Citation Nr: 21009256 Decision Date: 02/22/21 Archive Date: 02/22/21 DOCKET NO. 11-03 963 DATE: February 22, 2021 ORDER For the entire period on appeal, an initial disability rating of 100 percent for posttraumatic stress disorder (PTSD) is granted. Entitlement to an initial disability rating in excess of 20 percent for diabetes mellitus is denied. Beginning June 30, 2016, the appeal seeking entitlement to a total disability rating based upon individual unemployability (TDIU), having now been rendered moot, is dismissed. Beginning June 30, 2016, entitlement to special monthly compensation (SMC) at the housebound rate is granted. REMANDED For the period on appeal prior to June 30, 2016, entitlement to an extraschedular TDIU based solely on the Veteran’s service-connected diabetes mellitus is remanded. FINDINGS OF FACT 1. For the entire period on appeal, the Veteran’s PTSD symptoms most nearly approximates total occupational and social impairment. 2. For the entire period on appeal, the Veteran’s diabetes mellitus has required an oral hypoglycemic agent and a restricted diet, but not insulin or regulation of activities. 3. Beginning June 30, 2016, the claim of entitlement to a TDIU is rendered moot in light of the Board’s grant herein of a total schedular disability rating for PTSD for the entire period on appeal. 4. Beginning June 30, 2016, the Veteran has a service-connected disability rated as total (PTSD), and his other service-connected disabilities are rated as at least 60 percent disabling. CONCLUSIONS OF LAW 1. For the entire period on appeal, the criteria for an initial disability rating of 100 percent for PTSD are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.130, Diagnostic Code (DC) 9411. 2. The criteria for an initial disability rating in excess of 20 percent for diabetes mellitus are not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.119, DC 7913. 3. The matter of the Veteran’s entitlement to a TDIU has been rendered moot by the award of a total (100 percent) schedular rating for PTSD for the entire appeal period, leaving no question of law or fact to decide regarding that issue. 38 U.S.C. §§ 7104, 7105; 38 C.F.R. §§ 3.340, 3.341, 4.14, 4.16. 4. Beginning June 30, 2016, the criteria for SMC at the housebound rate are met. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant in this case, served on active duty from May 1966 to June 1969. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2009 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). By way of procedural background, the Board previously remanded these matters for additional development in decisions dated January 2014 and July 2017. The issue of entitlement to SMC at the housebound rate has been raised by the record and added to the appeal. Akles v. Derwinski, 1 Vet. App. 118 (1991). The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Increased Ratings Claims Disability evaluations are determined by comparing a veteran’s present symptoms with the criteria set forth in the VA Schedule for Rating Disabilities, which is based upon average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt is resolved in favor of the veteran. 38 C.F.R. § 4.3. The veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Staged ratings are appropriate for any initial rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Where a veteran is diagnosed with multiple disabilities of the same body part or system, and it is unclear from the record which symptoms are attributable to each distinct disability, the Board is precluded from differentiating between the symptomatology and the disabilities. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether a veteran’s particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. at 469. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau, 492 F.3d 1372, 1377. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 1. Entitlement to an initial disability rating in excess of 50 percent for PTSD The criteria for rating psychiatric disabilities, other than eating disorders, are set forth in the General Rating Formula for Mental Disorders (General Rating Formula). 