Citation Nr: 21012406 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 04-00 199 DATE: March 4, 2021 ORDER For the period on appeal, prior to March 25, 2010, entitlement to a rating in excess of 30 percent for hiatal hernia with gastroesophageal reflux disease (GERD) is denied. Effective March 25, 2010, entitlement to a rating of 60 percent for hiatal hernia with gastroesophageal reflux disease (GERD) is granted. An extraschedular rating for hiatal hernia with gastroesophageal reflux disease (GERD) is denied. Entitlement to special monthly compensation (SMC) pursuant to 38 U.S.C. § 1114(s) is granted, effective May 12, 2016. FINDINGS OF FACT 1. For the period on appeal, prior to March 25, 2010, the Veteran’s hiatal hernia with gastroesophageal reflux disease (GERD) is manifest by persistently recurring epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. 2. From March 25, 2010 forward, the Veteran’s hiatal hernia with gastroesophageal reflux disease (GERD) is manifest by severe heartburn, hematemesis, regurgitation, reflux, diarrhea, chest, arm and shoulder pain, difficulty swallowing, dizziness, headache, and fatigue, productive of a severe impairment of health. 3. The Veteran’s disability picture is not exceptional as the hiatal hernia with gastroesophageal reflux disease (GERD) does not markedly interfere with employment or require frequent periods of hospitalization 4. The Veteran has been granted TDIU based on a single service-connected disability and in addition he has service-connected disabilities independently ratable at at least 60 percent as of May 12, 2016. CONCLUSIONS OF LAW 1. For the period on appeal, prior to March 25, 2010, the criteria for a rating in excess of 30 percent for hiatal hernia with gastroesophageal reflux (GERD) have not been met. Diagnostic Code (DC) 7346. 2. Effective March 25, 2010, the criteria for entitlement to a rating of 60 percent for hiatal hernia with gastroesophageal reflux (GERD) have been met. Diagnostic Code (DC) 7346. 3. The criteria for an extraschedular rating for hiatal hernia have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.130, Diagnostic Code (DC) 7346. 4. The criteria for entitlement to SMC pursuant to 38 U.S.C. § 1114(s) have been met effective May 12, 2016. 38 U.S.C. §§ 1114(s), 5101, 5103, 5103A, 5107, 5121; 38 C.F.R. § 3.350. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1969 to December 1972. As an initial matter, this case has a complicated procedural history. This matter comes before the Board of Veterans’ Appeals (Board) from a March 2003 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). The Board first issued a decision in this case in May 2005 when it denied entitlement to a rating in excess of 30 percent for hiatal hernia with GERD. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In February 2006, pursuant to a Joint Motion for Partial Remand, the Court partially vacated and remanded the May 2005 Board decision. In December 2006 the Board denied entitlement to a rating in excess of 30 percent for hiatal hernia with GERD, to include on an extraschedular basis. Subsequently, this matter has been appealed to the Court an additional four times, resulting in three Board decisions in February 2009, May 2014, and October 2019, and two Board remands in June 2012 and October 2015. Most recently, the Court remanded the matter to the Board in August 2020 pursuant to a Joint Motion for Vacatur and Remand to address the August 13, 2015, Vocational Assessment by W.C., MS, when adjudicating whether Appellant’s hernia symptoms exhibit marked interference with employment. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). Increased Rating The Veteran is currently rated at 30 percent under DC 7346 for a hiatal hernia and contends that he is entitled to an extraschedular rating because his symptoms are not contemplated by the rating criteria. The Veteran’s hiatal hernia with GERD is rated pursuant to 38 C.F.R. § 4.114, Diagnostic Code (DC) 7346, for hiatal hernia. Pursuant to DC 7346, a 10 percent disability rating is warranted for two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent evaluation is warranted for persistently recurring epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. The maximum 60 percent evaluation is warranted for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. The Board observes that the terms “considerable” and “severe” are not defined in the VA rating schedule. However, rather than applying a mechanical formula, the Board must evaluate all the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. 