickly, and feeling fearful. Id. He describes constantly watching his neighbors and avoiding them because they are from Vietnam. Id. The Veteran was afforded a May 2011 VA contract psychiatric examination wherein he described symptoms of depression and recollections of the war, of moderate severity, occurring constantly, continuously or ongoing. See May 2011 C&P Exam. He reported his symptoms affected his total daily functioning, and that he had trouble sleeping. Id. He denied a history of suicide attempts or violent behavior. Id. The Veteran was prescribed medications and received psychotherapy to manage his symptoms. Id. The Veteran described a surge in his symptoms after watching a movie about Vietnam in 2010, and indicated that he was socially isolated and had conflictual relationships with family members beginning during that past year. Id. The Veteran reported that in 2001 he had to go on disability from being a bus driver due to eye problems primarily. Id. The Veteran described experiencing flashbacks and dreams of his experiences in Vietnam, and recently experiencing the feeling that he had then, that he did not know what he was fighting for. See May 2011 C&P Exam. He reported that he verbally lashed out at his wife, or anybody around him. Id. The Veteran reported sometimes he could not stop thinking about his experiences during Vietnam, to include flashbacks and nightmares. Id. The Veteran reported that he attended church and therapy session, but had no friends, and easily became upset with family members. Id. He had restricted range of affect. Id. He reported having difficulty falling and staying asleep. Id. He explained he had an increased startle reflex to sounds, and was more vigilant about his surroundings and prone to fears. Id. The examiner observed that the Veteran’s orientation was within normal limits, and his appearance and hygiene were grossly appropriate. See May 2011 C&P Exam. The Veteran’s behavior was appropriate, but there were disturbances of motivation and low mood. Id. At that time, there was no active suicidal ideation, and communication, speech, and concentration were within normal limits. Id. Panic attacks were absent, and suspiciousness was not present. Id. There was no reported history of delusions, or hallucinations, and obsessive-compulsive behavior was absent. Id. Thought processes were appropriate and judgment was not impaired. Id. Thinking and memory were within normal limits. See May 2011 C&P Exam. The Veteran indicated he had fleeting suicidal ideas, and reported that after watching Private Ryan he alternately thought about drinking antifreeze or walking in front of a truck when he was thinking of all the young men that could not be saved. Id. In sum, the VA examiner, Dr. Medina, noted that the Veteran had persistent symptoms which caused distress or impairment in social, occupational or other areas of functioning best described as occupational and social impairment with decrease in work efficiency and intermittent inability to perform occupational tasks although generally functioning satisfactorily with routine behavior, self-care, and normal conversation. See May 2011 C&P Exam. The Veteran had difficulty establishing and maintaining effective work/school and social relationships because of his PTSD, and effective family role functioning. Id. VA treatment records from 2012 show that the Veteran had trouble sleeping, intrusive thoughts about Vietnam, and got depressed often. See Stockbridge CBOC records, received May 2012 in CAPRI. He took Remeron to help him sleep. Id. The Veteran was afforded a VA examination for PTSD in May 2013. See May 2013 Review Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire. At that time, the Veteran diagnosed the Veteran as having PTSD and mood disorder due to thyroid dysfunction, cancer (prostate, gastric) noting the Veteran endorsed and or was observed or noted as having symptoms of helplessness, decreased mood and energy, dysphoria, passive suicidal ideation, and feelings of worthlessness. Id. The examiner assessed the Veteran as experiencing occupational and social impairment with reduced reliability and productivity, with both conditions contributing to the impairment. Id. The Veteran reported being on his second marriage, with one adult daughter. Id. The Veteran denied ever being admitted to a psychiatric hospital, attempting suicide or homicide, or having auditory or visual hallucinations. Id. The Veteran had difficulty falling or staying asleep, irritability or outbursts of anger, markedly diminished interest or participation in significant activities, and these symptoms described clinically significant distress or impairment in social, occupational or other important areas of functioning. Id. At his May 2013 VA examination, the Veteran endorsed symptoms of depressed mood, anxiety, chronic sleep impairment, and disturbances of motivation and mood. See May 2013 Review Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire. The