Citation Nr: 21030510 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 16-39 771 DATE: May 19, 2021 ORDER Service connection for diabetes mellitus type II has been withdrawn. Service connection for upper radiculopathy (C5-6 and 6-8) has been withdrawn. Service connection for an inner ear condition with balance problems has been withdrawn. Service connection for a heart condition is granted. Service connection for a left foot condition is granted. Service connection for a right wrist condition is granted. Service connection for a left wrist condition is granted. Service connection for migraines is granted. Service connection for depression, to include as secondary to service-connected conditions, is granted. Prior to February 5, 2021, an initial disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD) is denied. From February 5, 2021, a disability rating of 70 percent, but no higher, for PTSD is granted, subject to the laws and regulations governing monetary benefits. REMANDED Service connection for hypertension, to include as secondary to a heart condition, is remanded. Service connection for chronic fatigue syndrome is remanded. Service connection for fibromyalgia is remanded. Service connection for joint pain is remanded. Service connection for muscle pain is remanded. Entitlement to an initial compensable rating muscle pain is remanded for hearing loss is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. Entitlement to special monthly compensation (SMC), based on aid and attendance or housebound status, is remanded. FINDINGS OF FACT 1. At the February 2021 Board hearing, the Veteran (with the agreement of his Veterans Service Organization representative) withdrew his appeals for diabetes mellitus type II, upper radiculopathy, and an inner ear condition with balance problems. The undersigned Veterans Law Judge is satisfied that this was an informed withdrawal. 2. The Veteran's heart condition is reasonably shown to be related to or caused by active service. 3. The Veteran's left foot condition is reasonably shown to be related to or caused by active service. 4. The Veteran's right wrist condition is reasonably shown to be related to or caused by active service. 5. The Veteran's left wrist condition is reasonably shown to be related to or caused by active service. 6. The Veteran's migraines are reasonably shown to be related to or caused by active service 7. At the Veteran's February 2021 Board hearing, he provided competent and credible testimony that his major depressive disorder (MDD) is reasonably shown to be related to or caused by his service-connected disabilities. 8. Prior to February 5, 2021, the Veteran's PTSD was characterized by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. It was not characterized by occupational and social impairment with reduced reliability and productivity. 9. From February 5, 2021, the Veteran's PTSD more nearly approximated occupational and social impairment with deficiencies in most areas. It has not been characterized as total occupational and social impairment. CONCLUSIONS OF LAW 1. The criteria have been met for withdrawal of an appeal by the Veteran (or his representative) of the claim for service connection for diabetes mellitus type II. 38 U.S.C. § 7105(b)(2), (d)(5); 38 C.F.R. § 20.204. 2. The criteria have been met for withdrawal of an appeal by the Veteran (or his representative) of the claim for service connection for upper radiculopathy. 38 U.S.C. § 7105(b)(2), (d)(5); 38 C.F.R. § 20.204. 3. The criteria have been met for withdrawal of an appeal by the Veteran (or his representative) of the claim for service connection for an inner ear condition with balance problems. 38 U.S.C. § 7105(b)(2), (d)(5); 38 C.F.R. § 20.204. 4. The criteria have been met for service connection for a heart condition. 38 U.S.C. §§ 1101, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 5. The criteria have been met for service connection for a left foot condition. 38 U.S.C. §§ 1101, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 6. The criteria have been met for service connection for a right wrist condition. 38 U.S.C. §§ 1101, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 7. The criteria have been met for service connection for a left wrist condition. 38 U.S.C. §§ 1101, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 8. The criteria have been met for service connection for migraines. 38 U.S.C. §§ 1101, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 9. The criteria have been met for service connection for depression. 38 U.S.C. §§ 1110, 1131 5107; 38 C.F.R. § §§ 3.102, 3.303, 3.307, 3.309, 3.310. 10. Prior to February 5, 20201, the criteria have not been met for an initial rating in excess of 30 percent for PTSD. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321(a), 4.1, 4.3, 4.7, 4.130, Diagnostic Code (DC) 9411. 11. From February 5, 20201, the criteria have been met for a 70 percent rating for PTSD. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321(a), 4.1, 4.3, 4.7, 4.130, DC 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1974 to June 1992 and from January 2008 to January 2009. These matters are before the Board of Veterans' Appeals (Board) on appeal from August 2014, September 2014, and October 2015 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). In August 2015, and January 2016, the Veteran disagreed with the rating decisions. In a September 2013 rating decision, the RO granted service connection for bilateral hearing loss and assigned a noncompensable (0 percent) rating effective May 21, 2012. In an August 2014 rating decision, the RO granted service connection for PTSD and assigned a 30 percent rating effective February 12, 2014. The Veteran subsequently disagreed with these initial ratings so even though the underlying service connection claims were granted, his increased rating claims are still on appeal. AB v. Brown, 6 Vet. App. 35, 39 (1993). In February 2021, the Veteran testified before the undersigned Veterans Law Judge (VLJ) via videoconference. Withdrawal of Claims 1. The appeal for service connection for diabetes mellitus type II has been dismissed. 