Citation Nr: 21077124 Decision Date: 12/28/21 Archive Date: 12/28/21 DOCKET NO. 13-06 139A DATE: December 28, 2021 ORDER 1. Entitlement to an initial evaluation in excess of 10 percent from May 21, 2007 to November 14, 2010 for ischemic heart disease (IHD) is denied. 2. Entitlement to an increased evaluation in excess of 30 percent from November 15, 2010 to April 5, 2016 for IHD is denied. 3. Entitlement to a 100 percent evaluation for IHD since April 6, 2016 is granted. 4. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) on an extraschedular basis prior is granted. 5. Entitlement to special monthly compensation (SMC) at the housebound rate since April 6, 2016 is granted. REMANDED Entitlement to an increased evaluation in excess of 70 percent for post-traumatic stress disorder (PTSD) since May 5, 2010 is remanded. FINDINGS OF FACT 1. For the period from May 21, 2007 to November 14, 2010, the Veteran's IHD did not result in a workload of 7 METs or less; more than one episode of acute congestive heart failure in a year; left ventricular dysfunction with an ejection fraction of 50 percent or less; chronic congestive heart failure; or the presence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram or X-ray. 2. For the period from November 15, 2010 to April 5, 2016, the Veteran's IHD did not result in a workload of 5 METs or less; more than one episode of acute congestive heart failure in a year; left ventricular dysfunction with an ejection fraction of 50 percent or less; or chronic congestive heart failure. 3. Since April 6, 2016, the Veteran's IHD has resulted in a workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope. 4. The Veteran has been prevented from securing and following a substantially gainful occupation due to the combined effects of his service-connected disabilities throughout the appeal period. 5. Since April 6, 2016, the Veteran has been assigned a 100 percent rating for IHD and has separate additional service-connected disabilities rated at 60 percent or higher. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for the Veteran's IHD from May 21, 2007 to November 14, 2010 were not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.31, 4.104, Diagnostic Code (DC) 7005. 2. The criteria for an increased rating in excess of 30 percent for the Veteran's IHD from November 15, 2010 to April 5, 2016 were not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.31, 4.104, DC 7005. 3. The criteria for a 100 percent rating for the Veteran's IHD since April 6, 2016 are met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.31, 4.104, DC 7005. 4. The criteria for entitlement to a TDIU are met throughout the appeal period. 38 U.S.C. § 1155; 38 C.F.R. § 4.16. 5. The criteria for SMC at the housebound rate since April 6, 2016 are met. 38 U.S.C. § 1114; 38 C.F.R. § 3.350. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service with the Marine Corps from November 1964 to November 1968. This matter is on appeal from August 2010 and August 2012 rating decisions. The Veteran was afforded an April 2016 hearing before a Veterans Law Judge (VLJ). A transcript of the hearing has been associated with the claims record. The Board remanded this appeal in July 2016 for additional development. In a February 2018 rating decision, the Veteran's IHD evaluation was increased to 100 percent effective August 2, 2017. While the assigned rating is the maximum disability rating assignable for this disability, higher ratings are available for this disability prior to August 2, 2017 and the Veteran has not indicated that the current staged ratings are the maximum benefit sought. As higher ratings are available and a claimant is presumed to be seeking the maximum available rating for disabilities, the claim remains on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). In June 2020, the Veteran submitted another VA Form 9 and selected the option for a Board hearing at a local VA office. The Board did not attempt to schedule the Veteran for a hearing. Instead, the Board issued a letter in June 2020, advising the Veteran that the VLJ who performed the hearing in April 2016 was no longer available. The Veteran was asked to respond to the letter indicating if he would like another hearing and was notified that if he did not respond in 30 days it would be assumed that he did not want a second hearing. No response was received from the Veteran. In a September 2020 Board decision, the claims on appeal were denied. However, in July 2021, the United States Court of Appeals for Veterans Claims (Court) vacated the September 2020 Board decision and remanded the appeal back to the Board, pursuant to a July 2021 Joint Motion for Remand (JMR). The basis for the JMR was that the Board violated its duty to provide the Veteran with a hearing pursuant to the June 2020 VA Form 9 prior to making a decision on the claim. In a November 2021 correspondence, the Veteran's representative advised the Board that he no longer wants a Board hearing, thus, the June 2020 hearing request is considered withdrawn. 38 C.F.R. § 20.704(e). This claim has been advanced on the docket pursuant to 38 C.F.R. § 20.900. The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). I. Increased Rating 1. Entitlement to a rating in excess of 10 percent from May 21, 2007 to November 15, 2010, and in excess of 30 percent from November 15, 2012 to August 1, 2017, for IHD. Legal Criteria Ratings are based on a schedule of reductions in earning capacity from specific injuries or combination of injuries. The ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civil occupations. 