examiner indicated that the Veteran was not a threat of danger or injury to himself or others, and his PTSD had not prevented him from performing his job as a bus operator for nearly 30 years. Id. Nevertheless, the examiner noted that the sequence of very serious physical health conditions starting in 2001 (service-connected conditions per the examiner) and resulting medical care, including the Veteran’s mood disorder, moderately to severely impacted his ability to perform physical and sedentary activities of employment. Id. As such, the examiner opined that the Veteran had been unable to work since 2001. Id. An April 2017 private psychological assessment by Dr. C. Nord, recorded the Veteran’s reports that his symptoms surged in 2010 after watching a movie on Vietnam triggering depression and recollections of war. See April 2017 C. Nord. The Veteran reported problems with recent and remote memory. Id. Dr. Nord noted testing placed the Veteran in the severe range of depression. Id. Socially, the Veteran had at that time been married twice, and was the father of one adult child. The Veteran was taking prescribed medications to include Fluoxetine, Mirtazipine, and Zoloft. Id. The Veteran experienced suicidal thoughts, and recurring thoughts. He explained he had woken during the night trying to strangle his wife. Id. Dr. Nord indicated that the Veteran was oriented, but suffered from depression, suicidal ideation, and fleeting thoughts of homicidal ideation (due to his irritability and uncontrollable temper). See April 2017 C. Nord. The Veteran denied hallucinations or delusions. Id. His affect was within normal limits, although insight, perceptions and judgment were poor. Id. He suffered from poor recent and remote memory issues. Id. As such, Dr. Nord noted the Veteran was a very severely depressed individual who suffered from poor memory, attentional issues, and poorly recognized anger and irritability issues. Id. The Veteran reported little interest of pleasure in doing things, little energy, low self-esteem, trouble concentrating, and fleeting thoughts of suicide. Id. He reported issues of carelessness, difficulty sustaining attention in activities, lack of follow through, inability to organize, easy distractibility, forgetfulness and losing important things. Id. In sum, Dr. Nord described the Veteran as “a sad, sad individual who barely exists.” See April 2017 C. Nord. Further, he was on a lot of medications for a variety of conditions, to include social phobia and fleeting suicidal ideation. Id. Given this, Dr. Nord concluded that the Veteran experienced “total social and occupational impairment due to the conditions identified.” Id. The examiner included PTSD, major depression, and social phobia with agoraphobia as the Veteran’s psychiatric diagnoses. Id. He indicated that the Veteran was unable to perform full time competitive work in part due to his service-connected psychiatric impairment, and that he suffered social phobia and could not be around a lot of people. Id. He observed that even if the Veteran was to return to part-time work, his fear of people and attentional issues would cause him to be unable to perform the duties given to him. Id. Finally, given the Veteran’s depression and mood swings, the examiner considered him unable to control his temper, making him unpredictable. Id. At his March 2020 hearing, the Veteran reported experiencing anxiety, nervousness, apprehension, weird dreams, night sweats, and feeling he was being followed. See March 2020 Hearing Transcript. He said that he had hallucinations, and difficulty getting along with others (does not like to be around his grandkids because of the noise they make). Id. He described himself as argumentative over nothing, and indicated that he was going through his third divorce. Id. He reported that he wakes at night and wants to take his frustration out on his wife. Id. He gave an example of a recent urge to grab his wife and throw her out a window (did not act on it, rather walks away). Id. He reported that sometimes he has the urge to “end it all” rather than put others through the frustration that he is experiencing. Id. The Veteran describes having a mood where he just wants to be in a room by himself, prefers the dark, has crying spells three or four times a week, feels useless and then feels sorry for himself. See March 2020 Hearing Transcript. He experiences anger, and avoids social gatherings because he finds himself going off on people, and explodes for no reason. Id. He said the less he associates with others, the better off he is. Id. He thinks he is running his daughter off because of his condition. Id. He describes having taken a real estate course but having to give it up because he could not concentrate, and he was blowing up on customers. Id. He reported that he forgets a lot (misplaces shoes and keys), thinks others are talking about him if they whisper, and has problems sleeping at night. Id. He indicated that VA