Citation Nr: 21021843 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 16-33 393 DATE: April 14, 2021 ORDER Entitlement to a disability rating higher than 20 percent for the service-connected right hip impaired flexion is denied. Entitlement to a disability rating higher than 10 percent for the service-connected right hip impaired extension is denied. Entitlement to a disability rating higher than 10 percent for the service-connected right knee disability is denied. Entitlement to a disability rating of 70 percent, but not higher, for the service-connected acquired mental disability is granted. Entitlement to Special Monthly Compensation (SMC) based on the need for aid and attendance of housebound status is denied. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) for the period prior to February 14, 2017, is granted. FINDINGS OF FACT 1. The service-connected right hip impaired flexion is manifested by flexion that is limited to 30 degrees. 2. The service-connected right hip impaired extension is currently assigned the maximum rating provided by the rating schedule. 3. The service-connected right knee disability is manifested by flexion that is limited to less than 30 degrees. 4. The service-connected acquired mental disability is manifested by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, but not total occupational and social impairment. 5. The Veteran is not in need of aid and attendance due to service-connected disabilities, and is not housebound, nor does he have a single disability rated at 100 percent and additional disabilities rated at 60 percent. 6. For the period prior to February 14, 2017, the Veteran’s service-connected disabilities rendered him unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for a disability rating higher than 20 percent for the service-connected right hip disability are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5252 (2019). 2. The criteria for a disability rating higher than 10 percent for the service-connected right hip impaired extension are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5251 (2019). 3. The criteria for a disability rating higher than 10 percent for the service-connected right knee disability are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260 (2019). 4. The criteria for a disability rating of 70 percent for the service-connected mental disability are met; the criteria for a rating of 100 percent are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.130, Diagnostic Code 9440 (2019). 5. The criteria for SMC based on the need for aid and attendance or housebound status are not met. 38 U.S.C. §§ 1114, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.350, 3.352, 4.2, 4.3, 4.6, 4.10, 4.40, 4.45, 4.59 (2019). 6. Prior to February 14, 2017, the criteria for TDIU were met. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.15, 4.16 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a veteran (the Veteran) who had active duty service from November 1975 to February 1996. This appeal comes before the Board of Veterans’ Appeals (Board) from rating decisions dated May 2014 and June 2016 of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran initially requested a Board hearing, but subsequently withdrew his request. VA added additional relevant treatment records to the claims file. He was offered the opportunity to waive consideration of this evidence in the first instance by the Agency of Original Jurisdiction (AOJ), at which time he was notified that he had 45 days to respond. As he did not respond, the Board will consider this evidence in the first instance. Increased Ratings—Law and Regulations Disability ratings are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in a veteran’s condition. Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. See 38 C.F.R. § 4.1. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Nevertheless, where a veteran is appealing the rating for an already established service-connected condition, his present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. Staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection of parts of the musculoskeletal system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. The functional loss may be due to absence of part, or all, of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca, supra; see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016). Generally, lay evidence is competent regarding identification of a disease with unique and readily identifiable features which are capable of lay observation. A lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir 2007). Lay persons may also provide competent evidence regarding a contemporaneous medical diagnosis or a description of symptoms in service which supports a later diagnosis by a medical professional. However, a lay person is not competent to provide evidence as to more complex medical questions, i.e., those which are not capable of lay observation. Lay statements are not competent evidence regarding diagnosis or etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); Jandreau, at 1377, n. 4 (‘sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer’); 38 C.F.R. § 3.159(a)(2). After the evidence has been assembled, it is the Board’s responsibility to evaluate the entire record. 38 U.S.C. § 7104(a) (West 2014). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.3. A VA claimant need only demonstrate that there is an approximate balance of positive and negative evidence in order to prevail. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996); Gilbert at 54. Entitlement to a disability rating higher than 20 percent for the service-connected right hip impaired flexion. Entitlement to a disability rating higher than 10 percent for the service-connected right hip impaired extension. The current appeal arises from a service connection claim received at VA on February 28, 2013. In a May 2014 rating decision, VA granted service connection for impairment of right hip extension and assigned an initial disability rating of 10 percent under Diagnostic Code 5251, effective February 28, 2013. VA also granted service connection for impairment of right hip flexion (characterized as degenerative joint disease) and assigned an initial disability rating of 20 percent under Diagnostic Code 5252 (limitation of flexion), effective February 28, 2013. Under Diagnostic Code 5251, there is only a single rating available for limitation of extension. A 10 percent rating is the maximum allowable. 38 C.F.R. § 4.71a, Diagnostic Code 5251. Under Diagnostic Code 5252, a rating of 40 percent is allowable if flexion is limited to 10 degrees. A rating of 30 percent is allowable if flexion is limited to 20 degrees. A rating of 20 percent is allowable if flexion is limited to 30 degrees. A rating of 10 percent is allowable if flexion is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5252. The Board notes that 38 C.F.R. § 4.71a was substantially amended, effective February 7, 2021. However, these codes were not changed. A January 2014 VA Examination reveals a diagnosis of degenerative joint disease. Range of motion was to 30 degrees of flexion, at which point, pain began. Extension was to 5 degrees, at which point, pain began. There were no flares reported. The Veteran could not perform repetitive use testing because he said it was too painful. Muscle strength was 3/5. The examiner opined that the Veteran was only capable of sedentary work, which was inconsistent with his work history, involving physical labor (Record 01/28/2014). An April 2017 VA Examination reveals a diagnosis of osteoarthritis. The Veteran stated that he has flares of right hip pain that seem to occur randomly. He will avoid weight bearing especially when he has a flare. With a flare, he will take to his recliner and apply a heating pad to either the hip or knee to obtain some relief. He has in the past had steroid injections into the right hip, but without any long-term benefit. Range of motion was from 30 degrees flexion and 20 degrees extension. After 3 repetitions, flexion was measured to 40 degrees and extension to 15 degrees. Muscle strength was full, with no atrophy. It was opined that the Veteran would not be able to do physical work. He could do a sedentary job provided that he could get up and stretch his hip and knee as needed to decrease the pain (Record 04/28/2017). A December 2017 rheumatology note reveals severe osteoarthritis of the right hip which is “quite debilitation” (Record 02/08/2018 at 8). Range of motion was not assessed. Outpatient treatment records can be summarized as showing complaint of hip pain associated with motion, as well as decreased strength and endurance in the right lower extremity. After a review of all the evidence, the Board finds that the criteria for higher ratings are not met for either disability. As noted above, there is only a single rating for limitation of hip extension. Therefore, the rating schedule does not contemplate a rating higher than is currently assigned. Regarding flexion, the rating schedule is fundamentally based on measurements of range of motion. Here, the Veteran’s range of flexion has been measured and is not supportive of a rating higher than 20 percent. The Board understands that repetitive use of the joint causes pain, which may reduce flexion; however, there is no indication that it would reduce flexion to 20 degrees or less, which is required for a rating higher than 20 percent. In sum, the Board finds that the Veteran's symptoms are most consistent with the currently assigned ratings. The Veteran's symptomatology does not more nearly approximate the criteria for any higher rating. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against each claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 371 (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). Entitlement to a disability rating higher than 10 percent for the service-connected right knee disability. In a May 1996 rating decision, VA granted service connection for a right knee disorder and assigned an initial disability rating of 10 percent under Diagnostic Code 5260, effective March 1, 1996, the date following service separation. In December 1999, the rating was decreased to 0 percent. The current appeal arises from a service connection claim received at VA on February 28, 2013. In May 2014, the rating was increased to 10 percent, effective February 28, 2013. Ratings for limitation of knee motion are addressed by Diagnostic Codes 5260 and 5261. Diagnostic Code 5260 addresses limitation of flexion of the knee. Under that code, a 30 percent rating is for application were flexion is limited to 15 degrees; a 20 percent rating is for application where flexion is limited to 30 degrees; a 10 percent rating is for application where flexion is limited to 45 degrees; a 0 percent rating is for application where flexion limited to 60 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. This code was not changed in the recent amendment to 38 C.F.R. § 4.71a. Diagnostic Code 5261 addresses limitation of extension of the knee. Under that code, a 50 percent rating is for application where extension is limited to 45 degrees; a 40 percent rating is for application where extension is limited to 30 degrees; a 30 percent rating is for application where extension is limited to 20 degrees; a 20 percent rating is for application where extension is limited to 15 degrees; a 10 percent rating is for application where extension is limited to 10 degrees; a 0 percent rating is for application where extension is limited to 5 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. This code was not changed in the recent amendment to 38 C.F.R. § 4.71a. Diagnostic Code 5256 governs ankylosis (complete bony fixation) of the knee, which is neither asserted nor shown here with respect to either knee. Former Diagnostic Code 5257 addresses recurrent subluxation or lateral instability of the knee. Under that code, a 30 percent rating is for application where subluxation or lateral instability is severe. A 20 percent rating is for application where subluxation or lateral instability is moderate. A 10 percent rating is for application where subluxation or lateral instability is slight. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The amendments to Diagnostic Code 5257 require a diagnosed condition affecting stability of the joint or subluxation. In this case, there are no such diagnoses. The Board notes that the criteria under Diagnostic Codes 5257, 5260, and 5261 are not considered to be overlapping, and therefore separate ratings can be assigned where appropriate symptomatology is shown. Diagnostic Code 5258 rates based on dislocation of the semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. A 20 percent rating is the only rating available. Diagnostic Code 5259 provides a 10 percent rating for symptomatic removal of the semilunar cartilage. These codes were not changed in the recent amendment to 38 C.F.R. § 4.71a. A January 2014 VA Examination reveals a diagnosis of degenerative joint disease. Range of motion was to 90 degrees of flexion, with painful motion starting at 60 degrees. There was no limitation of extension; however, motion was painful at 20 degrees. The Veteran could not perform repetitive use testing because it was too painful. Muscle strength was 3/5. Joint stability could not be tested. The Veteran had a meniscal condition with frequent locking and joint pain. The Veteran had a history of meniscectomy (Record 01/28/2014). An April 2017 VA Examination reveals a diagnosis of osteoarthritis. The Veteran reported that he will have flares of pain in the right knee that seem to occur randomly. He states that he had a flare of the right knee pain earlier that week. He will avoid prolonged weight bearing. He was unable to do any running. Flexion was measured to 90 degrees and extension was full. There was pain with weight bearing. The Veteran would often have flares more severe than what he was experiencing. The range of motion at those times could not be determined because at those times the Veteran avoids the activities that cause more pain. Strength was full, with no muscle atrophy. There was no history of subluxation. The Veteran stated that he will have occasional swelling of the right knee occurring 4-5 times per month, lasting about 24 hours. All joint stability testing was normal. It was opined that the Veteran would not be able to do a physical job. He could do a sedentary job provided he was able to stand periodically to stretch his knee (Record 04/28/2017). Outpatient treatment records can be summarized as showing a painful right knee, as well as decreased strength in the right lower extremity. After a review of all the evidence, the Board finds that the criteria for a rating higher than 10 percent are not met, and that no separate compensable ratings are warranted. Regarding flexion and extension of the knee, the rating schedule is fundamentally based on measurements of range of motion. Here, the Veteran’s range of flexion and extension have been measured and the results are not supportive of a rating higher than 10 percent for impairment of knee flexion; and, as extension is normal, a separate rating is not warranted. Regarding instability, the evidence does not demonstrate lateral instability to any extent, or subluxation, even considering the Veteran’s statements. See English v. Wilkie, 30 Vet. App. 347 (2018). There is also no diagnosed condition affecting stability (pertinent to the amended rating schedule). Regarding meniscal conditions, the Veteran has a history of a meniscal condition, with meniscectomy. However, the maximum rating is 10 percent under Diagnostic Code 5259. As the condition has been surgically repaired, Diagnostic Code 5258 is not applicable. In sum, the Board finds that the service-connected right knee disability is manifested flexion that is limited to less than 30 degrees, with normal extension, without lateral instability or subluxation, and without distinct meniscal involvement. Considering these findings of fact, the Board concludes that a disability rating higher than 10 percent for the service-connected right knee disability is not warranted, and that no separate ratings are warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette, 28 Vet. App. 366, 371. Entitlement to a disability rating higher than 50 percent for the service-connected mental disability. The current appeal arises from a service connection claim received at VA on February 28, 2013. After initially denying the claim, in a June 2016 rating decision, VA granted service connection for an acquired psychiatric disorder and assigned an initial disability rating of 50 percent under Diagnostic Code 9440, effective February 28, 2013. Pertinent to the claim on appeal, the General Rating Formula for Mental Disorders at 38 C.F.R. § 4.130 provides the following ratings for psychiatric disabilities: A 100 percent rating contemplates total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent rating, may be assigned for 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); and inability to establish and maintain effective relationships. The criteria for a 70 percent rating are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). A 50 percent rating is warranted if it is productive of 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 compete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 30 percent rating is warranted for PTSD if there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, recent events). A 10 percent rating is