Case A26036019

R. FEINBERG · 2026 · Case ID: A26036019

MIXED

Summary

The veteran, who served in the Army with multiple service periods including June 1990, January 1993, and June 1999, with additional Army National Guard service, appeals decisions regarding entitlement to a Total Disability based on Individual Unemployability (TDIU), Dependents' Educational Assistance (DEA), Special Monthly Compensation (SMC), and increased ratings for right knee conditions and a psychiatric disorder. The Board granted TDIU effective July 21, 2022, and basic eligibility for DEA effective the same date, finding the veteran's combined service-connected disabilities precluded substantially gainful employment. However, the Board denied entitlement to an earlier effective date for TDIU and DEA, as well as increased ratings for right knee extension limitation, subluxation, repaired meniscus, flexion limitation, and scars, and a higher rating for the psychiatric disorder. The Board found the evidence did not support the claimed higher ratings or earlier effective dates, concluding the veteran's symptoms, while severe, did not meet the criteria for total occupational and social impairment for the psychiatric disorder, nor did they meet the specific thresholds for higher knee ratings. The SMC claim was denied as the veteran did not meet the criteria for housebound status.

Service Branch

ARMY

Special Benefit

SMC - HOUSEBOUND; TDIU

Docket No.

250514-543486

Full Decision Text

Citation Nr: A26036019
Decision Date: 04/17/26 Archive Date: 04/17/26

DOCKET NO. 250514-543486
DATE: April 17, 2026

ORDER

Entitlement to an effective date earlier than July 21, 2022, for the grant of a total disability rating based on individual unemployability (TDIU) is denied.

Entitlement to a TDIU as of July 21, 2022, is granted.

Basic eligibility to Dependents' Educational Assistance (DEA) based on permanent and total disability status as of July 21, 2022, is granted.

Entitlement to an effective date earlier than October 23, 2023, for the grant of special monthly compensation (SMC) at the housebound rate is denied.

A rating of over 30 percent for right knee arthritis with impaired extension status post anterior cruciate ligament (ACL) tear (right knee extension limitation) as of October 23, 2023, is denied.

A rating of over 20 percent for right knee arthritis with subluxation status post ACL tear (right knee subluxation) as of October 23, 2023, is denied.

A rating of over 20 percent for right knee arthritis status post meniscal tear (right repaired meniscus) as of October 23, 2023, is denied.

A compensable rating for right knee arthritis with impaired flexion status post ACL tear (right knee flexion limitation) as of October 23, 2023, is denied.

A compensable rating for right knee lateral, anterior medial patella, and medial inferior scars (right knee scars) is denied.

A rating of over 70 percent for an adjustment disorder with mixed anxiety and depressed mood and insomnia disorder (psychiatric disorder) as of October 23, 2023, is denied.

FINDINGS OF FACT

1. A June 2022 rating decision granted service connection for multiple right knee disabilities effective March 25, 2021.

2. A February 2023 rating decision adjudicated the evaluations assigned for the Veteran's right knee disabilities and granted service connection for a psychiatric disorder effective July 21, 2022.

3. The Veteran did not continuously pursue appellate review of the evaluations assigned for the right knee disabilities within one year of notice of the February 2023 rating decision; accordingly, the February 2023 rating decision became final as to those evaluations.

4. No issue of entitlement to a TDIU remained pending from the March 2021 claim stream or from the finally adjudicated right knee evaluation issues addressed in the February 2023 rating decision.

5. VA received the Veteran's intent to file a claim on July 21, 2022, followed by an October 2022 VA Form 21-526EZ, Fully Developed Claim, listing a claim for service connection of a psychiatric disorder, among other issues, and he also submitted a statement describing how his service-connected disability picture affected his ability to work.

6. The record shows that entitlement to a TDIU was reasonably raised in connection with a pending claim stream for a psychiatric disorder, and that claim stream remained before VA until a TDIU was granted.

7. Prior to July 21, 2022, there was no pending claim, continuously pursued issue, or reasonably raised TDIU issue within the scope of this appeal that could support an earlier effective date for TDIU.

8. Resolving reasonable doubt in the Veteran's favor, from July 21, 2022, to October 22, 2023, his service-connected psychiatric disorder and right knee disabilities, considered together, precluded him from securing or following substantially gainful employment consistent with his education, training, and work history.

9. VA has determined that the Veteran's total disability was permanent for DEA purposes; as a TDIU was warranted as of July 21, 2022, basic eligibility for DEA arose on July 21, 2022.

10. Prior to October 23, 2023, the Veteran did not have a single service-connected disability rated as total or a TDIU based on a single disability; nor does the record show that he was factually housebound due to service-connected disability.

11. The weight of the evidence is against finding that the Veteran's right knee extension limitation more nearly approximated 30 degrees or more during the period on appeal.

12. The weight of the evidence is against finding that the Veteran's right knee subluxation more nearly approximated an unrepaired ACL or failed repair of an ACL tear during the period on appeal.

13. The Veteran's right repaired meniscus is rated as 20 percent disabling, which is the maximum schedular rating permitted for dislocation of semilunar cartilage.

14. The weight of the
service-connected disability rated as total or a TDIU based on a single disability; nor does the record show that he was factually housebound due to service-connected disability.

11. The weight of the evidence is against finding that the Veteran's right knee extension limitation more nearly approximated 30 degrees or more during the period on appeal.

12. The weight of the evidence is against finding that the Veteran's right knee subluxation more nearly approximated an unrepaired ACL or failed repair of an ACL tear during the period on appeal.

13. The Veteran's right repaired meniscus is rated as 20 percent disabling, which is the maximum schedular rating permitted for dislocation of semilunar cartilage.

14. The weight of the evidence is against finding that the Veteran's right knee flexion limitation more nearly approximated 45 degrees or less during the period on appeal.

15. The weight of the evidence is against finding that the Veteran's right knee scars more nearly approximated one or two painful or unstable scars, or scars involving an area of 144 square inches (929 sq. cm.) during the period on appeal.

16. The severity, frequency, and duration of the Veteran's psychiatric disorder symptoms did not more closely approximate total occupational and social impairment during the period on appeal.

CONCLUSIONS OF LAW

1. The criteria for an effective date prior to July 21, 2022, for the grant of a TDIU are not met. 38?U.S.C. §§?5107, 5110, 7105; 38?C.F.R. §§?3.400, 3.2500.

2. The criteria for a TDIU as of July 21, 2022, are met. 38?U.S.C. §§?1155, 5107; 38?C.F.R. §§?3.340, 3.341, 3.400, 4.15, 4.16, 4.19.

3. The criteria for basic eligibility for DEA as of July 21, 2022, are met. 38 U.S.C. §§ 3500, 3501; 38 C.F.R. §§ 3.807, 21.3021.

