Citation Nr: 21028647 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 16-29 962 DATE: May 11, 2021 ORDER Service connection for a left hip disorder to include as secondary to service-connected prostate cancer is denied. A total disability rating based on individual unemployability (TDIU) due to service-connected posttraumatic stress disorder (PTSD) from September 5, 2014 is granted. Special monthly compensation (SMC) pursuant to 38 C.F.R. § 1114(s); 38 C.F.R. § 3.350(i), effective from March 28, 2016, is granted. FINDINGS OF FACT 1. The preponderance of the evidence shows that the Veteran's current left hip disorder was not diagnosed in service or within one year after discharge from service, is not otherwise related to or caused by active service, and is not caused by or aggravated by service-connected prostate cancer. 2. The evidence is evenly balanced as to whether the Veteran has been unable to secure or follow a substantially gainful occupation as a result of his service-connected PTSD since September 5, 2014. 3. Beginning on March 28, 2016, the Veteran's other service-connected disabilities are independently ratable at 60 percent or more and they include prostate cancer, rated as 60 percent disabling; tinnitus, rated as 10 percent disabling; erectile dysfunction, rated as noncompensable (0 percent disabling); scars, residuals of prostate cancer surgery, rated as noncompensable (0 percent disabling); and bilateral hearing loss, rated as noncompensable (0 percent disabling). CONCLUSIONS OF LAW 1. The criteria for service connection for a left hip disorder to include as secondary to service-connected prostate cancer are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for a TDIU due to service-connected PTSD are met from September 5, 2014. 38 U.S.C. §§ 1155, 7104; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. 3. The criteria for SMC at the statutory housebound pursuant to 38 C.F.R. § 1114(s); 38 C.F.R. § 3.350(i)rate are met as of March 28, 2016, but not earlier. 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 in the United States Army from July 1968 to August 1971. This case is before the Board of Veterans' Appeals (Board) on appeal from Regional Office (RO) rating decisions dated in June 2015 and December 2017. In the June 2015 rating decision, the RO denied entitlement to a TDIU. The Veteran's notice of disagreement (NOD) was received in April 2016. The RO issued a statement of the case (SOC) in June 2016. The Veteran's VA Form 9, substantive appeal to the Board, was received in June 2016. In the December 2017 rating decision, the RO denied service connection for a left hip disorder. The Veteran's notice of disagreement (NOD) was received in February 2018. The RO issued a statement of the case (SOC) in March 2018. The Veteran's VA Form 9, substantive appeal to the Board, was received in May 2018. In February 2019 and May 2020, the Board remanded the issue of entitlement to a TDIU to the RO for further development and adjudicative action. In April 2020, the Board remanded the issue of entitlement to service connection for a left hip disorder to the RO for further development and adjudicative action. 1. Entitlement to service connection for a left hip disorder to include as secondary to service-connected prostate cancer. The Veteran contends that his current left hip disorder is caused by or related to active military service. Specifically, he asserts that his current left hip disorder is caused by or related to repetitive, high intensity and high impact forces and running during training service in the military. In the alternative, the Veteran contends that his left hip disorder is caused by or aggravated by his service-connected prostate cancer. The Veteran states that his left hip pain began after his prostate cancer diagnosis. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Service connection for a claimed disability may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service-connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a). The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury or disease and/or at least as likely as not caused by or aggravated by his service-connected prostate cancer. While the Veteran has a current disability, diagnosed as degenerative joint disease of the left hip, status post left total hip arthroplasty, the preponderance of the evidence shows that the Veteran's left hip degenerative joint disease was not chronic in service, did not manifest to a compensable degree within the presumptive period, was not noted in service with attributable continuity of symptomatology, and is not otherwise related to an in-service injury, event, or disease. Furthermore, the preponderance of the evidence weighs against finding that the Veteran's degenerative joint disease of the left hip, status post left total hip arthroplasty is proximately due to or the result of or aggravated beyond its natural progression by service-connected prostate cancer. Turning to the evidence of record, the Veteran's VA treatment records shows that he was diagnosed with degenerative joint disease of the hips. The Veteran underwent a left total hip arthroplasty in January 2012. The Veteran underwent a left hip revision in October 2014. A May 2016 VA treatment record shows that the Veteran continued to experience chronic hip pain after the revision of the left total hip arthroplasty. Thus, the medical evidence shows that the Veteran has a current diagnosis of a left hip disorder. The Veteran's service treatment records reveal that the Veteran did not complain of or receive treatment for symptoms related to the left hip during active military service. The service treatment records also reflect