Citation Nr: 21041415 Decision Date: 07/09/21 Archive Date: 07/09/21 DOCKET NO. 18-54 870 DATE: July 9, 2021 ORDER Service connection for tinnitus is granted. An initial compensable evaluation for bilateral hearing loss prior to November 4, 2019 is denied. An evaluation in excess of 20 percent for bilateral hearing loss from November 4, 2019 is denied. An initial evaluation in excess of 70 percent for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD), prior to October 15, 2019 is denied. A total disability rating based on individual unemployability as a result of service-connected disabilities (TDIU) from August 6, 2015 to January 30, 2019 is granted. Special monthly compensation (SMC) under 38 U.S.C. § 1114(s) from May 24, 2018 to January 30, 2019 is granted. REMANDED Entitlement to a separate rating for an auditory processing disorder. FINDINGS OF FACT 1. The Veteran's tinnitus is related to his hearing loss. 2. Prior to November 4, 2019, the Veteran's hearing loss manifested as no worse than Level I hearing loss in each ear. 3. From November 4, 2019, the Veteran's hearing loss manifested as no worse than Level V hearing loss in each ear. 4. Prior to October 15, 2019, the Veteran's acquired psychiatric disability was not productive of total social and occupational impairment. 5. From August 6, 2015 to January 30, 2019, the Veteran's acquired psychiatric disability rendered him unemployable or unable to secure and follow a substantially gainful occupation. 6. Upon implementation of this Board decision, from May 24, 2018 to January 30, 2019, the Veteran will be in receipt of a TDIU based on his PTSD as well as a separate 60 percent rating for diabetic nephropathy. CONCLUSIONS OF LAW 1. The criteria for service connection for tinnitus are met. 38 U.S.C. §§ 1101, 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2020). 2. The criteria for an initial compensable evaluation for bilateral hearing loss prior to November 4, 2019 are not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.85, 4.86, Diagnostic Code 6100 (2020). 3. The criteria for an evaluation in excess of 20 percent for bilateral hearing loss from November 4, 2019 are not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.85, 4.86, Diagnostic Code 6100 (2020). 4. The criteria for an initial evaluation in excess of 70 percent for an acquired psychiatric disability, to include PTSD, prior to October 15, 2019 are not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2020). 5. The criteria for a TDIU from August 6, 2015 to January 30, 2019 are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.15, 4.16, 4.19 (2020). 6. The criteria for SMC under 38 U.S.C. § 1114(s) from May 24, 2018 to January 30, 2019 are met. 38 U.S.C. §§ 1114(s), 5107 (2012); 38 C.F.R. §§ 3.350(i), 3.352(a) (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1969 to July 1974. This appeal is before the Board of Veterans' Appeals (Board) from May 2016 and June 2016 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. In August 2019, the Board granted an evaluation of 70 percent for PTSD and denied a higher rating as well as a compensable evaluation for bilateral hearing loss. The Veteran appealed the denials to the United States Court of Appeals for Veterans Claims (Court), which vacated the denials in an August 2020 order granting a joint motion for remand (JMR). The issues are therefore again before the Board. 1. Entitlement to service connection for tinnitus The August 2020 JMR has instructed that the record evidence raises the issue of entitlement to service connection for tinnitus and that the Board should adjudicate this issue. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection requires: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection is also warranted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(b). For certain chronic diseases, including organic diseases of the nervous system such as tinnitus, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within one year following discharge from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). When a chronic disease is not shown to have manifested to a compensable degree within one year after service, under 38 C.F.R. § 3.303(b) for the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. When the fact of chronicity in service is not adequately supported, a showing of continuity after discharge is required to support a claim for such diseases; however, such continuity of symptomatology may only support a claim for those chronic diseases listed under 38 C.F.R. § 3.309(a). 