38 U.S.C. § 1155. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. The Veteran's IHD is rated under DC 7005. Throughout the period on appeal, under DC 7005 a 10 percent rating is warranted when the Veteran experiences a workload of greater than 7 METs but not greater than 10 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; or if continuous medication is required, a 30 percent rating is warranted when the Veteran experiences a workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; or there is evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or x-ray; a 60 percent rating is warranted when the Veteran experiences a workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of 30 to 50 percent; and a 100 percent rating is warranted when the Veteran experiences congestive heart failure; a workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent. A Note following DC 7005 provides if nonservice-connected arteriosclerotic heart disease is superimposed on service-connected valvular or other non-arteriosclerotic heart disease, request a medical opinion as to which condition is causing the current signs and symptoms. Where 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. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. One MET is defined as the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. An effective date for an increased rating should not be assigned mechanically based on the date of a diagnosis. Rather, all of the facts should be examined to determine the date that the disability first manifested. Accordingly, the effective date for an increased rating, as well as for an initial rating or for staged ratings, is predicated on when the increase in the level of disability can be ascertained. Swain v. McDonald, 27 Vet. App. 219, 224 (2015); DeLisio v. Shinseki, 25 Vet. App. 45, 56 (2011). In determining when an increase is "factually ascertainable," all of the evidence must be looked to, including testimonial evidence and expert medical opinions, and an effective date must be assigned based on that evidence. See McGrath v. Gober, 14 Vet. App. 28, 35-36 (2000); VAOPGCPREC 12-98. Thus, "it is the information in a medical opinion, and not the date the medical opinion [that] was provided that is relevant when assigning an effective date." Tatum v. Shinseki, 24 Vet. App. 139, 145 (2010); see also Young v. McDonald, 766 F.3d 1348 (Fed. Cir. 2014). Where 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. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Analysis The Veteran contends that he should have a higher rating or ratings for IHD prior to August 2, 2007. Review of the Veteran's medical treatment records demonstrates that in June 2006, the Veteran reported having chest pains a few months ago and went to the emergency room. However, he then stated that the chest pain stopped and did not wait to see a doctor. In August 2006, the Veteran reported a history of chest pain three months ago with symptoms of chest pressure, shortness of breath, nausea, vomiting and dizziness. The Veteran was given an impression of unstable angina and a left heart catheterization procedure with angioplasty and stenting was performed. In a September 2006 follow-up, the Veteran demonstrated an ejection fraction of 60 percent, and it was noted that he "has not really had much in the way of angina." He was assessed with IHD, "doing well." The Veteran was noted to have reported that another physician "heard a carotid bruit" but no clarification on the impact on his condition was made. In an October 2007 cardiac follow-up, the Veteran reported atypical chest discomfort with cold symptoms in the past month and described it as a "localized burning sensation in the left upper chest with and without exertion" lasting 1 to 2 minutes without radiation or associated symptoms. The Veteran stated having intermittent shortness of breath when performing activities such as carrying his granddaughter up a flight of stairs. The Veteran denied presyncope, syncope, orthopnea, paroxysmal nocturnal dyspnea, edema, claudication, or palpitation. A graded exercise tolerance test was conducted at the cardiac follow-up, and it was noted that there was no complaint of chest pain or diagnostic echocardiogram change beyond the noted baseline; as such, an interpretation for a negative graded exercise tolerance test was made. A hypertensive response was also noted during the test. The treating provider remarked that "from a cardiac standpoint, the Veteran is doing fairly well." During private treatment in March 2010, the Veteran reported experiencing recent chest discomfort and a heart scan would be scheduled to see if the Veteran's stents were still patent. The Veteran was noted to have a history of atherosclerotic coronary artery disease with an angioplasty and stenting in August 2006. The physician stated that the Veteran "has not had anything in the way of his anginal chest discomfort," and described that prior to his August 2006 procedure, he had a "pressure type discomfort in his chest with accompanied nausea and diaphoresis." The Veteran reported having some non-exertional left-sided squeezing discomfort that improved with "squeezing back" and would last 5 to 15 minutes, and these symptoms had been