38 C.F.R. § 4.130. Under the General Rating Formula, a 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted if the evidence establishes there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating (total occupational and social impairment) is warranted 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. Id. Effective August 4, 2014, VA amended the portion of the Rating Schedule dealing with mental disorders and its adjudication regulations that define the term “psychosis” to remove outdated references to the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) and replace them with references to the updated Fifth Edition (DSM-5). See 79 Fed. Reg. 149, 45094. The provisions of the interim final rule apply to all applications for benefits that are received by VA or that were pending before the Agency of Original Jurisdiction on or after August 4, 2014. Id. VA adopted as final, without change, the interim final rule and clarified that the provisions of this interim final rule do not apply to claims that have been certified for appeal to the Board or are pending before the Board as of August 4, 2014. See 80 Fed. Reg. 53, 14308 (March 19, 2015). In Golden v. Shulkin, 29 Vet. App. 221 (2018), the Court held that, given that the DSM-5 abandoned the Global Assessment of Functioning (GAF) scale and that VA has formally adopted the DSM-5, GAF scores are inapplicable to assign a psychiatric rating in cases where the DSM-5 applies when the appeal was certified after August 4, 2014. Here, however, the Veteran’s increased rating claim for PTSD was pending prior to August 4, 2014 and was certified to the Board prior to August 2014. See October 2012 VA Form 8. Nevertheless, because of the Court’s emphatic pronouncement in Golden that the GAF scores are methodologically flawed and are particularly unreliable as applied to psychiatric disorders, in this decision, the Board will place no reliance on GAF scores for rating this Veteran’s PTSD. When determining the appropriate disability evaluation to assign, the Board’s primary consideration is the veteran’s symptoms, but it must also make findings as to how those symptoms impact a veteran’s occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). The use of the term “such as” in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Thus, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Id. at 442. Nevertheless, all ratings in the General Rating Formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran’s impairment must be “due to” those symptoms; a veteran may only qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. The Board recognizes that the Court in Mauerhan, 16 Vet. App. 436, stated that the symptoms listed in VA’s General Rating Formula is not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. However, the Court further indicated that without those examples, differentiating between rating evaluations would be extremely ambiguous. In this matter, the Veteran is currently in receipt of an initial disability rating of 50 percent for PTSD for the entire period on appeal. He asserts that a higher rating is warranted. On review, the Board finds that the evidence is at least in equipoise as to whether the symptoms of the Veteran’s PTSD more nearly approximate the criteria for an initial rating of 100 percent for the entire period on appeal. First, the evidence reveals that the Veteran has demonstrated a persistent danger of hurting himself and others. The Veteran has endorsed suicidal ideation throughout the period on appeal, and although his suicide attempts (in the 1970s and 1980s) predate the period on appeal, suicide risk screenings in the Veteran’s VA treatment records note that prior suicide attempts are a risk factor for future suicidality. See VA treatment records dated June 2008 to August 2020; May 2011 Decision Review Officer (DRO) Hearing Transcript; June 2011 VA PTSD examination report; December 2012 Third Party Correspondence; February 2015 VA PTSD examination report; November 2015 VA PTSD examination report. Notably, in 2011, the Veteran threatened to kill himself after facing obstacles in getting his pain medication refilled. See VA treatment records dated January 2011 to February 2011. At the May 2011 DRO hearing, the Veteran testified that during that suicidal episode, he called the Suicide Hotline, presented to the VA, and was detained while police searched his car for a gun. Additionally, the Veteran has a history of actual and threatened violence towards others, both predating and throughout the period on appeal. See VA treatment records dated November 2001 to April 2010; February 2011 attachment to VA Form 9; May 2011 Correspondence; February 2015 VA PTSD examination report; November 2015 VA PTSD examination report. Indeed, decades prior, the Veteran shot his spouse during a flashback episode, resulting in the loss of her arm and blinding her in one eye, and during his last employment as a cement truck driver, the Veteran reported, “this guy kept cussing me and all that. I got out of my truck and told him I was going to kill him. I had enough of it. It brought me into a point of not being liked. When I got out and did that I just went into a rage. He went into a rage and then I snapped. Somebody