Citation Nr: 25005348 Decision Date: 04/21/25 Archive Date: 04/21/25 DOCKET NO. 18-38 256 DATE: April 21, 2025 ORDER Entitlement to higher staged ratings for lumbar strain with degenerative arthritis, rated as 20 percent from January 11, 2017, and 40 percent from August 6, 2024, is denied. Entitlement to higher staged ratings for degenerative disc disease of the cervical spine, rated as 20 percent from January 11, 2017, and 30 percent from August 6, 2024, is denied. Entitlement to an effective date of January 11, 2017, and no earlier, for allowance of special monthly compensation under 38 U.S.C. § 1114(s) is granted. FINDINGS OF FACT 1. The Veteran's lumbar strain with degenerative arthritis did not manifest functional impairment equivalent to forward flexion of the thoracolumbar spine to 30 degrees or less prior to August 6, 2024, or ankylosis or its functional equivalent from that date to warrant higher staged ratings during the appeal period. 2. The Veteran's degenerative disc disease of the cervical spine did not manifest functional impairment equivalent to forward flexion of the cervical spine to 15 degrees or less prior to August 6, 2024, or ankylosis or its functional equivalent from that date to warrant higher staged ratings during the appeal period. 3. A TDIU may be assigned based on the Veteran's PTSD alone from January 11, 2017; and, as he had additional service-connected disabilities independently ratable at 60 percent or greater from that date, he is eligible for SMC under the statutory housebound criteria. CONCLUSIONS OF LAW 1. The criteria for entitlement to higher staged ratings for lumbar strain with degenerative arthritis, rated as 20 percent from January 11, 2017, and 40 percent from August 6, 2024, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5242-5237. 2. The criteria for entitlement to higher staged ratings for degenerative disc disease of the cervical spine, rated as 20 percent from January 11, 2017, and 30 percent from August 6, 2024, have not been met. 3. The criteria for entitlement to an effective date of January 11, 2017, and no earlier, for allowance of special monthly compensated under 38 U.S.C. § 1114(s) have been met. 38 U.S.C. §§ 1114(s), 1155, 5107; 38 C.F.R. §§ 3.350, 3.352, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from February 2000 to February 2003 and from May 2006 to May 2007, with additional service in the Army National Guard. These matters come before the Board of Veterans' Appeals (Board) on appeal of a rating decision issued by the Department of Veterans Affairs (VA). The Board denied the issues listed above in a February 2023 decision. The Veteran appealed to the United States Court of Appeals for Veterans Claims (Court). In January 2024, the Court granted a Joint Motion for Partial Remand in which the parties agreed that the Board erred when it failed to provide an adequate statement of reasons or bases as to whether Appellant was entitled to higher ratings pursuant to the Court's ruling in Chavis v. McDonough, 34 Vet. App. 1, 3-4 (2021). The parties further agreed that the Board's remand of a total disability rating due to individual unemployability (TDIU) prior to June 28, 2019, may impact the effective date of the award of SMC, and, thus, the issue of SMC housebound for the period prior to June 28, 2019, was inextricably intertwined with the remanded claim of TDIU prior to June 28, 2019. They found that the Board should have considered it per the holding in Floore v. Shinseki, 26 Vet. App. 376, 383 (2013). The Board remanded the claims in July 2024. It asked the agency of original jurisdiction (AOJ) to schedule the Veteran for VA examinations and obtain medical opinions addressing functional loss in the absence of ameliorative effects of medication and whether the Veteran's spine manifested the functional equivalent of ankylosis at any time during the rating period. The Veteran appeared for VA examinations in October 2024. The AOJ attempted to obtain an opinion in December 2024. However, the VA examiner explained that: "This provider is unable to provide the requested opinions. the claims file was reviewed. there is no outstanding but obtainable information that would allow an opinion to be given. the inability to provide an opinion arises from a general deficit in medical knowledge." In other words, the examiner explained that no medical professional could answer the questions asked due to general inability of medical knowledge. This complies with the Board's remand directives. The Board will proceed with a final decision. While the claims were pending on remand, the AOJ granted additional benefits for the lumbar and cervical spine. It assigned a 40 percent rating for the lumbar spine and a 30 percent rating for the cervical spine both effective from August 6, 2024. This is considered a partial grant of those appeals. Higher staged ratings remain at issue before the Board. AB v. Brown, 6 Vet. App. 35 (1993). A brief procedural explanation is needed. A February 2023 Board decision remanded claims of entitlement to service connection for residuals of traumatic brain injury (TBI) and entitlement to a total disability rating for compensation purposes due to individual unemployability (TDIU) prior to June 28, 2019. A July 2023 rating decision granted service connection for TBI and assigned an earlier effective date of TDIU from January 11, 2017. As the claim was pending from that date, this