Citation Nr: 21026076 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 14-23 847 DATE: April 29, 2021 ORDER Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD) for the period prior to July 24, 2020, is denied. Entitlement to an increased 100 percent rating for PTSD for the period from July 24, 2020, to September 29, 2020, is granted. Entitlement to special monthly compensation (SMC) based on housebound status, for the period from July 24, 2020, to September 29, 2020, is granted. REMANDED The issue of entitlement to service connection for a disability of the upper respiratory system, to include diagnosed upper respiratory infections and diagnosed chronic obstructive pulmonary disorder (COPD), claimed as chronic / recurrent upper respiratory infections, is remanded. The issue of entitlement to a compensable disability rating for right knee retropatellar pain syndrome is remanded. FINDINGS OF FACT 1. Throughout the rating period prior to July 24, 2020, the Veteran’s PTSD is not shown to have been productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 2. Throughout the rating period from July 24, 2020, to September 29, 2020, the Veteran’s PTSD is reasonably shown to have been manifested by memory loss for names of close relatives, own occupation, or own name (and perhaps disorientation to time or place) productive of total occupational and social impairment. 3. Throughout the rating period from July 24, 2020, to September 29, 2020, the Veteran had a single service-connected disability rated as 100 percent disabling and additional service-connected disabilities independently rated as at least 60 percent, separate and distinct from the 100 percent service-connected disability and involving different bodily systems. CONCLUSIONS OF LAW 1. Throughout the rating period prior to July 24, 2020, the criteria for a rating in excess of 50 percent for the Veteran’s PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.130, Diagnostic Code 9411. 2. Throughout the rating period from July 24, 2020, to September 29, 2020, the criteria for a 100 percent rating for the Veteran’s PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.130, Diagnostic Code 9411. 3. Throughout the rating period from July 24, 2020, to September 29, 2020, the criteria for an award of SMC based upon housebound status have been met. 38 U.S.C. § 1155, 5110; 38 C.F.R. § 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 2003 to December 2007. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. The Veteran initially appealed a broader set of issues, addressed in a May 2014 statement of the case. However, the Veteran’s June 2014 VA Form 9 (Substantive Appeal) specifically limited the appeal to a smaller set of issues, as explained in the Board’s prior February 2020 decision in this case. This case was previously before the Board in February 2020, when the Board issued a decision resolving several issues in appellate status at that time and remanded the remaining issues on appeal to the Agency of Original Jurisdiction (AOJ) for additional development. Each of the issues remanded by the Board in February 2020 has now returned to the Board for further appellate review, with the exception of the issue of entitlement to service connection for a claimed sleep disorder, to include sleep apnea. During the processing of the Board’s remand, the AOJ issued a rating decision in November 2020 that granted entitlement to service connection for sleep apnea as secondary to the service-connected disability of PTSD, and notified the Veteran that this was “a full grant of the issue on appeal.” That issue is no longer in appellate status and has not been returned to the Board. During the processing of the Board’s February 2020 remand, the AOJ additionally granted an increased 70 percent rating for PTSD effective from July 24, 2020, and then also granted an increased 100 percent rating for PTSD effective from September 29, 2020. These increases were granted in rating decisions issued in October 2020 and November 2020. The Veteran maintains his appeal seeking further increases of the ratings for the periods prior to the September 29, 2020, effective date of the award of the 100 percent rating. To this extent, the PTSD rating issue remains in appellate status, and it has been returned to the Board for further appellate review. In September 2019, a videoconference Board hearing was held before the undersigned. A transcript of this hearing is of record. Increased Ratings Disability ratings are determined by comparing a Veteran’s symptomatology during the pertinent period on appeal with criteria set forth in VA’s Schedule for Rating Disabilities, which is based on 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 shall be applied under a particular diagnostic code, the higher rating will be assigned if the disability picture more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. An exception to this rule applies when the rating criteria are successive. In such a case, all the requirements of the lower levels must be met before a higher level is awarded, and 38 C.F.R. §§ 4.7 and 4.21 do not apply. Johnson v. Wilkie, 30 Vet. App. 245 (2018). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. With a claim for an increased initial rating, separate staged ratings may be assigned based on facts found. Fenderson v. West, 12 Vet. App. 119 (1999). In a claim for increase in a previously established rating, the present level of disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the evidence contains factual findings that demonstrate distinct time periods when the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, staged ratings are to be considered. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In determining whether a claimed benefit is warranted, VA must determine whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107 (a); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Lay evidence may be competent to address any matter not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a layperson. 38 C.F.R. § 3.159(a)(2). However, competent medical evidence is necessary where the determinative question is one requiring medical knowledge. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises or statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). The Board has reviewed all of the evidence in the Veteran’s claims file, with an emphasis on the evidence pertinent to the issue on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all contents of the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record but does not have to discuss each piece of evidence. Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. In McGrath v. Gober, 14 Vet. App. 28 (2000), the Court held that when evidence is created is irrelevant compared to when the Veteran was actually experiencing the symptoms. Thus, the Board will consider whether the evidence of record suggests that the severity of pertinent symptoms increased sometime prior to the date of the examination reports noting pertinent findings. The Board has also considered the history of the Veteran’s disabilities prior to the rating period on appeal to see if the history supports a higher rating during the rating period on appeal. Additional references to the Veteran’s service-connected disabilities are presented in evidence of record beyond that discussed below, including in VA medical reports associated with the Veteran’s treatment. The additional evidence of record does not present findings that significantly expand upon, revise, or contradict the findings in the most detailed evidence discussed by the Board in this decision. 1. Entitlement to a rating in excess of 50 percent for PTSD for the period prior to July 24, 2020, is denied. 2. Entitlement to an increased 100 percent rating for PTSD for the period from July 24, 2020, to September 29, 2020, is granted. The Veteran contends that he is entitled to higher ratings for his service-connected PTSD, asserting that the impairment has been more severe than the assigned ratings reflect. The Veteran’s PTSD has been rated under 38 C.F.R. § 4.130, Diagnostic Code 9411. This appeal arises from the initial disability rating assignment associated with the grant of service connection for PTSD. Therefore, the rating period on appeal begins with the October 2010 effective date of the grant of service connection. The Veteran is currently assigned a 50 percent rating for the period prior to July 24, 2020; a 70 percent rating for the remaining period prior to September 29, 2020; and a 100 percent rating thereafter. The Board here considers the Veteran’s appeal for assignment of higher ratings for the periods prior to the September 29, 2020, effective date of the maximum 100 percent rating. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a “holistic analysis” that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). A 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; 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 worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned for 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; or memory loss for names of close relatives, own occupation or own name. As discussed below, the Board finds that reasonable doubt can be resolved in the Veteran’s favor to grant entitlement to an increased 100 percent rating for the rating period from July 24, 2020, to September 29, 2020. Beyond that, the issue in this appeal is whether the Veteran’s associated symptoms have caused the level of impairment required for a disability rating in excess of 50 percent for the period prior to July 24, 2020. The Board concludes that the Veteran’s symptoms have not caused the level of impairment required for a disability rating in excess of 50 percent prior to July 24, 2020. The Veteran’s shown symptoms do not more closely approximate the symptoms associated with a 70 or 100 percent rating prior to July 24, 2020. A June 2011 VA psychiatric examination report, prepared in connection with his original claim of entitlement to service-connected compensation, is of record. The report shows that the Veteran at that time was employed in a job he had held for the prior 2 years, and he “has been engaged for the past 6 years.” This report shows that the Veteran reported “he has nightmares 3 times weekly,” “difficulty going back to sleep,” and “flashbacks ‘not triggered by anything at all’.” The report documents that the Veteran “does have triggers, however, which bring about thoughts, flashbacks, and nightmares, including ‘trash on the ground, ridges where there might be bombs and IEDs, driving close to curbs, burning trash, sewage, and a lot of traffic in general.’” The Veteran described a loss of interest in social activity: “I don’t want to go out. I want to stay alone.” He also described “I always have to look behind me to see what’s going on.” He described trying to avoid thoughts about war. He reported that his mood could be described as “angry and detached,” and he reported that “I don’t want to go around people.” He also described that he “fears ‘being killed.’ ‘I don’t know how or by what, but I think I might be killed.’” The Veteran reported “anger and irritability both at work and at home…. Anger and irritability have caused problems for me and my fiancée.” The Veteran also reported: “One time I hit someone else at a restaurant.” The Veteran furthermore reported that he “is easily startled,” “is hypervigilant,” and “sleeps with a weapon.” The June 2011 VA psychiatric examiner recorded that the Veteran “reports depression of 7 to 8 on a 10-scale of severity.” The Veteran had “decreased interest in doing things that he used to.” “His interest in intimacy has decreased.” “He generally … wak[es] up 4 or 5 times during the night … usually not feeling rested after rarely getting more than 4 hours of sleep.” “His energy level is reported as low and varies throughout the day.” “His ability to think, concentrate, and remember is decreased.” “He says, ‘I lose focus. My fiancée gives me things to do and I can’t remember what she told me.’” The June 2011 VA examiner noted that the Veteran “denies suicidal ideation.” “He reports anxiety of 8 on a 10-scale of severity.” “He says, ‘I go nuts sometimes with panic and anxiety, about once a week. It lasts a few hours and I just walk out of where[]ever I’m at when I have those panic episodes.’” The VA examiner reviewed the Veteran’s medical record and found “notes reveal problems with marriage [regarding his fiancée] and work.” In August 2016, the Veteran underwent another VA psychiatric examination, this time for the purpose of evaluating the severity of his PTSD for rating purposes. The VA examiner diagnosed “PTSD, Chronic, Mild,” and characterized the severity as: “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.” The report notes that the Veteran was “married and has three children,” and he was employed “as an adult detention officer.” The Veteran “reported he has not had any write-up within the last year but he has also been transferred to a position that requires less contact with others.” The report shows that the Veteran’s current symptoms included: “insomnia and over-sleeping,” “combat-related nightmares 5 of 7 days per week,” “fatigue,” “decreased motivation,” “irritable,” “anger outbursts (reported by claimant to be improved but still present),” “panic symptoms when he gets overstressed to include one panic attack involving the ER two years ago,” “sit facing the door in public and avoiding shopping due to too many people,” “avoids places where he knows Muslim people are seen,” “exaggerated startle to fireworks only,” and “flashback when the weather is hot or he smells sewage.” The report additionally notes “Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world,” as well as “Persistent negative emotional state.” The August 2016 