Citation Nr: 21069957 Decision Date: 11/22/21 Archive Date: 11/22/21 DOCKET NO. 21-00 348 DATE: November 22, 2021 ORDER Entitlement to a separate compensable rating for a left knee painful scar prior to February 4, 2014, is denied. Entitlement to a rating of 10 percent for a left knee painful scar, pursuant to Diagnostic Code (DC) 7804, is granted effective February 4, 2014. Entitlement to an increased rating in excess of 10 percent for a left knee painful scar, pursuant to DC 7804, is denied. Entitlement to a compensable rating for a left knee scar, status-post total knee replacement, pursuant to DC 7805, is denied. Entitlement to an initial rating in excess of 30 percent for right total knee replacement from October 1, 2014, is denied. Entitlement to an initial compensable rating for a right knee scar, status-post total knee replacement is denied. Entitlement to an initial 10 percent rating for hypertension is granted. Entitlement to an effective date prior to April 1, 2015, for the award of a total disability rating based on individual unemployability (TDIU) is denied. Entitlement to an effective date prior to April 1, 2015, for the award of basic eligibility for Dependents Educational Assistance (DEA) benefits under 38 U.S.C. Chapter 35 is denied. Entitlement to special monthly compensation (SMC) pursuant to 38 U.S.C. 1114(s), from October 1, 2014, is denied. FINDINGS OF FACT 1. Prior to February 4, 2014, the Veteran had a single left knee scar, linea, 18 cm in length which was linear, soft, dark in color, depressed and nontender, without adherence to the underlying tissue or tissue loss and no disfigurement, keloid formation or limitation of function of the knee due to the scar; the symptoms of the scar were considered in assessing the Veteran's post-surgical residuals under DC 5055. 2. On February 14, 2014, the Veteran underwent a second total knee replacement of the left knee, which resulted in as single linear scar, 23 cm in length which was painful in nature, but not unstable; no other pertinent symptoms are attributed to the scar; it does not adhere to underlying tissue, or result in disfigurement or keloid formation and does not limit function of the left knee. 3. The Veteran's right total knee replacement has not been manifested by chronic residuals consisting of severe painful motion or weakness in the affected extremity; there is no evidence of ankylosis or fixation of the joint, nor any evidence of tibial or fibular impairment; at most, extension is limited to 15 degrees due to pain, although extension has generally been found to be complete and normal. 4. The Veteran has a single surgical scar on the right knee which is 18 cm in length; it is neither painful, nor unstable. 5. The Veteran has a history of diastolic pressure greater than 100, requiring antihypertensive medication to control. 6. Prior to April 1, 2015, the Veteran did not meet the schedular criteria for a grant of TDIU; with the exception of his right and left knee disabilities, during periods when they were granted temporary total ratings due to post-surgical convalescence, his various service-connected disabilities did not prevent him from securing and following substantially gainful employment. 7. Eligibility for DEA benefits under 38 U.S.C. Chapter 35 arose on April 1, 2015. 8. From October 1, 2014, the Veteran has not had a disability rated as total with a separate disability rated as 60 percent disabling; he is not housebound under the traditional meaning of that term and is able to leave his home; he does not require aid and attendance nor has his disability resulted in the anatomical loss of either knee or has either knee been limited in natural action by the implanted prostheses. CONCLUSIONS OF LAW 1. The criteria for a compensable disability rating for a left knee post-surgical scar have not been met prior to February 4, 2014. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Codes (DCs) 7804, 7805. 2. Effective February 4, 2014, through the present, the criteria for a 10 percent disability rating, but no greater, for a left knee post-surgical scar, pursuant to DC 7804, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, DC 7804. 3. For the period on appeal the criteria for a compensable disability rating for a left knee post-surgical scar, pursuant to DC 7805, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, DC 7805. 4. The criteria for a rating in excess of 30 percent for a right knee disability, status-post total knee replacement, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DCs 5055, 5261. 5. The criteria for a compensable disability rating for a right knee scar, status-post total knee replacement, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, DCs 7804, 7805. 6. The criteria for a disability rating of 10 percent for service-connected hypertension, but no greater, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.21, 4.104, DC 7101. 7. The criteria for an effective date earlier than April 1, 2015, for the award of TDIU are not met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.400, 3.340, 3.341, 4.16. 8. The criteria for an effective date earlier than April 1, 2015, for the award of basic eligibility to DEA benefits under Chapter 35 are not met. 38 U.S.C.A. §§ 5101, 5107, 5110; 38 C.F.R. §§ 3.151, 3.157, 3.341, 3.400. 9. The criteria for entitlement to special monthly compensation pursuant to 38 U.S.C. 1114(s), or any other SMC grant, from October 1, 2014, have not been met. 38 U.S.C. § 1114; 38 C.F.R. § 3.350. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1958 to August 1961. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2017 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). This appeal comes before the Board pursuant to the Legacy system of appeals. However, the Board does acknowledge a slightly complicated procedural history in this matter. The issues decided herein were addressed in the June 2017 rating decision now on appeal. In July 2017, the Veteran's representative submitted a notice of disagreement (NOD) which appealed the issues contained herein, however, that NOD lacked a necessary signature for it to be complete. The RO did not respond. In June 2020, the Veteran representative submitted a statement in which he reiterated the Veteran's wish to appeal the issues in the June 2017 rating decision. The RO rejected the appeal as untimely, noting that the July 2017 NOD was incomplete. The Veteran appealed the RO's rejection of his NOD pursuant to the Appeals Modernization Act (AMA). In December 2020, the Board issued a decision pursuant to AMA which found the 2017 NOD to be timely, and remanded the issues included herein for further development under the holding in Manlincon v. West, 12 Vet. App. 238 (1999). Essentially, the Board remanded those issues so that the original Legacy appeal could be developed and a statement of the case (SOC) issued. The SOC was subsequently issued in January 2021, and