POSTTRAUMATIC STRESS DISORDER (PTSD)

S. CHARLES NEILL · 2026 · Case ID: A26039902

MIXED

Summary

The Veteran, a Veteran who served from September 1959 to June 1980, including service in Vietnam and earning the Bronze Star Medal and Combat Infantry Badge, appeals the denial of an increased rating for PTSD and the denial of TDIU. The Veteran also appeals the denial of spousal SMC A&A and the remand of his own SMC A&A claim. The Board denied the increased rating for PTSD, finding that while the Veteran has significant impairments, the evidence did not support a total occupational and social impairment rating. The Board found the contemporaneous evidence more probative than a retrospective private opinion that attributed some impairment to a non-service-connected disability. The Board granted TDIU, finding the Veteran's combined service-connected disabilities, including PTSD, diabetes, left leg issues, and hypertension, met the schedular requirements and rendered him unable to maintain substantially gainful employment. The Board granted spousal SMC A&A, finding the Veteran's spouse, who has ESRD and requires assistance with bathing, eating, medication management, and ambulation, met the criteria. The Board remanded the Veteran's own SMC A&A claim, noting a pre-decisional duty to assist error in failing to provide a VA examination for A&A based solely on his service-connected disabilities.

Rationale

Contemporaneous evidence more probative than retrospective opinion; Symptoms do not meet criteria for total occupational and social impairment; Failed to reconcile conflicting findings and explain total impairment conclusion

Special Benefit

SMC - AID & ATTENDANCE; TDIU

Docket No.

251216-605638

Full Decision Text

Citation Nr: A26039902
Decision Date: 04/29/26 Archive Date: 04/29/26

DOCKET NO. 251216-605638
DATE: April 29, 2026

ORDER

1. Entitlement to a rating in excess of 70 percent for posttraumatic stress disorder (PTSD) is denied.

2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is granted, subject to regulations governing payment of monetary awards.

3. Entitlement to spousal special monthly compensation (SMC) based on the need for aid and attendance (A&A) for the Veteran's spouse is granted, subject to regulations governing payment of monetary awards.

REMANDED

4. Entitlement to SMC based on the need for A&A for the Veteran is remanded.

FINDINGS OF FACT

1. The Veteran's PTSD was manifested by occupational and social impairment with deficiencies in most areas; total occupational and social impairment was not shown.

2. The Veteran's service-connected disabilities of PTSD (rated 70 percent); type 2 diabetes mellitus (rated 20 percent); left tibia and/or fibula fracture (rated 20 percent from July 6, 2023 to October 19, 2023, then 0 percent from that date); nonlinear hyperpigmentation of the right neck (rated 0 percent); nonlinear hyperpigmentation of the upper chest (rated 0 percent); nonlinear hyperpigmentation of the upper back (rated 0 percent); linear hyperpigmentation / scarring of the right upper arm (rated 0 percent); and hypertension (rated 0 percent), are rated 80 percent, combined, and are reasonably shown to be of such nature and severity as to preclude his participation in any regular substantially gainful employment consistent with his education and occupational experience.

3. The Veteran's spouse requires assistance with bathing/showering, eating or self-feeding, medication management, household activities, and her health care needs.

CONCLUSIONS OF LAW

1. A rating in excess of 70 percent for PTSD is not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.126, 4.130, Diagnostic Code (Code) 9411.

2. The schedular criteria for a TDIU are met, and a TDIU is warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.3, 4.14, 4.16.

3. The criteria for an award of SMC benefits based on A&A for the Veteran's spouse have been met. 38 U.S.C. §§ 1114, 1115, 5107; 38 C.F.R. §§ 3.102, 3.350, 3.351, 3.352.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The appellant is a Veteran who served on active duty from September 1959 to June 1980. He was awarded the Bronze Star Medal and Combat Infantry Badge, among other commendations.

These matters are before the Board of Veterans' Appeals (Board) on appeal from multiple Department of Veterans Affairs (VA) Regional Office (RO) rating decisions. A January 3, 2025 Higher Level Review rating decision, in relevant part, continued (from a February 8, 2024 rating decision) a 70 percent rating for PTSD. A May 12, 2025 rating decision denied entitlement to SMC and to spousal SMC. And a June 16, 2025 rating decision denied entitlement to a TDIU (citing to a special review mandated on January 3, 2025).