going on for 1 12 years with 1 to 2 episodes per month. The Veteran stated that, "he works in his yard without chest discomfort." Although, "he would have occasional shortness of breath especially when bent over working in the yard." The Veteran denied presyncope, syncope, orthopnea, paroxysmal nocturnal dyspnea, edema, claudication, or palpitation. The provider noted the Veteran "may have a rare episode when he feels his heart rate speeding up." The Veteran also denied a history of myocardial infarction, cerebrovascular accident, or heart murmur. A graded exercise tolerance test was conducted, and it was noted that there was no complaint of chest pain or diagnostic electrocardiogram change beyond the noted baseline; as such, an interpretation for a negative graded exercise tolerance test was made. The treating provider also explained to the Veteran that the reported symptoms were "not describing what sounds like his angina" as the Veteran experienced these symptoms very infrequently and they were non-exertional in nature. The Veteran was afforded a VA heart examination in February 2011. The examiner noted the Veteran had a history of percutaneous coronary intervention performed in 2006. The examiner found the Veteran's treatment plan included taking continuous medication for his condition. The examiner did not find the Veteran with congestive heart failure. The examiner found the Veteran's METs level at greater than 7 but less than 10 METS with dyspnea symptoms. No diagnostic exercise testing was held and no left ventricular ejection fraction was reported. The examiner did find evidence of cardiac hypertrophy or dilation, but denied that his heart was enlarged. The examiner did not find that the condition results in any functional impact. In March 2011, the Veteran was seen for cardiac follow-up. The Veteran stated that he was currently not experiencing any anginal symptoms. The Veteran reported experiencing occasional discomfort described as burning or indigestion unlike his previous chest pain prior to the 2006 stenting procedure. The Veteran stated that the symptoms were non-exertional and felt that they were more related to gastrointestinal issues because he currently has reflux and takes aspirin for arthritis pain. A graded exercise tolerance test was conducted, and it was noted that there was no complaint of chest pain or diagnostic electrocardiogram changes; as such, an interpretation for a negative graded exercise tolerance test was made. The treating provider observed that the Veteran performed well during the exercise test with no electrocardiogram changes or chest discomfort. The provider opined that the burning indigestion the Veteran was experiencing was indeed from his stomach and noted the Veteran would take 8 to 10 aspirin to treat his arthritis. In October 2011 the Veteran reported experiencing three episodes of tachycardia in the past several months, the longest lasting up to 45 minutes. The Veteran also stated that he would have episodes of palpitations and dizziness. The treating physician assessed the Veteran with episodes of tachycardia occurring fairly infrequently and possible intermittent atrial fibrillation. In February 2012, the Veteran reported an episode of fatigue and "feeling bad" that resulted in a stent being put in him in 2006. In March 2012, the Veteran reported a history of episodes of lightheadedness where he would experience "tunnel vision, everything turned white." The Veteran stated that such episodes sometimes occurred while driving and he would need to stop and pull over. The Veteran was assessed with orthostatic syncope and hypotension. The Veteran was afforded an April 2012 VA examination. The examiner noted the Veteran had a history of percutaneous coronary intervention performed in 2006. The examiner found the Veteran's treatment plan included taking continuous medication for his condition. The examiner did not find the Veteran with congestive heart failure or myocardial infarction. The examiner found the Veteran's METs level at greater than 5 but less than 7 METS with dyspnea and fatigue symptoms. No diagnostic exercise testing was held and no left ventricular ejection fraction was reported. The examiner did not find evidence of cardiac hypertrophy or dilation. X-ray views found no evidence of acute cardiopulmonary disease or masses, with no overall interval change in comparison to the prior examination. The examiner did not find that the condition results in any functional impact. In a November 2012 annual physical examination, the Veteran denied weakness, fatigue, chest pain, or shortness of breath. The Veteran's assessed coronary artery disease was found to be stable. In a November 2013 annual physical examination, the Veteran denied weakness, fatigue, chest pain, or shortness of breath. The Veteran's assessed coronary artery disease was found to be stable. In a December 2014 annual physical examination, the Veteran denied weakness, fatigue, chest pain, or shortness of breath. The Veteran's assessed coronary artery disease was found to be stable. In a March 2015 preoperative note, the Veteran reported that he would get shortness of breath whenever he tried to run or carry something heavy. The Veteran described that he had symptoms of chest and left arm pain with nausea prior to his 2006 stent procedure and stated that those symptoms never recurred after his stent was placed. The Veteran's "systemic