Citation Nr: 21066719 Decision Date: 11/02/21 Archive Date: 11/02/21 DOCKET NO. 17-44 708 DATE: November 2, 2021 ORDER An initial rating in excess of 30 percent prior to August 14, 2014, for posttraumatic stress disorder (PTSD) is denied. An initial rating of 70 percent, but no higher, from August 14, 2014, onward, for PTSD is granted. An increased rating in excess of 20 percent for diabetes mellitus is denied. The reduction of the 10 percent rating to non-compensable for bilateral hearing loss, effective March 16, 2016, was not proper, and restoration of the 10 percent rating is granted. An increased rating in excess of 10 percent for bilateral hearing loss is denied. The reduction of the 40 percent rating to non-compensable for peripheral vascular disease of the right lower extremity, effective March 10, 2016, was not proper, and restoration of the 40 percent rating is granted. An increased rating in excess of 20 percent prior to June 13, 2013, for peripheral vascular disease of the left lower extremity is denied. An increased rating of 40 percent, but no higher, from June 13, 2013 to June 1, 2017, for peripheral vascular disease of the left lower extremity is granted. An increased rating in excess of 60 percent from June 2, 2017, for peripheral vascular disease of the left lower extremity is denied. An increased rating in excess of 40 percent prior to June 2, 2017, for peripheral vascular disease of the right lower extremity is denied. An increased rating of 60 percent, but no higher, from June 2, 2017, onward, for peripheral vascular disease of the right lower extremity is granted. A total disability rating based on individual unemployability (TDIU) from January 29, 2013, is granted. Special monthly compensation (SMC) due to statutory housebound from January 29, 2013, is granted. FINDINGS OF FACT 1. The competent and probative evidence shows that for the period prior to August 14, 2014, the Veteran's PTSD is manifested as occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 2. The competent and probative evidence shows that for the period from August 14, 2014, onward, the Veteran's PTSD is manifested as occupational and social impairment with deficiencies in most areas. 3. The Veteran's diabetes mellitus required only insulin injections and restricted diet during the period on appeal. 4. The preponderance of the evidence does not establish that any improvement in the Veteran's ability to function under the ordinary conditions of life and work to warrant a reduction of his service-connected bilateral hearing loss rating. 5. Throughout the rating period on appeal, the weight of the competent and probative evidence shows at worst Level V hearing on the right ear and Level IV hearing on the left ear, with exceptional patterns of hearing loss in the right ear. 6. The Agency of Original Jurisdiction (AOJ) did not properly follow the procedural and notification steps required for the reduction of the disability rating for peripheral vascular disease of the right lower extremity. 7. The competent and probative evidence shows that for the period prior to June 13, 2013, the Veteran's peripheral vascular disease of the bilateral lower extremities, are manifest by diminished peripheral pulses, trophic changes, and claudication on walking more than 100 yards. 8. The competent and probative evidence shows that from June 13, 2013 to June 1, 2017, the Veteran's peripheral vascular disease of the bilateral lower extremities, are manifest by trophic changes and claudication on standing. 9. The competent and probative evidence shows that from June 2, 2017, onward, the Veteran's peripheral vascular disease of the bilateral lower extremities, are manifest by claudication on standing and persistent coldness. 10. The Veteran's service-connected PTSD alone is as likely as not of such nature and severity as to prevent him from securing or following substantially gainful employment from January 29, 2013. 11. As a result of this decision and from January 29, 2013, the Veteran is in receipt of a TDIU based on his service-connected PTSD alone, as well as additional service-connected disabilities rated as at least 60 percent disabling. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent prior to August 14, 2014, for PTSD are not met. 38 U.S.C. §§ 1155; 5107(b); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.130, Diagnostic Code (DC) 9411. 2. The criteria for a rating of 70 percent, but no higher, from August 14, 2014, onward, for PTSD are met. 38 U.S.C. §§ 1155; 5107(b); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.130, DC 9411. 3. The criteria for a rating in excess of 20 percent for diabetes mellitus type II are not met. 38 U.S.C. §§ 1155; 5107(b); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.119, DC 7913. 4. The criteria for reduction of the disability rating for bilateral hearing loss, effective March 16, 2016, are not met, and the reduction was not proper; restoration of the 10 percent rating is warranted. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.105(e), 3.344, DC 6100. 5. The criteria for a rating in excess of 10 percent for bilateral hearing loss are not met. 38 U.S.C. §§ 1110, 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.85-4.86, DC 6100. 6. The reduction in the disability evaluation for peripheral vascular disease of the right lower extremity from 40 percent to noncompensable effective March 10, 2016, was improper and is void ab initio; restoration of the 40 percent rating is warranted. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. § 3.105(e), DC 7114. 7. The criteria for a rating in excess of 20 percent prior to June 2, 2017, and in excess of 60 percent, thereafter, for peripheral vascular disease of the left lower extremity are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.104, 4.14, 4.3, 4.4, 4.7, DC 7114. 8. The criteria for a rating in excess of 40 percent prior to June 2, 2017, for peripheral vascular disease of the right lower extremity are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.104, 4.14, 4.3, 4.4, 4.7, DC 7114. 9. The criteria for a rating of 60 percent, but no higher, from June 2, 2017, onward, for peripheral vascular disease of the right lower extremity are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.104, 4.14, 4.3, 4.4, 4.7, DC 7114. 10. The criteria for an award of TDIU from January 29, 2013, are met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.3, 4.15, 4.16. 11. From January 29, 2013, the criteria for SMC due to being housebound are met. 38 U.S.C. § 1114(s), 5107(b); 38 C.F.R. § 3.350(i). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1967 to May 1969. This matter is before the Board of Veterans' Appeals (Board) on appeal from May 2016 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran requested a videoconference hearing before the Board. See 8/25/2017 VA Form 9; see also 12/22/2017 Form 9. However, the Veteran, through his authorized attorney representative, withdrew his request for a hearing. See 5/14/2021 Third Party Correspondence. As such, the request for a hearing has been withdrawn. See 38 C.F.R. § 20.704(e). Additionally, an August 2017 rating decision granted an increased rating of 40 percent for peripheral vascular disease of the right lower extremity, effective June 2, 2017. Further, a December 2017 rating decision granted an increased rating of 70 percent for PTSD, effective June 2, 2017, and an increased rating of 60 percent for peripheral vascular disease for the left lower extremity, effective June 2, 2017. Although increased ratings were granted, the issues remain in appellate status as the maximum schedular ratings had not been assigned for the entire period on appeal. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993). Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentages are based on the average impairment of earning capacity as a result of service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, the Board must also consider staged ratings, which are appropriate in this case. Hart v. Mansfield, 21 Vet. App. 505, 50910 (2007). Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other. Esteban v. Brown, 6 Vet. App. 259, 262 (1994); 38 C.F.R. § 4.14. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. In evaluating the evidence, the Board has been charged with the duty to assess the credibility and weight given to evidence. