Citation Nr: 21026663 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 17-36 214A DATE: May 3, 2021 ORDER New and material evidence having been received, the claim for entitlement to service connection for tinnitus is reopened and, to that extent, the claim is granted. Entitlement to service connection for tinnitus is granted. Entitlement to a 70 percent rating, but no higher, for posttraumatic stress disorder (PTSD) is granted. Entitlement to a disability rating in excess of 60 percent for coronary artery disease, status post angioplasty and stents (CAD), is denied. Entitlement to a total disability rating based upon individual unemployability due to service-connected disability (TDIU) prior to September 10, 2019, is granted. Entitlement to special monthly compensation (SMC) at the housebound rate is granted. REMANDED Entitlement to service connection for a skin disability, to include jungle rot, is remanded. FINDINGS OF FACT 1. In a March 2009 rating decision, the Department of Veterans Affairs (VA) Regional Office (RO) denied service connection for tinnitus. In July 2010 and December 2012, the RO found that new and material evidence had not been submitted to reopen the previously denied claim of service connection for tinnitus. The Veteran did not appeal the most recent decision and new and material evidence was not received within the one-year appeal period. 2. Evidence associated with the record since the December 2012 decision relates to unestablished facts and raises a reasonable possibility of substantiating the claim of entitlement to service connection for tinnitus. 3. The most probative evidence demonstrates that the Veteran's tinnitus had onset in service. 4. Throughout the period on appeal, the Veteran's PTSD manifested in occupational and social impairment with deficiencies in most areas, but not in total social impairment. 5. Metabolic equivalent (MET) testing shows the Veteran develops dyspnea and fatigue at a workload of greater than 3 but not greater than 5 METs. MET testing shows the Veteran did not develop these symptoms at a workload of 3 METs or less, and the evidence did not show chronic congestive heart failure or left ventricular dysfunction with an ejection fraction of less than 30 percent. 6. The most probative evidence demonstrates that the Veteran's PTSD renders him unable to secure and maintain substantially gainful employment throughout the period on appeal. 7. Throughout the period on appeal, the Veteran is in receipt of a TDIU based solely upon one disability as well as additional service-connected disabilities combining to more than 60 percent. CONCLUSIONS OF LAW 1. The criteria for reopening the previously denied claim for service connection for tinnitus have been met. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156(a). 2. The criteria for entitlement to service connection for tinnitus have been met. 38 U.S.C. §§ 1110, 1112, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for entitlement to a 70 percent rating, but no higher, for PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 4. The criteria for entitlement to a rating in excess of 60 percent for CAD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.100, 4.104, Diagnostic Code 7005. 5. The criteria for entitlement to a TDIU prior to September 10, 2019, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.16. 6. The criteria for SMC at the housebound rate have been met. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1965 to July 1969, to include service in the Republic of Vietnam. These matters come before the Board of Veterans' Appeals (Board) on appeal from a February 2017 decision by a VA RO. In May 2019, the Board declined to reopen the claim of entitlement to service connection for tinnitus, denied the claim for entitlement to an increased rating for PTSD, and remanded the claims for entitlement to service connection for a skin disorder, entitlement to an increased rating for CAD, and entitlement to a TDIU for further development. The Veteran appealed the denied issues to the United States Court of Appeals for Veterans Claims (Court). In February 2020, the Court granted a Joint Motion for Remand (JMR) in which the parties agreed to vacate the Board's decision with respect to these matters and remand the claims to the Board. These matters, along with the remanded claims, have been returned to the Board for adjudication. 1. Whether new and material evidence has been received to reopen the claim for entitlement to service connection for tinnitus. If a claim of entitlement to service connection has been previously denied and that decision became final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C. § 5108. New evidence means existing evidence not previously submitted to agency decision-makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The credibility of the evidence is presumed for purposes of reopening the claim. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). The threshold for reopening is low. Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). The RO most recently denied the Veteran's claim of service connection for tinnitus in a December 2012 rating decision, finding that there was no evidence of a relationship to service. The Veteran was provided notice of this decision and his appellate rights but did not appeal the decision or submit new and material evidence within one year of the decision. Therefore, the decision is final. See 38 C.F.R. §§ 3.156, 20.302, 20.1103 (2010). The evidence received since the December 2012 rating decision includes evidence that is both new and material to the claim. See 38 C.F.R. § 3.156. This new evidence addresses the reason for the previous denial; that is, a nexus to service, and raises a reasonable possibility of substantiating the claim. The credibility of this evidence is presumed for purposes of reopening the claim. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). Accordingly, the claim is reopened and will be considered on the merits. The Board notes that the Veteran's representative has argued that additional service treatment records were added to the claims file that should have triggered reconsideration of the claim pursuant to 38 C.F.R. § 3.156(c). However, the record suggests that the Veteran's service treatment records, including a complaint of being hard of hearing, were of record at the time of the initial adjudication of the claim. In that regard, the original rating decision indicates that service treatment records for the Veteran's entire period of active service were considered. Accordingly, the Board finds it is appropriate to reopen, rather than reconsider, the claim. 2. Entitlement to service connection for tinnitus. Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). VA has established certain rules and presumptions for chronic diseases, such as tinnitus. See 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a); Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). With chronic diseases shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless attributable to intercurrent causes. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. § 3.303(b). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, chronic diseases are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Tinnitus is a noise in the ears, such as ringing, buzzing, roaring, or clicking. YT v. Brown, 9 Vet. App. 195, 196 (1996). Tinnitus is the type of disability that is capable of lay observation. Charles v. Principi, 16 Vet. App. 370, 374 (2002). In this case, the Veteran has consistently and credibly reported, since the initiation of his original claim, that his tinnitus had onset in service. The Board has no reason to doubt the Veteran's reports of experiencing tinnitus during service and presently and finds these statements credible. As tinnitus, a chronic disease, was present during service and is present currently, and is not clearly attributable to an intercurrent cause, service connection is granted. See 38 C.F.R. §§ 3.303(b), 3.309(a); see also Fountain v. McDonald, 27 Vet. App. 258, 271 (2015); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Increased Rating 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 (Rating Schedule). See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Different ratings may be assigned for different periods of time for the same disorder if the facts show distinct time periods with different levels of disability. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 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. 3. Entitlement to a disability rating in excess of 30 percent prior to September 10, 2019, and in excess of 70 percent thereafter, for PTSD. The Veteran is currently assigned a 30 percent disability rating prior to September 10, 2019, and a 70 percent rating thereafter, pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411, for PTSD. This matter stems from a May 2016 increased rating claim. In that regard, the Board notes that the Veteran's representative has argued that the Veteran's PTSD should be assigned a 70 percent rating dating back to the October 2009 effective date. Similarly, in the February 2020 JMR, the parties noted that the Board should consider evidence dating from several years prior to the initiation of the claim. However, the record reflects that service connection was awarded in an August 2012 rating decision. The Veteran filed a Notice of Disagreement with the decision and a Statement of the Case was issued in September 2013, but the Veteran did not complete a substantive appeal of the matter. Accordingly, the September 2013 decision became final. The Veteran did not file an increased rating claim until May 2016; as such, the Board may only consider whether an increased rating is warranted from that date or, if the evidence shows an increase in severity with the one year prior to the claim, from a date within that one year. 38 C.F.R. § 3.400(o). Further, while the Board has considered all of the evidence of record, the primary concern for an increased rating claim for a service-connected disability is the present level of disability. Although the overall history of the disability is to be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). 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 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause 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 normal conversation). 