Citation Nr: 21040261 Decision Date: 07/02/21 Archive Date: 07/02/21 DOCKET NO. 16-41 740 DATE: July 2, 2021 ORDER Prior to July 18, 2019, entitlement to an increased rating of 70 percent, but no higher, for posttraumatic stress disorder (PTSD) with unspecified anxiety disorder and traumatic brain injury (TBI) is granted, subject to controlling regulations governing the payment of monetary awards. From July 18, 2019, entitlement to an increased rating for PTSD with unspecified anxiety disorder and TBI, currently rated 70 percent is denied. Prior to October 30, 2019, entitlement to an increased rating for gastroesophageal disease (GERD) with hiatal hernia, currently rated noncompensable is denied. From October 30, 2019, entitlement to an increased rating for gastroesophageal disease (GERD) with hiatal hernia, currently rated 10 percent is denied. Entitlement to a total rating based on individual unemployability due to service-connected disabilities (TDIU) prior to July 18, 2019 is granted, subject to controlling regulations governing the payment of monetary awards. From July 18, 2019, entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is dismissed as moot. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran's service-connected PTSD with unspecified anxiety disorder and TBI symptoms and overall impairment have more nearly approximated deficiencies in most areas, but not total occupational and social impairment. 2. Prior to October 30, 2019, the Veteran's GERD with hiatal hernia is manifested by nausea, vomiting, abdominal cramps and pain; but has not more nearly approximated two or more symptoms of persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. 3. From October 30, 2019, the Veteran's GERD with hiatal hernia is manifested by heartburn, reflux, stomach cramps and pain; but has not more nearly approximated hematemesis, melena, anemia, weight loss, or substernal arm or shoulder pain productive of considerable impairment of health. 4. The Veteran's service-connected disabilities combine to render him unable to secure and follow a substantially gainful occupation prior to July 18, 2019. 5. From July 18, 2019, the Veteran is in receipt of a 100 percent combined schedular disability rating for his service-connected disabilities, and none of the Veteran's service-connected disabilities, alone, would warrant a TDIU, such that he would be entitled to special monthly compensation (SMC) under 38 U.S.C. § 1114(s)(1). CONCLUSIONS OF LAW 1. Prior to July 18, 2019, the criteria for an increased rating of 70 percent, but no higher, for PTSD with unspecified anxiety disorder and TBI have been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. § 4.130, Diagnostic Code 9411. 2. From July 18, 2019, the criteria for an increased rating of 70 percent, but no higher, for PTSD with unspecified anxiety disorder and TBI have been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. § 4.130, Diagnostic Code 9411. 3. Prior to October 30, 2019, the criteria for an increased rating for GERD with hiatal hernia, currently rated noncompensable have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.114, Diagnostic Codes 7399-7346. 4. From October 30, 2019, the criteria for an increased rating for GERD with hiatal hernia, currently rated 10 percent have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.114, Diagnostic Codes 7399-7346. 5. The criteria for a TDIU prior to July 18, 2019, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. 6. From July 18, 2019, the issue of entitlement to a TDIU is moot. 38 U.S.C. §§ 1114 (s)(1), 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16 REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 2007 to March 2008, and from March 2011 to April 2012. This case comes before the Board of Veterans' Appeals (Board) on appeal from December 2014 and January 2015 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). In the December 2014 rating decision, the RO, inter alia, continued the noncompensable rating for gastritis. In the January 2015 rating decision, the RO, inter alia, continued the 10 percent rating for anxiety not otherwise specified (NOS). The Veteran disagreed with the RO's determination. In a July 2016 rating decision, the RO increased the rating for anxiety NOS to 50 percent effecting March 12, 2014, the date of the claim. A Statement of the Case (SOC) was issued in July 2016 addressing the matters. The Veteran timely appealed. In November 2018, the Board found that entitlement to a TDIU was raised by the record in connection with the claims for increased ratings for GERD and PTSD. See Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). Those claims were filed in March 2014. Thus, the appeal period for the claims on appeal begins in March 2013, one year prior to the date of claim. 