Citation Nr: 21008016 Decision Date: 02/11/21 Archive Date: 02/11/21 DOCKET NO. 19-20 873 DATE: February 11, 2021 ORDER Prior to April 19, 2017, a total disability rating due to individual unemployability (TDIU) is granted. Prior to October 21, 2020, special monthly compensation (SMC) under 38 U.S.C. § 1114(s) is denied. FINDINGS OF FACT 1. Prior to April 19, 2017, the evidence is in equipoise that the Veteran is rendered unable to secure and follow substantially gainful employment due to a combination of his service-connected disabilities. 2. Prior to October 21, 2020, the Veteran did not have a single service-connected disability rated as total with additional service connected disabilities with a combined rating of 60 percent or higher. CONCLUSIONS OF LAW 1. Prior to April 19, 2017, the criteria to establish or a total disability rating due to individual unemployability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.15, 4.16. 2. Prior to October 21, 2020, the criteria for special monthly compensation for the statutory housebound status have not been met. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1963 to July 1969. This matter comes on appeal before the Board of Veterans’ Appeals (Board) from June 2017, January 2018, and January 2019 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). By way of procedural background, this matter was previously before the Board in November 2020. The issue of entitlement to a TDIU was remanded to implement grants of service connection and increased ratings in the November 2020 Board decision and consider whether a TDIU was warranted before the original effective date of January 10, 2020. While on remand, the RO instituted the Board’s awards of benefits, and granted TDIU effective April 19, 2017, the date the Veteran filed his intent to file, which related to a December 2017 VA Form 526EZ. Nevertheless, the increased rating claim for hypertension had been on appeal since September 2010, and whether a TDIU prior to April 19, 2017 is warranted is still on appeal. The claim has now been returned to the Board for further appellate consideration. Preliminary Matters 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); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). 1. Prior to April 19, 2017, a TDIU is granted; and 2. Prior to October 21, 2020, special monthly compensation (SMC) under 38 U.S.C. § 1114(s) is denied. The Veteran contends that the combination of his service- connected disabilities prohibits him from securing or following substantially gainful employment. It is the established policy of VA that all veterans who are unable to secure and maintain substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16. A finding of total disability is appropriate “when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation.” 38 C.F.R. §§ 3.340 (a)(1), 4.15. Controlling laws provide that a TDIU may be assigned when a veteran has one service-connected disability rated at 60 percent or more, or two or more service-connected disabilities where at least one disability is rated at 40 percent or more and the combined rating is at least 70 percent. 38 C.F.R. § 4.16(a). The record must also show that the service-connected disabilities alone result in such impairment of mind or body that the average person would be precluded from securing or maintaining a substantially gainful occupation. Id. From September 1, 2010 to April 19, 2017, the Veteran was service-connected for PTSD (rated 30 percent disabling beginning September 1, 2010), prostate cancer (rated 40 percent disabling beginning September 1, 2009), diabetes mellitus (rated 20 percent disabling beginning December 23, 2008), right upper extremity unspecified idiopathic peripheral neuropathy (rated 20 percent disabling beginning August 6, 2009), right lower extremity unspecified idiopathic peripheral neuropathy (rated 10 percent under DC 8526 beginning August 6, 2009), left lower extremity unspecified idiopathic peripheral neuropathy (rated at 10 percent disabling under DC 8526 beginning August 6, 2009), hypertension (rated as noncompensable beginning September 1, 2010 and 10 percent beginning April 5, 2013), erectile dysfunction (rated as noncompensable beginning February 2, 2008), and lower abdomen scar (rated as noncompensable beginning February 2, 2008). Since September 1, 2010, the Veteran’s total combined disability rating was 80 percent. Thus, the Veteran in this case has met the schedular criteria for TDIU under 38 C.F.R. § 4.16(a) since at least that time. The remaining question is whether the Veteran’s service-connected disabilities preclude the Veteran from securing and following substantially gainful employment. See 38 C.F.R. § 4.16(a). The fact that a veteran is unemployed or has difficulty finding employment does not alone warrant assignment of a TDIU, as a high rating itself establishes