Citation Nr: 21071537 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 16-11 225A DATE: November 30, 2021 ORDER The appeal for entitlement to an initial compensable disability rating for left ear hearing loss is dismissed. The appeal for entitlement to a higher initial disability rating for peripheral neuropathy of the left lower extremity is dismissed. From April 27, 2012, a 100 percent initial disability rating for posttraumatic stress disorder (PTSD) is granted. From April 27, 2012, entitlement to a separate 100 percent rating for Crohn's disease as a complication of diabetes mellitus, type II, is granted. Entitlement to a total disability rating based on individual unemployability (TDIU), prior to November 11, 2016, is dismissed as moot. Entitlement to special monthly compensation (SMC) at the housebound rate from April 27, 2012, is granted. FINDINGS OF FACT 1. On October 14, 2021, prior to the promulgation of a decision in the appeal, the Board of Veterans' Appeals (Board) received notification from the Veteran, through his authorized representative, which indicated that a withdrawal of the issues of his claims of entitlement to higher initial ratings for left ear hearing loss and peripheral neuropathy of the left lower extremity on appeal is requested. 2. From April 27, 2012, the date of service connection, the evidence is at least evenly balanced as to whether the symptoms and impairment caused by the Veteran's PTSD more nearly approximate total occupational and social impairment. 3. From April 27, 2012, the symptoms of the Veteran's Crohn's disease have more nearly approximated pronounced impairment and resulted in anemia. 4. The awards of 100 percent ratings for PTSD and Crohn's disease, as well as the award of SMC for being statutorily housebound from April 27, 2012, has rendered the issue of entitlement to a TDIU, prior to November 11, 2016, moot. 5. The Veteran is service connected for both PTSD and Crohn's disease, each independently rated 100 percent disabling, since April 27, 2012. CONCLUSIONS OF LAW 1. The criteria for withdrawal of an appeal on the issue of entitlement to an initial compensable disability rating for left ear hearing loss by the Veteran and his authorized representative have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 2. The criteria for withdrawal of an appeal on the issue of entitlement to a higher initial disability for peripheral neuropathy of the left lower extremity by the Veteran and his authorized representative have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 3. The criteria for an initial 100 percent disability rating for PTSD have been met for the entire period on appeal. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.125, 4.126, 4.130, Diagnostic Code 9411. 4. The criteria for a separate initial 100 percent disability rating for Crohn's disease as a complication of diabetes mellitus, type II, have been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.114, Diagnostic Code 7323. 5. The appeal for a TDIU, prior to November 11, 2016, is dismissed as moot. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16 6. The criteria for establishing entitlement to SMC at the housebound rate from April 27, 2012, have been met. 38 U.S.C. § 1114; 38 C.F.R. § 3.350. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Preliminary Matters The Veteran had honorable active duty service with the United States Army from October 1968 to June 1971, to include service in Vietnam. This matter is before the Board of Veterans' Appeals (Board) on appeal from a September 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). By way of background, in June 2019, the Board, in pertinent part, denied the issues of entitlement to higher initial disability ratings for the service-connected disabilities of left ear hearing loss, peripheral neuropathy of the left lower extremity, and PTSD. The Board also remanded the issues of entitlement to a higher initial disability rating for diabetes mellitus, type II, and entitlement to a TDIU, prior to November 11, 2016. The Veteran appealed the Board's June 2019 decision as to the denial of the issues of entitlement to higher initial disability ratings for the service-connected disabilities of left ear hearing loss, peripheral neuropathy of the left lower extremity, and PTSD to the United States Court of Appeals for Veterans Claims (Court). In a May 2020 Order, the Court granted a May 2020 Joint Motion for Partial Remand (JMPR) vacating the Board's June 2019 decision as to these issues, and remanding the matters for further consideration and instructions consistent with the JMPR. Then, in an October 2021 correspondence, the Veteran's attorney indicated that the Veteran wished to withdraw the appeal for the issues of entitlement to higher initial disability ratings for left ear hearing loss and peripheral neuropathy of the left lower extremity. The remaining issues have returned to the Board for further appellate consideration. DISMISSAL 1. The appeal for entitlement to an initial compensable disability rating for left ear hearing loss is dismissed. 