38 U.S.C. § 5110(b)(3). The Board remanded the matters for further evidentiary development to include additional VA examinations. While in remand status, in an April 2020 rating decision, the RO recharacterized the claim for anxiety NOS to PTSD with unspecified anxiety disorder and TBI, and increased the rating to 70 percent effective July 18, 2019, creating a staged rating. The RO also recharacterized the claim for gastritis to GERD with hiatal hernia, and increased the rating to 10 percent effective October 30, 2019, creating a staged rating. Although higher ratings have been granted for PTSD with unspecified anxiety disorder and TBI, and GERD with hiatal hernia, these issues remains in appellate status, as the maximum available benefit has not been assigned. AB v. Brown, 6 Vet. App. 35, 38 (1993). For the reasons indicated in the discussion below, the examinations ordered by the Board were conducted and are adequate to decide the claims; therefore, the agency of original jurisdiction has substantially complied with the Board's remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). HIGHER RATINGS Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C. § 1155. Separate diagnostic codes identify the various disabilities. Id. It is necessary to rate the disability from the point of view of the Veteran working or seeking work, 38 C.F.R. § 4.2, and to resolve any reasonable doubt regarding the extent of the disability in the Veteran's favor. 38 C.F.R. § 4.3. If there is a question as to which disability rating to apply to the Veteran's disability, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where a claimant appeals the denial of a claim for an increased disability rating for a disability for which service connection was in effect before, he filed the claim for increase, the present level of disability is the primary concern, and past medical reports should not be given precedence over current medical findings. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994). Where VA's adjudication of the claim for increase is lengthy and factual findings show distinct time periods where the service-connected disability exhibits symptoms which would warrant different ratings, different or staged ratings may be assigned for such different periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). 1. PTSD with unspecified anxiety disorder and TBI The criterion for rating PTSD disorder is contained in the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating is warranted when there is objective evidence demonstrating occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory, for example, 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. A 70 percent rating is assigned when there is objective evidence demonstrating occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities, speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately, or effectively; impaired impulse control, such as unprovoked irritability with periods of violence; spatial disorientation, neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; inability to establish and maintain effective relationships. A 100 percent rating is warranted when there is 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 and place, memory loss for names of close relatives, own occupation, or own name. In Mauerhan v. Principi, 16 Vet. App. 436 (2002), the Court held that use of the term such as in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating . Accordingly, the evidence considered in determining the level of impairment under section 4.130 is not restricted to the symptoms provided in the diagnostic code. Rather, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders. In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116 (Fed. Cir. 2013), the Federal Circuit held that a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. The Federal Circuit explained that in the context of a 70 percent rating, section 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas. Id. at 118. The Federal Circuit indicated that "[a]lthough the veteran's symptomatology is the primary consideration, the regulation also requires an ultimate factual conclusion as to the veteran's level of impairment in most areas." Id. The Veteran seeks a rating in excess of 50 percent prior to July 18, 2019, and in excess of 70 percent thereafter for his service-connected PTSD with unspecified anxiety disorder and TBI. He contends that the ratings currently assigned does not reflect the severity of the disability. Prior to July 18, 2019, the evidence of record indicates that the Veteran's PTSD with unspecified anxiety disorder and TBI symptoms more nearly approximate the criteria for a 70 percent rating. In this case, a January 2014 VA clinical record indicate the Veteran experienced panic attacks 1-2 times daily for several years. Half of the episodes were more pronounced, in which he must isolate himself from other people, often in the corner of a room. A July 2015 VA clinical