that the Veteran was not diagnosed with degenerative joint disease of the left hip at any time during service. In the July 1972 Report of Medical History as part of the Veteran's separation examination, the Veteran denied arthritis and bone, joint, or other deformity. He also did not report experiencing any hip problems in the Report of Medical History. The July 1972 separation examination reveals that the Veteran's lower extremities and spine, other musculoskeletal were evaluated as clinically normal. The physician also did not document that the Veteran had a left hip disorder in the examination report. Thus, there is no medical evidence of a left hip disorder during active military service. The first medical evidence of complaints or a diagnosis of a left hip disorder was in an April 2009 private treatment record. The physician noted that a March 2009 CT scan of the abdomen and pelvis revealed advanced degenerative changes in the left hip with subchondral sclerosis, cystic changes, and moderate marginal osteophyte formation. Thus, the first medical evidence of a left hip problem after service occurred approximately 38 years after discharge from service. The Veteran also does not contend that the onset of his left hip symptoms began during service. Specifically, he asserts that his symptoms began after his prostate cancer or surgery. In light of the foregoing, regarding the issue of whether service connection is warranted on the basis of the presumption of service connection for chronic diseases, the weight of the above evidence is against manifestation of degenerative joint disease of the left hip in service or within the one-year presumptive period. See 38 U.S.C. § 1101 (3), 1112(a)(1), 1113; 38 C.F.R. §§ 3.307 (a), 3.309(a). Further, the claims file contains a negative medical opinion with respect to the issue of whether the Veteran's current diagnosis of degenerative joint disease of the left hip, status post left total hip arthroplasty is caused by or related to active military service. Specifically, in May 2020, a VA nurse practitioner provided the medical opinion that the Veteran's left hip condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The nurse practitioner explained that the Veteran's service treatment records to include the July 1971 separation history and examination are entirely negative regarding the hip. Personnel records indicate his military occupational specialty as armor crewman. He completed an eight-week course, yet all remaining military records are negative for excessive and/or persistent training in this category. Further records indicate he had several assigned/reassigned positions and he primarily worked in clerical position and radio operator. The Veteran previously noted his primary military job was clerical, which has a low probability of repetitive, high intensity, and high impact activity. The nurse practitioner explained that as cited in Up-to-date, aging is the most clearly associated risk factor in joint arthritis. Posttraumatic arthritis occurs when joint injury is considered and the "pathologic changes are often evidence within 10 years after injury, with the time of onset influenced in part by the age of the individual at the time of the injury." The nurse practitioner noted that the Veteran's post-military records are negative for left hip pain by either healthcare personnel or the Veteran until 35 to 40 years post-service and records are negative for hip pain/injury in service. The nurse practitioner concluded that because the Veteran primarily worked in a non-impact position, it is unlikely this his left hip which first manifest numerous years post service is caused by or related to military service. The nurse practitioner's medical opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Although the Veteran believes his degenerative joint disease of the left hip, status post left total hip arthroplasty is related to repetitive, high intensity and high impact forces and running during training in the military, he is not competent to provide a nexus opinion in this case. This issue is medically complex, as it requires knowledge of interpreting complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The diagnosis and etiology of left hip degenerative joint disease cannot be competently addressed by the Veteran as a lay person based on personal observation, such as, visual observation or by any other senses. The diagnosis of left hip degenerative joint disease was based on interpretation of symptoms, and clinical and diagnostic tests, which requires medical knowledge. The only competent evidence regarding a whether any nexus exists between the Veteran's left hip degenerative joint disease, status post left total hip arthroplasty and his military service is the opinion of the nurse practitioner, which definitively concluded that the Veteran's current left hip degenerative joint disease was less likely than not related to the Veteran's military service. The May 2020 medical opinion is considered probative, based upon a complete review of the Veteran's entire claims file and supported by detailed rationale. Accordingly, the opinion is found to carry significant weight. The Veteran has not provided any competent medical or lay evidence to rebut this opinion or otherwise diminish its probative weight. See Wray v. Brown, 7 Vet. App. 488, 492-93 (1995). Consequently, the Board gives more probative weight to the August 2018 VA medical opinion than the Veteran's lay statements. With respect to whether the Veteran's service-connected prostate cancer caused or aggravated the Veteran's current left hip disorder, the record contains a negative medical opinion. Specifically, the nurse