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Indeed, the U.S. Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000). In doing so, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Owens v. Brown, 7 Vet. App. 429, 433 (1995). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran is competent to report symptoms observable by sense and contemporaneous medical diagnoses, but not competent to diagnose or assess the etiology of complex medical disorders. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). 1. An initial rating in excess of 30 percent prior to June 2, 2017, and in excess of 70 percent, thereafter, for PTSD. The Veteran contends an increased rating for his PTSD. Psychiatric disabilities are rated based on the General Rating Formula codified in 38 C.F.R. § 4.130, which provides disability ratings are based on a spectrum of symptoms. "A veteran may qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of a similar severity, frequency, and duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV) and (5th ed. 2013) (DSM-5). See Mauerhan v. Principi, 16 Vet. App. 436, 44243 (2002). VA is to engage in a holistic analysis in which it assesses the severity, frequency, and duration of the signs and symptoms of the Veteran's service-connected mental disorder; quantifies the level of occupational and social impairment caused by those signs and symptoms; and assigns an evaluation that most nearly approximates that level of occupational and social impairment. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017). Under the General Rating Formula for Mental Disorders per 38 C.F.R. § 4.130, in pertinent part, a 30 percent disability rating is warranted when there is occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted if the disability is productive of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material; forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. The criteria for a 100 percent rating are: 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 hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Considerations in evaluating a mental disorder include the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The evaluation must be based on all evidence of record that bears on occupational and social impairment rather than solely on an examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). Although the extent of social impairment is a consideration in determining the level of disability, the rating may not be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Initially, the Board notes that this claim for a higher rating for the acquired psychiatric disorder was pending before the agency of original jurisdiction on or after August 4, 2014. Therefore, the Board finds that the DSM-5 applies to the current appeal. See 53 Fed. Reg. 14308 (Mar. 19, 2015); 38 C.F.R. §§ 3.384, 4.125, 4.126, 4.127, and 4.130. Accordingly, the Board's adjudication of this claim will not include any discussion of the Global Assessment of Functioning (GAF) scores found in the record. See Golden v. Shulkin, 29 Vet. App. 221 (2018) (holding that given that the DSM-5 abandoned the GAF scale and that VA has formally adopted the DSM-5, the Board errs when it uses GAF scores to assign a psychiatric rating in cases where the DSM-5 applies). The record showed that the Veteran was assigned an initial disability rating of 30 percent under 38 C.F.R. § 4.130, DC 9411, effective November 19, 2012, and 70 percent, effective June 2, 2017. Prior to August 14, 2014 After review of the relevant medical and lay evidence, the Board finds that a rating in excess of 30 percent, for the period prior to August 14, 2014, for PTSD is not warranted. An April 2013 VA psychiatric examination, after an in-person examination and review of the Veteran's relevant medical history, shows that the Veteran had symptoms, such as anxiety, suspiciousness, chronic sleep impairment, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. The examiner stated that the Veteran had an occupational and social impairment due to mild and transient symptoms, which decrease work efficiency and ability to perform occupational tasks. See 4/11/2013 C&P Examination. A June 2014 statement from the Veteran reflects that he wakes up remembering the misery of war. Based on the totality of the evidence above, the Board finds that for the period prior to August 14, 2014, the Veteran's condition most nearly approximates the criteria for a rating of 30 percent. In this regard, the record generally showed that the Veteran had symptoms, such anxiety, suspiciousness, chronic sleep impairment, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. Socially, he had good relationships with his four living sisters and brothers as well as with his wife of over 40 years and their two sons and daughters. Occupationally, post-service, the Veteran was a truck driver for 40 years. As such, the Board finds that the prior to August 14, 2014, the frequency and severity of such symptoms most nearly approximate an occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The Board finds that the preponderance of the evidence weighs against the next-higher 50 percent rating as the competent evidence does not reflect an occupational and social impairment with reduced reliability. For example, at this time of the 2013 VA examination, he had good relationships with his sibling, wife, and children. The Veteran did not pose a threat to self or others. Additionally, as persuasive competent medical evidence, the examination report marked by the examiner from the April 2013 VA psychiatric examination did not reflect an indication of the Veteran's acquired psychiatric disorder as having an occupational and social impairment with reduced reliability and productivity. The Board does find a higher rating is warranted from August 14, 2014 forward and will discuss that period next. From August 14, 2014, onward After review of the relevant medical and lay evidence, the Board finds that a rating of 70 percent, but no higher, from August 14, 2014, onward, for PTSD is warranted. The Veteran underwent a VA psychiatric examination in August 2014. The Veteran reported symptoms, such as difficulty sleeping, nightmares, a marked leg tremor, suicidal thoughts, paranoia, and intrusive thoughts. He further reported that one night he was "walking around his property while armed, searching for enemies." The examiner noted symptoms, such as a depressed mood, anxiety, panic attacks, chronic sleep impairment, and mild memory loss. The objective examination showed that the Veteran was alert and oriented, and had a euthymic mood, a controlled affect, an average intelligence, a consistent memory, and no psychoses or bipolar processes. However, the examination also showed that the Veteran acknowledged a history of suicidal ideation. Finally, the examiner stated that the Veteran had an occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. See 8/14/2014 VA Examination. The Veteran had an additional VA psychiatric examination in March 2016. The Veteran reported difficulty sleeping, nightmares, intrusive thoughts, hypervigilance, and severe problems with memory and concentration. The Veteran had symptoms, such as anxiety, suspiciousness, chronic sleep impairment, and mild memory loss. The objective examination showed that the Veteran was cooperative, pleasant, alert, and oriented, and had a regular speech and good hygiene, grooming, and eye contact. However, he was also moderately anxious and had an increased psychomotor activity, a flat affect, and a moderately impaired attention, concentration, and cognitive organizational tasks. Additionally, he was confused about the sequence and causation of events, asked irrelevant questions, made errors in serial subtractions, and had a poorly organized thinking, poor insight, and a questionable basic judgment. Finally, the examiner stated that the Veteran had an occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. See 3/16/2016 C&P Examination. The most recent VA psychiatric examination was performed in June 2017. The Veteran reported periods of passive suicidal ideation that last for days. The Veteran's wife reported that the Veteran socially isolates and is irritable and easily angered. The Veteran had symptoms, such as a depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, and impairment of short and long-term memory. Additionally, he had a flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. Further, he had suicidal ideation and neglect of personal appearance and hygiene. The objective examination showed that the Veteran was cooperative and appeared sad and tearful. Finally, the examiner stated that the Veteran had an occupational and social impairment with deficiencies in most areas. See 6/2/2017 C&P Examination. Based on the totality of the evidence above, the Board finds that from August 14, 2014, onward, the Veteran's condition most nearly approximates the criteria for a rating of 70 percent. In this regard, the record generally showed that the Veteran had suicidal ideation. See Bankhead, 29 Vet. App. at 20 ("[T]he presence of suicidal ideation alone, that is, a veteran's thoughts of his or her own death or thoughts of engaging in suicide-related behavior, may cause occupational and social impairment with deficiencies in most areas."); Id. (affirming that suicidal ideation does not require suicidal intent, a plan, or preparatory behavior). Furthermore, the record generally showed that the Veteran had symptoms, such as a depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, and impairment of short and long-term memory. Additionally, he had a flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, and neglect of personal appearance and hygiene. As such, the Board finds that the frequency and severity of such symptoms most nearly approximate deficiencies in most areas, such as judgment, thinking, or mood. The Board finds that the preponderance of the evidence weighs against a higher, 100 percent rating as the competent evidence does not reflect total social and occupational impairment. As persuasive competent medical evidence, the examination report marked by the examiners from the August 2014, March 2016, and June 2017 VA psychiatric examinations did not reflect an indication of the Veteran's acquired psychiatric disorder as having a total occupational and social impairment. See Total, Merriam-Webster, https://www.merriam-webster.com/dictionary/total (defining the adjective "total" as, among other entries, absolute). Additionally, the record showed that the Veteran has a good relationship with his surviving siblings, his wife of over 40 years, and his children, except for one son. Further, he reported that while he stayed at the Oklahoma State Veterans Center, he got along well with residents and the staff reported that he has not shown behavioral problems; even when dealing with a difficult roommate. See 3/16/2016 C&P Examination, at page 4. Moreover, the record showed that the Veteran has not been violent with anyone. In addition, he was cooperative and answered all questions correctly. See 6/2/2017 C&P Examination. In light of the overall competent evidence, the Board finds that the preponderance of the evidence weighs against a higher 100 percent rating, to include a finding of total social impairment for the period on appeal. The Board acknowledges the Veteran's suicidal ideation and notes that it is contemplated and compensated in the current 70 percent rating but finds that when evaluating the period on appeal as a whole, he is not in persistent danger of harming himself or others as shown by the June 2017 VA psychiatric examination report noting passive suicidal ideation and no suicide attempts. Additionally, at the 2016 VA examination, the Veteran denied any intent to harm or kill himself or others. The Board finds such competent evidence tends to weigh against a finding of persistent danger of hurting self or others. Also, the 2016 VA examination did not reveal delusions and the Veteran denied hallucinations. Meanwhile, the 2017 VA examination also did not reflect peristent delusions or hallucinations. The Board recognizes the Veteran's contentions regarding experiencing worsening psychiatric symptoms, such as a diminished memory. See 11/4/2016 NOD. He is competent to make those assertions based on his observable symptomatology and the Board finds him credible. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board has considered that statement as supporting evidence; however, it finds that the symptomology described by the Veteran and show by the record is contemplated by the current 70 percent rating. The weight of the competent, probative evidence shows the Veteran's symptomatology reflects a frequency, severity, and duration more nearly approximated by the criteria for a rating of 70 percent disabling. In sum, after review of all the relevant competent medical and lay evidence of record, the Board finds that as of August 14, 2014, onward, the overall disability picture is more nearly approximated by a rating of 70 percent. 2. An increased rating in excess of 20 percent for diabetes mellitus. The Veteran's service-connected diabetes is rated as 20 percent disabling, effective June 29, 2001, in accordance with the General Rating Formula for the Endocrine System. 38 C.F.R. § 4.97, DC 7913. In July 2016, the Veteran applied for increased compensation for this service-connected disability. Under Diagnostic Code 7913, a 20 percent rating is warranted for diabetes requiring insulin and a restricted diet, or oral hypoglycemic agents and a restricted diet. A 40 percent rating is warranted when diabetes requires insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities). A 60 percent rating is warranted for diabetes requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating is warranted when diabetes requires more than one daily injection of insulin, restricted diet, and regulation of activities, with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. The Veteran contends that he was changed to injected medication and, as such, his diabetes mellitus is worse than reflected by his current evaluation of 20 percent. See 11/4/2016 NOD. A review of the Veteran's outpatient treatment records shows that he has been continuously treated for diabetes mellitus throughout the appeal period. Treatment has included regulation of diet and insulin medication. These records do not reflect regulation of activities. A March 2013 VA diabetes examination documented that the Veteran followed a restricted diet and was prescribed insulin more than one injection per day. His activities were not regulated. The Veteran had not been hospitalized during the past year for ketoacidosis or hypoglycemic reactions and he had diabetic care less than two times per month. Finally, the examiner opined that there was no functional impact. See 4/11/2013 C&P Examination. The Veteran underwent another VA diabetes examination in March 2016. The examination showed that the Veteran was prescribed insulin more than one injection per day. His activities were not regulated. The Veteran had not been hospitalized during the past year for ketoacidosis or hypoglycemic reactions and he saw his diabetic care provider less than two times per month. Finally, the examiner opined that there was no functional impact. See 3/11/2016 C&P Examination. An additional VA diabetes examination was conducted in August 2016. The examination showed that the Veteran was prescribed insulin and had 4 injections per day with each meal. His activities were not regulated. The Veteran had not been hospitalized during the past year for ketoacidosis or hypoglycemic reactions nad he saw his diabetic care providers less than two times per month. Finally, regarding functional impact, the examiner opined that the Veteran has balance problems and uses a walker at home and a wheelchair to get around. See 9/27/2016 VA Examination. The most recent VA diabetes examination was conducted in June 2017. The examination showed that the Veteran was prescribed insulin more than one injection per day. His activities were not regulated. The Veteran had not been hospitalized during the past year for ketoacidosis or hypoglycemic reactions and saw his diabetic care provider less than two times per month. Finally, regarding functional impact, the examiner stated that the Veteran reported an inability to work because he cannot walk too far. Additionally, he experiences difficulty with prolonged standing and walking, and uses a wheelchair all the time. See 6/6/2017 C&P Examination. After having carefully reviewed the evidence of record, the Board finds that the Veteran's symptoms of diabetes mellitus are already compensated by the current rating of 20 percent. In this regard, the evidence