record indicate the Veteran exhibited symptoms of depression, anxiety, chronic sleep impairment, daily panic attacks, and isolation. He complained of racing thoughts of trying to find solutions. The Veteran reported that he hides his anxiety from others, and when he is not at work, he isolates himself. An April 2016 VA examination report indicate the Veteran exhibited symptoms of depression, anxiety, and panic attacks. The Veteran reported that people made him anxious and he could not be around people. The examiner concluded that the Veteran's symptoms were equivalent to occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. A March 2018 VA examination report indicate the Veteran exhibited symptoms of depression, anxiety, and impaired impulse control, such as unprovoked irritability with periods of violence. He had difficulty in adapting to stressful circumstances, including work or a work-like setting. He exhibited suicidal ideation and neglect of personal appearance and hygiene. The Veteran reported that he married in 2012 and divorced in 2015, and the marriage ended due to his mental health issues from deployment the year before he married. The Veteran noted that he was physically aggressive in the marriage, had a quick temper, was easily angered, irritable, verbally abusive, threw objects when angry, and that his wife feared his anger. He does not date, as he is not capable of dating now due to his mental health issues. The Veteran further noted that he has no social activity outside his home and no friends. He reported that he was close to killing himself in 2015, but the gun jammed. The examiner concluded that the Veteran's symptoms were equivalent to occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A December 2019 VA examination report indicate the Veteran exhibited symptoms of anxiety, impulsivity, social isolation, and increased irritability. He had near-continuous panic or depression affecting the ability to function independently, appropriately and effectively. He had difficulty in adapting to stressful circumstances, including work or a work-like setting. He had obsessional rituals which interfere with routine activities. The Veteran reported that he tried to work, but the combination of physical pain and the need to interact with the public proved intolerable. The examiner concluded that the Veteran's symptoms were equivalent to total occupational and social impairment. Based on the evidence of record, including the medical records and the Veteran's competent and credible statements, the Board finds that prior to July 18, 2019, the Veteran's symptoms and impairment more nearly approximate occupational and social impairment with deficiencies in most areas to warrant a 70 percent rating. The Veteran is not, however, entitled to a higher 100 percent during any period on appeal. The VA examination reports, VA mental evaluations, and private clinical records dated from May 2012 to December 2019 show that the Veteran did not experience symptoms such as: grossly inappropriate behavior; persistent delusions or hallucinations; or persistent danger of hurting self or others. The Veteran's thought content did not appear delusional or psychotic. On numerous occasions the Veteran denied any auditory or visual hallucinations, or homicidal ideations. The Veteran did not demonstrate disorientation to time or place, and memory loss for names of close relatives, own occupation, or own name. Repeated examinations have shown that the Veteran does not exhibit intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene). He was also alert and oriented to all parameters. The evidence of record indicates that the Veteran has primary custody of his son and contact with other family members. The Board acknowledges the opinion of the December 2019 VA examiner, who concluded that the Veteran exhibited total occupational and social impairment. However, health care professionals are responsible for medical not legal determination and we and other VA adjudicators are responsible for legal or adjudicative determinations such as whether symptoms and impairment more nearly approximate a particular rating. 38 C.F.R. § 4.10 (assigning to medical examiners the "the responsibility of furnishing... full description of the effects of disability upon the person's ordinary activity"); 38 C.F.R. § 3.100(a) (delegating the Secretary's authority "to make findings and decisions... as to the entitlement of claimants to benefits" to, inter alia, VA "adjudicative personnel"); 38 C.F.R. § 4.2 ("It is the responsibility of the rating specialist to interpret reports of examination... so that the current rating may accurately reflect the elements of disability present"). Thus, the evidence reflects that the impairment caused by the Veteran's symptoms does not more nearly approximate total social impairment in the criteria for a 100 percent rating. Based on this evidence, the Board finds that throughout the entire period on appeal, the Veteran's service-connected PTSD with unspecified anxiety disorder and TBI has been productive of symptomatology and impairment that more nearly approximated the criteria for a 70 percent rating, but not higher. Thus, an increased rating of 70 percent for PTSD with unspecified anxiety disorder and TBI is warranted prior to July 18, 2019, and a rating higher than 70 percent is not warranted at any time during the appeal period. As the preponderance of the evidence is against any higher rating, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. 