that his disability makes it difficult for him to obtain and maintain employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Rather, the evidence must show that he is incapable “of performing the physical and mental acts required” to be employed. Id. at 363. Thus, the central question is whether a veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability, and not whether a veteran could find employment. Id. Consideration may be given to a veteran’s education, training, and special work experience, but not to his age or to impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. In Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013), the Federal Circuit held that, when a veteran is claiming TDIU based upon the combined effects of multiple service-connected disabilities, VA’s duty to assist “does not require obtaining a single medical opinion regarding the combined impact of all service-connected disabilities.” See also Smith v. Shinseki, 647 F.3d 1380, 1385-86 (Fed. Cir. 2011). Although VA must give full consideration, per 38 C.F.R. § 4.15, to “the effect of combinations of disability,” VA regulations place responsibility for the ultimate TDIU determination on VA adjudicators, not a medical examiner’s opinion. Geib, 733 F.3d at 1354; see also 38 C.F.R. § 4.16(a). The ultimate issue of whether TDIU should be awarded is not a medical issue, but rather is a determination for the VA adjudicator. See Moore v. Nicholson, 21 Vet. App. 211, 218 (2007), rev’d on other grounds sub nom, Moore v. Shinseki, 555 F.3d 1369 (Fed. Cir. 2009). There is no regulatory definition of “substantially gainful employment.” 38 C.F.R. § 4.16(a) provides guidance in that it states: “Marginal employment shall not be considered gainful employment.” It also says definitively that marginal employment exists 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. 38 C.F.R. § 4.16(a). Even if the income exceeds the poverty threshold, marginal employment may still exist on a facts-found basis. One example given is employment in a protected environment like a family business or a sheltered workshop. 38 C.F.R. § 4.16(a). VA must consider the nature of employment. Id. Notably, in Ray v. Wilkie, the Court of Appeals for Veterans Claims defined the term “unable to secure and follow a substantially gainful occupation” in § 4.16(b) to have two components: one economic and one noneconomic. The economic component means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. The non-economic component includes consideration of: the veteran’s history, education, skill, and training; whether the veteran has the physical ability to perform the type of activities required by the occupation at issue; and whether the veteran has the mental ability to perform the activities required by the occupation at issue. See Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). In adjudicating a TDIU claim, VA must consider the individual Veteran’s education, training, and work history. Hatlestad v. Derwinski, 1 Vet. App. 164 (1991). As an initial matter, the Veteran is currently service connected for AL amyloidosis at 100 percent beginning October 21, 2020, and obstructive sleep apnea, rated at 50 percent, effective August 8, 2018. The Veteran was not service connected for these disabilities prior to April 19, 2017, and the symptoms related to these disabilities prior to that date will not be considered in determining whether a TDIU is warranted. See Delrio v. Wilkie, 32 Vet. App. 232 (Fed. Cir. 2019). Turning to the evidence of record, the Veteran graduated high school and attended Michigan State University. He was a member of the ROTC and attended officer candidate training after college. The Veteran had a degree in business administration. After discharge from the military, the Veteran worked for IBM for 7 years. Following his employment at IBM, he worked in management for a savings and loan, and then with a food processing company. Subsequently, the Veteran worked as a Vice President of a computer department for yellow pages and for an advertising company. The Veteran’s most recent full time employment was overseeing the computer department for a trucking company. He last worked in November 2009, when he retired. He continued to work odd jobs delivering cars and medical materials to stay active. He also assisted his wife with her travel agency. See August 2010 VA treatment records. A July 2010 private treatment record indicated the peripheral neuropathy pain was worsening. He had poor treatment tolerance and poor symptom control. The symptoms were overall moderate. In October 2010, the diabetes mellitus and hypertension were evaluated. His glucose had been running 100-120. His last A1C was 6.2. A December 2010 private treatment record indicated that the Veteran was experiencing loss of bladder control after prostatectomy but no difficulty with