warranted for PTSD if there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. A 0 percent rating is warranted where a mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. An August 2010, note from a VA psychologist states that the Veteran’s symptoms include nightmares, flashbacks, hypervigilance, easily startled, difficulty expressing loving feelings, anger outbursts, irritability, sleep problems, heart palpitations, difficulty concentrating, and difficulty making decisions (Record 03/12/2013). An October 2015, VA Mental Disorders Examination reveals a diagnosis of adjustment disorder with anxiety resulting in occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. Symptoms included anxiety, suspiciousness, chronic sleep impairment, mild memory loss, impaired judgment, disturbances of motivation and mood, chronic irritability, occasional verbal aggression, self-deprecating ideations, psychomotor restlessness, insomnia, ruminative ideations regarding current employment and social functioning, and fears of continued difficulty in successfully managing his co-occurring psychiatric and somatic disorders to allow for his achieving adequate success and contentment in his life, and increasing fears of becoming socially isolated, fears of continued declines in physical functioning. The Veteran reported occasional depressive episodes. The Veteran was not employed. His last employment period ended during 2011. He reported that he was not experiencing significant impairment in his overall social functioning. He had several long-term friends and he reported receiving adequate emotional support from those individuals. He denied significant impairment in community settings. The results of a brief mental status examination found that the Veteran appeared his stated age, was adequately groomed, and casually attired. He displayed anxious affect and stated his mood in positive terms. The Veteran did not display any abnormal or inappropriate behavior during the 60-minute interview. The Veteran displayed an open and cooperative attitude towards the examiner. His speech production was within normal limits in terms of pitch, pace, and volume. The content of his speech indicated reality-based, concise, adaptive ideations and no evidence of formal thought disorder or frank psychotic thinking was observed. His skills in insight and judgment were assessed as intact. Concentration and memory were mildly impaired. He denied suicidal ideation or homicidal ideation (Record 10/28/2015). A private assessment dated in March 2016 reveals that the Veteran was divorced from his wife for mental cruelty on his part. He reported he had five jobs in 15 years. He reported in one situation he had a physical altercation that cost him his position. He stated he has no close friends, only a couple of acquaintances. He reported he spends most of his free time in his house as somewhat a recluse since the divorce. He reported great difficulty in sleeping. Throughout the four-session interview process, he exhibited tense anxiety and frustration. He exhibited flattened emotions with frequent anger outbursts. He has extensive memory problems—not able to remember even the names of people he has known for a long period of time. He has continued to report typical behavior and anger outburst with little or no provocations (Record 03/22/2016). A May 2016 VA Opinion essentially linked the Veteran’s diagnosis of a mental disorder to events in service. This was the basis for granting service connection (Record 05/22/2016). A May 2017 VA Examination reveals a diagnosis of adjustment disorder with mixed anxiety and depressed mood. This diagnosis was a progression of the already service-connected adjustment disorder with anxiety. The examiner opined that the diagnosed disability resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. Symptoms included depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The Veteran reported that he had been with his girlfriend for 5 1/2 years. “It’s the only relationship that matters.” Overall, the Veteran described a moderate level of impairment in social functioning. The Veteran reported no changes in occupational functioning since the previous exam in October 2015. He primarily did very physical shipping/receiving type work. He stated that he has not worked since 2012. He was on SSA for a primary diagnosis of Inflammatory Arthritis and a secondary diagnosis of Affective/Mood Disorder. He stated that the longest job he had after his military retirement was 9 years. The Veteran stated that he had started therapy during a time of particular stress associated with a dysfunctional relationship, and his need for the treatment dropped off once that situation resolved. The Veteran denied current legal or behavioral problems. Hygiene and grooming appeared good. He was alert and oriented to time, place, and person. He also was oriented to the purpose of this evaluation, which was discussed with him along with its associated limits of confidentiality. His behavior was appropriate. His eye contact was good. His attitude toward the examiner was friendly and cooperative. His mood at times appeared somewhat low. His affect appeared full ranging and unrestricted. His thought processes were logical and goal-directed, and the content of the conversation gave no indication of any psychosis or mania at the current time. The Veteran’s speech was unremarkable with regard to rate, rhythm, or volume. His judgment appeared intact; he did not report or describe any instances of recently or significantly impaired judgment. With regard to activities of daily living, such as obtaining and eating food, maintaining personal hygiene, and maintaining household chores. The Veteran denied any homicidal ideation. He also denied any current or recent suicidal ideation, but acknowledged that in the past when experiencing multiple