On December 16, 2025, VA received a VA Form 10182 in which the Veteran (and his attorney representative) selected the Evidence Submission lane and expressed disagreement with the January 2025 rating decision pertaining to the rating for PTSD, the May 2025 rating decision pertaining to entitlement to SMC and entitlement to spousal SMC, and the June 2025 rating decision pertaining to entitlement to a TDIU.

For the sake of clarity, in the PTSD claim, under the Evidence Submission review option of a Higher Level Rating decision, the Board may not consider evidence that accumulated between the prior (February 8, 2024) rating decision (more precisely, the evidence which the Agency of Original Jurisdiction (AOJ) considered in that decision), and the December 16, 2025, VA Form 10182, or evidence received more than 90 days after the December 16, 2025 VA Form 10182. 38 C.F.R. §§ 3.2601, 20.303. In the SMC claims, the Board may not consider evidence that accumulated between the May 12, 2025 rating decision and the December 16, 2025, VA Form 10182, or evidence received more than 90 days after the December 16, 2025 VA Form 10182. 38 C.F.R. § 20.303. And in the claim seeking a TDIU, the Board may not consider evidence that accumulated between the June 16, 2025 rating decision and the December 16, 2025 VA Form 10182, or evidence received more than 90 days after the December 16, 2025 VA Form 10182. 38 C.F.R. § 20.303. Upon review of the record, there is no extant evidence which accumulated during these time frames. See Cook v. McDonough, 36 Vet. App. 175 (2023).

As a final procedural observation, the Board notes that a claimant may generally request to switch dockets within a year of the AOJ decision on appeal. 38 C.F.R. § 20.202(c)(2). However, if the claimant has submitted evidence or testified at a Board hearing, a docket switch is no longer available. Id. Here, although a year has not passed since the issuance of the May 2025 and June 2025 AOJ decisions on appeal, see Williams v. McDonough, 37 Vet. App. 305 (2024), because the Veteran submitted evidence (in December 2025), the Board may adjudicate the appeal. Furthermore, in a December 2025 statement, the Veteran's attorney requested the appeal be advanced on the Board's docket based on the Veteran's age and explicitly waived any remaining time to change dockets pursuant to Williams. Accordingly, this appeal has been advanced on the Board's docket (as reflected in the header), and the Board will proceed to adjudicate the appeal.

1. Entitlement to a rating in excess of 70 percent for PTSD is denied.

Legal Criteria

Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity caused by the given disability. Separate diagnostic codes identify the various disabilities. 38?U.S.C. §?1155; 38 C.F.R. Part 4.

Where entitlement to compensation has already been established and increase in disability is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). "Staged" ratings may be warranted where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007).

When a question arises as to which of two ratings applies under a particular code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. 38?C.F.R. §?4.7. After careful consideration of the evidence, any reasonable doubt remaining, including regarding degree of disability, is resolved in favor of the Veteran. 38?U.S.C. §?5107; 38?C.F.R. §§?3.102, 4.3.

The Veteran's service-connected PTSD is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411, and the General Rating Formula for Mental Disorders. See June 2025 rating codesheet. Relevant to the issue on appeal, under the General Rating Formula for Mental Disorders, a 70 percent rating 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; speech intermittently illogical, obscure, or irrelevant; 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); inability to establish and maintain effective relationships.

A 100 percent rating is warranted for total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (ADLs) (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38?C.F.R. §?4.130, Code 9411.

Ratings for psychiatric disability are assigned according to the manifestation of particular symptoms, but the use of the term "such as" in 38?C.F.R. §?4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16?Vet. App.?436 (2002).

Accordingly, the evidence considered in determining the level of impairment from the acquired psychiatric disability under 38?C.F.R. §?4.130 is not restricted to the symptoms listed in Code 9411 (and the General Rating Formula). Instead, VA must consider all symptoms of a claimant's condition that affect occupational and social function. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38?C.F.R. §?4.126(a). When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. 38?C.F.R. §?4.126(b).