of record generally shows that the Veteran's diabetes mellitus is of such severity that it requires dietary restriction and insulin with more than one injection per day. The competent and probative evidence weighs against showing that Veteran has had regulation of activities as contemplated by the rating criteria. In this regard, the Court has explained that the term "regulation of activities" means that a claimant must have a medical need to avoid not only strenuous occupational activity, but also strenuous recreational activity. Camacho v. Nicholson, 21 Vet. App. 360, 363 (2007). Medical evidence is required to show that occupational and recreational activities have been restricted. Id. at 364. Neither VA treatment records nor the VA examinations from April 2013, March 2016, September 2016, or June 2017, documented a regulation of activities. In that regard, VA treatment records showed that in January 2014 the Veteran was encouraged to diet and exercise as tolerated. See 12/16/2017 CAPRI, at page 18. As such, the weight of the competent and probative evidence does not tends to support a finding of regulation of activity. The evidence of record does not warrant a rating in excess of the 20 percent assigned for the Veteran's diabetes mellitus at any time during the period pertinent to this appeal. Finally, the Board has considered the doctrine of reasonable doubt. However, as the most probative evidence of record is against the Veteran's claim, the Board finds that this doctrine is not for application. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 53. 3. The reduction of the 10 percent rating to non-compensable for bilateral hearing loss, effective March 16, 2016, was improper. Service connection for bilateral hearing loss was established in an April 2008 rating decision, which assigned a non-compensable rating, effective March 20, 2008. A September 2013 rating decision increased the disability rating to 10 percent, effective November 19, 2012 (the date VA received his increased rating claim). A May 2016 rating decision reduced the disability rating assigned to the service-connected bilateral hearing loss, from 10 percent to non-compensable, effective March 16, 2016. A Veteran's disability rating shall not be reduced unless an improvement in the disability is shown to have occurred. 38 C.F.R. § 3.344. The Court has consistently held that when a disability rating is reduced without following the applicable regulations, the reduction is void ab initio. See Greyzck v. West, 12 Vet. App. 288, 292 (1999). In any rating reduction case, VA must determine: (1) whether the evidence reflects an actual change in the disability based upon review of the entire recorded history of the condition; (2) whether the examination reports reflecting such change are based upon thorough examinations; and (3) whether any improvement actually reflects an improvement in the Veteran's ability to function under the ordinary conditions of life and work. See Murphy v. Shinseki, 26 Vet. App. 510, 516-17 (2014) citing Brown v. Brown, 5 Vet. App. 413, 421 (1993); see also Faust v. West, 13 Vet. App. 342, 349 (2000) (summarizing the requirements that VA must follow in all reduction cases, "regardless of the rating level or the length of time that the rating has been in effect"). In addressing whether improvement is shown, the comparison point generally is the last examination on which the rating at issue was assigned or continued. See Hohol v. Derwinski, 2 Vet. App. 169 (1992). These provisions impose a clear requirement that VA rating reductions be based upon review of the entire history of a Veteran's disability. See Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). In certain rating reduction cases, Veterans are to be afforded greater protections as set forth in 38 C.F.R. § 3.344(a) and (b). These provisions provide that rating agencies will handle cases affected by change of medical findings to produce the greatest degree of stability of disability ratings consistent with the laws and VA regulations governing disability compensation and pension. The provisions of 38 C.F.R. § 3.344(c) specify that these considerations are required for ratings that have continued for long periods at the same level (five years or more), and do not apply to disabilities which have not become stabilized and are likely to improve. Re-examinations disclosing improvement in these disabilities will warrant a reduction in rating. Generally, when reduction in the rating of a service-connected disability is contemplated and the lower rating would result in a reduction or discontinuance of compensation payments, a Rating Decision proposing the reduction or discontinuance will be prepared setting forth all material facts and reasons. 38 C.F.R. § 3.105(e). The Veteran must be notified of the contemplated action and furnished detailed reasons. Id. The Veteran must be given 60 days for the presentation of additional evidence to show that compensation payments should be continued at the present level. Id. Where a rating reduction was made without observance of law, the reduction must be vacated, and the prior rating restored. See Schafrath, 1 Vet. App. at 595. In considering the propriety of a reduction, the Board must focus on the evidence available to the AOJ at the time the reduction was effectuated (although post-reduction medical evidence may be considered in the context of considering whether actual improvement was demonstrated). See Dofflemyer v. Derwinski, 2 Vet. App. 277, 281-82 (1992). The Veteran need not demonstrate that he is entitled to retain the higher rating; rather, it must be shown by a preponderance of the evidence that the AOJ's reduction was warranted. See Kitchens v. Brown, 7 Vet. App. 320 (1995). Here, the provisions of 38 C.F.R. § 3.344(a) and (b) are not applicable as the Veteran's 10 percent disability rating for service-connected hearing loss was effective November 19, 2012, and reduced effective March 16, 2016; therefore, the rating had not been in effect for five years or more. Further, because the Veteran's combined disability rating did not decrease from 90 percent, the reduction for service-connected hearing loss did not result in a reduction or discontinuance of compensation payments. As such, a Rating Decision proposing the reduction was not required under 38 C.F.R. § 3.105(e). See Stelzel v. Mansfield, 508 F.3d 1345, 1349 (Fed. Cir. 2007); Tatum v. Shinseki, 24 Vet. App. 139, 143 (2010). The Board will now turn to the propriety of the rating reduction. The Board finds that the Veteran's rating reduction from 10 percent to non-compensable, effective March 16, 2016, was improper, as the AOJ failed to articulate how the preponderance of the evidence established an actual improvement in the Veteran's ability to function under the ordinary conditions of life and work. See Murphy, 26 Vet. App. at 516-17 (citing Brown, 5 Vet. App. at 421); see also Faust, 13 Vet. App. at 349. Specifically, the March 2013 and March 2016 VA examiners both reported functional loss in the Veteran's daily life and work, to include a need to see the person's face and have distance and background noises reduced to be able to communicate effectively, and that he cannot hear when more than one person is talking. The Board notes that none of the VA examiners discussed "an improvement" in the Veteran's condition. Finally, the Board also notes that the AOJ failed to address the competent and credible statement from the Veteran's wife contained in the November 2016 NOD, wherein his wife contends that the Veteran "complains that he has trouble hearing what people say." Further, relevant, but of less weight, during the June 2017 VA examination, the examiner stated that the Veteran reported that he experiences "decreased hearing sensitivity that gradually worsens over time" when recording the Veteran's functional impairment. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Board finds that, upon a review of the entire recorded history of the Veteran's service-connected hearing loss, the preponderance of the evidence does not reflect an actual improvement in his ability to function under the ordinary conditions of life and work. See Murphy, 26 Vet. App. at 516-17. This finding is primarily supported by a comparison of the 2013 and 2016 VA examination reports showing similar impairment and not showing disclosing improvement. Based upon the foregoing, the Board finds the preponderance of the evidence of record fails to establish that the AOJ's rating reduction was warranted. Therefore, the rating reduction, effective March 16, 2016, is vacated and the Veteran's prior 10 percent disability rating restored for service-connected bilateral hearing loss. 4. An increased rating in excess of 10 percent for bilateral hearing loss. The Veteran contends that he is entitled to a disability rating in excess of 10 percent for bilateral hearing loss, evaluated under DC 6100. Specifically, the Veteran's wife contends that the Veteran "complains that he has trouble hearing what people say." See 11/4/2016 NOD. Further, during the June 2017 VA examination, as functional impairment, the examiner stated that the Veteran reported that he experiences "decreased hearing sensitivity that gradually worsens over time." Disability ratings for hearing loss are assigned based on the results of controlled speech discrimination tests combined with the results of pure tone audiometry tests. See 38 C.F.R. §§ 4.85-4.86. An examination for VA rating purposes must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test, specifically, the Maryland CNC test, and a pure tone audiometry test. 38 C.F.R. § 4.85(a). Further, disability ratings for hearing impairment are assigned through a structured formula, i.e., a mechanical application of the rating schedule to numeric designations that are assigned after audiometric evaluations have been rendered. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). First, a Roman numeral designation of I through XI is assigned for the level of hearing impairment in each ear. Table VI is used to determine a Roman numeral designation based on a combination of the speech discrimination percentage and the average pure tone threshold, or the sum of the pure tone thresholds at 1000, 2000, 3000, and 4000 Hertz, divided by four. After a Roman numeral designation has been assigned for each ear, Table VII is used to determine the compensation rate by combining such designations for hearing impairment in both ears. 38 C.F.R. § 4.85. When the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86(a). When the pure tone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. That numeral will then be elevated to the next higher. 38 C.F.R. § 4.86(b). After reviewing the relevant medical and lay evidence and applying the above laws and regulations, the Board finds that Veteran is not entitled to a disability rating in excess of 10 percent for bilateral hearing loss. The Board first notes that based on the relevant competent audiological evidence the Veteran does have an exceptional pattern of hearing impairment in the right ear per 38 C.F.R. § 4.86(a). All applicable tests include valid pure tone scores. As such, the more favorable Table applies. See 38 C.F.R. §§ 4.85, 4.86. As noted above, the record shows that an April 2008 rating decision granted service connection for bilateral hearing loss and assigned a non-compensable rating, effective March 20, 2008. After that, the Veteran filed a claim for an increased rating on November 19, 2012. For historical context, as referenced in the section above, a March 2013 VA examination, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 55 60 65 75 75 LEFT 45 50 55 60 60 The right ear had an average of 69 decibels and the left ear had an average of 56 decibels. Speech audiometry revealed speech recognition ability of 100 percent in the right ear, and 88 percent in the left ear. See 3/29/2013 VA Examination. Utilizing Table VIA, 69 decibels pure tone threshold average for the right ear results in the designation of a Roman numeral V. Furthermore, his left ear pure tone average also combines with the left ear speech discrimination for no worse than a Roman numeral II, per Table VI. See 38 C.F.R. § 4.85. A roman numeral V and Roman numeral II combine for 10 percent disability rating in Table VII. A March 2016 VA examination, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 30 35 40 75 65 LEFT 30 30 35 40 60 The right ear had an average of 54 decibels and the left ear had an average of 41 decibels. Speech audiometry revealed speech recognition ability of 84 percent in the right ear, and 68 percent in the left ear. See 3/16/2016 C&P Examination. Using the above reported findings, the Veteran's right ear pure tone average combines with the right ear speech discrimination to yield no worse than a Roman numeral II in Table VI. Furthermore, his left ear pure tone average also combines with the left ear speech discrimination for no worse than a Roman numeral IV, per Table VI. See 38C.F.R. § 4.85. A roman numeral II and Roman numeral IV combine for a non-compensable, rating in Table VII. A June 2017 VA examination, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 15 20 65 65 LEFT 25 20 25 45 55 The right ear had an average of 41 decibels and the left ear had an average of 36 decibels. Speech audiometry revealed speech recognition ability of 96 percent in the right ear, and 96 percent in the left ear. See 6/2/2017 C&P Examination. Using the above reported findings, the Veteran's right ear pure tone average combines with the right ear speech discrimination to yield no worse than a Roman numeral I in Table VI. Furthermore, his left ear pure tone average also combines with the left ear speech discrimination for no worse than a Roman numeral I, per Table VI. See 38C.F.R. § 4.85. A roman numeral I and Roman numeral I combine for a non-compensable, rating in Table VII. The Board has considered the Veteran's contentions that he experiences decreased hearing sensitivity that gradually worsens over time. See 6/2/2017 C&P Examination. For example, at the March 2016 VA examination, he reported that is unable to hear when there is background noise and when there is more than one person talking. He is competent and credible to report any symptoms of hearing loss, such a difficulty hearing. See Jandreau, 492 F.3d at 1377. Nevertheless, VA's rating of hearing impairment is based on specific measurements that must be gathered by a state-licensed audiologist using specific tests, as discussed above. The Board finds that the competent medical evidence, to include the VA examination testing results, are more probative and outweigh the lay subjective reports of a more severe degree of disability, because they were provided by personnel with specialized training in hearing loss and directly address the rating criteria for the Veteran's hearing loss. The Board observes that VA's Schedule for Rating Disabilities has been found to contemplate the problems reported by the Veteran in terms of his difficulty hearing others. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (holding that "the rating criteria for hearing loss contemplate the functional effects of difficulty hearing and understanding speech"). Accordingly, this appeal for a rating in excess of 10 percent is denied. The Board has considered the applicability of the benefit of the doubt doctrine, but the preponderance of the evidence is against a higher rating. Under these circumstances, the doctrine is not applicable. 38 U.S.C. § 5107(b). 5. The reduction of the 40 percent rating to non-compensable for right lower extremity peripheral vascular disease, effective March 10, 2016, was improper. Without reaching the merits of the propriety of the reduction in this case, the Board finds that the reduction is void ab initio due to the AOJ's failure to adequately follow the procedural requirements set forth in 38 C.F.R. § 3.105(e), regarding reduction in benefits. The failure deprived the Veteran of adequate due process protections in this case. Generally, when reduction in the evaluation of a service-connected disability is contemplated and the lower evaluation would result in a reduction or discontinuance of compensation payments, a rating proposing the reduction or discontinuance will be prepared setting forth all material facts and reasons. The beneficiary must be notified of the contemplated action and furnished detailed reasons, therefore. The beneficiary must be given sixty days for the presentation of additional evidence to show that compensation payments should be continued at the present level. 