Citation Nr: 21003962 Decision Date: 01/25/21 Archive Date: 01/25/21 DOCKET NO. 14-08 578 DATE: January 25, 2021 ORDER 1. Entitlement to service connection for cerebrovascular accident/hypertensive encephalopathy, claimed as traumatic brain injury (TBI), is denied. 2. Entitlement to a disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD) is denied. 3. Entitlement to special monthly compensation (SMC) based on the need for regular aid and attendance of another person is denied. FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that the Veteran experienced an injury to the head, claimed as a TBI, in service. 2. The preponderance of the evidence is against a finding that the Veteran’s PTSD was manifested by occupational and social impairment with reduced reliability and productivity or worse. 3. The Veteran did not have a factual need for aid and attendance due to service-connected disabilities at any time during the appeal period. CONCLUSIONS OF LAW 1. The criteria for service connection for cerebrovascular accident/hypertensive encephalopathy, claimed as TBI, have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 1154(b), 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. The criteria for a disability rating in excess of 30 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.125, 4.126(a), 4.130, Diagnostic Code (DC) 9411. 3. The criteria for entitlement to SMC based on the need for regular aid and attendance of another person or by reason have not been met. 38 U.S.C. §§ 1114, 5107; 38 C.F.R. §§ 3.350, 3.352. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1953 to May 1955. The Veteran died during the pendency of the appeal in June 2019. The appellant, his surviving spouse, was substituted as the claimant. In May 2017, the Veteran and the appellant provided testimony in a video conference Board hearing before undersigned Veterans Law Judge (VLJ). A copy of the hearing transcript is associated with the claims file. In September 2017, the Board denied the claim of entitlement to service connection for TBI on appeal. The Veteran appealed the September 2017 decision to the United States Court of Appeals for Veterans Claims (Court). In August 2018, the Veteran and the Secretary of VA (parties) filed a Joint Motion for Partial Remand (JMPR) and remanded the TBI claim back to the Board, which was granted by the Court. The September 2017 Board decision also remanded the issues of entitlement to a disability rating in excess of 30 percent for PTSD and entitlement to SMC, however, these issues were not within the Court’s jurisdiction. These issues are currently still before the Board. Most recently, the Board remanded the claims in January 2019. There was substantial compliance with the Board’s remand directives to decide the claims on appeal at the present time. See Stegall v. West, 11 Vet. App. 268 (1998). The record shows that the Veteran’s service treatment records are fire-related. A formal finding was made by VA in June 2010 that all efforts to obtain the records have been exhausted and further attempts would be futile; therefore, the records are not available. Further, a Personnel Information Exchange Systems (PIES) attempt for service personnel records was made in June 2011 and was returned with a negative response indicating that the record is fire-related and the information requested cannot be reconstructed. Under such circumstances VA has a heightened duty to explain its findings and conclusions and to consider carefully the benefit of the doubt rule. Pruitt v. Derwinski, 2 Vet. App. 83, 85 (1992); O’Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). The Board’s analysis of the claims is undertaken with this duty in mind. The cited case law does not lower the legal standard for proving a claim of service connection but rather increases the Board’s obligation to evaluate and discuss in its decision all the evidence that may be favorable to the appellant. Russo v. Brown, 9 Vet. App. 46 (1996). 1. Entitlement to service connection for cerebrovascular accident/hypertensive encephalopathy, claimed as TBI. The parties to the August 2018 JMPR agreed that the Board erred by failing to address the combat presumption in 38 U.S.C.§ 1154(b) and relevant lay evidence of record. The parties also agreed that the Board erred by relying on an inadequate medical examination to deny the claim for service connection for TBI. Specifically, the record reflects that the Veteran served in Korea during the Korean war. The Veteran asserted that he fell and hit his head during combat, losing consciousness for a brief period. At the time of the September 2017 decision, the Board did not discuss whether the Veteran’s reports that he suffered from a TBI had occurred while engaging in combat in accordance to 38 U.S.C.§ 1154(b). Furthermore, the parties to the JMPR noted that while VA had afforded the Veteran medical examinations, he had not been afforded a VA TBI examination. The parties agreed that a remand was warranted to ensure that the duty to assist is fulfilled by providing the Veteran an adequate VA TBI examination. The terms of a Joint Motion will serve as a factor for consideration as to whether or to what extent other issues raised by the record need to be addressed by the Board. See Carter v. Shinseki, 26 Vet. App. 534, 542-43 (2014). Therefore, the crux of the JMPR was the finding by the parties that the Board did not adequately address the Veteran’s lay assertions in accordance with the combat presumption in 38 U.S.C.§ 1154(b) and the lack of a VA TBI examination. Thus, the Board will provide a discussion on this below. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). When a veteran has engaged in combat with the enemy, satisfactory lay or other evidence “shall be accepted as sufficient proof of service connection” for certain diseases or injuries, even if “there is no official record of such incurrence or aggravation in such service.” 