Citation Nr: 21064692 Decision Date: 10/21/21 Archive Date: 10/21/21 DOCKET NO. 18-47 231 DATE: October 21, 2021 ORDER Entitlement to service connection for a sinus disability is granted on a presumptive basis as due to exposure to particulate matter. Entitlement to a compensable rating for proctitis, external hemorrhoids, status post hemorrhoidectomy with anal pruritis is denied. Entitlement to a compensable rating for erectile dysfunction is denied. Entitlement to a compensable rating for bilateral pterygium is denied. Entitlement to an evaluation of 10 percent, but no higher, from December 28, 2013, for radiculopathy of the left lower extremity is granted. Entitlement to an evaluation of 10 percent, but no higher, from December 28, 2013, for radiculopathy of the right lower extremity is granted. Entitlement to an evaluation in excess of 10 percent prior to August 3, 2020, for degenerative disc disease of the lumbar spine with thoracolumbar strain is denied. Entitlement to an evaluation of 20 percent, but no higher, from August 3, 2020, for degenerative disc disease of the lumbar spine with thoracolumbar strain is granted. Entitlement to an evaluation in excess of 30 percent for tension headaches is denied. Entitlement to an evaluation in excess of 50 percent prior to January 23, 2019 for posttraumatic stress disorder (PTSD) with comorbid major depressive disorder, single episode with psychotic features, is denied. Entitlement to an evaluation in excess of 70 percent from January 23, 2019 to September 5, 2019 for PTSD is denied. Entitlement to a total disability evaluation of 100 percent from September 5, 2019 for PTSD is granted. Entitlement to special monthly compensation (SMC) pursuant to 38 U.S.C. § 1114 (s), from September 5, 2019, is granted. FINDINGS OF FACT 1. The Veteran served in Southwest Asia during the Persian Gulf War. 2. The Veteran is presumed exposed to fine, particulate matter during service in Southwest Asia during the Persian Gulf War. 3. The Veteran's sinus disability became manifest to a degree within 10 years from his date of separation from military service in Southwest Asia. 4. The Veteran had hemorrhoids of mild or moderate severity, at worst, prior to the hemorrhoidectomy and that after the removal, hemorrhoids have not recurred at any point during the appeal period; the Veteran's symptoms of hemorrhoids did not more nearly approximate hemorrhoids that were large, thrombotic, or irreducible, or associated with persistent bleeding, secondary anemia, or fissure, and the overall hemorrhoid disability was not shown to be more than moderate in degree. 5. Throughout the appeal period, the Veteran's erectile dysfunction has not been manifested by symptoms that more nearly approximate an internal or external penile deformity. 6. Throughout the appeal period, the Veteran's pterygium did not result in any incapacitating episodes as defined by the regulation, any visual impairment, or any scarring. 7. Throughout the appeal period, the evidence is at least evenly balanced as to whether the Veteran had a diagnosis of radiculopathy of the bilateral lower extremities, and the evidence preponderates for finding that his radiculopathy of the bilateral lower extremities was productive of mild, wholly sensory symptoms at worst. 8. For the period prior to August 3, 2020, the Veteran's lumbar spine disability manifested as loss in flexion to 80 degrees, at worst, with combined range of motion in 210 degrees, at worst, with consideration of pain. 9. For the period after August 3, 2020, his lumbar spine disability manifested as loss in flexion to 45 degrees, at worst, with combined range of motion in 175 degrees, with consideration of pain. 10. During the appeal period, the Veteran's headaches have been productive of characteristic prostrating attacks of headaches once every month, at worst, that required laying down and resulted in difficulty in concentration; however, the evidence preponderates against finding that the Veteran's headaches rendered him powerless or extremely exhausted, more than once a month, and caused severe economic inadaptability. 11. For the period prior to January 23, 2019, the Veteran's PTSD symptoms more nearly approximate occupational and social impairment with reduced reliability and productivity, but have not at any time more nearly approximate occupational and social impairment with deficiencies in most areas. 12. For the period from January 23, 2019 to September 5, 2019, the Veteran's PTSD symptoms more nearly approximate occupational and social impairment with deficiencies in most areas, but have not at any time more nearly approximate total occupational and social impairment. 13. The evidence is at least evenly balanced as to whether, for the period after September 5, 2019, the Veteran's PTSD symptoms more nearly approximate total occupational and social impairment. 14. Since September 5, 2019, the Veteran now has a service-connected disability rated as total and additional service-connected disabilities ratable at 60 percent or more. CONCLUSIONS OF LAW 1. The criteria for service connection for sinus disability have been met on a presumptive basis as due to exposure to particulate matter. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.2 (i), 3.102, 3.303, 3.317(e)(2); 86 Fed. Reg. 42724 (August 5, 2021), to be codified at 38 C.F.R. § 3.320. 2. The criteria for a compensable disability rating for proctitis, external hemorrhoids, status post hemorrhoidectomy with anal pruritis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.114, Diagnostic Code 7336. 3. The criteria for a compensable rating for erectile dysfunction throughout the claim period have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1-4.10, 4.115b, Diagnostic Code 7599-7522. 4. The criteria for a compensable evaluation for bilateral eye pterygium have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1-4.10, 4.79, Diagnostic Codes 6034. 5. With resolution of reasonable doubt in the Veteran's favor, the criteria for an evaluation of 10 percent, but no higher, for left lower extremity radiculopathy have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1- 4.10, 4.20, 4.21, 4.123, 4.124, 4.124A, Diagnostic Code 8620. 6. With resolution of reasonable doubt in the Veteran's favor, the criteria for an evaluation of 10 percent, but no higher, for right lower extremity radiculopathy have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1- 4.10, 4.20, 4.21, 4.123, 4.124, 4.124A, Diagnostic Code 8620. 7. The criteria for a rating higher than 10 percent prior to August 3, 2020, for degenerative joint disease of the lumbar spine have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.25, 4.71a, Diagnostic Codes 5237, 5242. 8. The criteria for a rating of 20 percent, but no higher, after August 3, 2020, for degenerative joint disease of the lumbar spine have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.25, 4.71a, Diagnostic Codes 5237, 5242. 9. The criteria for an evaluation in excess of 30 percent for tension headaches have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8100. 