Citation Nr: 21005706 Decision Date: 02/02/21 Archive Date: 02/02/21 DOCKET NO. 18-20 349 DATE: February 2, 2021 ORDER A higher rating in excess of 50 percent prior to January 12, 2016 for service connected posttraumatic stress disorder (PTSD) is denied. A higher rating in excess of 10 percent for right hand tendonitis is denied. A 10 percent rating for service-connected status post injury scar of the right hand is granted. A higher rating in excess of 10 percent for service-connected tinnitus is denied. Effective September 22, 2015, (exclusive of the period from January 12, 2016, until July 12, 2016), a total disability rating based on individual unemployability (TDIU), is granted. Effective September 22, 2015, entitlement to Educational Assistance Benefits under Chapter 35, Title 38 U.S. Code, also known as Dependents Educational Assistance (DEA) benefits, is granted. REMANDED A higher rating in excess of 70 percent for PTSD from July 12, 2016. Special monthly compensation (SMC) based on the need of aid and attendance. FINDINGS OF FACT 1. For the period prior to January 12, 2016, the symptoms of the Veteran’s PTSD have not more closely approximated occupational and social impairment with deficiencies in most areas. 2. The Veteran’s right hand tendonitis causes sharp pain inside the palm with limitation of motion, numbness, and weakness. 3. The Veteran’s status post injury scar manifesting from service-connected right hand disability is painful. 4. The Veteran’s tinnitus is currently rated at 10 percent, which is the highest schedular rating available. 5. Effective September 22, 2015 (exclusive of the period from January 12, 2016, until July 12, 2016), the combined effect of the Veteran’s service-connected disabilities rendered him unable to secure or maintain substantially gainful employment. 6. The Veteran has been found to have a permanent and total evaluation due to service-connected disabilities effective September 22, 2015. Accordingly, entitlement to DEA benefits under Chapter 35 is established from that date. CONCLUSIONS OF LAW 1. The criteria for a higher rating in excess of 50 percent for PTSD prior to January 12, 2016, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 3.102, 4.3, 4.7, 4.130, Diagnostic Code (DC) 9411. 2. The criteria for a higher rating in excess of 10 percent for right hand tendonitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.59, 4.71a, DC 5229. 3. The criteria for a 10 percent disability rating for status post injury scar of the right hand are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.118, DC 7804. 4. The criteria for a rating in excess of 10 percent for tinnitus have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.87, DC 6260. 5. The criteria for a TDIU from September 22, 2015 (exclusive of the period from January 12. 2016 until July 12, 2016) are met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.16, 20.302. 6. The criteria for entitlement to DEA benefits under Chapter 35, from September 22, 2015, are met. 38 U.S.C. §§ 3500, 3501, 3510, 5113; 38 C.F.R. § 3.807. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 2003 to September 2005. The case is on appeal from August 2016 and December 2017 rating decisions. The case was most recently before the Board in June 2019. At that time, the Board granted a partial 30 percent rating for the Veteran’s nephrolithiasis for the period from September 17, 2013 to September 16, 2014, and denied an evaluation in excess of 30 percent from September 17, 2014. In a June 2020 rating decision, the RO implemented the Board’s partial grant. The record does not reflect that the Veteran appealed the Board’s June 2019 decision to the United States Court of Appeal for Veterans Claims (Court) within 120 days, and the decision is now final. See 38 U.S.C. § 7266; 38 C.F.R. § 20.1100. Accordingly, the issues are no longer on appeal. The Board’s June 2019 decision also remanded the issue of higher ratings for PTSD. The August 2016 rating decision increased the Veteran’s PTSD rating from 30 percent to 50 percent effective September 16, 2014, granted an evaluation of 100 percent from January 12, 2016, and then assigned an evaluation of 70 percent from July 12, 2016. The December 2017 rating decision granted TDIU and DEA benefits effective June 13, 2017, which was within one year prior to the Veteran’s August 2017 application for a TDIU. See 38 U.S.C. § 5110(b)(3). However, the Board notes that the Veteran attributed his unemployability, in part, to his PTSD and associated symptoms. See August 7, 2017 Notice of Disagreement (NOD). Therefore, the Board finds that the issue of a TDIU is part and parcel of the Veteran’s June 2016 (see also September 22, 2015 intent to file) increased rating claim for PTSD pursuant to Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). Additional lay evidence received in support of the present appeal suggests that the Veteran’s service-connected disabilities, particularly his kidney disorder, his PTSD, and their respective symptoms render the Veteran in continuous need of aid and assistance from his spouse, to include to perform activities of daily living (ADLs). See August 7, 2017 Veteran’s sworn statement; and October 27, 2020 spouse’s sworn statement and attorney’s brief. Thus, the Board finds that the issue of entitlement to SMC on the basis of aid and attendance has been raised by the record and it is, therefore, part and parcel of the increase rating claim for PTSD. See Payne v. Wilkie, 31 Vet. App. 373 (2019); see also Bradley v. Peake, 22 Vet. App. 280, 294 (2008). In October 2020, and following the most recent supplemental statement of the case (SSOC), the Veteran’s representative submitted additional evidence. The Veteran’s representative waived initial RO consideration of the additional evidence. See October 27, 2020 brief; See 38 C.F.R. § 20.1304(c). The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion 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). Increased Ratings General 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. 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. PTSD Ratings Legal Criteria VA evaluates PTSD under the General Rating Formula for Mental Disorders provided in 38 C.F.R. § 4.130, DC 9411. Under that DC: A 10 percent rating is assigned when there is occupational and social impairment due to mild and transient symptoms which decrease work efficiency and ability to perform occupational tasks only during episodes of significant stress, or symptoms controlled by continuous medication. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). A 50 percent rating is assigned when symptoms such 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; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is warranted where there is occupational and social impairment with deficiencies in most areas, including work, school, family relationships, judgment, thinking or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. A 100 percent is warranted where there is 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; memory loss for names of close relatives, own occupation, or own name. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific evaluation. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). See also Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013) (explaining that the symptoms that could give rise to a given rating are those in like kind, i.e., of similar duration, severity, and frequency, to those provided in the non-exhaustive lists). Ultimately, a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time based on the facts found—a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 1. A higher rating for PTSD in excess of 50 percent for the period prior to January 12, 2016. Analysis As an initial matter, the Board notes that the Veteran was awarded a 100 percent rating evaluation for his PTSD for the period between January 12, 2016 to July 12, 2016. The Board will not interfere with such determination and will only proceed to adjudicate the periods prior to January 12, 2016. The period from July 12, 2016 will be address in the remand portion of this decision. Through his procedural appeal documents and statements, the Veteran contends that a higher rating in excess of 50 percent prior to January 12, 2016, is warranted for his PTSD. The Board has considered the Veteran’s statements, the relevant treatment records, the January 2016 Disability Benefits Questionnaire (DBQ), VA examinations afforded in September 2014, July 2016, September 2017, and the October 2020 private Vocational Assessment. After engaging in a holistic analysis assessing the severity, frequency and duration of the signs and symptoms of the Veteran’s PTSD, recognizing that the symptoms listed in the rating criteria are non-exhaustive examples and when looking at the effects determining the impairment level, the Board finds that for the period prior to January 12, 2016, the PTSD manifested as no worse than occupational and social impairment with reduced reliability and productivity. That level of impairment is contemplated by the already assigned 50 percent rating, which includes depressed, chronic sleep impairment, anxiety, short term memory loss, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The next highest 70 percent level is not approximated since occupational and social impairment with deficiencies in most areas, or worse, has not been found or shown within that specific period. See Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); Mauerhan, 16 Vet. App. 436, 442; see also Vazquez-Claudio, 713 F.3d 112, 117. As a preliminary matter, the Board notes that in September 2015, the Veteran submitted a VA Form 21-0966 (Intent to File). Within one year, the Veteran filed his complete increase rating claim, in part, for his PTSD. See June 20, 2016 VA Form 21-526EZ. The Board will consider the Veteran’s claim in light of the evidence corresponding to the appeal period, in this case, from September 2015, or within one years prior to such date if the evidence reflects that it is factually ascertainable that an increase in the severity of his disability warrants a higher rating. See 38 U.S.C. § 5110. Per the Veteran’s request, in September 2014 a PTSD DBQ was completed by a VA mental health provider at the Washington D.C. Veterans Administration Medical Center (VAMC). The VA provider noted that the Veteran had 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. That level of impairment actually corresponds to a 30 percent rating. The Veteran reported symptoms such as avoidance of trauma related stimuli, hyperarousal, sad mood, low energy, poor appetite, guilt, short-term memory problems, anhedonia, isolation, feelings of detachment and estrangement from others, hypervigilance, exaggerated startle response, problems with concentration and short-term memory, depressed mood, anxiety, chronic sleep impairment, nightmares, irritability, anger, disturbances of motivation and mood, difficulty adapting to stressful circumstances, including work or a worklike setting. The Veteran denied the presence of panic attacks, suicidal ideation, or homicidal ideation. He further noted that his mood was “pretty good,” energy levels were fair, there were no feelings of helplessness, though some feeling of hopelessness regarding his work. The Veteran also indicated that while he experienced in the past periods of depression that could last for weeks, “he could not remember the last time he experienced these symptoms.” This characterization of the level of impairment more nearly approximates the criteria required for a 50 percent rating. VA treatment records for the period in question reflect that in October 2014, the Veteran denied any depressed mood or loss of interest, nor was there any guilty feelings or suicidal ideation. See October 15, 2014 mental health note. The VA provider noted that while the Veteran reported a few traumatic experiences during service, which, in turn, caused occasional flashbacks, “they are not disturbing” and he has developed coping mechanisms. Per a December 2014 psychiatry outpatient note, the Veteran reported he was in a good mood and was improving productivity as a result of his medication. See December 11, 2014 psychiatry note. During an April 15, 2015 mental health follow up, the Veteran reported that he gets startled easily, but denied nightmares and indicated that his energy and sleep are good. The Veteran indicated that his PTSD “is controlled now.” See April 15, 2015 mental health note. Thereafter, in September 2015, the Veteran reported his symptoms were more active as he was experiencing depressed mood, decreased concentration, insomnia, nightmares once a week, hypervigilance, anxiety, and was on guard. Per a subsequent Veteran’s request, on January 12, 2016, a second PTSD DBQ was completed by a VA mental health provider at the D.C. VAMC. This time, the VA provider noted that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgement, thinking and/or mood. The VA provider acknowledged symptoms such as depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, impairment of short and long term memory, memory loss for names or close relatives, own occupation or own name, flattened affect, circumstantial, circumlocutory speech, speech intermittently illogical, obscure or irrelevant, difficulty in understanding complex commands, impaired judgment, impaired abstract thinking, disturbances of motivation and mood, difficulty in establishing and maintaining effective work or social relationships, difficulty adapting to stressful circumstances, including work or a worklike setting, inability to establish and maintain effective relationships, suicidal ideation, obsessional rituals which interfere with routine activities, impaired impulse control, such as unprovoked irritability with periods of violence, spatial disorientation and disorientation to time or place. In light of the foregoing, in a December 2017 rating decision, the RO granted a 100 percent rating evaluation effective January 12, 2016, date on which an increase in the severity of the Veteran’s PTSD was factually ascertainable. In the October 2020 brief, the Veteran’s attorney representative indicated that a 70 percent rating is warranted as such rating is supported by the medical evidence of record. The representative specifically pointed out that in a December 29, 2010 VA neuropsychology note the Veteran reported chronic sleep impairment, difficulty concentrating, exhibited irritability, and had suicidal ideation. He also indicated that, as shown by the September 16, 2014 PTSD DBQ, the Veteran was experiencing sad mood, low energy, sleep disturbances, social isolation, anger, depression, nightmares, short term memory problems, irritability, startled response, and hypervigilance. See Brief at p.11-12. As previously noted, a Veteran may experience multiple distinct degrees of disability that might result in different levels of compensation. As such, separate ratings can be assigned for separate periods of time based on the facts found. See Fenderson, 12 Vet. App. 119; see also Hart, 21 Vet. App. 505. First, while the December 2010 neuropsychology note made reference to some irritability and anger problems, the examination report does not suggest that such symptoms are the result of an impaired impulse control with unprovoked