Citation Nr: 21064294 Decision Date: 10/19/21 Archive Date: 10/19/21 DOCKET NO. 14-13 114 DATE: October 19, 2021 ORDER Entitlement to service connection for a cervical spine disorder, including as secondary to service-connected disabilities, is denied. Entitlement to service connection for a right hip disorder, including as secondary to service-connected disabilities, is denied. Entitlement to service connection for a left hip disorder, including as secondary to service-connected disabilities, is denied. Entitlement to service connection for a lumbar spine disorder, including as secondary to service-connected disabilities, is denied. Entitlement to service connection for bilateral hearing loss is granted. Entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD), including as secondary to service-connected disabilities, is denied. Entitlement to special monthly compensation (SMC) on the basis of housebound status is denied. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is granted, effective October 6, 2015. REMANDED Entitlement to special monthly compensation (SMC) on the basis of aid and attendance is remanded. FINDINGS OF FACT 1. The Veteran's cervical spine disorder was not manifested in service and is not attributable to service; a cervical spine disorder is not caused or aggravated by a service-connected disability. 2. The Veteran's right hip disorder was not manifested in service and is not attributable to service; a right hip disorder is not caused or aggravated by a service-connected disability. 3. The Veteran's left hip was not manifested in service and is not attributable to service; a left hip disorder is not caused or aggravated by a service-connected disability. 4. The Veteran's lumbar spine disorder was not manifested in service and is not attributable to service; a lumbar spine disorder is not caused or aggravated by a service-connected disability. 5. Bilateral hearing loss is attributable to service. 6. The Veteran's psychiatric disorder was not manifested in service and is not attributable to service; a psychiatric disorder is not caused or aggravated by a service-connected disability. 7. The Veteran does not have a single service-connected disability rated 100 percent disabling, with additional service-connected disability or disabilities independently ratable at 60 percent or more; nor is he shown to be permanently housebound by reason of his service-connected disabilities. 8. Since October 6, 2015, the Veteran's service-connected disabilities render him unable to engage and retain substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for service connection for a cervical spine disorder have not been met. 38 U.S.C. §§ 1101, 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2020). 2. The criteria for service connection for a right hip disorder have not been met. 38 U.S.C. §§ 1101, 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2020). 3. The criteria for service connection for a left hip disorder have not been met. 38 U.S.C. §§ 1101, 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2020). 4. The criteria for service connection for a lumbar spine disorder have not been met. 38 U.S.C. §§ 1101, 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2020). 5. The criteria for service connection for bilateral hearing loss disability have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.385 (2020). 6. The criteria for service connection for a psychiatric disorder have not been met. 38 U.S.C. §§ 1101, 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2020). 7. The criteria for SMC at the housebound rate have not been met. 38 U.S.C. § 1114; 38 C.F.R. §§ 3.350, 3.352 (2020). 8. Since October 6, 2015, the criteria for TDIU are met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16, 4.18 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from April 1965 to March 1967. These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions in September 2012 and April 2016 by the Department of Veterans Affairs (VA) Regional Office (RO). In the September 2012 rating decision, the RO, in pertinent part, denied service connection for a left hip disability, a neck disability, hearing loss, a right hip disability, a low back disability, and a nervous condition; the rating decision also denied a TDIU. In the April 2016 rating decision, the RO, in pertinent part, denied SMC based on housebound status and/or aid and attendance. In June 2018 and October 2020, the Board remanded the Veteran's claims to the Agency of Original Jurisdiction (AOJ). A supplemental statement of the case was most recently issued in June 2021. The case has since been returned to the Board for appellate review. The Board finds that there was substantial compliance with its remand orders. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268, 271 (1998). 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; 38 C.F.R. § 3.303(a) (2020). 