38 C.F.R. § 3.303(b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. Service treatment records do not reflect any symptoms of or treatment for tinnitus, and no such abnormality was noted at the Veteran's April 1974 separation examination. Additionally, no such abnormality was noted at yearly flight examinations for National Guard service in March 1975, February 1976, February 1977, February 1978, February 1979, February 1980, and March 1981. The Veteran underwent a VA examination for hearing loss in December 2015. The examination report states that the Veteran did not report recurrent tinnitus. VA treatment records reflect that in July 2016 the Veteran reported to his audiologist that tinnitus began in February on the left side. He stated that he mainly notices it when he lies down in the quiet. The Veteran underwent another VA examination for hearing loss in September 2018. He reported tinnitus that began in the 1990s. The examiner opined that tinnitus was less likely than not related to military noise exposure. This opinion was based on the rationale that onset was post-separation, and the current literature did not support late-onset noise-induced tinnitus. Private treatment records reflect that in December 2018 the Veteran was diagnosed by an audiologist with constant tinnitus of the left ear. In a statement accompanying his December 2018 substantive appeal for an increased bilateral hearing loss rating, the Veteran argued that a separate 10 percent rating was warranted for his tinnitus. In an August 2019 statement, the Veteran reported that he has experienced tinnitus since early November 1970. He described incidents when returning from a combat mission with impaired hearing, he was asked to stop yelling at debriefings. As his hearing returned after these missions, he had a recurrent ringing mostly in his left ear. He stated that it returned intermittently over five decades since. He stated that he was advised by his doctors not to make any record of this symptom if he wanted to keep active flying missions. As he was routinely told that there was no treatment for tinnitus, he saw no reason to report it. A September 2019 rating decision denied service connection for tinnitus based on a finding that the Veteran failed to report to a VA examination that month. In a November 2019 statement, the Veteran disputed the rating decision's finding, stating that he cancelled the VA examination due to travel and was given another number to call to reschedule. When he called that number, he was told that his claim was already adjudicated and closed. The Veteran underwent a VA examination in January 2020. He reported onset of tinnitus in service in the 1970s after a rocket attack. He was diagnosed with tinnitus, but an etiology opinion was not requested by VA. The Board finds that the evidence is at least in equipoise as to whether the Veteran's tinnitus is related to his service-connected hearing loss. While the September 2018 VA examiner gave an opinion explaining why tinnitus was less likely than not directly caused by in-service noise exposure, no opinion has been obtained as to secondary service connection. Such an opinion may have been intended to be obtained at the cancelled September 2019 VA examination. The Veteran has provided good cause for his failure to report to that examination, but VA not only failed to reschedule the examination as requested but inexplicably failed to request a tinnitus opinion at a hearing loss examination conducted just four months later in January 2020. Tinnitus is so commonly associated with hearing loss that the VA examination forms have a box to check when this is the case, and there is no evidence in the record against a finding that tinnitus is not caused or aggravated by the Veteran's hearing loss. For these reasons, the Board finds that the evidence is at least in equipoise as to whether the Veteran's tinnitus is related to his service-connected hearing loss, and service connection is therefore granted. Increased Ratings Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). 2. Entitlement to an initial compensable evaluation for bilateral hearing loss prior to November 4, 2019 3. Entitlement to an evaluation in excess of 20 percent for bilateral hearing loss from November 4, 2019 The Veteran claims increased evaluations for his bilateral hearing loss. The August 2020 JMR instructed that the Board failed to adjudicate the raised issue of entitlement to service connection for tinnitus and to determine whether a separate rating was warranted for an auditory processing disorder. The issue of tinnitus was addressed above, and the issue of an auditory processing disorder is addressed in the remand section. His rating for sensorineural hearing loss remains governed by the criteria of the ratings schedule, described below. In evaluating service-connected hearing loss, disability ratings are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are performed. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). An examination for hearing impairment for VA purposes must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test (Maryland CNC) and a pure tone audiometry test. 38 C.F.R. § 4.85. Evaluations of bilateral hearing loss range from noncompensable to 100 percent based on an organic impairment of hearing acuity, as measured by controlled speech discrimination tests in conjunction with the average hearing threshold, as measured by pure tone audiometric tests in the frequencies of 1000, 2000, 3000 and 4000 cycles per second. The rating schedule establishes 11 auditory acuity Levels designated from Level I for essentially normal hearing acuity through Level XI for profound deafness. VA audiological evaluations are conducted using a controlled speech discrimination