KIDNEY DISEASE OF

APRIL MADDOX · 2023 · Case ID: 23022062

MIXED

Summary

The veteran, who served in the Army from June 1968 to May 1971, July 1972 to July 1978, and June 1982 to October 1984, appeals rating decisions concerning bladder cancer, erectile dysfunction (ED), PTSD with substance abuse, and TDIU. The Board granted service connection for bladder cancer with staged ratings: 10% from October 1, 2018, to December 10, 2019; 20% from December 10, 2019, to January 11, 2022; and 40% from January 11, 2022, to May 13, 2022. The Board denied higher ratings for bladder cancer for the periods before December 10, 2019, and after May 13, 2022, finding the evidence did not support higher evaluations. The claim for ED was denied due to lack of penile deformity, despite loss of erectile power and receipt of Special Monthly Compensation for loss of use of a creative organ. The veteran's claim for an increased rating for PTSD with substance abuse was denied, as the Board found the evidence supported the existing 70% rating but not a higher one, weighing the VA examiners' opinions more heavily than a private evaluation. However, the Board granted TDIU for the period between October 1, 2018, and May 13, 2019, finding the evidence in equipoise regarding the veteran's inability to secure substantially gainful employment due to his service-connected disabilities, resolving doubt in his favor. An effective date of October 1, 2018, was granted for Dependents' Educational Assistance (DEA) benefits, aligning with the TDIU award.

Rationale

Symptoms during Oct 2018 - Dec 2019 period (daytime voiding 2-3 hours) aligned with 10% rating criteria.; Symptoms during Dec 2019 - Jan 2022 period (nighttime voiding 3 times, daytime voiding 3-4 times/hour after fluids) warranted 20% rating.; Symptoms during Jan 2022 - May 2013 period (daytime voiding <1 hour) warranted 40% rating.; Higher ratings denied due to lack of evidence for more severe symptoms (e.g., appliance use >4 times/day, retention requiring catheterization).

Service Branch

ARMY

Special Benefit

TDIU

Docket No.

19-02 045

Full Decision Text

Citation Nr: 23022062
Decision Date: 04/11/23 Archive Date: 04/11/23

DOCKET NO. 19-02 045
DATE: April 11, 2023

ORDER

An evaluation in excess of 10 percent for bladder cancer, to include residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer) for the period on appeal between October 1, 2018, and December 10, 2019, is denied.

An evaluation of 20 percent, but no higher, for bladder cancer, to include residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer) for the period on appeal between December 10, 2019, and January 11, 2022, is granted.

An evaluation of 40 percent but no higher, for bladder cancer, to include residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer) for the period on appeal between January 11, 2022, and May 13, 2022, is granted.

An evaluation in excess of 60 percent for bladder cancer, to include residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer) for the period on appeal beginning May 13, 2022, is denied.

A compensable evaluation for erectile dysfunction (ED) for the period on appeal beginning February 1, 2018, is denied.

An evaluation in excess of 70 percent for post-traumatic stress disorder (PTSD) with substance abuse for the period on appeal beginning November 15, 2018, is denied.

A total disability rating based on individual unemployability due to service-connected disabilities (TDIU) for the period on appeal between October 1, 2018, and May 13, 2019, is granted.

An effective date of October 1, 2018, for basic eligibility to Dependents' Educational Assistance (DEA) is granted.

FINDINGS OF FACT

1. For the period on appeal between October 1, 2018, and December 10, 2019, the evidence of record demonstrates that the Veteran's bladder cancer, to include residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer), was manifested by daytime voiding intervals between two and three hours.

2. For the period on appeal between December 10, 2019, and January 11, 2022, the evidence of record demonstrates that the Veteran's bladder cancer, to include residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer), was manifested by awakening to void three times per night.

3. For the period on appeal between January 11, 2022, and May 13, 2022, the evidence of record demonstrates that the Veteran's bladder cancer, to include residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer), was manifested by daytime voiding intervals of less than one hour.

4. For the period on appeal beginning May 13, 2022, the evidence of record demonstrates that the Veteran's bladder cancer, to include residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer), was manifested by the use of an appliance or the wearing of absorbent materials that must be changed more than four times a day.

5. For the period on appeal beginning February 1, 2018, the evidence of record demonstrates that the Veteran's ED was manifested by loss of erectile power; the Veteran's ED was not manifested by penile deformity.

6. During the period on appeal beginning November 15, 2018, the Veteran's PTSD with substance abuse has been manifested by no worse than occupational and social impairment with deficiencies in most areas; the Veteran's acquired psychiatric disorder has not resulted in total occupational and social impairment.

7. During the period on appeal between October 1, 2018, and May 13, 2019, the Veteran's service-connected disabilities precluded him from securing and maintaining a substantially gainful occupation.

CONCLUSIONS OF LAW

1. For the period on appeal between October 1, 2018, and December 10, 2019, the criteria for an evaluation in excess of 10 percent for bladder cancer, to include residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer) have not been met. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 3.102, 3.105, 3.343, 3.344, 4.1, 4.2, 4.3
Veteran's service-connected disabilities precluded him from securing and maintaining a substantially gainful occupation.

CONCLUSIONS OF LAW

1. For the period on appeal between October 1, 2018, and December 10, 2019, the criteria for an evaluation in excess of 10 percent for bladder cancer, to include residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer) have not been met. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 3.102, 3.105, 3.343, 3.344, 4.1, 4.2, 4.3, 4.7, 4.10, 4.59, 4.115a, 4.115b, Diagnostic Code (DC) 7528.

2. For the period on appeal between December 10, 2019, and January 11, 2022, the criteria for an evaluation of 20 percent, but no higher, for bladder cancer, to include residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer) have been met. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 3.102, 3.105, 3.343, 3.344, 4.1, 4.2, 4.3, 4.7, 4.10, 4.59, 4.115a, 4.115b, DC 7528.

3. For the period on appeal between January 11, 2022, and May 13, 2022, the criteria for an evaluation of 40 percent, but no higher, for bladder cancer, to include residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer) have been met. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 3.102, 3.105, 3.343, 3.344, 4.1, 4.2, 4.3, 4.7, 4.10, 4.59, 4.115a, 4.115b, DC 7528.

4. For the period on appeal beginning May 13, 2022, the criteria for an evaluation in excess of 60 percent for bladder cancer, to include residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer) have not been met. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 3.102, 3.105, 3.343, 3.344, 4.1, 4.2, 4.3, 4.7, 4.10, 4.59, 4.115a, 4.115b, DC 7528.

5. For the period on appeal beginning February 1, 2018, the criteria for a compensable evaluation for ED have not been met. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.20, 4.27, 4.31, 4.59, 4.115b, DC 7522, 7599.

6. For the period on appeal beginning November 15, 2018, the criteria for an evaluation in excess of 70 percent for PTSD with substance abuse have not been met. 38?U.S.C. §§?1155, 5107; 38 C.F.R. §§ 3.102,?4.1, 4.2, 4.3, 4.7, 4.10, 4.126, 4.130, DC 9411.

7. For the period on appeal between October 1, 2018, and May 13, 2019, the criteria for entitlement to a TDIU have been met. 38 U.S.C. § 5107; 38 C.F.R. § 3.102, 3.340, 3.341, 4.16, 4.19.

8. The criteria for an effective date of October 1, 2018, but no earlier, for basic eligibility to DEA have been
?4.1, 4.2, 4.3, 4.7, 4.10, 4.126, 4.130, DC 9411.

7. For the period on appeal between October 1, 2018, and May 13, 2019, the criteria for entitlement to a TDIU have been met. 38 U.S.C. § 5107; 38 C.F.R. § 3.102, 3.340, 3.341, 4.16, 4.19.

8. The criteria for an effective date of October 1, 2018, but no earlier, for basic eligibility to DEA have been met. 38 U.S.C. §§ 3501, 3510, 3512, 5107; 38 C.F.R. §§ 3.102, 3.807, 21.3021, 4.3.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from June 1968 to May 1971, from July 1972 to July 1978, and June 1982 to October 1984. This case comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued in July 2018, January 2019, August 2019, and June 2022 by a Department of Veterans Affairs (VA) Regional Office (RO).

On January 11, 2022, the Veteran testified at a Board hearing before a Veterans Law Judge; a transcript of the hearing is associated with the record.

I. Increased Rating Issues

Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant's favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7.

Separate ratings can be assigned for separate periods based on the facts found - a practice known as "staged" ratings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994); Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id.

The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10.

1. Bladder cancer, to include residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer)

The Veteran contends that he is entitled to increased ratings for his service-connected bladder cancer, to include residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer).

In an August 2017 rating decision, the RO granted service connection for prostate cancer with a 100 percent evaluation under Diagnostic Code (DC) 7528, effective April 20, 2016. Pursuant to DC 7528, in a February 2018 rating decision, the RO proposed a reduction of the Veteran's evaluation for prostate cancer to 10 percent. In a July 2018 rating decision, the RO recharacterized the Veteran's prostate cancer as residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer), and implemented the reduction of the Veteran's rating for such disability to 10 percent, effective on October 1, 2018. The Veteran timely appealed.

In a June 2022 rating decision, the RO granted service connection for bladder cancer, effective April 20, 2016, combining this with the Veteran's service-connected residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer). Thus,
8 rating decision, the RO proposed a reduction of the Veteran's evaluation for prostate cancer to 10 percent. In a July 2018 rating decision, the RO recharacterized the Veteran's prostate cancer as residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer), and implemented the reduction of the Veteran's rating for such disability to 10 percent, effective on October 1, 2018. The Veteran timely appealed.

In a June 2022 rating decision, the RO granted service connection for bladder cancer, effective April 20, 2016, combining this with the Veteran's service-connected residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer). Thus, the RO re-characterized the Veteran's disorder as bladder cancer to include residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer); and granted an increased rating of 60 percent for such disorder, effective May 13, 2022.

The Veteran's bladder cancer, to include residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer) has been rated by under 38 C.F.R. § 4.115b, DC 7528, which concerns malignant neoplasms of the genitourinary system. Under DC 7528, a 100 percent evaluation is assigned for active malignancy, and then the diagnostic criteria assign an evaluation for residuals following active malignancy under the appropriate genitourinary dysfunction under 38 C.F.R. § 4.115a.