bowel control. The private treatment records also noted the Veteran was not working “by choice.” An October 2010 VA treatment record noted the Veteran wanted to attend group therapy in November 2010, but he was unsure what his work schedule was going to be for that month. A November 2010 mental health treatment record indicated the Veteran had less episodes of crying, continued to be irritable and angry, and felt depressed. He denied audio and visual hallucinations and suicidal and homicidal ideations. The Veteran began attending a 16 week basic coping skills PTSD therapy group in November 2010. January 2011, February 2011, and August 2011 private treatment records indicated the Veteran’s peripheral neuropathy was stable with symptoms of painful paresthesia and sensory ataxia. The Veteran also was being treated for an underlying mood disorder without side effects and good tolerance. His depression was stable, and he denied suicidal ideations. The hypertension was stable on medications without side effects. A February 2011 VA mental health treatment record showed the Veteran was doing fairly well. He completed the PTSD group therapy. He had missed a few days of his medications. He slept 5 to 7 hours per night with an improvement of nightmares and flashbacks. He was not as depressed as before but had somatic complaints. He denied audio or visual hallucinations and suicidal and homicidal ideations. He tried to keep himself busy. A February 2011 private treatment record indicated the Veteran was not working by choice. He had an epidural steroid injection for a nonservice-connected back disability before he left for India for two weeks. His pain returned after walking on marble floors in the Taj Mahal. In April 2011, the Veteran underwent a VA psychiatric examination. The Veteran reported irritability, difficulty sleeping, recurrent thoughts of people who died in Vietnam, psychological reactivity to things that reminded him of the war, and avoidance of shopping malls and crowds. He denied current illicit drug use and alcohol abuse. He had previously abstained from drinking, but since moving closer to Fort Bragg, he had starting drinking again, quantified as two drinks per day. A July 2010 VA mental status note discussed the Veteran experienced uncontrolled crying spells, sadness, and difficulty sleeping. August 2010 treatment records showed the Veteran had a depressed mood and isolative behavior. He had crying spells and occasional nightmares. He felt guilty for coming home from Vietnam. The Veteran’s post-service vocational history included working as a postal courier for one to one and a half years, IBM for seven years, management for information systems for a savings and loan company for two or three years, and management in a food processing company for one to one and half years. He worked for National Oats, and then was Vice President of Yellow Book. Finally, he then managed air computer systems for a trucking company for approximately two years. He retired approximately 10 years earlier but continued to assist his wife with her travel agency business by maintaining her computers and assisting her with group travel programs when they traveled abroad. On mental status examination, the Veteran was using two canes to move around due to a nonservice-connected back disability. He made good eye contact and was adequately groomed. He denied suicidal and homicidal ideations. No delusional thinking was seen. His mood was okay, and his affect tearful when discussing the war. He had constricted affect. His thought processes were linear and goal directed, and his insight and judgment were good. The Veteran’s immediate memory was intact, but he was only able to recall two of three objects after three minutes. He was able to spell “world” backwards and perform serial sevens, but with some latency. He was able to name objects, repeat a sentence, and follow a three stage command. He had some difficulty with the ability to copy intersecting pentagons. The Veteran’s speech was of normal rate and volume. The examiner concluded that the Veteran’s psychiatric symptoms caused occupational and social impairment with a decrease in work efficiency and intermittent inability to perform occupational tasks, although generally functioning satisfactorily with routine behavior, self-care, and normal conversation. The Veteran’s symptoms were primarily depressed move, anxiety, chronic sleep impairment, and irritability. He had no difficulty managing his financial affairs, benefits or performing activities of daily living, other than some impairment due to the nonservice-connected low back surgery. The Veteran exhibited latency with more complex instructions such as serial sevens and difficulty with spatial tasks as discussed above. He also had difficulty establishing and maintaining social relationships, described as distancing himself