2. GERD with hiatal hernia The Veteran seeks a rating in excess of 0 percent prior to October 30, 2019, and in excess of 10 percent thereafter, for his service-connected GERD with hiatal hernia. The Veteran's GERD with hiatal hernia is currently rated under Diagnostic Codes 7399-7346. As indicated by the hyphenated diagnostic code, the Veteran's GERD with hiatal hernia has been rated by analogy to a hiatal hernia. 38 C.F.R. §§ 4.20, 4.27 (when an unlisted disease, injury, or residual condition is encountered, requiring rating by analogy, the diagnostic code number will be "built-up" by using the first two digits of that part of the rating schedule which most closely identifies the part, or system, of the body involved and adding "99" for the unlisted condition). As indicated by the discussion below, this is the most appropriate diagnostic code under which to rate the Veteran's disability, and there is no other diagnostic code that would be appropriate in the evaluation of the Veteran's GERD with hiatal hernia or result in a separate or higher rating. Under Diagnostic Code 7346, a 10 percent evaluation is assigned when there are two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent rating is assigned for persistently recurrent epigastric distress with dysphagia, pyrosis and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 60 percent rating is assigned when there are symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114 Diagnostic Code 7346. Prior to October 30, 2019, the evidence of record indicates that the Veteran's overall disability picture does not nearly approximate the criteria for a 10 percent rating for service-connected GERD with hiatal hernia. For example, at his December 2014 VA examination, the Veteran reported symptoms of nausea and severe cramps. His treatment plan included Pepto-Bismol, Maalox, and Mylanta. He exhibited symptoms of nausea, vomiting, and abdominal cramps. An April 2016 VA examination report indicate the Veteran reported sharp stomach pain. He reported that he did not take continuous medication. A December 2018 VA examination report indicate the Veteran reported symptoms of stomach pains. His treatment plan included Pepto-Bismol and antacids. Repeated examinations have shown that the Veteran's GERD with hiatal hernia is not manifested by two or more symptoms of persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. For these reasons, the Board finds that the preponderance of the evidence is against the assignment of a compensable rating prior to October 30, 2019 for GERD with hiatal hernia. From October 30, 2019, the evidence of record further demonstrates that the Veteran's GERD with hiatal hernia symptoms does not nearly approximate the criteria for a rating in excess of 10 percent. For example, at his October 2019 VA examination, the Veteran reported symptoms of heartburn, stomach cramps, and pain. His treatment plan included antacids. He exhibited symptoms of pyrosis, reflux, regurgitation. However, the evidence of record has shown that the Veteran's GERD with hiatal hernia is not manifested by hematemesis, melena, anemia, or weight loss. Moreover, there has been no probative evidence that the Veteran's GERD with hiatal hernia has produced considerable impairment of health. In fact, October 2019 VA examiner affirmatively concluded that the Veteran's GERD with hiatal hernia did not produce a considerable impairment in his health. For these reasons, the Board finds that the preponderance of the evidence is against the assignment of rating in excess of 10 percent prior to October 30, 209 for GERD with hiatal hernia. Based on the foregoing, the Board finds that a noncompensable rating prior to October 30, 2019, and 10 percent thereafter for Veteran's GERD with hiatal hernia most accurately contemplates the symptomatology and resulting impairment demonstrated in the evidence of record. As the preponderance of the evidence is against any higher rating, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. 