A note after DC 7528 provides that, following the cessation of surgical, X-ray, antineoplastic chemotherapy, or other therapeutic procedure, the rating of 100 percent shall continue with a mandatory VA examination at the expiration of six months. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of 38 C.F.R. § 3.105(e). If there has been no local reoccurrence or metastasis, the disability is to be rated on residuals as voiding dysfunction or renal dysfunction, whichever is predominant. See 38 C.F.R. § 4.115b, Diagnostic Code 7528, Note.

Under 38 C.F.R. § 3.105(e), where a reduction in an evaluation of a service-connected disability is considered warranted and the lower evaluation would result in a reduction or discontinuance of compensation payments currently being made, a rating proposing the reduction or discontinuance must be prepared setting forth all material facts and reasons. In addition, the RO must notify the Veteran that he has 60 days to present additional evidence showing that compensation should be continued at the present level. The Veteran must be informed that he may request a predetermination hearing, provided that the request is received by VA within 30 days from the date of the notice. If no additional evidence is received within the 60-day period and no hearing is requested, final rating action will be taken and the award will be reduced or discontinued effective the last day of the month in which a 60-day period from the date of notice to the Veteran expires. Id.

Initially, the Board considered whether the claim would be more appropriately characterized as a formal reduction issue under the substantive provisions of 38 C.F.R. §§ 3.343 and 3.344. However, these provisions are not applicable because the provisions of 38 C.F.R. § 4.115b, DC 7528 contain a temporal element for continuance of a 100 percent rating for prostate cancer residuals. Therefore, the RO's action was not a "rating reduction" as the term is commonly understood. See Rossiello v. Principi, 3 Vet. App. 430 (1992)). The rating reduction in this case was procedural in nature and by operation of law. Therefore, the Board must determine if the procedural requirements of 38 C.F.R. § 3.105(e) were met and if the reduction was by operation of law under DC 7528. As discussed below, the Board finds that these requirements have been met.

The Veteran had a radical prostatectomy in April 2017, and he underwent a VA examination of his prostate cancer residuals in February 2018. The RO issued a rating reduction proposal in February 2018, which set forth the material facts and reasons for the proposed reduction. The Veteran was given more than 60 days to respond and present additional evidence.

In March 2018, the Veteran submitted a statement saying that his doctor could not state that his malignant growth of the genitourinary system (referring to his prostate cancer) could or could not come back. Along with this statement, the Veteran also submitted a copy of a private treatment record in which his doctor, Dr. S, noted that the Veteran had come in reporting that
had a radical prostatectomy in April 2017, and he underwent a VA examination of his prostate cancer residuals in February 2018. The RO issued a rating reduction proposal in February 2018, which set forth the material facts and reasons for the proposed reduction. The Veteran was given more than 60 days to respond and present additional evidence.

In March 2018, the Veteran submitted a statement saying that his doctor could not state that his malignant growth of the genitourinary system (referring to his prostate cancer) could or could not come back. Along with this statement, the Veteran also submitted a copy of a private treatment record in which his doctor, Dr. S, noted that the Veteran had come in reporting that he had received information from the VA that his disability for prostate cancer was "being cut down because he had no more cancer". Dr. S noted that the Veteran understood that "there is no way we can prove that." Dr. S also stated that it is "impossible to know if he has persistent disease," though he was at risk for a local reoccurrence. There was no indication in this treatment record of any active prostate cancer.

In July 2018, the RO issued a rating decision effectuating the reduction. The reduction was effective October 1, 2018, the first day of the month after expiration of the 60-day period from the date of notice of the July 2018 final rating action, as set forth in the applicable VA regulation. Thus, the notice requirements for the reduction of the assigned prostate cancer rating were satisfied. See 38 C.F.R. § 3.105(e).

In considering the evidence of record under the laws and regulations as set forth above, the Board concludes there that is no evidentiary basis for continuance of the 100 percent rating for prostate cancer under DC 7528 after October 1, 2018. The evidence of record, including pertinent VA examinations, VA treatment records, and private treatment records, does not reveal local recurrence or metastasis of the Veteran's prostate cancer.

Specifically, private treatment records from Dr. S dated March 2017 to January 2019 show no further malignancy. Moreover, the February 2018 VA examination report indicates that, after a 2017 radical prostatectomy, the Veteran's treatment for prostate cancer was completed, and he was in watching/waiting status. Therefore, given the lack of recurrence or metastasis of the prostate cancer on or after October 1, 2018, the initial 100 percent rating for prostate cancer was properly discontinued, and restoration of the total rating is not warranted. See 38 C.F.R. § 4.115b, DC 7528; Rossiello, 3 Vet. App. at 430.

Having determined that the RO correctly followed the process required to reduce the Veteran's rating under DC 7528, the Board must determine whether the Veteran has been assigned appropriate ratings, particularly from October 1, 2018, onward. In this regard, the Board notes that it is focusing its adjudication on whether a next higher disability rating is available to the Veteran. As the Veteran's initial 100 percent rating for bladder cancer, to include residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer) applies to the period between April 20, 2016, and October 1, 2018, the Veteran's rating for his disability during that period and his symptoms therein are moot for purposes of this decision. Thus, the Board will focus its analysis on whether an evaluation greater than 10 percent is warranted for the period on appeal between October 1, 2018, and May 13, 2022, and whether an evaluation greater than 60 percent is warranted for the period on appeal beginning May 13, 2022.

In this regard, the Board acknowledges that VA treatment records from August 2016 and September 2016 mentioned that the Veteran saw a non-VA urologist in September 2016. The Veteran did not specify who this urologist was, and the claims file does not currently include records of visits to a non-VA urologist from September 2016. Similarly, in an October 2016 VA Telephone Encounter Note, the Veteran stated that he had an outside (non-VA) prostate surgery on September 16, 2016. The Veteran did not indicate what procedure this referred to, and the claims file does not currently include records from this reported procedure.

However, these September 2016 non-VA urologist visits and the reported September 2016 prostate-related procedure occurred during a time when the Veteran is rated at 100 percent, well before the October 1, 2018, rating reduction. Also, the September 2016 non-VA u
file does not currently include records of visits to a non-VA urologist from September 2016. Similarly, in an October 2016 VA Telephone Encounter Note, the Veteran stated that he had an outside (non-VA) prostate surgery on September 16, 2016. The Veteran did not indicate what procedure this referred to, and the claims file does not currently include records from this reported procedure.

However, these September 2016 non-VA urologist visits and the reported September 2016 prostate-related procedure occurred during a time when the Veteran is rated at 100 percent, well before the October 1, 2018, rating reduction. Also, the September 2016 non-VA urologist visits and September 2016 prostate-related procedure are not mentioned again in the evidence of record after the aforementioned October 2016 VA Telephone Encounter Note. Thus, the Board finds that any information contained in the September 2016 non-VA medical records is moot, and a remand for the September 2016 non-VA medical records is not necessary at this time. The Board likewise finds that there is no prejudice against the Veteran if the Board moves forward to adjudicate this case at this time.

As noted earlier, under DC 7528, if there has been no local reoccurrence or metastasis, then the Veteran's cancer residuals are to be rated as voiding dysfunction or renal dysfunction, whichever is the predominant disability. 38 C.F.R. § 4.115b. The Veteran does not demonstrate any renal dysfunction due to his radical prostatectomy, but rather asserts a predominance of urinary or voiding dysfunction.

Under 38 C.F.R. § 4.115a, which concerns ratings of the genitourinary system, voiding dysfunction is rated under the three subcategories of urine leakage, urinary frequency, and obstructed voiding. Regarding urine leakage, the Board notes that a 20 percent evaluation requires the wearing of absorbent materials which must be changed less than two times per day. A 40 percent evaluation requires the wearing of absorbent materials which must be changed two to four times per day. A 60 percent evaluation requires the use of an appliance or the wearing of absorbent materials which must be changed more than four times per day. 38 C.F.R. § 4.115a, Continual Urine Leakage, Post-Surgical Urinary Diversion, Urinary Incontinence, and Stress Incontinence.

Regarding urinary frequency, the Board notes that a 10 percent evaluation is warranted with daytime voiding intervals between two and three hours or awakening to void two times per night. A 20 percent evaluation is warranted with daytime voiding intervals between one and two hours or awakening to void three to four times per night. A 40 percent evaluation is warranted with daytime voiding intervals of less than an hour or awakening to void five or more times per night. 38 C.F.R. § 4.115a, Urinary Frequency.

Finally, for obstructed voiding, a noncompensable rating contemplates obstructive symptomatology with or without stricture disease requiring dilatation one to two times per year. A 10 percent rating contemplates marked obstructive symptomatology (hesitancy, slow or weak stream, decreased force of stream) with any one or combination of the following: (1) post-void residuals greater than 150 cubic centimeters (cc); (2) uroflowmetry; markedly diminished peak flow rate (less than 10 cc per second); (3) recurrent urinary tract infections secondary to obstruction; and/or (4) stricture disease requiring periodic dilatation every two to three months. A 30 percent rating contemplates urinary retention requiring intermittent or continuous catheterization. 38 C.F.R. § 4.115a, Obstructed Voiding.

As background for the Veteran's bladder cancer prior to October 2018, the Veteran's VA medical records indicate that, in April 2014, the Veteran was found to have a 3 centimeter (cm) bladder tumor as a result of a February 2014 computed tomography (CT) urogram and a May 2014 cystoscopy. In May 2014, he underwent a transurethral resection of the bladder tumor (TURBT). By June 2015, a VA Neurology Outpatient Note stated that the Veteran's bladder cancer was in remission.

In a June 2016 VA examination for urinary tract conditions, the VA examiner found the Veteran to have bladder cancer status-post Bacillus Calmette-Guerin (BCG) treatment with residuals. The Veteran had finished BCG treatment in February 2016, and the bladder cancer was noted to be in remission. The Veteran was found to have a voiding dysfunction due to bladder
2014 computed tomography (CT) urogram and a May 2014 cystoscopy. In May 2014, he underwent a transurethral resection of the bladder tumor (TURBT). By June 2015, a VA Neurology Outpatient Note stated that the Veteran's bladder cancer was in remission.

In a June 2016 VA examination for urinary tract conditions, the VA examiner found the Veteran to have bladder cancer status-post Bacillus Calmette-Guerin (BCG) treatment with residuals. The Veteran had finished BCG treatment in February 2016, and the bladder cancer was noted to be in remission. The Veteran was found to have a voiding dysfunction due to bladder cancer. The voiding dysfunction caused increased urinary frequency with daytime voiding interval between two to three hours and nighttime awakening to void two times. The voiding dysfunction also caused signs and symptoms of obstructed voiding with markedly weak stream.