test together with the results of pure tone audiometry tests. The vertical line in Table VI (printed in 38 C.F.R. § 4.85) represents nine categories of the percentage of discrimination based on a controlled speech discrimination test. The horizontal columns in Table VI represent 9 categories of decibel loss based on the pure tone audiometry test. The numeric designation of impaired hearing (Levels I through XI) is determined for each ear by intersecting the vertical row appropriate for the percentage of discrimination and the horizontal column appropriate to the pure tone decibel loss. The percentage evaluation is found from Table VII in 38 C.F.R. § 4.85 by intersecting the vertical column appropriate for the numeric designation for the ear having the better hearing acuity and the horizontal row appropriate for the numeric designation for the level for the ear having the poorer hearing acuity. For example, if the better ear had a numeric designation of Level V and the poorer ear had a numeric designation of Level VII the percentage evaluation is 30 percent. See 38 C.F.R. § 4.85. Regulations also provide that in cases of exceptional hearing loss, i.e., when the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000 and 4000 hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86(a). The provisions of 38 C.F.R. § 4.86(b) further provide that when the pure tone threshold is 30 decibels or less at 1000 hertz and 70 decibels or more at 2000, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or VIa, whichever results in the higher numeral. The resulting numeral will then be evaluated to the next higher Roman numeral. The Veteran underwent a VA examination in December 2015. He reported having to ask people to repeat themselves when conversing. Pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 30 35 40 55 40 LEFT 30 40 45 55 42.5 Speech audiometry revealed speech recognition ability of 100 percent in the right ear and 96 percent in the left ear. He was diagnosed with bilateral sensorineural hearing loss. VA treatment records reflect that the Veteran was evaluated by his audiologist in July 2016. No thresholds were noted in the record, but the audiologist stated that no significant changes were noted since his last examination. In a statement accompanying his August 2016 notice of disagreement, the Veteran took issue with VA's testing of his hearing, arguing that being tested in a soundproof room was too removed from the reality of background noise to provide an adequate measure of his hearing loss. He stated his belief that his hearing loss warranted a 10 percent rating. The Veteran underwent another VA examination in September 2018. He reported that he was unable to go out because in most restaurants he cannot hear. He stated that he resorted to lip reading. It made him miss activities. He could not understand what people are saying if there is any background noise. Pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 40 40 50 70 50 LEFT 35 45 55 70 51.25 Speech audiometry revealed speech recognition ability of 96 percent in each ear. He was diagnosed with bilateral sensorineural hearing loss. Private treatment records reflect that the Veteran's hearing loss was evaluated in December 2018. He reported difficulty with background noise and "hidden hearing loss" which the audiologist stated sounded like auditory processing disorder. Pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 35 35 45 65 45 LEFT 35 35 50 65 46.25 Speech audiometry was not evaluated using the Maryland CNC test, and evaluation therefore cannot be based upon the results. In a 31-page statement accompanying his December 2018 substantive appeal, the Veteran argued that the evidence warranted a 10 percent rating. He stated that he had an auditory processing disorder, the effects of which the VA rating criteria did not contemplate. He provided medical journal articles discussing cochlear neuropathy, which caused "hidden" hearing loss undetectable by audiometric testing. Private treatment records reflect that the Veteran's hearing loss was evaluated in November 2019. Pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 35 45 55 75 52.5 LEFT 45 50 60 75 57.5 Speech audiometry was not evaluated using the Maryland CNC test, and evaluation therefore cannot be based upon the results. He was diagnosed with sensorineural hearing loss combined with poor auditory figure-ground and poor binaural integration. The Veteran underwent another VA examination in January 2020. He reported difficulty hearing at restaurants or social gatherings, stating that he could not distinguish the conversation from the background noise. Pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 40 45 50 70 51.25 LEFT 45 45 55 75 55 Speech audiometry revealed speech recognition ability of 72 percent in each ear. He was diagnosed with bilateral sensorineural hearing loss. The Board finds that a compensable rating is not warranted for the Veteran's hearing loss prior to November 4, 2019. Prior to then, his pure tone threshold averages were not measured any higher than 50 decibels in the right ear and 51.25 decibels in the left ear. His speech