1. For the period on appeal, prior to March 25, 2010, entitlement to a rating in excess of 30 percent for hiatal hernia with gastroesophageal reflux (GERD) 2. Effective March 25, 2010, entitlement to a rating of 60 percent for hiatal hernia with gastroesophageal reflux (GERD) For the reasons that follow, the Board finds the Veteran’s hiatal hernia with GERD manifested in persistently recurring epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health prior to March 25, 2010. Thereafter, the Board finds the Veteran’s disability manifested in severe heartburn, hematemesis (vomiting with blood), regurgitation, reflux, diarrhea, chest, arm and shoulder pain, difficulty swallowing, dizziness, headache, and fatigue, productive of a severe impairment of health. VA treatment records dated from 2000 to 2003 show occasional complaints of stomach problems and difficulties with acid reflux. It was noted that he was on medication for acid reflux at this time with varying levels of success. He reported that his GERD interfered with his career as a singer because he would have to stop singing approximately 40 minutes into his performance due to GERD symptoms. In a private medical letter dated May 2003, Dr. H.S. indicated that the Veteran had severe heartburn and regurgitation of food while trying to work as a singer. The Veteran followed diet recommendations but still experienced acid reflux when he tried to perform. It was indicated that this interfered with his ability to work. In September 2003, the Veteran testified at a hearing at the RO. He indicated significant weight loss in service and again in 1988, but that his current weight was 235 pounds. He indicated that he had not been hospitalized because of the disability or treated for or diagnosed with anemia. He reported diarrhea six times daily due to his medications. He reported that he vomited approximately once a week but did not vomit blood. He denied black tarry stools. He said he experienced reflux and chest and shoulder/arm pain daily, and difficulty swallowing approximately three times a week. He also reported regurgitation, especially with certain postural movements. VA outpatient records between July 2005 and September 2006 show some adjustments of the medication for the appellant’s GERD due to side effects of dizziness and swelling. An August 2006 note indicated that his GERD was stable with his medication regime (Prilosec). August 2006 private medical records reveal the veteran complained of pain and difficulty when swallowing which had been persistent for about one month as well as a sore throat. Anemia, recent weight change, vomiting and coughing up of blood were not noted. VA treatment records from November 2007 to June 2009 reveal the Veteran denied nausea, vomiting, hematemesis, or melena. He was told to lose weight and was maintained on omeprazole. A March 25, 2010 VA examination revealed reports of worsening symptoms since the November 2002 VA examination. The Veteran reported nausea and vomiting several times per week, hematemesis (blood in his vomit) or melena (blood in his stools) several times per week, regurgitation several times per week, weight loss of 28 pounds in the past six to eight months (10% of baseline), pain when swallowing, severe heartburn, shoulder and arm pain several times per week, frequent dysphagia, and medication side effects of headaches and dizziness. A barium swallow test was normal. The physician noted there was positive occult blood unrelated to his hiatal hernia. See also April 2010 EGD. An April 2010 EGD was completed for questionable melanotic stools. Results were normal except for the known hernia. In July 2011 the Veteran reported taking omeprazole about every other day when his reflux symptoms were bad enough, despite the dizziness and severe headaches the medication causes. A June 2013 EGD noted few esophageal changes, but his physician noted the Veteran was still having significant symptoms from hiatal hernia and reflux, which the physician suspected was causing problems with his voice and potential aspiration. 2016 and 2017 private and VA treatment records reveal continued medication changes due to side effects such as dizziness and weakness. The Veteran continued to report daily indigestion and heartburn and occasional vomiting despite medications. See, e.g., February 2016 and May 2017 VA treatment records. An April 2017 private EGD showed distal esophagitis with acute/chronic inflammation. Additionally, though the Veteran was evaluated for reports of dizziness in April and May 2018, evaluations indicated the dizziness appeared to be related to the Veteran’s positioning rather than side effects from medications. Additionally, between November 2017 and November 2018 the Veteran frequently sought treatment for orthopedic and neurological concerns, but records do not indicate any significant treatment for hiatal hernia with GERD other than continuing medications. As above, the Veteran has never been diagnosed with anemia. As for weight loss, a longitudinal review of the medical evidence shows no material weight loss present. For example, VA outpatient records show the Veteran weighed 236 pounds in June 2000, 242 pounds in August 2006, 248 pounds in December 2016, and 238 pounds