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. Upon review, the Board concludes that, throughout the period on appeal, the Veteran's symptoms most closely approximated the symptoms associated with a 70 percent rating, and resulted in a level of impairment that most closely approximated the level of impairment associated with a 70 percent rating. The Veteran first underwent VA examination in connection with this claim in May 2017. He reported that he had been in a relationship with his girlfriend for eight years, and that he had a 46-year-old son from his first marriage with whom he was not particularly close. He indicated that he had three close friends with whom he had regular contact, but that his activities were limited due to his heart disability. He also reported a fear of flying and going over bridges since he returned from Vietnam. The examiner noted symptoms of anxiety, sleep impairment, and hypervigilance, and ultimately opined that the Veteran's PTSD caused occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The Veteran again underwent VA examination in September 2019. He reported a strained relationship with his long-term girlfriend and a fear that she would leave him. He expressed a continued anger toward VA and medical professionals, and stated that he felt the military ruined his life. He was last employed in 2010 for the Department of Motor Vehicles, and reported that he had been terminated for his medical conditions that caused him to miss work and for being too "combustible" at work. The examiner noted symptoms including: depressed mood; anxiety; suspiciousness; panic attacks occurring weekly or less often; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; chronic sleep impairment; circumstantial, circumlocutory, or stereotyped speech; impaired judgment; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty adapting to stressful circumstances; inability to establish and maintain effective relationships; suicidal ideation, and impaired impulse control. The examiner ultimately opined that the Veteran's PTSD resulted in occupational and social impairment with deficiencies in most areas, and that his PTSD substantially impaired his ability to secure or follow a gainful position. Treatment records throughout the period on appeal reflect symptoms consistent with those noted on examination. In particular, the Veteran very frequently reported experiencing anxiety, and his providers often noted that his anxiety caused him to worry excessively about his physical health. In June 2019, he stated that he had recently had very little interest or pleasure in doing things, and that he felt down, depressed and hopeless. He also noted having a poor appetite or overeating, feeling bad about himself, having trouble concentrating, and thoughts about being better off dead. In August 2019, he reported having nightmares and being in a high arousal state throughout much of his life. The clinician noted that the Veteran tended to perseverate on his past trauma and demonstrated limited judgment and insight. Upon review, the Board finds that VA and private treatment records, the VA examinations, and the Veteran's lay statements show that the Veteran's PTSD was primarily manifested by symptoms associated with a 70 percent rating (suicidal ideation, near-continuous panic, impaired impulse control, difficulty in adapting to stressful circumstances) throughout the period on appeal. He also had symptoms that are not listed with a specific rating, such as hypervigilance, hyperarousal, and fear of flying or crossing bridges. The Board finds the severity, frequency, and duration of the Veteran's listed and unlisted symptoms most closely approximate the symptoms contemplated by a 70 percent rating, which are more severe, more frequent, and longer and duration than those contemplated by the rating criteria for a 30 or 50 percent rating, but less severe, less frequent, and shorter in duration than those contemplated by a 100 percent rating. See 38 C.F.R. § 4.126. The Board notes that the Veteran expressed suicidal ideation, which is similar to persistent danger of self-harm, which is contemplated by the 100 percent criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 19 (2017). However, the severity, frequency, and duration of the Veteran's suicidal ideation has not risen to the level contemplated by the 100 percent disability rating. While the Veteran reported frequently thinking about being better off dead, he regularly denied an intent or plan involving self-harm. The Board finds the level of impairment caused by the Veteran's symptoms most closely approximates the level associated with a 70 percent rating and that he experienced occupational and social impairment with reduced reliability and productivity with deficiencies in most areas. The evidence does not, however, demonstrate the level of impairment associated with a 100 percent rating. In that regard, while the Board finds below that the Veteran experiences total occupational impairment, he does not experience total social impairment. For example, he maintains a relationship with his girlfriend, although it is strained, and with a few friends. In short, the preponderance of the evidence weighs in favor of finding that the severity, frequency, and duration of the Veteran's symptoms resulted in the level of impairment required for a 70 percent rating throughout the period on appeal and, to that extent, the claim is granted. 