discrimination scores were measured no worse than 96 percent in each ear. Such readings, which were recorded as late as September 2018, constitute Level I hearing loss in both ears, which warrants a noncompensable rating. Furthermore, there is no evidence in the record indicating exceptional hearing loss as defined by 38 C.F.R. § 4.86. For these reasons, the Board finds that a compensable rating is not warranted for the Veteran's hearing loss prior to November 4, 2019. The Board further finds that an evaluation in excess of 20 percent is not warranted for the Veteran's hearing loss from November 4, 2019. During this period, his pure tone threshold averages were not measured any higher than 51.25 decibels in the right ear and 55 decibels in the left ear. His speech discrimination scores were measured no worse than 72 percent in each ear. Such readings constitute Level V hearing loss in both ears, which warrants a 20 percent rating. Furthermore, there is no evidence in the record indicating exceptional hearing loss as defined by 38 C.F.R. § 4.86. For these reasons, the Board finds that a rating in excess of 20 percent is not warranted for the Veteran's hearing loss from November 4, 2019. 4. Entitlement to an initial evaluation in excess of 70 percent for an acquired psychiatric disability, to include PTSD, prior to October 15, 2019 The Veteran claims an increased evaluation for his PTSD. In a February 2020 rating decision, he was awarded the maximum 100 percent rating for PTSD effective October 15, 2019. The Board will therefore only address the period prior to this date. Diagnostic Code 9411 of 38 C.F.R. § 4.130 specifically addresses PTSD; however, all psychiatric disabilities are evaluated under a general rating formula for mental disorders. Under the general rating formula, the Veteran's 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, 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 and effectively; impaired impulse control (such an 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); and inability to establish and maintain effective relationships. A total schedular rating of 100 percent 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 mental and personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). If the evidence shows that the Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the criteria for a particular rating, the appropriate equivalent rating will be assigned. Id. at 443. Furthermore, the rating code requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment at a level consistent with the assigned rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). VA treatment records reflect that in September 2015 the Veteran reported persistent PTSD symptoms. He denied depressed mood but admitted to being withdrawn. He was married for 36 years with three daughters and described good relationships with his immediate family. He denied suicidal ideation, homicidal ideation, delusions, hallucinations, or flashbacks. He described avid interests such as photography that he was able to pursue without interacting with others. He was diagnosed with PTSD. In a statement associated with his October 2015 claim, the Veteran stated that he had difficulty focusing on projects that made him unable to work for anyone. He reported difficulty with authority, nightmares, night sweats, insomnia, and hypervigilance. He stated that his symptoms forced him to be self-employed. In a second statement from October 2015, the Veteran listed the effects of his PTSD, including trust issues, lack of respect for authority, anger difficulty, seeking to control, becoming confrontational, inability to manage stress, substance abuse, reduced tolerance of others, nightmares, sleep difficulties, employability issues, social detachment, inappropriate behavior, unreasonable risks, difficulty with organization, time management issues, loss of leadership skills, mood swings, hypervigilance, threatening violence, startle response, inability to concentrate, emotional lability, numbness, feelings of betrayal and abandonment, guilt, and a sense of being overwhelmed. The Veteran underwent a VA examination in December 2015. He reported that he spends his free time traveling, hiking, and taking photographs. He described poor sleep quality and nightmares, avoidance, hypervigilance, and irritability. He had a history of alcohol abuse, but it was not a current issue. The examiner noted symptoms of suspiciousness, chronic sleep impairment, flattened affect, disturbances of motivation and mood, irritability, frequent social isolation, and quickness to take offense at perceived slights. He was diagnosed with chronic PTSD productive of occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. The examiner noted that he would quickly become irritable and agitated in any work setting, but he is otherwise capable to cognitively complete work such as he completed during his service. VA treatment records reflect that in January 2016 the Veteran stated that he would like to address anger management. He began group therapy in March 2016. In April 2016 he withdrew from individual and group therapy. In a statement accompanying his