VA examination report presents a listed inventory of symptoms featuring: anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, and disturbances of motivation and mood. The VA examiner reported that “No,” the Veteran did -not- “have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above.” The VA examiner explained that “At this time the claimant’s condition is improved from moderate to mild. The veteran was diagnosed with moderate PTSD in 2011.” The VA examiner discussed that “[h]is current medication reportedly has been somewhat effective as he reported noticing a difference in his mood and out[]bursts being somewhat improved. [H]is exaggerated startle response has improved to only including the sound of fireworks….” Furthermore, “[h]e appears to know what triggers him and avoids triggers. There is some improvement in his functioning compared to symptoms intensity described in his evaluation in 2011 and per claimant report.” In September 2016, the Veteran submitted a written statement from his wife in which she testified that she observed the Veteran become irritable and “angry,” and that he had “kept to himself.” She describes that he sometimes goes weeks without showering, and she describes “night sweats,” “talking in the sleep,” “always think[ing] someone is trying to break in our house,” “a large strain on our whole relationship,” “sitting in the dark staring at the walls,” and “crying in our closet.” The Board finds that this letter describes chronic sleep impairment, nightmares and low energy (compatible with chronic sleep impairment), loss of interest in social activity / self-isolation / detachment / decreased interest in activities (compatible with disturbances of motivation and mood and difficulty in establishing and maintaining effective relationships), hypervigilance (compatible with anxiety and suspiciousness), anger / irritability (compatible with disturbances of mood), marital problems (compatible with difficulty in maintaining effective relationships), depressed mood, and anxiety. These identified symptoms are reasonably consistent with the indications of the July 2011 and August 2016 VA examination reports and other evidence of record pertinent to the period. To the extent that the testimony indicates that the Veteran would sometimes go weeks without showering, the Board notes this for consideration discussed below. During the Veteran’s September 2019 Board hearing, the Veteran’s wife testified that the Veteran “wants to punch walls when he gets mad,” and “does odd things that we can’t really go into public at this point now with him, just because he can’t handle the stores…. He’s like turned into a hermit at the house.” The Veteran testified that he has been given an assignment at his job that worked for him by minimizing the extent to which he had to work around many people. The Veteran testified that the night prior to the hearing, he had a panic attack that required treatment at a VA hospital emergency room. The Veteran testified that, in addition to his more regular panic attacks, the exacerbated panic attack of the prior night was the second such attack that he had experienced. The Veteran’s family provided witness testimony indicating that the Veteran had been experiencing symptoms such as hypervigilance and sleep disturbances from as early as his return from overseas service. The Veteran’s VA medical reports of record now include documentation of the September 2019 emergency room treatment, showing that the Veteran experienced “chest pain” and became “very anxious” during the experience. In March 2020, the Veteran submitted a statement from his sister-in-law testifying to her observations of the Veteran’s “depression, anxiety, insomnia, relationship problems, trust issues, anger issues, [and] memory problems.” In July 2020, the Veteran underwent another VA psychiatric examination for the purpose of evaluating the severity of his PTSD for rating purposes. The VA examiner diagnosed “Post-Traumatic Stress Disorder, Moderate and chronic,” and characterized the severity as: “Occupational and social impairment with reduced reliability and productivity.” The Veteran reported that he was “working at the Sheriff’s office on the night shift. I live in a house that I am buying. I live with my wife and my kids…. I don’t have hobbies. I just work and go home.” The July 2020 VA examination report presents a listed inventory of symptoms featuring: depressed mood; anxiety; suspiciousness; panic attacks that occur weekly or less often; chronic sleep impairment; memory loss for names of close relatives, own occupation, or own name; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in adapting to stressful circumstances, including work or a work like setting; inability to establish and maintain effective relationships; obsessional rituals which interfere with routine activities; and impaired impulse control, such as unprovoked irritability with periods of violence. In a section of the report that asks the VA examiner to identify “other symptoms attributable to PTSD … that are not listed above,” the VA examiner noted the Veteran’s report: “I have major flashbacks. I have it pretty often. It is triggered by smells. If someone turns on the BBQ pit I go sit in the car.” The VA examiner also noted that “the family stated that the veteran is now experiencing notable memory lapses, disorientation and other mental health manifestations that were not noted on the August 2016 [VA examination report] but have now progressed….” The July 2020 VA examination report has served as the basis for the existing award of a 70 percent rating for the Veteran’s PTSD. A September 22, 2020, “Secure Messaging Primary Care” record from the VA medical system shows that the Veteran reported that “[a]bout two or three months ago I was having thoughts that I was better off not here, it was a horrible feeling and felt that I need to get back into therapy for that reason.” The Veteran further stated that “Everyday is a struggle for me to get out of bed and just be present for anything, even when I was on the phone with you my wife had to move my hand so I would stop pulling at my hair[.] I was not aware I was doing that [until] she pointed it out to me as she keeps an eye on me.” Private medical evidence dated September 29, 2020, includes evidence that has served as the basis for the existing award of a 100 percent rating for the Veteran’s PTSD. Included in this evidence is a September 29, 2020, Disability Benefits Questionnaire (DBQ) from a Dr. Nolen that was added to the claims-file in October 2020, and a September 29, 2020, medical opinion from a Dr. Allen that was added to the claims-file in November 2020. As the Veteran has already established entitlement to a 100 percent rating from September 29, 2020, onward, the pertinent rating periods are prior to September 29, 2020, and the Board has reviewed these items of evidence for any indication