practitioner in May 2020 provided the opinion that the Veteran's left hip condition is less likely than not proximately due to, result of, or aggravated by the veteran's service-connected prostate cancer. The nurse practitioner explained that as cited in Up-to-date, arthritis of the hip and other joints frequently increases with age, especially in those individuals 50 years of age and older. Hip arthritis is less common than knee or hand, yet additional risk factors to be considered are gender, genetics, anatomic factors (joint shape), obesity, and lifestyle. Greater trochanteric pain or bursitis is a common cause for lateral hip pain. Typically, due to gluteus medius or minimus tendinopathy. Risk factors are negative for prostate cancer or subsequent treatment and positive for female gender, obesity, low back pain, scoliosis, leg length discrepancy, hip and/or knee arthritis, and painful foot. The Veteran's post-military records document bursitis preceded first hip surgery and more than likely related to hip, knee, and back arthritis. The nurse practitioner noted that prostate cancer is a common male cancer, but the medical literature is negative for prostate cancer itself causing his left hip condition. The nurse practitioner further explained that in those with prostate cancer, bone health can be affected by androgen therapy even after discontinuation to include "increased risk of osteoporosis and a higher risk of vertebral and hip fractures...in addition, pelvic RT has been associated with a higher risk of pelvic fractures." However, the nurse practitioner observed that the records document prostate cancer was surgically treated in 2007 and radiation treatment was added and completed in 2010. The treatment records document the Veteran's advanced hip arthritis pre-dates the radiation treatment. Furthermore, the records are negative for androgen therapy. The Veteran's treatment records including bone imaging only document degenerative changes of the hip and do no show metastasis, fractures, or other such complications. The nurse practitioner concluded that it is unlikely that the Veteran's left hip conditions is secondary to and/or aggravated beyond its natural progression by service-connected prostate cancer. The opinion by the nurse practitioner is persuasive and probative as she provided an explanation based on the evidence of record and medical literature, as well as sound medical principles. Although the Veteran believes his left hip disorder is related to an in-service injury, event, or disease, or is secondary to his service-connected prostate cancer, he is not competent to provide a diagnosis of left knee degenerative joint disease or a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge and interpretation of medical testing. Therefore, it is outside the competence of the Veteran, because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the May 2020 negative medical opinion. The record does not contain any probative medical evidence or opinion that would indicate the Veteran's current left hip degenerative joint disease, status post left total hip arthroplasty is related to military service or his service-connected prostate cancer. As discussed above, the only probative medical evidence of record asserts that the Veteran's left hip degenerative joint disease, status post left total hip arthroplasty is not related to military service and is not caused by or aggravated by his service-connected prostate cancer. In conclusion, the evidence of record shows that the probative medical opinion provides evidence against the claim that the Veteran's left hip degenerative joint disease, status post left total hip arthroplasty is related to military service or is caused by or aggravated by service-connected prostate cancer. Thus, the preponderance of the evidence is against the Veteran's service connection claim for a left hip disorder and the claim is not warranted. 2. Entitlement to a TDIU due to service-connected PTSD. The Veteran contends that his service-connected PTSD prevents him from obtaining and/or maintaining substantially gainful employment. By way of history, the Veteran originally filed a TDIU claim in February 2012. In an April 2012 rating decision, the RO denied the claim. The Veteran did not appeal this decision; however, he requested the RO to reconsider the claim in June 2012. In a July 2012 rating decision, the RO continued the denial of entitlement to a TDIU. Although the Veteran was notified of this decision in a July 2012 letter at his then current address of record, the Veteran did not appeal the July 2012 rating decision. Thereafter, the Veteran filed another claim for TDIU in March 2013. The RO denied the claim in an April 2013 rating decision and he was notified of such denial in an April 2013 letter. The Veteran did not appeal this decision and no new and material evidence was received within one year of the April 2013 rating decision. The Veteran filed another claim for entitlement to TDIU in September 2014. A November 2014 rating decision denied the claim. Although notified of the decision at his then current address of record in a November 2014 letter, the Veteran did not appeal the decision. Thereafter, the Veteran filed claim for TDIU in February 2015. A March 2015 rating decision denied the claim. The Veteran was notified of this decision in a March 2015 letter. The Veteran did not appeal this decision. Finally, the Veteran filed a TDIU claim in April 2015 and the RO continued the denial of entitlement to a TDIU in June 2015. The current appeal stems from this rating decision. Nonetheless, new and material evidence (an August 2015 medical opinion from a private psychologist asserting that