38 U.S.C. § 1154(b). This statute does not eliminate the need for evidence of a nexus; it merely reduces, for veterans who have engaged in combat with the enemy, the burden of presenting evidence of incurrence or aggravation of an injury or disease in service. Collette v. Brown, 82 F.3d 389, 392 (Fed. Cir. 1996) (“Section 1154(b) does not create a statutory presumption that a combat veteran’s alleged disease or injury is service-connected”). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The Veteran contends that he experienced a TBI while in service. Specifically, during the May 2017 Board hearing, the Veteran reported that he was a gunner during the Korean war and asserted that while in combat, he was escaping from a “pretty bad situation,” fell, and hit his head. The Veteran stated that he “might have been [out] for a few minutes” but then was running again. He stated that the fall caused a scar on his ear, he sought medical attention, and was sent back to combat. He contended that he has had a lot of problems with dizziness and was diagnosed with traumatic brain injury at Huntsville Hospital. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claim for service connection for TBI. The reasons follow. Pursuant to the August 2018 JMPR, the Board remanded the claim in January 2019 to schedule a VA TBI examination. In a May 2019 statement, the appellant indicated that the Veteran was in failing health and there was a “DNR” or do-not-resuscitate order. She stated that the Veteran was unable to attend any examinations due to the fact that he was in a nursing home, receiving rehabilitation and that it was unknown when he would be able to attend the examination. Unfortunately, the Veteran passed away in June 2019. A medical opinion on the claimed TBI was provided by a VA psychiatrist in July 2020, which is discussed below. During the May 2017 hearing, the Veteran has asserted that he had a lot of problems with dizziness and went to Huntsville Hospital, where he was given a diagnosis for traumatic brain injury. In his August 2010 claim, the Veteran specified his claim for service-connection as a “possible TBI – head injury with loss of consciousness. The preponderance of the evidence is against a finding of a diagnosis of TBI upon review of medical records, including from Huntsville Hospital. Specifically, medical records from Helen Keller Emergency Room in March 2010 show that the Veteran presented with malignant hypertension and was unresponsive. It was noted that the Veteran did not report to work, and the family sent the police to find him. The Veteran was found lying on the floor for an unknown amount of time, which was thought to be greater than 24 hours. A computed tomography (CT) scan of the head was completed that was unremarkable. Magnetic resonance imaging (MRI) of the brain resulted in an impression of mild cerebral and cerebellar atrophy and deep white matter change due to aging and no acute abnormality identified. The Veteran was then transferred to Huntsville Hospital where neural services were available. Transfer diagnoses included “unresponsive, suspect anoxic brain injury;” “rhabdomyolysis;” “renal failure;” and “diabetes, type II.” Huntsville Hospital medical records from March 2010 note admitting diagnoses of “change in mental status rule out infectious versus metabolic cause and anoxic brain injury;” “tachycardia with high troponin level;” “acute rhabdomyolysis;” and “acute renal failure.” It was noted that a series of brain studies were performed, which essentially revealed brain changes consistent with encephalopathy. A CT scan of the head without contrast revealed a normal study with no acute findings. MRI of the brain with/without contrast revealed restricted diffusion in the posterior parietal and occipital lobes, which were noted could represent infraction, but was in a pattern typically seen with hypertensive encephalopathy. There was chronic microvascular ischemic change in the periventricular white matter. Magnetic resonance angiography of the head and neck also revealed normal findings. Discharge diagnoses included “hypertensive encephalopathy;” “acute renal failure;” “status-post rhabdomyolysis;” “chronic kidney disease;” “global aphasia secondary to #1;” “diabetes mellitus;” and “dyslipidemia.” An October 2011 VA medical record from the Huntsville Clinic indicates that the Veteran had minor problems with pressure like headaches in the right temple area and described wavy vision when he put on his glasses first thing in the morning. The VA physician stated that he believed most of this may be related to the Veteran’s blood sugar being high and advised him to be careful with glasses with high blood sugar as it will result in the glasses not fitting when blood sugar is brought down under control. Huntsville VA medical records do not include a diagnosis of TBI. Moreover, while the Veteran testified during the May 2017 Board hearing that he experienced dizziness post service, he denied any significant neurological symptoms and his head was normocephalic and atraumatic in September 2009, August 2010, December 2010, and April 2011 private medical records. While the Veteran believes he had a TBI, he was not competent to provide a diagnosis of TBI. A diagnosis of TBI is medically complex, and the Veteran had not shown the specialized medical education or knowledge to diagnose a TBI, particularly when such a diagnosis includes the use of MRIs and other imaging. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). A claim for service connection may encompass claims for any disability that may reasonably be encompassed by several factors, including the claimant’s description of the claim, the symptoms the claimant describes and the information the claimant submits or that the Secretary of VA obtains in support of the claim. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). While the Veteran was not diagnosed with a TBI, the Veteran had experienced, as described above, “a change in mental status” or “cerebrovascular accident,” which was diagnosed as hypertensive encephalopathy in March 2010/April 2010, months prior to his August 2010 claim for service connection. The Board believes this is the claimed “diagnosis of traumatic brain injury” at Huntsville Hospital referenced by the Veteran during the May 2017 Board hearing. Accordingly, the Board has re-characterized the claim as shown on the cover page of this decision and will consider whether the evidence supports a claim that his hypertensive encephalopathy was caused by or otherwise a result of service. As the Veteran’s service treatment records are fire-related, the Board has thoroughly reviewed the evidence of record to substantiate his claim, to include consideration of the combat presumption in 38 U.S.C.§ 1154(b), and found inconsistency in the Veteran’s statements; therefore the preponderance of the evidence is against a showing that a TBI was incurred in service. In a March 2014 substantive appeal (VA Form 9), the Veteran asserted that he was knocked unconscious during a battle in Korea. The Veteran stated that he remembered trying to run and crawl to safety, and when he got up he stumbled, fell, and must have hit his head on something. The Veteran elaborated that when he regained consciousness, his squad was nowhere around him and soldiers from another squad went by him. He stated that it was serious fighting and running that day to get back to the line and entrenchment for protection. See also May 2017 Board hearing transcript. VA’s General Counsel has held that “[t]he ordinary meaning of the phrase ‘engaged in combat with the enemy,’ as used in 38 U.S.C. § 1154 (b), requires that a veteran have participated in events constituting an actual fight or encounter with a military foe or hostile unit or instrumentality.” The issue of whether any particular set of circumstances constitutes engagement in combat with the enemy for purposes of section 1154(b) must be resolved on a case-by-case basis with evaluation of all pertinent evidence and assessment of the credibility, probative value, and relative weight of the evidence. VA O.G.C. Prec. Op. No. 12-99, 65 Fed. Reg. 6,256-58 (2000). As a general matter, evidence of participation in an “operation” or “campaign” often would not, in itself, establish that a veteran engaged in combat, because those terms ordinarily may encompass both combat and non-combat activities. However, there may be circumstances in which the context of a particular service-department record indicates that reference to a particular operation or campaign reflects engagement in combat. Further, evidence of participation in a particular “operation” or “campaign” must be considered by VA in relation to other evidence of record, even if it does not, in itself, conclusively establish engagement in combat with the enemy. See id. The record indicates that the Veteran served during the Korean War era from May 1953 to May 1955. The Veteran’s Certificate of Release or Discharge from Active Duty (DD-214) reflects that the Veteran’s most significant duty assignment was “ammo chief.” It is also noted that the Veteran received the National Defense Service Medal, United Nations Service Medal for Korea, Korean Service Medal, and Good Conduct Medal, however, such awards do not provide confirmation that he personally “engaged in combat with the enemy.” The Veteran had denied combat wounds and intense fear and did not provide any specific details regarding his combat experience during medical treatment. For example, in a January 2011 VA examination for posttraumatic stress disorder (PTSD), the Veteran denied that he sustained any combat wounds but reported leg swelling. When asked to describe a PTSD stressor event that he found particularly traumatic, the Veteran vaguely stated, “combat experience.” Further, the Veteran denied intense fear and said that he always felt there was a way out. In the examination report, the examiner noted that the Veteran was not injured when asked for the health-care facilities where trauma-related injuries were treated. The examiner also noted that the Veteran was initially unable to report any traumatic events in service and then later endorsed being involved in firefights and said, “anytime people are killed it is going to bother you.” The Veteran noted that people were injured/killed during firefights, but the examiner was unable to obtain much detail from the Veteran regarding his experiences, except that one fellow veteran had the name Harmony. In a May 2012 VA medical record, the Veteran reported that he was a machine gun loader, that he saw a great deal of death, and lost comrades. In an August 2014 VA medical record, the Veteran claimed that his PTSD was worse and the psychiatrist indicated that the Veteran did not describe particularly traumatic events to her. She noted that the Veteran reported receiving incoming fire and feeling for dead bodies in the water as they crossed the river. The Veteran did not report in these records that he fell and hit his head in service. His DD Form 214 also shows, “none,” under section 29 for wounds received as a result of action with enemy forces. Moreover, while the Veteran reported dizziness post-service during the May 2017 Board hearing, he denied any significant neurological symptoms and his head was normocephalic and atraumatic in August 2010, December 2010, and April 2011 private medical records. An August 2009 private medical record, which was completed prior to the Veteran’s stroke in 2010, the Veteran denied dizzy spells. An August 2010 VA medical record also reflects that the Veteran denied “significant head trauma,” addressing