4. The criteria for an effective date earlier than October 23, 2023, for the award of SMC at the housebound rate are not met. 38 U.S.C. §§ 1114(s), 5107, 5110; 38 C.F.R. §§ 3.350(i), 3.352, 3.400.

5. The criteria for a rating of over 30 percent for right knee extension limitation as of October 23, 2023, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5261.

6. The criteria for a rating of over 20 percent for right knee subluxation as of October 23, 2023, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257.

7. The criteria for a rating of over 20 percent for a right repaired meniscus as of October 23, 2023, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5258.

8. The criteria for a compensable rating for right knee flexion limitation as of October 23, 2023, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5260.

9. The criteria for a compensable rating for right knee scars as of October 23, 2023, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.118, Diagnostic Codes 7802.

10. The criteria for a disability rating of over 70 percent for a psychiatric disorder as of October 23, 2023, are not met.
C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5260.

9. The criteria for a compensable rating for right knee scars as of October 23, 2023, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.118, Diagnostic Codes 7802.

10. The criteria for a disability rating of over 70 percent for a psychiatric disorder as of October 23, 2023, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9440.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from June 1990 to August 1990, January 1993, and June 1999, with additional service in the Army National Guard.

This case is before the Board of Veterans' Appeals (Board) on appeal from a September 2024 rating decision and a March 2025 Higher-Level Review (HLR) decision from a Department of Veterans Affairs (VA) agency of original jurisdiction (AOJ).

In May 2024, the Veteran submitted a VA 21-8940 Veterans Application for Increased Compensation Based on Unemployability, claiming unemployability secondary to his service-connected psychiatric disorder and right knee disabilities.

In September 2024, the AOJ issued the rating decision on appeal, which deferred the issue of entitlement to a TDIU and granted increased evaluations for the Veteran's service-connected psychiatric disorder and right knee disabilities effective October 23, 2023. A November 2024 rating decision denied entitlement to a TDIU.

In November 2024, the Veteran submitted a VA Form 20-0996, Decision Review Request: HLR, and requested review of a November 2024 decision. In March 2025, the AOJ issued the HLR decision on appeal, which considered the evidence of record at the time of the prior November 2024 decision, and granted entitlement to a TDIU, SMC based on housebound criteria being met, and DEA, effective October 23, 2023.

In May 2025, the Veteran elected the Direct Review docket on VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement) regarding the evaluations granted for his service-connected psychiatric disorder and right knee disabilities in the September 2024 rating decision and regarding the effective date granted for a TDIU, SMC, and DEA.

Therefore, the Board may only consider the evidence of record at the time of the September 2024 rating decision on appeal regarding entitlement to increased ratings for a psychiatric disorder and right knee disabilities and evidence of record at the time of the November 2024 decision regarding entitlement to effective dates earlier than October 23, 2023, for the award of a TDIU, SMC, and DEA. 38 C.F.R. § 20.301. The Board cannot consider any evidence submitted after the September 2024 and November 2024 rating decisions regarding their respective issues. 38 C.F.R. §§ 20.300, 20.301, 20.801.

During the pendency of the present Board appeal, the AOJ issued a July 2025 rating decision granting service connection for the Veteran's left knee disabilities effective March 25, 2021. That decision is not before the Board in the present Direct Review appeal. As discussed above, the Board's review is limited to the evidence of record at the time of the AOJ decisions on appeal. 38 C.F.R. § 20.301. Accordingly, the Board does not rely on the July 2025 rating decision to alter the disposition of the present appeal. The Board notes, however, that the July 2025 decision may bear on whether entitlement to a TDIU could be established from an earlier date in a separate review stream.

If the Veteran would like VA to consider any submitted evidence that the Board could not, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claims, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

Effective
to alter the disposition of the present appeal. The Board notes, however, that the July 2025 decision may bear on whether entitlement to a TDIU could be established from an earlier date in a separate review stream.

Effective Date

The Veteran argues that earlier effective dates are warranted for TDIU, SMC, and DEA because his service-connected knee and psychiatric disabilities prevented substantially gainful employment well before October 23, 2023.

A "claim" is a written or electronic communication requesting a determination of entitlement or evidencing a belief in entitlement to a specific benefit under the laws administered by VA submitted on an application form prescribed by the Secretary. 38 C.F.R. §§ 3.1(p), 3.155.

A claimant may continuously pursue a claim or an issue by timely and properly filing one of the following administrative review options after any decision by the AOJ, Board, or by the U.S. Court of Appeals for Veterans Claims (Court): (1) following notice of a decision on an initial claim or a supplemental claim; the claimant may file a supplemental claim, request a higher-level review, or appeal to the Board; (2) following notice of a decision on a higher-level review, the claimant may file a supplemental claim or appeal to the Board, (3) following notice of a decision on an appeal to the Board, the claimant may file a supplemental claim or file a notice of appeal to the Court, (4) following a decision on an appeal to the Court, the claimant may file a supplemental claim. 38?C.F.R. § 3.2500.

Generally, if no review option is filed within one year from the date of notice of an AOJ decision, that decision becomes final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103.

Typically, the effective date of an award of compensation will be the date VA received the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. For increased compensation, the effective date may be as early as the date it is factually ascertainable that an increase in disability occurred, if a complete claim or intent to file is received within one year from that date; otherwise, it is the date of claim. 38 C.F.R. § 3.400(o)(2).

A claimant may continuously pursue a claim or an issue by timely filing one of the available review options after an AOJ decision. 38 C.F.R. § 3.2500. In addition, when evidence of unemployability is submitted during the course of a claim for a higher rating, entitlement to TDIU is part and parcel of that rating claim. Rice v. Shinseki, 22 Vet. App. 447 (2009).

TDIU

1. Entitlement to a TDIU prior to July 21, 2022.

The Board finds that no effective date earlier than July 21, 2022, is legally available in this appeal.

The Veteran submitted an intent to file in March 2021, followed by a March 2022 claim seeking service connection for bilateral knee disabilities and other disorders. A June 2022 rating decision granted service connection for several right knee disabilities, effective March 25, 2021. On July 21, 2022, VA received another intent to file. In October 2022, the Veteran filed additional claims involving the right knee and psychiatric disorder, and he submitted a statement describing how his orthopedic limitations had affected his work history and employability. A February 2023 rating decision granted service connection for a psychiatric disorder at 50 percent effective July 21, 2022, and adjudicated the right knee evaluation issues.

The record demonstrates that the February 2023 rating decision is final regarding the evaluation of the right knee disabilities because it was not appealed by way of an NOD, higher-level review, or supplemental claim application within a year of the decision. 38?U.S.C. §?7105(a), (c); 38 C.F.R. § 20.1103.

In July 2023, the Veteran filed a claim for
disorder, and he submitted a statement describing how his orthopedic limitations had affected his work history and employability. A February 2023 rating decision granted service connection for a psychiatric disorder at 50 percent effective July 21, 2022, and adjudicated the right knee evaluation issues.