As background for the Veteran's prostate cancer prior to October 2018, the Veteran's VA medical treatment notes indicate that the Veteran was found to have prostate cancer in April 2016 as a result of a transrectal ultrasound guided prostate biopsy. Private treatment records from March 2017 and April 2017 reflect that the Veteran presented to his private physician, Dr. S, with untreated prostate cancer with a fairly significant volume of perineural invasion. An MRI showed a 1cm ovoid nodule in the left peripheral zone. On April 25, 2017, Dr. S performed a radical retropubic prostatectomy with bilateral obturator lymphadenectomy on the Veteran. The Veteran was found to have a positive margin at the bladder neck with a second bladder neck biopsy coming out negative. After the April 2017 prostatectomy, the Veteran was found to have minimal stress urine incontinence.

In a February 2018 VA examination for prostate conditions, the VA examiner stated that the Veteran had a diagnosis of prostate cancer from 2014, and he was status-post prostatectomy from 2017. The Veteran reported that the onset of the symptoms was in 2012 or 2013, and it began with blood in the urine and specks of brown blood in his sperm. He had a radical suprapubic prostatectomy in 2017, as well as brachytherapy. Treatment was completed, and he was in watchful waiting status.

The February 2018 VA examiner found that the Veteran's voiding dysfunction caused increased urinary frequency with daytime voiding intervals between two to three hours, and it caused signs and symptoms of obstructed voiding with hesitancy. The Veteran was also found to have ED attributable to the prostate diagnosis. The prostate cancer impacted his ability to work in that he had easy fatigability.

The Board notes that the Veteran is service connected for ED due to prostate cancer, and such disorder will be discussed in a later section. The Board also notes that the Veteran's 10 percent evaluation (effective October 1, 2018) for bladder cancer to include residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer) was based on the February 2018 VA examination report.

Looking at the medical records from October 2018 onward, a January 2019 private treatment note stated that the Veteran's stress urinary incontinence was totally resolved, and the only complaint he had was his ED. In a September 2019 VA Telehealth Note, the examiner gave an assessment of favorable intermediate risk prostate cancer that appeared to be cured by surgery. The examiner also noted that the Veteran had a history of bladder cancer with a need for yearly cystoscopies.

In a December 10, 2019, VA Primary Care Nursing Note, the Veteran reported that he got up at night three times to void. He denied pain, urgency, or frequency with urination.

At the January 11, 2022, Board hearing, the Veteran reported that, after his prostate surgery, he noticed "a lot of leakage," and the problem had not gone away. He stated that he started leaking within 10 or 15 minutes of drinking fluids. Whenever he would drink something, he would go to the bathroom three or four times an hour, particularly in hot weather. At night, he had to go to the bathroom about two times. He also stated that, if he had to go out, he did not drink anything for a while. He noted that he stopped telling his private physician, Dr. S, about his constant leaking problem even though it had continued. The Veteran stated that, Dr. S may have thought that the problem resolved, but in actuality, the Veteran had stopped reporting the problem to him.

The Veteran further stated that he tried using diapers that VA provided, but he could not wear them because it looked like he had a huge bulge in the front, which he found embarrassing. Instead, he used toilet paper, which he changed or replaced throughout the day. When asked how often he had to replace such toilet paper, he stated that, if he drank three or four teas, he had to replace the toilet paper three times for each tea drink.

In a May 2022 VA examination for urinary tract conditions, the VA examiner stated that the Veteran had a diagnosis of bladder cancer that was in remission. The VA examiner found that treatment was completed, and there were no residuals or complications due to the neoplasm (including metastases) or its treatment other than voiding dysfunction. The VA examiner found that the Veteran's voiding dysfunction caused urine leakage that required absorbent material that had to be changed more than four times a day. The voiding dysfunction did not require the use of an appliance, and it did not cause increased urinary frequency or signs or symptoms of obstructed voiding.

Considering all the evidence described above, the Board finds that an evaluation in excess of 10 percent for bladder cancer, to include residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer) is not warranted for the period on appeal between October 1, 2018, and December 10, 2019.

In this regard, during the period between October 1, 2018, and December 10, 2019, the Veteran's symptomatology most closely paralleled the types of symptoms in the criteria for a 10 percent disability rating under 38 C.F.R. § 4.115a. Specifically, during this period, the evidence of record demonstrates that the Veteran was shown to exhibit symptoms of daytime voiding intervals between two and three hours. Between October 1, 2018, and December 10, 2019, the Veteran was not shown to exhibit obstructed voiding with urinary retention requiring intermittent or continuous catheterization, as would be required to warrant an evaluation in excess of 10 percent for obstructed voiding under 38 C.F.R. § 4.115a. He also was not shown to exhibit symptoms of urinary frequency with daytime voiding intervals of less than two hours or awakening to void more than two times per night, as would be required to warrant an evaluation in excess of 10 percent for urinary frequency under 38 C.F.R. § 4.115a. He also was not shown to exhibit urine leakage that required the use of absorbent material that had to be changed less than two times per day, as would be required to warrant an evaluation in excess of 10 percent for urinary leakage or incontinence under 38 C.F.R. § 4.115a.

However, as shown above, in a December 10, 2019, VA Primary Care Nursing Note, the Veteran reported that he got up at night three times to void. Then at the January 11, 2022, Board hearing, the Veteran reported that, when he would drink fluids, he would go to the bathroom three or four times an hour, and at night, he had to go to the bathroom about two times.

Therefore, the Board finds that, a 20 percent evaluation under 38 C.F.R. § 4.115a is warranted for the period on appeal between December 10, 2019, and January 11, 2022. Then, during the period on appeal between January 11, 2022, and May 13, 2022, the Veteran was shown to have daytime voiding intervals of less than one hour. As a
to void. Then at the January 11, 2022, Board hearing, the Veteran reported that, when he would drink fluids, he would go to the bathroom three or four times an hour, and at night, he had to go to the bathroom about two times.

Therefore, the Board finds that, a 20 percent evaluation under 38 C.F.R. § 4.115a is warranted for the period on appeal between December 10, 2019, and January 11, 2022. Then, during the period on appeal between January 11, 2022, and May 13, 2022, the Veteran was shown to have daytime voiding intervals of less than one hour. As a result, a 40 percent evaluation under 38 C.F.R. § 4.115a is warranted for the period between January 11, 2022, and May 13, 2022.

Between December 10, 2019, and January 11, 2022, the Veteran did not exhibit daytime voiding intervals less than one hour or awakening to void five or more times per night, and he did not wear absorbent materials that had to be changed two to four times a day, as would be required to warrant an evaluation in excess of 20 percent for urinary leakage or incontinence under 38 C.F.R. § 4.115a. Likewise, he also was not shown to exhibit obstructed voiding with urinary retention requiring intermittent or continuous catheterization. As such, the Board finds that a 20 percent evaluation is appropriate for the Veteran's disorder for the period on appeal between December 10, 2019, and January 11, 2022.

Between January 11, 2022, and May 13, 2022, the Veteran was not shown to use an appliance or wear absorbent material that had to be changed more than four times a day, as would be required to warrant an evaluation in excess of 40 percent for urinary leakage or incontinence under 38 C.F.R. § 4.115a. Likewise, he also was not shown to exhibit obstructed voiding with urinary retention requiring intermittent or continuous catheterization. As such, the Board finds that a 40 percent evaluation is appropriate for the Veteran's disorder for the period on appeal between January 11, 2022, and May 13, 2022.

The Board notes that, although the Veteran reported at the January 2022 Board hearing that he had to replace his absorbent material three or four times for each tea drink, he did not more specifically indicate how many times per day he had to change such absorbent material. The criteria under 38 C.F.R. § 4.115a allows for a 40 percent evaluation if a voiding dysfunction requires absorbent materials to be changed two to four times a day, which results in the same 40 percent evaluation the Board is now assigning for the period between January 11, 2022, and May 13, 2022. The Board cannot assign two separate ratings for urine leakage and urinary frequency, both under 38 C.F.R. § 4.115a, as such would result in impermissible pyramiding.

Regarding the period on appeal beginning May 13, 2022, the Board finds that the Veteran's symptomatology most closely paralleled the types of symptoms in the criteria for a 60 percent disability rating under 38 C.F.R. § 4.115a. In this regard, the Board observes that, during this period, the evidence of record demonstrates that the Veteran used an appliance or wore absorbent material that had to be changed at least four times a day. An evaluation in excess of 60 percent for bladder cancer, to include residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer) is not warranted for the period on appeal beginning May 13, 2022. The Board notes that 60 percent is the highest schedular evaluation allowed under 38 C.F.R. § 4.115a for a voiding dysfunction with urine leakage or incontinence. See 38 C.F.R. §§ 4.115a, 4.115b, DC 7528.

The Board also notes that the highest available schedular evaluation allowed for symptoms of urinary frequency and obstructed voiding is 40 percent. Thus, for the period on appeal beginning May 13, 2022, a rating related to urine leakage or incontinence is the most favorable to the Veteran in this case.

The Board acknowledges the Veteran's assertions that his bladder cancer, to include residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer) is of a sufficient severity as to warrant higher disability ratings than those described above. However, the competent medical evidence offering specific determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal. Thus, the Veteran's own assessment as to the severity of the symptoms and their relationship to the rating criteria are less probative than the opinions of medical practitioners who have specialized knowledge and skill in excess of him. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Woehlaert, supra.

In sum, based on the evidence described above, the Board finds that the Veteran is entitled to an evaluation of 20 percent, but no higher, under 38 C.F.R. § 4.115a for his bladder cancer to include residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer) for the period on appeal between December 10, 2019, and January 11, 2022. Additionally, for the period on appeal between January 11, 2022, and May 13, 2022, the Veteran's disorder is entitled to an evaluation of 40 percent, but no higher, under 38 C.F.R. § 4.115a. However, the weight of the probative evidence is against the assignment of an evaluation in excess of 10 percent for the Veteran's bladder cancer to include residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer) during the period on appeal between October 1, 2018, and December 10, 2019. The weight of the probative evidence is also against the assignment of an evaluation in excess of 60 percent for the Veteran's bladder cancer to include residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer) during the period on appeal beginning May 13, 2022.