his medical history during a review of systems. In a March 2013 VA examination for PTSD, the examiner indicated that the Veteran did not have a diagnosis of TBI. In July 2020, a VA TBI opinion was provided. The examiner opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. He noted that there is no clear evidence from the medical record reviewed that the Veteran suffered a TBI and found that the Veteran did not meet the criteria for a diagnosis of TBI. He explained that based on the medical record review, the Veteran had no documentation of a head injury while in the service. The examiner added that there are several medical records that indicated that the Veteran did not report any head injuries while in service and medical records do not indicate evidence of cognitive problems after the claimed head injury in between 1953 and 1955. The examiner’s opinion is consistent with October 2017 and March 2013 VA examination reports for PTSD, which the examiners indicated that the Veteran did not have a diagnosis of TBI. In light of the internal inconsistencies and contradictory documentary evidence, the Board finds that the Veteran’s assertions of combat service, specifically that he fell and hit his head during combat, are not credible, nor does the contemporaneous record support a finding of combat service. The Board finds that the Veteran’s May 2017 testimony of minimal probative value to support a finding that the Veteran “engaged in combat with the enemy,” as contemplated by 38 U.S.C. § 1154(b) or that he sustained a head injury in service, as it is inconsistent with his statements in medical records described above. The Veteran denied combat wounds and intense fear and did not provide any specific details regarding his combat experience during medical treatment, which weighs against his allegation of having sustained a TBI in service The Board notes that the Veteran was stationed in Korea during the Korea War era, but the mere presence in a combat zone is not sufficient to show that the Veteran actually engaged in combat with enemy forces. VA O.G.C. Prec. Op. No. 12-99, 65 Fed. Reg. 6,256-58. When VA granted service connection for PTSD, it was based on the relaxed evidentiary standard under 38 C.F.R. § 3.304(f)(3), which is related to the veteran’s fear of hostile military or terrorist activity. See February 2012 Rating Decision. In other words, it was not granted based on a finding that the Veteran had engaged in combat. The preponderance of the evidence is against a finding that the Veteran participated in an event constituting an actual fight or encounter with a military foe, hostile unit, or instrumentality, particularly one which he sustained a head injury. For the foregoing reasons, the Board finds that the record shows that the Veteran did not engage in combat during service. Finally, the Board notes that the presumption allowed under 38 U.S.C. § 1154(b) does not reduce the other requirements necessary to establish service connection, such as the existence of a current disability and evidence of a nexus between that disability and the in-service injury. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. The provisions of 38 U.S.C. § 1154(b) assist only in establishing the occurrence of the in-service injury. This statute does not provide a substitute for required medical nexus evidence or the existence of a current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Dalton v. Nicholson, 21 Vet. App. 23, 37 (2007). The Veteran was not diagnosed with a TBI in service, and events post service, including complaints of “pressure like headaches,” and the cerebrovascular accident was attributable to a cause other than a TBI (hypertensive encephalopathy). The record does not contain a competent and credible medical opinion that establishes a nexus between the Veteran’s claimed TBI and service. The only competent and credible medical opinion in the record is that of the VA examiner who found the required nexus to be lacking. Absent credible and probative evidence of an in-service event, and competent and probative evidence of a nexus between the Veteran’s claimed TBI and service, the Board finds that the Veteran’s cerebrovascular accident/hypertensive encephalopathy, claimed as TBI, was not incurred in service and is not otherwise related to active service, as the appellant has not offered competent medical evidence in support of her claim. Accordingly, service connection for cerebrovascular accident/hypertensive encephalopathy, claimed as TBI, is not warranted. The preponderance of the evidence is against the claim of service connection for cerebrovascular accident/hypertensive encephalopathy, claimed as TBI, the benefit-of-the-doubt doctrine is not for application, and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to a disability rating in excess of 30 percent for PTSD. Disability ratings are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). The percentage ratings in the Rating Schedule represent the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. The percentage ratings are generally adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the disability. Diagnostic Codes (DCs) are assigned by the rating officials to individual disabilities. DCs provide rating criteria specific to a particular disability. If two DCs are applicable to the same disability, the DC that allows for the higher disability rating applies. See 38 C.F.R. § 4.7. When a question arises as to which of two ratings apply under a particular DC, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. See id. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of a veteran. 