Citation Nr: 21072237 Decision Date: 12/02/21 Archive Date: 12/02/21 DOCKET NO. 16-15 018 DATE: December 2, 2021 ORDER Entitlement to compensation under 38 U.S.C. § 1151 for additional disabilities to include pneumonia and bilateral upper and lower extremity numbness status post C2-C7 fusion is denied. Entitlement to an initial rating in excess of 70 percent for an acquired psychiatric disability, to include anxiety and post-traumatic stress disorder (PTSD) is denied. FINDINGS OF FACT 1. The Veteran's pneumonia and bilateral upper and lower extremity disability was not due to the carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing treatment, nor was such a disability proximately caused by an event not reasonably foreseeable. 2. The Veteran's acquired psychiatric disability to include anxiety and PTSD have manifested in weekly panic attacks, suicidal ideation, difficulty in adapting to stressful circumstances, inability in establishing and maintaining effective relationships, suspiciousness, depressed mood, disturbances of motivation and mood, and anxiety. CONCLUSIONS OF LAW 1. The criteria for entitlement to compensation under 38 U.S.C. § 1151 for additional disabilities to include pneumonia and bilateral upper and lower extremity numbness status post C2-C7 fusion, have not been met. 38 U.S.C. §§ 1151, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.361. 2. The criteria for an initial rating in excess of 70 percent for an acquired psychiatric disability, to include anxiety and PTSD, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code (DC) 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from August 1980 to July 1982. These matters come before the Board of Veterans' Appeals (Board) on appeal from a March 2014 and September 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office. The Board initially notes that during the pendency of the appeal the VA regional office granted service connection for a post-traumatic stress disorder and recharacterized her service-connected unspecified anxiety as one for PTSD. The VA regional office subsequently assigned an initial disability rating of 70 percent effective March 12, 2012. Given that the Veteran has multiple diagnosis of psychiatric disorders to include anxiety and PTSD, the Board find it appropriate to recharacterize her PTSD claim as one for an acquired psychiatric disorder to include anxiety and PTSD in order to encompass all conditions reasonably contemplated by the claim. Clemons v. Shinseki, 23 Vet. App. 1 (2009). These matters were previously before the Board in September 2018 but was remanded for additional development. In April 2021, the Board received notice that the Veteran requested her case be remanded to the Agency of Original Jurisdiction for an initial review of the additional evidence submitted in her appeal. As such, in May 2021, the Board remanded her appeal accordingly and further sought additional development of her appeal. In a September 2021 supplemental statement of the case (SSOC), her claim for compensation under 38 U.S.C. § 1151 and initial increased rating for PTSD in excess of 70 percent was denied. These matters are again before the Board for adjudication. 1. Entitlement to compensation under 38 U.S. C. 1151 for additional disabilities to include pneumonia and bilateral upper and lower extremity numbness, status post C2-C7 fusion is denied. The Veteran asserts that she developed pneumonia and bilateral upper and lower extremity numbness as a result of her July 2011 C2-C7 fusion and August 2011 washout and closure of a wound dehiscence. Under applicable law, when a veteran suffers additional disability or death as the result of training, hospital care, medical or surgical treatment, or an examination by VA, disability compensation shall be awarded in the same manner as if such additional disability or death were service-connected. 38 U.S.C. § 1151; 38 C.F.R. § 3.358 (a). To be awarded compensation under section 1151, a veteran must show that VA treatment (or other qualifying event) resulted in additional disability, and further, that the proximate cause of the additional disability was carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing the medical or surgical treatment, or that the proximate cause of the disability was an event which was not reasonably foreseeable. 38 U.S.C. § 1151; 38 C.F.R. § 3.361. See also VAOPGCPREC 40-97, 63 Fed. Reg. 31,262 (1998). Regarding the first prong of the analysis, to determine additional disability exists, the veteran's physical condition immediately prior to the beginning of the hospital care, medical or surgical treatment, or other relevant incident in which the claimed disease or injury was sustained upon which the claim is based, is compared to the veteran's condition after such treatment, examination or program has stopped. 38 C.F.R. § 3.361 (b). Provided that additional disability exists, the next consideration is whether the causation requirements for a valid claim for benefits have been met, to consist of both actual and proximate causation. In order to establish actual causation, the evidence must show that the medical or surgical treatment rendered resulted in the veteran's additional disability. If it is shown merely that a claimant received medical care or treatment, and has an additional disability, that in and of itself would not demonstrate actual causation. 38 C.F.R. § 3.361 (c)(1). Also, the proximate cause of the disability claimed must be the event that directly caused it, as distinguished from a remote contributing cause. To establish that carelessness, negligence, lack of proper skill, error in judgment or other instance of fault proximately caused the additional disability, it must be shown that VA failed to exercise the degree of care expected by a reasonable treatment provider, or furnished the treatment at issue without informed consent. 