in April 2018. Additionally, at least some of the weight loss has been intentional to ameliorate some of his symptoms. See August 2002 Correspondence. Therefore, not only has the Veteran’s weight remained within a relatively stable range, but it cannot all be categorized as an adverse effect of his disability. The Board has also considered the Veteran’s lay statements that his disability has been more severe than that contemplated by the 30 percent rating criteria for the entire period on appeal. While he is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses, he is not competent to identify a specific level of disability of this disorder according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran’s hiatal hernia has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and other clinical evidence) directly address the criteria under which this disability is evaluated. Moreover, as the examiner has the requisite medical expertise to render a medical opinion regarding the degree of impairment caused by the disability and had sufficient facts and data on which to base the conclusion, the Board affords the medical opinion and findings great probative value. As such, these records are more probative than the Veteran’s subjective complaints of increased symptomatology. Additionally, as above, though medical records indicate continuing treatment and medication for hernia with GERD over the entire period on appeal, the medical evidence prior to March 2010 reveals a relatively stable condition without some of the more severe symptoms the Veteran is currently experiencing, such as hematemesis. Further, records from 2016 onward do not indicate any significant change in his treatment. Though the Veteran reported frequently for treatment of his back disability in 2017 and 2018, there are no significant complaints related to his hernia during that same period. Though the absence of significant treatment during this time period is not altogether dispositive of the claim, it is nonetheless probative evidence to be considered in deciding this claim and may be viewed as evidence indicating a lesser severity of illness than contended. See AZ v. Shinseki, 731 F.3d 1303, 1318 (Fed. Cir. 2013) (recognizing the widely held view that the absence of an entry in a record may be considered evidence that the fact did not occur if it appears that the fact would have been recorded if present). Accordingly, the Board finds that prior to March 25, 2010, the Veteran’s hiatal hernia with GERD manifested in persistently recurring epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health, corresponding to the criteria for a 30 percent rating under DC 7346. A higher 60 percent rating under DC 7346 is not warranted unless there are symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. As above, though the Veteran’s statements to the VA reflect progressively worsening symptoms, the objective medical evidence do not reflect any of the explicitly listed symptoms prior to the March 2010 VA examination. Additionally, the evidence reflects the combination of the Veteran’s symptoms produces a considerable, but not severe, impairment of health. Thus, the Veteran’s hiatal hernia with GERD did not more nearly approximate a combination of symptoms productive of severe impairment of health prior to March 25, 2010, and a higher 60 percent rating under DC 7346 is not warranted. However, as of March 25, 2010, resolving all reasonable doubt in favor of the Veteran, the Board finds the Veteran’s hiatal hernia with GERD results in a combination of symptoms productive of severe impairment of health. Specifically, his disability is manifested by vomiting with blood (hematemesis); regurgitation; severe recurrent heart burn; frequent dysphagia; acid reflux; pain in his shoulders, chest, and arms; diarrhea; and headaches, dizziness, and fatigue resulting from medications. Therefore, a rating of 60 percent, the maximum schedular rating, is granted effective March 25, 2010. 3. An extraschedular rating for hiatal hernia with gastroesophageal reflux disease (GERD) The Veteran contends that an extraschedular rating greater than 60 percent is warranted due to a marked interreference in employment. Consideration of an extraschedular rating requires a three-step inquiry. The first question is whether the schedular rating criteria adequately contemplate the Veteran’s disability picture. If the schedular evaluation does not contemplate the level of disability and symptomatology shown and is found inadequate, then the second inquiry is whether the exceptional disability picture exhibits other related factors, such as marked interference with employment or frequent periods of hospitalization. See Thun v. Peake, 22 Vet. App. 111 (2008). The first Thun element compares a claimant’s symptoms to the rating criteria, while the second addresses the resulting effects of those symptoms. Thus, the first and second