of impairment for any factually ascertainable portion of a rating period that is on appeal. Dr. Allen’s September 2020 opinion states that “the veteran has been in a constant state of depression and hyperarousal for the last year.” The opinion also states that the Veteran’s “psychiatric symptoms have created problems with trust, closeness, intimacy, communication, decision-making, and problem-solving. His wife complains of receiving less than adequate emotional and practical support from the veteran.” The opinion refers to the veteran’s “chronic suicidal ideation,” including periods of “active suicidal ideation.” The report further describes the Veteran’s difficulties with anger management, hypervigilance, irritability, “no active friendships,” “emotional isolation,” “fractured familial relationships,” “anhedonia,” that he will “go several weeks without fully engaging in basic self-hygiene practices,” concentration problems, verbal altercations, memory problems, panic attacks, and chronic daytime somnolence. The Board notes that Dr. Allen’s September 2020 opinion cites the “secure messaging note” with the Veteran’s statements from earlier the same month. The Board also notes that Dr. Allen discusses that the Veteran “has received multiple reprimands and has had suspensions threatened as a result of physical and verbal aggression at work. In 2019, he was mandated to see an Employee Assistance Program (EAP) psychologist for one month after hurling expletives at his supervisor during an act of verbal insubordination.” Additionally, “[t]he veteran is also ‘non-promotable’. He has a profile at work as result of all of the disciplinary actions that have been taken against him.” Dr. Allen goes on to describe details of symptoms that “have worsened since the time of his last C&P evaluation” in July 2020, including hyperphagia / overeating (citing a July 2020 treatment note) and trichotillomania / “pulling out of his hair …. [with] visible bald patches,” citing the earlier September 2020 evidence. Dr. Allen concludes that the Veteran’s “level of social and occupational impairment is: Occupational and social impairment with reduced reliability and productivity.” The Board notes that this description adopts language from the criteria for a 50 percent rating. Dr. Nolen’s September 2020 Disability Benefits Questionnaire presents a description of psychiatric symptoms and impairment without indication of a clear factually ascertainable date of onset of prior worsening. Dr. Nolen’s assessment concluded that the Veteran had “occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood.” The Board notes that this description adopts language from the criteria for a 70 percent rating. The Veteran’s PTSD symptomatology and impairments are discussed in additional evidence of record, including VA treatment records, some of which is rather detailed (such as a report from April 2014). The Board has reviewed this evidence and finds that it does not present information that substantively expands upon or contradicts the detailed findings and information presented in the evidence discussed above. With regard to the question of whether the evidence shows psychiatric impairment meeting the criteria for a 100 percent rating from July 24, 2020, to September 29, 2020, the Board finds that reasonable doubt can be resolved to conclude that it does. VA has already formally recognized that the impairment was 100 percent disabling by September 29, 2020. Merely a short time of two months prior, the July 2020 VA examination report presents indications that the Veteran was experiencing symptoms of “memory loss for names of close relatives, own occupation, or own name,” which is a listed exemplar of the rating criteria for a 100 percent rating. The July 2020 VA examination report also describes “disorientation and other mental health manifestations that … have now progressed.” This suggests a greater degree of severity in the Veteran’s disorientation suggestive of disorientation to time or place, another exemplar of the rating criteria for a 100 percent rating, accompanying the severe memory impairment. The evidence is not entirely clear in this regard, but the Board finds that reasonable doubt can be resolved in the Veteran’s favor to find that the total occupational impairment already established from September 2020 was present at the modestly earlier date of July 24, 2020. A 100 percent rating from July 24, 2020, is warranted; to this extent the appeal is granted. Next, the Board turns its attention to the question of the Veteran’s claimed entitlement to a rating in excess of 50 percent for the period prior to July 24, 2020. The Board notes that an above-discussed September 2020 VA record shows that the Veteran described suicidal ideation occurring “two or three months” prior. Because suicidal ideation matches a symptom exemplar in the criteria for a 70 percent rating (and possibly higher), the Board has considered whether this evidence indicates the presence of such symptomatology prior to the July 2020 effective date of the Veteran’s currently assigned 70 percent rating. The Board finds that, considering this evidence together with the rest of the evidence of record, it does not. Significantly, the July 2020 VA examination report (approximately two months prior to the September 2020 statement) shows that the Veteran had “No signs of SI/HI [suicidal or homicidal ideation] plan or intent” at that time, and “Suicidal Ideation” was an item left unchecked in the inventory of symptoms at that time. The other evidence of record, including treatment reports, do not otherwise indicate onset of suicidal ideation prior to the date of the July 2020 VA examination report / the current effective date of the award of a 70 percent rating. Reading the September 2020 statement together with the rest of the evidence of record, the Board finds that the reported suicidal ideation began in July 2020 and not prior to the date of the July 2020 VA examination report / the current effective date of the award of a 70 percent rating. Accordingly, the reported suicidal ideation is not a symptom for consideration in the rating analysis of the rating period prior to July 24, 2020. Similarly, with regard to the Veteran’s September 2020 report of pulling out his hair, the Board finds that this symptom does not pertain to any ascertainable portion of the rating period prior to July 24, 2020. The July 2020 VA examination report presents an exhaustive inventory of symptoms, including in a section of the report purposed to identify “any other symptoms attributable to PTSD (and other mental disorders) that are not listed above,” and the July 2020 VA examination report indicates no symptomatology involving the Veteran pulling out his hair. Reading the September 2020 statement together with the rest of the evidence of record, the Board finds that the reported behavior of pulling out his hair began in July 