38 C.F.R. § 3.361 (d)(1). Proximate cause may also be established where the additional disability was an event not reasonably foreseeable, based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable but must be one that a reasonable medical provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider the type of risk that a reasonable health care provider would have disclosed as part of the procedures for informed consent (in accordance with 38 C.F.R. § 17.32). 38 C.F.R. § 3.361 (d)(2). Pneumonia Upon review of the evidence, the Board finds that the Veteran was diagnosed with left lingular pneumonia in a July 17, 2011 VA treatment record, a week after she was discharged after undergoing a C2-C7 cervical fusion. However, the Board finds that the Veteran's diagnosis of pneumonia was not caused by her July 2011 C2-C7 cervical fusion treatment. The Veteran's VA treatment record following her C2-C7 cervical fusion demonstrate that she remained in the hospital for five to seven days following her cervical fusion surgery and at the time of discharge her lungs were clear. Notably, her July 17, 2011 VA treatment record indicates she was one week status post discharge when she was seen for her cough and eventually diagnosed with left lingular pneumonia. Aside from this single diagnosis, her medical treatment records do not reflect continuous treatment for pneumonia. There is also no evidence that she was treated for pneumonia after her August 2011 washout and closure of a wound dehiscence. A July 2020 VA examiner also stated that she developed pneumonia in the week after her discharge in July 2011, 10 days after initial cervical procedure. While she was evaluated for possible infections after her cervical fusion surgery, only a urinary tract infection was identified and treated before she was discharged. As such, the July 2020 VA examiner opined that there is no indication that she had pneumonia prior to leaving VA hospital and that there is no indication her pneumonia is related to her cervical fusion surgery. Instead, the VA examiner states her pneumonia was an acute infection process which resolved completely with appropriate treatment and was not chronic or ongoing. The July 2020 VA examiner further opined that it was less likely than not that additional disability resulted from carelessness, negligence, lack of skill, or similar incidence of fault on the part of the attending VA personnel. Aside from her urinary tract infection at the time of discharge, the VA examiner stated her cervical fusion procedure and immediate post-operative course was completed without complication. As such, her post-operative pneumonia developed due to community exposure and not any action or inaction on part of VA. The July 2020 VA examiner also opined that it is at least as likely as not that her pneumonia resulted from an event that could not have been reasonably foreseen by a reasonable healthcare provider. To that extent, the VA examiner stated that while infections can and do occur after surgical procedures, a community acquired pneumonia occurring shortly after a surgical procedure, contracted outside hospital care, is not an infection related to the surgical procedure and is not foreseeable. The Board has considered the Veteran's lay assertion that her pneumonia was caused by the July 2011 cervical fusion surgery. While the Veteran is competent to testify as to her symptoms, she is not competent to provide an opinion as to the etiology of her condition as she has not shown that she has the required skills or knowledge to do so. Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Aside from her lay assertion, there is no medical evidence indicating that her pneumonia was in any way caused by the July 2011 cervical fusion surgery. Instead, the Board finds that the VA medical treatment records and July 2021 VA medical opinion are most probative. Specifically, the VA treatment records indicates that she did not develop pneumonia during the course of her hospital stay for her cervical fusion surgery. Notably, the July 17, 2011 VA treatment records indicates that her lungs were clear at the time of her cervical fusion discharge. The July 2020 VA medical opinion is also probative as it is predicated on a thorough review of the pertinent evidence of record and provided complete medical rationales, relying on and citing to the records received. Moreover, the clinicians offered clear conclusions with supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion...must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). As such, the Board finds that the preponderance of the evidence is against finding that her pneumonia is an additional disability due to the carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing treatment, or that it a disability proximately caused by an event not reasonably foreseeable. Bilateral upper and lower extremity disability The Veteran further asserts that her bilateral upper and lower extremity pain and numbness are also caused by the July 2011 cervical fusion and August 2011 washout and closure of a wound dehiscence. Upon review of the evidence, the Board finds that the Veteran's bilateral upper and lower extremity disabilities are not an additional disability caused by the July 2011 cervical fusion and August 2011 washout and closure of a wound dehiscence. First, the Board finds that her bilateral upper extremity disability is not an additional disability caused by the July 2011 cervical fusion or August 2011 washout and closure of a wound dehiscence. As provided above, to determine whether there is an additional disability, the Veteran's physical condition immediately prior to the beginning of the hospital care, medical or surgical treatment, or other relevant incident in which the claimed disease or injury was sustained upon which the claim is based, is compared to the veteran's condition after such treatment, examination or program has stopped. 