2. The appeal for entitlement to a higher initial disability rating for peripheral neuropathy of the left lower extremity is dismissed. The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 19.55. Withdrawal may be made by the Veteran or by his or her authorized representative. 38 C.F.R. § 19.55. In the present case, by way of an October 2021 correspondence, the Veteran, through his representative, withdrew the appeal for the issues of entitlement to higher initial disability ratings for left ear hearing loss and peripheral neuropathy of the left lower extremity; hence, there remain no allegations of errors of fact or law for appellate consideration of these issues. Accordingly, the Board does not have jurisdiction to review the appeal of these issues and it is dismissed. INCREASED RATING Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The Schedule is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. When two evaluations are potentially applicable, VA will assign the higher evaluation when the disability more nearly approximates the criteria for the higher rating. 38 C.F.R. § 4.7. VA will resolve reasonable doubt as to the degree of disability in favor of the Veteran. 38 C.F.R. § 4.1. If the evidence for and against a claim is in equipoise, the claim will be granted. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. 1. From April 27, 2012, a 100 percent initial disability rating for PTSD is granted. The Veteran asserts entitlement to a higher disability rating for his PTSD. The Veteran has been service connected for PTSD since April 27, 2012, when he was rated as 30 percent disabled. Subsequently, in an August 2017 rating decision, his rating was increased to 50 percent, effective March 30, 2017. The Veteran's PTSD is rated according to the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Under the General Rating Formula, a 50 percent disability rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (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. Id. A 70 percent disability rating is warranted when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. The symptoms listed in the rating schedule are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). See 38 C.F.R. § 4.130. The Board finds that after careful consideration of the record, a 100 percent rating is warranted for the Veteran's PTSD for the entire appeal period. The Veteran underwent a VA psychiatric examination in July 2013. The examiner noted a diagnosis of PTSD. The examiner indicated that the Veteran experienced more severe mental health difficulties immediately following discharge. Thereafter, he continued to have mental health problems, including nightmares, sleep disturbances, a tendency to withdraw from others, jitteriness from loud noises, and a startle reflex, but to a lesser degree. The Veteran reported that his first marriage suffered as a result of problems coping mentally after returning from Vietnam. His wife at that time could no longer manage his moods, behaviors, or drinking. His current wife also had difficulties; however, she gave the Veteran an ultimatum to get help, or she was leaving. The examiner indicated that the Veteran's PTSD symptoms included depressed mood, anxiety, and flattened affect. The examiner also noted that the Veteran withdrew socially. VA treatment records do not indicate that the Veteran sought treatment for mental health symptoms prior to February 2015. A February 2015 VA treatment record shows that that the Veteran saw a social worker for an evaluation of his mental health. The Veteran reported that he was minimally active, spent most of his time in bed, needed help with most activities of daily living, and that he could not leave home without his wife's assistance. He also stated that he did not go anywhere except to medical appointments. The Veteran further indicated that he "spent 50 years avoiding anything remotely related to Vietnam." The Veteran's wife reported that the Veteran had night sweats, nightmares, sleep disturbance, and that he always isolated and avoided crowded areas. The social worker noted that the Veteran's PTSD disability rating at that time was "based on minimal information elicited during his ratings eval," referring to the July 2013 VA examination. A March 2015 VA treatment record shows that the Veteran reported thoughts about dying or being better off dead. An August 2015 VA treatment record shows that the treating psychiatrist noted that the Veteran had suicidal ideation, but it was limited in intensity and duration. The Veteran underwent another VA psychiatric examination in March 2017. The examiner noted that the Veteran's wife had assisted considerably in providing information during the evaluation. The Veteran reported that he lived with his wife and her daughter. The wife's daughter, a nurse, had recently moved in to assist in the medical care of the Veteran. The Veteran was in contact with his three daughters from his first marriage "every two or three years." He had no friends or anyone with whom he socialized. The Veteran's PTSD symptoms interfered with the execution of his job duties, especially in terms of distractibility and not wanting to communicate with people. He stated that he resigned "when I [the Veteran] just couldn't go to work anymore" for a combination of medical and psychological factors. The examiner indicated