psychiatrist, Dr. Grewal has given him medications to help with sleep. See March 2020 Hearing Transcript. He endorsed anxiety attacks, but when asked to describe them, indicated that he has thoughts to do things that he wouldn’t ordinarily do. Id. For example, he recently experienced thoughts that he wanted to grab a police officer’s gun (so left the store instead). Id. The Board concludes that the evidence is sufficient to show that the severity of the Veteran’s PTSD disorder more closely approximates the criteria for a 100 percent disability evaluation for the periods on appeal. The Board finds the severity, frequency, and duration of the Veteran’s symptoms more closely approximate the symptoms contemplated by a 100 percent rating. Throughout the relevant period, the Veteran’s PTSD with mood disorder has caused a variety of psychiatric symptoms from the 70 percent as well as the 100 percent rating criteria, to include inability to establish and maintain effective relationships, specifically discussed by Dr. Medina in 2011 as difficulty with social relationships and effective family role functioning. See May 2011 C&P Exam. This also includes depression, with an April 2017 assessment by Dr. Nord describing the Veteran as “a sad, sad individual who barely exists.” See April 2017 C. Nord. In addition, the Veteran experienced anxiety, endorsed in his 2013 VA examination, and described further in his March 2020 hearing when he detailed feeling anxiety, nervousness and apprehension. See May 2013 Review Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire; see March 2020 Hearing Transcript. The Veteran experienced social isolation described in the May 2011 examination as being isolated and having conflictual relationships with family. See May 2011 C&P. It was also detailed as recently as his Board hearing as avoiding social gatherings finding that he explodes on people. See March 2020 Hearing Transcript. Indeed, the record shows that the Veteran recently divorced for the third time. See August 2020 VA 27-0820 Report of General Information. The record also shows occupational impairment, described in 2011 as impairment in occupational functioning with decrease in work efficiency and intermittent inability to perform occupational tasks, and difficulty establishing and maintaining effective work relationships, and detailed at his hearing as being unable to concentrate, and blowing up on customers. See May 2011 C&P Exam; see March 2020 Hearing Transcript. Sleep impairment has also been present, variously described as difficulty falling asleep in January 2011, difficulty falling and staying asleep and nightmares in May 2011, chronic sleep impairment in May 2013, and weird dreams at his May 2020 Hearing. See January 2011 Correspondence; May 2011 C&P Exam; See May 2013 Review Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire; see March 2020 Hearing Transcript. Irritability was also present described in May 2013 as irritability or outbursts of anger, and in April 2017 as an uncontrollable temper, and in March 2020 as going off on people and exploding for no reason. See May 2013 Review Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire; see April 2017 C. Nord; see March 2020 Hearing Transcript. In addition, suicidal and homicidal ideation were present. Specifically, in May 2011 the Veteran reported thinking about drinking antifreeze or walking in front of a truck; in May 2013 the examiner indicated that there was passive suicidal ideation; and, in April 2017 Dr. Nord indicated that the Veteran had fleeting suicidal ideation. See May 2011 C&P Exam; see May 2013 Review Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire; see April 2017 C. Nord. Further, in April 2017 Dr. Nord indicated that there was homicidal ideation due to the Veteran’s irritability and uncontrollable temper, and at his Board hearing he described a recent urge to grab his wife and throw her out a window. See April 2017 C. Nord; see March 2020 Hearing Transcript. In sum, the evidence shows that the overall impairment caused by the Veteran’s psychiatric symptomology, while not squarely falling within the symptomology of the 100 percent rating, more nearly approximates total and social occupational impairment. See 38 C.F.R. §§ 4.7, 4.130. Resolving all doubt in favor of the Veteran the Board concludes that the medical and lay evidence of record supports an increased schedular rating for 100 percent, for the entire period on appeal. The Board notes that the Veteran expressed suicidal ideation, similar to persistent danger of self-harm, which is contemplated by the 100 percent criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 19 (2017). Here, the severity, frequency, and duration of the Veteran’s suicidal ideation, appears to rise to the level contemplated by the 100 percent disability rating where he has contemplated methods such as drinking antifreeze to kill himself. Accordingly, the Veteran’s claim is granted. 