stressors, he had thoughts about “How much can I handle?” He noted that he sees suicide as “the coward’s way” and he reminds himself that “This stuff can be handled. I like living.” At the time of evaluation, suicidal and homicidal ideation were denied. The Veteran reports that he continues to be fearful of lightning and thunderstorms. He is mistrustful of authority figures. The Veteran reported that he does not socialize much, and prefers to keep to himself. His primary satisfaction comes from his relationship with his girlfriend (Record 05/02/2017). Outpatient treatment records can be summarized as showing complaints of anxiety, depression, social withdrawal, irritability, aggression, memory loss, poor judgment, and difficulty maintaining a job. After a review of all of the evidence, the Board finds that the criteria for a rating of 70 percent are met; however the criteria for a rating of 100 percent are not met. As set out in detail above, the rating schedule provides examples of the type and degree of symptoms or their effects that would justify a 70 percent rating. See 38 C.F.R. § 4.130; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002) (symptoms listed in the rating criteria are simply examples of the type and degree of the symptoms, or their effects, that would justify a particular rating; analysis should not be limited solely to whether the claimant exhibited the symptoms listed in the rating scheme). The Court of Appeals for the Federal Circuit has embraced the Mauerhan Court’s interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). Here, the Veteran has anxiety and depression, as well as anger outbursts. These symptoms represent a deficiency in mood. He as a deficiency in judgment, as noted by the October 2015 examiner. He has demonstrated cruelty to his former spouse. This demonstrates a deficiency in family relations. He has an impaired memory. This demonstrates a deficiency in thinking. He has a checkered work history and has not held a job since 2011. This demonstrates a deficiency in work. Thus, the Board finds that the evidence substantiates occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. These are the fundamental criteria for a rating of 70 percent. The evidence does not substantiate total occupational and social impairment. The Veteran has demonstrated full orientation on examination. He has normal speech and has not reported delusional or hallucinatory thought content. In short, the gross impairment of behavior resulting in severe disorientation of the individual, which is contemplated by the 100 percent rating criteria, is simply not evident in this case at any time. In sum, the Board finds that the service-connected acquired mental disability is manifested by occupational and social impairment with reduced reliability and productivity. In light of this finding of fact, the Board concludes that a disability rating higher than 50 percent for the service-connected mental disability is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette, 28 Vet. App. 366, 371. SMC—Law and Regulations Special monthly compensation is payable at a specified rate if a veteran, as the result of service-connected disability, has suffered the anatomical loss or loss of use of both feet, or of one hand and one foot; or is blind in both eyes, with visual acuity of 5/200 or less; or is permanently bedridden or so helpless as to be in need of regular aid and attendance. 38 U.S.C. § 1114(l) (West 2014); 38 C.F.R. § 3.350(b). The criteria for determining that a veteran is so helpless as to be in need of “regular aid and attendance” are contained in 38 C.F.R. § 3.352(a). Those criteria include: (1) Inability of the claimant to dress or undress him or herself or to keep him or herself ordinarily clean and presentable; (2) Frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without assistance; (3) Inability of the claimant to feed him or herself through loss of coordination of upper extremities or through extreme weakness; (4) Inability to attend to the wants of nature; or (5) Incapacity, either physical or mental, that requires care or assistance on a regular basis to protect the claimant from hazards or dangers incident to his or her daily environment. 38 C.F.R. § 3.352(a) Being “bedridden” will also be a proper basis for finding that a veteran is in need of regular aid and attendance. The term “bedridden” means a condition which, through its essential character, actually requires that the claimant remain in bed. However, the fact that someone has voluntarily taken to bed or that a physician has prescribed rest in bed for the greater or lesser part of the day to promote convalescence or cure is not sufficient. Id. Special monthly compensation is payable at a specified rate if a veteran under 38 U.S.C. § 1114(s) when 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 or more, 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 C.F.R. § 3.350(i). For the purpose of meeting the first criterion, a rating of 100 percent may be based on any of the following grants of total disability: on a schedular basis, on an extraschedular basis, or on the basis of a temporary total rating pursuant to 38 C.F.R. §§ 4.28 (pre-stabilization rating), 4.29 (temporary total hospital rating) or, 4.30 (temporary total convalescence rating). Additionally, a total disability rating based on individual unemployability (TDIU) may meet the criterion, but only if assigned for a single disability. See Bradley v. Peake, 22 Vet. App. 280 (2008); Buie v. Shinseki, 24 Vet. App. 242 (2011). While the separate disabilities rated as 60 percent disabling must involve separate and distinct anatomical segments or body systems, the fact that the total disability and the independent 60 percent disabilities result from a common etiological agent will not preclude entitlement. With regard to the permanently