the Veteran's PTSD resulted in him being unable to seek, obtain, or maintain employment) was associated with the claims in August 2015. As new and material evidence as to entitlement to a TDIU was received within one year of the November 2014 rating decision that denied such claim, that rating decision is not final and is subject to reconsideration. Thus, the appeal period for consideration of entitlement to TDIU is from September 5, 2014. Total disability will be considered to exist when there is present any impairment of mind or body, which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. If the total rating is based on a disability or combination of disabilities for which the Schedule for Rating Disabilities provides an evaluation of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age. 38 C.F.R. § 3.341. In evaluating total disability, full consideration must be given to unusual physical or mental effects in individual cases, to peculiar effects of occupational activities, to defects in physical or mental endowment preventing the usual amount of success in overcoming the handicap of disability and to the effects of combinations of disability. 38 C.F.R. § 4.15. In order to establish an inability to maintain a substantially gainful occupation, as required for a TDIU award pursuant to 38 C.F.R. § 3.340(a), a veteran is not required to submit proof that he is 100 percent unemployable. See Roberson v. Principi, 251 F.3d 1378, 1385 (2001). Instead, the regulations contemplate more flexibility in the employability determination. Id. If the schedular rating is less than total, a total disability evaluation can be assigned based on individual unemployability if the veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disability, provided that he or she has one service-connected disability rated at 60 percent or higher; or two or more service-connected disabilities, with one disability rated at 40 percent or higher and the combined rating is 70 percent or higher. 38 C.F.R. § 4.16(a). It is provided further that the existence or degree of nonservice-connected disabilities or previous unemployability status will be disregarded where the percentages referred to in this paragraph for the service-connected disability or disabilities are met and in the judgment of the rating agency such service-connected disabilities render the Veteran unemployable. From September 5, 2014 to March 28, 2016, the Veteran was in receipt of service connection for the following: PTSD, rated as 70% disabling; prostate cancer rated as 40 percent disabling; and erectile dysfunction, rated as noncompensable. From March 28, 2016, the Veteran was in receipt of service connection for the following: PTSD, rated as 70 percent disabling; prostate cancer rated as 40 percent disabling; tinnitus, rated as 10 percent disabling; erectile dysfunction, rated as noncompensable; scars, residuals of prostate cancer, rated as noncompensable; and bilateral hearing loss, rated as noncompensable. The combined evaluation for compensation is 80 percent prior to March 28, 2016; and, 90 percent as of March 28, 2016. Thus, the Veteran meet the schedular percentage threshold requirements for consideration of a TDIU pursuant to the provisions of 38 C.F.R. § 4.16(a) from September 5, 2014. The crucial inquiry in determining whether the Veteran is entitled to TDIU is not whether the Veteran is able to pursue his profession of choice, or indeed any particular job. Instead, the Board must inquire as to whether the Veteran can secure and follow a substantially gainful occupation in a more general sense. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The fact that a veteran is unemployed is not enough. It must be determined that his service-connected disorders without regard to his advancing age make him incapable of performing the acts required by employment. Id. Consideration may be given to the veteran's education, special training, and previous work experience, but not to the veteran's age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16; see also Van Hoose v. Brown, 4 Vet. App. 361 (1993). In this case, the collective evidence suggests that the Veteran's service-connected PTSD has rendered him unable to secure or follow a substantially gainful occupation throughout the relevant appeal period. The evidence shows that the Veteran was unemployed throughout the appeal period. Specifically, in the Veteran's Application for Increased Compensation Based on Unemployability form, VA Form 21-8940, dated in May 2015, the Veteran contends the date his service-connected PTSD affected full-time employment and the date he became too disabled to work was in July 2010. He worked as medical tech for the same company from July 1977 to July 2010. The Veteran stated that he did not leave his last job because of his disability. He completed two years of college. Turning to the medical evidence of record, a January 2015 PTSD Disability Benefits Questionnaire (DBQ) filled out by the Veteran's VA psychologist reveals that the Veteran experienced depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintain effective work and social relations; difficulty in adapting to stressful circumstances, including work or a worklike setting, and inability to established and maintain effective relationships. The Veteran's symptoms also included avoidance, persistent and exaggerated negative beliefs or expectations about oneself, others, and the world, persistent negative emotional state, markedly diminished interest or participations in significant activities, persistent inability to experience positive emotions, irritable behavior and angry outbursts, exaggerated startle response, and problems with