4. Entitlement to a disability rating in excess of 60 percent for CAD. This matter stems from a May 2016 increased rating claim. The Veteran is currently assigned a 60 percent disability rating pursuant to 38 C.F.R. § 4.104, Diagnostic Code 7005, for arteriosclerotic heart disease (CAD). Under Diagnostic Code 7005, a 60 percent rating is warranted for more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is warranted for chronic congestive heart failure, or; workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. One MET is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. 38 C.F.R. § 4.104, Note (2). When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. Id. For the purposes of a 60 percent evaluation, the rating criteria do not require a separate showing of left ventricular dysfunction in addition to an ejection fraction of 30 to 50 percent. Otero-Castro v. Principi, 16 Vet. App. 375, 382 (2002). Additionally, the phrase "30 to 50 percent" means 30 percent through 50 percent. Id. at 380. For the purposes of a 100 percent evaluation, the rating criteria do not require a separate showing of left ventricular dysfunction in addition to an ejection fraction of less than 30 percent. See id. at 382. The Veteran first underwent VA examination in May 2017. The examiner noted a history of CAD and myocardial infarction, and that the examiner had undergone an angioplasty with two stents in 2002. After an abnormal stress test in 2015, the Veteran had been instructed to exercise and lose weight. The examiner further noted that at a recent primary care visit in May 2017, the Veteran had complained of a decreased exercise tolerance and his ejection fraction was between 50 and 55 percent. The Veteran's CAD required continuous medication, but he experienced no congestive heart failure, arrhythmia, heart valve condition, infectious heart condition, or pericardial adhesions. Peripheral pulses were normal and there was no peripheral edema or evidence of hypertrophy or dilatation. An interview-based METs test indicated that the Veteran experienced fatigue with greater than 3 but not greater than 5 METs, and the examiner indicated that the Veteran should be reevaluated in one year following cardiac rehabilitation. The Veteran again underwent VA examination in September 2019. He reported decreased stamina and still required continuous medication to manage his condition. The examiner noted an estimated ejection fraction of 60 to 65 percent with a small pericardial effusion. There were no signs of congestive heart failure, cardiac arrhythmia, a heart valve condition, infectious cardiac conditions, or pericardial adhesions. There was no cardiac hypertrophy or dilatation and a chest x-ray was normal. The examiner noted that exercise stress testing was not required as part of the Veteran's current treatment plan and was not without risk, but that an interview-based METs test indicated that the Veteran experienced dyspnea and fatigue at greater than 3 but not greater than 5 METs. The Veteran most recently underwent VA examination in October 2020. The Veteran reported that he had intermittent heart palpitations, but the examiner noted that a recent stress test revealed no evidence of ischemia. Continuous medication was still required, and there continued to be no evidence of congestive heart failure, a heart valve condition, infectious cardiac conditions, or pericardial adhesions. The Veteran did experience arrhythmia in the form of intermittent atrial fibrillations, and reported more than four episodes in the past 12 months. Evidence of cardiac hypertrophy was documented in an October 2020 chest x-ray and echocardiogram, but there was no cardiac dilatation. The ejection fraction was 60 to 65 percent. An interview-based METs test revealed that the Veteran experienced palpitations with greater than 5 but not greater than 7 METs. Treatment records throughout the period on appeal reflect symptoms and findings consistent with those noted on VA examination. In that regard, when the Veteran's ejection fraction was noted it was never less than 50 percent. There is no evidence of congestive heart failure, and the Veteran did not experience symptoms at 3 METs or less. The Board notes that the Veteran very frequently complained of chest pain to his clinicians; however, these episodes were nearly always determined to be related to gastrointestinal or musculoskeletal issues. The Veteran is competent to report his readily observable symptoms, including chest pain and heart palpitations, as well as the level of activity at which he experiences symptoms. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Board finds the Veteran credible in this regard. Considering all relevant evidence of record, the Board finds the evidence weighs against a finding that a total rating is warranted pursuant to Diagnostic Code 7005. In that regard, the evidence does not demonstrate that the Veteran experienced chronic or, indeed, any congestive heart failure. There is no indication that a workload of 3 METs or less resulted in symptoms at any point during the period on appeal. The Veteran's ejection fraction was, at worst, 50 to 55 percent. The Board concludes that the Veteran's CAD resulted in symptoms such as dyspnea, fatigue, and palpitations at more than 3 METs throughout the appeal period. These findings correspond to the criteria for a 60 percent rating under DC 7005. A higher 100 percent rating is not warranted unless there is chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. Thus, the Board concludes that the Veteran's CAD did not meet the criteria corresponding to a higher 100 percent rating and the claim is denied. 