that the Veteran's PTSD symptoms included anxiety, suspiciousness, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances (including work or a work like setting). The Veteran underwent a private psychiatric evaluation in August 2021 with Dr. M.C., diplomate of the American Board of Psychiatry and Neurology. Dr. M.C. noted that he reviewed the Veteran's medical record, service record, VA examination reports, attestations, and ancillary information regarding the Veteran. Dr. M.C. indicated that, upon the Veteran's return to civilian life following his service in Vietnam, the Veteran was dysfunctional both occupationally and socially. Although the Veteran had been employed in various full-time positions through November 2013, "he failed to maintain meaningful and gainful employment, after that time, due to irritability, anger, threatening behavior, poor focus and concentration, nonexistent task completion, and a concomitant substance use disorder." During the interview with Dr. M.C., the Veteran reported that, since 6-12 months after his exposure to trauma, he experienced daily nightmares, an exaggerated startle response, agitation, the desire for social isolation, and threatening behavior. The Veteran stated that he would have never seen a psychiatrist due to the stigma associated with "being crazy." He indicated that it was decades before he was agreeable to discuss anything associated with how he felt. He stated, "It was 2013 when I try [sic] to get some assistance." The Veteran noted that he worked after separation from service. However, he described that while employed, he had frequent interpersonal conflicts with coworkers. He had physical altercations, difficulty controlling his temper, extreme anger, and low frustration tolerance. He stated that he was not above violence, having assaulted several individuals. The Veteran further stated that he lost many jobs due to disciplinary issues, and the vast majority was associated with threatening behavior and violence. The Veteran also described persistent irritability, poor focus and concentration, daily dissociative episodes, and difficulties even within his home environment. He described the presence of anxiety and depression as part of his day-to-day life and feeling emotionally numb and cut off from society. He became increasingly irascible at home and "snapping at anyone for nothing." The Veteran reported that his symptoms became very severe in 2013, but he was loath to accept treatment until it became apparent that he was deteriorating rapidly. The Veteran indicated that he had undergone various VA examinations, which he stated "lasted approximately fifteen minutes and provided no benefit." Dr. M.C. noted that, for several years leading up to 2013, the Veteran described persistent difficulties in occupational settings and was fired from multiple jobs due to threatening behavior. He stated that he struggled with suicidal ideation, poor concentration, insomnia, irritability, and anger. The Veteran removed himself from the workforce in 2013, knowing that "something bad would happen." Since his discharge from service, he always felt hostile and irritable, and these feelings never left him. Based on his interview of the Veteran, as well as a thorough review of the Veteran's medical record, service record, VA examination reports, lay attestations, and ancillary information, Dr. M.C. concluded that the Veteran has had symptoms of PTSD since his active duty service in Vietnam. Dr. M.C. stated, "The entire constellation of PTSD symptomatology was evident between 6-12 months after his active duty service. As the disease processes progressed, Mr. [REDACTED] [the Veteran] became significantly more impaired, due to PTSD, removing himself from full-time employment in 2013 due to mental illness." Dr. M.C. further stated, "The VA examinations, performed throughout his clinical history, have severely minimized the Veteran symptomatology suggesting his impairments were mild to moderate." Dr. M.C. indicated that the Veteran was "thoroughly ashamed to interact with the mental health care system" due to the stigma attached to mental health issues during the time of his discharge from service. Dr. M.C.'s discussion with the Veteran revealed that, since his discharge, the Veteran had a great deal of difficulty in his interpersonal relationships, both socially and occupationally. By 2013, the Veteran manifested thoughts of suicide, periods of violence, threatening behavior, irritability, anger, and complete dysfunction in occupational settings and social settings. Dr. M.C. stated, "The symptoms have been present and progressive following his discharge from active duty service through the current day." With further regard to social relationships, Dr. M.C. noted that the Veteran's wife is "essentially a caregiver, and he [the Veteran] relies on her for virtually all aspects of basic day-to-day functioning." The Board affords the private medical evidence more probative value than the VA examinations of record. Dr. M.C., the private medical professional, conducted an exhaustive review of the Veteran's medical evidence, citing specific treatment records in the evaluation report. Furthermore, Dr. M.C. conducted a thorough interview