irritability. Moreover, the foregoing evidence does not correspond to the period herein decided and the more contemporaneous medical evidence of record confirms a different level of severity. With respect to the representative’s arguments regarding the symptoms noted during the September 2014 PTSD DBQ, the VA provider indeed noted the presence of some anger and irritability. Nevertheless, the Veteran self-indicated that his mood was “pretty good” with fair energy levels, no feelings of helplessness, though some feeling of hopelessness, however, with respect to his occupational capabilities. Such statements as to the severity of his PTSD are well supported by the contemporaneous VA treatment records for this particular period. The Board has weighed all the evidence and, after considering it as a whole, finds that the severity level of the Veteran’s PTSD symptoms for the period in question more nearly approximate the criteria for a 50 percent disability rating. That level of impairment contemplates symptoms such as short-term memory problems and difficulty adapting to stressful circumstances, including work or a worklike setting. In light of the foregoing, and considering the other evidence of record, the frequency and severity of the manifestations of the Veteran’s PTSD for the period prior to January 12, 2016, have resulted in impairment equating to no more than the currently assigned 50 percent level. The Board notes that neither the September 2014 PTSD DBQ nor the VA treatment records for this period include findings of symptoms such as poor judgement or thinking due to suicidal ideations, illogical, obscure, or irrelevant speech, inability to function independently, spatial disorientation, or neglect of personal appearance and hygiene; symptoms that more nearly approximate the criteria for a higher 70 percent. Nor were the identified symptoms of such severity, frequency, or duration to more nearly approximate the criteria for a higher 70 percent. In reaching the above determination, the Board has considered that when determining when an increase is “factually ascertainable” all the evidence of record, including the testimonial evidence and expert medical opinions and the fact that it is the information in a medical opinion, and not the date the medical opinion was provided, is what is relevant when assigning an effective date. See McGrath v. Gober, 14 Vet. App. 28, 35-36 (2000); VAOPGCPREC 12-98; see also Tatum v. Shinseki, 24 Vet. App. 139, 145 (2010); and Young v. McDonald, 766 F.3d 1348 (Fed. Cir. 2014). However, in the present case the probative medical evidence corresponding to this period herein discussed, which is mostly represented by the Veteran’s VA treatment records, reflects that prior to January 12, 2016, his PTSD symptoms did not warrant a higher rating in excess of 50 percent during the relevant rating period on appeal. As the preponderance of the evidence is against the claim through this period, the benefit-of-the-doubt doctrine is not applicable, and prior to January 12, 2016, a higher rating in excess of 50 percent for service-connected PTSD and associated symptoms is 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). 2. A higher rating in excess of 10 percent for right hand tendonitis. Specific Legal Criteria The Veteran’s right hand tendonitis is rated by analogy under the provisions set forth in 38 C.F.R. § 4.71a, DC 5229. Under that DC, a noncompensable rating is warranted when there is limitation of motion if the index or long finger with a gap of less than one inch (2.5 cm) between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or; with extension limited by more than 30 degrees. A maximum 10 percent rating is warranted for both the major and minor fingers when there is limitation of motion of the index or long finger with a gap of one inch (2.5 cm) between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or; or; with extension limited by more than 30 degrees. When an evaluation of a disability is based on limitation of motion, the Board must also consider, in conjunction with the otherwise applicable DC, any additional functional loss the veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Painful motion is entitled to at least the minimum compensable rating. 38 C.F.R. § 4.59; Sowers v. McDonald, 27 Vet. App. 472 (2016); Burton v. Shinseki, 25 Vet. App. 1 (2011); see also Southall-Norman v. McDonald, 28 Vet. App. 346, 352 (2016). Analysis The present claim stems from the August 2017 increase claim based on a TDIU, in which the Veteran indicated, in part, that his right hand tendonitis had worsened, precluding him from securing and maintaining substantially gainful employment. In a December 2017 rating decision, the RO increased the Veteran’s rating disability from noncompensable to a 10 percent rating on the basis of functional loss due to painful motion effective August 7, 2017, date on which the claim for increase was received. In an April 2018 NOD, the Veteran’s representative contended that a higher rating in excess of 10 percent is warranted from the earliest possible date. As to the earliest effective date, the Board notes that by a December 2009 rating decision, the RO granted service connection for right hand tendonitis and a noncompensable rating was assigned effective April 17, 2009, date on which the service connection claim was received. The Veteran did not initiate an appeal by filing a NOD within one year from the December 2009 rating decision and the decision became final. See 38 C.F.R. § 20.302. No additional evidence or claim was received until the present August 2017 claim for increase. In light of the foregoing, the Board finds that August 7, 2017, is the earliest possible date allowed by law, which in this case, is the date on which a claim for increased was received. See 38 C.F.R. § 3.400. Now turning to the higher rating contention, the Veteran was afforded a VA examination in connection with this claim in October 2017. At that time, the Veteran reported pain between his index finger and his thumb and that usage of the right hand results in pain inside the palm and on and around the tendon as well as causing the thumb and index fingers to go numb and become easily fatigued. The Veteran also reported that things like weather and stress can cause the injury to become painful. The Veteran also reported flare-ups are triggered by stress, usage, vibrations or sleeping on the hand. He indicated that pain requires ice and pain killers during flares. The Veteran also stated that using the hand for work and even for personal care is difficult. His right hand pain interferes with his use of a computer mouse and the keyboard for any extended periods of time causing pain that it is near impossible to write an entire paragraph. He cannot handle any duties that requires writing. The vibration from power tools are unbearable. The examination report reflects that there was normal range of motion in the fingers for both hands, including on repetition. However, pain was noted in the fingers of the right hand during flexion, extension and opposition with thumb. The examiner noted tenderness or pain on palpation of the right hand; however, that did not result in functional loss. The Veteran was able to perform repetitive use over time without additional functional loss. The VA examiner noted that on repetitive use over time, there was no evidence indicating that pain, weakness, fatigability, or incoordination significantly limited the Veteran’s functional ability. The Veteran’s hand grip strength was recorded as 5 out of 5 bilaterally. There was no ankylosis on any finger bilaterally. In sum, the VA examiner indicated that the claimed disability