the Veteran timely appealed that decision via VA Form 9 (Appeal to the Board of Veterans' Appeals) in March 2021. As such, these issues now come before the Board on appeal from the original June 2017 rating decision pursuant to the Legacy system of appeals. In his VA Form 9, the Veteran initially requested a hearing before a Veterans Law Judge. In an October 2021 correspondence, the Veteran's representative stated that the Veteran wished to withdraw his hearing request and proceed with a decision on the merits of the claim. Increased Rating Disability ratings are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The Veteran's entire history is reviewed when making disability evaluations. See generally, Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 4.1. Where, as in the case of the Veteran's right knee disability and hypertension, the question for consideration is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of staged ratings are required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Where, as in the case of the Veteran's left knee disabilities, entitlement to compensation has already been established and an increase in the assigned evaluation is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Further, "[w]here there is a question as to which of two evaluations shall be applied, 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. 1. Entitlement to an increased rating in excess of 10 percent from June 16, 2016, and a compensable rating from May 15, 2017, for a left knee painful scar 2. Entitlement to an effective date prior to June 16, 2016, for the grant of a 10 percent evaluation for a left knee scar pursuant to Diagnostic Code (DC) 7804 3. Entitlement to a compensable rating for a left knee scar, status-post total knee replacement, pursuant to DC 7805 The Veteran has been service connected for a left knee disability since 1964, status-post total knee replacement since July 24, 1998. It is noted that he appears to have undergone the initial total knee replacement in July 1998, with a revision being completed on February 4, 2014. The ratings for the Veteran's overlying knee disability with total knee replacement were addressed by the Board in a November 2017 rating decision and are not for consideration herein. This appeal addresses the ratings for scars associated with the Veteran's left knee replacement surgeries. The Veteran's left knee has two separate ratings for scars. The Veteran has a noncompensable rating pursuant to Diagnostic Code (DC) 7805; and a separate rating pursuant to DC 7804 which rates a scar as 10 percent disabling from June 16, 2016, to May 5, 2017, and noncompensable thereafter. He seeks higher ratings for these scars. He also seeks an effective date prior to June 16, 2016, for his painful scar. It is noted here that this appeal is associated with the Veteran's increased rating for a knee disability filed in February 2009, and therefore the Board will consider entitlement to compensable ratings for a scar from the date of that claim. This appeal has a complicated procedural history, which the Board will address below. For the reasons addressed below, the Board finds prior to February 4, 2014, a separate rating for the Veteran's right knee scar is not warranted in this matter. Thereafter, a single 10 percent rating should be granted for the entire appeal period. The Veteran has a single surgical scar, which is rated twice, once under DC 7805, which compensates for "other" scars, and once under DC 7804, which compensates for scars which are unstable or painful. DC 7805 compensates for "other" scars which do not meet the descriptions of scars compensated elsewhere. However, that rating code does not allow for a compensable rating on its own, and rather instructs the rating party to rate the disability pursuant to DCs 7800, 7801, 7802, or 7804. Any other symptoms not addressed by those rating codes should be rated based on an equivalent code. 38 C.F.R. § 4.118, DC 7805. Initially, it is noted that DC 7800 applies to scars of the head, face or neck, and therefore is not applicable in this matter. DC 7801 applies to scars not of the head, face or neck, which include underlying tissue damage, and require an area of at least 6 square inches for a compensable rating. This is also not applicable in this matter. Finally, DC 7802 applies to scars not of the head, face or neck, which are not associated with underlying tissue damage, but covering an area of at least 144 square inches. This is also not applicable in this matter. DC 7804 rates scars which are either unstable or painful. Under the rating criteria, a 10 percent rating is assigned for one or two scars which are either unstable or painful. For a higher rating, three or more unstable or painful scars must be shown. 38 C.F.R. § 4.118, DC 7804. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Id., Note (1). If one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Id., Note (2). Generally speaking, compensating a single disability twice under separate rating criteria would constitute impermissible pyramiding. 38 C.F.R. § 4.14. However, DC 7804 specifically allows for a separate evaluation in addition to an evaluation under DCs 7800-7803 or 7805, when applicable. 38 C.F.R. § 4.118, DC 7804, Note (3). As such, two separate ratings may be afforded the Veteran for his scar. Initially, the Board notes that the Veteran's claim dates to February 2009. The Veteran underwent an initial total knee replacement in 1998, with a revision of that knee replacement on February 4, 2014. Prior to February 4, 2014, the Veteran's scar was generally found to be linear and non-painful. It was certainly not unstable. No other scar-related pathology is noted throughout the medical record prior to February 2014, and as such, there is no basis upon which to assign a compensable rating for the scar, which is separate and distinct from the knee replacement itself. Indeed, in a 2002 rating decision, the scar itself was considered in rating the residuals of the knee surgery under DC 5055. At that time, the scar was approximately 18 cm by 2 mm in size, linear, soft, dark in color, depressed and nontender. There was no adherence to the underlying tissue or tissue loss. There was no disfigurement, keloid formation or limitation of function of the knee due to the scar. While the Board could technically grant a separate rating for the surgical scar prior to February 2014, because no compensable symptoms are found in the record, it would not provide any additional benefit to the Veteran to do so. Additionally, as the scar itself was considered when rating residuals of the knee surgery under DC 5055, which does not provide for multiple ratings based on the individual symptoms, providing a separate non-compensable rating for a scar prior to February 2014 could constitute impermissible pyramiding. As such, the Board will not assign a separate rating for the scar prior to February 4, 