5. Entitlement to a TDIU prior to September 10, 2019. The Veteran asserts that he was unable to secure and follow a substantially gainful occupation as a result of his service-connected disabilities prior to September 10, 2019, the date from which a TDIU is currently assigned. VA will grant a total rating for compensation purposes based on unemployability when the evidence shows a veteran is precluded from obtaining or maintaining any gainful employment consistent with his education and occupational experience, by reason of his service-connected disabilities. 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). In arriving at a conclusion, consideration may be given to the veteran's level of education, special training, and previous work experience, but not to his age or the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. The Court has held that the term "unable to secure and follow a substantially gainful occupation" in 38 C.F.R. § 4.16 has two components. First, there is an economic component which essentially contemplates an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. Second, there is a non-economic component dealing with the individual veteran's ability to "follow and secure" employment. For the second component, attention must be given to: (a) the veteran's history, education, skill and training, (b) the veteran's physical ability (both exertional and non-exertional) to perform the type of activities (e.g., sedentary, light, medium, heavy or very heavy) required by the occupation at issue, with relevant factors such as lifting, bending, sitting, standing, walking, climbing, grasping, typing, reaching, auditory and visual, and (c) whether the Veteran has the mental ability to perform the type of activities required by the occupation at issue, with relevant factors such as memory, concentration, and ability to adapt to change, handle work place stress, get along with coworkers and demonstrate reliability and productivity. Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). As "sedentary" is defined as "[r]equiring or marked by much sitting " the Board finds that sedentary employment is a job where the worker primarily sits down. WEBSTER'S II NEW COLLEGE DICTIONARY 999 (1999). If there is only one service-connected disability, it must be rated at least 60 percent disabling to qualify for TDIU benefits; if there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Preliminarily, the Board finds that the Veteran meets the threshold schedular disability percentage requirement for TDIU consideration. 38 C.F.R. § 4.16(a). In that regard, throughout the period on appeal the Veteran has a combined disability rating of at least 70 percent with a single disability rated at more than 40 percent disabling. Military personnel records reflect the Veteran's military occupation specialty was that of an administrative specialist. On his application for unemployability he reported that his service-connected PTSD and CAD prevent him from following a substantially gainful occupation. The Veteran reported completing an associate degree in sociology, with some coursework toward a bachelor's degree. He reported he last worked full-time in 2010 for the California Department of Motor Vehicles, and that before that he was a warehouse worker. The record reflects that the Veteran's service-connected PTSD and CAD significantly limit him both mentally and physically. The Veteran underwent a vocational assessment by a private certified rehabilitation counselor, F.F., in December 2020. F.F. reported that the Veteran's disabilities, taken separately or together, rendered him unable to maintain employment. The Veteran's CAD was noted to result in frequent chest discomfort, chronic shortness of breath, and fatigue with any nominal activity. The Veteran also reported that he was unsteady and cautious when standing and ambulating, and that he was limited with standing, walking, and climbing stairs due to weakness, dyspnea, and fatigue. With respect to PTSD, F.F. noted that the Veteran's psychiatric symptoms included hypervigilance, a tendency to isolate himself, panic attacks, unprovoked anger and irritability, and a history of suicidal isolation. Hypervigilance rendered him distracted and unable to concentrate, while panic attacks caused exhaustion. His tendency to isolate himself as a coping mechanism was so great that he would stay in his bedroom alone at home for up to 8 daytime hours at a time. His unprovoked irritability and anger manifested verbally and he would occasionally throw things. His difficulty sleeping was so great that he had extreme fatigue during the day. He had limited concentration and memory and required reminders from his wife. F.F. opined that the Veteran's PTSD negatively impacted his ability to learn and perform new job tasks efficiently and accurately due to severe impairments in concentration and remaining on task. Taken as a whole, the Veteran's symptoms suggest he was unable to obtain and maintain employment similar to jobs he has performed in the past as a result of his service-connected disabilities. While he asserted that both CAD and PTSD affected his employability, the Board finds his PTSD alone is severe enough to render him essentially unemployable. Regardless of the Veteran's education and work history, his PTSD was severe enough to limit his ability to perform in any type of work environment. As treatment records