from his family and irritability with his wife. He was diagnosed with PTSD. A May 2011 VA mental health treatment record noted the Veteran had depressive symptoms evidenced by poor sleep, withdrawn and isolative behavior, and depressed mood. His PTSD symptoms included intrusive thoughts, recurrent nightmares, flashbacks, irritability, hypervigilance, and social isolation. He had crying spells, disturbed sleep, and occasionally heard things that weren’t there. He denied suicidal or homicidal ideations, nightmares, and flashbacks. A May 2011 VA treatment record showed the Veteran’s blood sugars were running between 120 to 130. A May 2011 letter indicated the Veteran’s A1C was 5.8, which considered to be well controlled. Another May 2011 letter indicated the Veteran’s A1C was 5.8, within normal limits, and his PSA, liver enzymes, and urine analysis were within normal limits. A September 2011 VA mental health treatment note indicated the Veteran was doing “good.” In the previous few weeks, he cried anytime there was a military issue. He had surgery on his back, and he was not getting better, which was making him depressed. His sleep was disturbed due to pain. He denied nightmares and flashbacks but was yelling at his wife. He denied audio and visual hallucinations and suicidal and homicidal ideations. On mental status examination he was alert and oriented to person, had good impulse control, judgment, and insight. The Veteran was afforded a November 2011 VA examination for the diabetic peripheral neuropathy. The Veteran had tingling in the right lower extremity but not the left lower extremity. He also had right arm numbness. He was taking Gabapentin but was now taking Lyrica. The Veteran’s symptoms were moderate intermittent pain in the right upper and bilateral lower extremities and mild intermittent pain in the left upper extremity. He also had moderate paresthesias and/or dysesthesias in the right lower extremity, moderate numbness in the right upper extremity, and mild numbness in the bilateral lower extremities. His strength was normal in the upper and lower extremities. He had decreased deep tendon reflexes in the right bicep, triceps, and brachioradialis. The deep tendon reflexes were absent in both ankles. The left bicep, left triceps, left brachioradialis, and bilateral knee deep tendon reflexes were normal. Light touch/monofilament testing was decreased in the right inner/outer forearm, right hand/fingers. Bilateral knees/thighs, bilateral ankles/lower legs, and bilateral feet and toes. Light touch/monofilament testing was normal in the bilateral shoulders, left inner/outer forearm, and left hand/fingers. He had muscle atrophy in the bilateral calves with maximum bulk of 26 centimeters. He also had trophic changes with no leg hair from mid calves down to his feet and brown hyperpigmentation of the bilateral lower legs. The examiner diagnosed the Veteran with right upper extremity diabetic peripheral neuropathy with mild incomplete paralysis of the radial nerve, median nerve, and ulnar nerve. The left upper extremity was normal. The examiner also diagnosed the Veteran with bilateral lower extremity diabetic peripheral neuropathy with moderate incomplete paralysis of the right sciatic and femoral nerves and mild incomplete paralysis of the left sciatic and femoral nerves. The examiner reported the Veteran was retired, but occasionally helped his wife with her travel business. However, he was unable to perform the manual part of the job, such as carrying luggage. The Veteran was treated at VA mental health in January 2012. He reported he was doing better. He did not feel as depressed, was getting along well with his spouse, denied audio and visual hallucinations, slept better, denied nightmares and flashbacks, and denied suicidal and homicidal ideations. A May 2012 letter indicated the Veteran’s A1C was 6.3, within normal limits, and his PSA, liver enzymes, and urine analysis were within normal limits. A September 2012 VA mental health note indicated the Veteran was doing okay. He had difficulty sleeping, woke up several times a night, had nightmares and flashbacks A January 2013 VA mental health treatment note indicated the Veteran was doing fairly well, but the Veteran reported he felt “blaw” (sic) all the time. His granddaughter was living with him, and they did not get along, which was stressful. He slept approximately 6 hours per night, but his sleep was irregular. He had flashbacks when he watched military movies. He felt as if he should not have left the military. He denied audio and visual hallucinations and denied suicidal and homicidal ideations. He had multiple somatic complaints, but he felt the medications were helping. An April 2013 VA mental health treatment record noted the Veteran was doing fairly well. He had more up days than down, he slept up to 6 hours per night, and he was