2014. On February 4, 2014, the Veteran underwent a second total knee replacement surgery, identified as a revision of the prior knee replacement surgery. Following that surgery, an April 2016 VA examination identified a single linear surgical scar of the left knee, which was 23 cm in length. It was not unstable, but it was painful. There were no other pertinent findings. For example, it was not found to adhere to any underlying tissue, it did not have keloid formation, it did not result in disfigurement, the underling tissue was not lost. It did not have frequent loss of covering of the skin over the scar. It did not interfere with the Veteran's employability or functional use of the knee. The Board does acknowledge a May 2017 VA knee examination which also identified a left knee scar, 24 cm by 1 cm in length. Although that examination did not specifically identify any symptoms such as pain, it was not a full scar examination, and the focus was on the overlying knee surgery residuals themselves. For his part, the Veteran continues to pursue the claim, implying ongoing pain in the scar. At the present, the Veteran has a rating pursuant to DC 7805, effective April 1, 2015, the date his post-surgical convalescence concluded following his second left knee surgery. He has been assigned a separate 10 percent rating pursuant to DC 7804, effective June 6, 2016, the date of his first VA examination, extending to May 5, 2017, the date of the knee examination which did not specifically identify any symptoms associated with the scar. Affording the Veteran the benefit of the doubt, the Board will extend the 10 percent rating under DC 7804 forward to February 4, 2014, the date of his surgery which resulted in the painful, but not unstable scar. It will also extent that 10 percent rating beyond May 5, 2017, to the present. While the May 2017 examination report did not specifically identify any pain in the scar, it was not a full scar examination, and it did not request that the examiner fully assess all symptoms associated with the scar. Rather, that examination report primarily focused on the orthopaedic residuals of the surgery. As such, given the Veteran's assertions that he continues to have pain in the scar, the Board will continue the 10 percent award through the present. The Board notes that this is a single scar, which is only manifested by pain and is not unstable in any way, as such there is no basis upon which to grant a rating in excess of 10 percent for any period between February 4, 2014, and the present, under DC 7804. While the Board will not disturb the separate non-compensable rating pursuant to DC 7805, it does not find that at any point on appeal a separate compensable rating is warranted. In this regard, the Veteran's symptoms have been fully accommodated by DC 7804, which account for painful or unstable scars. The only pertinent symptom attributable to the scar is pain, and DC 7804 compensates for that pain. No other pertinent or specific symptoms are reported, and there is no basis upon which to grant a higher rating pursuant to DC 7805. In sum, the Board finds that prior to February 4, 2014, there is no basis upon which to grant a separate compensable rating for a left knee post-surgical scar, to this extent the appeal for an earlier effective date is denied. From that date to the present, the criteria for a 10 percent rating under DC 7804 have been met, as such, an earlier effective date for that rating is granted, but a rating in excess of 10 percent is denied for any period on appeal. Although a separate noncompensable rating is assigned from April 1, 2015, under DC 7805, there is no basis upon which to award a higher rating, and that claim is denied. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. 4. Entitlement to an initial rating in excess of 30 percent for right total knee replacement from October 1, 2014 5. Entitlement to an initial compensable rating for a right knee scar, status-post total knee replacement The Veteran was granted service connection of a right knee disability with a temporary-total 100 percent rating effective August 29, 2014. Effective October 1, 2014, the disability is rated 30 percent disabling. He seeks a higher rating from October 1, 2014. He is also in receipt of a noncompensable rating for a right knee scar, associated with total knee replacement surgery, effective August 29, 2014. He seeks higher ratings for that disability. The Board finds that the claims should be denied. The Veteran's right knee disability is rated pursuant to DC 5055, which rates knee disabilities which are status-post prosthetic replacement. It should be noted that, during the course of this appeal, the schedular criteria for evaluating the knee have been amended. Specifically, the criteria pertaining prosthetic replacement of the knee under 38 C.F.R. § 4.71a, DC 5055, was amended effective February 7, 2021. See 85 Fed. Reg. 76,453 (November 30, 2020). Where a law or regulation changes during the pendency of a claim for increased rating, the Board should first determine whether application of the revised version would produce retroactive results. In particular, a new rule may not extinguish any rights or benefits the claimant had prior to enactment of the new rule. VAOPGCPREC 07-03 (November 19, 2003). However, if the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110; Karnas v. Derwinski, 1 Vet. App. 308, 313 (1991), overruled in part, Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). As the Veteran's claim was received prior to the effective date of the regulation changes, the Board must consider the Veteran's right knee replacement under both the old and the revised rating criteria and must apply the old rating criteria if the result is more favorable to the Veteran. Id. Initially, the rating criteria afforded a 100 percent total rating for one year following implantation of the prosthesis. Thereafter, a 30 percent minimum rating is assigned. A maximum 60 percent rating is not warranted unless there are chronic residuals consisting of severe painful motion or weakness in the affected extremity. With intermediate degrees of residual weakness, pain or limitation of motion rate by analogy to diagnostic codes 5256, 5261, or 5262. 