VA is responsible for determining whether the evidence persuasively favors one side or another. 38?C.F.R. § 4.3. When there is an approximate or nearly equal balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the appellant and the claim will be granted on the merits. 38?U.S.C. §?5107(b). When the evidence persuasively favors against the claims of the appellant, the benefit of the doubt doctrine is inapplicable and the claim will be denied on its merits. 38?U.S.C. §?5107; Lynch v. McDonough, 21 F.4th 776, 781 (Fed. Cir. 2021) (en banc).

An increased rating may be assigned for up to one year prior to receipt of a formal claim for increase, when it is factually ascertainable that an increase in disability had occurred during that period. 38 C.F.R. § 3.400(o)(2). Consequently, the evaluation period for consideration here is from July 2022 (a year prior to the July 6, 2023 date of receipt of a supplemental claim for a TDIU (apparently construed by the RO as a claim for increase for PTSD).

Factual Background

[The evidentiary record detailed below includes evidence relevant to all claims on appeal and is included in this portion of the decision as it contains evidence relevant to the PTSD claim.]

A May 2023 VA Program of Comprehensive Assistance for Family Caregivers (PCAFC) assessment notes the Veteran is able to drive independently three to four
disability had occurred during that period. 38 C.F.R. § 3.400(o)(2). Consequently, the evaluation period for consideration here is from July 2022 (a year prior to the July 6, 2023 date of receipt of a supplemental claim for a TDIU (apparently construed by the RO as a claim for increase for PTSD).

Factual Background

[The evidentiary record detailed below includes evidence relevant to all claims on appeal and is included in this portion of the decision as it contains evidence relevant to the PTSD claim.]

A May 2023 VA Program of Comprehensive Assistance for Family Caregivers (PCAFC) assessment notes the Veteran is able to drive independently three to four times per week, four to five miles from his residence. He last worked in 2005 or 2006 as a security guard. He reported that a typical day entails walking his dog to the mailbox, playing games on his phone, watching television, and driving his wife to dialysis. He generally microwaves dinner or eats dinner prepared by his adult daughter. His daughter also assists the Veteran with grooming and reminds him to take his medications because he forgets at times. He denied an exercise or activity routine; he reported that he sometimes forgets where he placed his cane and that he no longer uses the stove because he may forget to turn it off. He reported that he is a fall risk. A depression screen was negative; he denied suicidal ideation. He also denied alcohol use, substance use, and other addictive behaviors. He reported right leg pain that he hopes will improve so he can travel.

He reported that "his daughter supports him 100%[.]" He explained that his daughter helps comb his hair, clean his dentures, and put on his compression socks. He is otherwise independent with bathing, dressing, undressing, toileting (noting the use of Depends), and eating (food that is already prepared). The Veteran's daughter reported that she handles all household chores because the Veteran is a fall risk. She also fears the Veteran may fall victim to a financial scam because he had done so in the past. She reported that she pays the Veteran's bills, monitors his bank statements, and manages his finances.

A June 2023 VA treatment record notes a PTSD screen was negative.

A subsequent June 2023 VA PCAFC functional assessment including ADLs notes the Veteran is independent in eating, grooming, washing his upper body, bathing, and dressing / undressing. He reported that his daughter helps at times with cleaning his dentures and his spouse helps clean his back in the shower as needed. The Veteran reported that he showers a few times per week because he is "lazy" but his daughter reported her belief that the Veteran is having difficulty due to pain. The Veteran requires substantial / maximal assistance with putting on / taking off socks and shoes. Regarding toileting, the Veteran is independent (noting his use of incontinence briefs which his spouse reports he does not change often enough).

Regarding mobility, the Veteran is independent to roll, sitting to lying, lying to sitting, sitting to standing, bed to chair transfer, toilet transfer, walking 10 feet, walking 50 feet with two turns, walking 150 feet, walking 10 feet on uneven surfaces, walking indoors and traversing one step. The Veteran lives on the main level of a two-story home; his adult daughter lives upstairs; the Veteran does not attempt the stairs due to fall concerns. He does not attempt to pick up objects, carry something in both hands, walk for 15 minutes, or walk across the street. He does walk his dog about 150 feet and uses a shopping cart for balance at the store. The Veteran takes medication and requires visual or verbal reminders.