Thun elements, although interrelated, involve separate and distinct analyses. Yancy v. McDonald, 27 Vet. App. 484, 495 (2016). If the veteran’s disability picture meets the second inquiry, then the third step is to refer the case to the Director of Compensation Services to determine whether an extraschedular rating is warranted. See Thun, 22 Vet. App. 111. Regarding the first element, in the October 2019 Board decision, the Board conceded that all the Veteran’s symptoms are not specifically contemplated by the schedular rating criteria. Regarding the second Thun element, although the available schedular evaluations are inadequate to rate the Veteran’s combination of symptoms, the exceptional disability picture does not exhibit other related factors, such as marked interference with employment or frequent periods of hospitalization. The Veteran’s symptoms are not so severe as to cause marked interference with employment or frequent hospitalizations. The Veteran has not had any frequent periods of hospitalization related to the hiatal hernia, nor does he contend so. He has been service-connected for this disability since 1977 and in this period has had physicians’ appointments, been prescribed medications, and underwent several procedures, including esophagogastroduodenoscopies (EGDs), related to the hernia. However, there is no evidence of any periods of hospitalization that required an overnight stay. Therefore, the disability picture does not result in frequent hospitalizations. Regarding marked interference with employment, the Veteran contends that his hernia with GERD interferes with his ability to work as a singer in a one-man band, as his reflux and stomach problems prevent him from singing. The evidence shows that he is unemployed and has not worked since 1988. His previous jobs have included a custodian, a musician, and a heavy equipment operator. He completed eleven years of education and dropped out of high school in his senior year. The Veteran’s Social Security Administration (SSA) records show that he has been receiving disability benefits due to a nonservice-connected back disability since 1988. The decision makes no mention of the Veteran’s hiatal hernia, which had been present since 1977 and was active during the period surrounding the decision. The Veteran has also made statements as to how this back disability has caused significant interference in obtaining employment. For example, in an April 2003 correspondence with VA, the Veteran referred to himself as a “marked man” due to his multi-level degenerative disc disease because of how it restricted him from employment opportunities. As such, the evidence shows that a major cause of his unemployability is a back disorder, which is unrelated to his hiatal hernia. In testimony before a hearing officer at the RO in September 2003 he indicated that he continued to receive Social Security disability benefits and that his self-employment as a one-man band involved performing about two nights per week. The Veteran did not stop performing until 2000, about 10 years after he first received Social Security disability benefits. The staged rating currently in effect already contemplates significant occupational impairment. Any interference with his ability to work was proportional to the severity of his disability. The September 2002 VA examination found the Veteran could perform work in a job or environment which allowed intermittent verbal communications and work duties that could be interrupted for short breaks as needed. The March 2010 VA examiner did not note any effect of his hiatal hernia on his usual occupation because the Veteran was unemployed at the time due to degenerative disc disease of the lower back. However, she did indicate that his hiatal hernia had no effect on his usual daily activities. The Board has considered the August 13, 2015, Vocational Assessment by W.C., MS. Mr. W.C. concluded that the Veteran could not perform any work due to his inability to attend consistently to any type of work environment due to his symptoms. However, this opinion is inadequate for two reasons. First, Mr. W.C.’s curriculum vitae indicates that he is an expert in vocational assessment and is not medically trained. Therefore, though he may be qualified to render an opinion on what occupations the Veteran is able to perform despite his physical limitations, he is not qualified to assess the Veteran’s physical limitations in the first instance. See Sklar v. Brown, 5 Vet. App. 140, 146 (1993) (professional credentials and experience of opinion providers are properly considered in assigning probative value). Here, Mr. W.C. has done both. Second, Mr. W.C.’s conclusion was based, in large part, on the Veteran’s own subjective reports. However, these reports are inconsistent with the totality of the evidence. For example, the report indicated that the Veteran reported that he stopped working due to