38 C.F.R. § 4.3. PTSD is evaluated under the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130, DC 9411. Under the General Rating Formula for Mental Disorders, a 30 percent disability rating is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent disability rating is assigned for PTSD manifested by 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, and difficulty in establishing and maintaining effective work and social relationships. A 70 percent disability rating requires 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); or inability to establish and maintain effective relationships. A 100 percent disability rating requires 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; or memory loss for names of close relatives, own occupation, or own name. The Veteran’s records include evaluations based on the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV), which includes Global Assessment Functioning (GAF) scores, and the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (5th ed. 2013) (DSM-5), which does not use GAF scores. The Board notes that the use of the GAF scale has been abandoned in the DSM-5 because of, among other reasons, “its conceptual lack of clarity” and “questionable psychometrics in routine practice.” See Diagnostic and Statistical Manual for Mental Disorders, Fifth edition, p. 16 (2013). The United States Court of Appeals for Veterans Claims (Court) has held that the use of GAF scores to assign disability ratings in instances where the DSM-5 applies, is inappropriate. See Golden v. Shulkin, 29 Vet. App. 221 (2018). However, the Court acknowledged that the Secretary did not intend the provisions of this final rule to apply to claims that were pending before the Board (certified for appeal) on or before August 4, 2014. Id. The current Veteran’s claim was certified for appeal to the Board in October 2016, and, thus, the Board shall not discuss GAF scores below. The Court in Mauerhan v. Principi stated that “when evaluating mental health disorders, the factors listed in the Rating Schedule are simply examples of the type and degree of symptoms, or their effects, that would justify a particular rating; analysis should not be limited solely to whether a veteran exhibited the symptoms listed in the Rating Schedule. Rather, the determination should be based on all of a veteran’s symptoms affecting his level of occupation and social impairment.” See Mauerhan, 16 Vet. App. 436, 442-43 (2002). The lists of symptoms under the Rating Schedule are meant to be examples of symptoms that would warrant the disability evaluation but are not meant to be exhaustive. Id. If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational and social impairment equivalent to that which would be caused by those listed in the rating criteria the appropriate equivalent rating will be assigned. Id. at 442. The Veteran asserted that his PTSD should be rated higher than the assigned disability rating of 30 percent under 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411. Specifically, during the May 2017 Board hearing, the Veteran testified his PTSD had increased in severity since his last rating. He reported problems sleeping, dreams of his service time in Korea, avoiding large crowds, being quick to anger, anxiety, nervousness, and fidgeting. The Veteran was afforded an initial evaluation for PTSD VA examination in January 2011. The examiner noted the frequency, severity, and duration of non-PTSD psychiatric/mental symptoms as the Veteran’s wife reporting that the Veteran had been experiencing memory problems for the past year, which was exacerbated after a reported stroke in March 2010. The Veteran denied significant depression at the time and endorsed intermittent anxiety. His appetite was described as “good” with stable weight and no recent suicidal ideation, intent, or plan. The Veteran reported a history of suicidal ideation approximately a year prior and indicated that his spiritual beliefs would prevent him from acting on the suicidal ideation. The examiner noted that the Veteran’s general appearance was “clean, neatly groomed, appropriately dressed, casually dressed.” The examiner also indicated that the Veteran was “cooperative, friendly, relaxed, attentive” with appropriate affect. The Veteran had no history of delusions or hallucinations with a “pretty good” mood, appropriate affect and denied homicidal thoughts. The presence of suicidal thoughts was noted as intermittent suicidal ideation but there was no current active suicidal ideation, intent or plan. Upon examination, the examiner concluded that the Veteran was orientated in all spheres but exhibited a short attention span and was unable to spell a word forward and backwards, reversing the letters in the backwards spelling. The Veteran appeared confused a times and looked at his wife for help in answering some questions. His wife stated that she noticed the Veteran’s irritability one year prior to the stroke and exacerbating after the stroke. The Veteran reported problems due to cognitive difficulties since the stroke. His memory was noted to have been moderately impaired, specifically that he was confused at times on dates, his wife helped him during the interview at times, and he was unable to recall his social security number. He reported distressing recollection at times, “not too often, about once a week,” about combat experiences but denied nightmares. He noted some distress at times in discussing experiences but did not feel that his experience affected his relationships with other people. The Veteran’s wife was managing his financial affairs and would likely have had difficulty managing finances independently due to cognitive problems. The examiner found that the Veteran did not report enough symptoms to meet full DSM-IV diagnosis of PTSD at the time but stated that it was unclear if the Veteran’s cognitive difficulties may have been limiting his report of symptoms. The Veteran was afforded another VA examination for PTSD in March 2013. The examiner diagnosed the Veteran with mood disorder NOS (not otherwise