The clinician opined the Veteran has minimal judgment and physical ability to cope, make appropriate decisions, and take action in a changing environment or a potentially harmful situation. She also opined he is at risk of self-neglect due to dehydration or malnutrition; impairment of orientation, memory, reasoning and / or judgment; inability to manage medication and seek medical treatment; and unsafe / unhealthy living conditions. She found that the Veteran can be left alone for most of the day and can go to familiar places alone. He does not have delusions / hallucinations, agitation, or impulsiveness. She opined he can provide and / or arrange for his health and safety but cannot identify his own needs (noting multiple disagreements during the assessment between the Veteran and caregiver daughter).

A July 2023 VA mental health treatment record notes the Veteran's daughter called to inquire about the services offered. The Veteran denied having any concerns about mood, depression, feeling down, sadness, irrit
malnutrition; impairment of orientation, memory, reasoning and / or judgment; inability to manage medication and seek medical treatment; and unsafe / unhealthy living conditions. She found that the Veteran can be left alone for most of the day and can go to familiar places alone. He does not have delusions / hallucinations, agitation, or impulsiveness. She opined he can provide and / or arrange for his health and safety but cannot identify his own needs (noting multiple disagreements during the assessment between the Veteran and caregiver daughter).

A July 2023 VA mental health treatment record notes the Veteran's daughter called to inquire about the services offered. The Veteran denied having any concerns about mood, depression, feeling down, sadness, irritability, anger, anxiety, nervousness, negative thoughts or memories, sleep concerns, or memory. He did not endorse any mental health concerns and did not report any suicidal or homicidal ideation.

On November 1, 2023 VA PTSD examination, the diagnosis was PTSD. The Veteran reported that he is married and continues to have positive family relationships with his adult children, grandchildren and [great] grandchildren. He maintains a few friends in different states but rarely sees them. He prefers to isolate and stay home; he fears criminal activity in public settings. He reported that he enjoys bowling but has not been in three years. He reported an educational history of "some college for electrician and Notary public." He denied current mental health treatment and reported distrust in others. The examiner noted that the Veteran was irritable with some questions and appeared to be denying most symptoms, which appears to be a defense mechanism due to his lack of trust. The Veteran denied a legal / behavioral history and denied a substance abuse history. The examiner noted symptoms of: depressed mood; anxiety; suspiciousness; chronic sleep impairment; flattened affect; disturbances of motivation and mood; difficulty adapting to stressful circumstances, including work or a work like setting; and impaired impulse control.

On examination, the Veteran was oriented, made good eye contact, and spoke with a normal tone and rate. He was appropriately dressed and well-groomed. He presented with an irritated mood and normal range of affect. His cognition, impulse control, and judgment were intact. There was no obvious impairment of thought process, thought content, or communications. There was no evidence of delusions or internal stimuli. The Veteran denied suicidal ideation, homicidal ideation, and thoughts of self-harm. The examiner opined that the Veteran's PTSD most closely approximates occupational and social impairment with reduced reliability and productivity (the criteria for a 50 percent rating).

The examiner opined that the Veteran's PTSD impacts his ability to perform all forms of work, including sedentary labor, because his ability to maintain appropriate social interaction with coworkers and customers would be moderately to severely impaired due to his suspiciousness, anxiety, irritability, and depressed mood. His ability to handle low stress in an occupational environment would be moderately to severely impaired as evidenced by his suspiciousness, anxiety, irritability, and depressed mood. His ability to understand, remember, and apply information would be mildly impaired by his poor sleep quality and depressed mood. And his ability to concentrate, persist, and maintain pace would be moderately impaired by his poor sleep quality, anxiety, depressed mood, and suspiciousness of others.

On December 16, 2025, VA received a statement from the Veteran's daughter, L., dated November 10, 2025. She reported that she handles all household tasks, including cooking, laundry, and cleaning. She reported that the Veteran requires a reminder to shower daily and that she physically helps him bathe due to knee pain and fatigue. She opined that the fatigue is due to poor sleep and diabetes. He is generally able to toilet independently (noting he wears Depends) but does require assistance putting on pants because his legs are numb. She explained that the Veteran lacks motivation to help around the house and has moods where he does not want to do anything; she reported that he would stay in bed if she allowed it. She reported that she reminds him to take medications and schedules his appointments. She also reported that the Veteran no longer drives; instead, she drives him and her mother (the Veteran's wife of 65 years) to church and appointments. She also wrote, "I take them wherever I go, so they don't have to sit at home, unless I'm on a break."