January 2017 notice of disagreement, the Veteran stated his belief that his PTSD warranted a 70 percent evaluation. He argued that the VA examiner ignored his occupational impairments, obsessive compulsive issues, impaired impulse control, tendency to violence, difficulty adapting to stress, and inability to maintain some relationships. He claimed that he asked to provide more information at the end of the examination and was told know. He also believed that his VA social worker set him up to receive a 30 percent rating, accusing her of gross misconduct. From his perspective, the anger management group therapy was forced upon him; he would have rather seen a psychiatrist. His symptoms included changes of mood, bouts of depression, sense of betrayal, sleeplessness, anger, and withdrawal from social contacts. He considered himself unemployable. VA treatment records reflect that in January 2017 the Veteran reported longstanding PTSD symptoms including recurrent nightmares, flashbacks, intrusive thoughts, social withdrawal, depressed mood, generalized anxiety, difficulty concentrating, poor attention span, insomnia, irritability, and night sweats. Mood was depressed and irritable with a congruent affect. Insight and judgment were intact. His chief complaint was sleep. He was diagnosed with chronic PTSD. He was prescribed medication, and in March 2017 he reported improved sleep though still with nightmares and intrusive thoughts. In September 2017 his psychiatrist noted irritability, poor concentration, hypervigilance, and exaggerated startle response. In March 2018 he requested marital counseling. They completed several sessions but in August 2018 he reported feeling that their relationship was at an impasse. In a 43-page statement accompanying his December 2018 substantive appeal, the Veteran requested a 70 percent evaluation for his PTSD. He believed this was warranted based on obsessional rituals, illogical speech, near-continuous panic, impaired impulse control, spatial disorientation, neglect of personal appearance, difficulty adapting to stress, and inability to establish and maintain relationships. He stated that he experienced anxiety attacks on each of his 2016 appointments with a VA social worker. He appeared to be under the impression that he was not compensated for the anxiety and depression associated with his PTSD or for the portion of his mental health symptoms resulting from his diabetes. He discussed his opinion that VA's schedular rating criteria were "inadequate and archaic." The Veteran submitted a disability benefits questionnaire completed in December 2018 by his VA treating psychiatrist. The psychiatrist noted symptoms of depressed mood; anxiety; suspiciousness; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; chronic sleep impairment; speech intermittently illogical, obscure, or irrelevant; disturbances of motivation and mood; difficulty in establishing and maintaining effective relationships; difficulty adapting to stress; inability to establish and maintain relationships; impaired impulse control, such as unprovoked irritability with periods of violence; neglect of personal appearance and hygiene; intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene; insomnia; intrusive thoughts; combat related nightmares; avoidance; isolation; poor concentration; hypervigilance; and exaggerated startle response. The Veteran was noted to have severe social impairment impacting employment, relationships, and the ability to enjoy those things he finds meaningful. The psychiatrist diagnosed PTSD productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and mood. VA treatment records reflect that in March 2019 the Veteran reported that his medication was no longer effective. His psychiatrist increased his dosage. The Board finds that an evaluation in excess of 70 percent is not warranted for the Veteran's PTSD prior to October 15, 2019. A higher rating is available for total social and occupational impairment. The evidence weighs against symptoms of such severity. His symptoms have never required hospitalization or in-patient treatment. He has not exhibited suicidal or homicidal ideation. The most prominent symptoms that he reports in his treatment records are anger issues, sleep difficulties, social withdrawal, depression, and anxiety. Notably, the bulk of the Veteran's statements during the appeal period are lengthy, detailed explanations of how his symptoms meet the criteria for a 70 percent rating. He describes more serious symptoms such as propensity to violence and intermittent inability to maintain hygiene, but his treatment records do not reflect such issues, and no actual violent incidents have been described during the appeal period. Moreover, while his social impairment has caused difficulties in his marriage, he maintains his marriage and his relationships with his adult children. For these reasons, the Board finds that an evaluation in excess of 70 percent is not warranted for the Veteran's PTSD prior to October 15, 2019. 