8. Entitlement to a TDIU Following the holding set forth above concerning the Veteran's claim for an increased rating for the disability of PTSD, the Board notes that the Veteran has been awarded a 100 percent rating for PTSD from October 22, 2010. The United States Court of Appeals for Veterans Claims (Court) has recognized that a 100 percent rating under the Schedule for Rating Disabilities means that a Veteran is totally disabled. Holland v. Brown, 6 Vet. App. 443, 446 (1994), citing Swan v. Derwinski, 1 Vet. App. 20, 22 (1990). Thus, if VA has found a Veteran to be totally disabled as a result of a single service-connected disability or combination of disabilities pursuant to the rating schedule, there is neither a need, nor authority, to otherwise rate that Veteran totally disabled on any other basis. See Herlehy v. Principi, 15 Vet. App. 33, 35 (2001) (finding a request for TDIU moot where 100 percent schedular rating was awarded for the same period); but see Bradley v. Peake, 22 Vet. App. 280 (2008) (holding that the Board may not dismiss as moot a claim for TDIU based upon a single disability when additional service-connected disabilities may entitle the Veteran to special monthly compensation (SMC) under 38 U.S.C. § 1114 (s)). While the Board is cognizant of the decision of the Court in Bradley v. Peake, 22 Vet. App. 280 (2008), in this case the Veteran is in receipt of a 100 percent schedular rating for PTSD and his remaining service-connected disabilities, in part, equate to independent 60 percent ratings.. 38 U.S.C. § 1114 (s); Bradley, 22 Vet. App. At 280; Buie v. Shinseki, 24 Vet. App. 242 (2010); 38 C.F.R. §§ 3.350 (i), 4.29, 4.30. As such, while the Board has considered the holding in Bradley, the grant of a 100 percent schedular rating for PTSD in this case renders the Veteran's TDIU claim moot for the entire period of the appeal, as there is no possible additional benefit for the Veteran from that point forward based upon the current record. See Buie v. Shinseki, 24 Vet. App. 242 (2011). Accordingly, the claim for a TDIU is dismissed a moot. 9. Entitlement to SMC SMC is payable where a veteran has a single service-connected disability rated as 100 percent and (1) has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. 38 U.S.C. § 1114; 38 C.F.R. § 3.350. In this case, the Board has determined that the Veteran is entitled to 100 percent for his PTSD with mood disorder for the entire appellate period. Further, he has additional service-connected urinary incontinence ratable at 60 percent since 2008. A TDIU may satisfy the “rated as total” element of 38 U.S.C. § 1114 (s), if the TDIU is awarded for a single disability. See Buie v. Shinseki, 24 Vet. App. 242 (2011). Here, a TDIU is awarded for PTSD or urinary incontinence, such that the most advantageous award should be granted to the Veteran when determining his SMC. Accordingly, he is entitled to SMC . REASONS FOR REMAND 9. Entitlement to service connection for bilateral hearing loss is remanded. The Veteran claims entitlement to service connection for a bilateral hearing loss disability. The Board notes that hearing loss disability is defined by regulation and must be shown by audiometry. 38 C.F.R. §§ 3.385, 4.85. At his hearing, the Veteran and his representative indicated that the Veteran’s hearing loss has worsened since his most recent VA examination in 2013. See March 2020 Hearing Transcript. Specifically, the Veteran reported that his wife notices that he turns the TV up loud, and yet he describes his hearing as muddled such that he tries to understand what is said. Id. Indeed, the Board notes that the VA examiner from the most recent June 2013 examination indicated that there was no diagnosis because there was no pathology. See June 2013 VA Examination Hearing Loss and Tinnitus Disability Benefits Questionnaire. The examiner concluded that the Veteran’s pure tone average and speech reception threshold were not in good agreement even after retesting and reinstruction, and due to these factors, the test was invalid and retesting at a later date was recommended. Id. The June 2013 VA examiner recommended retesting at a later date. See June 2013 VA Examination Hearing Loss and Tinnitus Disability Benefits Questionnaire. No further testing to assess the severity of the Veteran’s bilateral hearing loss was conducted. Additionally, it is not clear whether the failure to obtain valid responses was due to malingering or due to inadequacies in the testing (or lack of expertise by the examiner). Another examination to clarify the matter (and assess the current severity of the bilateral hearing loss) is necessary. See Barr v. Nicholson, 21 Vet. App. 303 (2007). As such, remand for a VA audiometric examination to determine the nature and etiology of any hearing loss is necessary. 