2020 and not prior to the date of the July 2020 VA examination report / the current effective date of the award of a 70 percent rating. Accordingly, the reported behavior of pulling out his hair is not a symptom for consideration in the rating analysis of the rating period prior to July 24, 2020. The July 2020 VA examiner characterized the severity of the Veteran’s PTSD impairment (at the end of the rating period prior to July 24, 2020) as “Occupational and social impairment with reduced reliability and productivity.” The August 2016 VA examiner characterized the Veteran’s PTSD impairment (in the middle of the rating period prior to July 24, 2020) as “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.” Both of these summaries of psychiatric impairment match the descriptions of impairment presented in the criteria for disability ratings of 50 percent or lower. Both of these VA examination reports specifically invited the examiners to consider whether the level of impairment was better summarized by the terms presented by the criteria for a 70 percent rating: “occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood.” Both VA examiners determined that the psychiatric impairment was better summarized by the terms of the criteria for disability ratings of 50 percent or lower. The Board finds that none of the competent medical evidence otherwise describes the Veteran’s psychiatric impairment during the rating period prior to July 24, 2020, in terms matching those of the criteria for a rating in excess of 50 percent. The Board has carefully considered the Veteran’s shown symptomatology during the period prior to July 24, 2020. The July 2011 VA examination report showed that the Veteran’s pertinent symptoms / manifestations included chronic sleep impairment (an exemplar for a 30 percent rating), nightmares and low energy (compatible with chronic sleep impairment), flashbacks (arguably compatible with spatial disorientation or disorientation to time and place), loss of interest in social activity / self-isolation / detachment / decreased interest in activities / decreased interest in intimacy (compatible with disturbances of motivation and mood and difficulty in establishing and maintaining effective relationships), hypervigilance / sleeping with a weapon / being easily startled (compatible with anxiety and suspiciousness), avoidance of thoughts and items associated with traumatic triggers (compatible with anxiety), anger / irritability (compatible with disturbances of mood), fear of being killed (compatible with anxiety), marital problems (compatible with difficulty in maintaining effective relationships), an instance of “hitting someone else” (arguably compatible with impaired impulse control (such as unprovoked irritability with periods of violence)), depressed mood (an exemplar for a 30 percent rating), memory lapses with decreased effectiveness of thinking / concentration / focus (compatible with difficulty in understanding complex commands, impairment of short and long-term memory, impaired abstract thinking), anxiety (an exemplar for a 30 percent rating), and weekly panic attacks (an exemplar for a 30 percent rating). Of the symptoms / manifestations identified in the July 2011 VA examination report, only flashbacks (arguably compatible with spatial disorientation or disorientation to time and place) and an instance of “hitting someone else” (arguably compatible with impaired impulse control (such as unprovoked irritability with periods of violence)) are suggestive of symptoms compatible with the exemplars associated with ratings in excess of 50 percent. The August 2016 VA examination report’s inventory showed that the Veteran’s pertinent symptoms / manifestations included: anxiety (an exemplar for a 30 percent rating), suspiciousness (an exemplar for a 30 percent rating), panic attacks that occur weekly or less often (an exemplar for a 30 percent rating), chronic sleep impairment (an exemplar for a 30 percent rating), and disturbances of motivation and mood (an exemplar for a 50 percent rating). The report also suggests symptoms / manifestations of exaggerated startle response to the sound of fireworks (compatible with anxiety and suspiciousness), avoidance of thoughts and items associated with traumatic triggers (compatible with anxiety), anger / irritability (compatible with disturbances of mood), decreased social activity / self-isolation / detachment / decreased interest in activities / decreased interest in intimacy (compatible with disturbances of motivation and mood and difficulty in establishing and maintaining effective relationships), nightmares and fatigue (compatible with chronic sleep impairment), irritability with anger outbursts (arguably compatible with impaired impulse control), “sit facing the door in public and avoiding shopping due to too many people” (compatible with anxiety and suspiciousness), “avoids places where he knows Muslim people are seen” (compatible with anxiety and suspiciousness), flashbacks (arguably compatible with spatial disorientation or disorientation to time and place), “[p]ersistent and exaggerated negative beliefs or expectations about oneself, others, or the world,” (compatible with disturbances of motivation and mood), and “[p]ersistent negative emotional state” (compatible with depressed mood and disturbances of motivation and mood). Of the symptoms / manifestations identified in the August 2016 VA examination report, only flashbacks (arguably compatible with spatial disorientation or disorientation to time and place) and irritability with anger outbursts (arguably compatible with impaired impulse control) are suggestive of symptoms compatible with the exemplars associated with ratings in excess of 50 percent. Other evidence from this period, such as the September 2016 written testimony of the Veteran’s spouse, essentially reiterated and reinforced indications of symptoms previously shown in the July 2011 and August 2016 VA examination reports. However, an additional symptom report involving the Veteran sometimes going periods of weeks without showering was reported. This is arguably compatible with neglect of personal appearance and hygiene, an exemplar associated with a rating in excess of 50 percent. The Board also notes that the above-discussed September 2020 medical opinion of Dr. Allen refers to the Veteran’s history of verbal altercations, including “hurling expletives at his supervisor during an act of verbal insubordination” in 2019. Dr. Allen further summarized that, “[t]he veteran is also ‘non-promotable’. He has a profile at work as result of all of the disciplinary actions that have been taken against him.” Dr. Allen’s report indicates that the Veteran’s employment features impaired, but sufficiently functional, relationships as his employment has continued. The Veteran’s testimony at his September 2019 Board hearing described that he maintained his employment by agreeing to an assignment that worked for him by minimizing the extent to which he would have to work around many people. The Board has considered that these difficulties with irritability and angry outbursts further inform the other indications of impaired impulse control. The Board finds that none of the other evidence of record shows additional symptoms or manifestations of PTSD during the period prior to July 24, 2020, that are substantially distinct from those contemplated in the analysis above. For the period prior to July 24, 2020, the shown symptoms most compatible with symptom exemplars in the criteria for ratings in excess of 50 percent are flashbacks (arguably compatible with spatial disorientation) and irritability with anger outbursts (arguably compatible with impaired impulse control), and irregular showering (arguably compatible with neglect of hygiene). The Board must determine whether the symptoms caused the level of impairment required for a disability rating in excess of 50 percent prior to July 24, 2020. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). The Board finds that they did not. As discussed above, the August 2016 VA examiner determined in the middle of the rating period that the Veteran’s psychiatric impairment did -not- result in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood; the August 2016 VA examiner characterized the severity of the Veteran’s PTSD as “mild” at that time. Also as discussed above, the September 2020 VA examiner determined at the end of the rating period that the Veteran’s psychiatric impairment had -not- resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Although VA has otherwise determined that impairment meeting the criteria for a higher rating was reasonably shown from July 24, 2020, onward, the Board finds no basis for identifying such impairment from any earlier date in the July 2020 VA examination report’s finding that the Veteran’s PTSD had to that point manifested in “occupational and social impairment with reduced reliability and productivity,” matching the language of the criteria for a 50 percent rating and describing less than the severity of impairment contemplated by higher ratings. Considering the specific indications of the August 2016 and July 2020 VA examination reports showing that the Veteran was not occupationally and socially impaired to the point of deficiency in most areas, the Board has sought to determine whether other evidence overcomes these findings with persuasive indications to the contrary. The evidence does not show that the Veteran’s flashbacks, irritability, and showering lapses were of such severity, frequency, and duration as to render him deficient in most areas. The flashbacks are not indicated to have resulted in spatial disorientation or disorientation to time and place of the severity, frequency, and duration of impairment contemplated by the criteria for a rating in excess of 50 percent. The irritable outbursts are not shown to have resulted in impulse control lapses and periods of violence of the severity, frequency, and duration of impairment contemplated by the criteria for a rating in excess of 50 percent. The showering lapses are not indicated to have resulted in hygiene neglect of such severity, frequency, and duration to result in deficiencies in most areas. Even acknowledging that the Veteran’s episodes of irritable anger included verbal altercations and an incident of hitting someone, the irritability with anger outbursts are not indicated to have resulted in such severity, frequency, and duration of impaired impulse control with periods of violence as to have rendered the Veteran deficient in most areas. The flashbacks and irritability were noted by both the August 2016 and July 2020 VA examiners, and contemplated in both assessments indicating that the associated impairment did not result in deficiencies in most areas prior to July 24, 2020. The Board finds that the evidence pertinent to the period prior to July 24, 2020, does not otherwise show that the Veteran’s symptoms, including flashbacks and irritability with anger outbursts, caused occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood, as contemplated by the criteria for a 70 percent rating. The Board finds the level of impairment caused by the Veteran’s symptoms for the period prior to July 24, 2020, most closely approximates the level associated with a 50 percent rating. The Veteran experienced occupational and social impairment with reduced reliability and productivity. The VA examination reports provide assessments of the Veteran’s impairment that specifically match the rating criteria for ratings no higher than 50 percent. The Board finds that the evidence of record does not show occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood during the period prior to July 24, 2020. As discussed above, to the extent that some of the Veteran’s symptoms described in the evidence may not exactly match the exemplars listed with a specific rating, the Board finds the severity, frequency, and duration of the Veteran’s symptoms prior to July 24, 2020, more closely approximate the symptoms contemplated by a 50 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by higher ratings. See 38 C.F.R. § 4.126. Even with consideration of symptoms such as flashbacks and irritability with angry outbursts, the Veteran’s symptomatology prior to July 24, 2020, is not shown to have included symptoms of comparable severity, frequency, and duration as contemplated by the criteria for higher ratings. In short, the preponderance of the evidence weighs against finding that the severity, frequency, and duration of the Veteran’s symptoms resulted in the level of impairment required for a rating in excess of 50 percent. For the period prior to July 24, 2020, the criteria for a rating in excess of 50 percent are not met, and the appeal must be denied to this extent. To summarize, the Board finds that the evidence supports finding, with resolution of reasonable doubt in the Veteran’s favor, an increased 100 percent disability rating from July 24, 2020, to September 29, 2020. Beyond that award, the Board finds that the preponderance of the evidence is against entitlement to any other increased rating for the Veteran’s PTSD in this case. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Increased Ratings Conclusion As discussed above, the evidence supports the award of an increased rating to a certain extent, but the preponderance of the evidence weighs against awarding any further increased ratings this case. The Board has considered whether there is any other basis for granting further increased ratings but has found none. As the preponderance of the evidence is against assignment of any further increased ratings in this case, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record in connection with the disabilities for consideration in this appeal (aside from those matters addressed in this decision, such as the grant of SMC discussed below). See Doucette v. Shulkin, 28 Vet. App. 366 (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). 