2. The appeal for service connection for upper radiculopathy has been dismissed. 3. The appeal for service connection for an inner ear condition with balance problems has been dismissed. As there is considerable overlap in the applicable evidence for the Veteran's claims, the Board will discuss them together. The Board may dismiss any appeal which fails to allege specific error of fact or law in the decision being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board issues a decision. 38 C.F.R. § 20.204. Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204. In the present case, at his February 2021 Board hearing, the Veteran (with the agreement of his Veterans Service Organization representative) withdrew his appeals for diabetes mellitus type II, upper radiculopathy, and an inner ear condition with balance problems. The undersigned Veterans Law Judge is satisfied that this was an informed withdrawal, and, hence, there remain no allegations of errors of fact or law for appellate consideration concerning these issues. Accordingly, the Board does not have jurisdiction to review these appeals, and they are dismissed. Service Connection Legal Criteria Service connection may be granted for a disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C. §§ 1101, 1131. Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Certain disabilities, including arthritis, organic neurological disorders, and psychoses, are presumed to be serviced connected if manifested to a compensable degree within one year following service. 38 C.F.R. §§ 3.303, 3.307, 3.309. 1. Service connection for a heart condition is granted. In a January 1984 service treatment record (STR), the Veteran was seen for his heart. In an August 1990 STR, the Veteran was seen for routine treatment. The examiner noted that the Veteran had a past medical history that suggested the presence of a heart murmur. The Veteran reported that he had been told that he either had an enlarged heart or a heart murmur. A September 1990 STR noted that the Veteran had an intermittent and irregular heartbeat on his echocardiogram. A February 2007 STR diagnosed the Veteran with mitral regurgitation. It was noted that the Veteran had very early aortic sclerosis with trace aortic insufficiency. In a September 2014 VA examination report, the Veteran was diagnosed with mild mitral valve regurgitation and mild tricuspid valve regurgitation. At his February 2021 Board hearing, the Veteran testified that he continued to have heart problems since active service. Analysis Although a causal relationship has not been demonstrated through competent medical opinion evidence, the absence of a "valid medical opinion" is not an absolute bar to service connection. Davidson v. Shinseki, 581 F.3d at 1316. The Board finds that the Veteran's statements and his February 2021 testimony, combined with multiple in-service STRs, leads the Board to determine that it is at least as likely as not that the Veteran's current heart condition began during active service. The Board finds that the evidence demonstrates that the Veteran's heart condition, which began during active service and continues to the present, to be competent and credible evidence of continuing symptoms since active service. 38 C.F.R. §§ 3.303, 3.307, 3.309. The Board notes that, under the continuity of symptoms provision, "symptoms, not treatment, are the essence of any evidence of continuity of symptom[s]." Savage v. Gober, 10 Vet. App. 488, 496 (1997) (referencing 38 C.F.R. § 3.303(b)). Based on the above analysis, the Board determines that at the very least, the evidence is evenly balanced for and against ("in relative equipoise") as to whether the Veteran's heart condition is related to active service. Accordingly, resolving all reasonable doubt in the Veteran's favor, the Board finds that service connection for a heart condition is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Service connection for a left foot condition is granted. In a June 1993 STR, the Veteran reported that he had pain when he walked on his left foot after twisting his ankle. In a November 2004 Report of Medical Examination, the Veteran was diagnosed with moderate pes planus. In a September 2014 VA examination report, the Veteran was diagnosed with flat feet and plantar fasciitis. In his February 2021 Board hearing, the Veteran testified that for his first seven years in the Army, he was always doing physical training in uniform and in his combat boots on concrete. The Veteran reported, and his medical records confirm, that when he originally entered into active service, he did not have pes planus. During active service, in 1993, he was diagnosed with moderate flat feet. The Veteran testified that while he was serving in Iraq, he was again diagnosed with flat feet, but this time it was severe. He noted that his feet became much worse and he was taking pain medication every day for pain in his feet. Analysis Although a causal relationship has not been demonstrated through competent medical opinion evidence, the absence of a "valid medical opinion" is not an absolute bar to service connection. Davidson v. Shinseki, 581 F.3d at 1316. The Board finds that the Veteran's statements and his February 2021 testimony, combined with multiple in-service STRs, leads the Board to determine that it is at least as likely as not that the Veteran's current left foot condition began during active service. The Board finds that the evidence demonstrates that the Veteran's left foot condition, which began during active service and continues to the present, to be competent and credible evidence of continuing symptoms since active service. 