She reported that she manages the Veteran's finances because he makes unnecessary purchases and cannot make appropriate decisions. She also reported that he has trouble sleeping and is awake most of the night playing solitaire or watching television; she explained that he feels more relaxed when there is noise in the background. She explained that
stay in bed if she allowed it. She reported that she reminds him to take medications and schedules his appointments. She also reported that the Veteran no longer drives; instead, she drives him and her mother (the Veteran's wife of 65 years) to church and appointments. She also wrote, "I take them wherever I go, so they don't have to sit at home, unless I'm on a break."

She reported that she manages the Veteran's finances because he makes unnecessary purchases and cannot make appropriate decisions. She also reported that he has trouble sleeping and is awake most of the night playing solitaire or watching television; she explained that he feels more relaxed when there is noise in the background. She explained that the Veteran has anxiety, frustrates easily, and has a quick temper; she believes he feels shame that he can no longer do things he did when he was a soldier. She explained that he does not trust people in public and is constantly on alert; he becomes exhausted and feels drained after being out. She also explained that the Veteran is depressed because he feels isolated and misses the camaraderie of the military (including friends who have died).

The Veteran's daughter explained that due to the Veteran's diabetes, she cooks for him and monitors his A1C / sugar levels. She explained that if not for her, the Veteran would choose to eat snacks and fast food. She also noted that the Veteran's left knee pain causes limitation in mobility because he cannot stand for long periods and uses a rollator. She reported that he experienced a fall in October 2025.

The Veteran's daughter opined that he cannot work because he is quick-tempered, always on guard, does not sleep well, is fatigued and irritable, has trouble concentrating, and would not feel safe in a workplace.

On December 16, 2025, VA also received a private PTSD disability benefits questionnaire (DBQ) from Dr. K.B., dated December 6, 2025. The diagnosis was PTSD. She checked the respective boxes to report his symptoms include: depressed mood; anxiety; suspiciousness; panic attacks more than once a week; near continuous panic or depression affecting the ability to function independently, appropriately, and effectively; chronic sleep impairment; impairment of short and long term memory; difficulty in understanding complex commands; impaired judgment; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty adapting to stressful circumstances, including work or a work like setting; inability to establish and maintain effective relationships; obsessional rituals which interfere with routine activities; impaired impulse control; neglect of personal appearance and hygiene; and intermittent inability to perform ADLs, including maintenance of personal hygiene. Dr. K.B. opined that the Veteran's PTSD most closely approximates total occupational and social impairment.

The Veteran submitted a separate report from Dr. K.B. (also dated December 6, 2025) which reports that the Veteran is a high school graduate with three adult children. He denied a history of legal troubles or substance abuse. His daughter and granddaughter assist him with ADLs, including household activities and personal hygiene. The Veteran relies on them for transportation, managing finances, and reminders to use the bathroom and eat (noting that he is diabetic and does not want to be bothered). The Veteran reported nightmares two to three times per month and inconsistent flashbacks of Vietnam (often triggered by watching the news). He reported that he avoids crowds and conflict; he is only comfortable around family and other veterans that he knows.

The Veteran reported sleep trouble at night (necessitating daytime naps), irritability, and anger with family members. He reported loss of short and long-term memory, including forgetting where he placed items. He reported being on edge and hypervigilant most of the time; he also reported unspecified obsessive rituals and that he needs to have loud noise around him all of the time. Dr. K.B. cited to several treatment records outlined above and also cited to a December 2024 private SMC examination report which includes notations of subdural hematoma, impaired mobility and balance, and short term memory deficits. It also notes reduced cognition, generalized weakness, poor balance with a history of falls, vertigo, and dizziness. Lastly, it notes the Veteran requires assistance with bathing, showering, dressing, ambulating in the home, hygiene, toileting, medication management, and household needs. Dr. K.B. also detailed the Veteran's daughter's November 2025 statement.