38 C.F.R. § 3.105(e). In addition, the beneficiary must be informed that he or she will have an opportunity for a predetermination hearing, provided that the request for a hearing is received within thirty days of such notice; if a predetermination hearing is timely requested, benefits payments shall be continued at the previously established level pending a final determination concerning the proposed action. See 38 C.F.R. § 3.105(i). In the May 2016 rating decision on appeal, the 40 percent rating for peripheral vascular disease of the right lower extremity, in effect since November 19, 2012, was reduced to noncompensable, effective March 10, 2016. The decision notes "[a]s this reduction in evaluation does not result in a reduction in your overall disability evaluation and compensation[,] which was in place prior to this rating decision, the action is hereby taken and no due process procedures are required." However, the record showed that since October 27, 2015, the Veteran's combined disability rating was rated as 100 percent, and as a result of the reduction on March 10, 2016, the Veteran's combined evaluation for compensation decreased to 90 percent. As such, the Veteran should have been notified of the contemplated action and furnished detailed reasons, therefore. In view of the foregoing, the Board finds that the Veteran was not notified of the proposed reduction, was not given sixty days for the presentation of additional evidence to show that compensation payments should be continued at the present level, and was not informed of an opportunity for a predetermination hearing, prior to the reduction in benefits that occurred in the May 2016 rating decision. Because the AOJ failed to afford the Veteran notice of the proposed reduction, outlining the reasons for the reduction, prior to the reduction in benefits in the May 2016 rating decision, the reduction in this case was not proper. Accordingly, the Board finds that the reduction in this case is void ab initio and the Veteran's prior 40 percent rating for service-connected peripheral vascular disease of the right lower extremity is restored. 6. An increased rating in excess of 20 percent prior to June 2, 2017, and in excess of 60 percent, thereafter, for peripheral vascular disease of the left lower extremity. 7. An increased rating in excess of 40 percent for peripheral vascular disease of the right lower extremity. Under Diagnostic Code 7114, a 20 percent rating will be assigned when there is claudication on walking more than 100, and diminished peripheral pulses or ankle/brachial index of 0.9 or less. A 40 percent rating will be assigned for peripheral vascular disease with claudication on walking between 25 and 100 yards on a level grade at 2 miles per hour, and; trophic changes (thin skin, absence of hair, dystrophic nails), or ankle/brachial index of 0.7 or less. A 60 percent rating will be assigned for claudication on walking less than 25 yards on a level grade at 2 miles per hour, and; either persistent coldness of the extremity or ankle/brachial index of 0.5 or less. A 100 percent rating will be assigned with ischemic limb pain at rest, and either deep ischemic ulcers or ankle/brachial index of 0.4 or less. 38 C.F.R. § 4.104. As of now, the Veteran is in receipt of a 20 percent disability rating for the service-connected peripheral vascular disease of the left lower extremity from November 19, 2012, and 60 percent from June 2, 2017, under DC 7114. Additionally, the Veteran is in receipt of a 40 percent disability rating for the service-connected peripheral vascular disease of the right lower extremity from November 19, 2012, under DC 7114. 38 C.F.R. § 4.104. He contends that an increased rating is warranted. Prior to June 13, 2013 Turning to the evidence, in March 2013, the Veteran was afforded a VA artery and vein conditions examination. The objective examination showed that the Veteran had bilateral claudication on walking more than 100 yards and diminished peripheral pulses and trophic changes bilaterally. Ankle and brachial indexes were recorded as 0.71 for his right ankle, and 0.79 for his left ankle. Regarding functional impact, the examiner opined that due to his disability, the Veteran was unable to walk far distances or stand or drive for long periods. See 4/11/2013 C&P Examination, at pages 6 to 12. After a review of all the lay and medical evidence of record, the Board finds that prior to June 13, 2013, an increased rating greater than 20 percent for peripheral vascular disease of the left lower extremity is not warranted. A rating of 40 percent requires claudication on walking between 25 and 100 yards on a level grade at 2 miles per hour. The record supports that the Veteran had claudication only on walking more than 100 yards, prior to June 13, 2013. As such, the preponderance of the evidence is against finding that a disability rating in excess than 20 percent is warranted prior to June 13, 2013, for peripheral vascular disease of the left lower extremity. Regarding peripheral vascular disease of the right lower extremity, prior to June 13, 2013, an increased rating greater than 40 percent for peripheral vascular disease of the right lower extremity is not warranted. A rating of 60 percent requires claudication on walking less than 25 yards on a level grade at 2 miles per hour. The record supports that the Veteran had claudication only on walking more than 100 yards, prior to June 2, 2017. As such, the preponderance of the evidence is against finding that a disability rating in excess than 40 percent is warranted prior to June 13, 2013, for peripheral vascular disease of the right lower extremity. As of June 13, 2013 In March 2016, the Veteran was afforded another VA examination for his peripheral vascular disease. The examiner diagnosed the Veteran with minimal peripheral artery disease of the left lower extremity and determined that the Veteran did not have a diagnosis of peripheral artery disease of the right lower extremity. The objective examination showed that the Veteran had bilateral persistent coldness and diminished peripheral pulses. No trophic changes or claudication were documented. Ankle and brachial indexes in the right ankle were 1.09, and for his left ankle 0.98. Regarding functional impact, the examiner opined that the Veteran was unable to stand for prolonged periods, walk at a fast pace, or sit for prolonged periods without standing to change positions. See 3/10/2016 C&P Examination. In addition, a May 2016 addendum opinion to the March 2016 VA peripheral vascular disease examination, stated that the persistent coolness of the extremity was most likely attributable to the Veteran's known service-connected peripheral neuropathy. The reviewing clinician stated that the ankle brachial index testing results from the March 2013 VA examination was not consistent with the normal ankle brachial index testing results from the January 2010 VA examination. As such, the reviewing clinician opined that the Veteran did not have a diagnosis of peripheral artery disease because it was never accurately diagnosed. See 5/17/2016 C&P Examination. However, the Board finds this opinion inadequate. A more recent June 2017 VA examination, as discussed below, confirmed that the Veteran in fact has a diagnosis of peripheral vascular disease of the right lower extremity. As such, the Board affords this addendum opinion little weight. VA treatment records from June 13, 2013 showed that the Veteran had neurogenic claudication just to standing due to a low back disability. See 9/27/2013 CAPRI, at page 105. Beginning June 13, 2013, the service-connected peripheral vascular disease of the bilateral lower extremities has been manifested by claudication on standing, more nearly approximating ischemic limb pain at rest, and trophic changes. See Merriam-Webster, Rest, https://www.merriam-webster.com/dictionary/rest (defining "rest", among other entries, but most relevant here, as "a state of motionlessness or inactivity"). As such, regarding the left lower extremity, a rating of 40 percent, but no higher, is warranted. However, regarding the right lower extremity, a rating in excess of 40 percent is not warranted. As of June 2, 2017 The most recent VA examination was conducted in June 2017. The objective examination showed that the Veteran had bilateral persistent coldness, diminished peripheral pulses, ischemic limb pain at rest, and trophic changes. Ankle and brachial indexes were recorded as 0.80 for his right ankle, and 1.05 for his left ankle. Regarding functional