is the maximum grant of benefits for those issues under the circumstances of the appeal. The rating decision eliminated the appeal stream for those issues and the claims were not returned to the Board. The parties to the JMPR found that the issue of SMC housebound for the period prior to June 28, 2019, was inextricably intertwined with the remanded claim of TDIU prior to June 28, 2019, and the Board should have considered it. The Board can't consider it within that appeal stream because that stream no longer exists. Nevertheless, the Board will resolve reasonable doubt in the Veteran's favor and incorporate the issue of SMC under the housebound criteria prior to June 28, 2019, in the present appeal stream. This course of action is not prejudicial because the appeal stream originates from the same claim filed on January 11, 2017. Increased Rating - Lumbar Spine The Veteran seeks increased ratings for his lumbar spine disability. He claimed that he manifested the functional equivalent of ankylosis of the lumbar spine. Disability ratings are determined by the application of VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999). Effective February 7, 2021, VA revised the criteria for evaluating musculoskeletal disorders. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76464 (Nov. 30, 2020); Correction, 86 Fed. Reg. 8142, 8143 (Feb. 4, 2021) (changing the new diagnostic code applicable to plantar fasciitis from 5285 to 5269). VA's General Counsel has held that where a law or regulation changes during the pendency of a claim for a higher rating, the Board must first determine whether the revised version is more favorable to the veteran. If the revised version of the regulation is more favorable, the retroactive reach of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. VA must consider the claim for a higher rating pursuant to the former and revised regulations during the latter part of this appeal. See VAOPGCPREC 3 2000, 65 Fed. Reg. 33,422 (2000); DeSousa v. Gober, 10 Vet. App. 461, 467 (1997). Therefore, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021, and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. In this regard, the Board observes that former regulation 38 C.F.R. § 19.9(b)(2) (now 38 C.F.R. § 20.904(d)(2)) provided that the Board has the authority to consider appeals in light of laws, including but not limited to statutes, regulations and court decisions that were not previously considered by the agency of original jurisdiction. In Disabled American Veterans v. Sec of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003), the United States Court of Appeals for the Federal Circuit (Federal Circuit) specifically upheld the validity of 38 C.F.R. § 19.9(b)(2) (now renumbered as 38 C.F.R. § 20.904(d)(2)). Id. at 1349. As such, pursuant to 38 C.F.R. § 20.904(d)(2), the Board will proceed to adjudicate the Veteran's claim. Disabilities of the spine are evaluated under the General Rating Formula for Diseases and Injuries of the Spine at 38 C.F.R. § 4.71a. Under such code, a 20 percent rating is assigned when there is forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; a combined range of motion of the thoracolumbar spine not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for limitation of forward flexion of the thoracolumbar spine to 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted if there is unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted if there is unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula. Any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, are rated separately under an appropriate diagnostic code. Id. at Note (1). Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (IVDS), a 10 percent disability rating is warranted for IVDS with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months; a 20 percent disability rating is warranted for IVDS with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months; a 40 percent disability rating is warranted for IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a 60 percent disability rating is warranted for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a. Note (1) to Diagnostic Code 5243 provides that, for purposes of ratings under Diagnostic Code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Note (2) provides that, if intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, each segment is to be rated on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. 38 C.F.R. § 4.71a. In rating musculoskeletal disabilities, it is necessary to consider functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness, along with the schedular criteria. DeLuca v. Brown, 8 Vet. App. 202 (1995). The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated innervation, or other pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. The factors of joint disability reside in reductions of their normal excursion of movements in different planes of motion. Less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.), more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.), weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.), excess fatigability, incoordination, pain on movement, swelling, deformity, or atrophy of disuse as well as instability of station, disturbance of locomotion, interference with sitting, standing, and weight bearing are relevant considerations for determination of joint disabilities. 38 C.F.R. § 4.45. Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011) (holding that 38 C.F.R. § 4.59 applies to disabilities other than arthritis). However, painful motion alone is not a functional loss without some restriction of the normal working movements of the body. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the U.S. Court of Appeals for Veterans Claims (Court) held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flare ups from the veterans themselves, when a flare-up is not observable at the time of examination. Such information must be considered in rating the Veteran's functional impairment. Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Dorland's Illustrated Medical Dictionary, 94 (32nd ed. 2012). Applicable law has held that the criteria of 38 C.F.R. § 4.40 and 4.45 permit consideration of a rating for ankylosis if functional loss is consistent with that contemplated by ankylosis; in other words, if it is the functional equivalent of ankylosis. Chavis v. McDonough, 34 Vet. App. 1, 11 (2021). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C. § 5107(b). An approximate balance of the evidence includes but is not limited to equipoise. Lynch v. McDonough, 21 F.4th 776, 781 (Fed. Cir. 2021). Evidence is not in "approximate balance" or "nearly equal" when the evidence persuasively favors one side or the other. Id. In the aforementioned revision, DC 5242 was designated for degenerative arthritis, degenerative disc disease other than intervertebral disc syndrome. DC 5243 was designated for IVDS where there is disc herniation with compression and/or irritation of the adjacent nerve root. It is again noted that the effective date of this revised criteria may not be applied prior to February 7, 2021. The revisions to the rating schedule did not alter the General Rating Formula. The Board finds that the persuasive weight of the evidence is against assigning higher staged ratings for the Veteran's lumbar spine. All evidence was considered. See Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the Board is not required to discuss every piece of evidence in a claims file). VA examination reports were reviewed. The Veteran's range of motion under ordinary conditions, at its lowest, was to 50 degrees of forward flexion in October 2024. This does not reach the threshold of forward flexion limited to 30 degrees as required for a 40 percent rating. See 38 C.F.R. § 4.7, 4.71a, DC 5237-5242. Further, based on his complaints of difficulty walking, stranding, and sitting for prolonged periods due to pain, the examiner estimated that the forward flexion would be limited to 30 degrees. Such would represent the first that the competent medical evidence would support the assignment of a 40 percent rating. The AOJ assigned a 40 percent rating from August 6, 2024. This was in response to a VA examination on that date finding that the Veteran would be limited to 30 degrees of forward flexion during flare-ups and after repeated use over time. This is the maximum rating that may be assigned for limited motion under the rating schedule. See Mitchell, 25 Vet. App. at 43. Consideration was given to functional loss after repeated use over time and during flare-ups. The March 2017 VA examiner estimated that the Veteran would have forward flexion limited to 40 degrees during flare-ups and after repeated use over time. The May 2022 VA examiner estimated that the Veteran would have forward flexion limited to 60 degrees during flare-ups and after repeated use over time. This does not reach the level of functional loss required for a higher rating. The DeLuca factors and the criteria of §§ 4.45 and 4.59 were considered. The evidence does not suggest that higher ratings are warranted for the periods on appeal, i.e., a rating in excess of 20 percent prior to August 6, 2024, and in excess of 40 percent from that date. The evidence likewise does not suggest that separate ratings may be assigned based on bowel or bladder impairment. No such symptomatology was identified at the 2017, 2022, or 2024 examinations. The Veteran likewise did not report symptoms of lumbar radiculopathy to the VA examiners. The Board does not see evidence of the same to the extent required for a separate compensable rating. The JMPR was reviewed. The parties agreed that the Board did not address whether the Veteran had the functional equivalent of ankylosis. They cited evidence including: (1) a February 2017 note in which the Veteran reported in a Statement in Support of Claim that sometimes he cannot look down or move his head backward; (2) a March 2017 VA examination report in which the examiner said that the Veteran "has to avoid looking down and all movements in prolonged periods of time"; and (3) the same examination report in which the Veteran said he "cannot stand completely upright during a flare up and states that any movement causes severe pain during a flare up" and further stated that he has a flare up "every couple months" and that it lasts about three days. A higher rating is not warranted on the basis of the cited evidence. The Veteran's report of experiencing difficulty moving his head relate to the cervical spine, which will be discussed in the next section. The Veteran is competent to report what happens during a lumbar flare-up. Yet, even taking his statements as true, the fact that he cannot stand completely upright during a flare-up occurring every couple of months and lasting about