Dr. K.B. opined that the Veteran's PTSD "has been present and of the same severity since at least [07/06/2023], the date of claim." She also opined that the Veteran has been unable to sustain substantially
ations of subdural hematoma, impaired mobility and balance, and short term memory deficits. It also notes reduced cognition, generalized weakness, poor balance with a history of falls, vertigo, and dizziness. Lastly, it notes the Veteran requires assistance with bathing, showering, dressing, ambulating in the home, hygiene, toileting, medication management, and household needs. Dr. K.B. also detailed the Veteran's daughter's November 2025 statement.

Dr. K.B. opined that the Veteran's PTSD "has been present and of the same severity since at least [07/06/2023], the date of claim." She also opined that the Veteran has been unable to sustain substantially gainful employment since July 6, 2023 due to his PTSD. She explained that the Veteran would have an inability to focus on work tasks and increased work absences due to re-experiencing symptoms, that his avoidance symptoms would interfere with his ability to interact appropriate, that his arousal and reactivity symptoms would make him more reactive to normal workplace stressors and interpersonal conflicts, and that negative thoughts and feelings "would contribute to an increased risk for suicidal thoughts, and ongoing depressive symptoms that would decrease his work productivity." [The Board notes Dr. K.B. did not report that the Veteran has suicidal ideation and, in fact, cited to three treatment records in which the Veteran denied suicidal ideation.]

Analysis

The Veteran's PTSD has been assigned a 70 percent rating throughout the period for consideration.

The Board has considered whether a 100 percent schedular rating was warranted at any time during the appeal period and finds that it was not. Throughout the period for consideration, the Veteran has maintained his marriage to his wife of 65 years. He has also maintained close relationships with his three children, grandchildren, and great grandchildren. Although he has not seen them for a few years, he reported that he maintains a friendship with several friends in other states. He also attends church (with his daughter's assistance), takes his dog for short walks, and goes shopping.

Examination reports and treatment records show he has been consistently described as alert, oriented, cooperative, and adequately or well-groomed with good hygiene. His speech and motor movements have been normal, his thought process has generally been logical and goal-directed, and his cognitive functions were normal.

The Board acknowledges Dr. K.B.'s opinion that the Veteran's PTSD manifests in total occupational and social impairment and has been of the same severity since at least the July 2023 date of claim for increase. However, the symptomatology outlined above more closely approximates the currently assigned 70 percent rating (or lesser ratings). Notably, there were no hallucinations, delusions, phobias, or suicidal/homicidal ideations; there was not gross impairment in thought processes or communication; there was not grossly inappropriate behavior; there was not persistent danger of hurting himself or others; there was not disorientation to time or place; and there was not memory loss for names of close relatives, own occupation, or own name, or other symptoms of such nature and severity.

Furthermore, Dr. K.B. failed to explain how she arrived at her conclusion that the Veteran's PTSD was manifested by total occupational and social impairment and has been of the same severity throughout. The contemporaneous evidence shows that the Veteran drove his wife to medical appointments (at least for some time during the earlier portion of the period for consideration), goes shopping, and attends church. A May 2023 depression screen was negative. A June 2023 screen was negative. And in July 2023 the Veteran explicitly denied mental health concerns. Additionally, Dr. K.B. failed to reconcile her conclusion with the contemporaneous findings noted on November 2023 VA examination, including the examiner's opinion that the Veteran's PTSD most closely approximates occupational and social impairment with reduced reliability and productivity (the criteria for a 50 percent rating). She found that the Veteran has obsessional rituals but failed to identify such (or how they interfere with routine activities). She also opined that the Veteran would experience an increased risk of suicidal thoughts if he were to work, but the record shows that the Veteran has consistently denied suicidal thoughts and ideation throughout. Lastly, her opinion is based in part on a private December 2024 SMC examination report (discussed further in the Remand section) which lists symptomatology and impairment due to subdural hematoma, a non-service-connected disability. Accordingly, the Board finds the contemporaneous medical evidence more probative than a retrospective opinion regarding symptom severity provided several years later which considers (at least in part) symptomatology attributed to a non-service-connected disability. Sklar v. Brown, 5 Vet. App. 140, 146 (199
also opined that the Veteran would experience an increased risk of suicidal thoughts if he were to work, but the record shows that the Veteran has consistently denied suicidal thoughts and ideation throughout. Lastly, her opinion is based in part on a private December 2024 SMC examination report (discussed further in the Remand section) which lists symptomatology and impairment due to subdural hematoma, a non-service-connected disability. Accordingly, the Board finds the contemporaneous medical evidence more probative than a retrospective opinion regarding symptom severity provided several years later which considers (at least in part) symptomatology attributed to a non-service-connected disability. Sklar v. Brown, 5 Vet. App. 140, 146 (1993).