10. Entitlement to an increased rating for non-Hodgkin’s lymphoma, postoperative residuals, stomach injury is remanded. The Veteran claims a rating greater than 10 percent for his non-Hodgkin’s lymphoma which is currently evaluated according to DC 7310-7301. Under DC 7310, stomach injuries are rated as adhesions of the peritoneum under DC 7301. Under DC 7301, the criteria for a higher rating of 30 percent is moderately severe; partial obstruction manifested by delayed motility of barium meal and less frequent and less prolonged periods of pain; and a 50 percent rating is for severe impairment from definite partial obstruction shown by X-ray with frequent and prolonged episodes of severe colic distension, nausea, or vomiting, following severe peritonitis, a ruptured appendix, a perforated ulcer, or an operation with drainage. At the March 2020 hearing, the Veteran described his non-Hodgkin’s lymphoma symptoms as loose bowels and diarrhea, stomach swelling/bloating, nausea and feeling as if he needs to throw up, which he does at times. See March 2020 Hearing Transcript. He indicated that he took prescription and over-the-counter medications, and avoided foods that irritated his stomach. Id. He described experiencing heartburn (at times feeling like he’s going to have a heart attack, but being told that its pain from the acid reflux and heartburn). Id. The Veteran indicated that he had lost weight from lack of eating due to stomach irritation, swelling, and related burping (embarrassed by this, lack of enjoyment eating). Id. He reported being seen by gastroenterologist, Dr. Gregory Gibson as recently as two months earlier. Id. Based on the Veteran’s reports of recent treatment by Dr. Gibson, evidence indicates that there is outstanding relevant VA or private treatment records, and remand is required to allow VA to obtain the outstanding records. 38 C.F.R. § 3.159. The May 2013 VA examination for non-Hodgkin’s indicated that there was no anemia, and no complications, with the abdomen revealing no evidence of tenderness. See May 2013 VA Examination Disability Benefits Questionnaire Hematologic and Lymphatic Conditions, including Leukemia. Yet, the examiner also states that there was not enough information as to values for pernicious anemia or other hemic conditions. Id. As such, there is an internal inconsistency that renders this opinion deficient. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Further based on the Veteran’s competent reports, it appears that the VA examination finding no evidence of complications does not accurately reflect his current symptomatology, which appears to have worsened. As such, the Board requires another VA examination to ascertain the current severity of the Veteran’s non-Hodgkin’s lymphoma. See Snuffer v. Gober, 10 Vet. App. 400, 403 (2007). The matters are REMANDED for the following action: The Board recognizes the potential practical difficulties in scheduling an examination in light of the COVID-19 epidemic and requests flexibility and understanding in affording the Veteran any warranted examination. 1. Ask the Veteran to clarify whether the outstanding records from Dr. Gibson are private or VA treatment records. If they are private records, complete a VA Form 21-4142 for the necessary facility. Make two requests for the authorized records from the named facility, unless it is clear after the first request that a second request would be futile. Otherwise, obtain the Veteran’s VA treatment records for the requisite period. 2. Arrange for an audiological examination of the Veteran (with audiometric studies) to ascertain the current severity of his bilateral hearing loss. The Veteran’s record must be reviewed by the examiner in conjunction with the examination. In addition to reporting audiometry findings, the examiner should elicit from the Veteran an account of the impact his hearing loss has on daily activity functioning, and should comment regarding whether the account is consistent with the findings on audiometry, as well as on the impact the level of hearing impairment shown by audiometry would be expected to have on occupational functioning. If the responses on audiometry remain inconsistent, and the testing is determined to be invalid, the examiner should indicate whether such is due to malingering, inability to understand directions, language difficulties, or inadequacies in the testing methodology (and if it is due to either of the latter two, indicate whether the problem can be rectified by any available testing/methodology. If so, such should be arranged. All opinions must include rationale. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected non-Hodgkin’s lymphoma. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria (with regard to the schedule of ratings for the digestive system, section 4.114). All opinions must include rationale. The examiner should conduct the necessary testing to determine the severity of the Veteran’s disability, and should comment on whether there is pernicious anemia. (continued on the next page) YVETTE R. WHITE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Barner, 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.