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 servicethe so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. For chronic diseases, if chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § § 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310. At the outset, the Board notes that the Veteran does not allege, and the evidence does not show, that the Veteran was exposed to combat during service. As such, the provisions of 38 U.S.C. § 1154 are not applicable in this case. 1. Entitlement to service connection for a cervical spine disorder, including as secondary to service-connected disabilities. 2. Entitlement to service connection for a right hip disorder, including as secondary to service-connected disabilities. 3. Entitlement to service connection for a left hip disorder, including as secondary to service-connected disabilities. 4. Entitlement to service connection for a lumbar spine disorder, including as secondary to service-connected disabilities. 5. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, including as secondary to service-connected disabilities. Based on the evidence of record, the Board finds that the Veteran's claims of entitlement to service connection for cervical and lumbar spine disorders, right and left hip disorders, a psychiatric disorder, including as secondary to service-connected disabilities, are denied. The Board observes that the Veteran does not contend that his cervical spine disorder, lumbar spine disorder, right and left hip disorders, and psychiatric disorder began in service; instead, the Veteran alleges that his cervical spine disorder, lumbar spine disorder, right and left hip disorders, and psychiatric disorder are the result of his service-connected disabilities. Nevertheless, the Board observes that the medical evidence does not reflect that the Veteran experienced a cervical spine disorder, a lumbar spine disorder, right and left hip disorders, or a psychiatric disorder during service or within one year of separation. Additionally, there is nothing to suggest that there were characteristic manifestations sufficient to identify a cervical spine disorder, a lumbar spine disorder, right and left hip disorders, or a psychiatric disorder during service or within one year of separation. 38 C.F.R. § 3.303(b). There is no diagnosis of PTSD based on any claimed stressor or fear of hostile military or terrorist activity; the Appellant did not engage in combat with the enemy, and there is no credible evidence corroborating any of the Appellant's alleged in-service stressors. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability); see also 38 C.F.R. § 3.304(f). Further, there is no competent evidence of a relationship between the Veteran's cervical spine disorder, lumbar spine disorder, right and left hip disorders, or a psychiatric disorder and his active service. His cervical and lumbar spine disorders have been linked to the Veteran's age and body composition, and his right and left hip disorders have been related to the Veteran's post-service lumbar spine injury. Moreover, the October 2019 VA examiner indicated that the Veteran's lumbar spine injury in 1965 was acute and resolved; the VA examiner noted that the Veteran had no further complaints related to his low back until over 30 years after service, which was subsequent to the post-service work-related injury. Additionally, the March 2021 VA examiner indicated that the Veteran's anxiety disorder is not related to and did not have its onset in service. Thus, service connection on a direct basis, is not supported by the record and is denied. Turning to secondary service connection, the Veteran is service connected for obstructive sleep apnea, chronic sinusitis, migraine headaches, pes planus, right shoulder sprain, left shoulder tendonitis, right neck scar, residuals of a left ankle fracture, gastroesophageal reflux disease, right and left lower extremity peripheral neuropathy, right ankle fracture residuals, bilateral metatarsalgia, and allergic rhinitis. The Veteran has been diagnosed with and treated for cervical disc disease, degenerative joint disease of the lumbar spine, anxiety disorder and major depressive disorder, and right and left hip trochanter bursitis. Review of the record shows that the Veteran's treating providers, as well as the October 2019, March 2021, and April 2021 VA examiners, have not linked the Veteran's cervical disc disease, degenerative joint disease of the lumbar spine, anxiety disorder and major depressive disorder, and right and left hip trochanter bursitis to any of his service-connected disabilities. There is also no indication that the Veteran's cervical disc disease, degenerative joint disease of the lumbar spine, anxiety disorder and major depressive disorder, and right and left hip trochanter bursitis were aggravated by his service-connected disabilities. In particular, the March 2021 and April 2021 VA examiners noted that the Veteran was first treated for cervical disc disease and lumbar spine degenerative joint disease, as well as psychiatric and right and left hip complaints more than 30 years after separation. The March 2021 VA PTSD examination report indicated that the Veteran initially attributed his psychiatric complaints to occupational stressors. As discussed earlier, the Veteran's cervical