impact, the examiner stated that the Veteran reported difficulty with prolonged standing and walking, and that he uses a wheelchair all the time and a walker at home. See 6/2/2017 C&P Examination. Beginning June 2, 2017, the service-connected peripheral vascular disease of the bilateral lower extremities has been manifested by claudication on standing, as noted above this is more akin to ischemic limb pain at rest, and persistent coldness. As such, regarding the left lower extremity, a rating in excess of 60 percent is not warranted. Regarding the right lower extremity, a rating of 60 percent, but no higher, is warranted. The record does not tend to show evidence of deep ischemic ulcers or ankle/brachial index of 0.4 or less (criteria for 100 percent rating). Thus, a rating in excess of 60 percent is not warranted throughout the entire period on appeal. Based on the foregoing evidence, the Board finds that, prior to June 13, 2013, a rating higher disability rating than 20 percent for peripheral vascular disease of the left lower extremity and a rating higher than 40 percent for peripheral vascular disease of the right lower extremity are not warranted. Beginning June 13, 2013, a rating of 40 percent, but no higher, for peripheral vascular disease of the left lower extremity is warranted and a rating in excess of 40 percent for peripheral vascular disease of the right lower extremity is not warranted. Beginning June 2, 2017, a rating higher than 60 percent for peripheral vascular disease of the left lower extremity is not warranted and a rating of 60 percent, but no higher, for peripheral vascular disease of the right lower extremity, under DC 7114 is warranted. 38 C.F.R. § § 4.3, 4.7. 8. A TDIU. The Veteran seeks entitlement to a TDIU. After affording the Veteran the benefit of the doubt, the Board finds that the competent and probative evidence is at least in equipoise as to whether the Veteran's service-connected PTSD precludes him from securing or following gainful employment. A total disability rating may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation due to service-connected disabilities. 38 C.F.R. §§ 3.340, 4.16(a). This is so, provided that the unemployability is the result of a single service-connected disability ratable at 60 percent or more, or the result of two or more service-connected disabilities, where at least one disability is ratable at 40 percent or more and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). In determining unemployability for VA purposes, consideration may be given to the veteran's level of education, special training, and previous work experience, but not to age or any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19; Hersey v. Derwinski, 2 Vet. App. 91, 94 (1992); Faust v. West, 13 Vet. App. 342 (2000). The sole fact that a veteran is unemployed or has difficulty securing employment is not enough, as a high rating in itself is a recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (citing 38 C.F.R. §§ 4.1, 4.15, 4.16(a)). Entitlement to a TDIU is based on an individual's particular circumstances. Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). The Court has held that the term unable to secure and follow a substantially gainful occupation in 38 C.F.R. § 4.16 has two components. First, there is an economic component which essentially contemplates an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. Second, there is a non-economic component dealing with the individual veteran's ability to follow and secure employment. For the second component, attention must be given to: (a) the veteran's history, education, skill and training, (b) the veteran's physical ability (both exertional and non-exertional) to perform the type of activities (e.g., sedentary, light, medium, heavy or very heavy) required by the occupation at issue, with relevant factors such as lifting, bending, sitting, standing, walking, climbing, grasping, typing, reaching, auditory and visual, and (c) whether the Veteran has the mental ability to perform the type of activities required by the occupation at issue, with relevant factors such as memory, concentration, and ability to adapt to change, handle work place stress, get along with coworkers and demonstrate reliability and productivity. Ray v. Wilkie, 31 Vet. App. 58, 72-73 (2019). The Court has stated that "a veteran can establish marginal employment either by demonstrating an income less than the poverty threshold established by the U.S. Census Bureau or by the facts of his particular case." Ortiz-Valles v. McDonald, 28 Vet. App. 6, 71 (2016) (emphasis in original). Regardless of the method, "if the evidence or facts reflect that a veteran is capable only of marginal employment, he [or she] is incapable of securing or following a substantially gainful occupation and is therefore entitled to [TDIU] if his service-connected disabilities are the cause of that incapability." Id. In making a determination, the Board must consider all the evidence of record and make appropriate determinations of competence, credibility, and weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). When there is an approximate balance of positive and negative evidence regarding any material issue, all reasonable doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The record shows that the Veteran meets the percentage threshold for consideration of a TDIU per 38 C.F.R. § 4.16(a) since November 19, 2012. In detail, service connection is in effect for PTSD (30 percent from November 19, 2012; 70 percent from August 14, 2014), peripheral vascular disease of the left lower extremity (20 percent from November 19, 2012, 40 percent from June 13, 2013, and 60 percent from June 2, 2017), peripheral vascular disease of the right lower extremity (40 percent from November 19, 2012, and 60 percent from June 2, 2017), urinary incontinence (10 percent from November 19, 2012, at 20 percent from October 27, 2015; and 40 percent from July 12, 2016), bilateral cataracts (30 percent from September 30, 2009), diabetic nephropathy (30 percent from July 12, 2016), diabetes mellitus type II (20 percent from June 29, 2001), peripheral neuropathy of the left lower extremity (previously DC 8621) (10 percent from November 19, 2012, and 20 percent from October 27, 2015), peripheral neuropathy of the right lower extremity (previously DC 8621) (10 percent from November 19, 2012, and 20 percent from October 27, 2015), tinnitus (10 percent from March 20, 2008), peripheral neuropathy of the left lower extremity (closed out) (10 percent from September 30, 2009), peripheral neuropathy of the right lower extremity (closed out) (10 percent from September 30, 2009), and bilateral hearing loss at non-compensable from March 20, 2008, and 10 percent from November 19, 2012). Since November 19, 2012, the Veteran's combined disability rating has been 70 percent or higher. The sole fact that a veteran is unemployed or has difficulty obtaining employment is not enough. The question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (citing 38 C.F.R. §§ 4.1, 4.15, 4.16(a)). Thus, the Board must evaluate whether there are circumstances, apart from any non-service-connected conditions and advancing age, which would justify a total rating based on unemployability. See id.; see also 38 C.F.R. § 4.16(b). In making this determination, consideration may be given to his or her level of education, special training, and previous work experience, but not to his or her age or occupational impairment caused by non-service-connected disabilities. It should additionally be noted that marginal employment or employment provided on account of disability or special accommodation is not substantially gainful. See 38 C.F.R. §§ 3.341, 4.16, 4.18, 4.19; Hersey v. Derwinski, 2 Vet. App. 91, 94 (1992); Faust v. West, 13 Vet. App. 342 (2000). Entitlement to a TDIU is based on an individual's particular circumstances. Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). In this case, the evidence of record, as reported by the Veteran, establishes that he has a high school education and last worked full-time on January 29, 2013 as a self-employed oil field service business owner. See 10/27/2015 VA Form 21-8940. Further, the Veteran reported that he sold his business on March 13, 2013, and that he does not receive any income from the business. See 11/4/2016 VA 21-4185; see also 6/14/2017 VA 21-4185. Next, the Board will review, relevant competent evidence describing the impact and/or impairment from his service-connected PTSD. An April 2013 VA psychiatric examination noted that the Veteran had symptoms, such as anxiety, suspiciousness, chronic sleep impairment, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. The examiner stated that the Veteran had an occupational and social impairment due to mild and transient symptoms, which decrease work efficiency and ability to perform occupational tasks. See 4/11/2013 C&P Examination. The Veteran underwent another VA psychiatric examination in August 2014. The Veteran reported symptoms, such as difficulty sleeping, nightmares, a marked leg tremor, suicidal thoughts, paranoia, and intrusive thoughts. He further reported that one night he was "walking around his property while armed, searching for enemies." The examiner noted symptoms, such as a depressed mood, anxiety, panic attacks, chronic sleep impairment, and mild memory loss. The objective examination showed that the Veteran was alert and oriented, and had a euthymic mood, a controlled affect, an average intelligence, a consistent memory, and no psychoses or bipolar processes. However, the examination also showed that the Veteran acknowledged a history of suicidal ideation. Finally, the examiner stated that the Veteran had an occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. See 8/14/2014 VA Examination. An additional VA psychiatric examination was conducted in March 2016. The Veteran reported difficulty sleeping, nightmares, intrusive thoughts, hypervigilance, and severe problems with memory and concentration. The Veteran had symptoms, such as anxiety, suspiciousness, chronic sleep impairment, and mild memory loss. The objective examination showed that the Veteran was cooperative, pleasant, alert, and oriented, and had a regular speech and good hygiene, grooming, and eye contact. However, he was also moderately anxious and had an increased psychomotor activity, a flat affect, and a moderately impaired attention, concentration, and cognitive organizational tasks. Additionally, he was confused about the sequence and causation of events, asked irrelevant questions, made errors in serial subtractions, and had a poorly organized thinking, poor insight, and a questionable basic judgment. Finally, the examiner stated that the Veteran had an occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. See 3/16/2016 C&P Examination. The most recent VA examination was performed in June 2017. The Veteran reported periods of passive suicidal ideation that last for days. The Veteran's wife reported that the Veteran socially isolates and is irritable and easily angered. The Veteran had symptoms, such as a depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, and impairment of short and long-term memory. Additionally, he had a flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. Further, he had suicidal ideation and neglect of personal appearance and hygiene. The objective examination showed that the Veteran was cooperative and appeared sad and tearful. Finally, the examiner stated that the Veteran had an occupational and social impairment with deficiencies in most areas. See 6/2/2017 C&P Examination. Based on the evidence above, and resolving doubt in favor of the Veteran, the Board finds that the Veteran's service-connected PTSD alone is as likely as not of such nature and severity as to prevent him from securing or following substantially gainful employment. In this regard, he is no longer able to maintain employment because of his lack of concentration as well as the requirement of being around others. Additionally, the evidence of record shows the Veteran is largely socially isolated, has mood disturbances, anger outbursts, suicidal ideation, and short and long-term memory deficits. Further, the Veteran is hypervigilant and neglects his personal appearance and hygiene. In the Board's review of the facts, to include the Veteran's education, work history, and impairment from his service-connected PTSD, he has a complex and multifaceted disability picture that is incompatible with substantially gainful employment. The Board further finds that sedentary work is not a realistic option for the Veteran given his education level and limited work experience. As stated above, he has a high school education and last worked in 2013 as a business owner. There is no indication that the Veteran has the skills and experience to secure and maintain a job in the modern work environment. Moreover, there is no evidence that the Veteran has any experience in a socially isolated position that would be appropriate for one with his educational and occupational background. In summary, the Board finds the evidence to be in equipoise with respect to whether the Veteran's service-connected PTSD alone precludes him from obtaining and retaining substantially gainful employment. When reasonable doubt is resolved in the Veteran's favor, the Board finds that the Veteran's service-connected PTSD is as likely as not of such nature and severity as to prevent him from securing or following substantially gainful employment from January 29, 2013. 38 U.S.C. § 5107(b). 9. SMC under the provisions of 38 U.S.C. § 1114(s). The Court has held that VA has a "well-established" duty to maximize a claimant's benefits. See Buie v. Shinseki, 24 Vet. App. 242 at 250; AB v. Brown, 6 Vet. App. 35, 38 (1993); see also Bradley v. Peake, 22 Vet. App. 280 (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. There is no prejudice to the Veteran in the Board considering entitlement to SMC in in the first instance, as eligibility for this benefit turns solely on the application of law, and the Board's decision is favorable to the extent permitted by law, as discussed below. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993) (holding that where the Board addresses a question that has not been addressed by the AOJ, the Board must consider the potential for prejudice to the appellant). In any event, SMC benefits "are to be accorded when a veteran becomes eligible, without need for a separate claim." Bradley, 22 Vet. App. at 294 (citing Akles v. Derwinski, 1 Vet. App. 118, 121 (1991)). In other words, SMC is not a wholly different benefit but an issue within a claim for an increased or higher initial disability evaluation. SMC is payable at a specified rate under 38 U.S.C. § 1114(s) when a veteran has a single service-connected disability rated as 100 percent and: (1) has an additional service-connected disability or disabilities independently ratable at 60 percent or more, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems; or (2) is permanently housebound by reason of service-connected disability or disabilities. 38 C.F.R. § 3.350(i). While the separate disabilities rated as 60 percent disabling must involve separate and distinct anatomical segments or body systems, the fact that the total disability and the independent 60 percent disabilities result from a common etiological agent will not preclude entitlement. In this case, the Board notes that as a result of this decision, a TDIU based solely on the Veteran's service-connected PTSD has been granted. Thus, for SMC purposes, this disability satisfies the requirement of a "service-connected disability rated as total." See Buie, 24 Vet. App. at 251; see also Bradley, 22 Vet. App. at 293. From January 29, 2013, the Veteran is service connected for peripheral vascular disease of the left lower extremity, peripheral vascular disease of the right lower extremity, urinary incontinence, bilateral cataracts, diabetic nephropathy, diabetes mellitus type II, peripheral neuropathy of the left lower extremity (previously DC 8621), peripheral neuropathy of the right lower extremity (previously DC 8621), tinnitus, peripheral neuropathy of the left lower extremity (closed out), peripheral neuropathy of the right lower extremity (closed out), and bilateral hearing loss. The Veteran has a single service-connected disability rated as total, PTSD, as well as additional service-connected disabilities, rated at least 60 percent disabling. As such, the criteria for an award of SMC under 38 U.S.C. § 1114(s) from January 29, 2013, is warranted. Paul Sorisio Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J.F., Associate 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.