In reaching the foregoing conclusions, the Board has resolved all doubt in the Veteran's favor, which has resulted in 20 percent evaluation for the period between December 10, 2019, and January 11, 2022, and a 40 percent evaluation for the period between January 11, 2022, and May 13, 2022, for the Veteran's bladder cancer to include residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer). 38 C.F.R. §§ 4.115a, 4.115b, DC 7528. However, to the extent that higher ratings are denied herein, the Board finds that the weight of the probative evidence is against such aspects of the Veteran's claim. Consequently, the benefit of the doubt doctrine is not applicable in such regard, and the Veteran's claim is otherwise denied. 38?U.S.C. §§?5107, 5110; 38?C.F.R. §§?3.102.

2. ED

The Veteran contends that he is entitled to increased ratings for his service-connected ED.

In July 2018 rating decision, the Veteran was awarded a separate rating for his ED with a noncompensable (0 percent) evaluation, effective February 1, 2018, the date a VA examination showed such objective impairment associated with his prostate cancer diagnosis. The Veteran was also awarded special monthly compensation (SMC) based on the loss of use of a creative organ pursuant to U.S.C. § 1114(k), effective February 1, 2018.

At the January 2022 Board hearing, the Veteran stated that, after the surgery, he noticed his penis was not straight, and it would bear off to the left. When he asked his private physician, Dr. S, about it, Dr. S stated that sometimes happens. Dr. S explained to him that he could get more blood to one side than the other. Dr. S noted that it would probably stay like that. The Veteran then ordered Viagra from VA, and after that, his penis did not work anymore. He noted that his penis is still crooked. He stated that,
the loss of use of a creative organ pursuant to U.S.C. § 1114(k), effective February 1, 2018.

At the January 2022 Board hearing, the Veteran stated that, after the surgery, he noticed his penis was not straight, and it would bear off to the left. When he asked his private physician, Dr. S, about it, Dr. S stated that sometimes happens. Dr. S explained to him that he could get more blood to one side than the other. Dr. S noted that it would probably stay like that. The Veteran then ordered Viagra from VA, and after that, his penis did not work anymore. He noted that his penis is still crooked. He stated that, when he is excited, it will veer off and bend in the middle.

At a February 2018 VA examination for prostate conditions, the VA examiner found that the Veteran had ED attributable to the prostate diagnosis. The Veteran was not able to achieve an erection sufficient for penetration and ejaculation without medication. At the time, he had not used medications to treat ED. There was no mention of a penile deformity.

In an October 2018 VA Triage Note, the Veteran reported having ED since his prostate surgery in April 2017. He stated that ED was minimal after his surgery and had remained frustrating at best. Function had all but disappeared. In other October 2018 VA medical treatment notes, the Veteran was told that ED was a known potential complication of a radical prostatectomy, and he was given Viagra.

The Board notes that there is no diagnostic code specific to ED. See generally 38 C.F.R. § 4.115b, Ratings of the Genitourinary System, DCs 7500-42. However, when a veteran is diagnosed with an unlisted disease, the condition must be rated under an analogous diagnostic code. 38 C.F.R. §§ 4.20, 4.27 (providing that unlisted disabilities requiring rating by analogy will be coded as the first two numbers of the most closely related body part and "99"). Also, hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating assigned. 38 C.F.R. § 4.27. Here, the RO has rated the Veteran's ED under DC 7599-7522, which represents an unlisted genitourinary disability evaluated by analogy to penis deformity with loss of erectile power. See 38 C.F.R. § 4.115b, DC 7522.

Pursuant to DC 7522, a 20 percent rating is warranted for deformity of the penis with the loss of erectile power. This is the only schedular rating provided under this DC. Additionally, in every instance where the schedule does not provide a zero percent rating for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable rating are not met. 38 C.F.R. § 4.31. The Board notes that no other schedular criteria are applicable to ED.

As discussed above, the RO has separately awarded SMC based upon loss of use of a creative organ under 38 U.S.C. § 1114(k). This compensation contemplates impotence and may be awarded even if a veteran can achieve erection and penetration with the use of medication. A separate rating under DC 7522 may only be awarded for deformity of the penis with loss of erectile power. However, a compensable rating under DC 7522 is not warranted in the absence of deformity, which includes either internal or external distortion of the penis. Williams v. Wilkie, 30 Vet. App. 134 (2018).

Thus, the record reflects that the Veteran has been awarded VA compensation for impotence regardless of whether his impotence is complete or whether medications or implantations allow some form of erection and penetration. As such, any further compensation for ED alone, regardless of the severity, would constitute impermissible pyramiding. 38 C.F.R. § 4.14. As such, the evidence must demonstrate "deformity of the penis" to warrant a higher schedular rating under DC 7522.

However, after a review of the record, the Board finds that an initial compensable rating for the Veteran's ED is not warranted as he does not have a deformity of the penis. In this regard, the relevant evidence, including the Veteran's February 2018 VA examination report, his VA and private treatment records, and lay statements, reflect that he has loss of erectile power. However, the Board finds that most probative evidence does not demonstrate a deformity of the penis.

In this regard, the Board acknowledges that at the January 2022 Board hearing, the Veteran alleged that
. As such, the evidence must demonstrate "deformity of the penis" to warrant a higher schedular rating under DC 7522.

In this regard, the Board acknowledges that at the January 2022 Board hearing, the Veteran alleged that he has a deformity of the penis consisting of bending in the middle. The Board further acknowledges that the Veteran is competent to describe the physical appearance of his penis. See Layno v. Brown, 6 Vet. App. 465, 469-71 (1994) (a lay person is competent to report symptoms based on personal observation when no special knowledge or training is required).

However, the Veteran's medical providers, including the February 2018 VA prostate examiner did not find or report that the Veteran had penile deformity. The Veteran's VA and private medical treatment records are negative for any report or diagnosis of a penile deformity.

Thus, although the Board finds that the most probative evidence of record reflects the Veteran has loss of erectile power, the evidence of record fails to demonstrate the presence of a penile deformity so as to warrant the assignment of an initial compensable rating for his ED.

The Board acknowledges the Veteran's assertions that his ED is of a sufficient severity so as to warrant higher disability ratings than those discussed above. However, the competent medical evidence offering specific determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disabilities on appeal. Thus, the Veteran's own assessment as to the severity of the symptoms and their relationship to the rating criteria are less probative than the opinions of medical practitioners who have specialized knowledge and skill in excess of him. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Woehlaert, supra.

The Board has also considered whether staged ratings under Fenderson, supra, are appropriate for the Veteran's ED. However, the Board finds that his symptomatology has been stable throughout the appeal period. Therefore, assigning staged ratings is not warranted. Further, neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record, in regard to the initial rating claim adjudicated herein. Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record).

Thus, the Board finds that the weight of the probative evidence is against an assignment of compensable evaluation for the Veteran's ED for the relevant period on appeal beginning February 1, 2018. In reaching the above determinations, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the weight of the probative evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.7.

3. PTSD with substance abuse

The Veteran contends that he is entitled to increased ratings for PTSD with substance abuse.

By way of history, in a June 2011 rating decision, the RO awarded the Veteran service connection for PTSD with substance abuse with a 50 percent evaluation under 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411, effective June 23, 2010. The 50 percent rating was continued in a February 2013 rating decision. In an August 2016 rating decision, the RO awarded the Veteran an increased rating of 70 percent for PTSD, effective April 20, 2016. The Veteran timely appealed with a notice of disagreement (NOD) in November 2016. However, after an August 2017 statement of the case (SOC) that again denied the claim of increased ratings for PTSD, the Veteran did not timely file a VA Form 9 to appeal the decision.

The Veteran filed the current claim for an increased rating for PTSD with substance abuse on November 15, 2018. The RO denied the Veteran's claim in the January 2019 rating decision currently at issue. The Veteran timely appealed.

The Board notes that the current appeal period for the issue of increased ratings for
the RO awarded the Veteran an increased rating of 70 percent for PTSD, effective April 20, 2016. The Veteran timely appealed with a notice of disagreement (NOD) in November 2016. However, after an August 2017 statement of the case (SOC) that again denied the claim of increased ratings for PTSD, the Veteran did not timely file a VA Form 9 to appeal the decision.

The Board notes that the current appeal period for the issue of increased ratings for PTSD with substance abuse begins on November 15, 2018, the date VA received the Veteran's claim that led to the January 2019 rating decision currently at issue, plus a one-year look-back period. Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010). The 70 percent evaluation for PTSD with substance abuse applies to the entire period currently on appeal.

DC 9411 provides that an acquired psychiatric disorder should be evaluated pursuant to the General Rating Formula for Mental Disorders (General Formula). 38 C.F.R. § 4.130. Under the General Formula, a 70 percent evaluation is warranted where there is 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; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id.

A 100 percent evaluation is warranted where 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 or place; or memory loss for names of close relatives, own occupation, or own name. Id.

As the United States Court of Appeals for the Federal Circuit explained, evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed.Cir.2013). The symptoms listed are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms[,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas" - i.e., "the regulation... requires an ultimate factual conclusion as to the Veteran's level of impairment in 'most areas.'" Vazquez-Claudio, 713 F.3d at 117-18; 38 C.F.R. § 4.130, DC 9413.

Furthermore, when evaluating a mental disorder, the Board must consider the "frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission," and must also "assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination." 38 C.F.R. § 4.126(a).

In Bankhead v. Shulkin, 29 Vet. App. 10 (2017), the Court held that the language of the general rating formula "indicates that the presence of suicidal ideation alone...may cause occupational and social impairment with deficiencies in most areas." However, as recognized by the Court, VA must engage in a holistic analysis in assessing the severity, frequency, and duration of the signs and symptoms of a veteran's service-connected psychiatric disability, and their resulting social and occupational impairment.

In a January 2019 statement, a friend of the Veteran, DC, stated that he had known the Veteran for 10 years, and the Veteran had been a guest
38 C.F.R. § 4.126(a).

In a January 2019 statement, a friend of the Veteran, DC, stated that he had known the Veteran for 10 years, and the Veteran had been a guest in his home for BBQs and beers numerous times. DC recalled that, one night after a few beers, the Veteran became very agitated, acting very strange. He became paranoid and wanted to fight. DC stated that, when the Veteran was agitated, it seemed like he went back in time, perhaps with a flashback from Vietnam. The Veteran yelled, "Get the fuck away from me". DC and his wife eventually calmed him down. He laid on the couch, and in time, he fell asleep. DC noticed that the Veteran's breathing became very shallow; and at times, DC could not tell if he was breathing at all. DC stayed up all night monitoring the Veteran's breathing. When the Veteran awoke in the morning, he did not remember anything. DC said the incident was very disturbing. DC stated that, for the most part, the Veteran is a very kind, giving person, but there is something very disturbing "pinned up in his conscience".