5. Entitlement to a TDIU from August 6, 2015 to January 30, 2019 The Veteran seeks a TDIU. He contends that his service-connected disabilities, when considered in combination, render him unemployable. A February 2020 rating decision granted a TDIU due to PTSD from January 30, 2019 to October 15, 2019. For the period after October 15, 2019, a TDIU due to PTSD is unavailable, as the Veteran is already in receipt of a 100 percent rating for PTSD, and neither the Veteran nor his representative have claimed unemployability due solely to another service-connected disability. See Bradley v. Peake, 22 Vet. App. 280, 293-94 (2008). In a November 2020 brief, the Veteran's representative argued that a TDIU due to PTSD was warranted prior to January 30, 2019. The Board therefore has jurisdiction over this intertwined matter. See Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). Total disability means that there is present any impairment of mind or body sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. §§ 3.340, 4.15. A substantially gainful occupation has been defined as "an occupation that provides an annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days that the Veteran actually works and without regard to the Veteran's earned annual income." Faust v. West, 13 Vet. App. 342 (2000). When jobs are not realistically within his physical and mental capabilities, a veteran is determined unable to engage in a substantially gainful occupation. Moore v. Derwinski, 1 Vet. App. 356 (1991) (citing Timmerman v. Weinberger, 510 F.2d 439 (8th Cir. 1975)). In making this determination, consideration may be given to factors such as the veteran's level of education, special training, and previous work experience, but not to age or impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). A veteran is totally disabled if his service-connected disability or combination of service-connected disabilities is rated at 100 percent pursuant to the Schedule for Rating Disabilities. 38 C.F.R. § 3.340(a)(2). Even if a veteran is less than 100 percent disabled, he still is deemed totally disabled under the Schedule for Rating Disabilities if he satisfies two requirements. 38 C.F.R. § 4.16(a). First, the veteran must meet a minimum percent evaluation. If he has one service-connected disability, it must be evaluated at 60 percent or more. If he has two or more service-connected disabilities, at least one disability must be evaluated at 40 percent or more and the combined evaluation of all the disabilities must be 70 percent or more. The following will be considered as one disability with respect to the minimum percent evaluation: (1) disabilities of one or both upper extremities or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system (e.g., orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric), (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. Second, the veteran must be found to be unable to secure and follow a substantially gainful occupation as a result of his service-connected disability or disabilities. Id. Where a veteran does not meet the percentage evaluation requirements under 4.16(a), he still may be deemed totally disabled on an extraschedular basis under 38 C.F.R. § 4.16(b) when the evidence nonetheless indicates that the veteran is unemployable by reason of his service-connected disabilities. Under such circumstance the matter is referred to the Director of the Compensation and Pension Service ("Director") for consideration. Id.; see also Bagwell v. Brown, 9 Vet. App. 337 (1996); Floyd v. Brown, 9 Vet. App. 88 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). Extraschedular TDIU consideration requires contemplation of the following factors: severity of the veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue. 38 C.F.R. § 4.16(b). Although the Board does not have the authority to award an extraschedular TDIU prior to referral to the Director, the Board has jurisdiction to review and award extraschedular ratings in claims that have been denied by the Director. See Kuppamala v. McDonald, 27 Vet. App. 447 (2015). In determining whether a TDIU is warranted, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. In his October 2019 application for a TDIU, the Veteran stated that he had become too disabled to work due to his PTSD in 2005. He stated that he last worked full-time in January 2019, at which time he left a job as a paratransit driver that he had held for less than two months. In an accompanying statement, he explained that he had worked in insurance sales and consulting until 2005. He described how he was unable to continue work as a driver due to exhaustion from PTSD-caused sleep issues and medication side effects. He was also involved in confrontations with maintenance workers and supervisors. He provided a 12-page resignation letter he submitted to his employer which detailed the safety problems that he found made it impossible for him to work there. The Veteran's current 100 percent rating for PTSD is predicated on his November 2019 VA examination. In that report, the examiner noted that the Veteran came into the meeting with a tirade against VA and the examiner, presuming that the examiner had purposely given him a low disability rating initially for PTSD. The examiner opined that his quickness to become