38 C.F.R. § 4.71a, DC 5055. Effective February 7, 2021, the criteria was amended to include knee resurfacing, as well as prosthetic replacement (here, the Board notes that the Veteran has had a prosthetic knee replacement, so consideration as a resurfacing is not appropriate in this matter). The rating criteria was further amended to only allow for a temporary-total 100 percent rating for 4 months following implantation of the prosthesis. The minimum 30 percent rating was amended to apply only to prosthetic replacement and instruct ratings based on resurfacing be given pursuant to DCs 5256 through 5262. As the former version of the rating criteria is generally unaffected by the amendments, at least as far as this matter is concerned, but does technically provide for a greater benefit, the Board will generally consider this appeal pursuant to the prior rating criteria. Initially, the Board notes that private treatment records indicate that the Veteran underwent a total right knee replacement on August 6, 2013. Based on this date, the Veteran would only be entitled to a maximum temporary 100 percent rating through August 2014. It is noted that the Veteran's temporary total rating was extended to October 1, 2014, which was nearly 14 months after the date of his surgery. The Board will not disturb this gratuitous grant of an additional month of temporary 100 percent rating for the right knee. However, the Board does note that the rating criteria only allows for the temporary 100 percent rating for one year following surgical implantation of a knee prosthesis, and therefore such a rating is not warranted from that date forward. Turning to the question of the Veteran's right knee disability rating from October 1, 2014, the Board does not find that a rating in excess of 30 percent is warranted. Private treatment records from this time generally find good results from the Veteran's right knee replacement. For example, on May 20, 2015, a private orthopaedic surgeon noted that his primary knee replacement was progressed well over the proceeding two years. In May 2016, he submitted a knee impairment questionnaire completed by a physician's assistant, which identified the right total knee replacement occurred in February 2014, however, that appears to be by history, and there are no records to reflect that the surgery took place at such a later date. That questionnaire identified painful extension at 15 degrees nad painful flexion of the knee at 90 degrees. he was noted ot have walking tolerance up to 5 minutes and discomfort with stairs, as well as sitting and standing from a seated position. The physicians assistant indicated that he could not perform any job duties on a permanent basis. In June 2016, the Veteran was afforded a VA examination to assess the severity of his knee disability. Flare-ups in the right knee were described as pain in the knee cap. Right knee showed normal extension and flexion limited to 100 degrees. pain was noted on examination but did not further limit range of motion. There was some evidence of suprapatellar tenderness and pain with weight bearing, but no evidence of crepitus. No additional loss was found with repetitive use testing. the examination was neither medically consistent nor inconsistent with the Veteran's statements regarding loss of use over time, however, the examiner stated that factors such as pain, weakness, fatigability, or incoordination would not significantly limit functional ability with repeated use over time. The examination was neither medically consistent nor inconsistent with the Veteran's statements regarding flare-ups. Muscle strength showed active movement against some resistance. No ankylosis or fixation of the joint was identified. He had not evidence of subluxation or stability. Joint stability testing returned normal results. The examiner found intermediate residuals of weakness, or pain limiting motion in the right knee, but not chronic residuals or evidence of severe painful motion. In May 2017, a new VA examination was conducted. At that time he reported stiffness, jabbing and throbbing with spasms in both knees. He reported flare-ups of pain requiring him to sit in his recliner until his medication works, with additional use of muscle cream and rest. He also reported difficulty going from sitting to standing, and walking or standing for extended distances. Right knee showed complete and full extension, with flexion limited to 115 degrees. Pain was only identified on flexion. There was some localized tenderness in the right patella. There was pain with weight bearing, but no crepitus. No additional loss of function was found with repeated use over time, and his statements were neither medically consistent nor inconsistent with his statements regarding such use over time. The examination was neither medically consistent nor inconsistent with the Veteran's descriptions of flare-ups. He had some swelling and interference with standing in the right knee. Muscle strength showed active movement against some resistance. He had no atrophy. He had no fixation of the joint or ankylosis. No evidence of instability was identified. There was no impairment of the tibia or fibula. Functionally, the condition impacted his ability to walk, bend, stand, and move from sitting to standing. Other available private and VA treatment records are available, but generally show a well-tolerated knee replacement with no significant loss of range of motion or other functional use. There is no evidence of ankylosis or impairment of the tibia or fibula. In light of the above, the Board does not find that the Veteran's right knee has been manifested by chronic residuals consisting of severe painful motion or weakness in the affected extremity. While he certainly does have some residuals from his surgery, they are not so severe as to completely impede use of the knee or leg. There is no general weakness identified at any point. As such, a 60 percent rating is not supported. As to whether intermediate degrees of an increase should be awarded, the Board finds that this is not the case. The rating criteria instructs that intermediate levels of disability be rated pursuant to three specific DCs. The Veteran's knee is able to move and there is no evidence of fixation or ankylosis. As such, a rating under DC 5256 is not warranted in this matter. Likewise, he has not shown any evidence of impairment of the tibia or fibula, thus a rating under DC 5262 is not supported. At most he has shown some evidence of painful motion on extension at 15 degrees in May 2016, however, affording the Veteran the benefit of the doubt, such limitation would only afford a 20 percent rating, which is less than the 30 percent minimum rating presently assigned. Turning to the question of the Veteran's right knee scar, status-post total knee replacement, the Board does not find that a compensable rating is warranted. As noted above, the Veteran's scar is rated pursuant to DC 7805, which compensates for "other" scars, and instructs that the disability be rated pursuant to DC 7800, 7801, 7802, or 7804. 38 C.F.R. § 4.118, DC 7805. DC 7800 addresses scars of the head, face or neck, and there is no indication that such criteria would apply in this matter, as the scar in question is a surgical scar of the knee. Likewise, DC 7801 applies to scars associated with underlying tissue damage greater than 6 square inches in area, and DC 7802 addresses scars of an area greater than 144 square inches in area. There is no evidence of such pathology and they also do not apply. DC 7804 grants a minimum 10 percent rating for one or two scars which are painful or unstable. For a higher rating, more than two scars must be present. 