In an October 2021 statement, the Veteran stated that, between October 1, 2018, and May 13, 2019, due to his PTSD, he could not deal with people, and he could not leave the house. He was constantly depressed, and this caused him to lose a massive amount of weight. His conditions continued to worsen to where he was physically not able to function, and he was not able to work. He lacked energy and had constant depression. He stated that his conditions continue to worsen, and he will never be able to work again in his life.

At the January 2022 Board hearing, the Veteran reported that he experiences anxiety attacks and gets very little sleep. He stated that he used to do a lot of drinking, but he stopped drinking because of his cancer. He described an incident where he was at a friend's house when he stopped breathing, and they stayed up with him all night. He stated that he stays away from people because he does not trust them. He stated that he has seen what people really are in an uncontrolled environment, such as a war. He stated that this is what set him off because he saw the true nature of people come out. He stated that he feels safer at home.

The Veteran stated that, if he went out with other people, he would experience anxiety attacks frequently. If he was by himself and he did not have to deal with people, he could pretty much control what he thinks. He stated that he does not go to the grocery store or drug store, and he has his groceries delivered. The only time he leaves the house is when he has to go to the doctor for treatment or surgery. Other than that, he does not go anywhere, and he does not want to go anywhere.

The Veteran further stated that he had one friend that he talked to every morning over the phone, but he did not have other friends. He noted that he does not socialize with his friend in person, and his friend was a Vietnam veteran. The Veteran had four children and 10 or 12 grandchildren, but he did not talk to any of them. He stated that, when he came back from active service, he was attacked by his own family (particularly aunts and uncles) who were "not pro-American". He noted that his grandfather served in World War I, and his father served in World War II; and he felt it was his duty to serve.

Additionally, the Veteran stated that, when he is home alone during the day, he does not shower or take care of his personal needs. He stated that, when he showers, it lowers his body temperature, and he ends up sneezing all the time. He also does not get dressed or put on clean clothes every day. He noted that he was wearing the same clothes he had on for a week. He stated that nobody comes to see him, so he can do what he wants.

At a December 2018 VA examination, the VA examiner diagnosed the Veteran with PTSD and alcohol use disorder in sustained remission. The VA examiner that the Veteran's symptoms attributable to PTSD included chronic sleep disturbance, nightmares, agitation, short temper, intrusive memories of trauma exposure, avoidance of triggers related to memories of trauma, flashbacks, persistent negative beliefs about himself, others or the world, self-blame, negative emotional state, diminished interest, panic attacks, hypervigilance, exaggerated startle response, poor concentration with related memory problems, estrangement, and anxiety. The symptoms attributable to alcohol use disorder (in sustained remission) included prior excessive use of alcohol despite negative consequences with more than one year sobriety. The Veteran had previously used alcohol to avoid memories of trauma and to manage anxiety and depression related to these memories. The VA examiner found that, due to the Veteran's PTSD, he had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood.

The VA examiner found symptoms of depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, mild memory loss (such as forgetting names, directions or recent events), impairment of short and long term memory (for example, retention of only highly learned material, while forgetting to complete tasks), flattened affect, disturbances of motivation and mood, inability to establish and maintain effective relationships, suicidal ideation, and impaired impulse control (such as unprovoked irritability with periods of violence).

The VA examiner observed that the Veteran's dress was appropriate, but his clothes were somewhat unclean. He was deemed to be a reliable informant due to clear cognition, non-defensive response to questions, and a report of information without evidence of manipulation or exaggeration. His thought process was logical and goal-directed, and he was able to track the conversation during the interview and provide a coherent history. His judgment and insight were intact, and his speech pattern was within normal limits. He was able to make and maintain good eye contact. His mood was anxious, and his affect was agitated; and he became more agitated and tearful when discussing his trauma exposure history. He expressed passive suicidal ideation. There was no evidence of homicidal ideation or audio or visual hallucinations, and there was no evidence of a thought disorder. He was capable of managing his financial affairs.

The Veteran reported that he was not sleeping at all except right after taking Hydrocodone. He had gone through cancer treatments since his last review, including surgeries on his bladder and prostate; and he continued to have pain associated with the surgeries. The Veteran reported having combat-related nightmares whenever he had a bad day with intrusive memoires. He would wake up feeling as if he was in Vietnam and was trying to get home. He described a recent nightmare where he was trying to get a pilot out of a burning plane in 1975. The Veteran's short-term memory was "really bad", but his long-term memory was good. He reported having intrusive memories of Vietnam when he smelled certain things or heard things. He was jumpy and vigilant, and he had panic attacks on a weekly basis. He did not trust people in general, and he felt better off without them. He felt depressed every day. The Veteran stated that, after the prostate surgery, he felt that he had been "half a man". He was taking Viagra to improve erectile functioning, and he could not be sexually active as frequently as in the past. His appetite was good, and he had more energy since having the prostate removal. At the time of the December 2018 VA examination, the Veteran had not been in mental health treatment since 2013, and he was not taking medication for sleep or mood. He stated that he attempted suicide over 30 years ago, and he recalled how he affected too many people. He did not have a plan to attempt suicide again. The December 2018 VA examiner found that the Veteran did not appear to pose a threat of danger or injury to himself or others.

The Veteran had a history of alcohol dependence. He reported abstinence for one or two years. He described an incident where he tried a shot of alcohol and was frightened because he stopped breathing for a while. He stopped drinking and did not miss it.

In a March 2019 VA Mental Health Initial Evaluation Note, the Veteran stated that he did not feel he could trust people, and he did not want to be around people. He stated that he had only one friend whom he could call and not feel like he was being judged. He reported that he lived alone, and he did not communicate with his kids because they did not understand him. He also stated that he felt he did wrong by going to Vietnam because he felt that he was looked down for loving his country. He reported that he stopped drinking a year and a half ago because he once stopped breathing when drinking and taking hydrocodone, and he felt embarrassed that his friend had to take care of him. He reported he still had cravings. Related to his PTSD, he still felt hypervigilance and an inability to trust people. He was unable to quantify how often nightmares, flashbacks, and intrusive memories bothered him. He reported that he would become anxious at times for no reason. He stated that, since he quit drinking, he no longer felt worthless. He denied having hallucinations or current suicidal or homicidal thoughts. The Veteran acknowledged that suicide would not fix anything.

The examiner observed that the Veteran was alert, attentive, cooperative, reasonable, and somewhat guarded. The Veteran's speech was slow with increased latency of response, but his language was intact. His mood was euthymic; and his affect was blunted, restricted, and constricted. There was no perceptual disturbance; and his thought process was linear, goal-directed, and logical. He had some impaired remote memory, but his insight and judgment were good.

At a May 2019 VA examination, the VA examiner diagnosed the Veteran with PTSD and alcohol use disorder. The Veteran's PTSD was characterized by exposure to a traumatic event, intrusive dreams and memories related to the trauma, avoidance of reminders symbolic of the trauma, and heightened arousal. His alcohol use disorder was characterized by the maladaptive use of alcohol which impacted important areas of life functioning. The alcohol use disorder was secondary to the PTSD and served as a form of self-medication. The Veteran had been reportedly sober for three or four years, but he had recently relapsed. The VA examiner found that the Veteran had occupational and social impairment with reduced reliability and productivity. At the time of the May 2019 VA examination, he was not receiving mental health treatment.

The VA examiner found that the Veteran had symptoms of depressed mood, anxiety, suspiciousness, panic attacks that occurred weekly or less often, chronic sleep impairment, mild memory loss (such as forgetting names, directions or recent events), impairment of short and long term memory (for example, retention of only highly learned material, while forgetting to complete tasks), flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, inability to establish and maintain effective relationships, suicidal ideation, impaired
years, but he had recently relapsed. The VA examiner found that the Veteran had occupational and social impairment with reduced reliability and productivity. At the time of the May 2019 VA examination, he was not receiving mental health treatment.

The VA examiner found that the Veteran had symptoms of depressed mood, anxiety, suspiciousness, panic attacks that occurred weekly or less often, chronic sleep impairment, mild memory loss (such as forgetting names, directions or recent events), impairment of short and long term memory (for example, retention of only highly learned material, while forgetting to complete tasks), flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, inability to establish and maintain effective relationships, suicidal ideation, impaired impulse control (such as unprovoked irritability with periods of violence), and neglect of personal appearance and hygiene.

The VA examiner observed that the Veteran's grooming and hygiene were poor. His motor activity was calm, and he maintained eye contact throughout the interview. His speech was unimpaired. He reported that he had impairment in his long- and short-term memory. His mood was anxious, and his affect was congruent. He was oriented; and there were no perceptual, thought process or thought content issues. He reported that he had past suicidal ideation, but he denied current intent. He denied any homicidal ideation. The May 2019 VA examiner found that the Veteran did not appear to pose a threat of danger or injury to himself or others.

The Veteran reported that he had a positive relationship with his parents and siblings. He had been married four times, but he was separated at the time of this examination. He had four children. His relationship with one of his children was positive, but he was distant with the others.

The Veteran reported that, after discharge from active service, he was more wary of other people, and he felt others were selfish and self-centered. The Veteran that he retired from work as a mechanic in 2011, and he stopped working due to too much stress, as well as due to his alcohol abuse. The Veteran stated that he had been self employed as a mechanic for much of his life. He stated that he had always worked by himself due to his inability to get along with others and work in a cooperative manner. He was impulsive and had a history of unprovoked irritability with periods of violence. His alcohol abuse and his mood instability (due to his PTSD) impacted his reliability, productivity and ability to function in the workplace. He lacked motivation and was excessively anxious when in public. He had episodes where he had panic attacks that impeded his ability to function occupationally and socially.

In a November 2020 private psychological evaluation, the Veteran reported that, following his discharge from the military, he began working as a long-haul trucker. He was drinking heavily and away from home for 13 weeks at a time. His drinking and isolated type career path created havoc within his marriage and family. He subsequently divorced and remarried several times. He had strained relationships with his four children, and he was in contact with only one of his children. He reported that he had attempted suicide on three occasions because of his self-described survivor's guilt.