In July 2023, the Veteran filed a claim for service connection of a psychiatric disorder symptom. An October 2023 rating decision continued the 50 percent rating in consideration of the claimed symptom. In December 2023, the Veteran submitted a VA Form 20-0996, Decision Review Request: HLR, and requested review of the October 2023 decision. In April 2024, the AOJ issued the HLR decision, finding that an increased evaluation for the psychiatric disorder was not warranted. In May 2024, the Veteran filed VA Form 21-8940, Application for Increased Compensation Based on Unemployability, stating that he was unemployable due to his right knee disabilities and psychiatric disorder.

Accordingly, the Board finds the February 2023 rating decision remained open regarding the Veteran's psychiatric disorder, and that entitlement to a TDIU was reasonably raised in the July 21, 2022, claim stream through his psychiatric disorder claim, particularly considering his October 2022 statement describing the impact of his service-connected limitations on his work history and employability. The Board finds that TDIU was part and parcel of the pending compensation claims rather than a freestanding claim first arising with the formal VA Form 21-8940 received in May 2024. See Rice, 22 Vet. App. 447.

The Board acknowledges that a July 2025 rating decision issued after the AOJ decisions on appeal granted service connection for left knee disabilities effective March 25, 2021, and that this later grant could affect the effective date for a TDIU. However, the July 2025 rating decision is not before the Board in the present appeal. Moreover, because the Veteran elected the Direct Review docket, the Board's review is limited to the evidence of record at the time of the AOJ decisions on the issues on appeal. 38 C.F.R. § 20.301. Accordingly, the Board does not rely on the July 2025 rating decision to alter the disposition of the present Direct Review appeal, although that decision may be relevant in a separate review stream.

Accordingly, the earliest possible effective date for a TDIU in this appeal is July 21, 2022. As such, there is no basis to assign an effective date prior to July 21, 2022, for the grant of a TDIU. The claim is denied.

2. Entitlement to a TDIU from July 21, 2022, to October 22, 2023.

A review of the record demonstrates that a TDIU was warranted as of July 21, 2022.

A TDIU may be assigned when the schedular rating is less than total, and a veteran is unable to secure or follow a substantially gainful occupation due to service-connected disabilities. 38 C.F.R. § 4.16(a). To qualify for schedular consideration of a TDIU, if there is only one such disability, this disability shall be ratable at 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. Id.

The Veteran had the following service-connected disabilities at the time of the November 2024 rating decision: psychiatric disorder (50 percent from July 21, 2022, 70 percent from October 23, 2023); right knee extension limitation (20 percent from March 25, 2021, 10 percent from December 1, 2022, 30 percent from October 23, 2023); right knee subluxation (10 percent from March 25, 2021, 20 percent from December 1, 2022); right knee dislocated semilunar cartilage (10 percent from March 25, 2021, 20 percent from October 23, 2023); right knee scars (0 percent from July 21, 2022); right knee impaired flexion (10 percent from March 25,
July 21, 2022, 70 percent from October 23, 2023); right knee extension limitation (20 percent from March 25, 2021, 10 percent from December 1, 2022, 30 percent from October 23, 2023); right knee subluxation (10 percent from March 25, 2021, 20 percent from December 1, 2022); right knee dislocated semilunar cartilage (10 percent from March 25, 2021, 20 percent from October 23, 2023); right knee scars (0 percent from July 21, 2022); right knee impaired flexion (10 percent from March 25, 2021, 0 percent from June 23, 2022). The Veteran's combined rating during the evidentiary period was 40 percent from March 25, 2021, 70 percent from July 21, 2022, and 90 percent from October 23, 2023.

The percentage threshold for a schedular TDIU was met as of July 21, 2022, to October 22, 2023. See 38 C.F.R. § 4.25. Accordingly, the Board may consider the claim for a TDIU on a schedular basis. 38 C.F.R. § 4.16(a).

The record from July 21, 2022, through October 22, 2023, shows psychiatric disorder symptoms of anxiety, chronic sleep impairment, depressed mood, disturbances of motivation and mood, mild memory impairment, and occupational and social impairment with reduced reliability and productivity. The contemporaneous record during this period repeatedly framed the Veteran's work impairment as the product of combined orthopedic and psychiatric effects. In the October 2022 lay statement, the Veteran linked worsening anxiety and PTSD symptoms to repeated knee collapses and the fear of reinjury, while also detailing extensive physical limits caused by the knees themselves.

After resolving all reasonable doubt in favor of the Veteran, the Veteran's service-connected PTSD and right knee disabilities have precluded him from the ability to secure and follow a substantially gainful occupation consistent with his education, skills, training, and work history during the period he was statutorily eligible for a TDIU during the evidentiary period, July 21, 2022, to October 22, 2023. See 38 C.F.R. § 4.16(a). Accordingly, a TDIU is warranted.

DEA

Entitlement to DEA prior to October 23, 2023.

Eligibility for DEA under 38 U.S.C. Chapter 35 requires that the Veteran have a permanent and total service-connected disability. The AOJ has already determined that the Veteran's service-connected disabilities are permanent and totally disabling for DEA purposes in connection with the March 13, 2025, award of a TDIU.

Because the Board has granted a TDIU effective July 21, 2022, and the underlying total disability has been found permanent, basic eligibility for DEA is likewise established as of that date. The claim is granted.

SMC

Entitlement to SMC based on housebound status prior to October 23, 2023.

Under 38 U.S.C. § 1114(s), SMC is payable at the housebound rate if a veteran has a single service-connected disability rated as 100 percent and either of the following are met: (1) there is additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems; or (2) he or she is permanently housebound by reason of service-connected disability or disabilities. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i).

The requirement of "permanently housebound" will be considered to have been met when the veteran is substantially confined to his or her house (ward or clinical areas, if institutionalized) or immediate premises due to a service-connected disability or disabilities which it is reasonably certain will remain throughout his or her lifetime. Id.

In Bradley v. Peake, the Court held that if the evidence supports a finding of TDIU based solely upon a single service-connected disability, then such a TDIU rating may serve as the factual predicate for an award of SMC pursuant to 38 U.S.C. § 1114(s). Bradley v. Peake, 22 Vet. App. 280, 293 (2008).

The Veteran does not have a single service-connected disability rated at 100 percent, or a 100 percent rating based on TDIU for a single disability, prior to October
institutionalized) or immediate premises due to a service-connected disability or disabilities which it is reasonably certain will remain throughout his or her lifetime. Id.

The Veteran does not have a single service-connected disability rated at 100 percent, or a 100 percent rating based on TDIU for a single disability, prior to October 23, 2023. Thus, the criteria for SMC based on either statutory housebound status or housebound-in-fact are not met prior to October 23, 2023. See 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i).