specified) and stated that the Veteran did not meet the DSM-IV diagnostic symptom criteria for PTSD. The examiner also confirmed a diagnosis of dementia due to multiple etiologies. The Veteran reported psychosocial and environmental problems of “being dependent” and his wife reported the Veteran’s “inability to function on his own.” The examiner noted that Veteran was unable to find and maintain gainful employment due to the cognitive impairments of dementia. The examiner found that it was less likely than not that the Veteran was unemployable due to any other mental disorder alone and that he had been working part time as a driver until his stroke in 2010. She indicated that the Veteran’s mood disorder caused symptoms including fluctuations in mood and a history of sleep disturbance and that his dementia caused significant cognitive impairment. She found that total occupational and social impairment best summarized the Veteran’s level of occupational and social impairment with regards to all mental diagnoses. She specified that it is estimated that 90 percent of the current impairment is due to the cognitive impairment of dementia and explained that prior to the impaired cognition following a stroke, he was living independently and still working part time at age 76. The examination report shows that Veteran reported that his mood was good, but his wife says that he is very irritable if anyone comes around and quickly becomes angry about “every little thing.” The examiner noted that objectively his mood during the examination was neutral and his affect was mildly restricted. The Veteran denied suicidal and homicidal ideation and reported good sleep. The Veteran was nicely dressed and groomed and was cooperative and friendly with the examiner but was noted not to speak spontaneously. He was alert at times but turned to his wife for information. The examiner found that the Veteran was not capable of managing his own financial affairs because of his cognitive impairment. The Veteran was most recently afforded a PTSD examination in October 2017. The examiner noted a mental disorder diagnosis of major neurocognitive disorder with behavioral disturbance. She commented that it was the Veteran’s primary issue and the cause of his severe impairments in functioning. She added that the neurocognitive symptoms are most prominent and while the Veteran appeared to be experiencing a few symptoms of PTSD, he did not appear to meet the full criteria. The examiner found that total occupational and social impairment best summarized the Veteran’s level of occupational and social impairment with regard to all mental diagnoses. She noted that the Veteran had two prior PTSD examinations and in neither examination was diagnosed with PTSD. The Veteran’s wife stated that the Veteran had a stroke which prevented him from returning to work and that he had the job for two years and denied any problems on the job. The Veteran was casually dressed with good grooming and hygiene at the examination. He did not speak spontaneously and often turned to his wife to provide information. He denied suicidal and homicidal ideation and was not oriented to date but was orientated to person and state. He was administered SLUMS for memory and scored a 12 out of 30, which is in the dementia range. Symptoms attributable to PTSD were noted as sleep disturbance and a decline in energy/motivation. The Veteran also felt down and depressed at times but did not spontaneously report a number of symptoms of depression. The examiner noted that it was difficult to determine the severity and duration of depression due to cognitive impairments and that the Veteran also had problems with irritability at times. The Veteran’s wife reported that he did not like being around a lot of people or large crowds and could jump easily. The Veteran did not spontaneously report a number of symptoms of PTSD and his wife often had to prompt him to report symptoms. The Veteran dreamed about the war occasionally, once every six months or so and that he would “sometimes” think about war during the daytime, which would upset him but “not often.” The Veteran’s wife also reported some mild problems with hyperarousal. The examiner found that the Veteran did not appear to meet full criteria for PTSD and did have some problems with irritability that could be related neurocognitive disorder and associated mood disturbance. The Veteran was not competent to manage his finances due to major neurocognitive disorder. The 50 percent rating contemplates symptoms, such 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, and difficulty in establishing and maintaining effective work and social relationships. The Veteran’s PTSD symptoms do not rise to the level of severity of these types of symptoms, which is explained in detail below. The Veteran mainly had issues with memory and in the examinations discussed above, medical professionals have found the Veteran did not even reflect symptomatology that met the diagnostic criteria for PTSD. The symptoms which the examiners found total occupational and social impairment were from the Veteran’s dementia and the significant cognitive impairment that came from it. The March 2013 VA examiner found that it was less likely than not that the Veteran was unemployable due to any other mental disorder alone and that he had been working part time as a driver until his stroke in 2010. She specified that it is estimated that 90 percent of the current impairment is due to the cognitive impairment of dementia and explained that prior to the impaired cognition following a stroke, he was living independently and still working part time at age 76. This is consistent with the Veteran’s wife report during the October 2017 examination, specifically, the Veteran had a stroke which prevented him from returning to work and that he previously held a job