The Veteran last worked in 2012 when he was self-employed as a mechanic. He had a small storefront business, but he was unable to continue because he could not interact with the public and sustain his business. He reported that his alcohol abuse continued until four or five years ago.

The Veteran stated that he tried to obtain treatment from VA for his psychological problems and substance abuse. However, his suspiciousness and guarded behavior resulted in poor outcomes. On one occasion, he terminated treatment with a VA psychiatrist when the doctor began inquiring about his possession of weapons. At the time of the November 2020 psychological evaluation, the Veteran was not in any form of mental health treatment. He expressed helplessness and hopelessness because he believed he had limited time left on earth. He spent time at home with his two dogs, which he believed protected him from undisclosed dangers. He lived alone in his own home in California. He was reportedly self-sufficient, and he cared for his own needs. He had only one friend, and he was estranged from family.

The private examiner found that the Veteran was adequately groomed and dressed appropriately, and he appeared his chronological age. He was generally cooperative, but he was obviously irritable and suspicious of the interview. His mental status was generally uncompromised. He was alert, well oriented, logical, coherent, and able to coherently communicate his needs despite his hearing difficulties, which made communication difficult at times. He did not report any psychotic experiences, and he did not report any present suicidal ideation. However, the examiner opined that the Veteran's present nihilistic thinking and lack of optimism for the future suggested a continued suicide risk. The Veteran slept poorly and experienced nightmares and intrusive memories on a regular basis. Counting and calculations were slow. The Veteran's attention and concentration and short- and long-term memory were mildly impaired. His mood was poor, and he was socially isolated and anhedonic. He denied current problems with alcohol. His intelligence appeared to be within the average range. The private examiner stated that the Veteran's insight and judgment were impaired, as evidence by his failed relationships and inability to interact with others.

The Veteran had a depressed mood nearly every day, and he had markedly diminished interest or pleasure in all or most all activities. He had a decrease in appetite, daily insomnia, slowed activity, loss of energy, feelings of worthlessness or inappropriate guilt, and impaired concentration, as well as recurrent thoughts of death or suicidal ideation.

The Veteran stated that he was unable to work as early as 2012 when he lost his career as a self-employed mechanic. The private examiner observed that the medical records detailed the collapse of four marriages and three suicidal attempts during the 1980s while the Veteran abused alcohol to self-treat his psychological disorder.

The private examiner opined that the Veteran's PTSD and depression were totally affecting his ability to function in any competitive situation. The private examiner found that the Veteran demonstrated occupational and social impairment with deficiencies in most area, such as work (attention, concentration), social relations, and enjoyment of life. The private examiner stated that these psychological difficulties were solely responsible for the Veteran's difficulties in performing occupational duties.

The private examiner found that the Veteran had deficiencies in family relations, deficiencies in mood, persistent irrational fears, difficulty in adapting to stressful circumstances, intrusive recollections of a traumatic experience, grossly inappropriate behavior, persistent danger of hurting self and others, deficiencies in work or school, gross impairment in thought processes or communication, difficulty in adapting to stressful circumstances, unprovoked hostility and irritability, inability to establish and maintain effective relationships, deficiencies in judgment, suicidal ideation, and depression affecting ability to function independently, appropriately, or effectively.

The private examiner further found that the Veteran had markedly limited ability to remember locations and work-like procedures, maintain attention and concentration for extended periods, perform activities within a schedule, maintain regular attendance, be punctual within customary tolerance, sustain ordinary routine without supervision, work in coordination with or proximity to others without being distracted by them, complete a normal work week without interruptions from psychologically based symptoms, perform at a consistent pace without an unreasonable number and length of rest periods, interact appropriately with the general public, accept instructions and respond appropriately to criticism from supervisors, get along with coworkers or peers without distracting them or exhibiting behavioral extremes, maintain socially appropriate behavior and adhere to basic standards of neatness and cleanliness, respond appropriately to changes in the work setting, be aware of normal hazards and take appropriate precautions, or set realistic goals or make plans independently. He also had moderately limited ability to travel to unfamiliar places or use public transportation.

Considering the evidence of record described above, the Board finds that the symptoms associated with the Veteran's PTSD with substance abuse have more closely paralleled the type of symptoms described in the criteria for the currently assigned 70 percent disability rating. The Veteran exhibited no worse than occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, impairment of short- and long-term memory (for example, retention of only highly learned material, while forgetting to complete tasks), flattened affect, difficulty in adapting to stressful circumstances (including work or a work-like setting), inability to establish and maintain effective relationships, suicidal ideation, impaired impulse control (such as unprovoked irritability with periods of violence), and neglect of personal appearance and hygiene. See 38 C.F.R. § 4.130, DC 9411.

A higher rating of 100 percent is not warranted, as the Veteran's acquired psychiatric disorder did not result in total occupational and social impairment due to symptoms such as persistent delusions or hallucinations; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene
of short- and long-term memory (for example, retention of only highly learned material, while forgetting to complete tasks), flattened affect, difficulty in adapting to stressful circumstances (including work or a work-like setting), inability to establish and maintain effective relationships, suicidal ideation, impaired impulse control (such as unprovoked irritability with periods of violence), and neglect of personal appearance and hygiene. See 38 C.F.R. § 4.130, DC 9411.

The Board acknowledges that the November 2020 private psychological evaluation found that the Veteran exhibited gross impairment in thought processes or communication, grossly inappropriate behavior, and persistent danger of hurting self or others, which are listed under the criteria for a 100 percent disability rating for mental disorders. Id. However, the Veteran still does not exhibit a majority of the symptoms or types of symptoms that would warrant a 100 percent disability rating for PTSD. The Board also notes that, although the Veteran has exhibited passive suicidal ideation, he has not had a suicide attempt since the 1980s; and he has not demonstrated an active plan or intent to commit suicide during the period on appeal since November 15, 2018. The December 2018 and May 2019 VA examiners found that the Veteran did not appear to pose a threat of danger or injury to himself or others.

Additionally, the Veteran's psychiatric examiners other than the September 2020 private examiner have found the Veteran to be alert, attentive, cooperative, and reasonable. They also found that the Veteran's thought process was linear, logical, and goal-directed; and there was no evidence of a thought disorder. There were no perceptual or thought content issues. His judgment, insight, speech, and language were found to be intact. This evidence is inconsistent with the September 2020 private examiner's findings of gross impairment of thought process or communication.

Thus, based on the above, the weight of the probative evidence is against the assignment of an evaluation in excess of the currently assigned 70 percent for the Veteran's service-connected PTSD with substance abuse.

The Board acknowledges the Veteran's assertions that his PTSD with substance abuse is of a sufficient severity so as to warrant a higher disability rating. However, the competent medical evidence offering specific determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal. Thus, the Veteran's own assessment as to the severity of the symptoms and their relationship to the rating criteria are less probative than the opinions of medical practitioners who have specialized knowledge and skill in excess of him. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Woehlaert v. Nicholson, 21 Vet. App. 456 (2007).

Moreover, the Board finds the report of the December 2018 and May 2019 VA examiners to be the more probative evidence of record concerning whether the Veteran's PTSD with substance abuse is severe enough to warrant a higher disability rating. The VA examiners' rationales are logical and well-reasoned and based on consideration of the Veteran's claims file, medical records, and post-service history. Thus, the Board is satisfied that the December 2018 and May 2019 VA examiners' opinions are competent, credible, persuasive, and probative for deciding this appeal.

The Board has also considered whether staged ratings under Hart, supra, are appropriate for the Veteran's acquired psychiatric disorder; however, the Board finds that, his symptomatology was stable throughout the appeal period for purposes of increased ratings for psychiatric disorders under VA regulations. Therefore, assigning staged ratings is not warranted in this case.

The weight of the probative evidence is against the assignment of an evaluation in excess of 70 percent for the Veteran's PTSD with substance abuse. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the weight of the probative evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990).

II. TDIU

The Veteran contends that he is entitled to a TDIU for the period prior to May
probative evidence is against the assignment of an evaluation in excess of 70 percent for the Veteran's PTSD with substance abuse. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the weight of the probative evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990).

II. TDIU

The Veteran contends that he is entitled to a TDIU for the period prior to May 13, 2019. The Veteran was granted a TDIU in an August 2019 rating decision with an effective date of May 13, 2019. The RO awarded an effective date of May 13, 2019, because that was the date the Veteran submitted his VA Form 21-8940 Veteran's Application for Increased Compensation Based on Unemployability (TDIU Application).

A TDIU may be assigned, where the schedular rating is less than total, when a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability, such disability shall be ratable as 60 percent or more, and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). A claim for a TDIU may be raised as a separate claim, or it may be raised in the context of an initial rating or a claim for an increase. See Rice v. Shinseki, 22 Vet. App. 447, 452-53 (2009).

Unlike the regular disability rating schedule, which is based on the average work-related impairment caused by a disability, "entitlement to a TDIU is based on an individual's particular circumstances." Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). Therefore, when adjudicating a TDIU claim, VA must take into account the individual veteran's education, training, and work history. Hatlestad v. Derwinski, 1 Vet. App. 164 (1991) (level of education is a factor in deciding employability); Friscia v. Brown, 7 Vet. App. 294 (1994) (considering Veteran's experience as a pilot, his training in business administration and computer programming, and his history of obtaining and losing 19 jobs in the previous 18 years); Beaty v. Brown, 6 Vet. App. 532 (1994) (considering Veteran's 8th grade education and sole occupation as a farmer); Moore v. Derwinski, 1 Vet. App. 356 (1991) (considering Veteran's master's degree in education and his part-time work as a tutor).

Age may not be considered as a factor when evaluating unemployability or intercurrent disability, and it may not be used as a basis for a TDIU. 38 C.F.R. § 4.19. There must be a determination that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age or a non-service-connected disability. 38 C.F.R. §§ 3.340, 3.341, 4.16. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question, however, is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993).

In Ray v. Wilkie, 31 Vet. App. 58 (2019), the United States Court of Appeals for Veterans Claims (Court) held that the initial extra-schedular referral decision under § 4.16(b) should address whether there is "sufficient evidence to substantiate a reasonable possibility that a veteran is unemployable by reason of his or her service-connected disabilities". Moreover, the Court defined the term "unable to secure and follow a substantially gainful occupation" in § 4.16(b) to include 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
Wilkie, 31 Vet. App. 58 (2019), the United States Court of Appeals for Veterans Claims (Court) held that the initial extra-schedular referral decision under § 4.16(b) should address whether there is "sufficient evidence to substantiate a reasonable possibility that a veteran is unemployable by reason of his or her service-connected disabilities". Moreover, the Court defined the term "unable to secure and follow a substantially gainful occupation" in § 4.16(b) to include 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 the 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.