concentration. The VA psychologist determined that the Veteran's PTSD symptoms result in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. The private psychologist noted that the Veteran's greatest obstacle to social and occupational functioning was his irritability and poor judgment. The private psychologist attributed his irritability and poor judgement to the Veteran's PTSD, but noted that it was likely exacerbated by his substance abuse. The Veteran was provided with a VA examination in June 2015. The examination shows that the Veteran experienced depressed mood, anxiety, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, and impaired impulse control. The examiner noted that the Veteran also experiences avoidance, persistent and exaggerated negative beliefs or expectations about oneself, others, and the world, persistent negative emotional state, irritable behavior and angry outbursts, hypervigilance, exaggerated startle response, and problems with concentration. The examiner determined that the Veteran's PTSD symptoms result in occupational and social impairment with reduced reliability and productivity. The examiner provided the opinion that the Veteran's PTSD resulted in mild impairment with respect to reliability and productivity. Mild to moderate impairment with respect to concentration. Moderate impairment with intermittent severe impairment with respect to the ability to interact with supervisors. Mild impairment with intermittent moderate impairment regarding the ability to interact with coworkers. Moderate intermittent impairment of mood due to PTSD, including episodic anxiety and depression. There was no impairment due to PTSD regarding judgement, abstract thinking, and self-care. An August 2015 PTSD DBQ provided by the Veteran's VA psychologist shows that the Veteran's PTSD resulted in the following symptoms: depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, near-continuous panic or depression affective the ability to function independently, appropriately, and effectively, chronic sleep impairment, impairment of short and longterm memory, flattened affect, impaired judgement, impaired abstract thinking, disturbances of motivation and mood, difficulty in establishing and maintain effective work and social relations; difficulty in adapting to stressful circumstances, including work or a worklike setting, inability to established and maintain effective relationships, impaired impulse control, neglect of personal appearance and hygiene, and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. The Veteran's symptoms also included avoidance, markedly diminished interest or participations in significant activities, feelings of detachment or estrangement from others, irritability or outbursts of anger, hypervigilance, and exaggerated startle response. The VA psychologist determined that the Veteran's PTSD symptoms result in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. The VA psychologist stated that since his last examination, the Veteran has not been able to seek, obtain, or maintain employment. His irritability, distrust, and other hypervigilance behaviors predict that he would have severe struggles to adapt to any workplace setting and his work history demonstrates the difficulties he has had in the past. His problems with his service credits and ongoing dispute with VA over his compensation ratings created a feeling that the federal government is "conspiring against [him]." The VA psychologist noted that the Veteran has continued to struggle with symptoms of PTSD and depression. He still suffers from nightmares, intrusive memories, irritability, hypervigilance, and avoidance. He isolates, not wanted to be around other people and he does not trust them. He becomes angry over minor things, such as a crying baby. He is easily overwhelmed and goes into panic states, feeling very anxious and he leaves the situation to calm down. Due to increased anxiety and irritability, the Veteran agreed to begin a trial of antidepressant medication for the first time. The Veteran underwent another VA examination for PTSD in June 2016. The examination shows that the Veteran experienced depressed mood, anxiety, chronic sleep impairment, mild memory loss. The examiner noted that the Veteran also experiences avoidance, persistent and exaggerated negative beliefs or expectations about oneself, others, and the world, persistent negative emotional state, irritable behavior and angry outbursts, hypervigilance, and exaggerated startle response. The examiner stated that the Veteran reported that he experiences persistent anxiety when he is out in public, out of his house. Concentration and memory are diminished. He has intermittent feelings of worthlessness and hopelessness. The VA examiner determined that the Veteran's PTSD symptoms result in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The Veteran most recently underwent a VA examination for PTSD in February 2019. The examination shows that the Veteran experienced anxiety, suspiciousness, chronic sleep impairment, impairment of short and long term memory, disturbances of motivation and mood, difficulty in establishing and maintain effective work and social relations, and difficulty in adapting to stressful circumstances, including work or a worklike setting. The examiner noted that the Veteran also experiences avoidance, markedly diminished interest or participation in significant events, feelings of detachment or estrangement from others, and hypervigilance. The VA examiner determined that the Veteran's PTSD symptoms result in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. The Board notes that the ultimate question of whether a veteran is capable of