disease" was found to be stable. In a separate March 2015 anesthesiology note, the Veteran was determined to have excellent exercise tolerance. In a January 2016 annual physical examination, the Veteran denied weakness, fatigue, chest pain, or shortness of breath. The Veteran's assessed coronary artery disease was found to be stable. At the Veteran's April 6, 2016 hearing, the Veteran testified that his heart condition had worsened. The Veteran stated that he had symptoms of chest pain, that his left arm would go to sleep a lot of times, and he experience shortness of breath when walking upstairs or doing anything. Thereafter, during an August 2, 2017 VA examination, a physician found that the Veteran's IHD results in a workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope. In November 2021, the Veteran submitted a statement in regard to the severity of his heart condition during the period on appeal. He stated that he experienced ongoing chest pain throughout the appeal period. He also stated that he was unable to perform law work or do much of anything due to frequent occurrences of shortness of breath, fatigue, dizziness, and lightheadedness. He further stated that he was always scared that something would happen to his heart. After review of the evidence of record, the Board finds the preponderance of the evidence is against a finding for an increased rating in excess of 10 percent from May 21, 2007 to November 15, 2010 and 30 percent from November 15, 2010 to April 5, 2016 for the Veteran's IHD. However, the Board finds that a 100 percent rating for this condition is warranted since April 6, 2016. As noted above, prior to November 15, 2010, the Veteran was not found to experience a workload not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness or syncope, evidence of cardiac hypertrophy or dilatation, more than one episode of acute congestive heart failure in a year, left ventricular dysfunction with an ejection fraction of 50 percent or less, or chronic congestive heart failure or additional surgery. In addition, prior to April 5, 2016, he was not found to experience a workload of 5 METs or less, more than one episode of acute congestive heart failure in a year, left ventricular dysfunction with an ejection fraction of 50 percent or less, or chronic congestive heart failure. In this regard, the February 2011 and April 2012 examiners did not find the presence of such symptoms. In addition, both examiners found that the condition did not result in functional impairment. Furthermore, the Veteran's medical records also do not indicate the presence of such diagnostic findings or symptoms prior to April 5, 2016. The Board notes that the VA examinations in February 2011 and April 2012 did not conduct exercise METs or the LVEF value obtained; the METs estimate was provided based on the Veteran's responses. Nonetheless, the February 2011 and April 2012 examination opinions are the most probative evidence of record concerning the Veteran's level of disability during this period. Both examiners found the Veteran's workload at worst greater than 5 METS but not greater than 7 METs. The examiners found no evidence of congestive heart failure. The examiners did not find the Veteran's IHD resulted in occupational impact. Annual physical examinations conducted during the period show the Veteran did not complain of weakness, fatigue or shortness of breath; and the treating physicians found the Veteran's heart disability to be stable. The Board also notes that the Veteran sought treatment for chest symptoms in March 2010. However, he reported working in the yard without chest discomfort. He also reported occasional shortness of breath especially when bent over working in the yard, but Veteran denied presyncope, syncope, orthopnea, paroxysmal nocturnal dyspnea, edema, claudication, or palpitation. The provider noted the Veteran "may have a rare episode when he feels his heart rate speeding up." However, the provider found a graded exercise tolerance test was conducted that indicated no complaint of chest pain or diagnostic electrocardiogram change beyond the noted baseline. The treating provider also explained to the Veteran that the reported symptoms were "not describing what sounds like his angina" as the Veteran experienced these symptoms very infrequently and they were non-exertional in nature. In addition, in a November 2021 correspondence, the Veteran reported experiencing ongoing chest pain and an inability to perform law work or do much of anything due to frequent occurrences of shortness of breath, fatigue, dizziness, and lightheadedness throughout the appeal period. The Veteran is competent to report symptoms of IHD. See Layno v. Brown, 6 Vet. App. 465, 470 (1994): However, as documented above, the contemporaneous medical evidence, including the Veteran's statements made during treatment do not reflect the symptoms reported in November 2021. The Board finds the contemporaneous accounts of the Veteran's symptoms found in his treatment records and the February 2011 and April 2012 examinations are more competent and credible as to the severity of his IHD symptoms throughout the period on appeal than the November 2021 statement, which was made years later and in the context of seeking additional compensation. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (observing that statements made to physicians for the purposes of diagnosis and treatment are trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care); see also Caluza v. Brown, 7 Vet. App. 498 (1995). However, the Board finds that a 100 percent rating for IHD is warranted as of April 6, 2016. In this regard, the Veteran reported his symptoms had worsened and that he experiences shortness of breath when walking upstairs or doing anything during the Board hearing held on such date. In addition, the examination conducted on August 2, 2017 confirmed that he experiences IHD symptoms indicative of a 100 percent rating. There is no evidence indicating diagnostic findings or symptoms indicative of a rating in excess of 30 percent prior to April 6, 2016 or the onset of diagnostic findings or symptoms indicative of a 100 percent between April 6, 2016 and the August 2017 examination. Therefore, April 6, 2016 is the first date where the evidence indicates that the Veteran experienced IHD resulting in a workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope. See Swain, 27 Vet. App. at 219. In sum, the preponderance of the evidence shows that the Veteran's IHD, from May 21, 2007 to November 14, 2010, did not result in a workload of 7 METs or less; more than one episode of acute congestive heart failure in a year; left ventricular dysfunction with an ejection fraction of 50 percent or less; chronic congestive heart failure; or the presence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram or X-ray; from November 15, 2010 to April 5, 2016, did not result in a workload of 5 METs or less; more than one episode of acute congestive heart failure in a year; left ventricular dysfunction with an ejection fraction of 50 percent or less; or chronic congestive heart failure; and since April 6, 2016, has resulted in a workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope. Therefore, as there is no reasonable doubt to be resolved, a 100 percent rating for IHD is warranted as of April 6, 2016, but additional higher ratings are not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Although the Board is remanding another claim for additional development, remand is not necessary for this issue, as there is no reasonable possibility that further assistance would substantiate the claim. See 38 C.F.R. § 3.159(d). II. A TDIU 2. Entitlement to a TDIU on an extraschedular basis prior to May 5, 2010. Legal Criteria Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability, such disability shall be ratable as 60 percent or more, and if there are two or more disabilities, there shall 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). For the purpose of meeting these schedular criteria, disabilities affecting a single body system, e.g. orthopedic, will be considered as one disability. Id. When the criteria under 38 C.F.R. § 4.16(a) are not met, entitlement to a TDIU on an extraschedular basis may be considered when the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. 38 C.F.R. § 4.16(b). The Board does not have the authority to assign an extraschedular TDIU in the first instance. Bowling v. Principi, 15 Vet. App. 1 (2001). Rating boards will refer to the Director of the Compensation Service for extra-schedular consideration all cases of veterans who 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 adjudicating this question, the Board is permitted to exercise jurisdiction over the question and gives no deference to Director's adjudication. See Kuppamala v. McDonald, 27 Vet. App. 447 (2015) (applying principles announced in Wages to 38 C.F.R. § 3.321(b) extraschedular adjudication, namely, Director of C&P decision is not evidence, and is not a policy decision, but is simply a decision or adjudication that is adopted by the RO and reviewed de novo by the Board). Cf. Wages, 27 Vet. App. 233 (holding that a decision of TDIU under 38 C.F.R. § 4.16(b) by the Director of C&P is not evidence, and is not a policy decision, but is simply a decision or adjudication that is adopted by the RO and reviewed de novo by the Board). Here, the central inquiry is whether the Veteran's service-connected disabilities, alone, are of sufficient severity to preclude him from obtaining and maintaining all forms of substantially gainful employment. See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). In determining whether a veteran can secure and follow a substantially gainful occupation, attention must be given to: The veteran's history, education, skill, and training; Whether the veteran has the physical ability (both exertional and nonexertional) to perform the type of activities (e.g., sedentary, light, medium, heavy, or very heavy) required by the occupation at issue. Factors that may be relevant include, but are not limited to, the veteran's limitations, if any, concerning lifting, bending, sitting, standing, walking, climbing, grasping, typing, and reaching, as well as auditory and visual limitations; and Whether the veteran has the mental ability to perform the activities required by the occupation at issue. Factors that may be relevant include, but are not limited to, the veteran's limitations, if any, concerning memory, concentration, ability to adapt to change, handle workplace stress, get along with coworkers, and demonstrate reliability and productivity. Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). Substantially gainful employment is defined as work which is more than marginal and which permits the individual to earn a living wage. Moore v. Derwinski, 1 Vet. App. 356 (1991). Substantially gainful employment does not include marginal employment, which is generally deemed to exist when a veteran's earned annual income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Marginal employment may also be held to exist on facts found basis, including but not limited to employment in a protected environment such as family business or sheltered workshop, when earned annual income exceeds the poverty threshold. 38 C.F.R. § 4.16(a); see also Ortiz-Valles v. McDonald, 28 Vet. App. 65, 71 (2016) ("[T]he only logical reading of the regulation compels the conclusion that a veteran might be found unable to secure or follow a substantially gainful occupation when the evidence demonstrates that he or she cannot secure or follow an occupation capable of producing income that is more than marginal-i.e., with income that exceeds the amount published by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person."). In Faust v. West, 13 Vet. App. 342 (2000), the Court defined "substantially gainful employment" as an occupation that provides an annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days that the Veteran actually works and without regard to the veteran's earned annual income. More recently, the Court clarified that the phrase "unable to secure and follow a substantially gainful occupation" in § 4.16(b) has both an economic component and a non-economic component. Ray, 31 Vet. App. at 73. As it relates to the Veteran's history of self-employment, the Board notes that employment in a protected environment such as a family business or sheltered workshop may be considered marginal employment on a facts found basis. 38 C.F.R. § 4.16(a). Additionally, under 38 C.F.R. § 4.16(a), marginal employment shall not be considered substantially gainful employment. The term "protected environment" is not defined in VA regulation, but requires consideration of the particular facts of each Veteran's case. Cantrell v. Shulkin, 28 Vet. App. 382, 390 (2017). Analysis The Veteran asserts entitlement to a TDIU prior to May 5, 2010 on an extraschedular basis due to the combined effects of his service-connected disabilities. In a November 2010 TDIU claim form, he reported that he is unable to work due to PTSD, a sinus condition, and headaches. The Board notes that a January 2013 rating decision awarded schedular TDIU effective May 5, 2010. Prior to May 5, 2010, the Veteran was service connected for PTSD evaluated at 50 percent effective July 26, 2005; IHD evaluated at 10 percent since May 21, 2007; post-operative deviated septum with deformity post-nasal drip evaluated at 10 percent effective since July 1, 1977; and seventh rib, post-operative donor partial resection, evaluated as noncompensable. Here, the Veteran's service-connected disabilities prior to May 5, 2010 did not meet the schedular criteria during the appeal period since the combined rating was at 60 percent and there was no single disability rated at 60 percent. Nevertheless, even when the percentage requirements of 38 C.F.R. § 4.16(a) are not met, individual unemployability benefits may be granted on an extraschedular basis in exceptional cases when the veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disability. 38 C.F.R. § 4.16 (b). VA referred the appeal to the Director of Compensation and Pensions Services for administrative review for extra-schedular consideration. In May 2020, the Director of Compensation and Pension Service issued an advisory opinion. The Director found the preponderance of the medical evidence of record did not support that the Veteran's service-connected disabilities were of such severity to preclude him from the ability to perform activities consistent with gainful employment in both a physical and sedentary nature. The Director noted the Veteran's PTSD, his most significant disability, was not shown by examinations to cause him to be unable to pursue or follow gainful employment. While the Veteran's service-connected disabilities did result in impairment to his overall functioning, the Director found that the preponderance of the evidence did not show gainful employment was precluded due to the Veteran's service-connected conditions prior to May 5, 2010. Review of the medical treatment record shows in November 2004 the Veteran reported that he retired from the Post Office three years ago. The Veteran stated that he worked for 30 years as a windows clerk and noted the job as stressful. The Veteran further reported that he currently does real estate work but he "gets tired of that real fast." In November 2005, the Veteran stated that he planned to retire from his real estate job soon. In April 2006, the Veteran reported that he continued to sell real estate, but that he has not done so in the past 6 months. In July 2006, the Veteran stated he planned to quit working in real estate all together. In November 2006, the Veteran stated that he retired 5 years ago but since then he was hired and quit jobs in real estate and a car business because he "didn't like either one." At the Veteran's June 2010 VA examination for PTSD, the Veteran reported a work history as a postal worker for 30 years. The Veteran stated that he retired in 2005 and described his reasons for retirement as due to becoming age eligible and duration of work. The Veteran reported that he was currently not working. In the Veteran's October 2010 application for