irritable and angry was how he reacts to other people as well, rendering him unemployable. The examiner elaborated that the Veteran was fully unable to work in any capacity as a result of his PTSD symptoms, as he would become irritable and angry in any setting in which he interacted with anybody else. The Board finds that the evidence is at least in equipoise as to whether the Veteran's acquired psychiatric disability rendered him unemployable or unable to secure and follow a substantially gainful occupation from August 6, 2015 to January 30, 2019. His 70 percent rating for PTSD meets the necessary threshold for a schedular TDIU under 38 C.F.R. § 4.16(a). His current TDIU based on PTSD was assigned based on the findings of the November 2019 VA examination and effective the date he left his most recent full-time job. The Veteran's statements, however, along with his resignation statement, clearly establish that the job was a short-lived endeavor that was doomed from the start, in no way indicative of employability. Moreover, the tirade experienced by the November 2019 VA examiner is hardly a phenomenon constrained to the period beginning in January 2019. Rather, since filing his initial claim the Veteran has been submitting lengthy argumentative statements which more than establish his inability to function in a workplace environment. For these reasons, the Board finds that the evidence is at least in equipoise as to whether the Veteran's acquired psychiatric disability rendered him unemployable or unable to secure and follow a substantially gainful occupation from August 6, 2015 to January 30, 2019, and a TDIU for this period is therefore granted. 6. Entitlement to SMC under 38 U.S.C. § 1114(s) prior to January 30, 2019 The Veteran is currently in receipt of SMC under 38 U.S.C. § 1114(s) effective January 30, 2019. Special monthly compensation provided by 38 U.S.C. § 1114(s) is payable where a veteran has a single service-connected disability rated as total and either (1) has additional service-connected disability or disabilities independently ratable at 60 percent or more, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). The issue of entitlement to SMC was not addressed in any statement of the case; however, the Board has a duty to maximize benefits and policy, and to consider entitlement to SMC where applicable. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); Bradley v. Peake, 22 Vet. App. 280, 294 (2008). Here, in a March 2020 statement, the Veteran requested that his SMC be retroactive to May 24, 2018, the effective date of his 60 percent rating for diabetic nephropathy. The Board finds that SMC under 38 U.S.C. § 1114(s) is warranted for the additional period from May 24, 2018 to January 30, 2019. Upon implementation of this Board decision, during this period the Veteran will be in receipt of a TDIU based on his PTSD as well as a separate 60 percent rating for diabetic nephropathy. SMC under 38 U.S.C. § 1114(s) is thus warranted. See Bradley, 22 Vet. App. at 293-94. Prior to May 24, 2018, the Veteran is not in receipt of a rating of 60 percent or greater for a disability other than PTSD. Moreover, he does not allege that he meets the criteria for being housebound prior to this date, nor is there evidence in the record to suggest otherwise. For these reasons, SMC under 38 U.S.C. § 1114(s) is granted for the additional period from May 24, 2018 to January 30, 2019. REASONS FOR REMAND Entitlement to a separate rating for an auditory processing disorder As discussed above, the Veteran's private audiologist diagnosed a probable auditory processing disorder in December 2018. Medical literature provided by the Veteran indicates that such disorders may cause hearing difficulties that are not contemplated by the rating criteria for sensorineural hearing loss. Remand is thus necessary for a VA examination to determine whether the Veteran has such a disorder and, if so, its severity. The matter is REMANDED for the following action: 1. Obtain and associate with the claims file any additional medical evidence that may have come into existence but has not been associated with the record. 2. Schedule the Veteran for a VA examination with a qualified examiner to determine whether the Veteran has an auditory processing disorder. If so, the examiner should report the extent of the Veteran's disability in accordance with VA rating criteria, by analogy if necessary. The claims file must be reviewed by the examiner. All opinions are to be accompanied by a rationale consistent with the evidence of record. A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested. If the examiner cannot provide an opinion without resorting to speculation, he or she shall provide complete explanations stating why this is so. In so doing, the examiner shall explain whether any inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 3. After completing the above, and any other development deemed necessary, readjudicate the appeal. If any benefit sought remains denied, return the appeal to the Board. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Gallagher, 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.