3. Entitlement to SMC based on housebound status, for the period from July 24, 2020, to September 29, 2020, is granted. SMC is payable at the housebound rate where the Veteran has a single service-connected disability rated at 100 percent and one or more distinct service-connected disabilities, which are independently ratable at 60 percent and involve different anatomical segments or bodily systems. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). The Veteran is also already in receipt of SMC based on housebound status established on the foundation of the 100 percent rating for PTSD and a 60 percent combined rating from additional independently ratable disabilities effective from September 29, 2020. As a result of the Board’s determinations in this decision, discussed above, the Veteran will now be awarded a newly increased 100 percent disability rating for PTSD from the earlier effective date of July 24, 2020. All of the Veteran’s other disability ratings during the period from July 24, 2020, to September 29, 2020, are identical to the ratings assigned from September 29, 2020, onward. Therefore, the Board’s grant of the 100 percent disability rating for PTSD from the earlier effective date of July 24, 2020, results in the Veteran’s complete set of disability ratings from July 24, 2020, becoming identical to the ratings in effect from September 29, 2020. VA has already formally established that these ratings meet the criteria for entitlement to SMC at the housebound rate under 38 U.S.C. § 1114(s) from September 29, 2020. Because the identical ratings are now in effect from July 24, 2020, entitlement to SMC at the housebound rate under 38 U.S.C. § 1114(s) is now warranted from July 24, 2020. REASONS FOR REMAND 1. The issue of entitlement to service connection for a disability of the upper respiratory system, to include diagnosed upper respiratory infections and diagnosed COPD, claimed as chronic / recurrent upper respiratory infections, is remanded. The July 2020 VA medical opinion addressing the Veteran’s claim of entitlement to service connection for an upper respiratory disability does not provide sufficient clarity of findings to adequately inform final appellate review of this issue. The VA examiner discussed that the Veteran’s “chronic/recurrent upper respiratory infections,” beginning with “onset: 2003 …. Refers to proximity to burn pits while being stationed in Iraq,” and additionally “[r]efers to taking antibiotics [al]though this was for sinus infection not respiratory infection.” The VA examiner opined that “THE VETERAN’S URI, RESOLVED IS AT LEAST AS LIKELY AS NOT RELATED TO THE DESCRIBED IN-SERVICE SYMPTOMS / EVENTS.” The July 2020 VA medical opinion asserts “STRs document URI being treated within AD.” However, the VA examiner also states: “Service member has no existing chronic complication of the 2007 acute infection nor takes any medication for a respiratory infection. Resolved within service w/o sequelae.” The VA examiner concludes: “Service member has no CURRENT etiologically related upper respiratory infections.” The Board’s consideration of the July 2020 VA medical opinion is complicated by the fact that, although the Veteran may not have had any upper respiratory infection at the time of the July 2020 VA examination, the VA examiner cites an inaccurate factual premise in noting that the Veteran has no current upper respiratory infection for the purposes of the compensation claim on appeal. The United States Court of Appeals for Veterans Claims (Court) has held the requirement that a current disability be present is satisfied when a claimant has a disability at the time of a claim for VA disability compensation is filed or at any time during the pendency of that claim. See McClain v. Nicholson, 21 Vet. App. 19 (2007). The claim on appeal has been pending from the time of the Veteran’s September 2010 filing of the claim. The Veteran’s post-service VA medical records show diagnosed instances of upper respiratory infection during the pendency of this claim on appeal, including in January 2019 when the Veteran received emergency room treatment for an “UPPER RESPIRATORY INFECTION,” and in May 2011 when the Veteran complained of “upper respiratory / breathing problems” to a VA provider. The Veteran’s post-service upper respiratory infection diagnosis is associated with symptoms compatible with those shown during service and associated with his in-service upper respiratory infection diagnosis. The Board finds that a remand is necessary to obtain clarification from a supplemental medical opinion that recognizes that the evidence shows that the Veteran has, for the purposes of this claim on appeal, a current diagnosis of upper respiratory infection. A medical opinion addressing the question of whether the Veteran’s sufficiently current diagnosis of upper respiratory infection is etiologically linked to the Veteran’s in-service exposures and his in-service upper respiratory infection problems is required. The Board additionally notes that the July 2020 VA examination report identifies a diagnosis of chronic obstructive pulmonary disease (COPD) that is current and active. The forthcoming supplemental medical opinion shall have the opportunity to clarify a determination as to whether this diagnosis is etiologically linked to the Veteran’s military service, to include the Veteran’s cited in-service environmental exposures and symptom experiences. 2. The issue of entitlement to a compensable disability rating for right knee retropatellar pain syndrome is remanded. The Veteran’s most recent VA examination of his right knee disability was conducted in July 2020. Subsequently, in September 2020, the Veteran submitted copies of private medical records from Baptist Medical Center documenting his emergency department treatment for “Right knee pain” diagnosed as a “sprain.” The submitted documents indicate that the Veteran was discharged with “Walking Aids, Crutches” and instructed to follow-up “Within 1-2 days.” An accompanying September 2020 “Accident Investigation Report” shows that the incident began when the Veteran’s “right knee gave out.” The Board finds that the Veteran’s submission of this documentation represents a communication to VA asserting a worsening of his service-connected right knee disability. The Board finds that a new VA examination is warranted to provide the updated data and findings necessary to support an informed appellate review of the right knee disability rating issue on appeal. VA’s General Counsel has indicated that a new examination is appropriate when there is an assertion of an increase in severity since the last examination. VAOPGCPREC 11-95 (1995). The Board finds that a new VA examination is warranted to assess the