increased compensation based on unemployability, the Veteran reported working for the postal service from 1973 to 2005 and claimed his PTSD and sinus headaches prevented him from obtaining and maintaining gainful employment. The Veteran stated that he left his job with the Post Office due to headaches. The Board notes the October 2010 questionnaire from the Veteran's treating VA psychiatrist found the Veteran would not have been able to function in a work setting due to severe occupational social and interpersonal limitations; that his limitations would result in absences occurring at least 3 or more times a month; and that such symptoms appeared in early 2005. The psychiatrist found the Veteran to be markedly limited in his ability to remember locations and procedures; maintain attention and concentration for extended periods; maintain regular attendance; work in close proximity to others without distraction; complete a workweek without limitation; accept instruction and criticism from supervisors; get along with co-workers; respond to changes in the workplace; and set goals or make plans independently. The Board finds that a TDIU is warranted on an extraschedular basis due to the combined effects of his disabilities. In this regard, the Veteran's treating psychiatrist found that he has been unable to work since 2005. This is highly credible evidence as this treatment provider is the best independent evaluator as to whether the Veteran was prevented from securing and maintaining substantially gainful employment due to PTSD. While the evidence shows that the Veteran attempted to work in real estate and, presumably, car sales, at points during the appeal period, there is no evidence indicating either position constituted more than marginal employment. Both fields by their nature have highly commission based income structures. The evidence indicates that the Veteran was not successful at either, so it is highly unlikely that either position constituted more than marginal employment. To the extent that the Veteran's PTSD did not prevent him from performing unskilled manual labor, such as performing landscaping or custodial work, his service-connected deviated septum with related headaches and IHD would have prevented him from working in such fields. As the evidence shows that, throughout the appeal period, the combined effects of the Veteran's service-connected disabilities have prevented him from securing and following substantially gainful employment, a TDIU on an extraschedular basis is warranted. III. SMC 3. SMC at the housebound rate prior to August 2, 2017. Legal Criteria SMC is payable where the Veteran has a single service-connected disability rated as 100 percent and (1) has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). Analysis The Veteran is currently assigned SMC at the housebound rate as of August 2, 2017 based on a 100 percent rating for IHD and additional service-connected disabilities independently ratable at 60 percent or higher since such date. The issue of an earlier effective date for these SMC benefits is before the Board. In this regard, VA has a "well-established" duty to maximize a claimant's benefits. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); see also Bradley v. Peake, 22 Vet. App. 280 (2008) (finding that SMC benefits are to be accorded when a Veteran becomes eligible without need for a separate claim). As granted herein, the Veteran is now rated 100 percent as of April 6, 2016 for IHD and he also has additional service-connected disabilities independently ratable at 60 percent or higher since such date. Thus, SMC based on housebound is warranted as of the earlier date. However, the Veteran has not claimed and the evidence does not indicate that he has been permanently housebound due to service-connected disabilities prior to April 6, 2016. Therefore, SMC at the housebound rate is warranted since April 6, 2016, but the benefit-of-the-doubt doctrine is not applicable and SMC prior to such date is not warranted. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Although the Board is remanding other claims for additional development, remand is not necessary for this issue, as there is no reasonable possibility that further assistance would substantiate the claim. See 38 C.F.R. § 3.159(d). REASONS FOR REMAND Entitlement to an increased evaluation in excess of 70 percent for PTSD for the period since May 5, 2010. The most recent VA PTSD examination was held in August 2017. The most recent medical records associated with the case file regarding his PTSD are from December 2019. A June 2019 psychiatry note indicates that the Veteran had an increase in anxiety. Given that it is the Veteran's contention that he is entitled to an increased rating for his PTSD due to the condition worsening, and medical evidence indicates worsening anxiety, the Veteran is entitled to a current VA PTSD examination to assess his current level of disability. See Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (VA has a duty to provide the Veteran with a thorough and contemporaneous medical examination); see also Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). This claim is REMANDED for the following action: Schedule the Veteran for a VA examination to assess the severity of the service-connected PTSD. DAVID JIMERFIELD Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Temple, 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.