Lastly the Board acknowledges the Veteran's daughter's reports that she reminds him to take medication, manages his finances, prepares meals, completes household tasks, drives to appointments, and assists with dressing and bathing as needed. However, as she explains, not all symptomatology / functional impairment is solely attributable to the Veteran's PTSD. His daughter explicitly linked some of the impairment to other disabilities, including diabetes (including the need to prepare specific meals and numbness of the legs) and leg and knee pain (including limited mobility and the need for physical assistance bathing and dressing).

The Board acknowledges that the U.S. Court of Appeals for Veterans Claims (CAVC) has made it clear that the Board must consider the totality of the Veteran's symptoms when determining the rating to be assigned for a psychiatric disability. Under the 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). The presence or absence of any one symptom listed in the criteria is not necessarily dispositive of any particular disability level. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013); Mauerhan v. Principi, 16?Vet. App.?436 (2002). Here, the overall record does not present a disability picture of total occupational and social impairment; rather, the totality of the evidence shows that the Veteran's service-connected PTSD more closely approximates occupational and social impairment with deficiencies in most areas (or lesser severity at times) throughout. Accordingly, a rating in excess of 70 percent is not warranted, and the appeal in this matter must be denied.

2. Entitlement to a TDIU is granted.

Legal Criteria

A TDIU may be assigned, where the schedular rating is less than total, when the Veteran is unable to maintain a substantially gainful occupation as a result of service-connected disability. 38 C.F.R. §§ 3.340, 3.341, 4.16. If there is only one such disability, it must be rated at 60 percent or more; if there are two or more disabilities, at least one must be rated at 40 percent or more, with sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a).

For the above purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system, e.g., orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric, (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war.

Total disability will be considered to exist when there is impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation; provided that permanent total disability shall be taken to exist when the impairment is reasonably certain to continue throughout the life of the disabled person. 38 C.F.R. § 4.15.

Substantially gainful employment is defined as work that is more than marginal and that permits the individual to earn a living wage. Moore v. Derwinski, 1 Vet. App. 356 (1991). In Faust v. West, 13 Vet. App. 342 (2000), the CAVC defined substantially gainful employment as "an occupation that provides an annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days that the Veteran actually works and without regard to the Veteran's earned annual income."

The sole fact that a claim
is reasonably certain to continue throughout the life of the disabled person. 38 C.F.R. § 4.15.

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 and keep employment. Rather, the dispositive question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether the Veteran can find employment.

In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training, and previous work experience, but not to his age or impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19.

In a claim for a TDIU, the ultimate question of whether a Veteran is capable of substantially gainful employment is not a medical one; that determination instead is for the adjudicator. 38 C.F.R. § 4.16(a); Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013).

VA is responsible for determining whether the evidence persuasively favors one side or another. 38 C.F.R. § 4.3. When there is an approximate or nearly equal balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the Veteran and the claim will be granted on the merits. 38 U.S.C. § 5107(b). When the evidence persuasively favors against the claims of the Veteran, the benefit of the doubt doctrine is inapplicable and the claim will be denied on its merits. 38?U.S.C. §?5107; Lynch v. McDonough, 21 F.4th 776, 781 (Fed. Cir. 2021) (en banc).

Factual Background and Analysis

[The evidentiary record pertaining to the Veteran's PTSD outlined above is incorporated into this TDIU section.]