was going to die. Either him or I…” May 2011 DRO hearing transcript; see also VA treatment records dated June 2008 to April 2010; VA PTSD examination reports dated February 2015 and November 2015. In May 2011 Correspondence, the Veteran explained, “I have very few friends and am prone to angry and violent outbursts. I stay away from people because I fear I may hurt someone. If it were not for the medications I take I would lose my temper more often. Since returning from Vietnam I have been a very violent and angry person. I have been in mental institutions and prisons and jail and have lived a very antisocial existence. I have self medicated and done everything I can to forget the war. I have hurt many people I was around, even severely disabling my wife.” Second, the evidence shows that the Veteran has experienced an intermittent inability to perform activities of daily living. In a November 2010 VA addendum, the Veteran reported that his spouse has to get him up and pick out his clothes for him or he would just stay in bed all day. In an attachment to his February 2011 VA Form 9, the Veteran stated, “My wife helps me with most day-to-day activities. My stress level is high. I am unable to concentrate on one thing at a time. My wife helps me in all areas of daily living.” In May 2011 Correspondence, the Veteran wrote, “I require constant help from my wife in order to get through most days. Most daily living activities I am unable to do without her help or a list. I just can’t remember.” During the June 2011 VA PTSD examination, the Veteran reported that his spouse has to lay out his clothes every day and prompt him to do activities, and that he was incapable of even fixing a sandwich. Third, the evidence demonstrates that the Veteran has some degree of disorientation to time or place. During the June 2011 VA PTSD examination, the Veteran reported that he had been getting lost when he drives his car, and in a December 2012 VA neuropsychological evaluation report, the VA provider indicated that while the Veteran was grossly oriented to time, he misstated the season of the year and the calendar date. Finally, the September 2020 VA PTSD examiner found that, as a result of the Veteran’s PTSD symptoms, he has difficulty attending to or is easily distracted from the task at hand, he has intrusive thoughts which interfere with the ability to stay focused on the task at hand, he has significant difficulty remembering instructions and details of work assignments, and his sleep is so disrupted that he is usually fatigued at work, making concentration and focus on work assignments difficult. After resolution of all reasonable doubt in the Veteran’s favor, the Board concludes that the lay and medical evidence supports a finding that the Veteran’s PTSD has resulted in total occupational and social impairment, as the rating criteria specifically contemplate the Veteran’s symptoms of persistent danger of hurting himself or others, intermittent inability to perform activities of daily living, and disorientation to time or place. For these reasons, the Board finds that the Veteran’s PTSD symptoms more nearly approximate the criteria for an initial disability rating of 100 percent for the entire period on appeal. A 100 percent rating is the maximum schedular rating allowed under the General Rating Formula. 2. Entitlement to an initial disability rating in excess of 20 percent for diabetes mellitus The Veteran’s diabetes mellitus is rated under DC 7913. Effective December 10, 2017, VA revised the criteria for rating disabilities of the endocrine system (including diabetes mellitus). The instant initial rating claim stems from an original service connection claim that was filed in March 2009. When the regulations concerning entitlement to a higher rating are changed during the course of an appeal, the veteran may be entitled to resolution of his claim under the criteria that is more advantageous, although the revised rating criteria may be applied only prospectively from the effective date of the change forward unless the regulatory change specifically permits retroactive application. 