impacts his functional capacity. In light of the foregoing, in the December 2017 rating decision the RO increased the Veteran’s rating evaluation from noncompensable to a 10 percent rating. In the October 2020 brief, the Veteran’s attorney argued that the Veteran’s VA treatment records support a rating in excess of 10 percent. In support of his contention, the Veteran’s representative stated that the Veteran was not able to fully grasp objects and that once a month, the Veteran would experience right hand pain so severe that it prevented him from typing on a computer and could be exacerbated by touch as light as rubbing. See brief at p.5. In an October 2020 Vocational Assessment, Mr. F.F., RCR, indicated that the Veteran required the assistance and help from his wife to dress due to dominant right upper extremity limitations. See October 13, 2020 Vocational Assessment at p.33. With respect to the current evaluation, the Board notes that in this case, despite the absence of objective medical evidence showing limitation of motion of the index or long finger with a gap of one inch (2.5 cm) between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or; with extension limited by more than 30 degrees, the RO found the Veteran entitled to at least the minimum compensable rating under that DC due to painful motion pursuant to 38 C.F.R. § 4.59; Sowers, 27 Vet. App. 472; Burton, 25 Vet. App. 1; and Southall-Norman, 28 Vet. App. 346, 352. That is also the maximum schedular rating allowed for his right hand tendonitis under that DC and a higher schedular rating is not permissible. See Smith v. Nicholson, 451 F.3d 1344 (Fed. Cir. 2006). Accordingly, the Board has also considered whether referral to the Director of Compensation Service for extraschedular consideration is warranted pursuant to Thun v. Peake, 22 Vet. App. 111 (2008), aff’d sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). In Thun, the Court of Appeals for Veterans Claims (Court) held that there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. The first element requires the Board to determine whether the “evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate.” Id. This requires the Board to compare a veteran’s specific symptoms and their severity with those contemplated by the rating schedule. King v. Shulkin, 29 Vet. App. 174, 178-79 (2017). If the Board determines that a Veteran’s symptoms or their severity is not contemplated by the rating schedule, the second element requires the Board to “determine whether the claimant’s exceptional disability picture exhibits other related factors,” such as marked interference with employment or frequent periods of hospitalization. Thun, 22 Vet. App. at 116. Finally, if the first two elements are met, the final element mandates that the Board refer the claim to the Under Secretary for Benefits or the Director of Compensation Service for a determination about whether an extraschedular rating is warranted. Id. See also 38 C.F.R. § 3.321 (b). Here, the Board finds that the first Thun element is not satisfied for the claimed disability, described by the Veteran and his representative as easily-triggered severe right hand pain that causes the Veteran functional impairment. It is precisely because of such functional impairment that the RO found the Veteran entitled to at least the minimum rating pursuant to 38 C.F.R. § 4.59. Unlike some DCs, the provisions set forth in 38 C.F.R. § 4.59 do not explicitly include particular symptoms, but instead encompass any additional functional loss the veteran may have sustained by virtue of the painful motion. As such, 38 C.F.R. § 4.59 contemplates the entire range of impairment resulting from the Veteran’s functional loss due to pain. Moreover, the October 2017 notes indicating the presence of pain on motion; however, that does not result in, or cause functional loss is also supported by the VA treatment records for the appellate period in question as they reflect that, besides the Veteran’s sporadic complaints of right hand pain (e.g. see July 16, 2019 progress notes), he has not reported additional symptoms nor identified any unique or unusual symptoms during the pendency of the appeal to warrant referral for extraschedular consideration. See 38 C.F.R. § 3.21(b). For the reasons set forth above, the Board finds that the Veteran’s specific symptoms and their severity are contemplated by the currently assigned 10 percent rating. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against a higher rating on an extraschedular basis, that doctrine is inapplicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 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). 3. A compensable rating for status post injury scar of the right hand. Scars Legal Criteria Under DC 7804, a 10 percent rating is warranted for one or two scars that are unstable or painful. 38 C.F.R. § 4.118, DC 7804. Three or four scars that are unstable or painful scars warrants a 20 percent rating. Five or more scars that are unstable or painful warrants a 30 percent rating. 38 C.F.R. § 4.118. Note 1 to DC 7804 instructs that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note 2 states if one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Note 3 states scars evaluated under DCs 7800, 7801, 7802, or 7805 may also receive an evaluation under this DC, when applicable. In this case, the Veteran’s status post injury scar of the right hand is currently rated under DC 7805. Therefore, the provisions set forth in DC 7804 are applicable. Analysis The present appeal also stems from an August 2017 increase claim based on a TDIU, in which the Veteran indicated, in part, that his right hand scar contributed to his inability to secure and maintain substantially gainful employment. By a December 2017 rating decision, the RO granted a separate award of service connection for the Veteran’s status post injury scar of the right hand and a noncompensable rating was assigned effective April 17, 2009, the original date of the right hand disability award. Up to that time, the Veteran’s status post injury scar had been rated as part of his running award for his right hand tendonitis. The Veteran contends that his right hand scar warrants the “highest possible rating from the earliest possible date.” See April 19, 2018 NOD. The Veteran was initially afforded a VA examination in connection with his right hand disability in September 2009. At that time, the VA examiner noted the presence of a scar located on dorsum of right hand secondary to a 2003 injury while in service. The examiner further indicated that the scar measured 1 cm by 0.2 cm. The examination reports described the scar as not painful on examination, no skin breakdown, no underlying tissue damage, no inflammation, edema, nor keloid formation. It was further noted that the scar is not disfiguring and that it does not contribute to limitation of motion or function. Per the Veteran’s request, a Scars and Disfigurement Disability Benefits Questionnaire (DBQ) was completed by Dr. P.G.R., the Veteran’s VA provider at the D.C. VAMC. The VA provider noted that during active duty, the Veteran had a six-inch knife penetrate his right dorsal surface of the hand resulting in a puncture wound requiring sutures on site that later dissolved. The Veteran reported sensitivity to touch over the scar and pain that is sharp-lighting like. The VA provider described the Veteran’s scar as a painful linear scar. Thereafter, the Veteran was afforded a VA examination in connection with the present claim in October 2017. The Veteran reported that the usage of the hand resulted in pain inside of the palm on and around the tendon as well as severe sensitivity