Regardless, the weight of the competent and probative evidence is against finding that the Veteran is substantially confined to his home due to his service-connected disabilities prior to October 23, 2023. The October 2022 lay statement showed profound functional limits, but it also reflected that the Veteran attempted walking outside the home, went shopping, drove for short periods, and attended medical treatment. That evidence demonstrates severe impairment, not substantial confinement to the home and immediate premises required for a finding of housebound-in-fact. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i)(2).

Because the weight of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply, and entitlement to SMC(s) during the period on appeal before October 23, 2023, is not warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The claim is denied.

Increased Rating

Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations shall be applied, VA will assign the higher evaluation if the disability picture more nearly approximates the criteria required for that rating. Otherwise, it will assign the lower rating. 38 C.F.R. § 4.7. VA resolves any reasonable doubt regarding the degree of disability in favor of the Veteran. 38 C.F.R. § 4.3.

Where a claimant appeals the denial of a claim for an increased disability rating for a disability for which service connection was in effect before he filed the claim for increase, the present level of disability is the primary concern, and past medical reports should not be given precedence over current medical findings. Francisco v. Brown, 7?Vet. App.?55, 57-58 (1994). Nevertheless, where the evidence contains factual findings that show a change in the severity of symptoms during the rating period on appeal, the Board can assign different or "staged" ratings for such different periods. See Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007).

In evaluating a disability, the current examination reports are considered in light of the whole recorded history to ensure that the current rating accurately reflects the disorder's severity. The medical and industrial history are to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10.

The combined rating for disabilities of an extremity shall not exceed the rating for the amputation at the elective level, were amputation to be performed. For example, the combined evaluations for disabilities below the knee shall not exceed the 40 percent evaluation, diagnostic code 5165. This 40 percent rating may be further combined with evaluation for disabilities above the knee but not to exceed the above the knee amputation elective level. Painful neuroma of a stump after amputation shall be assigned the evaluation for the elective site of reamputation. 38 C.F.R. § 4.68.

When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria.").

Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011).

In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint."

In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves when a flare-up is not observable at the time of examination.

Veterans are competent to report observable symptoms in the realm of their personal knowledge. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). VA must give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed Cir. 2009).

The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C. § 5107(b). Under that provision, VA shall consider all information, including lay and medical evidence of record, in a case before the Secretary concerning benefits under laws the Secretary administers. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990).

The higher evaluation will be assigned when two disability evaluations are potentially applicable, and the disability picture more nearly approximates the criteria for the higher rating. 38?C.F.R. §?4.7. VA has an independent obligation to consider all potentially applicable provisions of law and regulation and apply the diagnostic criteria in a manner that maximizes benefits. Schafrath v. Derwinski, 1?Vet. App.?589 (1991); Bradley v. Peake, 22?Vet. App.?280 (2008).

1. A rating of over 30 percent for right knee extension limitation as of October 23, 2023
. 49, 57-58 (1990).

1. A rating of over 30 percent for right knee extension limitation as of October 23, 2023.

In October 2022 and July 2023 statements, the Veteran reported seeking a higher rating for right knee extension limitation because of pain with motion and severe functional limits with all activities.

The Veteran's right knee extension limitation is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5261, for limitation of extension of the leg. Under Diagnostic Code 5261, a noncompensable rating is warranted for extension limited to 5 degrees. A 10 percent rating is warranted for extension limited to 10 degrees. A 20 percent rating is warranted for extension limited to 15 degrees. A 30 percent rating is warranted for extension limited to 20 degrees. A 40 percent rating is warranted for extension limited to 30 degrees. A 50 percent rating is warranted for extension limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261.

In the December 2022 VA examination, the examiner diagnosed knee ACL tear, knee joint osteoarthritis, recurrent subluxation, and arthroscopy scars. The Veteran reported daily right knee pain, frequent catching and locking, instability on incline or decline, and the need to stop walking after about 15 minutes. He also reported experiencing severe flare-ups that lasted up to 24 hours, were characterized by sharp pain and range of motion limitation that severely restricts mobility, precipitated by overuse and cold weather, and alleviated by heating, cooling, resting, and activity modification.

Passive and active range of motion testing and testing after three repetitions during the December 2022 VA examination showed extension limited to 5 degrees. There was evidence of pain with extension, weight-bearing, and active and passive motion, but not non-weight-bearing, on rest, or non-movement. Pain caused functional loss and restricted squatting. The examiner opined that pain would significantly limit functional ability with repeated use over time to extension at 5 degrees. The examiner opined that pain would significantly limit functional ability with flare-ups to extension at 10 degrees. The examiner noted that the Veteran was prescribed a cane and brace for ambulation.

In the June 2024 VA examination, the examiner diagnosed right knee instability, post-traumatic arthritis, and status post meniscectomy. The Veteran reported chronic sharp and shooting pain, lack of stability, swelling, locking, clicking, stiffness, catching, grinding, hyperextension, and pain with extension. The Veteran reported constant use of a brace and a cane, and occasional use of crutches. He reported that severe flare-ups of the right knee occurred every 6 to 7 months, lasting a day to 4 weeks, precipitated by activity, and alleviated by rest, time, heat, ice, and medication.

Active and passive range of motion testing and testing after three repetitions during the June 2024 VA examination showed extension limited to 25 degrees. Pain was noted at 45 degrees of extension. The examiner noted pain with all movement and non-movement, and that it reduced the Veteran's extension. The examiner opined that pain, lack of endurance, and instability would result in further limitation after repeated use over time and, during flare-ups, would limit extension to 25 degrees.

The December 2022 and June 2024 VA examinations are adequate; further, they estimated functional loss during a flare-up as required by Sharp and satisfied the Correia testing requirements.

The Board finds that the evidence of record persuasively weighs against a rating of over 30 percent for right knee extension limitation. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain, particularly during flare-ups. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements of severe flare-ups would not result in limitation of motion more nearly approximating extension limited to 30 degrees.

During the period on appeal, the record shows, at worst, as opined by the June 2024 examiner, that extension
further, they estimated functional loss during a flare-up as required by Sharp and satisfied the Correia testing requirements.

During the period on appeal, the record shows, at worst, as opined by the June 2024 examiner, that extension would likely be limited to 25 degrees after repeated use over time and during flare-ups. That evidence supports the existing 30 percent evaluation, but it does not approach the 40 percent level, which requires limitation to 30 degrees. Even after considering pain, weakness, lack of endurance, and the Veteran's reports of severe flare-ups, no examiner estimated, and the record does not support a finding of extension limited to 30 degrees or more.

In conclusion, the Board finds that the evidence of record persuasively weighs against the Veteran's claim for a rating of over 30 percent for right knee extension limitation. As the evidence of record persuasively weighs against a rating of over 30 percent, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Lynch v. McDonough, 21 F.4th 776 (2021). The claim is denied.