for two years and denied any problems on that job. There is no documentation of the Veteran having psychotic symptoms, and the Veteran has consistently denied having psychotic symptoms. Thus, the evidence reflects that the Veteran’s occupational and social impairment were from the Veteran’s dementia that was exacerbated after his stroke in 2010, for which service-connection was denied herein, and not his service-connected PTSD. Aside from the notation in the January 2011 VA examination report, which was a history in the year prior, the record shows that the Veteran has consistently denied suicidal ideation, intent, or plan, and he was deemed to be a low suicide risk in VA treatment records since the January 2011 examination. Specifically, August 2010 VA medical records reflect that suicidal thoughts occurred in 2003. The facts of this case are distinguishable from Bankhead v. Shulkin, 29 Vet. App. 10 (2017), in which the Court held that the presence of suicidal ideation alone may cause occupational and social impairment with deficiencies in most areas (a 70 percent disability rating under 38 C.F.R. § 4.130). Under the facts of Bankhead, the claimant was noted to have had recurrent suicidal thoughts and behaviors of varying severity, frequency, and duration throughout the relevant appeal period. Here, the January 2011 VA examination report shows that while the Veteran reported a history of suicidal ideation, he did not have any at the current time, with no intent or plan. Further, he indicated that his spiritual beliefs would prevent him from acting on suicidal ideation and thus this statement did not amount to the level of occupational and social impairment contemplated by the 70 percent disability rating. The Board notes that VA treatment records and VA examination reports covering a nine-year period overwhelmingly reflect that the Veteran has denied suicidal ideation, which the Board finds is evidence against suicidal ideation. The January 2013 statement does not more nearly approximate occupational and social impairment with deficiencies in most areas, but rather reflects a lesser degree of impairment that is contemplated by the 30 percent rating assigned, which 30 percent rating contemplates exacerbations of the disability. The Board has fully considered the frequency, severity, and duration of all of the Veteran’s psychiatric symptoms with respect to their effect on other areas of overall occupational and social functioning. 38 C.F.R. § 4.126(a). The Veteran has previously contended that a higher rating percentage is warranted based on a lowered GAF score, however, the Board notes that the use of the GAF scale has been abandoned in the DSM-5 because of, among other reasons, “its conceptual lack of clarity” and “questionable psychometrics in routine practice.” See Diagnostic and Statistical Manual for Mental Disorders, Fifth edition, p. 16. A thorough review of the symptomology of the Veteran’s PTSD during the appeal period does not more closely reflect the level of symptomatology that falls under the 50 percent or greater rating. The Board has accorded more probative value to the clinical findings made by medical professionals and treatment providers. For all the above reasons, the Board finds the preponderance of the evidence is against a finding that the Veteran’s PTSD symptoms demonstrated occupational and social impairment with reduced reliability and productivity to warrant an increased 50 percent rating. Thus, the Board finds no higher than a 30 percent evaluation is warranted for the Veteran’s PTSD symptoms. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application, and the claim is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. 3. Entitlement to SMC based on the need for regular aid and attendance of another person. Compensation at the aid and attendance rate is payable when the veteran, due to service-connected disability, has suffered the anatomical loss or loss of use of both feet or one hand and one foot, or is blind in both eyes, or is permanently bedridden or so helpless as to be in need of regular aid and attendance. 38 U.S.C. § 1114(l); 38 C.F.R. § 3.350(b). Determinations as to the need for regular aid and attendance are factual and must be based upon the actual requirements for personal assistance from others. In making such determinations, consideration is given to such conditions as: the inability of the claimant to dress or undress himself, or to keep himself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without assistance; the inability of the claimant to feed himself through loss of coordination of upper extremities or through extreme weakness; the inability to attend to the wants of nature; or incapacity, either physical or mental, which requires care or assistance on a regular basis to protect a claimant from hazards or dangers incident to one’s daily environment. It is not required that all of the disabling conditions enumerated be present before a favorable rating is made. The particular personal functions that the claimant is unable to perform should be considered in connection with his condition as a whole. It is only necessary that the claimant be so helpless as to be in need of regular aid and attendance, not that there is a constant need. “Bedridden” constitutes a condition which, through its essential character, actually requires that an individual remain in bed. The fact that a claimant has voluntarily taken to bed, or that a physician has prescribed bed rest for a lesser or greater portion of the day will not suffice. 