3. Entitlement to a TDIU Where the schedular rating is less than total, a total disability rating may nonetheless be assigned when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disability; provided that, in pertinent part, if there is only one such disability, the disability shall be rated at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability rated 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § §§ 3.340, 3.341(a), 4.16(a). Entitlement to a total rating must be based solely on the impact of service-connected disabilities on the ability to secure and follow substantially gainful employment. See 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). For VA purposes, the term unemployability is synonymous with an inability to secure and follow a substantially gainful occupation. VAOPGPREC 75-91; 57 Fed. Reg. 2317 (1992). Consideration may be given to the level of education, special training, and previous work experience in arriving at a conclusion. Individual unemployability, however, must be determined without regard to any nonservice-connected disabilities or advancing age. 38 C.F.R. § §§ 3.341 (a), 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). In Ray v. Wilkie, 31 Vet. App. 58, 73 (2019), the Court defined the term unable to secure and follow a substantially gainful occupation as having two components: one economic and one noneconomic. The economic component means 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. The non-economic component includes consideration of: Veteran's history, education, skill, and training; whether the veteran has the physical ability to perform the type of activities required by the occupation at issue; and whether the veteran has the mental ability to perform the activities required by the occupation at issue. In this case, the Veteran is service connected for PTSD with unspecified anxiety disorder, rated as 70 percent disabling; migraine headaches associated with PTSD with unspecified anxiety disorder, rated as 50 percent disabling; lumbar strain with IVDS, rated as 40 percent disabling; radiculopathy left lower extremity associated with lumbar strain with IVDS, rated at 40 percent disabling; tinnitus, rated as 10 percent disabling; and GERD with hiatal hernia rated as 10 percent disabling. The Veteran is in receipt of a combined 70 percent rating as of the March 12, 2014 date of claim, 80 percent as of July 1, 2018, 90 percent as of July 7, 2019, and 100 percent from July 18, 2019. Prior to July 18, 2019, the Veteran meets the percentage requirements set forth in section 4.16(a) for consideration of TDIU. Thus, the next question for consideration is whether his service-connected disabilities prevented him from securing and following substantially gainful employment prior to July 18, 2019. In this case, the Veteran submitted a VA Form 21-8940 for TDIU in August 2018, on which he reported that he was last employed as a cashier at Taco Bell from March 3, 2015 to August 22, 2015. He reported that his disabilities affected full-time employment on June 24, 2015 and became too disabled to work on that date. He indicated that he completed one year of college and had not had any education and training since becoming too disabled to work. In an August 2018 letter, a VA psychiatrist reported that the Veteran had been under her care since July 2015, and has experienced significant anxiety as well as regular panic attacks that can be severe. The psychiatrist noted the Veteran's anxiety is worsened around people and when out in public, which has interfered with his ability to maintain a job. Also, the Veteran had nightmares and flashbacks and significant difficulty with insomnia as well as irritability. The VA psychiatrist further noted that the Veteran has been actively participating in treatment but has continued to struggle with symptoms that affect his daily life. In a September 2018 letter, the Veteran's mother reported that due to his PTSD he cannot work well in public settings and gets severe anxiety and panic attacks often and almost every day this happens where he cannot leave home. She indicated that his TBI causes memory and balancing issues, and his migraines causes severe pain, nausea, and irritability. She also indicated that the Veteran's lower back and lower left leg disabilities prevents him from heavy lifting, walking long periods, shopping, and caring for his son. A May 2014 VA examiner indicated the Veteran's back disability impacts his ability to work due to no heavy lifting, limited walking and range of motion, and taking frequent breaks. A December 2014 VA examination report indicates the Veteran's GERD, as the Veteran stated he is unable to find a job where he can work around the condition. An April 2016 VA examination repot shows the Veteran's GERD disability did not impact his ability to work. A June 2017 VA examiner indicated the Veteran's back disability impacts his ability to work, as he would be limited in those occupations that require heavy or unassisted lifting, repetitive rotation of the back, carrying, pushing or pulling heavy objects, vibrational stresses, overhead work, and prolonged