2. A rating of over 20 percent for right knee subluxation as of October 23, 2023.

In October 2022 and July 2023 statements, the Veteran reported seeking a higher rating for right knee subluxation because of pain, instability, repeated episodes of giving way, weakness, stiffness, clicking, locking, swelling, tenderness, fatigue, frequent flare-ups, assistive device use, and severe functional limits with all activities and occasional falls.

The Veteran's right knee subluxation is currently rated 20 percent under 38 C.F.R. § 4.71a, Diagnostic Code 5257, for other impairment of the knee. Under Diagnostic Code 5257, a 10 percent rating is warranted for recurrent subluxation or instability, a 10 percent rating is warranted for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 20 percent rating is warranted for one of the following: (a) Sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation; or (b) Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A maximum 30 percent rating is warranted for unrepaired or failed repair of a complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation.

During the December 2022 VA examination, the Veteran reported symptoms of pain with frequent catching and locking, and that he cannot walk more than about 15 minutes because the knee is unstable and gives way.

The December 2022 VA examiner diagnosed recurrent subluxation and noted instability, brace use, and cane use prescribed by a physician. The examiner noted that the Veteran had frequent episodes of joint "locking" and pain, and that the Veteran's right knee condition limits his capacity to perform duties that require prolonged standing, prolonged walking, repeated or sustained squatting, running, or jumping.

The June 2024 VA examiner recorded constant brace and cane use and occasional crutch use prescribed by a physician. The June 2024 VA examiner clarified that an October 2022 MRI report found no subluxation and that nothing was found to explain the lack of stability, locking, or catching.

The December 2022 and June 2024 VA examinations are adequate because they are based on accurate medical history and provide explanations with clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008
Veteran's right knee condition limits his capacity to perform duties that require prolonged standing, prolonged walking, repeated or sustained squatting, running, or jumping.

The Board finds that the Veteran has significant right knee instability symptoms; however, those symptoms are fully contemplated by the 20 percent rating and do not warrant a 30 percent rating. The Board has carefully considered the Veteran's reports about subluxation. English, 30 Vet. App. 347, 352-53. However, overall, the lay and medical evidence does not persuasively establish an unrepaired or failed repair of a complete ligament tear as contemplated by the 30 percent rating. The December 2022 VA examiner expressly stated that the cause of the ACL tear could not be determined without speculation and presumed that the tear may have been partial and repaired. The June 2024 VA examination report clarifies that the October 2022 MRI did not support a subluxation diagnosis.

In conclusion, the Board finds that the evidence of record persuasively weighs against the Veteran's claim for a rating of over 20 percent for right knee subluxation. As the evidence of record persuasively weighs against a rating of over 20 percent, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); Lynch, 21 F.4th 776; 38 C.F.R. §§ 4.3, 4.7. The claim is denied.

3. A rating of over 20 percent for a right repaired meniscus as of October 23, 2023.

The Veteran seeks a higher rating for a right repaired meniscus.

The Veteran's right knee repaired meniscus is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5258. Under Diagnostic Code 5258, a 20 percent rating is warranted for dislocation of a semilunar cartilage with frequent episodes of "locking, pain", and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258.

As the Veteran receives the highest schedular rating for dislocation of a semilunar cartilage, there is no basis to award a higher evaluation.

In conclusion, the Board finds that the evidence of record persuasively weighs against the Veteran's claim for a rating of over 20 percent for a right repaired meniscus. As the evidence of record persuasively weighs against a rating of over 20 percent, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); Lynch, 21 F.4th 776; 38 C.F.R. §§ 4.3, 4.7. The claim is denied.

4. A compensable rating for right knee flexion limitation as of October 23, 2023.

In October 2022 and July 2023 statements, the Veteran reported seeking a higher rating for right knee flexion limitation because of pain with motion and severe functional limits with all activities.

The Veteran's right knee flexion limitation is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5260, for limitation of flexion of the leg. Under Diagnostic Code 5260, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260.

Passive and active range of motion testing and testing after three repetitions during the December 2022 VA examination showed flexion limited to 90 degrees. There was evidence of pain with flexion, weight-bearing, and active and passive motion, but not non-weight-bearing, on rest, or non-movement. Pain caused functional loss and restricted squatting. The examiner opined that pain would significantly limit functional ability with repeated use over time, limiting flexion to 85 degrees
20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260.

Passive and active range of motion testing and testing after three repetitions during the December 2022 VA examination showed flexion limited to 90 degrees. There was evidence of pain with flexion, weight-bearing, and active and passive motion, but not non-weight-bearing, on rest, or non-movement. Pain caused functional loss and restricted squatting. The examiner opined that pain would significantly limit functional ability with repeated use over time, limiting flexion to 85 degrees. The examiner opined that pain would significantly limit functional ability with flare-ups to flexion at 80 degrees. The Veteran is prescribed a cane and brace for ambulation. The examiner found no evidence of muscle atrophy, ankylosis, recurrent patellar instability, or tibial or fibular impairment. There were no other pertinent physical findings, complications, conditions, signs, or symptoms.

In the June 2024 VA knee examination, the examiner diagnosed right knee instability, post-traumatic arthritis, and status post meniscectomy. The Veteran reported chronic sharp and shooting pain, lack of stability, swelling, locking, clicking, stiffness, catching, grinding, hyperextension, and pain with flexion and extension. The Veteran reported constant use of a brace and cane and occasional use of crutches. He reported that severe flare-ups of the right knee occurred every 6 to 7 months, lasting a day to 4 weeks, precipitated by activity, and alleviated by rest, time, heat, ice, and medication.

Active and passive range of motion testing and testing after three repetitions during the June 2024 VA knee examination showed flexion limited to 65 degrees. Pain was noted at 60 degrees flexion. The examiner noted pain with all movement and non-movement, and that it reduced the Veteran's flexion. The examiner opined that pain, lack of endurance, and instability would result in further limitation with repeated use over time and during flare-ups, limiting flexion to 65 degrees.

The December 2022 and June 2024 VA examiners also found no evidence of muscle atrophy, ankylosis, recurrent patellar dislocation, shin splints (medial tibial stress syndrome), stress fractures, or any other tibial or fibular impairment.

The December 2022 and June 2024 VA examinations are adequate; further, they estimated functional loss during a flare-up as required by Sharp and satisfied the Correia testing requirements.

The Board finds that the evidence of record persuasively weighs against a compensable rating for right knee flexion limitation. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain during flare-ups. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that frequent and severe flare-ups would not result in limitation of motion more nearly approximating flexion limited to 45 degrees.

Under Diagnostic Code 5260, the Veteran's right knee disability is noncompensable because the Veteran's flexion was estimated to be limited to 65 degrees, at worst. Under Diagnostic Code 5260, evaluations of 10 percent are only warranted for flexion limited to 31-45 degrees; thus, only in the instance that the flexion limitation reached 45 degrees would a 10 percent evaluation have been warranted under Diagnostic Code 5260 for the appeals period.