of the Veteran, allowing the Veteran the opportunity to finally speak about his mental health issue, as the evidence shows that the Veteran felt inhibited to do so for decades following separation from service. Notably, during the private evaluation, the Veteran reported that the VA examinations conducted during the appeal period provided no benefit, as the examinations lasted for a mere 15 minutes. Furthermore, as previously noted, the February 2015 VA treatment record shows that the social worker indicated that the July 2013 VA examination elicited minimal information. Accordingly, the Board affords more probative value to the private medical evidence of record. The 30 percent initial rating and 50 percent increased rating were primarily based on the July 2013 and March 2017 VA examinations, which, the Board finds, were not accurate representations of the Veteran's symptoms. Occupationally the Veteran has been unemployed since 2013. He reported on how he has lost multiple jobs due to disciplinary issues, involving threatening behavior and violence. The record during the appeal period shows the Veteran's limited social engagement. With regard to social functioning, the Veteran has reported having no friends and solely interacting with his wife, as she is his caregiver. He has three daughters; however, he does not keep in contact with them. He is mostly isolated. The above evidence reflects that during the entire claim period, the Veteran has been unable to maintain employment and that he is significantly socially isolated. The record reflects that he worked various jobs up until 2013; however, for several years leading up to 2013, the Veteran described persistent difficulties in occupational settings and was fired from multiple jobs due to threatening behavior. He was forced to remove himself from the workforce in 2013 due to the danger he posed to himself and others. Thus, as shown by his transient jobs and repeated terminations from jobs, he has been unable to sustain any gainful employment due to his psychiatric symptoms. He has otherwise been unemployed during the entire claim period, and the evidence reflects that he would be severely impaired from performing any employment due to his psychiatric symptoms. He has a severe lack of motivation and concentration and has a history of violent behavior towards others. Other than his relationship with his wife, who is his caregiver, as the Veteran needs help with most activities of daily living, the evidence shows that he has no social relationships. Based on the totality of the evidence, and resolving reasonable doubt in favor of the Veteran, the Board finds that there is sufficient evidence to show that the severity of the Veteran's PTSD more closely approximates the criteria for a 100 percent disability evaluation throughout the period on appeal. 2. From April 27, 2012, entitlement to a separate 100 percent rating for Crohn's disease as a complication of diabetes mellitus, type II, is granted. The Veteran contends that he is entitled to a separate compensable rating for Crohn's disease under 38 C.F.R. § 4.114, Diagnostic Code 7323. See October 2021 attorney brief. Under Diagnostic Code 7323, a 10 percent rating is assigned for moderate symptoms, with infrequent exacerbations. A 30 percent rating is assigned for moderately severe symptoms, with frequent exacerbations. A 60 percent rating is warranted for severe symptoms, with numerous attacks a year and malnutrition, the health only fair during remissions. A 100 percent rating is warranted for pronounced symptoms, resulting in marked malnutrition, anemia, and general debility, or with serious complication such as liver abscess. Id. By way of procedural history, the Veteran has been service connected for diabetes mellitus, type II, since April 27, 2012, under Diagnostic Code 7913. Diagnostic Code 7913 allows for separate compensable ratings for complications of diabetes unless they are a part of the criteria used to support a 100 percent rating. Diagnostic Code 7913 Note (1). In order to be eligible for a separate compensable rating, the Veteran must prove that secondary service connection is warranted for a current disability. Secondary service connection is limited to disabilities that are proximately due to, the result of, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists, (2) an already service-connected disability, and (3) that the disability for which secondary service connection is sought was either (a) caused or (b) aggravated by the already service-connected disability. See Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran was diagnosed with diabetes mellitus and Crohn's disease in 2005 and 2011, respectively. See December 2017 VA treatment record; July 2018 VA examination report. A September 2011 VA treatment record notes a diagnosis of a perianal abscess. An April 2012 VA treatment record shows that the Veteran underwent surgery for drainage of a perianal abscess. A June 2012 VA treatment record shows that the Veteran presented for a post-surgery wound check. Since the surgery, the Veteran had "very slow progress in wound healing." A July 2012 VA treatment record notes the Veteran's history of Crohn's disease and diabetes mellitus, type