10. For the period prior to January 23, 2019, the criteria for a rating higher than 50 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411. 11. For the period from January 23, 2019 to September 5, 2019, the criteria for a rating higher than 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411. 12. With resolution of reasonable doubt in the Veteran' favor, for the period from September 5, 2019, the criteria for a total 100 percent rating for PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411. 13. The criteria for SMC pursuant to 38 U.S.C. § 1114 (s), from September 5, 2019, have been met. 38 U.S.C. § 1114 (s). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 2006 to December 2013, with service in Iraq from October 2007 to December 2008 and from August 2010 to August 2011. The Board previously remanded the issues of hemorrhoids, erectile dysfunction, and radiculopathy of lower extremities for further development in December 2019. The case has now been returned to the Board for appellate review. During the pendency of appeal, the RO granted total disability rating based on individual unemployability due to service-connected disabilities (TDIU), effective December 28, 2013, a day after separation from service, in a November 2020 rating decision. As this grant represents a full grant of the benefits sought, this issue is no longer on appeal. See Grantham v. Brown, 114 F.3d. 1156 (Fed. Cir. 1997). In August 2021, the Board granted the motion to withdraw representation, filed by Attorney J. Michael Woods in January 2021. The Veteran has not selected a new representative since then. He is currently unrepresented. Service Connection 1. Service connection for sinus disability Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service disease or injury; and (3) a causal relationship between the current disability and the in service disease or injury. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010). Consistent with this framework, service connection is warranted for a disease first diagnosed after discharge 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). Effective August 5, 2021, VA issued an interim final rule amending its adjudication regulations and establishing presumptive service connection for three chronic respiratory health conditions, to include sinusitis and rhinitis, in association with presumed exposures to fine, particulate matter. These presumptions apply to veterans with a qualifying period of service, i.e., who served on active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War, as well as in Afghanistan, Syria, Djibouti, or Uzbekistan, on or after September 19, 2001, during the Gulf War. See Presumptive Service Connection for Respiratory Conditions Due to Exposure to Particulate Matter, 86 Fed. Reg. 42724 (August 5, 2021), to be codified at 38 C.F.R. § 3.320. A qualifying disease shall be service-connected even though there is no evidence of such disease during the period of service if it becomes manifest to any degree (including non-compensable) within 10 years from the date of separation from military service. The Persian Gulf War began on August 2, 1990, and the Southwest Asia theater of operations encompasses Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, and the Red Sea. 38 C.F.R. §§ 3.2 (i), 3.317(e)(2). The Veteran's military personnel record reflects that he served on active duty in Iraq from October 2007 to December 2008 and from August 2010 to August 2011. The Veteran has a period of service that qualifies for the presumption as a result of his military service in Iraq. The Veteran is presumed exposed to fine, particulate matter during such service, and there is no affirmative evidence to establish he was not exposed to fine, particulate matter during such service. A December 2016 VA examination reflects a diagnosis of chronic sinusitis. The Veteran reported having increased sinus pressure, rhinorrhea, and nasal congestion. He further stated that his symptoms were constant and were not exacerbated by the seasons. The Veteran reported that he had not seen a doctor about this condition and had not had any medications or other medical therapies. The examiner noted that the Veteran had pansinusitis with current, near and constant signs or symptoms of headaches and purulent discharge. The examiner reviewed a November 2016 MRI, which showed prominent mucous retention cyst in the left maxillary sinus and trace mucosal thickening in the maxillary, ethmoid, and sphenoid sinuses bilaterally. The Veteran's sinusitis became manifest to a degree within 10 years from the date of his qualifying period of service in Iraq as shown during the December 2016 VA examination. McGrath v. Gober, 14 Vet. App. 28, 35 (2000) (in determining the date entitlement arose, when an original claim for benefits is pending, the Board must determine when a claimant's disability manifested itself under all the "facts found" and "the date on which the evidence is submitted is irrelevant"); Traut v. Brown, 6 Vet. App. 495 (1994) (establishing service connection on a presumptive basis does not require that a chronic disease be diagnosed within the applicable time period; rather, symptoms that manifest within this time period may subsequently be determined to have been early manifestations of a chronic disease). On this point, the Board notes that a December 2019 medical opinion states that the Veteran has a diagnosis of rhinitis, not sinusitis. Since both rhinitis and sinusitis are now included in the presumptive diseases, the distinction made in the December 2019 medical opinion is immaterial with respect to the claim of service connection. A qualifying disease will not be presumed service-connected if there is affirmative evidence that (1) the disease was not incurred during or aggravated by a qualifying period of service; or (2) the disease was caused by a supervening condition or event that occurred between the veteran's most recent departure from a qualifying period of service and the onset of the disease; or (3) the disease is the result of the veteran's own willful misconduct. Willful misconduct means an act involving conscious wrongdoing or known prohibited action. It involves deliberate or intentional wrongdoing with knowledge of, or wanton and reckless disregard of its probable consequences. 38 C.F.R. § 3.1 (n)(1). There is no affirmative evidence that the disease was not incurred in service. The December 2019 negative nexus opinion was made without knowledge of the presumption and the studies underlying it. It is not probative and cannot overcome the presumption. There is also no evidence that the disease was caused by a supervening condition or event or is the result of the Veteran's willful misconduct. Moreover, the rationale for the December 2019 opinion is based on lack of treatment records for the condition; however, this fact is consistent with the Veteran's report that he has not sought treatment for the condition. In any case, both December 2016 and December 2019 examiners found a medical condition that qualifies as either sinusitis or rhinitis. As the Veteran's sinus disability manifested to a degree within 10 years of his qualifying period of service in Southwest Asia during the Persian Gulf War, and he is presumed to have been exposed to particulate matter based on his service in Southwest Asia during the Persian Gulf War, specifically in Iraq from October 2007 to December 2008 and from August 2010 to August 2011, entitlement to service connection for sinus disability is warranted on a presumptive basis. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Veteran is requesting higher ratings for the already established service-connected disabilities of hemorrhoids, erectile dysfunction, bilateral pterygium, lumbar degenerative disc disease, radiculopathy of the left lower extremity, radiculopathy of the right lower extremity, tension headaches, and PTSD. As such, the present disability level is the primary concern and past medical reports do not take precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, "staged" ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The issues of increased evaluation for radiculopathy of the bilateral lower extremities, hemorrhoids, erectile dysfunction, pterygium originate from a claim received on September 17, 2014. Since this was received within one year since the Veteran's separation from military, the appeal period for these disabilities run from December 28, 2013. As for the issue of PTSD, headaches, and lumbar degenerative disc disease, they originate from a claim for TDIU received on August 3, 2016. The Board notes that the issues of increased evaluation for headaches and lumbar degenerative disc disease were considered in March 2015 and June 2015 rating decisions, together with the above-mentioned radiculopathy of the bilateral lower extremities, hemorrhoids, erectile dysfunction, and pterygium. However, the August 2015 notice of disagreement did not include the issues of PTSD, headaches, and lumbar degenerative disc disease. As such, the June 2015 rating decision became final prior to the Veteran's August 2016 claim for TDIU. The appeal period for increased evaluation for PTSD, headaches, and lumbar degenerative disc disease runs from August 3, 2016, and the Board considers the pertinent evidence dated since August 3, 2015. 2. Compensable evaluation for proctitis, external hemorrhoids, status post hemorrhoidectomy with anal pruritis The Veteran contends that he is entitled to a compensable evaluation for his hemorrhoids because he has 3 internal and external hemorrhoids. August 2015 Notice of Disagreement. The Veteran's hemorrhoids are currently rated noncompensable under Diagnostic Code 7336, 38 C.F.R. § 4.114, Diagnostic Code 7336. Under the applicable criteria, mild or moderate internal or external hemorrhoids warrant a noncompensable disability rating. Large or thrombotic, irreducible hemorrhoids, with excessive redundant tissue, evidencing frequent recurrences, warrant a 10 percent disability rating. A 20 percent disability rating is warranted with persistent bleeding and with secondary anemia, or with fissures, which is the highest schedular rating under this Diagnostic Code. Id. A December 2014 VA examination reflects a diagnosis of internal or external hemorrhoids. The Veteran reported that he had started having hemorrhoids in 2008 and since then, the symptoms had been on and off. He stated that they itched and hurt occasionally, but usually went away on their own. The treatment plan included continuous medication of suppositories. The examiner determined that the Veteran had mild or moderate symptoms of swollen, inflamed vein with rectal itching and pain. No scar was noted. Functional impairment caused by hemorrhoids was difficulty sitting when he had pain with external hemorrhoids. VA treatment records indicate that the Veteran had excision of left lateral internal and external and posterior external hemorrhoids in October 2015. An August 2020 VA examination reflects a diagnosis of internal or external hemorrhoids with status post hemorrhoidectomy. The Veteran reported that the condition had begun in 2011 when he realized his rectum was growing and hanging. He reported having a surgery in 2016 to remove hemorrhoids and that he felt that hemorrhoids were coming back again. He reported feeling of tiredness and fatigue. He was not taking continuous medication for the condition. The examiner did not find presence of hemorrhoids upon physical examination. No scar was noted. The CBC test conducted for the examination did not show any abnormality. The examiner proposed to change the diagnosis of hemorrhoids to status post hemorrhoidectomy. Based on a review of the evidence, to include associated VA treatment records, the evidence preponderates against finding that the Veteran's hemorrhoids manifested as large or thrombotic, irreducible with excessive anemia or with fissures. Indeed, the evidence shows that the Veteran had hemorrhoids of mild or moderate severity, at worst, prior to the hemorrhoidectomy and that after the removal, hemorrhoids have not recurred. The claim for a compensable rating for hemorrhoids is not warranted. 3. Compensable evaluation for erectile dysfunction The Veteran's erectile dysfunction is currently rated noncompensable under Diagnostic Code 7599-7522. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. Diagnostic Code 7599 is used to identify unlisted genitourinary disabilities not specifically listed in the VA Rating Schedule. 38 C.F.R. §§ 4.20, 4.27. Diagnostic Code 7522 is used to rate deformity of the penis with loss of erectile power. In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. Under Diagnostic Code 7522, the only schedular evaluation available is a 20 percent rating for a deformity of the penis with loss of erectile power. As "deformity" is not defined in the rating criteria, the term is given its ordinary meaning. Prokarym v. McDonald, 27 Vet. App. 307, 310 (2015). In medical terminology, a "deformity" is a "distortion of any part or general disfigurement of the body." Dorland's Illustrated Medical Dictionary 478 (32 ed. 2012). Furthermore, a "deformity" under Diagnostic Code 7599-7522 means either an internal or external distortion of the penis. Williams v. Wilkie, 30 Vet. App. 134, 138 (2018). In this case, a noncompensable rating was assigned, even though the schedule did not provide criteria for one, because the requirements for the only compensable evaluation were not met. 38 C.F.R. § 4.31. A footnote to Diagnostic Code 7522 also instructs the rater to review the claim for entitlement to special monthly compensation (SMC) under 38 C.F.R. § 3.350. Here, the Veteran was granted SMC based on the loss of use of a creative organ, effective May 27, 2017, which is the same effective date as his noncompensable evaluation for service-connected erectile dysfunction. The issue is whether the Veteran's erectile dysfunction has been manifested by symptoms that more nearly approximate an internal or external penile deformity to meet the compensable rating criteria of Diagnostic Code 7599-7522. For the following reasons, an initial compensable disability rating for service-connected erectile dysfunction is not warranted. Turning to the evidence, a December 2014 VA examination reflects a diagnosis of