current severity of the Veteran’s right knee disability. Additionally, the Veteran’s submissions of a portion of the private medical records from his September 2020 right knee evaluation and treatment has notified VA that additional pertinent private medical records exist. During the processing of this remand, the AOJ shall have the opportunity to take the appropriate steps to offer assistance to the Veteran in obtaining the records for review in the claims-file. The matters are REMANDED for the following action: 1. Please secure for the record copies of complete updated clinical records (any not already of record) of all VA and non-VA treatment the Veteran has received for the disabilities on appeal. Please ask the Veteran to provide the releases necessary for VA to secure any adequately identified private treatment records that the Veteran may wish VA to assist him in obtaining for the record. In particular, ask the Veteran to complete a VA Form 21-4142 for any new outstanding records associated with his right knee injury evaluation and treatment in September 2020 (and thereafter), including from Baptist Medical Center in San Antonio, Texas (identified in the Veteran’s September 2020 submission of partial records from that provider). 2. After the record is determined to be complete, the AOJ should arrange for the Veteran’s claims-file to be forwarded to the VA examiner who authored the July 2020 VA respiratory disabilities examination report for a clarifying addendum / opinion regarding the nature and etiology of the Veteran’s upper respiratory disabilities featuring diagnosed recurrent upper respiratory infections (current during the pendency of this appeal) and COPD. If the examiner who provided the July 2020 opinion is unavailable, another qualified medical professional may provide the requested opinion. A new examination should only be performed if the medical professional providing the opinion finds one is necessary. The examiner must review the Veteran’s claims file, and based on such review (and, if necessary, examination of the Veteran), provide an opinion responding to the following: (a) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s upper respiratory infections during the pendency of this claim (from September 2010 to the present, including his documented January 2019 emergency room diagnosis of an upper respiratory infection) represents a chronic or recurrent pathology that is etiologically related to his upper respiratory infection and symptoms during his military service? In particular, please specifically address (i) the Veteran’s in-service history of medical attention to upper respiratory infection, documented in his available service treatment records in 2003; (ii) his documented in-service history of upper respiratory symptomatology including during Persian Gulf deployment in 2007, (iii) the Veteran’s lay testimony regarding in-service and post-service upper respiratory symptomatology, and (iv) the Veteran’s contention that his upper respiratory health has been impaired by his having been “exposed to burn pits, burned vehicles, other burning - foreign land objects, such as burning houses and cars or whatnot” during deployment to the Persian Gulf. (b) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s diagnosed COPD is etiologically related to his upper respiratory infection and symptoms during his military service? In particular, please specifically address (i) the Veteran’s in-service history of medical attention to upper respiratory infection, documented in his available service treatment records in 2003; (ii) his documented in-service history of upper respiratory symptomatology including during Persian Gulf deployment in 2007, (iii) the Veteran’s lay testimony regarding in-service and post-service upper respiratory symptomatology, and (iv) the Veteran’s contention that his upper respiratory health has been impaired by his having been “exposed to burn pits, burned vehicles, other burning - foreign land objects, such as burning houses and cars or whatnot” during deployment to the Persian Gulf. For the purposes of this analysis, please assume that the Veteran’s testimony is factually accurate and discuss whether the Veteran’s upper respiratory infections or COPD are of a nature that would be at least as likely as not related to the described in-service symptoms / events. In addressing the above, the examiner must consider and discuss the pertinent medical, periodical, and other objective evidence, and all lay assertions. The examiner is also advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the Veteran’s assertions in any regard are discounted, the examiner should clearly so state and explain the reasons. All examination findings/testing results, along with a complete, clearly-stated rationale for the conclusions reached, must be provided. 3. After the record is determined to be complete, schedule a VA examination to ascertain the severity of the Veteran’s service-connected right knee disability. The claims-file must be made available to, and be reviewed by, the examiner. All indicated testing should be accomplished and all symptomatology associated with the right knee disability should be identified. In addition to all findings identified on the appropriate examination forms, the VA examiner should determine the effective ranges of motion of the right knee, and address each of the following items: (a) The examiner’s report should reflect range of motion tests in a written report by recording separate sets of the range of motion test results for both active and passive motion, in weight bearing and nonweight-bearing (to the extent applicable), and, if possible, in comparison to the opposite, undamaged, joint (to the extent applicable). (b) The examiner should describe objective evidence of painful motion, if any, during each test. (c) The examiner is also asked to describe whether pain, weakness, fatigue and/or incoordination significantly limits functional ability during flares or repetitive use, and if so, the examiner must estimate range of motion during flares or repetitive use. If the examination does not take place during a flare or following repetitive use over time, the examiner should have the Veteran describe and/or demonstrate the extent of motion loss during flares or repetitive use and provide the extent of motion loss described in terms of degrees. If there is no pain and/or no limitation of function, such facts must be noted in the report. If the VA examiner is unable to offer an opinion without resorting to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. The Board is not permitted to accept a rationale that the examiner is unable to offer an opinion without resort to speculation based on an aversion to offering an opinion on issues not directly observed. M. C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Barone, 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.