disc disease and lumbar spine degenerative joint disease were attributed to his age and body composition. To the extent that the September 2020 Disability Benefits Questionnaire (DBQ) attributes the Veteran's major depressive disorder to his service-connected disabilities, the Board points out that the March 2021 VA examiner, a psychiatrist, noted that the DBQ was completed by a primary care physician, without the requisite training to determine the etiology of the Veteran's major depressive disorder. Moreover, the March 2021 VA examiner noted that timing and nature of the Veteran's symptoms, as well as the lack of need for crisis intervention, inpatient psychiatric treatment, or consistent mental health service reflect that the Veteran's psychiatric disorder was neither caused by, nor aggravated beyond its natural progression, by the Veteran's service-connected disabilities. Moreover, regarding the Veteran's cervical and lumbar spine disorders, and his right and left hip disorders, the March 2021 and April 2021 VA examiners concluded that these disorders are not proximately due to or the result of Veteran's service-connected disabilities. The March 2021 and April 2021 VA cervical spine, lumbar spine, and hip examiners noted that the Veteran's cervical spine disc disease, lumbar spine degenerative disc disease, and right and left hip bursitis were not proximately due to or aggravated by the Veteran's service-connected disabilities because there was no pathophysiological or anatomical relationship between his right and left ankle disabilities, and his neck, hips, and back; the VA examiners noted that the Veteran, upon physical examination, did not demonstrate any evidence of antalgic gait, weight-shifting during ambulation, or other restricted movement which would suggest such a relationship. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). To the extent that there are lay statements, including those of the Veteran, asserting a connection between the Veteran's cervical disc disease, degenerative joint disease of the lumbar spine, anxiety disorder and major depressive disorder, and right and left hip trochanter bursitis and his service-connected disabilities, the Board finds that the determining the etiology of the Veteran's cervical disc disease, degenerative joint disease of the lumbar spine, anxiety disorder and major depressive disorder, and right and left hip trochanter bursitis is beyond the competence of a lay person. While the Veteran is competent to report pain, anxiety, depressed mood, and other observable symptoms, related to the Veteran's cervical disc disease, degenerative joint disease of the lumbar spine, anxiety disorder and major depressive disorder, and right and left hip trochanter bursitis, the cause of those symptoms and whether those symptoms are caused or aggravated by another disability, are medical questions that require medical training, knowledge, and expertise. Thus, the Veteran's and the other lay opinions are not competent evidence of a nexus or aggravation. Further, even if the lay statements were to be found competent, the Board finds that the probative value of the general lay assertions is outweighed by the specific, well-reasoned opinion of the October 2019, March 2021, and April 2021 VA opinions and the clinical evidence of record. The VA examiners explained the reasons for the conclusions reached and based the findings on an accurate characterization of the evidence of record. For the foregoing reasons, the most probative evidence of record preponderates against the claim for service connection for cervical disc disease, degenerative joint disease of the lumbar spine, a psychiatric, and right and left hip trochanter bursitis secondary to service-connected disabilities. 6. Entitlement to service connection for bilateral hearing loss. The Veteran contends that he has bilateral hearing loss that was incurred during active service. The Board acknowledges that the Veteran's military occupational specialty (MOS) is field artillery basic, and that this had a high probability for hazardous noise exposure. The threshold for normal hearing is from 0 to 20 decibels. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). For the purposes of applying the laws administered by VA, impaired hearing is considered a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The Veteran's service records appear to contain only whisper voice testing to determine his hearing levels at entry. Nonetheless, an audiogram was performed at his February 1967 separation examination. The Board notes that prior to January 1, 1967, audiometric results were reported in standards set forth by the American Standards Association (ASA). Since December 31, 1970, the International Standards Organization - American National Standards Institute (ISO-ANSI) standards generally have been used. Audiometric data originally recorded using ASA standards is converted to the ISO-ANSI standard by adding between 5 and 15 decibels to the recorded data as follows: HERTZ 500 1000 2000 3000 4000 ADD 15 10 10 20 5 To facilitate data comparison, the Board has converted