38 C.F.R. §§ 3.303, 3.307, 3.309. The Board notes that, under the continuity of symptoms provision, "symptoms, not treatment, are the essence of any evidence of continuity of symptom[s]." Savage v. Gober, 10 Vet. App. 488, 496 (1997) (referencing 38 C.F.R. § 3.303(b)). Based on the above analysis, the Board determines that at the very least, the evidence is evenly balanced for and against ("in relative equipoise") as to whether the Veteran's left foot condition is related to active service. Accordingly, resolving all reasonable doubt in the Veteran's favor, the Board finds that service connection for a left foot condition is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Service connection for a right wrist condition is granted. 4. Service connection for a left wrist condition is granted. As there is considerable overlap in the applicable evidence for the Veteran's claims, the Board will discuss them together. In a May 2008 STR, the Veteran reported right wrist pain. In a September 2014 VA examination report, the Veteran was diagnosed with bilateral wrist degenerative joint disease (DJD), carpal tunnel syndrome, and tenosynovitis. In his February 2021 Board hearing, the Veteran testified that the May 2008 STR was incorrect and that, at the time, he actually injured both his wrists. During the hearing, the Veteran stated that his current bilateral wrist symptoms were a continuation of his wrist pain during active service. The Board notes that in a July 2014 Social Security Administration (SSA) disability determination, the Veteran's wrists were listed as disabilities that contributed to him receiving Social Security Disability (SSD). Analysis Although a causal relationship has not been demonstrated through competent medical opinion evidence, the absence of a "valid medical opinion" is not an absolute bar to service connection. Davidson v. Shinseki, 581 F.3d at 1316. The Board finds that the Veteran's statements and his February 2021 testimony, combined with multiple in-service STRs and the July 2014 SSA determination, leads the Board to determine that it is at least as likely as not that the Veteran's current bilateral wrist conditions began during active service. The Board finds that the evidence demonstrates that the Veteran's bilateral wrist conditions, which began during active service and continues to the present, to be competent and credible evidence of continuing symptoms since active service. 38 C.F.R. §§ 3.303, 3.307, 3.309. The Board notes that, under the continuity of symptoms provision, "symptoms, not treatment, are the essence of any evidence of continuity of symptom[s]." Savage v. Gober, 10 Vet. App. 488, 496 (1997) (referencing 38 C.F.R. § 3.303(b)). Based on the above analysis, the Board determines that at the very least, the evidence is evenly balanced for and against ("in relative equipoise") as to whether the Veteran's bilateral wrist conditions are related to active service. Accordingly, resolving all reasonable doubt in the Veteran's favor, the Board finds that service connection for right and left wrist conditions is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 5. Service connection for migraines is granted. In a February 1983 STR, the Veteran complained of headaches and vomiting for three days. The Veteran stated he had never had headaches like this before. In a January 1984 STR, the Veteran again reported having headaches. In a February 1991 STR, the Veteran reported that he had headaches for the past 4 days. He stated that he vomited, had nausea, dizziness, and body aches. In an October 2015 VA examination report, the Veteran was diagnosed with migraines, including migraine variants. In his February 2021 Board hearing, the Veteran testified that he had been having headaches ever since his time in active service. He also stated that he was in charge of running the largest burn pit in Iraq, at Camp victory, and was exposed to smoke every day. The Veteran testified that they were never told what they were burning, but just told to burn it. He stated that he had migraines about three times per month and that they were prostrating. Analysis Although a causal relationship has not been demonstrated through competent medical opinion evidence, the absence of a "valid medical opinion" is not an absolute bar to service connection. Davidson v. Shinseki, 581 F.3d at 1316. The Board finds that the Veteran's statements and his February 2021 testimony, combined with multiple in-service STRs, leads the Board to determine that it is at least as likely as not that the Veteran's current migraines began during active service. The Board finds that the evidence demonstrates that the Veteran's migraines, which began during active service and continues to the present, to be competent and credible evidence of continuing symptoms since active service. 