38 C.F.R. § 4.118, DC 7804. A May 2016 private knee questionnaire did not discuss any surgical scars associated with the Veteran's disability. A June 2016 VA scars examination identified painful scars on the left knee, but the Veteran denied any such symptoms in the right knee. On examination, a single linear scar, 18.0 cm in length was identified. The examiner did not find that the scar would impact his ability to work. It was neither painful, nor unstable. In May 2017, a VA knee examination identified a right knee hyperpigmented scar, 17 cm in length and .3 cm in width. It was not painful or unstable. VA and private treatment records generally find the right knee surgery to have been successful. No specific pathology or symptoms related to the right knee scar have been identified. Based on the available evidence, the Board does not find that a compensable rating is warranted for the Veteran's right knee scar. While his scar is certainly lengthy, that would be anticipated based on the type of surgery he underwent for his right knee disability, in this case, a total joint replacement. It has generally healed well. It is linear in nature. It is not deep, and he has not reported that it is painful. There is no evidence that the scar suffers frequent loss of covering of the skin over the scar. As such, a compensable rating is not supported. In sum, the Board finds that the Veteran's right knee total knee replacement does not warrant a rating in excess of the 30 percent already assigned. Neither does the associated scar warrant a compensable rating. As such, the claims are denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. 6. Entitlement to an initial compensable rating for hypertension The Veteran is in receipt of service connection for hypertension, with a noncompensable rating. He seeks a compensable rating. The Board finds that a 10 percent evaluation should be awarded, although no higher. The Veteran's hypertension is rated under DC 7101, which compensates for hypertensive vascular disease. Under the applicable criteria, for a compensable rating to be assigned, diastolic pressure must be recorded as predominantly 100 pr more, or; systolic pressure predominantly 160 or more, or; there must be a history of diastolic pressure predominantly 100 or more which requires continuous medication for control. For ratings in excess of the minimum 10 percent, diastolic pressure must be predominantly 110 or more, or; systolic pressure must be predominantly 200 or more. 38 C.F.R. § 4.104, DC 7101. Historically, the Veteran was diagnosed with hypertension in June 1995. At that time he showed blood pressure readings of 150/90. In November 1995, he showed blood pressure of 154/94. In March 1996, his blood pressure was 190/100 and 162/100. In October 1996, his blood pressure was 160/80. In April 1997, blood pressure was 180/100. In February 1990, the Veteran's blood pressure was 152/96 and hypertension was deemed chronic. Similar high scores of 222/110, 206/118, 202/112, 168/93, 155/79, 154/82, and 159/80 were identified in February 1998. He was prescribed medical therapy to treat his severe systemic hypertension. Subsequent blood pressure readings showed that his condition was responsive to treatment and readings of 127/63, and 140/90 were seen in March 2016; 127/76 in September 2015; and 120/58 in July 2013. In May 2017, a VA examination diagnosed hypertension, requiring treatment via medication to maintain. The examiner did not find a current history of diastolic pressure predominantly 100 or more, noting present readings of 175/80, 126/73, and 123/70. While more recent medial findings pertaining to the appeal period do not show diastolic pressure greater than 100 or systolic pressure greater than 160, the Board does note that the Veteran is prescribed hypertensive medications to control his condition, which would account for the more normal readings. Rather, prior to his prescription for hypertensive medications, he had a significant history of diastolic pressure predominantly greater than 100. It would be medically incorrect and unsound to require the Veteran to cease taking such medication merely to prove that the medication works for rating purposes. As such, the Board is satisfied that the Veteran has a history of diastolic blood pressure predominantly greater than 100, requiring antihypertensive medications to control. Notably, this was stated by the RO in the January 2021 SOC, finding that a 10 percent rating is warranted, before curiously concluding that no compensable symptoms were identified. The Board presumes that this was an error, and will now correct that mistake. Based on this evidence, the Board agrees that a minimum 10 percent rating is warranted as there is a history of diastolic blood pressure predominantly 100 or more with the requirement for antihypertensive medication to control. To this extent, the appeal is granted. However, in allowing this grant, the Board does not identify any evidence of diastolic pressure predominantly 110 or more, or; systolic pressure predominantly 200 or more. As such, a rating in excess of 10 percent is not supported. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. Earlier Effective Dates TDIU and DEA Generally, except as otherwise provided, the effective date of an evaluation and award of pension, compensation, or dependency and indemnity compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date which the entitlement arose, whichever is later. See 38 U.S.C.A. § 5110 (West 2002 & Supp. 2014); 38 C.F.R. § 3.400 (2014). The effective date of an original award of direct service connection is the day following separation from active service or date entitlement arose if the claim is received within one year after separation from service; otherwise, it is the date of receipt of claim, or date entitlement arose, whichever is later. 38 U.S.C.A. § 5110; 38 C.F.R. § 3.400(b)(2)(i). A TDIU is assigned when a veteran's service-connected disability or disabilities are not rated as 100 percent disabling, but are of such severity that the veteran cannot secure or follow a substantially gainful occupation solely because of that disability or disabilities. 