to touch of the skin surrounding the scar. The examination report indicates that, even without using the hand, things like the weather and stress can cause the injury to become painful, and that these problems have remained the same since the injury. It was further noted that it has become increasingly difficult to suppress the pain and impairment of the injury. Nonetheless, the VA examiner later noted that the Veteran’s scar was neither painful nor unstable. The Board finds that the evidence is at least in equipoise regarding whether a compensable rating for a right hand scar is warranted. In this regard, the Veteran has competently reported experiencing pain in relation to his right hand scar, including in the reports made to his VA provider in September 2014 and during his October 2017 VA examination. While the September 2009 and October 2017 VA examiners reported there was no presence of scar pain, “objective” medical evidence is not categorically necessary to award this benefit. See, e.g., English v. Wilkie, 30 Vet. App. 347 (2018). The Board finds the Veteran’s “subjective” lay statements credible as he has not only consistently reported a painful scar, but this was also acknowledged by the September 2014 VA provider and noted by the October 2017 VA examiner. The Veteran is in the best position and situation of knowing whether the scar is painful. Thus, when resolving reasonable doubt in the Veteran’s favor, the Board finds that his status post injury scar from his right hand disability is painful. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Accordingly, a 10 percent rating is warranted for the scar under DC 7804. Although a 10 percent rating is warranted for the painful scar, an even higher rating is not warranted as the evidence does not show at least three painful scars or that the existing scar is unstable as defined by Note 1 to DC 7804. 4. A higher rating in excess of 10 percent for tinnitus. The Veteran’s tinnitus is currently rated under 38 C.F.R. § 4.87, DC 6260. The applicable rating schedule directs that recurrent tinnitus, whether the sound is perceived in one ear, both ears, or in the head, will be assigned a single 10 percent evaluation. See 38 C.F.R. § 4.87. The Board notes that by a March 2010 rating decision, the RO granted service connection for bilateral tinnitus with a 10 percent disability rating effective April 17, 2009, the date on which the service connection claim was received. The Veteran did not initiate an appeal by filing a NOD within one year from the March 2010 rating decision, and the decision became final. See 38 C.F.R. § 20.302. With respect to the current evaluation, the Veteran is assigned the maximum schedular rating for tinnitus. Thus, a higher schedular rating is not permissible. See Smith v. Nicholson, 451 F.3d 1344 (Fed. Cir. 2006). There are no other contentions for this claim identifying any unique or unusual symptoms to warrant referral for extraschedular consideration. See 38 C.F.R. § 3.21(b). The evidence of record points to symptoms which are fully contemplated by DC 6260. In reaching the above-stated conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against a higher schedular rating or an extraschedular rating, that doctrine is inapplicable. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Therefore, a higher rating in excess of 10 percent for tinnitus is not warranted. 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). 5. TDIU prior to June 13, 2017. 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). Marginal employment shall not be considered substantially gainful employment. In Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009), the Court indicated that a claim for a TDIU is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities, either as part of the initial adjudication of a claim or, if a disability upon which entitlement to TDIU is based has already been found to be service connected, as part of a claim for increased compensation. The distinction between the two is important for purposes of assigning an effective date for an award of compensation. Marginal employment is not considered substantially gainful employment and is 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 also may be held to exist on a facts-found basis when earned annual income exceeds the poverty threshold. Such situations may include, but are not limited to, employment in a protected environment such as a family business or sheltered workshop. 38 C.F.R. § 4.16(a); see Ortiz-Valles v. McDonald, 28 Vet. App. 65 (2016); Cantrell v. Shulkin, 28 Vet. App. 382 (2017). 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). Procedural Background At the outset, the Board notes that a TDIU is in effect from June 13, 2017. The Veteran contends that a TDIU is warranted for the period prior to that date as the aggregate effect of his service-connected PTSD, kidney disorder, right hand tendonitis, and tinnitus have precluded him from securing or maintaining substantially gainful employment ever since 2009. As previously noted, the present claim stems from a September 22, 2015 intent to file, later substantiated by a June 20, 2016 formal increase rating claim, in part, for a higher rating for PTSD. From January 12, 2016 to July 12, 2016, the Veteran had been granted a 100 percent schedular rating solely based on his service-connected PTSD. The Board notes that the presence of a schedular 100 percent disability rating does not necessarily render the issue of TDIU moot.  See Bradley, 22 Vet. App. 280, 293-94 (holding that 100 percent evaluation does not render a TDIU claim moot where there is a possibility that TDIU will impact entitlement to special monthly compensation (SMC) based on receipt of service connection for a disability with a 100 percent rating and another with a separate 60 percent rating). See also 38 C.F.R. § 3.350(i) (laying out the required criteria for SMC at the housebound rate). In this case, however, while the Veteran had a single disability rated at 100 from January 12, 2016 to July 12, 2016, he did not have an additional disability independently rated at 60 percent, nor, does he allege that any single disability alone rendered him unable to work. Rather, the Veteran and his representative’s contention has been that the combined effect of his service-connected disabilities renders him unemployable and that SMC is warranted; but at the aid and attendance rate and, therefore, under the facts of this case, his 100 percent schedular combined disability rating, exclusively for the period between January 12, 2016 to July 12, 2016, does render his TDIU claim moot for that period. Thus, the issue has been appropriately recharacterized above. Analysis The question for the Board is whether the Veteran’s service-connected disabilities precluded him from securing or maintaining substantial gainful employment at any time prior to June 13, 2017, exclusive of the period from January 12, 2016 to July 12, 2016. The Veteran has a combined rating evaluation of 70 percent effective September 16, 2014, with at least one disability rated a 40 percent or more; a 100 percent rating from January 12, 2016 to July 12, 2016; and 80 percent combined rating evaluation effective July 12, 2016, with at least one disability rated at 40 percent or more. For purposes of the present appeal, from September 22, 2015, the Veteran is service-connected for posttraumatic stress disorder (PTSD) rated at 50 percent until January 12, 2016, 100 percent from January 12, 2016 to July 12, 2016, and 70 percent thereafter; nephrolithiasis rated at 30 percent; tinnitus rated at 10 percent; right hand tendonitis rated at 10 percent; and right hand