three days does not suggest that a higher rating is warranted. He statements mean that he only experiences "immobility and consolidation' of the lumbar spine for 3 days every couple of months. A couple is defined a pair, or a brace, or an indefinite small number. See Couple, Merriam-Webster Online Dictionary, https://www.merriam-webster.com/dictionary/couple (last accessed April 16, 2025). Therefore, at its worst, the Veteran's lumbar spine disability only had immobility and consolidation for 10 percent of the month every few months. As VA disability compensation is payable on a monthly basis, it does not seem reasonable to assign a higher rating for impairment that the Veteran had for a small fraction of the month every few months. See 38 C.F.R. §§ 3.31, 4.7 ("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."). At the August 2024 VA examination, the Veteran did not renew his reports of being completely unable to move due to his lumbar spine flare-ups. He said that he has flare-ups several times a week lasting for the entire day described as sharp pain 7 out of 10 resulting in difficulty walking, standing, and sitting for prolonged period. He did not state he was unable to move. The examiner estimated that the Veteran would still be able to have forward flexion to 30 degrees during such periods. This does not suggest that the lumbar spine was immobile and consolidated to the extent that a higher rating may be assigned. In summary, the persuasive weight of the evidence is against the claim for higher staged ratings for lumbar strain with degenerative arthritis, rated as 20 percent from January 11, 2017, and 40 percent from August 6, 2024. The benefit-of-the-doubt is not invoked. 38 U.S.C. § 5107(a). The appeal is denied. Increased Rating - Cervical Spine The Veteran seeks increased ratings for his cervical spine disability. He claimed that he manifested the functional equivalent of ankylosis of the cervical spine. Disabilities of the cervical spine are evaluated under the General Rating Formula at 38 C.F.R. § 4.71a. Therein, a 20 percent rating is assigned when there is forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees or the combined range of motion of the cervical spine does not exceed 170 degrees, or there is muscle spasm or guarding severe enough to result in abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30-degree rating is assigned for forward flexion of the cervical spine 15 degrees or less or favorable ankylosis of the entire cervical spine. A 40 percent rating is assigned for unfavorable ankylosis of the entire cervical spine. A 100 percent rating is assigned for unfavorable ankylosis of the entire spine. The persuasive weight of the evidence is against higher staged ratings for the cervical spine. All relevant evidence was reviewed. VA examination reports were reviewed. Prior to August 6, 2024, the Veteran's range of motion under ordinary conditions, at its worst, was to 35 degrees at the VA examinations in March 2017 and May 2022. This does not reach the threshold of forward flexion limited to 15 degrees as required for a 30 percent rating. Consideration was given to functional loss after repeated use over time and during flare-ups. The Veteran did not report flare-ups to the March 2017 VA examiner. After repeated use over time, the examiner estimated that the Veteran would not be additionally limited in functional ability. The May 2022 VA examiner estimated that the Veteran would have forward flexion limited to 30 degrees during flare-ups and after repeated use over time. This does not reach the level of functional loss required for a higher rating. The AOJ assigned a 30 percent rating from August 6, 2024. This was in response to a VA examination on that date finding that the Veteran would be limited to 15 degrees of forward flexion during flare-ups and after repeated use over time. This is the maximum rating that may be assigned for limited motion under the rating schedule. See Mitchell, 25 Vet. App. at 43. Consideration was given to the DeLuca factors and the criteria of §§ 4.45 and 4.59. The evidence does not suggest that higher ratings are warranted on that basis. The evidence does not suggest that separate ratings may be assigned based on bowel or bladder impairment. The Veteran's cervical/upper extremity radiculopathy has already been recognized as service-connected and granted its own compensable rating. The Board does not have appellate purview to adjudicate its rating herein. See De Hart v. McDonough, 37 Vet. App. 371, 375 (2024) (holding that "once radiculopathy is recognized by VA as a distinct service-connected disability with its own rating criteria, it is subject to the same general rules that would govern the appeal of any other separately adjudicated issue"). As previously discussed, the parties to the JMPR agreed that the Board did not address whether the Veteran had the functional equivalent of ankylosis. A higher rating is not warranted on the basis of the evidence cited by the parties and as noted above. The February 2017 treatment note does not suggest that the joint was completely immobile. Although the Veteran said that he "cannot look down or move his head backward", he did not endorse the inability to rotate his head side-to-side or forward. The March 2017 VA examiners report that the Veteran must avoid looking down and all movements in prolonged periods of time also does not suggest