the ASA standards from the Veteran's February 1967 audiometric testing to the ISO-ANSI standards with the conversions represented by the figures on the right in each column in parentheses. The February 1967 audiological testing showed that the Veteran's pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 (15) 0 (10) 0 (10) --- 0 (5) LEFT 0 (15) 0 (10) 0 (10) --- 0 (5) As previously discussed, the Veteran had hazardous noise exposure, as his military occupational specialty was field artillery. At the October 2011 VA examination, audiometric testing showed: HERTZ 500 1000 2000 3000 4000 RIGHT 20 20 25 45 50 LEFT 20 25 25 45 50 Pure-tone threshold averages were 35 on the right and 36 on the left, and Maryland CNC testing was 96 percent on the right and 96 percent on the left. At the August 2020 VA examination, audiometric testing showed: HERTZ 500 1000 2000 3000 4000 RIGHT 20 25 25 45 50 LEFT 20 20 25 40 50 Pure-tone threshold averages were 36 on the right and 34 on the left, and Maryland CNC testing was 100 percent on the right and 100 percent on the left. At the October 2011 VA examination, the VA examiner opined that the Veteran's bilateral hearing loss was not likely incurred in or caused by the Veteran's noise exposure during service because the Veteran had normal hearing at separation, despite exposure to heavy artillery noise; the VA examiner noted that other factors such as the normal aging process are for consideration, as aging can result in permanent hearing loss. The VA examiner also opined that the Veteran's bilateral hearing loss was at least as likely as not (50 percent or greater probability) proximately due to or the result of the Veteran's service-connected tinnitus. The VA examiner stated that prolonged exposure to high intensity noise, such as that experienced by the Veteran during his military service, can cause damage to inner ear structures resulting in permanent hearing loss and/or tinnitus. The VA examiner acknowledged that tinnitus is a subjective symptom that is usually secondary to hearing loss, but found that, because the Veteran had normal hearing bilaterally at separation, no relationship between the Veteran's service-connected tinnitus and his bilateral hearing loss could be established. Nevertheless, the VA examiner found that the Veteran's now service-connected tinnitus is likely caused by or the result of military noise exposure; the VA examiner explained that the Veteran's tinnitus is likely related to the Veteran's bilateral hearing loss because tinnitus is a symptom associated with hearing loss. At the October 2019 VA examination, the VA examiner opined that it was unlikely that the Veteran's bilateral hearing loss was caused by or the result of the Veteran's military service, including his service-connected tinnitus. In the rationale, the VA examiner noted that the Veteran's service treatment records and February 1967 separation examination did not reflect hearing loss. The VA examiner also noted that there is no evidence of complaints of hearing loss for approximately 50 years after service. The VA examiner acknowledged that the medical literature indicates that exposures to high intensity noise levels can cause permanent or progressive hearing loss during prolonged periods of exposure, but did not have an effect on hearing years after high intensity noise exposure. The VA examiner found that it is "highly probable" that the Veteran's bilateral high frequency hearing loss is due to presbycusis or agerelated hearing loss, or a combination of both the aging process and noise exposure. Regarding bilateral hearing loss disability, the Board finds that the evidence of record demonstrates that service connection is warranted. Regarding bilateral hearing loss disability, as previously discussed, the results of his October 2011 and October 2019 audiological examinations confirm that he has sufficient hearing loss in both of his ears to meet the threshold minimum requirements of 38 C.F.R. § 3.385 to be considered an actual "disability." The Board acknowledges that bilateral hearing loss for VA disability purposes was not shown during service or at separation, but nonetheless points out that the absence of evidence of bilateral hearing loss at separation or for many years after is not determinative as to whether bilateral hearing loss is related to military service and does not preclude service connection of bilateral hearing loss in this case. To this point, the Board notes that, although the Veteran did not have bilateral hearing loss for VA disability purposes at separation, it is impossible to determine if the Veteran's hearing worsened during his active service. See Hensley at 159 (the absence of hearing loss disability in service is not in and of itself fatal to a claim for service connection for bilateral hearing loss disability). Moreover, to the extent that the Veteran's in-service noise exposure is not in question, the Veteran is currently service-connected for tinnitus related to that noise exposure, and tinnitus is causally related to bilateral hearing loss on a secondary basis, it defies logic to find that the Veteran's tinnitus is related to military noise exposure, but that his hearing loss is not. In this regard, the Board notes that the October 2011 VA examiner essentially conceded this point in opining that the Veteran's service-connected tinnitus was caused by military noise exposure and that the Veteran's bilateral hearing loss and tinnitus share the same etiology because tinnitus is a symptom associated with hearing loss. The Veteran's competent and credible statements thus provide a nexus linking his current bilateral hearing loss disability to his in-service noise exposure; harmful noise exposure is consistent with the conditions of his service. Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2008) (lay evidence may suffice to prove service connection on its own merits). In this regard, the Board notes that the Veteran has credibly stated that he experienced decreased hearing since the time of his in-service noise exposure. The Board acknowledges that the October 2011 and October 2019 VA examiners found that the Veteran's bilateral hearing loss disability was less likely than not caused by exposure to hazardous noise during service because service treatment records indicate that the Veteran did not experience difficulty hearing in service and the Veteran did not have hearing loss sufficient to constitute a disability at separation from service. However, the Board finds these VA examination reports inadequate because the examiners did not consider the Veteran's credible lay statements regarding hearing loss since service. Hence, on this record, the evidence is found to be at least evenly balanced in showing that the Veteran's bilateral hearing loss disability is at least as likely as not had clinical onset following his exposure to harmful noise levels in connection with his period of active duty. In resolving all reasonable doubt in the Veteran's favor, service connection is granted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Special Monthly Compensation 7. Entitlement to SMC on the basis of housebound status. Under 38 U.S.C. § 1114(s), special monthly compensation at the housebound rate is payable if, in addition to having a single permanent service-connected disability rated 100 percent disabling under the VA's Schedule for Rating Disabilities, the Veteran: has additional service-connected disability or disabilities independently ratable at 60 percent or more, separate and distinct from the permanent disability rated as 100 percent disabling and involving different anatomical segments or bodily systems, or, is "permanently housebound" by reason of service-connected disability. Although no additional disability compensation may be paid when a total schedular disability rating is already in effect, a separate award of a total disability rating based on individual unemployability (TDIU) predicated on a single disability may form the basis for an award of special monthly compensation. See Bradley v. Peake, 22 Vet. App. 280 (2008). The requirement of "permanently housebound" is met when the Veteran is substantially confined to his or her dwelling and the immediate premises or, if institutionalized, to the ward or clinical area, and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his or her lifetime. 38 C.F.R. § 3.351(d). Regarding entitlement to SMC at the housebound rate, the Board observes that the Veteran does not have single disability rated at 100 percent. Moreover, the grant of TDIU, as discussed below, is not predicated on a single service-connected disability. However, even if a single disability formed the basis of the Board's grant of TDIU, he does not have additional service-connected disability or disabilities independently ratable at 60 percent or more. Additionally, there is no persuasive evidence that he is permanently housebound by reason of his service-connected disabilities. For all the foregoing reasons, the Board finds that special monthly compensation at the housebound rate, is not warranted. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application, and the claim must be denied. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). TDIU 8. Entitlement to TDIU. VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that a veteran is precluded, by reason of his service- connected disabilities, from obtaining and maintaining any form of gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. A TDIU may be granted only when it is established that the service-connected disabilities are so severe, standing alone, as to prevent the retaining or obtaining of substantially gainful employment. If there is only one service-connected disability, it must be ratable at 60 percent or more to qualify for benefits based on individual unemployability. If there are two or more such disabilities, there must be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). For purposes of this section, disabilities of both upper or lower extremities will be considered a single disability. 