38 C.F.R. §§ 3.303, 3.307, 3.309. The Board notes that, under the continuity of symptoms provision, "symptoms, not treatment, are the essence of any evidence of continuity of symptom[s]." Savage v. Gober, 10 Vet. App. 488, 496 (1997) (referencing 38 C.F.R. § 3.303(b)). Based on the above analysis, the Board determines that at the very least, the evidence is evenly balanced for and against ("in relative equipoise") as to whether the Veteran's migraines are related to active service. Accordingly, resolving all reasonable doubt in the Veteran's favor, the Board finds that service connection for migraines is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 6. Service connection for depression, to include as secondary to service-connected conditions, is granted. Legal Criteria Service connection may be established on a secondary basis for a disability which is proximately due to or the result of 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) proximately caused by or (b) proximately aggravated by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Factual Background and Analysis In an October 2015 VA examination report, the Veteran was diagnosed with PTSD and MDD. The examiner noted that the Veteran had more than one mental disorder diagnosed and that it was possible to differentiate what symptoms were attributable to each diagnosis. The Veteran's MDD symptoms appeared to be associated with the pain caused by his now-service-connected disabilities. The VA examiner opined that it was less likely than not that the Veteran's MDD was related to his PTSD, but it was at least as likely as not that it was related to pain. In his February 2021 hearing, the Veteran testified that he believed his MDD was related to his PTSD. He also stated that the pain from his many disabilities caused him to become depressed. Based on the above evidence, the Board finds that the October 2015 VA opinion, concluding that the Veteran's MDD was at least as likely as not related to the pain caused by his disabilities, is competent and credible medical evidence of a positive nexus. Because these disabilities have now been service-connected, the Board finds that service connection for depression is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. Increased Rating Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. 1. Prior to February 5, 2021, an initial disability rating in excess of 30 percent for PTSD is denied. 2. From February 5, 2021, a disability rating of 70 percent for PTSD is granted. As there is considerable overlap in the applicable evidence for the Veteran's claims, the Board will discuss them together. Under the General Rating Formula for Mental Disorders, a 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). See 38 C.F.R. § 4.130, DC 9411, General Rating Formula for Mental Disorders. A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-term 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; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affection 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); inability to establish and maintain effective relationships. Id. The maximum 100 percent rating is warranted 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 person hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. Prior to February 5, 2021 Prior to February 5, 2021, the Veteran's PTSD is rated 30 percent, effective February 12, 2014, under DC 9411. 38 C.F.R. § 4.130, DC 9411. He contends that it is more severe than this initial 30 percent rating. In a July 2014 VA examination report, the Veteran was diagnosed with PTSD. The examiner noted that the Veteran was diagnosed with only one mental disorder. The examiner characterized the Veteran's PTSD as causing 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 reported that he had been married twice. He was married from the age of 19 to 25, and from 28 to the present. The Veteran noted that he and his wife have been separated for 17 years. The Veteran lived with his girlfriend. He had no friends, he socialized with his family. The Veteran reported that he had depression PTSD, fatigue, memory loss, lack of focus, concentration problems, migraines, and sleep problems. The VA examiner noted that the Veteran's PTSD symptoms consisted of depressed mood, anxiety, and chronic sleep impairment. During the examination, the Veteran was alert and fully oriented. His speech was normal in rate, tone, and syntax. Thought content and process were unremarkable. The Veteran's mood presented as euthymic with full and reactive affect. There was no observable responsiveness to internal stimuli. He denied hallucinations, delusions, suicidal and homicidal ideation, intent, and planning. There was no observable impairment in attention, concentration, or memory. In a July 2014 SSA determination, the Veteran was awarded SSD because of his PTSD and his other disabilities. In an October 2015 VA examination report, the Veteran was diagnosed with PTSD and MDD. The examiner noted that the Veteran had more than one mental disorder diagnosed, and it was possible to differentiate the symptoms attributable to each. The Board notes that the Veteran has already been granted service connection for his depression earlier in this decision. The examiner characterized the Veteran's PTSD as causing 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's PTSD symptoms consisted of depressed mood, anxiety, suspiciousness, and chronic sleep impairment. The Board notes that throughout this appeal period, the Veteran received medical treatment for his PTSD. These treatment reports did not evaluate the nature, extent, and severity of his PTSD. While not discussed specifically, the Board has reviewed them and taken them into consideration. Based on the above, the probative medical evidence indicates that, prior to February 5, 2021, a disability rating in excess of 30 percent for PTSD is not warranted. 