immobility. Immobility in certain positions and unable to move for prolonged periods of time is not the same as fully immobile and consolidated in a favorable or unfavorable ankylosis to the extent that a higher rating is warranted. Moreover, the Veteran did not renew his reports that he could not look down or move his head backward at the August 2024 VA examination. He said that he has flare-ups daily lasting for several hours described as sharp pain 5 out of 10 resulting in difficulty looking down and performing any activity requiring sudden neck movement. He did not state he was unable to move. The examiner estimated that the Veteran would still be able to have forward flexion to 15 degrees (and some level of range of motion in all planes) during such periods. This does not suggest that the lumbar spine was immobile and consolidated to the extent that a higher rating may be assigned. See Chavis, 34 Vet. App. at 11. The persuasive weight of the evidence is against the claim for higher staged ratings for cervical spine degenerative disc disease, rated as 20 percent from January 11, 2017, and 30 percent from August 6, 2024. The benefit-of-the-doubt is not invoked. 38 U.S.C. § 5107(a). The appeal is denied. Additionally, the below analysis concerning SMC establishes that the Veteran has been granted a TDIU from January 11, 2017. He is being granted SMC under the housebound criteria from that date based on a TDIU based on his PTSD alone and additional disabilities independently ratable at 60 percent or greater. The Veteran thereby receives the maximum allowable compensation possible in this appeal. No further compensation is available. Any failure of the Board in not granting further staged ratings for his spine is a harmless error. Earlier Effective Date - SMC The Veteran seeks an earlier effective date of SMC under the statutory housebound criteria. He alleges that it is intertwined with his rating for TDIU. Under 38 U.S.C. § 1114(s), special monthly compensation (SMC) may be granted if the veteran has a service-connected disability rated as total, and (1) has additional service-connected disability or disabilities independently ratable at 60 percent or more, or, (2) by reason of such veteran's service-connected disability or disabilities, is permanently housebound. Id. VA's duty to maximize benefits requires it to assess all a claimant's service-connected disabilities to determine whether any combination of the disabilities establishes eligibility for SMC under 38 U.S.C. § 1114(s). See Buie v. Shinseki, 24 Vet. App. 242, 250-51 (2010); Bradley v. Peake, 22 Vet. App. 280, 294 (2008). In Bradley, 22 Vet. App. at 294, the Court held that 38 U.S.C. § 1114(s) permits a TDIU rating based on a single disability to satisfy the statutory requirement of a "total" rating. When a veteran is awarded TDIU based on a single disability and receives schedular disability ratings for other conditions, SMC based on the statutory housebound criteria may be awarded so long as the same disability is not counted twice, i.e., as a basis for TDIU and as a separate disability rated 60 percent or more disabling. See 75 Fed. Reg. 11,229, 11,230, Summary of Precedent Opinions of the VA General Counsel (March 10, 2010) (withdrawing (VAOPGCPREC 6-1999 in light of Bradley, 22 Vet. App. at 280). The Veteran has been assigned a TDIU from January 11, 2017. The question is whether he is eligible for TDIU due to a single service-connected disability. If so, and the evidence shows additional disabilities independently ratable at 60 percent or greater, then he is eligible for SMC under the statutory housebound criteria. After reviewing the entirety of the evidence, the Board finds that the Veteran may be assigned a TDIU due to the severity of his PTSD alone. He has been assigned a 70 percent rating for PTSD from January 11, 2017. A combined 100 percent rating has been in effect since July 12, 2023. He has not worked since January 2015. VA medical records show a severe level of functional impairment due to PTSD, with symptoms including suicidal ideation, and difficulty in adapting to stressful circumstances, including work or a work like setting. A VA Form 28-1902f, Feasibility Determination Narrative, noted that the Veteran reported mental health symptoms impacting his ability to work, including difficulty being around people; difficulty staying focused and concentrating related to anxiety; feeling tired with poor sleep; nightmares; avoidance; low energy; anxiety; and irritability. The Board will resolve reasonable doubt in his favor and find that TDIU is warranted by PTSD alone. The Veteran has additional service-connected disabilities with a combined rating of at least 60 percent since January 11, 2017. These include radiculopathy of the right upper extremity, rated 40 percent; lumbar strain with degenerative arthritis, rated 20 percent; cervical spine degenerative disc disease, rated 20 percent; tinnitus, rated 10 percent; and TBI residuals, rated 10 percent. This amounts to more than 60 percent, and does not count the Veteran's PTSD. SMC is warranted under the housebound criteria at 38 U.S.C. § 1114(s) from January 11, 2017. The appeal is granted. Considering his entitlement to TDIU also from January 11, 2017, the Veteran has now been granted the maximum compensation allowed by law. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Reed, 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.