The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment).

Separate ratings are not warranted under Diagnostic Codes 5256, 5262, or 5263 as the weight of the competent and probative evidence is against finding ankylosis, a tibial or fibular impairment, or genu recurvatum.

A separate rating is also not warranted under Diagnostic Code 5259 for the symptomatic removal of semilunar cartilage because the Veteran is already in receipt of a higher rating under Diagnostic Code 5258 for a current dislocated semilunar cartilage.

In conclusion, the Board finds that the evidence of record
107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment).

In conclusion, the Board finds that the evidence of record persuasively weighs against the Veteran's claim for a compensable rating for right knee flexion limitation. As the evidence of record persuasively weighs against a compensable rating, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); Lynch, 21 F.4th 776; 38 C.F.R. §§ 4.3, 4.7. The claim is denied.

5. A compensable rating for right knee scars.

The Veteran's right knee scars are rated noncompensable under Diagnostic Code 7802.

Diagnostic Code 7802 is for burn scars or scars due to other causes, not of the head, face, or neck, that are not associated with underlying soft tissue damage. 38 C.F.R. § 4.118. Under these criteria, a scar with an area or areas of 144 square inches (929 sq. cm.) or greater warrants a 10 percent rating. 38 C.F.R. § 4.118. Note 1 to Diagnostic Code 7802 instructed that a superficial scar was one not associated with underlying soft tissue damage. Id.

The December 2022 VA examiner described the right knee arthroscopy scars as difficult to visualize, stable, and non-tender, with a combined area of about 1.2 sq. cm., and found no underlying tissue damage.

The Board finds that the evidence of record persuasively weighs against the assignment of a compensable evaluation under Diagnostic Code 7802 because the Veteran's right knee scars are not manifest by an area or areas of 144 square inches (929 sq. cm.) or greater.

The Board has also considered the other Diagnostic Codes pertaining to scars. The Veteran has described substantial knee pain, instability, and functional loss, but he has not identified separate scar pain, instability, skin breakdown, or another distinct disabling effect attributable to the scars themselves. Further, the Veteran's right knee scars are not of the head, face, or neck, are not deep and non-linear, and are not associated with underlying soft tissue damage. Moreover, the Veteran's right knee scars are not unstable or painful. Therefore, Diagnostic Codes 7800, 7801, and 7804 are inapplicable. Finally, the evidence of record shows that there are no other disabling effects not considered in the rating provided under Diagnostic Codes 7800-04, as contemplated under Diagnostic Code 7805.

The Board acknowledges that the Veteran believes that the disability on appeal has been more severe than the assigned disability rating reflects. The Veteran is competent to report observable symptoms; however, the Veteran does not assert, and medical treatment records do not show that the Veteran's right knee scars are manifest by an area or areas of 144 square inches (929 sq. cm.) or greater.

In conclusion, the Board finds that the evidence of record persuasively weighs against the Veteran's claim for a compensable rating for right knee scars. As the evidence of record persuasively weighs against a compensable rating, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); Lynch, 21 F.4th 776; 38 C.F.R. §§ 4.3, 4.7. The claim is denied.

6. A rating of over 70 percent for a psychiatric disorder as of October 23, 2023.

The Veteran contends that he is entitled to a 100 percent rating for his psychiatric disorder due to the severity, persistence, and debilitating impact of his diagnosed chronic PTSD, unspecified anxiety disorder, unspecified depressive disorder, and recurrent chronic insomnia. In a December 2024 correspondence, he reported that between November 2022 and June 2024, he attended 44 mental health appointments, including counseling, psychiatry, and sleep therapy, with special approval for increased access to care due to the severity. Despite ongoing treatment, he reported severe and chronic symptoms, including persistently elevated patient health questionnaire-9 (PHQ-9) depression scores, neglect of personal hygiene, extreme anxiety and suspicion, frequent panic attacks, impaired judgment, memory loss, severe insomnia, low motivation, impaired impulse control, hallucinations, spatial disorientation, and an inability to establish or maintain social relationships, resulting in significant isolation. He described near-daily functional impairment, stating that most days he is unable to get out of bed or care for himself, with profound feelings of abandonment and hopelessness. He reported severely disrupted sleep, often limited to 2 to 3 hours per night. He reported constant anxiety, hypervigilance in public settings, and preoccupation with perceived threats, contributing to social withdrawal and anger outbursts that have damaged personal relationships. The Veteran also described persistent suicidal ideation, planning behaviors, and episodes of self-harm, sometimes resulting in institutionalization and further social strain. He argues that these symptoms result in total occupational and social impairment, warranting a 100 percent rating.

In an August 2024 statement, the Veteran's spouse reported decades of progressively worsening symptoms that she has personally witnessed since their early adulthood. She describes the onset of his depression, anxiety, sleep disturbance, and trauma-related symptoms beginning after his initial military injuries, which were compounded by repeated physical injuries, inadequate medical care, financial instability, and a persistent sense of betrayal by both the military and civilian employers. Over time, she observed his condition deteriorate into chronic insomnia, severe mood instability, anger outbursts, social withdrawal, and an inability to cope with stress, ultimately requiring ongoing therapy and repeated psychiatric hospitalizations. She reports that he experiences persistent suicidal ideation, panic attacks, hallucinations, and episodes of extreme rage, with periods of little to no sleep that significantly impair his judgment and functioning. His symptoms have caused profound strain on their marriage and family, including fear among their children of finding him deceased, and a constant need for supervision to ensure his safety. Despite his efforts to seek treatment and comply with care, she emphasizes that his condition remains severe and unmanageable, affecting his ability to function independently, maintain employment, or sustain relationships, and has created a continuous state of crisis within the household, supporting her belief that his level of impairment meets the criteria for a total psychiatric disability rating.

During the June 2024 VA examination, the Veteran reported residing with his spouse of 31 years and described this marriage as good and supportive, though strained at times due to mood lability. The Veteran has three children with whom he maintains a good relationship, but it is strained at times due to mood lability. The Veteran has maintained a few friendships and feels under-socially supported due to social withdrawal. The Veteran maintains regular contact with his family of origin. He is currently unemployed, and last worked in 2015 in retail, where he was for 1.5 years before a mental health hospitalization during which he was fired from his job. The Veteran reported experiencing current mental health issues, which included significant symptoms of anxiety and depression, feelings of detachment from others, low mood and motivation, sleep disturbances, irritability and angry outbursts, variable appetite, and social withdrawal. The Veteran reported that he sees a therapist quarterly and is prescribed Klonopin for sleep and mood stability, which he reported was moderately effective currently. The Veteran also reported suicidal ideation approximately every other day, which is passive without a plan or intent. The Veteran reported being hospitalized for mental health issues several times and had previous suicide attempts.

Under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. V
The Veteran reported being hospitalized for mental health issues several times and had previous suicide attempts.

Under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013).