limitations from side effects of his medications. However, as above, the Veteran stopped working in the late 1980’s due to his back disability and has not previously contended he stopped working due to the medications; rather he contends it is due to the reflux and pain that occurs after the Veteran starts singing. Additionally, Mr. W.C. indicated that the Veteran reported that he had eight days per month with little to no symptoms, and 12-15 days per month with significant symptoms where he is unable to do much of anything. However, this is not consistent with the longitudinal evidence. As above, between the September 2002 and March 2010 VA examinations, treatment records reflect continuing follow-up and medication changes, complaints of dizziness as a side effect of medications, reflux, and occasional dysphagia. See, e.g., April 2003 VA treatment records; August 2006 VA treatment records; September 2006 VA treatment records. It is not until the March 2010 VA examination where more severe symptoms, such as vomiting with blood are reflected consistently in the medical evidence. Regardless, even considering the worsening of his symptoms shown by the March 2010 VA examination, these symptoms are still not consistent with the Veteran’s reports of 12-15 days per month where he is unable to function normally. In July 2011 the Veteran reported taking omeprazole about every other day despite side effects of dizziness and severe headaches. Subsequent medical records reflect continuing monitoring of the disability without significant changes in symptomatology. See, e.g., February 2016 and May 2017 VA treatment records. Further, as above, early 2018 evaluations indicated the dizziness appeared to be related to the Veteran’s positioning rather than side effects from medications. Other VA treatment records between November 2017 and November 2018 do not indicate any significant treatment for hiatal hernia with GERD other than continuing medications. Accordingly, the Veteran’s reports to the August 2015 vocational examiner are inconsistent with his reports to his physicians in the years prior to and after the vocational assessment. Accordingly, the Board gives more weight to the contemporaneous medical statements made by the Veteran. Curry v. Brown, 7 Vet. App. 59 (1994). Consequently, the Board finds the August 2015 vocational assessment to be entitled to no probative weight as its conclusions were based, at least in part, on the Veteran’s statements regarding the severity and frequency of his symptoms which, as previously discussed, were found to be not consistent with other evidence in file. See Kowalski v. Nicholson, 19 Vet. App. 171 (2005); see also Coburn v. Nicholson, 19 Vet. App. 427 (2006); Swann v. Brown, 5 Vet. App. 229, 233 (1993). Additionally, while the August 2015 vocational assessment questioned the competence of the September 2002 VA examiner to opine on vocational related matters, the Board finds the medical findings of the VA examination are consistent with the medical evidence at that time. Further, the VA examiner’s conclusion was squarely within her competence as a medical professional, i.e., the limiting effects of the Veteran’s symptoms. Therefore, the Board finds that the September 2002 examiner’s opinion is consistent with the totality of the evidence at that time and within her competence, and the opinion is entitled to great probative weight for the period prior to March 2010, when evidence shows a worsening of the Veteran’s symptoms. Further, the Board notes that the Veteran has contended his hernia and GERD symptoms cause depression. However, in 2011 the Court’s Memorandum Decision held that it was not error for the Board to fail to adjudicate the unraised secondary service connection issue of depression. Subsequently, the Veteran was granted a 70 percent rating for PTSD with depression, effective May 12, 2016, the date the Veteran filed the claim, and was later granted TDIU effective that same date based solely on PTSD and depression. Accordingly, any depression symptoms are already compensated from the date he applied for compensation. More importantly, his depression symptoms have been found to be related to his PTSD rather than his hernia with GERD. In May 2013 and July 2017, the Director of Compensation could not find any evidence of record to substantiate marked interference in employment sufficient to warrant the assignment of an extraschedular rating. After examining the record, the Board concludes the Veteran’s service-connected hiatal hernia with GERD does not cause marked interference with employment. Although “marked interference with employment” is a term of art left undefined by case law and regulations, the Board has interpreted this standard broadly. However, this cannot reasonably be construed as limiting consideration to the effect of the service-connected disability on one’s chosen profession, as the Veteran would