38 C.F.R. § 4.16. Generally, TDIU is awarded on a schedular basis, which requires that, if there is only one service-connected disability, this disability shall be ratable at 60 percent or more. If there is more than one disability, there must be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more 38 C.F.R. § 4.16(a). The Board has a requirement to maximize a claimant's possible benefits, to include consideration of TDIU and whether it would result in Special Monthly Compensation (SMC) under the housebound criteria. This is discussed in more detail below, however, a total disability rating based on individual unemployability (TDIU) satisfies the total (100 percent) rating requirement if the TDIU evaluation was, or can be, predicated upon a single disability and there exists additional disability or disabilities independently ratable at 60 percent or more, for purposes of entitlement to special monthly compensation for a housebound rating. Bradley v. Peake, 22 Vet. App. 280, 293 (2008). In other words, a TDIU rating based on a single disability, but not multiple disabilities, is permitted to satisfy the statutory requirement of a total rating. Bradley, 22 Vet. App. at 293. Nonetheless, the TDIU rating based on a single disability that satisfies the total (100 percent) rating requirement must be separate and distinct from the additional disability or disabilities independently ratable at 60 percent or more for purposes of housebound benefits. Bradley, 22 Vet. App. at 293. In addition, the decision to treat multiple disabilities as one under 38 C.F.R. § 4.16 (a) is specifically limited to TDIU ratings. That is, a TDIU rating based on multiple service-connected disabilities does not satisfy the criteria for one total disability in considering entitlement to housebound benefits under 38 U.S.C. § 1114 (s). Bradley, 22 Vet. App. at 290-91. Basic eligibility to DEA exists where the Veteran was discharged from service under conditions other than dishonorable and has a total disability permanent in nature as a result of a service-connected disability. 38 U.S.C. § 3501 (a)(1); 38 C.F.R. §§ 3.807(a), 21.3021. With certain exceptions that are not applicable to the instant claim, the effective date for the grant of such award shall, to the extent feasible, correspond to effective dates for awards of disability compensation. 38 U.S.C. § 5113(a). 7. Entitlement to an effective date prior to April 1, 2015, for the award of a total disability rating based on individual unemployability (TDIU) 8. Entitlement to an effective date prior to April 1, 2015, for the award of basic eligibility for Dependents Educational Assistance (DEA) benefits under 38 U.S.C. Chapter 35 The Veteran has been granted entitlement to TDIU effective April 1, 2015, with an associated award of basic eligibility to DEA benefits. He seeks an earlier effective date for those grants. The Board finds that the claims should be denied. Initially, the Board notes that the Veteran filed a VA Form 21-8940 (Application for Increased Compensation Based on Unemployability) on April 25, 2016, the earliest he expressed intent to file a claim for TDIU. However, as discussed above, many of the issues presently on appeal to include the increased rating claim for the Veteran's left knee scars and hypertension, date to a claim filed in 2009. A claim for TDIU is part and parcel of any increased rating claim when reasonably raised by the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Thus, the question on appeal is not when the Veteran filed his claim for TDIU (and by-proxy basic entitlement to DEA), but rather whether the Veteran met the criteria for that grant prior to April 1, 2015. Generally speaking, prior to April 1, 2015, the Veteran does not meet the schedular criteria for a grant of TDIU. Specifically, from February 2, 2014, to April 1, 2015, the Veteran is rated with a combined 100 percent rating for his various service-connected disabilities, thus does not meet the basic schedular criteria for a grant of TDIU. Prior to February 4, 2014, the Veteran had a combined rating of 50 percent, consisting of a 30 percent rating for the left knee, 10 percent rating for major depressive disorder, 10 percent for hypertension, adjusted to reflect he increased rating claim granted for hypertension, above. As the Veteran does not have a single disability rated as 60 percent disabling, or a combined rating of 70 percent with a single disability rated 40 percent or greater, the basic schedular criteria for TDIU are not met. Thus, because the basic schedular criteria for a grant of TDIU are not met prior to April 1, 2015, the Board cannot grant TDIU on a schedular basis. As is noted above, and discussed in more detail below, even when a 100 percent combined rating is awarded, the Board must still consider whether a single disability results in TDIU for purposes of maximizing benefits by way of SMC based on housebound status. From October 1, 2014, to April 1, 2015, the Veteran had a combined rating of 100 percent, with a temporary total rating for the left knee due to post-surgical convalescence. From August 29, 2014, to October 1, 2014, the Veteran is also in receipt of a 100 percent rating for a service-connected right knee disability. As the Veteran has two separate disabilities, both rated 100 percent, he is already entitled to SMC based on housebound status. Further, the remaining disabilities not rated 100 percent do not meet the basic schedular criteria for a grant of TDIU. As such, TDIU is not warranted for this period on appeal, and any grant for purposes of entitlement to SMC would be moot, as it is already in effect. From October 1, 2014, to April 1, 2015, the Board similarly finds that such consideration is not warranted. During this period, excluding the 100 percent rating for the Veteran's left knee, he has a combined rating of 50 percent, with individual ratings of 30 percent for a right knee disability, and 10 percent each for a left knee scar, hypertension, left knee instability, and major depressive disorder with noncompensable ratings for a right and left knee scar. This also does not meet the schedular criteria for a grant of TDIU based on the non-100 percent-rated disabilities. Finally, under Roberson v. Principi, 251 F.3d 1378 (2001) and Rice v. Shinseki, 22 Vet. App. 447 (2009), the Board must also consider TDIU even when the schedular criteria are not met. VA policy is that all Veterans unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated as totally disabled. 38 C.F.R. § 4.16 (b), rating boards should refer to the Director of Compensation and Pension Service for extraschedular consideration all cases where Veterans are unemployable by reason of service-connected disabilities but who fail to meet the percentage requirements set forth in 38 C.F.R. § 4.16 (a). In sum, the Board cannot grant an extraschedular TDIU in the first instance, but may determine whether referral for such consideration is warranted. In the present matter, the available medical evidence certainly shows that his various service-connected disabilities have affected his mobility, and it is undisputed that the Veteran was not working during that time, the Veteran has a work history as a Level 2 supervisor with the New York City Transit Authority, and as a driver for Hertz rental car. He took management courses between 1983 and 1985, and completed at least two years of college. While he was service-connected for a psychiatric disability, that disability was rated as 10 percent disabling, which generally is indicative of at most mild or transient symptoms which decrease the ability to perform work activities