38 C.F.R. § 4.130, DC 9411. There is no competent and credible evidence at any point prior to February 5, 2021 that characterized the Veteran's symptoms as occupational and social impairment with reduced reliability and productivity, or worse. Id. Rather, overall, the Veteran's PTSD symptoms caused occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. Id. Because of this, prior to February 5, 2021, a disability rating in excess of 30 percent for PTSD is not warranted. From February 5, 2021 In his February 2021 Board hearing, the Veteran testified that he believes his current job (writing parking tickets at a parking lot) is the only job he can do. He can go by himself in his own car, has complete flexibility with his schedule, and can work at his own pace. Doing this work, the Veteran does not see anyone else and can call in sick and make up a day, or even an entire week. The Veteran has now been working at this job for a year. The Social Security Administration which, as the United States Court of Appeals for Veterans Claims (Court) indicated in Faust v. West, 13 Vet. App. 342 (2000), is the most closely analogous legal context to VA's adjudication process, uses the similar terms "sheltered or special environment" and "sheltered employment." These are not precisely defined in title 20 of the Code of Federal Regulations, but 20 CFR 404.1574 (a)(3) reads: "If you are working in a sheltered workshop, you may or may not be earning the amounts you are being paid. The fact that the sheltered workshop or similar facility is operating at a loss or is receiving some charitable contributions or government aid does not establish that you are not earning all you are being paid...." A Social Security policy statement on determining whether work constitutes "substantial gainful activity" gives the following definition for sheltered employment: "Sheltered employment is employment provided for handicapped individuals in a protected environment under an institutional program." SSR 83-33, 1983 SSR LEXIS 34. Based on the Veteran's description of his job situation, the Board finds that the Veteran's job qualifies as "sheltered employment." The Veteran testified that his current symptoms include "great depression." He stated that when he drove this car, he felt out of control because he felt trapped and unsafe. He testified that he felt out of control and knew he acted inappropriately when driving. The Veteran also stated that he checked the locks on his door and had a security alarm system in his house, but still got up at night to check them. He testified that he had nightmares and had to sleep in a separate bed from his girlfriend because he would "yell out" while he slept and react aggressively if touched. The Veteran reported that he felt "lots of anger and irritability, especially in traffic." He testified that he forgets things almost daily, even during conversations. The Veteran testified that he lived with his girlfriend for about a year and a half. These days, the Veteran saw his kids about twice a year because he lived in a different state. He was not in touch with his siblings that often. The Veteran testified that he really did not have any friends and did not go anywhere. Based on this evidence, affording the Veteran the benefit of the doubt, from February 5, 2021, the date of his Board hearing, his PTSD symptoms more nearly approximate a 70 percent rating. 38 C.F.R. § 4.130, DC 9411. Based on the Veteran's testimony, the Board finds that his symptoms more nearly approximate occupational and social impairment with deficiencies in most areas. Id. At no point during the appeal period has his PTSD been characterized by total occupational and social impairment. Id. The Board finds that the July 2014 and October 2015 VA examination reports, describing the Veteran's PTSD symptoms, to be the most probative evidence of record because the examiners reviewed the claims file and provided detailed rationales. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). While the Veteran is competent (qualified) to observe his PTSD symptoms, he does not have the training or credentials to determine the current nature, extent, and severity of those symptoms, as reflected by the applicable diagnostic criteria. Additionally, he does not have the training or credentials to determine the proper disability evaluations concerning his PTSD. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Because of this, the preponderance of the evidence is against a finding that the Veteran's PTSD warrants a rating in excess of 30 prior to February 5, 2021. Based on his February 2021 testimony, however, from February 5, 2021, a rating of 70 percent is warranted. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). The Board will address the Veteran's claim for a TDIU in the remand section. The Board is sympathetic to the Veteran's reports and understands that his PTSD has significant effects on his daily life. However, this disability more nearly approximates the assigned evaluations and do not warrant additional increases in the ratings at this time. The Board also notes that this decision does not leave the Veteran without recourse. If his service-connected disabilities should worsen in the future, he is free to file a claim for an increased disability rating at that time. REASONS FOR REMAND The Board notes that, according to a July 2014 SSA memo, the Veteran has receiving Social Security Disability payments since March 2014. From a review of the records in the Veteran's claims folder, it does not appear that the RO has attempted to obtain the Veteran's complete Social Security Administration (SSA) file. Once VA is put on notice (becomes aware) that the Veteran is receiving SSA benefits, VA has a duty to obtain the records associated with that decision. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). Because of this, the RO must attempt to obtain and associate with the record the Veteran's complete SSA records. 1. Service connection for hypertension, to include as secondary to a heart condition, is remanded. In a September 2014 VA examination report, the Veteran was diagnosed with hypertension. The Board notes that the Veteran had high blood pressure during active service. While the VA examiner opined that it was less likely than not that the Veteran's hypertension was related to active service, no opinion was given as to whether his hypertension was related to his now-service-connected heart condition. Because of this, a new VA examination is necessary to determine whether the Veteran's hypertension was caused or aggravated by his heart condition. 2. Service connection for chronic fatigue syndrome is remanded. 3. Service connection for fibromyalgia is remanded. 4. Service connection for joint pain is remanded. 5. Service connection for muscle pain is remanded. As there is considerable overlap in the applicable evidence for the Veteran's claims, the Board will discuss them together. In his February 2021 Board hearing, the Veteran testified that all these conditions started within a year of him coming back from Iraq and that even during service in Iraq, he was constantly in pain and was losing mobility. The Veteran stated that he was in charge of running the largest burn pit in Iraq, at Camp Victory, and was exposed to smoke inhalation every day. The Veteran testified that he was never told what he was burning, he was just told to burn it. He noted that he never had any of these conditions prior to serving in Iraq. In an October 2015 VA examination report, the examiner noted that the Veteran could not be diagnosed with CFS until other illnesses causing fatigue had been ruled out. However, he was never given any other examinations to determine what, if any, other illnesses were causing these conditions. Because of this, new VA examinations are necessary to determine if the Veteran is diagnosed with CFS, fibromyalgia, joint pain, and muscle pain, and if so, whether they are related to active service or to his other service-connected disabilities. 6. Entitlement to an initial compensable rating for hearing loss is remanded. The last VA examination the Veteran had to evaluate his service-connected hearing loss was in June 2014. In his February 2021 hearing, the Veteran noted that his hearing was worse than when evaluated. Because of this, and in light of the Veteran's testimony, a new VA examination is necessary to determine the current nature, extent, and severity of his hearing loss. 38 C.F.R. § 3.159(c)(4). [CONTINUED ON NEXT PAGE] 7. A total disability rating based on individual unemployability (TDIU) is remanded. 8. Special monthly compensation (SMC), based on aid and attendance or housebound status, is remanded. As there is considerable overlap in the applicable evidence for the Veteran's claims, the Board will discuss them together. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims (Court) held that a TDIU claim is part of a claim for a higher rating when such claim is raised by the record or asserted by the Veteran. The Court further held that when evidence of unemployability is submitted during the pendency of a claim for an increased evaluation, the claim for TDIU is part and parcel of the claim for benefits for the underlying disability. Id. In the February 2021 Board hearing, the Veteran testified that he only worked four hours a day every second week. He noted that after he returned from Iraq, he tried to work at a construction company, and they let him work even though he was not able to do the work required. The Board notes that the Veteran has been on SSD since 2014. The Veteran testified that his current job is the only job he can do. He can go by himself in his own car, has complete flexibility with his schedule and can work at his own pace. During his job writing tickets at a parking lot, the Veteran does not see anyone else and can call in sick and make up a day, or even an entire week. The Veteran has been working at this job for a year. The Board finds that the Veteran's current job qualifies as "sheltered employment." Because the Veteran job does not qualify as a "substantial gainful occupation," the TDIU claim has been recognized as part and parcel of the increased rating appeals and is before the Board. The Board finds that a remand is warranted to allow the Veteran an opportunity to complete and return a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability. Additionally, the Board finds that an opinion should be obtained as to the combined effects of the Veteran's service-connected disabilities. See Geib v. Shinseki, 733 F.3d 1350 (Fed. Cir. 2013); Floore v. Shinseki, 26 Vet. App. 376 (2013). Finally, VA has a "well-established" duty to maximize a claimant's benefits. See Buie v. Shinseki, 24 Vet. App. 242 (2011); AB v. Brown, 6 Vet. App. 35, 38 (1993). This duty to maximize benefits requires VA to assess all a claimant's disabilities to determine whether any combination of disabilities establishes entitlement to SMC under 38 U.S.C. § 1114. See Bradley v. Peake, 22 Vet. App. 280, 294 (2008). During the pendency of the appeal for increased ratings, the matter of SMC has been raised by the record. In the February 2021 hearing, the Veteran testified that he needed assistance with things around his home that he could not handle on his own. The SMC claim has been recognized as part and parcel of the increased rating appeal and is before the Board. The matters are REMANDED for the following actions: 1. Please note that, by law, ALL remanded claims must be processed expeditiously. 