scar now rated at 10 percent. Accordingly, the criteria for a TDIU on a schedular basis is met for the period in question. See 38 C.F.R. § 4.16(a). In an August 2017 VA Form 21-8940 (Application for Increased Compensation Based on Individual Unemployability), the Veteran reported last working full-time as an I.T. manager in June 2008, as the effects of his service-connected PTSD, nephrolithiasis, and right hand tendonitis precluded him from securing or maintaining gainful employment. As for his education, the Veteran indicated that it was limited to a two-year Microsoft Certification and that he has been enrolled at the North Virginia Community College since 2013 to present. As previously noted, a TDIU requires evidence that the Veteran is unable to pursue a substantially gainful occupation due to his service-connected disabilities. The Board has reviewed the evidence of record and, for the reasons set forth below, finds that from September 22, 2015 (exclusive of January 12, 2016 until July 12, 2016), the Veteran’s service-connected nephrolithiasis and associated symptoms, PTSD and associated symptoms, and the effects of his right hand tendonitis have precluded him from securing or following substantially gainful employment. With respect to the Veteran’s nephrolithiasis disability, VA treatment records reflect that in October 2015, the Veteran presented with multiple complaints of pain described as shooting and intermittent as a result of passing stones perineal pain. He reported symptoms of dysuria, frequency of urination, and swelling, with constipation and abdominal pain and lethargy. See October 10, 2015 Urology note. In December 4, 2015, the VA urologist indicated that the Veteran continued to experience lethargy and intermittent colic that interfered with his ability to work. An April 10, 2017 progress note reflects the Veteran continued to report painful, cloudy, and frequent urination with hesitancy. Per the Veteran’s request, a kidney conditions DBQ was completed in December 2015 by the Veteran’s VA attending urologist. The physician noted that the Veteran suffers from Recurrent Uric Acid Kidney Stones for which he is on continuous medication. The VA provider stated that the Veteran experiences lethargy, weakness, intermittent pain, and occasional attacks of colic as a result of his disability. The VA urologist indicated that the Veteran’s kidney condition impacts his ability to work as the Veteran is really concerned about the symptoms produced by his disability, such as anxiety, insomnia, intermittent renal colic, and severe pain. The Veteran was afforded a kidney conditions VA examination in July 2016. The examiner noted the Veteran experiences strained urination, blood, fatigue, back pain, painful voiding, and hesitation in urine. It was further noted that the condition has worsened over the years, as the Veteran is often in significant pain, is fatigued, is unable to control his bladder, and experiences painful hesitant urination, as well as pain in the bladder and kidneys that causes inability to get out of bed. In sum, the VA examiner opined that the Veteran’s kidney condition renders him unable to work due to frequency in kidney stones and abdominal pain, which, in turn, results in difficulty concentrating and focusing due to his pain. In an October 2020 private Vocational Assessment, Mr. F.F., CRC, indicated that prior to June 2017, the Veteran reported increased pain and lethargy which debilitated him, in turn, preventing him from completing tasks. The private counselor also noted that the Veteran’s pain made him unable to stand or ambulate due to overwhelming pain throughout his abdomen and flank, which required the Veteran to strictly rest for an undeterminable amount of time until the pain subsided and/or stones had passed. During the interview, the Veteran endorsed painful and frequent urination which required voiding at least once every 45 minutes. With respect to the Veteran’s PTSD, per the Veteran’s request, a PTSD DBQ was completed by a VA clinical psychologist in September 2014. The Board points out that while the date of the referenced DBQ is outside the appeal period, its contents are persuasive towards the remainder period on appeal. The report reflects that the Veteran had 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. The examiner, however, acknowledged symptoms such as hypervigilance, exaggerated startle response, problems with concentration, chronic sleep impairment, depressed mood, anxiety, disturbances of motivation and mood, and difficulty adapting to stressful circumstances, including work or a worklike setting that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The Veteran reported that he spent over 40 hours a week building a technology framework; however, it was on his own without remuneration. Per a subsequent request from the Veteran, in January 2016 a PTSD DBQ was completed by the Veteran’s VA attending psychiatrist at the D.C. VAMC. Dr. W.D. opined that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The VA provider noted that the Veteran worked well before his deployment to Iraq; however, since then it’s been “hard to function.” The report indicated that the Veteran has a history of speeding and reckless driving. The Veteran endorsed, and the examiner acknowledged, symptoms such as depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, impairment of short and long term memory, memory loss for names of close relatives, own occupation, or own name, flattened affect, circumstantial, circumlocutory speech, speech intermittently illogical, obscure or irrelevant, difficulty in understanding complex commands, impaired judgment, impaired abstract thinking, disturbances of motivation and mood, difficulty in establishing and maintaining effective work or social relationships, difficulty adapting to stressful circumstances, including work or a worklike setting, inability to establish and maintain effective relationships, suicidal ideation, obsessional rituals which interfere with routine activities, impaired impulse control, such as unprovoked irritability with periods of violence, spatial disorientation and disorientation to time or place. The report further indicates that the foregoing symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Thereafter, the Veteran was afforded a PTSD examination in July 2016. The report similarly reflects that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The Veteran reported he has not been working since 2014. The examiner acknowledged symptoms such as hypervigilance, exaggerated startle response, problems with concentration, chronic sleep impairment, depressed mood, anxiety, suspiciousness, mild memory loss, such as forgetting names, directions, impairment of short and long-term memory, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, suicidal ideation, and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. It was further noted that the veteran experiences emotional numbing, intrusive thoughts, avoidance, lack of interest, flashbacks and irritability. The VA examiner stated that these symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. In the October 2020 Vocational Assessment, Mr. F.F. indicated that the Veteran’s PTSD impairs his ability to function daily given his symptoms of hypervigilance, isolation tendency, general public avoidance due to suspiciousness, episodes of anger and irritability, flashbacks, panic attacks, impaired motivation, and a history of suicidal ideation. Specifically, the reviewing counselor noted that the Veteran’s chronic hypervigilance rendered him distracted and unable to concentrate, which, in turn, precludes him from focusing on a task