during periods of significant stress. It is notable that a 2013 letter from his private physician indicates that the Veteran's knee disabilities affect his ability to work, but also discussed how his various non-service-connected disabilities, such as diabetes, hyperlipidemia and coronary artery disease, also contributed to his inability to work. In short, the Board does not find that prior to April 1, 2015, the non-total rated disabilities either individually or combined to render the Veteran incapable of obtaining and maintaining employment. As the evidence of record does not support a finding that his service-connected disabilities alone prevented him from maintaining employment in general, the Board declines to remand the issue of entitlement to extraschedular TDIU prior to April 1, 2015, for further consideration. Therefore, the claim is denied. Finally, as the Veteran has not been found to have a total and permanent disability until April 1, 2015, the date he was found to be entitled to TDIU. Prior to that date, although he was in receipt of a 100 percent rating from February 2, 2014, that grant was predicated on a temporary total rating due to convalescence following surgery, and thus was not a "permanent and total" rating. Because eligibility for DEA benefits under 38 U.S.C. Chapter 35 is predicated on a finding of a permanent and total disability rating, entitlement to an effective date earlier than April 1, 2015, is precluded by law. See 38 U.S.C. §§ 3501 (a)(1), 5113(a); 38 C.F.R. §§ 3.807 (a), 21.3021. See also Sabonis v. Brown, 6 Vet. App. 426 (1994). In short, the Board does not find that entitlement to TDIU has been established prior to April 1, 2015. As that is the date basic entitlement arose to that disability, and that is the later of either the date of the claim or the date entitlement arose, an earlier effective date for that claim is not warranted. Likewise, as April 1, 2015, is the first date the Veteran was found to have a permanent and total disability, that is also the earliest date that basic entitlement to DEA benefits may be granted. As such, the claims are denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. Special Monthly Compensation Special monthly compensation benefits by reason of being housebound are payable if the Veteran has a single permanent disability rated 100 percent disabling, and has either (1) additional service-connected disability or disabilities independently ratable at 60 percent or more, or (2) is "permanently housebound" by reason of service-connected disability or disabilities. 38 U.S.C. § 1114 (s); 38 C.F.R. § 3.350 (i). The disabilities independently ratable at 60 percent or more must be separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems. 38 C.F.R. § 3.350 (i)(1). A veteran is permanently housebound when he is substantially confined to his house (ward or clinical areas, if institutionalized) or immediate premises as a direct result of his service-connected permanent disability or disabilities, and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his or her lifetime. 38 U.S.C. § 1114 (s); 38 C.F.R. § 3.350 (i)(2). Housebound benefits are not available to a Veteran whose 100 percent disability rating is based on multiple disabilities, none of which is rated at 100 percent disabling. Guerra v. Shinseki, 642 F.3d 1046 (Fed. Cir. 2011). However, as noted above, a total disability rating based on individual unemployability (TDIU) satisfies the total (100 percent) rating requirement if the TDIU evaluation was, or can be, predicated upon a single disability and there exists additional disability or disabilities independently ratable at 60 percent or more, for purposes of entitlement to special monthly compensation for a housebound rating. Bradley v. Peake, 22 Vet. App. 280, 293 (2008). In other words, a TDIU rating based on a single disability, but not multiple disabilities, is permitted to satisfy the statutory requirement of a total rating. Bradley, 22 Vet. App. at 293. Nonetheless, the TDIU rating based on a single disability that satisfies the total (100 percent) rating requirement must be separate and distinct from the additional disability or disabilities independently ratable at 60 percent or more for purposes of housebound benefits. Bradley, 22 Vet. App. at 293. In addition, the decision to treat multiple disabilities as one under 38 C.F.R. § 4.16 (a) is specifically limited to TDIU ratings. That is, a TDIU rating based on multiple service-connected disabilities does not satisfy the criteria for one total disability in considering entitlement to housebound benefits under 38 U.S.C. § 1114 (s). Bradley, 22 Vet. App. at 290-91. A "TDIU rating that is based on multiple disabilities cannot satisfy the section 1114(s) requirements of 'a service-connected disability' because that requirement must be met by a single disability." Buie v. Shinseki, 24 Vet. App. 242, 249-250 (2010). However, VA's duty to maximize benefits requires VA to assess all of a claimant's disabilities, regardless of the order in which they were service-connected, to determine whether any combination of disabilities establishes housebound benefits under 38 U.S.C. § 1114(s). Buie, 24 Vet. App. at 249-250. If the veteran, as the result of service-connected disability, has suffered the anatomical loss or loss of use of both feet, or of one hand and one foot, or is blind in both eyes, with 5/200 visual acuity or less, or is permanently bedridden or with such significant disabilities as to be in need of regular aid and attendance. 38 C.F.R. § 1114(l). SMC may also be awarded based on need for regular aid and attendance, pursuant to 38 U.S.C. § 1114(t). Subject to 38 U.S.C. § 5503(c), if any veteran, as the result of service-connected disability, is in need of regular aid and attendance for the residuals of traumatic brain injury, is not eligible for compensation under subsection (r)(2), and in the absence of such regular aid and attendance would require hospitalization, nursing home care, or other residential institutional care, the veteran shall be paid, in addition to any other compensation under this section, a monthly aid and attendance allowance equal to the rate described in subsection (r)(2), which for purposes of section 1134 of this title shall be considered as additional compensation payable for disability. An allowance authorized under this subsection shall be paid in lieu of any allowance authorized by subsection (r)(1). 38 U.S.C. § 1114(t). SMC may also be granted pursuant to factors such as anatomical loss or loss of use of both legs with factors preventing natural knee action with prostheses in place. 38 U.S.C. § 1114(m). Other eligibility for SMC is predicated upon disabilities affecting the reproductive organs, visual acuity or hearing acuity, which are not relevant in this appeal. 