2. Contact the SSA, request and obtain the Veteran's complete Social Security records, including all decisions and any medical records relied upon in making those decisions. 3. In accordance with the provisions of 38 C.F.R. § 3.159(c)(1), contact the Veteran for additional information about treatment for his condition and make efforts to obtain all VA and private treatment records concerning these claims. 4. Provide the Veteran and his attorney with appropriate notice regarding the issue of entitlement to a TDIU, to include requesting that he complete and return a VA Form 21-8940 and any other necessary forms. All action necessitated by the Veteran's response must be accomplished. 5. The RO must undertake any and all development necessary to fulfill VA's duty to assist the Veteran in substantiating his appeal to establish SMC benefits based on the need for aid and assistance or at the homebound level, to include confirming the Veteran's educational and occupational history, scheduling and completing appropriate examinations, and obtaining retroactive medical opinions. 6. Schedule the Veteran for VA examinations to determine the nature and cause of any hypertension, CFS, fibromyalgia, joint paint, and muscle pain. Prior to the examinations, the claims folder and a copy of this remand must be made available to the examiner for review of the case. A notation to the effect that this record review took place should be included in the report. After the above has been completed, the examiner must opine as to whether it is at least as likely as not (a 50 percent probability or greater) that any diagnosed hypertension is causally related to active service, represents the initial manifestations of his current diagnoses, OR was proximately CAUSED BY or AGGRAVATED BY his service-connected heart condition. In reaching any conclusion, the examiner must consider the Veteran's STRs that noted high blood pressure during active service. Additionally, the examiner must opine as to whether it is at least as likely as not (a 50 percent probability or greater) that any diagnosed CFS, fibromyalgia, joint pain, or muscle pain is causally related to active service, represents the initial manifestations of his current diagnoses, OR was proximately CAUSED BY or AGGRAVATED BY his service-connected disabilities. In reaching any conclusion, the examiner must consider the Veteran's February 2021 testimony where he stated that all these conditions started within a year of him coming back from Iraq and that even during service in Iraq, he was constantly in pain and was losing mobility. The Veteran stated that he was in charge of running the largest burn pit in Iraq, at Camp Victory, and was exposed to smoke inhalation every day. The Veteran testified that he was never told what he was burning, he was just told to burn it. He noted that he never had any of these conditions prior to serving in Iraq. 7. Schedule the Veteran for a VA audiological examination to assess the current level of severity of his bilateral hearing loss disability. The entire claims file and a copy of this remand must be made available to the examiner prior to the examination. The examiner must note in the examination report that the evidence in the claims file has been reviewed. The examiner should perform all indicated tests and studies and report all clinical findings in detail. The most up-to-date Disability Benefits Questionnaire must be employed in ascertaining the symptoms and severity of this disorder, utilizing puretone threshold and Maryland CNC testing. The Veteran's subjective symptoms and functional effects of hearing loss must be fully considered, along with the objective findings shown on examination. 8. Forward the Veteran's claims file to an appropriate medical professional to obtain an opinion commenting on the effects of the combination of the Veteran's service-connected disabilities on his ability to secure and follow gainful employment. In rendering this "combined effects" opinion, the examiner should review the claims file and take into consideration the Veteran's level of education, special training, and previous work experience, but not age or any impairment caused by nonservice-connected disabilities. To the extent possible, there should be one opinion as to the combined effects of all the Veteran's service-connected disabilities, and not multiple opinions addressing each individual disability. 9. A detailed explanation (rationale) is requested for all opinions provided. (By law, the Board is not permitted to rely on any conclusion that is not supported by a thorough explanation. Providing an opinion or conclusion without a thorough explanation will delay processing of the claim and may also result in a clarification being requested). VICTORIA MOSHIASHWILI Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Abrams, 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.