and examinations throughout the period on appeal reflect, the Veteran has suffered from extremely high anxiety and other psychiatric symptoms that render him unable to successfully secure and maintain substantially gainful employment. Accordingly, entitlement to a TDIU prior to September 10, 2019, based solely on his PTSD is granted. While the Veteran has filed formal applications for a TDIU, in this case his claim for a TDIU is tied to his claim for an increased rating for PTSD filed in May 2016. Rice v. Shinseki, 22 Vet. App. 447 (2009). The February 2020 rating decision which awarded TDIU assigned it from the date of a September 2019 VA PTSD examination. Here, the Board has found that the Veteran's psychiatric symptoms remained consistent throughout the period on appeal and finds that TDIU is warranted prior throughout the appeal period for PTSD. The RO should initially address when TDIU should be assigned, considering the proper date of claim, so as to provide the Veteran with one review by the Secretary should he disagree with the assigned effective date. See 38 U.S.C. § 7104(a). 6. Entitlement to SMC at the housebound rate. Additional compensation is warranted on the basis of being housebound where the veteran (1) has, in addition to a single service-connected disability rated 100 percent disabling, additional service-connected disability or disabilities independently evaluated as 60 percent or more disabling which are separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). The fact that a single disability evaluated as 100 percent disabling and additional disability or disabilities independently evaluated as 60 percent or more disabling share a common etiology will not preclude entitlement. Although no formal claim for SMC has been submitted, one is not needed for an ancillary benefit that is part of an underlying claim of benefits. See 38 C.F.R. § 3.155(d)(2). See also Payne v. Wilkie, 31 Vet. App. 373 (2019); Hodge v. West, 155 F.3d 1356, 1362-63 (Fed. Cir. 1998) (VA is to "fully and sympathetically develop the veteran's claim to its optimum before deciding it on the merits."); Akles v. Derwinski, 1 Vet. App. 118, 121 (1991). Accordingly, the Board has jurisdiction over this ancillary issue. As a result of the decision above, the Veteran has one disability rated as 100 percent disabling; that is, he has been assigned a TDIU based upon a single disability. His remaining service-connected disability ratings, specifically a 60 percent rating for CAD, is separate and distinct from his PTSD rating and results in a rating of at least 60 percent. Accordingly, entitlement to SMC at the housebound rate is granted pursuant to 38 U.S.C. § 1114(s) and 38 C.F.R. § 3.350(i). The effective date of this award will coincide with the effective date assigned for TDIU, as noted above. REASONS FOR REMAND 1. Entitlement to service connection for a skin disability, to include jungle rot and/or tinea cruris, is remanded. The Veteran asserts that he has had a skin condition, specifically a rash of the groin, since his active duty service. Pursuant to the Board's May 2019 remand, the Veteran underwent VA examination in connection with this claim in September 2019. The Veteran opined that it was less likely than not that the Veteran had a skin disease related to service as there was no evidence of skin disease noted during his separation examination or service treatment records. However, a lack of documentation in the Veteran's service treatment records alone is not a sufficient basis on which to rest a negative opinion. Accordingly, the Board finds remand is warranted so that a new VA opinion may be obtained. Updated VA treatment records, as well as any relevant private treatment records identified by the Veteran, should be obtained ans associated with the file. The matters are REMANDED for the following actions: 1. Ask the Veteran to identify all outstanding treatment records relevant to his skin disability claim. All identified VA records should be added to the claims file. All other properly identified records should be obtained if the necessary authorization to obtain the records is provided by the Veteran. If any records are not available, or the Veteran identifies sources of treatment but does not provide authorization to obtain records, appropriate action should be taken (see 38 C.F.R. § 3.159(c)-(e)), to include notifying the Veteran of the unavailability of the records. 2. After records development is completed, the claims file should be sent to an appropriate examiner to offer an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any current skin disability, to include jungle rot and/or tinea cruris, had onset during service or is otherwise related to an in-service injury, event, or disease, to include exposure to herbicide agents. In offering the opinion, the examiner is asked to consider the Veteran's lay statements with respect to the onset of his skin symptoms. The examiner is also reminded that a lack of documentation in service medical records is not, alone, a sufficient basis for a negative opinion. The need for an examination is left to the discretion of the examiner. A rationale for all opinions offered is requested as adjudicators are precluded from making any medical findings. M. C. WILSON Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. D. Bruce, 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.