9. Entitlement to special monthly compensation (SMC) pursuant to 38 U.S.C. 1114(s), from October 1, 2014 The Veteran is in receipt of SMC pursuant to 38 U.S.C. § 1114(s), based on housebound status, from August 29, 2014, to October 1, 2014. He seeks to extend that benefit beyond October 1, 2014. The Board finds that the claim should be denied. The Veterans' grant of housebound status in 2014 was predicated on his ratings for his right and left knee disabilities during that period. Specifically, as noted above, at the time, DC 5055 afforded a full 12 month convalescence period following total knee replacement surgery. From February 4, 2014, through April 1, 2015, the Veteran was afforded a 100 percent disability rating for his left knee, following total knee replacement revision surgery. During that convalescent period, the Veteran was granted service connection of a right knee disability, also status-post total knee replacement. However, the Veteran's right knee surgery took place in August 2013, prior to the effective date for the grant of service connection of that disability. Nonetheless, the RO granted an additional month beyond August 2014 as a convalescent period for that right knee disability, ending on October 1, 2014. Thereafter, the rating was reduced to 30 percent (as addressed above, the Board has denied a rating in excess of 30 percent from October 1, 2014 for the right knee). The result of these ratings is that for the period between August 29, 2014, and October 1, 2014, the Veteran had a single disability rated as 100 percent or totally disabling, in this case the left knee, and a second disability which is rated at least 60 percent disabling, in this case the right knee, which meets the criteria for "housebound" status under the statutory guidelines. Beginning October 1, 2014, through April 1, 2015, the Veteran's right knee was reduced to 30 percent disabling, meaning he no longer met the statutory definition of housebound based on ratings for his disabilities. During that period of time, he was rated as 100 percent disabled due to his left knee disability, with separate ratings of 30 percent for the right knee; 10 percent each for major depressive disorder, left knee instability, hypertension, and a left knee scar; and noncompensable for right and left knee scars. Although he had a single disability rated as total during this period, his remaining disabilities did not independently, or combined rise to a separate 60 percent disability rating. Further, the medical evidence of record, while certainly indicative of the severity of his various service-connected disabilities, did not support a conclusion that the Veteran was "permanently housebound" by virtue of those disabilities. Indeed, throughout this period there is no indication that he was unable to leave the home; he actively participated in his healthcare through office visits; he did not indicate that he was completely incapable of self-support inside or outside the home. As such, from October 1, 2014, to April 1, 2015, he does not meet the criteria for housebound status, and thus is not entitled to SMC based on such status. From April 1, 2015, the Veteran's left knee disability has been reduced to 60 percent disabling, which is the maximum allowable rating for a status-post total knee replacement. From that date forward, even accounting for the claims granted, above, the Veteran's combined disability rating is 90 percent. Effective that date, the Veteran has been granted TDIU. However, for the period, the Veteran's grant of TDIU is generally predicated upon his combined disabilities. Here, although the Board acknowledges several 2016 opinions that the left knee alone would preclude employment, a clarifying opinion in May 2017 concluded that both the right and left knee replacements, with their associated disabilities, would preclude employment, and did not place unemployability on one single disability. This was further supported by a June 2013 opinion by a private treating physician which found the Veteran's right and left knees to contribute to unemployability. As the TDIU effective April 1, 2015, is based on multiple combined disabilities, it cannot satisfy the "total" rating for SMC purposes. See, Buie, supra. Further, even presuming that the TDIU grant effective April 1, 2015, was predicated upon the left knee alone, and could satisfy the "total" disability requirement, the remaining service-connected disabilities are not alone, or combined rated significantly that they would constitute a separate disability rated as 60 percent or more. As such, a rating based "housebound" rating is not supported during this appeal period. Similarly, while the Veteran is certainly disabled by his various service-connected disabilities, there is no indication that he is "housebound" in the traditional sense. He is able to engage in the activities of daily living, and there is no indication that he cannot engage in activities outside the home. While his knees certainly do cause him pain, he can walk for short distances or stand for certain periods of time. Further, he has actively engaged in his medical care outside of the home throughout the appeal period, and engaged with VA via in-person appearances for medical examinations and care, as necessary, which also imply he is not "housebound" in the traditional sense. As such, the Board does not finds that SMC, based on housebound is warranted for any period following October 1, 2014. The Board has also considered whether a higher level of SMC might be appropriate throughout the appeal period, but finds that it is not. In this regard, the medical records do not indicate the need for aid and attendance at any point. The Veteran is able to engage in the basic activities of daily living, such as feeding himself, bathing himself, toileting, etc. He has not required significant hospitalization, nursing home care, or other residential institutional care. As noted above, the Veteran is able to leave the home, and generally is able to care for himself. As such, SMC based on need for aid and attendance is also not supported. Finally, the Board has considered whether the Veteran's disabilities may warrant SMC based on any other level. Although the Veteran does suffer from left and right knee disabilities, there is no evidence that they have equated to anatomical loss of either lower extremity, indeed, while he does have pain, he is able to ambulate on both lower extremities. He is not permanently bedridden. His knee prostheses do allow for natural action of the knees. As such, SMC based on levels lower than housebound status are also not supported throughout the appeal period. In sum, the Board finds that at no point from October 1, 2014, has the Veteran met the criteria for SMC based on housebound status, nor has he been entitled to SMC on any other basis. As such, the claim is denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. 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. B.T. KNOPE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Pryce, Counsel