The Veteran's claim of entitlement to a TDIU arose during his claims of increased ratings for the other issues in this decision, including the Veteran's PTSD with substance abuse, ED, and bladder cancer to include residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer). The RO issued the rating decision proposing the reduced evaluation for bladder cancer, to include residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer) on February 19, 2018. Therefore, the relevant period on appeal goes back to that date.

The Board notes that, as discussed in the earlier sections, prior to February 2018, on August 21, 2017, the RO issued a rating decision granting service connection for prostate cancer and a statement of the case (SOC) denying service connection for bladder cancer and increased ratings for PTSD. The Veteran did not timely appeal those decisions. The rating decision proposing a reduced evaluation for bladder cancer, to include residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer) was issued over a year later.

As noted in the earlier section, the Veteran has a combined evaluation of 100 percent for the period on appeal prior to October 1, 2018. Thus, the issue of entitlement to a TDIU is moot for that period. Also, as mentioned above, the Veteran was granted a TDIU for the period beginning May 13, 2019. Thus, the Board will focus on whether the Veteran was entitled to a TDIU during the period on appeal between October 1, 2018, and May 13, 2019.

For the relevant period on appeal between October 1, 2018, and May 13, 2019, service connection has been established for PTSD with substance abuse, bilateral hearing loss, tinnitus, a tremor disorder, ED, and bladder cancer, to include residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer).

During the relevant period, the Veteran's PTSD is rated at 70 percent disabling for the entire period on appeal. The Veteran's bilateral hearing loss is rated at 20 percent disabling for the entire period on appeal; and his tinnitus is rated at 10 percent disabling for the entire period on appeal. The Veteran's tremor disorder is rated at 10 percent disabling for the entire period on appeal, and his ED is rated as noncompensable (0 percent disabling) for the entire period on appeal. The Veteran's bladder cancer, to include residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer), is rated at 10 percent disabling for the period between October 1, 2018, and December 10, 2019.

For the relevant period on appeal between October 1, 2018, and May 13, 2019, the Veteran has a combined disability evaluation of 80 percent. Thus, for the relevant period, the Veteran meets the schedular threshold for consideration of a TDIU.

The Veteran submitted a VA Form 21-8940 Veteran's Application for Increased Compensation Based on Unemployability (TDIU Application) on May 13, 2019. In the TDIU Application, the Veteran stated that his PTSD, hearing loss, tinnitus, tremor disorder, and prostate cancer (and voiding dysfunction) prevented him from securing or following any substantially gainful occupation. He reported that his disability affected his full-time employment on June 19, 2011. He last worked full time on November 13, 2012, and he became too disabled to work on that date. The most he had earned in one year was $70,000.00 in 2010 when he worked as an automotive mechanic.

The
VA Form 21-8940 Veteran's Application for Increased Compensation Based on Unemployability (TDIU Application) on May 13, 2019. In the TDIU Application, the Veteran stated that his PTSD, hearing loss, tinnitus, tremor disorder, and prostate cancer (and voiding dysfunction) prevented him from securing or following any substantially gainful occupation. He reported that his disability affected his full-time employment on June 19, 2011. He last worked full time on November 13, 2012, and he became too disabled to work on that date. The most he had earned in one year was $70,000.00 in 2010 when he worked as an automotive mechanic.

The Veteran reported that he worked for an automotive mechanic from November 13, 2006, to November 13, 2012, for 50 hours a week. His highest gross earnings per month in that position was $7,000.00. He stated that he left his last job because of his disability. He had not tried to obtain employment since he became too disabled to work. The Veteran further reported that he had completed one year of high school. He had no other education or training before or since he became too disabled to work.

At the January 2022 Board hearing, the Veteran reported that he stopped working in January 2012, and he was working as a mechanic at the time. He had worked as a mechanic for 40 years. He worked by himself and did not have any employees. He stated he did not have to deal with anybody. He also noted that he left school in ninth grade, and he got his GED. He also attended MO-Tech in 1979. The Veteran stated that, because of his service-connected disorders, he cannot go back to work. He had been making $88.00 an hour. Now, for example, his tremor disorder caused his hands to shake and made it difficult to use a wrench on a bolt or use a screwdriver, and this was frustrating and upsetting for him.

The Veteran also stated that he had difficulty dealing with people. When he was working as a mechanic, people would come in, and he would tell his customers to fill out the paperwork with a description of what is wrong. He would then leave the office, so he did not really have to deal with them. Then he would come back and ask them to leave the keys on the table so he could pick up the vehicle. Then he would wait until they had a ride home, and when they did, he would get the vehicle and do his work. He stated that, once it becomes hard to do your job, no amount of money is worth it because you are frustrated. At the Board hearing, which was done over a video call, the Veteran's representative observed that the Veteran's screen had been shaking throughout the hearing, and the Veteran stated that this was because his hands were on the little table the screen was sitting on.

At a March 2011 VA examination for PTSD, the Veteran reported that, since leaving service, he had worked as a mechanic for 40 years. In a July 2012 VA Psychology Outpatient Note, the Veteran reported that he drove a truck for many years, and then he ran his own racing car crew. At a January 2013 VA examination for PTSD, the Veteran reported that he dropped out of school after nine years, and he enlisted in the army at age 17. He worked as a mechanic and a truck driver; and at the time of this examination, he worked buying and selling things. At a December 2018 VA examination for PTSD, the Veteran stated that he had not worked since 2011 when he worked at a mechanic at his own shop, which he had done for 19 years. He felt that he had to stop working due to his intolerance of people.

In a March 2017 private Urology Clinic Note, the Veteran reported that he worked as an auto mechanic for over 50 years, and he retired six years ago at age 61. He stated that he was self-employed in the last part of his career. He had also been doing minor automotive repairs that did not require engine or transmission overhauls.

At a May 2019 VA examination for PTSD, the Veteran reported that he dropped out of high school in ninth grade, and he was an average student. He noted that he worked in high school as a paperboy. He enlisted in the Army and served for 13 years; and during his military service, he worked as a carpenter. After discharge from active service, he worked as a mechanic. He also returned to school and participated in a 50-week mechanics course. He retired in 2011. He stated that he stopped working due to his alcohol abuse and too much stress.

In a September 2020
his career. He had also been doing minor automotive repairs that did not require engine or transmission overhauls.

In a September 2020 private psychological evaluation, the Veteran reported that he last worked in 2012 when he was self-employed as a mechanic. He had a small storefront business, but he was unable to continue, as he could not interact with the public and sustain his business.

Regarding the Veteran's PTSD, in an October 2021 statement, the Veteran stated that, between October 1, 2018, and May 13, 2019, due to his PTSD, he could not deal with people, and he could not leave the house. He was constantly depressed, and this caused him to lose a massive amount of weight. His conditions continued to worsen to where he was physically not able to function, and he was not able to work. He lacked energy and had constant depression. He stated that his conditions had continued to worsen, and he would never be able to work again in his life.

At a December 2018 VA examination, the VA examiner diagnosed the Veteran with PTSD and alcohol disorder in sustained remission; and the VA examiner found that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The VA examiner stated that the Veteran's symptoms attributable to PTSD included chronic sleep disturbance, nightmares, agitation, short temper, intrusive memories of trauma exposure, avoidance of triggers related to memories of trauma, flashbacks, persistent negative beliefs about himself, others or the world, self-blame, negative emotional state, diminished interest, panic attacks, hypervigilance, exaggerated startle response, poor concentration with related memory problems, estrangement, and anxiety. The symptoms attributable to alcohol use disorder (in sustained remission) included prior excessive use of alcohol despite negative consequences with more than one year sobriety.

At the time of the December 2018 VA examination, the Veteran had been in a relationship with a girlfriend for about three years, but he described the relationship as "not good" because he was more depressed. He was more socially withdrawn, and his self-esteem was diminished. The Veteran and his girlfriend were becoming distant due to the intimacy problems. He was not able to talk about it with her, and he did not want her to have to learn or understand his problems. He believed the relationship would not survive much longer. The Veteran was living by himself, and he stated that he felt secure in his own home. He kept his home secure with a security system, and he had a dog. He noted that another of his dogs died six or seven months ago, which made him cry. The Veteran reported there were no other friends or visitors to the house. He reported that he talks with a friend named Bob every day, and Bob was also a Vietnam veteran. The Veteran had sisters, but he had no contact with
The Veteran and his girlfriend were becoming distant due to the intimacy problems. He was not able to talk about it with her, and he did not want her to have to learn or understand his problems. He believed the relationship would not survive much longer. The Veteran was living by himself, and he stated that he felt secure in his own home. He kept his home secure with a security system, and he had a dog. He noted that another of his dogs died six or seven months ago, which made him cry. The Veteran reported there were no other friends or visitors to the house. He reported that he talks with a friend named Bob every day, and Bob was also a Vietnam veteran. The Veteran had sisters, but he had no contact with them since 1993 or 1994 when his mother passed away. He stated that he did not want or need people in his life. The Veteran also stated that he felt that he had to stop working due to his intolerance of people.

The Veteran reported that he was not sleeping at all except right after taking Hydrocodone. He reported having combat-related nightmares whenever he had a bad day with intrusive memories. He would wake up feeling as if he was in Vietnam and was trying to get home. He described a recent nightmare where he was trying to get a pilot out of a burning plane in 1975. The Veteran's short-term memory was "really bad", but his long-term memory was good. He reported having intrusive memories of Vietnam when he smelled certain things or heard things. He was jumpy and vigilant, and he had panic attacks on a weekly basis. He did not trust people in general, and he felt better off without them. He felt depressed every day. The Veteran stated that, after the prostate surgery, he felt that he had been "half a man". He was taking Viagra to improve erectile functioning, and he could not be sexually active as frequently as in the past. His appetite was good, and he had more energy since having the prostate removal. At the time of the December 2018 VA examination, the Veteran had not been in mental health treatment since 2013, and he was not taking medication for sleep or mood. He stated that, although he attempted suicide over 30 years ago, he did not have a plan to attempt suicide again. The VA examiner found that the Veteran did not appear to pose a threat of danger or injury to himself or others.