due to his constant urge to be aware of his surroundings. Turning to the Veteran’s right hand tendonitis, the Veteran was afforded a VA examination in connection with this claim in October 2017. At that time, the Veteran reported pain between his index finger and his thumb, and that usage of the right hand resulted in pain inside the palm and on and around the tendon, as well as causing the thumb and index fingers to go numb and become easily fatigued. The Veteran also reported flare-ups are triggered by stress, usage, vibrations, or sleeping on the hand. The Veteran further stated that using the hand for work and even for personal care is difficult. His right hand pain interferes with his use of a computer mouse and the keyboard for any extended periods of time, causing pain that makes it near impossible to write an entire paragraph. He cannot handle any duties that requires writing. The vibration from power tools are unbearable. In the October 2020 brief, the Veteran’s attorney argued that the Veteran was not able to fully grasp objects, and that once a month the Veteran would experience right hand pain so severe that it prevented him from typing on a computer and could be exacerbated by touch as light as rubbing. In the October 2020 Vocational assessment, Mr. F.F. indicated that most sedentary jobs require the use of both upper extremities for repetitive tasks involving gross and fine manual dexterity, such as grasping, handling, and fine manipulation. However, in the Veteran’s case, the numbness, pain, and weakness in his dominant hand would at least as like as not limit his ability to perform tasks involving grasping and fine manipulation. In support of his opinion, Mr. F.F. cited to VA treatment records dated in August 2009 in which a VA provider noted that the Veteran’s pain travels to his thumb, and that his pain is described as sharp, exacerbated by physical activity and touch as light as rubbing. See private Vocational Assessment at p.22. Here, the Board notes the Veteran’s short 2-year post-service work experience appears to be limited to employment in the information technology field. There is no other indication in the record that the Veteran has any experience in, or the potential for, any other type of job, to include a non-physical one. As to the non economic component, the records reflect that ever since 2009, his disabilities progressed and interfered with his occupational and social functioning to a greater degree, particularly due to his chronic pain associated to his nephrolithiasis and PTSD and associated symptoms, as these eventually turned into a direct interference with his functional capacity. The Board has also considered the Veteran’s education, occupational field, and the effects and residuals of his right hand tendonitis over the performance of the necessary skills for such occupation. In conclusion, the Board notes that the overall impact of the Veteran’s service connected disabilities could reasonably result in poor focus and poor task completion in any type of work environment. According to Mr. F.F., the Vocational counselor, the Veteran’s right hand tendonitis and nephrolithiasis have precluded his ability to meet the physical demands of sedentary employment on a consistent and reliable basis since at least 2009, due to limitations in standing and walking when passing kidney stones or experiencing flank pain, and limitation with handling, grasping, and manipulating objects with the dominant right upper extremity. Moreover, this conclusion seems to be supported by the December 2015 and July 2016 VA examiners who, in general, indicated that the veteran’s kidney condition renders him unable to work due to frequency in kidney stones and abdominal pain, which, in turn, results in difficulty concentrating and focusing due to his pain. In addition, the October 2020 counselor also indicated that the PTSD symptomatology noted in the Veteran’s records render him unable to satisfy occupational standards such as adequate pace, productivity, reliability, or meet the communication requirements of a productive and professional workplace given the Veteran’s hypervigilance, isolation, panic attacks, and anger and irritability, among others. Here, the Board finds that the private counselor’s and VA examiner’s statements and opinions as to the aggregate effect of his right hand tendonitis, nephrolithiasis, and PTSD disabilities, and their respective associated symptoms, on his employability are sufficient and probative. As to the economic component, while the Veteran has reported that he worked over 40 hours a week building a technology framework (see September 2014 DBQ), he indicated that he was not being remunerated. This is supported by a Social Security Earning Statement received in August 2017, which reflects that the Veteran has not engaged in substantially gainful employment since 2009. See also July 2016 PTSD VA examination (The Veteran reported he has not been working since 2014). In sum, the issue of employability is not a medical issue but a legal one. See Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). Therefore, in light of the above, and after consideration of the Veteran’s individual circumstances, to include his education, training, and work history, the Board finds the combined severity of the Veteran’s service-connected disabilities have precluded him from securing or following a substantially gainful occupation as of September 22, 2015, the date the an intent to file was received with respect to the Veteran’s increase rating claim for PSTD. This is particularly so when reasonable doubt is resolved in the Veteran’s favor. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Consequently, effective September 22, 2015, but not earlier, a TDIU on a schedular basis is warranted. 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). 6. Entitlement to DEA benefits prior to June 13, 2017. Basic eligibility for Chapter 35 benefits for the child or surviving spouse of a veteran may be established if: (1) the veteran was discharged from service under conditions other than dishonorable, or died in service; and (2) the veteran has a permanent total service-connected disability; or (3) a permanent total service connected disability was in existence at the date of the veteran’s death; or (4) the veteran died as a result of a service-connected disability. 38 U.S.C. §§ 3500, 3501, 3510; 38 C.F.R. § 3.807. The Veteran contends that entitlement to an earlier effective date prior to June 13, 2017, for the award of DEA benefits under Ch. 35, is warranted as a TDIU was warranted prior to that date. As the Board has determined that a TDIU is warranted effective September 22, 2015, entitlement to DEA benefits from that date is warranted as well. For these reasons, DEA benefits from September 22, 2015 are granted. 