not having nightmares or flashbacks. He had recurrent thoughts of combat, but the medications were helping. He avoided crowds. He denied suicidal and homicidal ideations. He worked around his home and yard. A July 2013 VA treatment record indicated the Veteran was doing okay. He had one nightmare about being chased by Vietcong and had flashbacks. He slept 5 to 6 hours per night, felt depressed, but denied audio and visual hallucinations and suicidal and homicidal ideations. He went on trips with his wife, worked around the house, and took care of his dog. In October 2013, the Veteran was doing fairly well. He fell in Istanbul. His sleep was disrupted by pain from the fall, he had 1-2 nightmares, flashbacks, and he was upset about how the government was treating soldiers. He was depressed. He denied audio and visual hallucinations. The medications were helping. An April 2013 letter indicated the Veteran’s A1C was 6.3, within normal limits, and his PSA, liver enzymes, and urine analysis were within normal limits. A March 2014 VA treatment record noted the Veteran was doing fairly well. He was sleeping seven hours a night, denied nightmares and flashbacks, and felt depressed occasionally. He denied audio and visual hallucinations and suicidal and homicidal intent. He recently traveled to Africa with his wife who owned a travel agency. In June 2014, the Veteran was treated at VA for the PTSD. He was doing fairly well. He was short tempered with his spouse, felt depressed, slept 6 to 7 hours per night, but denied nightmares and flashbacks. Memorial Day was difficult for the Veteran. He watched television related to military actions, and his spouse yelled at him not to do so. He thought he saw something out of the corner of his eye, but nothing was there. His dog died three months earlier, and he saw his dog everywhere. He denied suicidal and homicidal ideations. In October 2014 the Veteran was treated by his primary care physician. His glucose had been running slightly elevated at around 120 - 125 in the mornings. The Veteran was treated for PTSD at VA in October 2014. The Veteran was doing fairly well. He slept 6 hours per night. He had “weird dreams” but no nightmares or flashbacks. He denied feeling depressed, having mood swings, or having audio or visual hallucinations. He denied suicidal and homicidal ideations. His spouse reported the medications were helping. The Veteran was treated for the PTSD in February 2015. He was doing fairly well. He had good days and bad days, had interrupted sleep five hours per night, had mixed dreams, and did not remember the content of his nightmares. He worried about his wife who was in the travel business. He was irritable and felt that someone was next to him when nobody was there. He denied suicidal and homicidal ideations. The Veteran was afforded an April 2015 VA examination for the diabetes mellitus. The diabetes was managed by a restricted diet and oral medication. The diabetes did not require regulation of his activities. He received physician care for the diabetes less than two times per month. He had no episodes of ketoacidosis or hypoglycemia requiring hospitalization in the last 12 months. He did not exhibit unintentional weight loss or progressive loss of strength due to the diabetes. He had diabetic peripheral neuropathy. The examiner indicated neither the diabetes nor the diabetic complications impacted his ability to work. The examiner found examination of the upper and lower extremities were normal, but the neurological examination was abnormal with decreased vibratory sense testing. No urinary or bowel incontinence was found. A corresponding April 2015 peripheral neuropathy examination report indicated the Veteran exhibited moderate bilateral lower extremity numbness. Strength and deep tendon reflexes were normal in all upper and lower extremities. Light touch/monofilament was normal in the bilateral upper and lower extremities. Position sense, vibration sense, and cold sensation testing were not conducted in the upper extremities. Position sense and cold sensation were normal and vibration sense was decreased in the lower extremities. No muscle atrophy or trophic changes were noted. The examiner found the Veteran did not have upper extremity peripheral neuropathy, but he had diabetic peripheral neuropathy that manifested as mild incomplete paralysis of the sciatic and femoral nerves in the bilateral lower extremities. The examiner indicated the diabetic peripheral neuropathy did not affect his ability to work but offered no rationale for this conclusion. A December 2016 VA examination for the hypertension disability indicated the Veteran was diagnosed with hypertension, for which he took continuous medication. The Veteran did not have a history of diastolic blood pressure predominately 100 or more, and his average blood pressure at the examination was 