A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation).

A 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity.

A 70 percent rating is assigned when symptoms such 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 worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood.

A 100 percent rating is assigned for total occupational and social impairment due to such symptoms as gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, or memory loss for names of close relatives, own occupation or own name.

The Board concludes that the Veteran's symptoms did not cause the level of impairment required for a disability rating of 100 percent. Throughout the period on appeal, the Veteran's symptoms more closely approximated the symptoms associated with a 70 percent rating and resulted in a level of impairment that most closely resembled the level of impairment associated with a 70 percent rating.

In June 2024, a VA psychologist examined the Veteran a determined he had a current adjustment disorder with mixed anxiety and depressed mood and a chronic insomnia disorder that resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and mood due to symptoms of depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss, such as forgetting names, directions or recent events, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances (including work or a work like setting), suicidal ideation, and intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene). The psychologist found no other symptoms attributable to mental disorders. The VA psychologist found that the Veteran had a low acute risk for suicidal ideation and encouraged the Veteran to discuss suicidal ideation with his primary care physician and provided him with the VA crisis line numbers.

The VA psychologist observed that the Veteran arrived on time for the examination, was appropriately groomed and dressed, and oriented with congruent affect and normal responsiveness. His memory, insight, and judgment appeared adequate, and he was engaged and cooperative throughout the examination, with organized and logical speech. The VA psychologist found the Veteran capable of managing his financial affairs.

The VA psychologist noted that the Veteran's mental health symptoms contribute to difficulty in the work environment, including having difficulty attending to and being easily distracted from work tasks, difficulty maintaining concentration and focus on work over a period, and intrusive thoughts that interfere with the ability to stay focused at work. Noting that the Veteran also has difficulty accepting supervision or receiving instructions without becoming angry; significant difficulty remembering instructions and details of work assignments; and significant difficulty functioning around other people and functioning as a team member. The psychologist opined that the Veteran's disrupted sleep would leave him fatigued at work, making concentration and focus on work assignments difficult. The Veteran is so depressed that he would have difficulty sustaining energy and motivation to complete assignments at work. The Veteran has panic attacks, irritability, and suspiciousness that would interfere with work tasks and interactions with others. The psychologist found that the Veteran encounters these difficulties in both active and sedentary work environments

The Veteran has received ongoing VA mental health treatment throughout the appeal period, with consistent documentation of symptoms associated with posttraumatic stress disorder (PTSD), anxiety, and depressive disorders, as well as intermittent reports related to suicidal ideation. Mental status examinations from October 2023 through September 2024 were largely consistent, showing that he was alert, fully oriented, appropriately groomed, and cooperative, with normal speech, linear and goal-directed thought processes, intact memory, and fair to good insight and judgment. His mood varied between anxious, dysphoric, and euthymic, with affect consistently congruent. No psychosis or cognitive impairment was observed.

VA treatment records show that screening tools, including PHQ-9 and Columbia Suicide Severity Rating Scale (C-SSRS), were administered on multiple occasions throughout the period on appeal, but they were negative for active suicidal ideation, and clinicians repeatedly noted no plan, intent, or preparatory behaviors. Notwithstanding these denials, clinicians documented that the Veteran intermittently endorsed fleeting, ego-dystonic thoughts of self-harm. The Veteran maintained a safety plan and demonstrated awareness of crisis resources. In February 2024, he continued to deny active suicidal ideation but acknowledged passive thoughts such as "not being around anymore," again without a plan or intent.

In June 2024, although screening remained negative, the Veteran experienced a temporary exacerbation of symptoms, including increased suicidal thoughts, associated with stress following a knee reinjury and uncertainty regarding his treatment plan. By July 2024, he reported improvement and increased ability to manage symptoms through therapy, though he continued to endorse occasional, ego-dystonic thoughts of self-harm without plan or intent. A clinician in September 2024 assessed the Veteran's acute suicide risk as low but noted the need for ongoing monitoring.

In September 2024, the Veteran reported that uncertainty regarding his medical condition and treatment plan exacerbated his anxiety, resulting in panic attacks, nightmares, and fleeting but intense suicidal thoughts. He also endorsed occasional stress-related thoughts of self-harm but denied any current plan, intent, means, or desire. A safety plan remained in place.

VA treatment records, the June 2024 VA examinations, and the Veteran's and his spouse's lay statements show that the Veteran's PTSD was manifested by symptoms associated with a 70 percent rating.

The Board has considered the Veteran's contention that his psychiatric disability warrants a 100 percent evaluation based on the severity, frequency, and duration of his symptoms, including depression, anxiety, chronic insomnia, panic attacks, social withdrawal, impaired functioning, and suicidal ideation. The Board has also carefully considered the August 2024 statement from his spouse describing longstanding and severe psychiatric difficulties, as well as the June 2024 VA examination report and the VA treatment records throughout the appeal period. After considering the entire evidentiary record, the Board finds that the Veteran's psychiatric disability has resulted in very serious impairment, but has not more nearly approximated total occupational and social impairment at any time during the period on appeal.

The Board does not dispute that the Veteran's psychiatric symptoms are severe. The June 2024 VA examiner expressly found occupational and social impairment with deficiencies in most areas, and identified symptoms including depressed mood, anxiety, suspiciousness, panic attacks, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty establishing and maintaining effective relationships, difficulty adapting to stressful circumstances, suicidal ideation, and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. The examiner
appeal period. After considering the entire evidentiary record, the Board finds that the Veteran's psychiatric disability has resulted in very serious impairment, but has not more nearly approximated total occupational and social impairment at any time during the period on appeal.

The Board does not dispute that the Veteran's psychiatric symptoms are severe. The June 2024 VA examiner expressly found occupational and social impairment with deficiencies in most areas, and identified symptoms including depressed mood, anxiety, suspiciousness, panic attacks, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty establishing and maintaining effective relationships, difficulty adapting to stressful circumstances, suicidal ideation, and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. The examiner further explained that the Veteran's symptoms would significantly interfere with work functioning, including concentration, persistence, interaction with others, accepting supervision, remembering instructions, and maintaining motivation. The Board finds this evidence highly probative and consistent with a 70 percent level of impairment.

However, the same June 2024 examination does not support a finding of total occupational and social impairment. The examiner did not find such a level of impairment; instead, the examiner specifically selected the level of impairment corresponding to deficiencies in most areas. Further, the objective findings on examination were not consistent with the type of profound psychiatric breakdown contemplated by a 100 percent rating. The Veteran arrived on time, was appropriately groomed and dressed, was oriented, cooperative, and engaged, and exhibited congruent affect, normal responsiveness, organized and logical speech, and adequate memory, insight, and judgment. He was also found capable of managing his financial affairs. Those findings weigh strongly against gross impairment in thought processes or communication, persistent disorientation, severe memory loss, or inability to perform basic mental tasks consistent with total impairment.