substantially gainful employment is not a medical question, but rather a determination that must be made by an adjudicator. See 38 C.F.R. § 4.16(a); Geib v. Shinseki, 733 F.3d 1350 (Fed. Cir. 2014) and Floore v. Shinseki, 26 Vet. App. 376, 381 (2013)). However, as a medical examiner is responsible for providing a full description of the functional effects of disability upon a person's ordinary activity (see 38 C.F.R. § 4.10), and has done so here. The findings, comments and opinions of the VA examiners and the VA psychologist have appropriately been considered as pertinent evidence, along with the Veteran's competent assertions, in determining whether he is able to perform the acts required for substantially gainful employment. Based on the foregoing, the Board finds that the overall evidence of record indicates that Veteran would be unable to maintain employment due to his service-connected PTSD as of September 5, 2014. Specifically, the Veteran's PTSD symptoms of depressed mood, anxiety, weekly panic attacks, chronic sleep impairment, impairment of short and long term memory, disturbances in motivation and mood, difficulty establishing and maintaining effective work relationships, difficulty in adapting to stressful circumstances, including work or a worklike setting, and irritability, and impaired impulse control would make it extremely difficult for him to maintain substantially gainful employment. Also persuasive is the treating VA psychologist's determination that the Veteran's PTSD symptoms of irritability, distrust, and other hypervigilance behaviors indicate that he would have severe struggles to adapt to any workplace setting. In a June 2015 VA examination, the examiner provided the opinion that the Veteran's PTSD symptoms resulted in mild to moderate impairment with respect to concentration, moderate impairment with intermittent severe impairment with respect to the ability to interact with supervisors, mild impairment with intermittent moderate impairment regarding the ability to interact with coworkers, and moderate intermittent impairment of mood due to PTSD, including episodic anxiety and depression. The Board finds that his PTSD would allow only marginal employment at best, given the excessive restrictions this would put on finding adequate employment. See Friscia v. Brown, 7 Vet. App. 294 (1995), citing Beaty v. Brown, 6 Vet. App. 532, 537 (1994) (TDIU may not be denied without producing evidence, as distinguished from mere conjecture, that the Veteran's disability does not prevent him or her from performing work that would produce sufficient income to be other than marginal). The evidence suggests that the Veteran's symptoms of PTSD and the affects that those symptoms would have on the Veteran being able to maintain employment were relative consistent throughout the relevant appeal period. Accordingly, the evidence is at least evenly balanced as to whether the Veteran is precluded by his service-connected PTSD from obtaining and maintaining substantially gainful employment in occupations related to his education, training, and work experience. Resolving any reasonable doubt in favor of the Veteran, the Board finds that entitlement to a TDIU is warranted from September 5, 2014. 3. Entitlement to SMC at the statutory housebound rate pursuant to 38 C.F.R. § 1114(s); 38 C.F.R. § 3.350(i). V A has a duty to infer a claim for special monthly compensation when the evidence of record indicates potential entitlement. See Akles v. Derwinski, 1 Vet. App. 118 (1991). SMC at the housebound rate is payable by law where the veteran has a single service-connected disability rated as 100 percent and has additional service-connected disability or disabilities independently ratable at 60 percent. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). The Board has granted TDIU based solely on service-connected PTSD. For SMC purposes, a TDIU predicated on one service-connected disability satisfies the requirement of a "single service-connected disability rated as total." Bradley v. Peake, 22 Vet. App. 280, 293 (2008). In this case, beginning on March 28, 2016, the Veteran also has additional service-connected disabilities independently rated at 60 percent or higher (his service-connected prostate cancer is rated as 60 percent disabling since March 28, 2016; and the disability ratings assigned for his service-connected tinnitus, erectile dysfunction, scars as residual of prostate cancer surgery, and bilateral hearing loss combined with the service-connected prostate cancer rating provide a combined rating of 60 percent, independently ratable from the service-connected PTSD/TDIU). Prior to March 28, 2016, the Veteran's service connected disabilities other than PTSD combined to 40 percent disabling or less (service-connected prostate cancer was rated as 20 percent disabling from September 20, 2010 to August 18, 2011 and 40 percent from August 19, 2011 to March 27, 2016, erectile dysfunction was rated as noncompensable, scars as residual of prostate cancer surgery was rated as noncompensable, and bilateral hearing loss was rated as noncompensable). (continued on next page) In light of the foregoing, the criteria are met for entitlement to SMC at the housebound rate effective from March 28, 2016, but not earlier. It is not until March 28, 2016 that the Veteran has a TDIU predicated solely on the service-connected PTSD and separate service-connected disabilities independently rated at 60 percent. Thus, entitlement to SMC at the statutory housebound rate under 38 U.S.C. § 1114(s) is warranted as of March 28, 2016. L. B. CRYAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Berry, 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.