erectile dysfunction. Treatment plan included Viagra. It was noted that he was able to achieve an erection sufficient to penetration and ejaculation with medication. Physical examination revealed normal penis and testis. No scar was noted. In the August 2015 notice of disagreement, the Veteran reported that erectile dysfunction had been a persistent problem and that Viagra's side effects outweighed the impact of the pill. An August 2020 VA examination reflects a diagnosis of erectile dysfunction. The Veteran reported the same symptoms. Additionally, he reported feeling tired and this problem affected his back problem. He reported that he was not being treated for this condition, but he had taken some Viagra. It was noted that he was not able to achieve an erection sufficient for penetration and ejaculation with medication. Physical examination revealed normal penis and testis. No scar was noted. The Board finds that although loss of erectile power is shown, the evidence preponderates against finding that the Veteran's erectile dysfunction resulted in internal or external distortion of the penis at any time during the appeal period. The claim for a compensable rating for erectile dysfunction is not warranted. 4. Compensable evaluation for bilateral pterygium The Veteran's pterygium of the bilateral eyes is currently rated noncompensable under Diagnostic Code 7800-6034. During the pendency of the appeal, VA issued a final rule revising the portion of the VA Schedule for Rating Disabilities that addresses the organs of special sense and schedule of ratings-eye. 89 Fed. Reg. 15316 (Apr. 10, 2018). The final rule went into effect May 13, 2018. Where there is a change in the rating criteria during the appeal period, the Board will consider the claim considering both the former and revised schedular rating criteria, although an increased evaluation based on the revised criteria cannot predate the effective date of the amendments. The former criteria for Diagnostic Code 6034 instructed to evaluate based on visual impairment, disfigurement (Diagnostic Code 7800), conjunctivitis (Diagnostic Code 6018), etc. depending on the particular findings. The revised criteria for Diagnostic Code 6034 instruct to evaluate based on the General Rating Formula for Diseases of the Eye, disfigurement (Diagnostic Code 7800), conjunctivitis (Diagnostic Code 6018), etc. depending on the particular findings, with all ratings to be combined pursuant to 38 C.F.R. § 4.25. The General Rating Formula for Diseases of the Eye instructs to rate based on incapacitating episodes or visual impairment, whichever would afford a higher rating. The change to the rating criteria effectively just added consideration of incapacitating episodes because visual impairment was to be considered in the former criteria. Regarding combining ratings under 38 C.F.R. § 4.25, this language appears to clarify how the rating criteria should be applied and does not represent a substantive change; separate disabling effects should have been combined pursuant to 38 C.F.R. § 4.25 under the former criteria. For a compensable rating based on incapacitating episodes under the General Rating Formal for Diseases of the Eye, a veteran must have required at least one but less than 3 treatment visits for his eye condition during the past 12 months. For the purposes of evaluations under 38 C.F.R. § 4.79, an incapacitating episode is an eye condition severe enough to require a clinic visit to a provider specifically for treatment purposes. 38 C.F.R. § 4.79, Note (1) (2018). Note (2) indicates that examples of treatment may include but are not limited to: systemic immunosuppressants or biologic agents; intravitreal or periocular injections; laser treatments; or other surgical interventions. 38 C.F.R. § 4.79 (2018). Here, the Veteran has not contended, and the record does not suggest, that the Veteran had undergone any treatment visits for his eye condition within 12 months of the effective date of the change in the rating criteria. A compensable rating is not warranted based on incapacitating episodes. The evaluation of visual impairment is based on impairment of visual acuity (excluding developmental errors of refraction), visual field, and muscle function. 38 C.F.R. § 4.75 (a). The amendments made no substantive changes to how visual acuity is rated. With regard to visual field and muscle function examinations, the use of a Goldmann chart is no longer required. There are otherwise no substantive changes to how those types of visual impairment are rated. Evaluation of visual acuity is based on corrected distance vision with central fixation. 38 C.F.R. § 4.76 (b)(1). The measurements for each eye are applied to the table for Impairment of Central Visual Acuity. 38 C.F.R. § 4.76 (c). Evaluation of visual field is based on the remaining field of vision in each eye. 38 C.F.R. § 4.77. The table of Ratings for Impairment of Visual Fields provides ratings for visual field loss. The first half of the table provides ratings based on loss of an entire half of field of vision in an eye. The second half of the table provides ratings based on the average concentric contraction of the visual field of each eye. Evaluation of visual field is based on the remaining field of vision in each eye. 38 C.F.R. § 4.79. Lastly, evaluation of visual impairment of muscle function is based on the degree of diplopia. 38 C.F.R. § 4.78. Here, the evidence shows that the Veteran's corrected distance vision remained 20/40 or better in each eye throughout the appeal period. See December 2014 and November 2020 VA examinations. Moreover, the evidence reflects that he did not have any muscle dysfunction such as diplopia or visual field defect throughout the appeal period. Id. A compensable rating is not warranted for visual impairment. The Veteran's pterygium could be rated under a scar diagnostic code. VA amended the criteria for rating skin disabilities effective from August 13, 2018. However, Diagnostic Code 7800 was not changed by the August 13, 2018, amendments. Under Diagnostic Code 7800, one characteristic of disfigurement warrants a 10 percent rating. A scar with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement warrants a 30 percent rating. A scar with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement warrants a 50 percent rating. A scar with visible or palpable tissue loss and either gross distortion of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement warrants an 80 percent rating. 