The Board has also considered the Veteran's December 2024 statement and his spouse's August 2024 statement, asserting symptoms such as neglect of hygiene, extreme anxiety, suspicion, frequent panic attacks, impaired judgment, memory loss, hallucinations, spatial disorientation, inability to maintain relationships, self-harm, prior institutionalization, and a near-complete inability to function independently. The Veteran and his spouse are competent to report observable symptoms, and the Board finds their statements credible insofar as they reflect serious ongoing psychiatric distress and substantial functional impairment. Their reports are also generally consistent with the evidence showing chronic sleep disturbance, anxiety, mood instability, social withdrawal, irritability, and intermittent suicidal ideation. Nonetheless, to the extent these statements suggest symptomatology approximating total impairment, the Board finds they are outweighed by the repeated clinical findings made by trained mental health professionals over the course of treatment and examination.

In that regard, the treatment records from October 2023 through September 2024 are remarkably consistent in documenting that the Veteran was alert, fully oriented, appropriately groomed or adequately groomed, cooperative, and logical, with normal speech, linear and goal-directed thought processes, intact memory, and fair to good insight and judgment. His affect was congruent, and although his mood varied from anxious and dysphoric to euthymic, clinicians repeatedly found no hallucinations, delusions, psychosis, gross cognitive impairment, or disorganized thinking. These repeated mental status findings are highly probative because they reflect observations made over time in a treatment setting, rather than a single retrospective description of symptoms. They weigh against a finding of gross impairment in thought processes or communication, persistent delusions or hallucinations, disorientation to time or place, memory loss of the severity contemplated by the 100 percent criteria, or other manifestations of total psychiatric impairment.

The Board acknowledges that the Veteran and his spouse reported hallucinations and spatial disorientation. However, these reports are not supported by contemporaneous clinical evidence. Throughout the treatment records at issue, clinicians repeatedly documented no perceptual disturbances, no psychotic symptoms, intact orientation, and no abnormal thought content. Similarly, although the Veteran asserted neglect of hygiene and inability to care for himself on most days, treatment and examination records consistently described him as adequately or appropriately groomed and casually dressed. The June 2024 examiner noted an intermittent inability to perform activities of daily living, including maintaining minimal personal hygiene, and the Board has fully considered that symptom. Even so, the overall record does not demonstrate a persistent inability to perform activities of daily living or a sustained failure to maintain minimal hygiene as contemplated by a 100 percent rating. Rather, the evidence shows that such impairment was intermittent and did not reflect total impairment.

The Board has also carefully considered the evidence concerning suicidal ideation. The Veteran reported at the June 2024 examination that he experienced passive suicidal ideation approximately every other day, without a plan or intent, and he reported prior hospitalizations and prior suicide attempts. His spouse also described persistent suicidal ideation, planning behaviors, self-harm, and the
intermittent inability to perform activities of daily living, including maintaining minimal personal hygiene, and the Board has fully considered that symptom. Even so, the overall record does not demonstrate a persistent inability to perform activities of daily living or a sustained failure to maintain minimal hygiene as contemplated by a 100 percent rating. Rather, the evidence shows that such impairment was intermittent and did not reflect total impairment.

The Board has also carefully considered the evidence concerning suicidal ideation. The Veteran reported at the June 2024 examination that he experienced passive suicidal ideation approximately every other day, without a plan or intent, and he reported prior hospitalizations and prior suicide attempts. His spouse also described persistent suicidal ideation, planning behaviors, self-harm, and the family's fear for his safety. Moreover, treatment records document intermittent fleeting or ego-dystonic thoughts of self-harm and a worsening of symptoms during periods of heightened medical stress, including in June 2024 and September 2024, when uncertainty regarding his knee condition and treatment plan reportedly intensified anxiety, panic attacks, nightmares, and fleeting but intense suicidal thoughts. The Board does not minimize the seriousness of these symptoms. The 70 percent criteria specifically contemplate suicidal ideation and are one of the types of symptoms that may support that evaluation.

The evidence does not show that the Veteran was in persistent danger of hurting himself or others, as contemplated by the 100 percent rating criteria. Screening instruments, including repeated C-SSRS screenings, were negative for active suicidal ideation during much of the appeal period. Clinicians repeatedly noted the absence of a plan, intent, and preparatory behavior. His suicidal thoughts were often described as fleeting, passive, or ego-dystonic. He maintained a safety plan, was aware of crisis resources, and in September 2024, a clinician conservatively assessed his immediate risk as low, while recommending continued monitoring. The June 2024 VA examiner likewise assessed low acute risk. Thus, while the record clearly reflects serious suicidal ideation and chronic risk factors, the more persuasive evidence does not show the persistent and acute dangerousness contemplated by the 100 percent level.

The Board further finds that the evidence does not establish total social impairment. The Veteran has reported significant social withdrawal, feeling under-supported, irritability, anger outbursts, and strain in his relationships. These limitations are substantial and consistent with the currently assigned 70 percent rating. However, the evidence does not show that he is totally socially impaired. At the June 2024 examination, he reported that he lived with his spouse of 31 years and described the marriage as good and supportive, though strained at times. He also reported good, though at times strained, relationships with his three children, a few friendships, and regular contact with his family of origin. These retained relationships are not consistent with total social impairment. While the spouse's statement reflects serious family strain and a high level of concern, it still indicates an ongoing family system and continuing involvement by close relatives, rather than a virtual absence of social functioning.

The Board recognizes that the evidence strongly supports a finding of profound occupational impairment. The June 2024 examiner described substantial work-related limitations, and the Veteran has not worked since 2015, reportedly after a mental health hospitalization during prior employment. The Board accepts that his psychiatric symptoms significantly impair, and may even preclude, occupational functioning. However, a 100 percent schedular evaluation requires both total occupational and social impairment. The fact that the Veteran may have severe, or even total, occupational impairment does not by itself establish entitlement to a 100 percent schedular rating where the evidence does not show total social impairment and does not reflect the type of gross psychiatric symptomatology contemplated by that level. The Board notes that the Veteran is already in receipt of a TDIU based only on his psychiatric disorder during this period on appeal.

In sum, the Board finds that the Veteran's psychiatric disability has been manifested by severe symptoms, including chronic anxiety, depression, suspiciousness, panic attacks, insomnia, impaired motivation, irritability, social withdrawal, difficulty adapting to stress, intermittent neglect of hygiene, and suicidal ideation. These symptoms have caused deficiencies in most areas, including work, family relations, judgment, thinking, and mood, and thus are consistent with the currently assigned 70 percent evaluation. However, the overall disability picture did not more nearly approximate total occupational and social impairment. The record does not persuasively show gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, persistent inability to perform activities of daily living, disorientation to time or place, or memory loss of the severity contemplated by the 100 percent criteria. The criteria for a 100 percent or higher rating are not met, and the appeal must be denied.

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