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). REASONS FOR REMAND 1. A higher rating in excess of 70 percent for PTSD from July 12, 2016. Although the Veteran appears to have specified in his appeal and procedural documents that the rating sought for his service-connected PTSD was a 70 percent disability rating, he has not expressly shown an intent to exclude consideration of an even higher rating. See AB v. Brown, 6 Vet. App. 35, 39 (1993) (a claimant will generally be presumed to be seeking the maximum benefit allowed by law and regulation). The Board notes that the Veteran was last afforded a VA examination to ascertain the severity of his PTSD in July 2016. VA treatment records reflect that in July 2017, the Veteran reported feeling “better and stable.” See July 21, 2017 mental health progress notes. Shortly thereafter, the Veteran reported “going pretty good,” however, with occasional bouts of depression. See October 20, 2017 mental health progress notes. During a July 2019 VA Recreation Therapy and Leisure Assessment (RTLA), the Veteran reported difficulty with concentration, however, indicated that overall, he is being able to drive to his appointments and has the financial means to participate in desired leisure activities. The Veteran also described himself as an “outgoing person.” See July 15, 2019 VA RTLA report. Thereafter, during a July 2018 mental health visit, the Veteran indicated that he was “doing pretty good” besides his lack of energy. See July 10, 2018 psychiatric follow-up appointment. See also July 30, 2018 progress notes (the Veteran reports he is not in acute distress at the time and did not report suicidal or homicidal ideation, intention or plan); and October 2, 2018 mental status examination (the Veteran’s mood is stressed and anxious; however, his cognitive function is grossly intact, his affect is clam and reactive, his thought processes are sequential and goal directed, his insight/judgement is good, and denies suicidal, homicidal ideation, or perceptual disturbances). Nevertheless, in an August 2017 sworn statement, the Veteran indicated that his PTSD made it difficult for him to focus on things he works on and causes memory impairment. He further indicated that, historically, his PTSD makes him anxious, nervous, hypervigilant, stressed, exhausted, and sleep deprived. He also stated that he struggles with his mood, particularly his motivation and desire to do things, which, in turn, makes him feel depressed most of the days. Ultimately, the Veteran indicated that it can go weeks at a time when he is not being able to concentrate, that he has a lot of difficulty trying not to feel hopeless and has reoccurring suicidal thoughts. See August 7, 2017 Veteran’s Affidavit at p.1-2. In a separate sworn statement by the Veteran’s spouse received in October 2020, Mrs. K.H. indicated that she has witnessed the severity of her husband’s PTSD symptoms worsened throughout the years. To that effect, she testified as to witnessing her husband’s “spatial disorientation” as a result of his PTSD, as well as his long and short-term memory issues. She described the Veteran as “disoriented” and with memory issues. In addition, Mrs. K.H. stated that her husband “neglects his personal appearance and hygiene for which she always has to remind him to bathe, take care of himself, brush his teeth and dress up appropriately. Mrs. K.H. indicated that her husband’s PTSD causes him to spend an overwhelming majority of time at home, experiences anxiety attacks, cannot navigate through large crowds, and has trouble interacting with men. She further noted that his memory issues cause him to take double dosages of medication in error. Ultimately, the Veteran’s spouse indicated that the Veteran is in constant need of aid and attendance, in great part, as a result of his PTSD and associated symptoms. The criteria for a total occupational and social impairment under DC 9411 considers gross impairment in thought processes or communication, peristent delusion or hallucinations, grossly inappropriate behavior, disorientation to time and place, and memory loss for names, own occupation, or own name. Here, while the lay statements suggest a more severe picture of the Veteran’s PTSD, VA treatment records suggest otherwise. In light of the foregoing, and upon consideration of the time lapsed after the last PTSD VA examination, the Board finds that a remand is warranted to ascertain the current extent and severity of the Veteran’s PTSD, to include consideration of the evidence herein discussed. See Snuffer v. Gober, 10 Vet. App. 400 (1997). 2. SMC based on the need of aid and attendance. As previously noted, the issue of SMC on the basis of aid and attendance has been reasonably raised by the record as part and parcel of the increased rating claim for PTSD. See Payne, 31 Vet. App. 373; see also Bradley, 22 Vet. App. 280, 294. (VA’s duty to maximize a claimant’s benefits includes consideration of whether his disabilities establish entitlement to SMC under 38 U.S.C. § 1114). For the reasons set forth below, the Board notes that prior to deciding the claim on the merits further development is warranted. See Hodge v. West, 155 F.3d 1356, 1362-63 (Fed. Cir. 1998) (VA is to “fully and sympathetically develop the Veteran’s claim to its optimum before deciding it on the merits.”); Akles v. Derwinski, 1 Vet. App. 118, 121 (1991). In her October 2020 sworn statement, the Veteran’s spouse indicated that the severity of her husband’s PTSD symptoms includes “spatial disorientation” as well as long and short-term memory issues. She described the Veteran as “disoriented,” with memory issues, “neglects his personal appearance and hygiene for which she always has to remind him to bathe, take care of himself, brush his teeth and dress up appropriately. Mrs. K.H. indicated that her husband’s PTSD causes him to spend an overwhelming majority of time at home, experiences anxiety attacks, cannot navigate through large crowds, and has trouble interacting with men. She further noted that his memory issues cause him to take double dosages of medication in error. In sum, Mrs. K.H. asserted that her husband is in constant need of aid and attendance, in great part, as a result of his PTSD and associated symptoms. See also October 2020 attorney’s brief at p.9 (the Veteran is in need of aid and attendance from his wife given his PTSD-related spatial disorientation, memory problems and persistent danger to hurt self or others (e.g. forgetting the stove on for which his wife is afraid the Veteran could burn the house down). The Board finds that the issue of SMC on the basis of aid and attendance is not only intertwined with the increase rating claim for PTSD, but additionally further development is necessary to clarify the conflicting lay and medical evidence of record (e.g. reports of feeling better and stable (see July 2017 VA mental health progress note); going pretty good with occasional bouts of depression (see October 2017 VA mental health progress notes); and that the Veteran is able to drive to his VA appointments and participate in desired leisure activities (see July 2019 VA RTLA). In light of the above, the issue is remanded for further development and adjudication, to include a VA examination and opinion as to the extent and severity of the Veteran’s service-connected disabilities, and to clarify the extent of aid and assistance required for the Veteran’s ADLs. The aforementioned matters are REMANDED for the following action: 1. Obtain updated VA treatment records dated since February 2018. 2. Thereafter, schedule the Veteran for a VA psychiatric examination (or telehealth interview, records review, etc., if an in-person examination is not feasible) to assess the severity of his service-connected PTSD for the period from July 12, 2016. 3. Also, schedule the Veteran for a VA examination (or telehealth interview, records review, etc., if an in-person examination is not feasible) to assess whether the Veteran requires aid and attendance due to the nephrolithiasis (recurrent kidney stones), right hand tendonitis, PTSD and associated symptoms, and any additional service connected disabilities. The examiner should assess whether any assistance deemed necessary is due to such service-connected disabilities as opposed to other nonservice-connected conditions. A complete rationale should be provided for the opinions expressed. E. BLOWERS Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board William Pagan, 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.