housebound requirement, this is met where a veteran is substantially confined as a direct result of a service-connected disability to his or her dwelling and the immediate premises or, if institutionalized, to the ward or clinic areas, and it is reasonably certain that the disability or disabilities and resulting confinement will continue throughout his or her lifetime. Id 38 U.S.C. § 1114(s) does not limit a service-connected disability rated as total to only a schedular rating of 100%. A rating of total disability based on individual unemployability based on a single disability satisfies the statutory requirement of a “total rating. See Bradley v. Peake, 22 Vet. App. 280 (2008) Entitlement to SMC based on the need for aid and attendance of housebound status. The Board has set out the evidence above regarding the service-connected disabilities. The Veteran has been able to attend examinations, and there is no indication, to include his statements, that he has anatomical loss or loss of use of both feet, or of one hand and one foot; that he is blind in both eyes, with visual acuity of 5/200 or less; or is permanently bedridden or so helpless as to be in need of regular aid and attendance. He is clearly not housebound. An October 2013 DBQ reveals that the Veteran was able to feed himself and prepare his own meals; he did not need assistance in bathing and tending to personal needs; he was not blind; he did not require nursing home care; he did not require medication management; he had the ability to manage financial affairs; and, he was able to perform personal hygiene and prepare meals (Record 11/01/2013 ). Additionally, even with the grant of a 70 percent rating for the service-connected mental disability, there is no basis for assignment of SMC based on statutory housebound status. His predominant service-connected disability is his mental disability. This forms the basis for his TDIU, as he has been found to be deficient in the ability to work due to his mental disability. The other disabilities (musculoskeletal and hearing) combined do not meet the criteria of a 60 percent rating. They combine to 40 percent. See Bradley v. Peake, 22 Vet. App. 280 (2008). Accordingly, the Veteran is not in need of aid and attendance; he is not actually housebound; and, he does not meet the statutory requirements for housebound status. In light of these findings of fact, the Board concludes that SMC is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette, 28 Vet. App. 366, 371. TDIU—Law and Regulations It is the established policy of VA that all veterans who are unable to secure and follow a 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. A claim for a total disability rating based upon individual unemployability presupposes that the rating for the service-connected disability is less than 100 percent, and only asks for TDIU because of subjective factors that the objective rating does not consider. Vettese v. Brown, 7 Vet. App. 31, 34-35 (1994). In evaluating a veteran’s employability, consideration may be given to his level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. The term substantially gainful occupation is not specifically defined for purposes of the regulations governing TDIU. However, marginal employment is not considered substantially gainful employment. Marginal employment includes situations in which an individual’s annual income does not exceed the poverty threshold for one person. Employment may be marginal even when the individual’s earned income exceeds the poverty threshold if employed in a protected environment such as a family business or sheltered workshop. 38 C.F.R. § 4.16(a). A total disability rating for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent for more. If there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and the combined rating must be 70 percent or more. 38 C.F.R. § 4.16(a). The Veteran has a combined disability rating of 70 percent for the entire period of the appeal. He has been granted TDIU; however, the RO determined that the effective date should be February 14, 2017, which leaves the issue on appeal from February 28, 2013, to February 14, 2017. Entitlement to TDIU. The Veteran has reported that he last worked in 2011, which is prior to the period on appeal. The RO granted TDIU in May 2017 and assigned the effective date of February 14, 2017, based on what it described as the date of claim, i.e., the date of receipt of the VA Form 21-8940 (Veterans Application for Increased Compensation Based on Unemployability). The Board notes that the date of receipt of a specific claim form for TDIU is not the date of claim if there are increased rating claims in initial adjudication status or in appellate status. In this case, there were several increased rating claims in appellate status at the time of the May 2017 rating decision, and at the time of receipt of the February 2017 claim. Accordingly, the date of receipt of the VA Form 21-8940 is irrelevant for the determination of the effective date for the grant of TDIU. There is no indication from the evidence that the Veteran was capable of substantially gainful employment from the date of claim for increased ratings (February 28, 2013) and the effective date chosen by the RO. To the extent there is any reasonable doubt regarding his ability to obtain or retain substantially gainful employment, the Board resolves such doubt in favor of the claim. In sum, the Board finds that the Veteran’s service-connected disabilities did render him unable to secure or follow a substantially gainful occupation prior to February 14, 2017. As this represents the full benefit sought on appeal, there is no prejudice resulting from any deficiency in the duties to notify or assist. K. A. KENNERLY Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. Cramp 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.