In a March 2019 VA Mental Health Initial Evaluation Note, the Veteran stated that he did not feel he could trust people, and he did not want to be around people. He stated that he had only one friend whom he could call and not feel like he was being judged. He reported that he lived alone, and he did not communicate with his kids because they did not understand him. He also stated that he felt he did wrong by going to Vietnam because he felt that he is looked down for loving his country. He reported that he stopped drinking a year and a half ago because he once stopped breathing when drinking and taking hydrocodone, and he felt embarrassed that his friend had to take care of him. He reported he still had cravings. Related to his PTSD, he still felt hypervigilance and an inability to trust people. He was unable to quantify how often nightmares, flashbacks, and intrusive memories bothered him. He reported that he would become anxious at times for no reason. He stated that, since he quit drinking, he no longer felt worthless. He denied having hallucinations or current suicidal or homicidal thoughts. The Veteran acknowledged that suicide would not fix anything.

At a May 2019 VA examination, the VA examiner diagnosed the Veteran with PTSD and alcohol use disorder, and the VA examiner stated that the Veteran had occupational and social impairment with reduced reliability and productivity. The Veteran's PTSD was characterized by exposure to a traumatic event, intrusive dreams and memories related to the trauma, avoidance of reminders symbolic of the trauma, and heightened arousal. His alcohol use disorder was characterized by the maladaptive use of alcohol which impacted important areas of life functioning. The alcohol use disorder was secondary to the PTSD and served as a form of self-medication. The Veteran was reportedly sober for
and his thought process was linear, goal-directed, and logical. He had some impaired remote memory, but his insight and judgment were good.

At a May 2019 VA examination, the VA examiner diagnosed the Veteran with PTSD and alcohol use disorder, and the VA examiner stated that the Veteran had occupational and social impairment with reduced reliability and productivity. The Veteran's PTSD was characterized by exposure to a traumatic event, intrusive dreams and memories related to the trauma, avoidance of reminders symbolic of the trauma, and heightened arousal. His alcohol use disorder was characterized by the maladaptive use of alcohol which impacted important areas of life functioning. The alcohol use disorder was secondary to the PTSD and served as a form of self-medication. The Veteran was reportedly sober for three or four years, but he had recently relapsed. At the time of the May 2019 VA examination, he was not receiving mental health treatment.

The VA examiner found that the Veteran had symptoms of depressed mood, anxiety, suspiciousness, panic attacks that occurred weekly or less often, chronic sleep impairment, mild memory loss (such as forgetting names, directions or recent events), impairment of short and long term memory (for example, retention of only highly learned material, while forgetting to complete tasks), flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, inability to establish and maintain effective relationships, suicidal ideation, impaired impulse control (such as unprovoked irritability with periods of violence), and neglect of personal appearance and hygiene.

The Veteran reported that, after discharge from active service, he was more wary of other people, and he felt others were selfish and self-centered. The Veteran stated that he retired from work as a mechanic in 2011, and he stopped working due to too much stress, as well as due to his alcohol abuse. The Veteran stated that he had been self employed as a mechanic for much of his life. He stated that he had always worked by himself due to his inability to get along with others and work in a cooperative manner. He was impulsive and had a history of unprovoked irritability with periods of violence. His alcohol abuse and his mood instability (due to his PTSD) impacted his reliability, productivity and ability to function in the workplace. He lacked motivation and was excessively anxious when in public. He had episodes where he had panic attacks that impeded his ability to function occupationally and socially.

Regarding the Veteran's bladder cancer, to include residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer), at a February 2018 VA examination for prostate conditions, the VA examiner reported that the Veteran had prostate cancer status-post prostatectomy. Treatment had been completed, and the Veteran was in watchful waiting status. The Veteran's voiding dysfunction caused increased urinary frequency with daytime voiding intervals between two to three hours; and it caused signs and symptoms of obstructed voiding with hesitancy. The VA examiner stated that the Veteran's prostate cancer impacted his ability to work due to easy fatigability.

In a March 2018 private treatment note, the Veteran's physician, Dr. S, stated that his incontinence was not quite as bad as it was, but it was still there. He got up once or twice a night, and he had cut down on fluids after 8:00 p.m. A CT scan shows no evidence of urinary abnormalities. Dr. S gave an assessment of urinary stress incontinence with mild to moderate stricture incontinence.

The Veteran's private treatment records from March 2017 through January 2019 report that the Veteran had bladder cancer that had been treated without evidence of recurrence. In an April 2018 private treatment note, Dr. S found that there might be a recurrence of small papillary lesions around the right ureteral orifice that were very suspicious for malignancy. However, Dr. S performed a blue light cystoscopy in May 2018,
still there. He got up once or twice a night, and he had cut down on fluids after 8:00 p.m. A CT scan shows no evidence of urinary abnormalities. Dr. S gave an assessment of urinary stress incontinence with mild to moderate stricture incontinence.

In a September 2019 VA Telehealth Note, the examiner gave an assessment of favorable intermediate risk prostate cancer that appeared to be cured by surgery. The examiner also noted that the Veteran had a history of bladder cancer with a need for yearly cystoscopies.

In a December 10, 2019, VA Primary Care Nursing Note, the Veteran reported that he got up at night three times to void. He denied pain, urgency, or frequency with urination.

Regarding the Veteran's ED, at a February 2018 VA examination for prostate conditions, the Veteran was found to have ED due to his prostate diagnosis. He was not able to achieve an erection sufficient for penetration and ejaculation without medication. He has not used medications to treat ED.

In an October 2018 VA Triage Note, the Veteran reported ED since his prostate surgery in April 2017. He stated that erectile function was minimal after his surgery and had remained frustrating at best. Function had all but disappeared. In other October 2018 VA medical treatment notes, the Veteran was told that ED was a known potential complication of a radical prostatectomy, and he was given Viagra.

Regarding the Veteran's hearing loss and tinnitus, at a May 2019 VA examination, the VA examiner diagnosed the Veteran with bilateral sensorineural hearing loss in the frequency range of 500 to 4000 Hz and in the frequency range of 600 Hz or higher. The Veteran's hearing loss impacted ordinary conditions of daily life, including the ability to work. The Veteran reported that he had difficulty understanding when people spoke to him. He had to face the person he was trying to listen to; and even then, he still sometimes had to ask the person to repeat themselves. Additionally, the Veteran reported that he had difficulty understanding people when they spoke to him over the telephone. The Veteran also reported recurrent tinnitus. He stated that the tinnitus was annoying, and it often interfered with his ability to get a restful night's sleep.

The VA examiner found that, in an employment setting, the Veteran would have difficulty understanding instructions being given to him unless the person giving him the instructions was facing him. Even if the person giving instructions was facing him, he would sometimes have difficulty understanding them, especially if there was background noise present.

In a June 2019 VA Primary Care Note, the Veteran was reported to have a diagnosis of normal to moderate-severely sensorineural hearing loss in the right ear and mild to severe sensorineural hearing loss in the left ear. The examiner offered to make an appointment for the Veteran to be fitted for hearing aids, but the Veteran declined.

Regarding the Veteran's essential tremor, at a June 2019 VA examination, the VA examiner diagnosed the Veteran with an essential tremor. The Veteran did not require continuous medication to control it, and there was no weakness in the upper or lower extremities. Gait, muscle strength, and reflexes were normal. Tremors in both hands were noted at rest and with writing, and a tremor in the right leg was also noted. The condition impacted the Veteran's ability to work in that he could not drive, operate machinery, type, write, or use tools. The VA examiner also noted that the Veteran could not lift more than one pound due to his essential tremor.

The Board has additionally reviewed the balance of the Veteran's other medical treatment records from the relevant period on appeal. The findings in the other medical treatment records are substantially similar to those noted in the medical examinations and treatment records described above.

Based on the evidence as described above, the Board finds that, for the period on appeal between October 1, 2018, and May 13, 2019, the evidence is in equipoise regarding whether the Veteran's service-connected disabilities, including his PTSD with substance abuse, bilateral hearing loss, tinnitus, a tremor disorder, ED, and bladder cancer, to include residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer), precluded him from securing or following substantially gainful employment. Considering the Veteran's
's other medical treatment records from the relevant period on appeal. The findings in the other medical treatment records are substantially similar to those noted in the medical examinations and treatment records described above.

Based on the evidence as described above, the Board finds that, for the period on appeal between October 1, 2018, and May 13, 2019, the evidence is in equipoise regarding whether the Veteran's service-connected disabilities, including his PTSD with substance abuse, bilateral hearing loss, tinnitus, a tremor disorder, ED, and bladder cancer, to include residuals, voiding dysfunction, status-post prostatectomy (previously evaluated as prostate cancer), precluded him from securing or following substantially gainful employment. Considering the Veteran's psychiatric and physical limitations, his education and background are not such that indicates that he would be able to secure and follow a substantially gainful occupation under the facts of this case. Therefore, resolving reasonable doubt in the Veteran's favor, the Board finds that entitlement to a TDIU is warranted for the period on appeal between October 1, 2018, and May 13, 2019. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990).

III. DEA

In an August 28, 2019, rating decision, the AOJ granted DEA from May 13, 2019, based on the Veteran's award of a TDIU effective May 13, 2019.

For the purposes of educational assistance under 38 U.S.C. Chapter 35, the child or surviving spouse of a veteran will have basic eligibility if the following conditions are met: (1) the veteran was discharged from service under conditions other than dishonorable, or died in service; and (2) the veteran has a permanent total service-connected disability; or (3) a permanent total service-connected disability was in existence at the date of the veteran's death; or (4) the veteran died as a result of a service-connected disability. 38 U.S.C. §§ 3501, 3510, 3512; 38 C.F.R. §§ 3.807(a), 21.3021.

In this case, the Veteran is entitled to an effective date of October 1, 2018, for the award of DEA benefits. As found in the previous section, the Veteran is entitled to an earlier effective date of October 1, 2018, for the grant of a TDIU.

DEA benefits may not be awarded prior to the effective date of an award for a permanent and total disability rating. 38 U.S.C. §§ 3501, 3510. Consequently, the Veteran is not entitled to an effective date earlier than October 1, 2018, for DEA benefits.

There is no reasonable doubt to be resolved as to this issue. 38 U.S.C. § 5107; 38 C.F.R. § 3.102, 4.3.

APRIL MADDOX

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Leung, Dawn

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.

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