38 C.F.R. § 3.361 (b). Here, prior to the July 2011 cervical fusion, her VA treatment records reflects that she reported having pain and numbness in her shoulders and back as early as May 2010. In December 2010, she continued to report numbness in her fingertips and hands and was eventually diagnosed with cervical radiculopathy in that same month. During a May 2011 pre-operative evaluation, it was noted that the Veteran had neuropathy due to cervical and lumbar injury. Most significantly, her July 2011 VA informed consent document indicates that the reason for her cervical fusion was to treat pain or numbness caused by compressed nerves in the spine. Additionally, a July 2020 VA examiner further states that the record does not support any significant progression of her bilateral upper extremity disabilities after the July 2011 cervical fusion and August 2011 washout and closure of a wound dehiscence. The VA examiner noted neurological evaluations since 2011 have documented normal neurological findings of her bilateral upper extremity. Although she reports ongoing mild bilateral upper extremity numbness, the objective examinations do not support any significant sensory deficits or any progressively worse sensory deficits since the July 2011 neck surgery. Notably, the VA examiner further states that as she reported numbness in bilateral hands before the July 2011 neck surgery and August 2011 washout and closure of wound dehiscence, then the VA treatment at issue did not cause bilateral upper extremity numbness. The VA examiner further opined that it is less likely than not that her bilateral upper extremity numbness resulted from carelessness, negligence, lack of skill, or similar incidence of fault on the part of the attending VA personnel. The VA examiner emphasized that the August 2011 washout and closure of a wound dehiscence was completed without complication, that there was no evidence of infection, and that she was discharged home without issues other than some numbness in T1 distribution. Subsequent neurological evaluation also failed to confirm any neurological deficits in the bilateral upper extremities. Regardless, the VA examiner stated she exhibited bilateral upper extremities numbness with objective improvement over time so there was no carelessness, negligence, lack of skill, or similar incidence of fault on the part of the attending VA personnel. The VA examiner further opined it was less likely than not that her bilateral upper extremity numbness resulted from an event that could not have reasonably been foreseen by a reasonable healthcare provider. Specifically, the VA examiner states that resolution or improvement in nerve related damage or symptoms is a goal of surgical intervention, but by no means, is a guarantee with surgical interventions. Failure to improve or resolve pain/numbness is a known risk of surgical intervention for spinal conditions. As the Veteran had numbness in the bilateral upper extremities, due to longstanding C7 fracture, before any VA surgical interventions, it would be a known possible outcome that her bilateral upper extremity numbness would continue after surgical interventions, including the July 2011 cervical fusion and the August 2011 washout and closure of wound dehiscence. As a known possible outcome of cervical procedures then, the continued bilateral upper extremity numbness after the July 2011 C2-T2 posterior segmental instrumentation with C2-T2 bilateral arthrodesis and the August 2011 washout and closure of wound dehiscence was a foreseeable outcome. As a known existing condition and given risks of persistence, the bilateral upper extremity numbness would have been discussed during the Informed Consent process prior to both the July 2011 cervical fusion and August 2011 washout and closure of wound dehiscence. Based on the foregoing evidence, the Board finds that the Veteran has not shown that her bilateral upper extremity numbness resulted from VA medical care as it was present prior to the July 2011 cervical fusion and August 2011 washout and closure of a wound dehiscence. With regards to her bilateral lower extremity disability, aside from a single report of numbness in her left lateral thigh in May 2010, the medical evidence prior to her July 2011 cervical fusion surgery did not reflect any additional reports or treatment for pain or numbness of the bilateral lower extremity. Following the July 2011 cervical fusion surgery, a July 11, 2011 post-operative report reflects that her bilateral lower extremities were weak. A November 2012 VA treatment record further reflect reports of subjective mild weakness in her lower extremities. During an August 2013 VA neurology consultation for complaints of left leg weakness, a nerve conduction velocity test showed she had a mild axonal conduction block in the right leg but had no abnormalities of the left leg nerve testing. However, the VA doctor noted an impression of left peroneal palsy as to her report of left leg weakness. While the Veteran's VA and private treatment records reflects a diagnosis of bilateral lower extremities, the evidence preponderates against a showing that it was actually caused or proximately caused by the July 2011 cervical fusion surgery and August 2011 washout and closure wound dehiscence. Specifically, the evidence indicates that her bilateral lower extremity disability was initially noted as a mild axonal conduction block in the right leg and possible left peroneal palsy during an August 2013 nerve conduction velocity test. In August 2014, a private doctor noted she had a diagnosis of sciatica due to displacement of the lumbar disc and herniated nucleus pulposus on the left side at L5-S1 and left lateral