138/83. No other pertinent physical findings were noted. The examiner indicated that the hypertension did not affect the Veteran’s ability to work but did not offer a rationale to support this conclusion. A January 2017 VA PTSD treatment note indicated the Veteran was not doing fine. He was no longer depressed and was less anxious. He denied nightmares, his appetite was good, and he slept well. He denied audio and visual hallucinations, and there was no evidence of delusions. He denied suicidal and homicidal ideations, plan, or intent. He did not drink alcohol or use illicit drugs. He exhibited good impulse control, judgment, and insight. The Veteran’s spouse, H.H., submitted a statement in September 2019. His spouse indicated that over the previous 10 years, the Veteran had struggled with his physical and emotional health. His issues had been severe over the previous 10 years, and he had been unable to work. When he was working, he had difficulty keeping up and handling the stress. He also had difficulty getting along with others. He became uncomfortable in crowded places and had panic attacks. He had these symptoms in large venues, like the state fair, but also in smaller places, like the grocery store. When their children came to visit, the Veteran often disappeared into the home office or bedroom because even that many people could be too much for him. He had a difficult time maintaining relationships. He also had difficulty with memory, such as locations of events, appointments, and medications. He had difficulty communicating. He said things that did not make sense or did not relate to the conversation. He did not finish tasks that he started. He had mood swings and a short temper. He became angry over things that he could not control, such as politics. He often disagreed with those who had different opinions than he did, and when they did not agree with him, it made him angry. He was unable to function normally under stress, and he missed deadlines. He had difficulty sleeping and nightmares. He also had incontinence due to the prostatectomy and had erectile dysfunction, which made him feel inadequate. The cancer heavily affected his energy. The diabetes caused neuropathy in his arms and legs. He dropped things often, could not do fine motor tasks like buttoning a shirt, and had fallen as a result of the neuropathy in his legs. He required a cane or walker to ambulate. His spouse took care of all the household chores or hired someone to do them. The Veteran stopped working more than 15 years earlier because he could no longer handle the stress of working full time. The Veteran’s daughter, P.J.A., also submitted a statement in September 2019. The Veteran struggled day to day with both mental and physical conditions. He could not handle stress. Politics and conflicts of opinion upset him. He could not handle it when others had a different opinion than he did. He had become less people oriented over the last 10 years than he was before that time. He was most comfortable when he was at home. When P.J.A. visited, the Veteran did not go anywhere or do anything outside of the house. He was on edge around others and in crowds. He was unmotivated. He no longer cared for the yard and did not work in his office like he did before. His memory had declined, and he repeated himself. He forgot conversations and had difficulty understanding what was being said. He forgot what he was talking about in the middle of a conversation. He had difficulty walking and stayed seated most of the time. He had several prostate surgeries, and each had left him weak and unable to do things he once could. He was fatigued, even without exertion. He was exhausted and in pain all the time, and it had been this way for the last decade. The Veteran submitted a private medical opinion from Dr. K.B., a psychologist, in October 2019. Dr. K.B. reviewed the claims file and interviewed the Veteran and concluded that the Veteran’s ongoing PTSD symptoms included difficulty interacting with co-workers and supervisors due to anger and irritability, poor sleep that would affect job performance and cause excessive tardiness and absences from work, intrusive thoughts about Vietnam, and feelings of guilt and depression that would be distracting for the Veteran and prevent him from focusing on his job tasks. Prior to April 19, 2017, Dr. K.B. specifically referenced an August 2010 VA treatment record that noted he had crying spells and was emotional recently. The Veteran felt guilty that he had come back from Vietnam. Dr. K.B. also noted that in an April 2011 VA treatment record, the Veteran’s irritability lead to problems with his current wife. He had also experienced poor sleep since Vietnam. He became choked up and distressed when seeing war memorials and watching war movies. He avoided shopping malls, crowds, and was irritable. A September 2011 