38 C.F.R. § 3.352(a). In Turco v. Brown, 9 Vet. App. 222, 224 (1996), the Court held that eligibility for special monthly compensation by reason of regular need for aid and attendance requires that at least one of the factors set forth in VA regulation is met. In addition, determinations that the claimant is so helpless as to be in need of regular aid and attendance will not be based solely upon an opinion that the claimant’s condition is such as would require him or her to be in bed. They must be based on the actual requirement of personal assistance from others. See Turco, 9 Vet. App. at 224. Following a review of the evidence of record, the Board finds that the preponderance of evidence weighs against the Veteran’s claim of entitlement to SMC based on the need for aid and attendance. At the time of the Veteran’s death, he was in receipt of service connection for posttraumatic stress disorder (PTSD) and bilateral hearing loss. In an October 2014 statement, the appellant and the Veteran indicated that the Veteran needed daily assistance to complete tasks, encouragement to engage in tasks, had cognitive difficulties, confused about dates, time, month, etc., and had impaired coordination. It was noted that the Veteran could not be left alone and could not do things such as climbing ladders, mowing lawn, driving, etc. that he was able to do before and now was diabetic and had prostate cancer. The Veteran proffered an April 2010 “attendant affidavit” from S.B. which lists the multiple services provided for the Veteran. An April 2013 letter from a private physician also notes that the Veteran had a history of multiple medical problems including spinal stenosis of the lumbar spine, degenerative disc disease, chronic kidney disease, cerebrovascular and cardiovascular disease, hypertension and insulin dependent diabetes. The physician indicated that the Veteran required assistance from his caregiver for all activities of daily living and only left home with the assistance of the caregiver. He stated that he was in the opinion that the Veteran was permanently disabled. The Veteran also submitted an “attendant affidavit” from J.N.H. dated April 2015. Based upon the evidence of record, the Board concludes that the preponderance of evidence weighs against the Veteran’s claim of entitlement to SMC based on the need for aid and attendance. While the Board acknowledges that the Veteran’s reports that required assistance, the evidence does not establish that the Veteran is in need for regular aid and attendance of another person to dress or undress himself, to keep himself ordinarily clean and presentable, to attended to the wants of nature, and to protect him from the hazards or dangers incident to his daily environment due to his service-connected disabilities. For example, a June 2010 examination for household status or permanent need for regular aid and attendance form (VA 21-2680) reflects a complete diagnosis of diabetes, muscle weakness, kidney disease, gastroesophageal reflux, constipation, lack of coordination, cerebrovascular accident, and hypertension. The disabilities listed which restrict his activities/functions were cognitive and impaired coordination. An April 2013 VA 21-2680 lists disabilities of diabetes, hypertension, atherosclerotic cardiovascular disease, and dementia. Upon VA examination for his service-connected PTSD in March 2013, the examiner noted that Veteran was unable to find and maintain gainful employment due to the cognitive impairments of dementia. The examiner found that it was less likely than not that the Veteran was unemployable due to any other mental disorder alone and that he had been working part time as a driver until his stroke in 2010. While she found that total occupational and social impairment best summarized the Veteran’s level of occupational and social impairment with regards to all mental diagnoses, she specified that it is estimated that 90 percent of the current impairment is due to the cognitive impairment of non-service connected dementia and explained that prior to the impaired cognition following a stroke, he was living independently and still working part time at age 76. Thus, only 10 percent was due to his service-connected PTSD. This is consistent with the Veteran’s wife report during the October 2017 examination, specifically, the Veteran had a stroke which prevented him from returning to work and that he previously held a job for two years and denied any problems on that job. A May 2019 letter from a private medical facility indicates that the Veteran was admitted to hospice with a terminal diagnosis of cerebral atherosclerosis with other health history including CVA, chronic kidney disease, diabetes, dementia, glaucoma, gastroesophageal reflux disease (GERD), and anxiety. It was noted that he had a significant decline in the preceding three months and was at that time bedbound and dependent in six out of six activities of daily living (ADL’s), but three months prior was up independently and required very little assistance with ADL’s. The Veteran is not in receipt of service-connection for a lumbar spine disability, degenerative disc disease, chronic kidney disease, cerebrovascular and cardiovascular disease, hypertension, diabetes, GERD, muscle weakness, etc., and his memory loss and cognitive issues has been largely attributed to non-service-connected dementia by a VA examiner. The Veteran also had been treated for non-service-connected disabilities that contributed to the Veteran’s claimed need for aid and attendance. The evidence does not support a finding that the symptomatology associated with the service-connected PTSD and hearing loss alone caused him to require the aid and assistance of another or permanently bedridden. In summary, the Board finds the preponderance of the evidence is against a finding that SMC based on the need for the regular aid and attendance of another person is warranted. As the preponderance of the evidence is against the claim, there is no reasonable doubt to be resolved, and the claim for SMC is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Cheng, 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.