L4-5. A July 2015 and March 2019 VA treatment further indicates that she has chronic lumbar back pain with leg weakness and chronic lumbar radiculopathy. A July 2020 VA examiner further opined that her cervical spine condition is unlikely to neuroanatomically affect the nerves to the lower extremities unless there is profound cervical spinal cord compression identified compromising the entire spinal nerve root system. Such is not the case for the Veteran as her April 2019 cervical magnetic resonance imaging (MRI) showed no spinal cord compression. Ultimately, the July 2020 VA examiner states her bilateral lower extremity numbness issues are in no way related to the July 2011 and August 2011 VA surgical procedures at issue. Instead, the July 2020 VA examiner states that her lower extremity numbness and pain were associated with her lumbar disc disease and leftward disc protrusion as documented in the 2016 and 2019 MRI. As to the cause of her mild axonal conduction block diagnosis of her right lower extremity, the VA examiner stated it was most commonly related to diabetes mellitus or alcohol abuse. The VA examiner noted that her history of heavy alcohol abuse, to include an overdose in 2013 was a possible contributor to her right lower extremity numbness. Most notably, the VA examiner states that her cervical spinal condition is unlikely to neuroanatomically affect the nerves to the lower extremities, unless there is profound cervical spinal cord compression identified that is compromising the entire spinal nerve root system. However, such was not the case for Veteran as an April 2019 cervical MRI shows no spinal cord compression. The Veteran's bilateral lower extremity condition is also not proximately caused by the carelessness, negligence, lack of proper skill, error in judgment, or similar instances of faulty on part of the VA facility furnishing treatment or an event not reasonably foreseeable. Specifically, a July 2020 VA examiner opined that it was less likely than not that failure on part of the VA to timely diagnose or treat her bilateral lower extremity allowed the disability to progress as she was properly evaluated for bilateral lower extremity numbness and reasonable treatments, to include pain medication, physical therapy, and steroid injections, were pursued. Although the July 2020 VA examiner opines that her bilateral lower extremity condition was an event not reasonably foreseeable, the VA examiner stated that her bilateral lower extremity numbness was not in any way related to her cervical procedure. As such it would not have been possible for VA providers in 2011 to predict or foresee complaints of bilateral lower extremity numbness, which were due to other factors, after the VA surgical procedures at issue. The Board understands the Veteran's sincerely held belief that her bilateral upper and lower extremity numbness were the result of her July 2011 and August 2011 VA treatment and that such was not reasonably foreseeable. While the Veteran, as a lay person, may report on observable symptoms and discomfort and the nature of the treatment she received, an assessment of the proper treatment for her symptoms is a complex, medical matter requiring training and clinical experience that lay persons do not possess. Therefore, her lay assessment of the cause of her pneumonia and bilateral upper and lower extremity are not competent as such are complex medical questions. Again, the Board reiterates that the mere fact that a claimant is harmed by an event that occurs coincidentally with VA care, treatment or an examination is not sufficient to establish causation. Mangham v. Shinseki, 23 Vet. App. 284, 287 (2009). As such, her statements are non-probative. Jandreu v. Nicholson, 492 F.3d at 1376-77 (noting general competence to testify as to symptoms but not to provide medical diagnosis). Ultimately, the Board accords greater probative weight to the July 2020 VA medical opinion as it is predicated on a thorough review of the record which includes medical records concerning the treatments in question and post-surgical reports of symptoms. Moreover, the opinion considered all the pertinent evidence of record and provided a complete rationale, relying on and citing to the records received. The VA examiner further offered a clear conclusion with supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion...must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Notably, there is no medical opinion of record to the contrary. Thus, based on the foregoing evidence, the Board finds that the preponderance of the evidence is against a finding that her pneumonia and bilateral upper and lower extremity were the result of her July 2011 cervical fusion or August 2011 washout and closure of a wound dehiscence. Accordingly, the benefit of the doubt doctrine is not applicable, and her claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to an initial rating in excess of 70 percent for an acquired psychiatric disability is denied. The Veteran further seeks an initial rating in excess of 70 percent for her acquired psychiatric disability. No specific assertion has been provided. The Veteran's acquired psychiatric disorder is currently assigned an initial rating of 70 percent under Diagnostic Code 9411 under the General Formula for Mental Disorders (General Formula). When considering an increased rating under the General Formula, the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). Under the General Formula, a 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; 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); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 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 or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name. Upon review of the evidence, the Veteran's February 2011 VA treatment record reflects