38 C.F.R. § 4.118. Note 1 to Diagnostic Code 7800 list the eight characteristics of disfigurement: a scar 5 or more inches in length; a scar at least one-quarter inch wide at widest part; surface contour of scar elevated or depressed on palpation; scar adherent to underlying tissue; skin hypo- or hyper-pigmented in an area exceeding six square inches; skin texture abnormal in an area exceeding six square inches; underlying soft tissue missing in an area exceeding six square inches; and, skin indurated and inflexible in an area exceeding six square inches. Id. Here, the evidence does not indicate that the Veteran's pterygium resulted in any of the characteristics of disfigurement as above. In fact, the December 2014 VA examination notes that his bilateral pterygium has resolved during the appeal period, while the October 2020 VA examination confirmed the diagnosis of bilateral pterygium. Both examinations did not reveal any scars due to pterygium. Lastly, the Veteran reported having cataracts in both eyes in his August 2015 notice of disagreement. However, the evidence of record, to include treatment records and examinations, does not reflect a diagnosis or treatment for cataracts. In sum, the Veteran's service-connected pterygium did not result in any incapacitating episodes as defined by the regulation, any visual impairment, or any scarring. A compensable evaluation is not warranted for the entire appeal period. 5. Increased evaluation for radiculopathy of the left lower extremity 6. Increased evaluation for radiculopathy of the right lower extremity The Veteran's radiculopathy of lower extremity is rated as 10 percent disabling from December 28, 2013 to December 29, 2014; noncompensable from December 29, 2014 to August 3, 2020; and 10 percent from August 3, 2020, for each lower extremity, under Diagnostic Code 8620, as neuritis. This disability is rated as paralysis of the sciatic nerve under Diagnostic Code 8520. Under Diagnostic Code 8520, the following ratings apply: a 10 percent rating is warranted for mild incomplete paralysis; a 20 percent rating is warranted for moderate incomplete paralysis; a 40 percent rating is warranted for moderately severe incomplete paralysis; a 60 percent rating is warranted for severe incomplete paralysis with marked muscular atrophy; and an 80 percent rating is warranted for complete paralysis resulting in the foot dangling and dropping, no possible active movement of muscles below the knee, and weakened or (very rarely) lost flexion of the knee. 38 C.F.R. § 4.124A , Diagnostic Code 8520. The rating schedule provides guidance for rating neurological disabilities. With regard to rating neurological disabilities, cranial or peripheral neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. 38 C.F.R. § 4.123. The maximum rating that can be assigned for neuritis not characterized by organic changes will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. Id. Cranial or peripheral neuralgia, usually characterized by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124A. Although it is outside of the appeal period, the Board notes that a March 2013 VA examination, conducted while he was still in service, reflects the Veteran's complaint of having pain that traveled from lower back to legs. However, he denied having spasms, paresthesia, or numbness. Physical examination revealed evidence of radiating pain on movement, described as sharp radiating down the legs. There was no muscle spasm or tenderness. Muscle tone was normal. Straight leg test was positive on both legs. Lasègue's sign was positive. But no atrophy was present in the limbs. Neurological examination of the lower extremities showed that the bilateral sensory function for sciatic nerve was decreased. Reflex exam was normal. The examiner stated that the peripheral nerve examination revealed neuritis and that there was sensory dysfunction demonstrated by decreased sensation. The examiner indicated that there were signs of lumbar IVDS. Diagnosis provided was bilateral lower extremity radiculopathy. A December 2014 VA examination did not find that the Veteran had radiculopathy. An August 2016 VA examination reflects the Veteran's complaint of pain that goes down to the knee from the low back. Muscle strength test, reflex exam, and sensory exam were normal. The Veteran did not have constant pain, intermittent pain, paresthesias and/or dysesthesias, or numbness in either lower extremity. He did not have intervertebral disc syndrome (IVDS). The examiner noted that the pain in the knees was independent of the back with no diagnosis of radiculopathy. An August 2020 VA examination reflects a diagnosis of "radiculopathy of bilateral lower extremity, 2011." The Veteran reported that the condition began in 2011 with pain at his knees and ankles. There was no treatment. The current symptoms reported was pain. There was no muscle atrophy. Muscle strength test, reflex exam, and sensory exam were all normal. The Veteran had moderate constant pain and mild numbness in both lower extremities. The examiner determined that he had mild radiculopathy involving sciatic nerve on both sides. He did not have IVDS. The examiner further noted an undated MRI of the lumbar spine, cited in a March 2020 treatment record, which showed mild degenerative disc disease at L4-5 level with mild to moderate left sided neural foraminal narrowing, which was consistent with his complaint of low back pain with more significant radiatio on the left as compared to the right side. Although the evidence of record is not consistent in finding that the Veteran has had radiculopathy of bilateral lower extremities, the evidence preponderates against finding that the Veteran's radiculopathy of the bilateral lower extremities was severe enough to be productive of symptoms worse than wholly sensory at any time during the appeal period. Indeed, the Veteran's radiculopathy was productive of constant pain and mild numbness, namely, of mild symptomatology. However, in light of such a mild manifestation of the disability, the lack of finding of radiculopathy in the VA examinations during the appeal period does not indicate that he did not have the symptoms of radiating pain. Resolving reasonable doubt in the Veteran's favor, the Board finds that the Veteran has had a diagnosis of radiculopathy of the bilateral lower extremities, which has been productive of mild, wholly sensory symptoms, during the entire appeal period. An evaluation of 10 percent, but no higher, for the entire appeal period from December 28, 2013 to the present is warranted for radiculopathy of the bilateral lower extremities. 7. Increased evaluation for degenerative disc disease of the lumbar spine with thoracolumbar strain The Veteran's lumbar spine disability is rated 10 percent disabling for the appeal period that begins with August 3, 2016, under Diagnostic Code 5242-5237. Recently, VA amended the criteria for rating the musculoskeletal system and muscle injures, effective from February 7, 2021. However, the criteria pertinent to the Veteran's disability were not changed in a manner that affects the analysis in this case. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Codes 5237, 5242). Under the General Rating Formula for Diagnostic Codes 5242 and 5237, with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, a 20 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the thoracolumbar spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assigned for unfavorable ankylosis of the entire spine. Several notes to the General Rating Formula for Diseases and Injuries of the Spine provide additional guidance. Note 1 provides that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, are to be rated separately, under an appropriate diagnostic code. In that regard, the Board notes that the Veteran has been rated separately for sciatic and femoral radiculopathy of the right and left lower extremities. The Veteran has not appealed the ratings assigned for those disabilities. Under Note 5, unfavorable ankylosis is defined as a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. In addition to the General Rating Formula for Diseases and Injuries of the Spine, intervertebral disc syndrome (IVDS) may be evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation. See 38 C.F.R. § 4.71a, Diagnostic Code 5243. The Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes provides that when intervertebral disc syndrome is productive of incapacitating episodes have a total duration of at least two weeks but less than four weeks during the past 12 months; a 20 percent rating is assigned. When intervertebral disc syndrome is productive of incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past twelve months, a 40 percent rating is assigned. When incapacitating episodes have a total duration of at least six weeks during the past 12 months, a maximum 60 percent rating is assigned. Note (1) following 38 C.F.R. § 4.71a, Diagnostic Code 5243 provides that an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Functional loss may be due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. 38 C.F.R. § 4.45. When evaluating disabilities of the joints, the Rating Schedule provides for consideration of additional functional impairment due to pain, weakness, fatigue, incoordination, and lack of endurance when assigning evaluations. 38 C.F.R. §§ 4.40, 4.45, 4.59 (2017); see DeLuca v. Brown, 8 Vet. App. 202 (1995). Turning to the evidence of record, a December 2015 VA treatment record reflects a complaint of focal low back pain without radiculopathy. He was assessed with mild lumbar spondylosis and mild lumbar facet arthrosis. An August 2016 VA examination reflects a diagnosis of degenerative arthritis of the spine. He reported constant low back pain, which was worse with sitting or standing more than one hour and pain going down to the knee. Treatment included steroid injections, NSAIDS, and TENS unit. He did not report flareups. The Veteran reported having difficulty with sitting or standing for more than one hour with pain when bending over due to the back disability. The initial range of motion test showed forward flexion to 80 degrees with combined range of motion in 210 degrees. Pain was noted in all motions. No IVDS was found. Regular use of cane due to the back disability was noted. A December 2019 medical opinion stated that the Veteran's mild spinal degenerative arthritis was unlikely to cause a change in the range of motion after repetitive use over time. An August 2020 VA examination reflects the Veteran's complaint of having flareups. According to him, the flareups were severe and precipitated by sitting, walking, and when laying down, as well as standing. They were alleviated by medication. The Veteran reported having a lot of pain. The initial range of motion test showed forward flexion to 45 degrees with combined range of motion in 175 degrees. Pain was noted in all motions. The examiner noted that the Veteran was having a flareup and also observed after repeated use over time with no additional loss in the range of motion. The Veteran had muscle spasm, not resulting in abnormal gait or abnormal spinal contour, and no guarding was observed. No ankylosis was found. He did not have IVDS. Occasional use of cane was noted. The examiner noted partial impairment of physical activities such as bending, running, jumping, climbing, and walking long distance. Based on the evidence of record, the Board finds that the Veteran's lumbar spine disability manifested as loss in flexion to 80 degrees, at worst, with combined range of motion in 210 degrees, at worst, prior to August 3, 2020. For the period after August 3, 2020, his lumbar spine disability manifested as loss in flexion to 45 degrees, at worst, with combined range of motion in 175 degrees. For both periods, limitation of motion due to pain was considered. The symptomatology of the Veteran's lumbar spine disability is more nearly approximated by the rating criteria for 10 percent prior to August 3, 2020 and by the rating criteria for 20 percent thereafter. In sum, a rating of 10 percent, but no higher, prior to August 3, 2020 and a rating of 20 percent, but no higher, after August 3, 2020, for the lumbar spine disability is warranted. 8. Evaluation in excess of 30 percent for tension headaches The Veteran's tension headaches are rated as 30 percent disability for the appeal period that begins with August 3, 2016, under Diagnostic Code 8100. Under Diagnostic Code 8100, a noncompensable rating is warranted for migraines with less frequent attacks. A 10 percent rating is warranted for migraines with characteristic prostrating attacks averaging one in 2 months over the last several months. A 30 percent rating is warranted for migraines with characteristic prostrating attacks occurring on an average once a month over the last several months. A 50 percent rating is warranted for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. A 50 percent rating is the highest schedular rating under Diagnostic Code 8100. The rating criteria of Diagnostic Code 8100 are considered successive, meaning that a claimant cannot fulfill the criteria of the higher rating without fulfilling those of the next lower rating. Johnson v. Wilkie, 30Vet. App.245, 252 (2018). The phrase "characteristic prostrating attacks" is used in the criteria corresponding to 10 percent and 30 percent ratings under Diagnostic Code 8100 to describe the nature and severity of migraines, but it is not defined in the regulation. Pursuant to Dorland's Illustrated Medical Dictionary 1531 (32d ed. 2012), prostration is defined as "extreme exhaustion or powerlessness." The phrase "characteristic prostrating attacks" is understood to describe migraine attacks that typically produce extreme exhaustion or powerlessness. The descriptive phrase "very frequent" connotes a frequency at least greater than once a month, as is required by the rating criteria corresponding to a lesser 30 percent rating. Johnson, 30 Vet. App. at 253. The phrase "completely prostrating" generally means that the migraines attack must render the veteran entirely powerless. Id. The completely prostrating attacks must also be "prolonged," which is defined as "to lengthen in time: extend duration: draw out: continue, protract." Id. (internal citation omitted). Lastly, the 50 percent rating criteria requires that the very frequent completely prostrating and prolonged attacks be "productive of severe economic inadaptability." Productive can be read as having either the meaning of "producing" or "capable of producing," and, with regard to severe economic inadaptability, nothing in Diagnostic Code 8100 requires that the claimant be completely unable to work in order to qualify for a 50 percent rating. Pierce v. Principi, 18Vet. App.440, 445-46 (2004). Turning to the evidence of record, an August 2016 VA examination reflects a diagnosis of tension headaches. He reported that