II. It further notes that the Veteran was being seen for a perianal wound that tracked down to his left scrotum. He was first seen in the Emergency Department in April 2012, at which time a surgical incision and drainage was performed with packing. The wound was reinfected and was treated with amoxicillin. At that time, the Veteran packed the wound three times a week with the help of a nurse. The Veteran was frustrated about the pain it caused when he sat for prolonged periods of time and the improper healing. A subsequent July 2012 VA treatment record shows that the Veteran was having one to two non-bloody bowel movements a day, but some blood did leak in from the fistula. A December 2013 VA treatment record shows that the Veteran reported that his anal pain had worsened, making it difficult to stand or sit, basically making him bedbound. The anal fistulas continued to leak a mucusy white/red tinged fluid. He had 5-6 small amounts of liquid bowel movements per day with no blood. He had night sweats with documented fevers. He was losing weight. A February 2015 VA treatment record shows that the Veteran was homebound due to his chronic Crohn's disease and open anal fistula. His wife was unable to work due to the Veteran's need for caretaking and wound care. A subsequent February 2015 VA treatment record lists chronic anemia and Crohn's disease as the Veteran's concurrent diseases. A February 2016 VA treatment record shows that the Veteran had lost around 40 pounds of weight when he was hospitalized during the prior year. A May 2016 VA treatment record notes the Veteran's history of Crohn's colitis complicated by anal fistula with setons x2 and recent Clostridium difficile (C. Diff colitis) in April 2016. The Veteran presented with generalized weakness and poor oral intake for five days. The Veteran's wife reported that, during the past week, the Veteran had generalized weakness, fatigue, increased sleep requirements, and poor oral intake of solids/fluids. A June 2016 VA treatment record shows that the Veteran continued to be weak and easily fatigued. An August 2017 VA treatment record shows that the Veteran had persisting fatigue and slight anemia. A September 2017 VA treatment record notes the Veteran's history of recurrent C. Diff, explosive diarrhea that led to bowel incontinence, as well as a fecal transplant in 2016. The Veteran was admitted again for possible C. Diff. The Veteran reported that he constantly drained from his perianal fissures from Crohn's disease. A January 2018 VA treatment record notes that the Veteran had recurrent Crohn's flares. It also noted that the Veteran's normocytic anemia was likely due to anemia of chronic disease (AOCD) due to his Crohn's disease. A February 2018 VA operative note shows that the Veteran underwent a laparoscopic Hartmann's procedure. The distal colon loop was not able to be brought up without tension despite attempts at mobilization; therefore, the planned lap colostomy was converted to a laparoscopic Hartmann's procedure. In July 2018, the Veteran was afforded a VA diabetes examination. The examiner provided an opinion as to the Veteran's contention that his Crohn's disease was aggravated by his diabetes mellitus. The examiner found that there was no evidence of such aggravation, ignoring pertinent treatment records that discussed the Veteran's Crohn's disease, Hartmann's pouch, and poor wound healing from diabetes mellitus. In June 2019, the Board deemed this opinion as inadequate since all pertinent treatment records were not discussed. A VA addendum opinion was obtained in November 2019. The examiner indicated that the Veteran's medical treatment records do not support any aggravation of Crohn's condition by his diabetes mellitus, type II. The examiner stated that the Veteran's diabetes condition has been stable with A1C readings from November 2016 to the present being between 5.9 to 7.1, indicating good control. His Hartmann's pouch procedure has had complications due to stoma necrosis, which has required four revision procedures to correct. The examiner indicated that, according to current medical literature, stoma necrosis is caused by deficient blood flow. She further stated that a stoma can be affected by both arterial and venous blood compromise. The cause of necrosis usually relates to the surgical procedure, such as tension or too much trimming of the mesentery, or the vascular system that provides blood flow to the intestine. A September 2021 letter from Dr. P.C., a private physician, provides a detailed summary of the Veteran's medical history of his diabetes mellitus and Crohn's disease. Dr. P.C. noted that the Veteran was diagnosed with diabetes mellitus, type II, in 2005, followed by a diagnosis of Crohn's disease in 2011. Dr. P.C. cited several medical studies pertaining to these conditions. He stated that medical research has found that inflammatory bowel diseases like Crohn's disease are aggravated by diabetes mellitus, type II. He indicated that the results of a 2011 study revealed a strong association between diabetes mellitus and the need for surgical intervention in patients with Crohn's disease. The study further showed that, as well as having an increased need for surgery, the diabetic