VA treatment record showed he experienced disturbed sleep due to pain, crying over military issues, and feeling depressed after surgery for a non-service connected disability because he was still not feeling better. Dr. K.B. also noted a September 2012 VA treatment record that reported the Veteran had nightmares and flashbacks after watching war movies and had disturbed sleep, October 2013 VA treatment records reporting he had disrupted sleep due to pain, June 2015 VA treatment records that showed the Veteran was angry and irritable, and May 2016 VA treatment records that indicated the Veteran was occasionally dizzy and his blood pressure was 182/78. Ultimately, based on the record review and an interview of the Veteran, Dr. K.B. concluded that the Veteran’s PTSD symptoms had continued uninterrupted and in their current severity since his initial claim in September 2010, and that it was more likely than not that the Veteran was unable to sustain gainful employment. The Veteran also submitted an October 2019 letter from Dr. M.B., a physician. Dr. M.B. also concluded that the combination of the Veteran’s service-connected disabilities affected his ability to maintain gainful employment. Dr. M.B. noted the Veteran had documented issues throughout the years to include sleep disturbances, difficulty with concentration, and irritability. Treatment records between 2010-2011 showed uncontrollable crying and mood swings, yelling at his wife, and sleep disturbances. An April 2011 VA examination noted poor sleep since returning from Vietnam and irritability that caused issues with both his ex and current spouses. Physically, the Veteran had high blood pressure that caused him to be dizzy, as noted in a May 2016 VA treatment note. In May 2016, he became upset at a mental health appointment, and his blood pressure increased. Because of his uncontrolled blood pressure, his PTSD symptoms were unable to be optimally treated. The service-connected diabetes mellitus and idiopathic peripheral neuropathy of the right upper and bilateral lower extremities result in pain going down both legs and right arm numbness. In a November 2011 VA examination, the Veteran reported he was able to help his wife with her travel agency but was unable to perform manual labor tasks like carrying luggage when they traveled. Due to the Veteran’s prostate cancer, he used the restroom every 2 to 3 hours and at least 2 times per night. He used absorbent pads and changes them 2 to 4 times a day on average. Dr. M.B. also discussed the statements submitted by his spouse and daughter, which both shared that he had difficulty with memory, frustration, anger, mood swings, difficulty finishing tasks, sleeping, and nightmares. He took a nap almost every day. He had difficulty walking due to the neuropathy in both legs, and he had difficulty adapting to stressful circumstances. The Veteran had a variety of jobs over the years working with IT, software, and computer systems. His previous jobs, although working with computers and software, required long hours in a stressful environment. He had difficulty getting along with management, had a short fuse, and was often angry at work. He was constantly stressed and would be unable to return to this type of employment due to his service-connected disabilities. Furthermore, Dr. M.B. concluded that his physical disabilities also prevented him from maintaining employment. His previous career in IT was a physical job, and the Veteran was prevented from working on his feet, lifting, standing, using his right hand, and bending for a significant amount of time due to his service-connected physical disabilities. Dr. M.B. also addressed the Veteran’s part time employment driving cars to and from different dealerships a few times a month and couriering medical specimens. He undertook this part time employment approximately 8 hours a week on average. Ultimately, the Veteran’s fatigue made it too difficult to continue this part time employment. He also helped his wife and traveled with her and her travel agency, but ultimately the travel also became too much for him. He reported he no longer helped her with the business except when she had an occasional computer issue. Dr. M.B. concluded that his service-connected disabilities more likely than not prevented the Veteran from maintaining substantially gainful employment since September 1, 2010. In an October 2019 VA Form 21-8940, Application for Increased Compensation Based on Unemployability, the Veteran reported he had 4 years of college. He asserted that all his service-connected disabilities prevented him from securing and following substantially gainful employment. He last worked full time on January 1, 2000 and became too disabled to work on January 1, 2008. He indicated he left his last job due to his disabilities, and he had not tried to obtain employment since he