that she had a previous suicide attempt by taking a lot of Zoloft many years ago. Following her July 2011 cervical fusion surgery, it was reported that she was agitated and kicked a nurse. A September 2012 VA treatment record further indicates that she was admitted to a psychiatric ward for two days which she later stated in September 2013 that it was for a nervous breakdown. In a September 2013 VA treatment record, she further reported having passive suicidal ideation but noted that her faith was a protective factor. In a January 2014 VA examination, a VA examiner indicated her symptoms of her anxiety consisted of depressed mood, anxiety, panic attacks occurring weekly or less often, chronic sleep impairments, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships. The VA examiner noted these symptoms resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. During the January 2014 VA examination, the Veteran reported having difficulty getting emotionally or sexually intimate with her husband after her military service which led to him leaving her after 13 years. She reported having two children who she keeps in contact with. Although she reports having a few friends, she stated that she does not have anyone that she can call a true friend. She had limited family support and is estranged from her sister. She reported volunteering for C-CAP two days per week to keep her from going crazy sitting in the house all the time. In a December 2015 VA treatment record, her mental status evaluation of the Veteran reflects she was casually dressed, and her memory was oriented and intact. There was also no signs or symptoms of psychotic thinking or suicidal thoughts. Similarly, in a February 2016 VA treatment record, it was noted that she was depressed and appeared tense but there were no reports of suicidal thoughts. Her August and September 2018 VA treatment records further reported her mood was "ok." She endorsed feeling safe and was linear, logical, and goal directed. There was no report of suicidal ideation or homicidal ideation. In an October 2019 VA examination, the Veteran reported feeling irritable all the time for a long time and that it has increased since her neck surgery due to being in pain all the time. She reported feeling restless and agitated. She also reported being anxious about 80 percent of the time. The VA examiner noted she experienced nervousness, tension, and difficulty relaxing. She also endorsed occasional panic attacks, less than weekly. She continued to report maintaining regular contact with her two children and but that she is only on good term with her son. However, her relationship with her daughter was strained. She further reported being married four times with the most recent in August 2015, but they later separated in November 2016. On examination, she was casually dressed, and her hygiene and grooming were adequate. Her behavior was also cooperative and engaged. Her symptoms noted on examination consisted of depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. Based on the foregoing evidence, the Board finds that the Veteran's acquired psychiatric disorder symptoms throughout the period on appeal manifested in suicidal ideation, near-continuous panic or depression affecting her ability to function independently, appropriately, and effectively, impaired impulse control, such as irritability with periods of violence, and inability to establish and maintain effective relationships. These symptoms are best contemplated under a 70 percent rating. The Board acknowledge the Veteran reported some symptoms contemplated under a 100 percent disability rating such as a previous suicide attempt, kicking a nurse, and passive suicidal ideation. However, aside from these reports, the majority of her VA treatment records do not evidence continuous and ongoing behaviors demonstrating persistent danger of hurting herself or other. While she reports having passive suicidal ideation, she reported that her faith served as a protective factor. As such, the Board finds that the severity, frequency, and duration of these symptoms more closely approximate the symptoms contemplated by a 70 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by a 100 percent rating. See 38 C.F.R. § 4.126. The Board acknowledge that TDIU has been granted during the pendency of the appeal, however, a 100 percent rating requires the presence of both total occupational and social impairment. Here, total social impairment is not shown by the record. While the Veteran has not been able to work, the evidence demonstrates that her occupational impairment is based on her physical disabilities. Despite having a strained relationship with her daughter, she continues to help her daughter and spends time with her grandchildren in a September 2021 VA treatment record. She also has a good relationship with her son and has a few friends. The evidence further shows that she volunteers with C-CAP. Thus, the evidence does not demonstrate total occupational and social impairment. The Board acknowledge that the Veteran experiences some symptoms contemplated by a 100 percent rating. However, the overall evidence does not demonstrate that these symptoms reach the level of impairment associated with a 100 percent rating. As noted above, the Veteran's other remaining symptoms were either contemplated by or more consistent with a 70 percent rating. In short, the preponderance of the evidence weighs against finding that the severity, frequency, and duration of the Veteran's symptoms resulted in the level of impairment required for a 100 percent rating. As the criteria for a 100 percent are not met, the Veteran's claim for an initial rating in excess of 70 percent must be denied. M. Tenner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Xiong, 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.