Crohn's disease patients also had significantly higher levels of disease activity and lower quality of life scores. Dr. P.C. indicated that another study in 2015 found that patients with diabetes mellitus, type II, had an increased rate of hospitalization related to Crohn's disease. Dr. P.C. cited a 2020 study in which it was concluded that there was a significant association between comorbid diabetes mellitus, type II, in patients with inflammatory bowel disease (IBD) and higher incidence of IBD-related hospitalization, flare, and complications, as well as increased risk of IBD-related surgery in patients with Crohn's disease. Based on his review of the Veteran's medical record and research, Dr. P.C. concluded that "the medical literature is coming to a clear consensus" that patients like the Veteran with diabetes mellitus, type II, suffer from greater complications of their Crohn's disease, more surgeries, and lower quality of life." Dr. P.C. further states that "there is no question" that the Veteran's service-connected diabetes mellitus, type II, aggravated his Crohn's disease beyond its natural progression and actively impaired his ability to heal from multiple surgical procedures. Furthermore, Dr. P.C. indicated that he did not agree with the November 2019 opinion provided by the VA examiner, indicating the inadequacy of the opinion, as the examiner did not consider relevant medical literature which shows that patients with diabetes mellitus, type II, have impaired wound healing due to the vascular complications of diabetes mediated by endothelial dysfunction. While there is conflicting medical evidence that weighs both for and against the claim, the Board finds that there is competent evidence to support the claim that the Veteran's current Crohn's disease is related to his service-connected diabetes mellitus, type II. Significantly, moreover, when there are two conflicting opinions and the evidence is in relative equipoise, reasonable doubt is resolved in favor of the Veteran. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Given the above evidence of record, the Board concludes that a separate 100 percent rating under Diagnostic Code 7323 is warranted. After a review of all the evidence, lay and medical, resolving reasonable doubt in favor of the Veteran, the Board finds that, for the entire initial rating period, the Veteran's Crohn's disease has been characterized by pronounced symptoms including weight loss, marked malnutrition, frequent bowel movements, pain, constant fatigue, and general debility. The evidence of record shows that, for the entire period on appeal, the Veteran's Crohn's disease and the procedures to treat this disability have resulted in frequent weight fluctuations, difficulty sleeping, constant fatigue, malnutrition, very frequent bowel movements, frequent flare-ups, periods of having no appetite, and pain. The medical evidence indicates that this level of severity continued throughout the period on appeal. The Board finds that, based upon all the evidence, lay and medical, and resolving all reasonable doubt in favor of the Veteran, the Veteran's Crohn's disease has been productive of "pronounced" symptoms for the entire initial rating period on appeal; therefore, a 100 percent disability rating is warranted under Diagnostic Code 7323 for the entire initial rating period. 38 C.F.R. §§ 4.3, 4.7, 4.114. The Board notes that the Veteran is also service connected for diabetic nephropathy associated with his diabetes mellitus, type II, under 38 C.F.R. § 4.115B, Diagnostic Code 7541. Diabetic nephropathy is a condition that involves urinary issues due to complications with the kidney. There is no pyramiding in light of these distinct disease entities and diagnostic codes. 38 C.F.R. § 4.14. TDIU Entitlement to a TDIU, prior to November 11, 2016, is dismissed as moot. A TDIU is considered a lesser benefit than the 100 percent rating, and the grant of a 100 percent rating generally renders moot the issue of entitlement to a TDIU for the period when the 100 percent rating is in effect. An exception to this is a when a TDIU predicated on a single disability (perhaps not ratable at the schedular 100-percent level) when considered together with another disability separately rated at 60 percent or greater may warrant payment of SMC under 38 U.S.C. § 1114(s). Bradley v. Peake, 22 Vet. App. 280 (2008). However, as the instant decision awards the Veteran 100 percent schedular ratings for his PTSD and Crohn's disease and SMC under 38 U.S.C. § 1114(s), his appeal as to the issue of entitlement to a TDIU, prior to November 11, 2016, is moot and is therefore dismissed. SMC Entitlement to SMC at the housebound rate from April 27, 2012, is granted. As a result of the Board's decision herein, granting 100 percent ratings for the Veteran's PTSD and Crohn's disease, the Veteran is in receipt of two service-connected disabilities, independently rated 100 percent disabling from April 27, 2012. Accordingly, SMC at the housebound rate from April 27, 2012, is warranted. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). S. Sorathia Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Y. MacDonald, 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.