38 U.S.C. § 5110(g); VAOPGCPREC 7-03; VAOPGCPREC 3-00; Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Here, the former rating criteria (pre-2017) govern the claim for the period from March 11, 2009 to December 9, 2017, and for the period from December 10, 2017 to the present, the severity of the Veteran’s diabetes mellitus must be considered under both the former (pre-2017) and revised (post-2017) rating criteria. The rating assigned must be based on whichever rating criteria is more favorable to the Veteran. See Kuzma, 341 F.3d 1327. Under the former rating criteria, effective prior to December 10, 2017, a 20 percent rating is assigned for diabetes mellitus requiring insulin and restricted diet, or; oral hypoglycemic agent and restricted diet. A 40 percent rating is assigned for diabetes mellitus requiring insulin, restricted diet, and regulation of activities. A 60 percent rating is assigned for diabetes mellitus requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic agent reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating is assigned for diabetes mellitus requiring more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. See 38 C.F.R. § 4.119, DC 7913 (effective prior to December 10, 2017). Under the revised rating criteria, effective December 10, 2017, a 20 percent rating is assigned for diabetes mellitus requiring one or more daily injection of insulin and restricted diet, or; oral hypoglycemic agent and restricted diet. A 40 percent rating is assigned for diabetes mellitus requiring one or more daily injection of insulin, restricted diet, and regulation of activities. A 60 percent rating is assigned for diabetes mellitus requiring one or more daily injection of insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating is assigned for diabetes mellitus requiring more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. See 38 C.F.R. § 4.119, DC 7913 (effective December 10, 2017). Under both former and revised rating criteria, Note (1) to DC 7913 provides that compensable complications of diabetes are to be rated separately unless they are part of the criteria used to support a 100 percent rating (under DC 7913). Noncompensable complications are considered part of the diabetic process under DC 7913. The term “regulation of activities” is defined in the rating criteria for a 100 percent disability rating under DC 7913 as “avoidance of strenuous occupational and recreational activities.” Although not specified in the rating criteria, the Board finds that this definition also applies to the “regulation of activities” discussed in the 40 percent and 60 percent disability ratings under DC 7913. Additionally, medical evidence is required to show that occupational and recreational activities have been restricted. See Camacho v. Nicholson, 21 Vet. App. 360, 363-64 (2007). Further, in light of the conjunctive “and” in the criteria for a 40 percent disability rating under DC 7913, all criteria must be met to establish entitlement to a 40 percent rating. See, e.g., Heuer v. Brown, 7 Vet. App. 379, 385 (1995) (holding that criteria expressed in the conjunctive are connected by “and”); Malone v. Gober, 10 Vet. App. 539 (1997) (construing “and” as conjunctive in a statute); cf. Johnson v. Brown, 7 Vet. App. 95, 97 (1994) (holding that “or” in the rating criteria shows that each is an independent basis for granting that rating). Here, the Veteran is currently in receipt of an initial disability rating of 20 percent for diabetes mellitus. He asserts that a higher rating is warranted. On review of the evidence, both lay and medical, the Board finds that the manifestations of the Veteran’s diabetes mellitus disability more nearly approximate the criteria for a 20 percent rating under both the former and revised versions of DC 7913 for the entire period on appeal. Although the Veteran’s diabetes mellitus has required an oral hypoglycemic agent and a restricted diet, it has not required the use of insulin or regulation of activities, so as to warrant a higher rating of 40 percent under either the former or revised versions of DC 7913. See VA diabetes mellitus examination reports dated May 2009, June 2011, February 2015, and September 2020; VA treatment records dated April 2009 to September 2020. The Board acknowledges the Veteran’s lay statements that his diabetes mellitus has required regulation of activities. See January 2010 Notice of Disagreement; May 2011 DRO hearing transcript; October 2012 VA Form 646; December 2012 Third Party Correspondence. However, as mentioned, medical evidence is required to show that occupational and recreational activities have been restricted, and here, no such medical evidence is shown in the Veteran’s VA treatment records or VA examination reports. See Camacho, 21 Vet. App. at 363-64. Furthermore, there is no evidence that the Veteran’s diabetes mellitus requires the use of insulin. In light of the conjunctive “and” in the criteria for a 40 percent disability rating under both former and revised versions of DC 7913, all criteria must be met to establish entitlement to a 40 percent rating. Here, two of the criteria for a 40 percent rating (under both the former and revised rating criteria) are not met. Lastly, the Board notes that the Veteran is already in receipt of separate ratings for complications of his diabetes mellitus, to include peripheral neuropathy of the bilateral upper and lower extremities and mild nonproliferative diabetic retinopathy. For these reasons, the preponderance of the evidence is against the assignment of an initial disability rating in excess of 20 percent for diabetes mellitus, under either the former or revised rating criteria. The appeal is therefore denied. 