38 C.F.R. § 4.16(a)(1). Veterans who, in light of their individual circumstances, but without regard to age, are unable to secure and follow a substantially gainful occupation as the result of service-connected disability shall be rated totally disabled, without regard to whether an average person would be rendered unemployable by the circumstances. Thus, the criteria include a subjective standard. Unemployability is synonymous with inability to secure and follow a substantially gainful occupation. VAOPGCPREC 75-91; 57 Fed. Reg. 2,317 (1992). "Substantially gainful employment" is that employment "which is ordinarily followed by the nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the veteran resides." Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). "Marginal employment shall not be considered substantially gainful employment." 38 C.F.R. § 4.16(a) (2020). The Veteran seeks entitlement to TDIU based on his service-connected disabilities. The Veteran submitted a completed VA Form 21-8940 (Application for Increased Compensation Based on Unemployability) in September 2011. The Veteran indicated that he had a college education and stopped working as a teacher in January 2005. The Veteran indicated that he stopped working due to his service-connected disabilities but that he receives retirement benefits and Social Security benefits unrelated to his disabilities. The Veteran also indicated that he has not sought employment or additional training since becoming too disabled to work. The Veteran is in receipt of a 50 percent disability evaluation for obstructive sleep apnea, effective December 3, 2015; a 50 percent disability evaluation for chronic sinusitis, effective April 30, 2019; a 50 percent disability evaluation for migraine headaches, effective April 30, 2019; a 50 percent disability evaluation for bilateral pes planus with heel valgus, effective April 23, 2021 (previously rated as 10 percent disabling from October 6, 2015); a 20 percent disability evaluation for right shoulder strain with tendonitis, effective October 6, 2015; a 20 percent disability evaluation for left shoulder tendonitis, effective October 6, 2015; a 10 percent disability evaluation for right neck scar, effective March 3, 1981; a 20 percent disability evaluation for residuals of a right ankle fracture, effective October 19, 2015 (previously rated as 10 percent disabling from August 27, 1979); a 10 percent disability evaluation for residuals of a left ankle fracture, effective October 19, 2010; a 10 percent disability evaluation for tinnitus, effective June 2, 2011; a 10 percent disability evaluation for gastroesophageal reflux disease, effective June 2, 2011; a 10 percent disability evaluation for bilateral metatarsalgia, effective October 6, 2015; a 10 percent disability evaluation, per lower extremity, for peripheral neuropathy, effective October 6, 2015; and a noncompensable disability evaluation for allergic rhinitis, effective April 30, 2019. The Veteran had a combined disability evaluation of 80 percent, effective October 6, 2015, and a combined disability evaluation of 90 percent, effective December 3, 2015; a combined 100 percent disability evaluation was assigned, effective April 30, 2019. See 38 C.F.R. § 4.25. Given that disabilities of both lower extremities and both upper extremities are considered one disability under 38 C.F.R. § 4.16(a)(1), the Veteran met the schedular criteria for TDIU under section 4.16(a) effective October 6, 2015. VA's General Counsel has concluded that the controlling VA regulations generally provide that Veterans who, in light of their individual circumstances, but without regard to age, are unable to secure and follow a substantially gainful occupation as the result of service-connected disability shall be rated totally disabled, without regard to whether an average person would be rendered unemployable by the circumstances. Thus, the criteria include a subjective standard. It was also determined that "unemployability" is synonymous with inability to secure and follow a substantially gainful occupation. VAOPGCPREC 75-91; 57 Fed. Reg. 2,317 (1992). For a Veteran to prevail on a claim based on unemployability, it is necessary that the record reflect some factor which places the claimant in a different position than other Veterans with the same disability rating. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is a recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the particular Veteran is capable of performing the physical and mental acts required by employment, not whether that Veteran can find employment. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Based on the evidence of record, the Board finds that, as of October 6, 2015, the Veteran's service-connected disabilities render the Veteran unable to obtain or sustain substantially gainful employment for the rating period on appeal. The Board acknowledges that the October 2011 TDIU examination report indicates that the VA examiner found that the Veteran's service-connected disabilities did not render him unemployable, and that the Veteran is able to sustain a gainful occupation with reasonable accommodations; the VA examiner found that the Veteran was capable of light sedentary or semi-sedentary work that did not require prolonged walking or standing. However, the Veteran's August 2019 VA headache examination report indicates that the Veteran's service-connected headaches render him unable to obtain to obtain and maintain gainful employment. Likewise, a review of the Veteran's treatment records and additional VA examination reports indicates that the Veteran's service-connected disabilities, in combination, are productive of symptomatology that contribute to his difficulty performing occupational tasks. In this regard, the Board notes that the Veteran's VA examination reports and treatment records indicate that the Veteran cannot stand or walk for prolonged periods, lift items weighing more than 10 pounds, or perform certain repetitive tasks, and that the Veteran experiences daytime hypersomnolence due to his service-connected obstructive sleep apnea. As such, the Board finds that the evidence of record reflects symptomatology that supports the Veteran's contentions that he is unable to perform the physical and mental acts required to be employable as of October 6, 2015. See Van Hoose, supra. As a result, the Veteran's service-connected disabilities prevent him from obtaining and maintaining substantial gainful employment. REASONS FOR REMAND 1. Entitlement to special monthly compensation (SMC) on the basis of aid and attendance. Given that service connection was granted for bilateral hearing loss and that the Veteran was awarded a TDIU herein, the Board finds that additional development is required as to the Veteran's claim of entitlement to SMC on the basis of aid and attendance. Although the Board granted TDIU based on the combined effects of the Veteran's service-connected disabilities, the Board observes that the AOJ found that the Veteran is permanently and totally disabled due to a service-connected disability effective April 30, 2019. However, the AOJ did not explain its reasoning or specify which disability rendered the Veteran permanently and totally disabled. Although no additional disability compensation may be paid when a total schedular disability rating is already in effect, a separate award of a total disability rating based on individual unemployability (TDIU) predicated on a single disability may form the basis for an award of special monthly compensation. See Bradley v. Peake, 22 Vet. App. 280 (2008). Moreover, it is unclear from the record whether the Veteran requires aid and attendance due to his service-connected disabilities. SMC is available when, as the result of service-connected disability, a Veteran suffers additional hardships above and beyond those contemplated by VA's schedule for rating disabilities. See 38 U.S.C. § 1114; 38 C.F.R. § § 3.350, 3.352. The rate of SMC varies according to the nature of the Veteran's service-connected disabilities. Basic levels of SMC are listed at 38 U.S.C. § 1114(k). Higher levels of SMC are provided at 38 U.S.C. § 1114 (l) through (t). Subsection (l) addresses SMC for Veterans with anatomical loss or loss of use of both feet, or of one hand and one foot, or blindness with visual acuity of 5/200 or less, or permanently bedridden, or with such significant disabilities as to be in need or regular aid and attendance. 38 U.S.C. § 1114(l). The following factors will be considered in determining whether the Veteran is entitled to SMC based on the need for aid and attendance: inability of claimant to dress or undress without assistance; to keep ordinarily clean and presentable without assistance; inability of claimant to feed himself or herself without assistance; inability to attend to the wants of nature; and incapacity that requires care or assistance on a regular basis to protect the claimant from the hazards or dangers incident to his or her daily environment. 38 C.F.R. § 3.352(a). The Board observes that the Veteran has not been afforded a VA aid and attendance examination, and thus, it is unclear whether the Veteran requires regular aid and attendance due to his service-connected disabilities. 38 U.S.C. § 1114(l). The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination for housebound status or permanent need for regular aid and attendance by an appropriate clinician to determine the current level of severity of all impairment resulting from his service-connected disabilities. The claims folder, including a copy of this remand, should be made available to the examiner for review prior to the examination. The examiner should acknowledge such review in the examination report. After examining the Veteran and reviewing the record, the examiner should address whether the Veteran is so helpless or so nearly helpless as to require the regular aid and attendance of another person due to his service-connected disabilities. 2. After completing all indicated development, if the claim remains denied, the Veteran should be furnished with a supplemental statement of the case and afforded a reasonable opportunity for response. GAYLE STROMMEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board H. Brokowsky, 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.