like the Board to do. Rather, the regulation appears to contemplate marked interference with employment in general. How a disability specifically impacts an individual veteran is not relevant to whether the disability is exceptional; here, the impact on a prior, specific job is not the relevant question for this aspect of the claim. Clearly, the Veteran’s disability is productive of some level of industrial loss which is anticipated by the ratings schedule and the assigned 30 and 60 percent staged rating. In this regard, if these problems did not cause difficulties there would be no basis for a compensable evaluation, let alone the current evaluation. It cannot be said that his occupational impairment is “marked” in degree, which, although a level less than total impairment, still indicates a rather significant level of impairment, which is not shown here. For example, he states he was a “one-man band” but could no longer do this activity because of problems with his voice. A one-man band implies he played musical instruments too, and any interference with his singing ability would not interfere with his ability to play instruments, so he could still work within the performing field. Regardless, to warrant extraschedular consideration, that interference must be marked in degree, and that is what is not shown here. Even accepting he could no longer sing because of the reflux symptoms, this does not demonstrate marked interference in other types of employment. The Board finds that the Veteran’s disability picture is not exceptional and does not exhibit related factors such as “marked interference with employment” or “frequent periods of hospitalization.” Accordingly, an extraschedular rating above 60 percent is not warranted. Therefore, the Board concludes that the Veteran’s disability picture does not exhibit other related factors such as marked interference with employment or frequent periods of hospitalization that would warrant further extraschedular consideration. 4. Entitlement to special monthly compensation (SMC) pursuant to 38 U.S.C. § 1114(s) is granted, effective May 12, 2016 A veteran is presumed to be seeking the maximum benefit allowed by law or regulation, and such a claim remains in controversy, even if partially granted, where less than the maximum benefit available is awarded. AB v. Brown, 6 Vet. App. 35, 38 (1993). Moreover, VA has a duty to fully and sympathetically develop a veteran’s claim to its optimum, which includes determining all potential claims raised by the evidence and applying all relevant laws and regulations. Moody v. Principi, 360 F.3d 1306, 1310 (Fed. Cir. 2004). Relevant to this appeal, a claim for increased disability compensation may include the “inferred issue” of entitlement to SMC even where the veteran has not expressly placed entitlement to SMC at issue. Akles v. Derwinski, 1 Vet. App. 118, 121 (1991). SMC at the housebound rate is payable where a veteran has a single service-connected disability rated as 100 percent and, in addition: (1) has a 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. See 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). Subsection 1114(s) requires that a disabled veteran whose disability level is determined by the ratings schedule must have at least one disability that is rated at 100 percent in order to qualify for the SMC provided by that statute. The Court declared, however, if a Veteran were awarded a TDIU based on multiple underlying disabilities and then later receives a schedular disability rating for a single, separate disability that would, by itself, create the basis for an award of a TDIU, that the order of the awards was not relevant to the inquiry as to whether any of the disabilities alone would render the Veteran unemployable and thus entitled to a TDIU rating based on that disability alone. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2010). The Veteran has been assigned TDIU based solely due to his PTSD, effective May 12, 2016. Although his PTSD is not rated as 100 percent, for SMC purposes this disability satisfies the requirement of a “service-connected disability rated as total.” See Buie, 24 Vet. App. at 251; see also Bradley v. Peake, 22 Vet. App. 280, 293 (2008). The Veteran is now granted a 60 percent evaluation for his hernia with GERD effective March 25, 2010. Because the Veteran has a single service-connected disability rated as total (i.e. his PTSD) and has additional service-connected disabilities that combine to be independently ratable at at least 60 percent as of May 12, 2016, the criteria for SMC at the housebound rate are met.   Thus, considering the Court’s decisions in Bradley and in Buie, entitlement to SMC at the housebound rate under 38 U.S.C. § 1114(s) is granted, effective May 12, 2016. Nathaniel J. Doan Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K.L. Blevins, 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.