3. Entitlement to a TDIU beginning June 30, 2016 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). 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. See 38 U.S.C. § 1155. Regarding the instant Veteran’s claim for a TDIU, this benefit contemplates a schedular rating less than total for the disability or disabilities on which the TDIU would be based. See 38 C.F.R. § 4.16(a). A TDIU is considered a lesser benefit than a 100 percent schedular rating, and the grant of a 100 percent rating generally renders moot the issue of entitlement to a TDIU for the period when the 100 percent rating is in effect. An exception to this is that a separate award at the housebound rate or a TDIU predicated on a single disability (perhaps not ratable at the schedular 100 percent level) when considered with another disability separately rated at 60 percent or more may warrant payment of SMC under 38 U.S.C. § 1114(s). Bradley v. Peake, 22 Vet. App. 280 (2008). As decided herein, the Veteran has now been awarded a 100 percent rating for PTSD for the entire period on appeal, effective March 11, 2009. His other service-connected disabilities include coronary artery disease (rated as 60 percent disabling, effective June 30, 2016), peripheral neuropathy of the right upper extremity (rated as 30 percent disabling, effective June 30, 2016), peripheral neuropathy of the left upper extremity (rated as 20 percent disabling, effective June 30, 2016), peripheral neuropathy of the right lower extremity (rated as 20 percent disabling, effective June 30, 2016), peripheral neuropathy of the left lower extremity (rated as 20 percent disabling, effective June 30, 2016), diabetes mellitus (rated as 20 percent disabling, effective March 11, 2009), tinnitus (rated as 10 percent disabling, effective May 19, 2011), mild nonproliferative diabetic retinopathy (rated noncompensable, effective May 19, 2011), and bilateral hearing loss (rated noncompensable, effective May 19, 2011). Based on the foregoing, beginning June 30, 2016, a TDIU would not be required to establish entitlement to SMC, as the Veteran already has a service-connected disability rated as total (PTSD) and other service-connected disabilities rated as at least 60 percent disabling. As such, entitlement to a TDIU is rendered moot beginning June 30, 2016. The Board will address the issue of entitlement to a TDIU for the period on appeal prior to June 30, 2016 in the Remand section below. 4. Entitlement to SMC at the housebound rate As previously mentioned, SMC at the housebound rate is payable where a veteran has a single service-connected disability rated as 100 percent and: (1) has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems; or (2) is permanently housebound by reason of service-connected disability or disabilities. 38 U.S.C. § 1114(s). This requirement is met when a veteran is substantially confined as a direct result of service-connected disabilities to his or her dwelling and the immediate premises, or if institutionalized, to the ward or clinical areas and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his or her lifetime. 38 C.F.R. § 3.350(i). Here, the Veteran has been awarded a 100 percent rating for PTSD for the entire period on appeal, effective March 11, 2009. The Veteran also has additional service-connected disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability (PTSD) and involving different anatomical segments or bodily systems. Apart from his disability rating for PTSD, the Veteran’s other service-connected disabilities include coronary artery disease (rated as 60 percent disabling, effective June 30, 2016), peripheral neuropathy of the right upper extremity (rated as 30 percent disabling, effective June 30, 2016), peripheral neuropathy of the left upper extremity (rated as 20 percent disabling, effective June 30, 2016), peripheral neuropathy of the right lower extremity (rated as 20 percent disabling, effective June 30, 2016), peripheral neuropathy of the left lower extremity (rated as 20 percent disabling, effective June 30, 2016), diabetes mellitus (rated as 20 percent disabling, effective March 11, 2009), tinnitus (rated as 10 percent disabling, effective May 19, 2011), mild nonproliferative