became too disabled to work. He listed previous employers as an automobile delivery driver for 4 hours per trip for three to four trips per month from May 2000 to March 2004, as a courier approximately 8 hours per week from November 2002 to September 2004, and as an assistant to his spouse at her travel agency between 10 -15 hours per week from September 2004 to January 2008. After a review of the evidence, both lay and medical, the Board finds the evidence is in equipoise that the Veteran is unable to follow substantially gainful employment due to the combined effects of the service-connected disabilities prior to April 19, 2017. Specifically, as discussed in the two October 2019 private medical opinions, the Veteran would be unable to maintain employment as a result of his PTSD, right upper extremity peripheral neuropathy, bilateral lower extremity peripheral neuropathy, residuals of prostate cancer, diabetes mellitus, and hypertension symptoms. The Veteran’s physical disabilities preclude him from any position that requires working on his feet, standing, bending, lifting, or using his right hand. The October 2019 private medical opinion from Dr. K.B. also indicated that the Veteran’s PTSD disability with neurocognitive deficits, which have been noted to include irritability, anger, isolation, difficulty interacting with supervisors and other employees, difficulty with memory, latency in following multistep directions, and difficulty adapting to stressful situations, make following sedentary employment not feasible. The October 2019 private medical opinion also explained that the Veteran’s prior employment in IT, although seemingly sedentary, also required a physical component to the job which required lifting, using his right hand, and standing when dealing with the physical computer systems. His previous IT positions were also in a stressful environment that he would have difficulty maintaining due to his PTSD symptoms. The Board also considered the Veteran was able to travel internationally at least three times with his wife and her travel agency early in the appellate period. When weighed against the other lay and medical evidence of record, the Board finds that this fact does not outweigh the Veteran’s statements and other lay and medical evidence of record that describe his physical and mental symptoms and what would be physically and mentally required of him to follow substantially gainful employment. The Board also acknowledges that he helped his wife with her travel agency during the appellate period. However, the Board finds that this employment was marginal as it was no more than part time employment, his earnings were less than the poverty threshold for one person, and the employment was within a protected environment, specifically working for his spouse. Taking in consideration both the lay and medical evidence of record, to include consideration of the Veteran’s employment history and his education level, and resolving reasonable doubt in the Veteran’s favor, the Board finds that a combination of the Veteran’s service-connected disabilities are of sufficient severity to preclude him from following gainful employment prior to April 19, 2017. The Board has also considered whether the Veteran is entitled to special monthly compensation (SMC) based on statutory housebound status prior to October 21, 2020. SMC is warranted if a veteran has a service-connected disability rated as total and has additional service-connected disabilities independently rated as 60 percent or more, or by reason of such service-connected disabilities is permanently housebound. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). In the present case, prior to October 21, 2020, the Veteran did not have a service-connected disability rated at 100 percent and additional service-connected disabilities rated at 60 percent or more. Although a TDIU is now granted prior to October 21, 2020, which could satisfy the total disability rating under some circumstances, the grant of the TDIU in this case is based on the combination of the Veteran’s service-connected disabilities and not on a single service-connected disability alone. Thus, prior to October 21, 2020, the Veteran does not have a single service-connected disability that is rated as total. Therefore, SMC based on statutory housebound status prior to October 21, 2020 is not warranted under 38 U.S.C. § 1114(s). However. beginning October 21, 2020, the Veteran was awarded service connection for an additional disability, AL Amyloidosis, which was rated as 100 percent disabling. At that point, the Veteran became eligible for SMC for statutory housebound status under 38 U.S.C. § 1114(s). Finally, the Board notes that neither the Veteran nor his attorney have raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Harper, 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.