he got headaches from forehead to the top of the head, which occurred almost daily, lasting one hour or two. When that happened, he had to stop working and would go to sleep. The treatment plan included taking ibuprofen. He had pulsating or throbbing head pain, on both sides of the head, and the pain worsened with physical activity. Headaches were accompanied by nausea, vomiting, sensitivity to light, and sensitivity to sound. A typical head pain lasted less than one day, on both sides of the head. The Veteran had characteristic prostrating attacks of headache pain, with less frequent attacks. He did not have very prostrating and prolonged attacks of head pain productive of severe economic inadaptability. He also reported inability to concentrate due to headaches. A January 2017 VA treatment record notes that the Veteran reported having two different types of headaches. The impression was probable migraine headaches, scalp muscle contraction headache. A December 2017 VA treatment record indicates that the Veteran was taking magnesium 840 mg daily for migraine. A June 2019 VA treatment record reflects the Veteran's report that headaches could last for an entire day, every day. He indicated having photosensitivity and nausea with headaches. He reported that it was triggered by stress form PTSD. The headaches would start above the eyes and go into the temples. A May 2020 VA examination reflects a diagnosis of tension headaches. The Veteran reported that his headaches had gotten worse since the last August 2016 VA examination. He reported having daily headaches upon awakening in the morning and upon going to sleep at night. Headaches were felt sometimes to the forehead and sometimes to the sides of the head. He described having shar pain. He also reported having ringing in the ears and blurred vision during the headaches, lasting a few minutes or just prior to headaches. He would take ibuprofen and lay down. Symptoms included pulsating or throbbing head pain on both sides of the head, accompanied with sensitivity to light. Duration of a typical head pain was less than one day on both sides of the head. He had characteristic prostrating attacks of headache once every month, but did not have very prostrating and prolonged attacks of headache productive of severe economic inadaptability. The examiner stated that the Veteran's headaches might cause difficulty in concentration while working when headaches occurred at work. Moreover, the examiner stated that based on a review of available medical records, the examiner was not able to find clinical documentation or other objective evidence that supported he had prostrating attacks related to chronic headache syndrome or incapacitation due to headaches. The Veteran is competent to report his readily observable symptoms. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran's reports regarding the frequency and severity of his headaches are generally consistent throughout the record during the appeal period. Additionally, it appears that the Veteran's statements have provided basis for the examiner's determination in the VA examinations. Based on a review of the evidence of record, the Board finds that the Veteran's headaches have been productive of characteristic prostrating attacks of headaches once every month, at worst, that required laying down and resulted in difficulty in concentration during the entire appeal period. However, the evidence preponderates against finding that the Veteran's headaches rendered him powerless or extremely exhausted, more than once a month, and caused severe economic inadaptability. The VA treatment records document that he sought treatment for his headaches, but they do not indicate a level of incapacitation due to headaches impacting his economic adaptability in a severe manner. A claim for an evaluation in excess of 30 percent for tension headaches is not warranted. 9. Evaluation in excess of 50 percent prior to January 23, 2019 and in excess of 70 percent thereafter for PTSD with comorbid major depressive disorder, single episode with psychotic features The Veteran's PTSD is rated as 50 percent disability prior to January 23, 2019 and 70 percent disability thereafter under Diagnostic Code 9411-9434. Diagnostic Code 9411 evaluates PTSD, and Diagnostic Code 9434 evaluates major depressive disorder. Both diagnostic codes refer to the General Rating Formula for Mental Disorders. Under this formula, a 50 percent evaluation is warranted where 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; impaired judgment; impaired abstract thinking; disturbance of motivation and mood; and difficultly in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130. A 70 percent evaluation is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. Id. A 100 percent evaluation 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; and memory loss for names of close relatives, own occupation, or own name. Id. Symptoms listed in the VA's General Rating Formula for Mental Disorders serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating, and are not intended to constitute an exhaustive list. See Mauerhan v. Principi, 16 Vet. App. 436, 442-44 (2002). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has emphasized that the list of symptoms under a given rating is a non-exhaustive list, as indicated by the words "such as" that precede each list of symptoms. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 115 (Fed. Cir. 2013). In Vazquez-Claudio, the Federal Circuit held "that a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage or others of similar severity, frequency, and duration." Id. at 117. Other language in the decision indicates that the phrase "others of similar severity, frequency, and duration," can be thought of as symptoms of like kind to those listed in the regulation for a given disability rating. Id. at 116. The nomenclature employed in the rating formula is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, of the American Psychiatric Association (DSM-5). See 38 C.F.R. § 4.130. When evaluating a mental disorder, the frequency, severity, duration of psychiatric symptoms, length of remissions, and the veteran's capacity for adjustment during periods of remission must be considered. See 38 C.F.R. § 4.126 (a). In addition, the evaluation must be based on all the evidence of record that bears on occupational and social impairment, not solely on the examiner's assessment of the level of disability at the moment of the examination. Id. Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely based on social impairment. See 38 C.F.R. § 4.126 (b). Turning to the evidence, a December 2015 VA treatment record indicates that the Veteran stopped going to school due to his memory and concentration issues. An August 2016 VA examination reflects a diagnosis of PTSD. He did not have more than one diagnosed mental disorder. The examiner determined that the Veteran's PTSD was productive of occupational and social impairment with reduced reliability and productivity. The Veteran reported that he was in college studying homeland security. The examiner stated that his poor interpersonal functioning might impact jobs where he had to interact with many people, but it did not render him unable to obtain and maintain employment. The examiner further noted that his mental illness had not impacted his college work. Symptoms noted were depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, flattened affect, disturbance of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. He was well dressed and groomed. He answered direct questions with minimal verbalization. He showed no disturbance with thought processes and denied any suicidal or homicidal ideation. Heavy alcohol use due to PTSD was noted. He was found capable of managing his financial affairs. In a December 2018 statement, the Veteran's fiancée reported that the Veteran had frequent panic attacks almost every day, triggered by large crowds, going out in the public, listening to music, general conversations, and driving. She noted that the Veteran was extremely forgetful, forgetting conversations and recent events. He would forget to take medications or appointments and names of friends and family members. He also left a stove one. She reported that he had frequent mood swings with depression and irritability, and difficulty with socializing due to the mood swings and irritability. She reported that he had visual and auditory hallucinations. The Veteran did not maintain hygiene as much as he should; he would wear the same clothes for three days or go without showering or shaving for some periods. Impulsiveness and trouble sleeping were also noted. The Veteran submitted a private disability benefits questionnaire (DBQ) by Dr. H.-G., conducted on January 23, 2019, with her accompanying report. He was diagnosed with PTSD only. The examiner determined that his PTSD was productive of occupational and social impairment with deficiencies in most areas. Symptoms noted were depressed mood, anxiety, suspiciousness, panic attacks more than once a week, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, chronic sleep impairment, mild memory loss, flattened affect, disturbance of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, inability to establish and maintain effective relationships, suicidal ideation, persistent delusions or hallucinations, neglect of personal appearance and hygiene, and intermittent inability to perform activities of daily living. The examiner noted that during the examination, the Veteran was vague with response, suspicious and seemed rather vigilant. He seemed cautious of the examination. The examiner observed that he was insecure and unsure of himself over the course of this social interaction. A May 2019 VA treatment record reflects the Veteran's complaint of feeling angry every day. He indicated having some passive suicidal ideation with no plan or intent. A September 2019 VA treatment record indicates that the Veteran was hospitalized from September 5 to 12 for psychiatric condition. The Veteran reported in July that year that he had a variety of memory problems that required family members to remind him to complete activities of daily living, turn off the stove when he cooked, and to take his medications. Memory concerns caused him to stop school, but he reported having graduated in 2017 with associate degree in homeland security. He reported suicidal thought and endorsed some auditory hallucinations. He was admitted for worsening PTSD symptoms, alcohol use, and suicidal thoughts. Based on a review of the evidence, the Board finds that the Veteran's PTSD gradually worsened during the appeal period. For the period prior to January 23, 2019, the Veteran's PTSD symptoms consisted of depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, flattened affect, disturbance of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. During this period, the Veteran was able to handle schoolwork and spend time with classmates, and eventually finished a degree in 2017. The Board finds that his PTSD was productive of occupational and social impairment with reduced productivity and reliability. However, as noted formally in the January 2019 DBQ, the Veteran's PTSD got worse since the graduation, and his symptoms consisted of worsening existing symptoms as well as additional symptoms of panic attacks, persistent hallucinations, neglect of personal appearance and hygiene, and intermittent inability to perform activities of daily living. Moreover, the record reflects that all these PTSD symptoms had gotten worse enough for him to seek hospitalization due to PTSD in September 2019. The Board finds that the Veteran's PTSD was productive of occupational and social impairment with deficiencies in most areas from January 23, 2019 to September 5, 2019 and, with resolution of reasonable doubt in the Veteran's favor, that it has been productive of total occupational and social impairment from September 5, 2019. 10. Entitlement to SMC pursuant to 38 U.S.C. § 1114 (s), from September 5, 2019 The Board finds, for the following reasons, that SMC pursuant to 38 U.S.C. § 1114 (s) is warranted for the period from September 5, 2019. Pursuant to 38 U.S.C. § 1114 (s), when a veteran has a service-connected disability rated as total and has additional service-connected disability independently ratable at 60 percent or more, she is entitled to SMC. 38 U.S.C. § 1114 (s)(1). The United States Court of Appeals for Veterans Claims (Court) has held that VA has a "well-established" duty to maximize a claimant's benefits. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); AB v. Brown, 6 Vet. App. 35 (1993); see also Bradley v. Peake, 22 Vet. App. 280, 294 (2008). This duty to maximize benefits requires VA to assess all of a claimant's disabilities to determine whether any combination of disabilities establishes entitlement to SMC under 38 U.S.C. § 1114. See Bradley, 22 Vet. App. at 280 (finding that SMC benefits are to be accorded when a Veteran becomes eligible without need for a separate claim"). (Continued on the next page) In the decision above, the Board has awarded a total (100 percent) rating for PTSD, from September 5, 2019. As the Veteran now has a service-connected disability rated as total. Moreover, as of September 5, 2019, the Veteran is service-connected for the following orthopedic disabilities with compensable ratings: left knee disability, 10 percent; right knee disability, 10 percent; right shoulder disability, 10 percent; right ankle disability, 10 percent; lumbar spine disability, 10 percent (prior to August 3, 2020 with 20 percent thereafter); radiculopathy of the left lower extremity, 10 percent; radiculopathy of the right lower extremity, 10 percent, with combined rating of 60 percent (after adding bilateral factors and rounding to the nearest degree divisible by 10). 38 C.F.R. § 4.25; 38 C.F.R. § 3.350 (i)(1). For the period after September 5, 2019, the Veteran meets the statutory criteria for SMC pursuant to 38 U.S.C. § 1114 (s). Entitlement to SMC pursuant to 38 U.S.C. § 1114 (s) is warranted during the period from September 5, 2019. Emily Tamlyn Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Y. Taylor 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.