sitting. He is limited in prolonged standing and walking and would need allowance for rest periods every 30 minutes. An April 2018 VA examiner indicated the Veteran's migraine headaches and TBI disabilities did not impact his ability to work. A December 2018 VA examiner indicated the Veteran's GERD disability impacts his ability to work, due to difficulty with prolonged sitting, bending, and lifting during episode of abdominal pain. An April 2019 VA examiner indicated that the Veteran's left lower extremity disability impacts his ability to work, as he cannot stand or walk for long. A July 2019 VA examiner indicated the Veteran's migraine headaches, as he experiences recurrent weekly headaches which interfere with normal work participation. An October 2019 VA examiner indicated the Veteran's TBI impacts his ability to work, due to migraine headaches occurring several times a week, and generally impairing, and he has to rest in a dark quiet room. An October 2019 VA examiner indicated the Veteran's tinnitus impacts his ability to work, as he cannot hear certain things being said and misses some parts of instruction. An October 2019 VA examiner indicated the Veteran's GERD disability did not impact his ability to work. Additionally, a March 2020 VA examiner determined the Veteran's migraine headaches and TBI disabilities did not impact his ability to work. The applicable regulations place responsibility for the ultimate TDIU determination on the VA, not a medical examiner. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). The above evidence reflects that the Veteran's service-connected PTSD with unspecified anxiety disorder, migraine headaches, lumbar strain with IVDS, radiculopathy left lower extremity, tinnitus, and GERD with hiatal hernia precluded him from securing substantially gainful employment given his educational and occupational history. Thus, entitlement to a TDIU is warranted prior to July 18, 2019. 38 C.F.R. § 4.16 (a). The Board will not assign an effective date for the grant of TDIU and will allow the RO to do so in the first instance, taking into consideration the last date on which the Veteran was employed full time in substantially gainful employment. See Urban v. Principi, 18 Vet. App. 143, 145 (2004) (per curiam order) ( To the extent that [the appellant] is arguing that the Board must assign, sua sponte, an effective date once it awards a rating of TDIU on appeal from an RO decision, such an argument is unavailing unless an NOD is then of record as to the downstream issue of an effective date for the assignment of that rating ). As noted, the Veteran is in receipt of a 100 percent rating from July 18, 2019. A TDIU claim does not automatically become moot when a combined 100 percent schedular rating is assigned based on multiple service-connected disabilities because a separate award of TDIU predicated on a single disability could form the basis for an award of SMC under 38 U.S.C. § 1114(s) (SMC warranted where Veteran has a totally rated service-connected disability, as well as "additional service-connected disabilities independently ratable at 60 percent or more"). Bradley v. Peake, 22 Vet. App. 280, 293 (2008) (holding that a grant of TDIU based on a single disability constitutes a totally rated service-connected disability for purposes of section 1114(s)); Buie v. Shinseki, 24 Vet. App. 242, 250 (2010). Thus, pursuant to Bradley and Buie, VA has a duty to maximize benefits and therefore must consider the TDIU issue for the entire period covered by the claim to include whether a TDIU based on a single disability is warranted. In this case, however, the grant of TDIU is not be predicated on a single disability but on multiple service-connected disabilities. Specifically, the grant of entitlement to TDIU is based on the cumulative symptomatology associated with the Veteran's service-connected disabilities. The above evidence reflects that there is no single disability that causes unemployability. Therefore, the grant of TDIU would be based on impairment from several service-connected disabilities, and not just a single disability. (Continued on the next page) As the Veteran has no single service-connected disability that is rated at 100 percent, and the Veteran's TDIU is predicated on multiple service-connected disabilities, the percentage rating criteria for SMC under 38 U.S.C. § 1114(s)(1) have not been met at any point during the period under consideration in this appeal. Therefore, entitlement to a TDIU from July 18, 2019 is moot, as the Veteran is already in receipt of a combined schedular evaluation of 100 percent, effective July 18, 2019, and TDIU is not based on a single disability and thus cannot assist the Veteran in obtaining SMC pursuant to 38 U.S.C. § 1114(s)(1). Jonathan Hager Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Walker, 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.