diabetic retinopathy (rated noncompensable, effective May 19, 2011), and bilateral hearing loss (rated noncompensable, effective May 19, 2011). Beginning June 30, 2016, these additional service-connected disabilities combine to a rating in excess of 60 percent and are separate and distinct from the Veteran’s PTSD, as they involve different anatomical segments or bodily systems. Accordingly, as the Veteran has a single service-connected disability rated as total (PTSD), and he has additional service-connected disabilities that are independently rated as at least 60 percent disabling, the criteria for SMC at the housebound rate have been met beginning June 30, 2016. Finally, the Veteran has not 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). REASONS FOR REMAND 1. Entitlement to a TDIU prior to June 30, 2016 For the period on appeal prior to June 30, 2016, the issue of entitlement to a TDIU is not rendered moot, since the award of a TDIU predicated on a single disability (perhaps not ratable at the schedular 100 percent level) when considered with another disability separately rated at 60 percent or more (here, the Veteran’s PTSD, rated as 100 percent disabling, effective March 11, 2009) may warrant payment of SMC under 38 U.S.C. § 1114(s). VA’s duty to maximize benefits requires VA to assess all of a claimant’s disabilities to determine whether any combination of disabilities establishes entitlement to SMC under 38 U.S.C. § 1114. See Bradley, 22 Vet. App. at 294 (finding that SMC “benefits are to be accorded when a Veteran becomes eligible without need for a separate claim”). Prior to June 30, 2016, the Veteran’s service-connected disabilities (apart from his PTSD) include diabetes mellitus (rated as 20 percent disabling, effective March 11, 2009), tinnitus (rated as 10 percent disabling, effective May 19, 2011), mild nonproliferative diabetic retinopathy (rated noncompensable, effective May 19, 2011), and bilateral hearing loss (rated noncompensable, effective May 19, 2011). While none of these service-connected disabilities, alone, would support an award of a schedular TDIU, the Board finds that entitlement to an extraschedular TDIU has previously been raised, and that the matter should be remanded so that it can be referred to the Director of Compensation for consideration of an extraschedular TDIU based solely on the Veteran’s service-connected diabetes mellitus. Notably, in the remand directives of its July 2017 decision, the Board provided, “If the Veteran does not meet the schedular criteria for TDIU under 38 C.F.R. § 4.16(a) (2016), refer the claim to the Director of Compensation for consideration of an extraschedular TDIU rating.” Additionally, in its July 2017 decision, the Board noted that the Veteran reported he was unable to work due to headaches and dizziness caused by the oral hypoglycemic medication taken for his diabetes mellitus, and requested an addendum opinion on whether the Veteran’s diabetes mellitus resulted in any functional impairment, which was provided in September 2020. See also February 2011 attachment to VA Form 9 (“I am unable to exert myself without becoming faint.”); May 2011 Correspondence (“My blood sugar fluctuates and causes me to be dizzy, lightheaded and extremely tired all the time.”); May 2011 DRO hearing transcript (Veteran testified that he is not able to engage in any strenuous activity, stating that he is weak all the time and when his blood sugar gets low, he is dizzy). The Board also acknowledges the Veteran’s argument, through his representative, that the RO “committed reversible error in denying [the] Veteran’s claim for the grant of individual unemployability, by failing to consider submitting this case for extraschedular consideration, under 38 C.F.R. § 4.16(b), because evidence establishes [the] Veteran was unable to perform marginal employment because of his service connected disabilities…” See October 2020 Third Party Correspondence. As the Board is precluded from awarding TDIU on an extraschedular basis in the first instance, it must ensure that the claim is referred to the Director of VA’s Compensation and Pension Service for extraschedular consideration. Bowling v. Principi, 15 Vet. App. 1, 10 (2001). (Continued on the next page) Accordingly, the matter is REMANDED for the following action: Refer the claim for a TDIU based solely on the Veteran’s diabetes mellitus for the period prior to June 30, 2016 to the Director of Compensation and Pension Service for consideration of extraschedular TDIU, and then readjudicate the remanded claim. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. M. Gill, 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.