The Veteran's service-connected disabilities of PTSD (rated 70 percent); type 2 diabetes mellitus (rated 20 percent); left tibia and/or fibula fracture (rated 20 percent from July 6, 2023 to October 19, 2023, then 0 percent from that date); nonlinear hyperpigmentation of the right neck (rated 0 percent); nonlinear hyperpigmentation of the upper chest (rated 0 percent); nonlinear hyperpigmentation of the upper back (rated 0 percent); linear hyperpigmentation / scarring of the right upper arm (rated 0 percent); and hypertension (rated 0 percent), are rated 80 percent, combined. The 38 C.F.R. § 4.16(a) schedular rating requirements for a TDIU are met. The remaining (and dispositive) question is whether his service-connected disabilities render him incapable of maintaining regular substantially gainful occupation consistent with his education and work experience.

In VA Form 21-8940's received in August 2023 and October 2023, the Veteran reported that his PTSD and his type 2 diabetes mellitus prevent him from securing or following substantially gainful employment. In his updated October 2023 Form 21-8940, he reported that he most recently worked as a security guard in 2008 and that he left that job due to his disabilities. He also reported that he is a high school graduate without additional training.

The symptoms and manifestations associated with the Veteran's PTSD are outlined above (in the claim for increase). Notably, a November 2023 VA examiner opined that the Veteran's PTSD impacts his ability to perform all forms of work, including sedentary labor, because his ability to maintain appropriate social interaction with coworkers and customers would be moderately to severely impaired; his ability to handle low stress in an occupational environment would be moderately to severely impaired; his ability to concentrate, persist, and maintain pace would be moderately impaired; and his ability to understand, remember, and apply information would be mildly impaired.

Additionally, Dr. K.B.
due to his disabilities. He also reported that he is a high school graduate without additional training.

Additionally, Dr. K.B. has opined that the Veteran has been unable to sustain substantially gainful employment since July 6, 2023 due to his PTSD. She opined that he would be unable to focus on work tasks, that he would have difficulty acting appropriately in a workplace (including to stressors and interpersonal conflicts), and that he would experience an increased risk of suicidal thoughts and depressive symptoms.

Lastly, L., the Veteran's daughter who acts in substantial part as a caretaker for the Veteran and his spouse, has opined that the Veteran is unable to work because he is quick-tempered, always on guard, does not sleep well, is fatigued and irritable, has trouble concentrating, and would not feel safe in a workplace.

Turning to the Veteran's other service-connected disabilities, the evidence suggests that the Veteran's diabetes mellitus manifests in fatigue and leg numbness (as reported by his daughter (a lay person, and not a medical provider)).

Lastly, the Veteran's left leg disability is manifested by pain, impaired mobility, and falls. It limits prolonged standing and requires use of a cane. See February 2024 VA knee and lower leg conditions examination report.

Upon longitudinal review of the evidence of record, and resolving reasonable doubt in the Veteran's favor, the Board finds the evidence at least in approximate balance that a TDIU is warranted.

As outlined above, the Veteran's PTSD results in occupational and social impairment with deficiencies in most areas. Specifically, it results in anxiety, stress, difficulty concentrating, difficulty maintaining relationships, difficulty interacting with others, hypervigilance, and suspiciousness. His left leg disability limits his ability to perform prolonged standing and walking. And his diabetes results in fatigue and the need to follow a specific diet. Such impairment limits the Veteran's ability to perform physical work and to interact with others (employees and customers) in a less physical environment.

The Board acknowledges Dr. K.B.'s opinion that the Veteran has been unable to sustain substantially gainful employment since July 2023 solely due to his PTSD. However, for the reasons outlined above, the Board finds Dr. K.B.'s retrospective opinion provided several years after the date of claim (including that such has been manifested by total impairment since July 2023) less probative than the contemporaneous evidence of record.

Resolving any remaining reasonable doubt in the Veteran's favor, as required (see 38 C.F.R. § 4.3), the Board finds that a TDIU is warranted based on the combined effect of all of the Veteran's service-connected disabilities (and not based on a single disability, alone).

[The assignment of an effective date for the award of a TDIU is downstream issue for the AOJ to address in the first instance.]

3. Entitlement to SMC based on the need for A&A for the Veteran's spouse is granted.

Legal Criteria

The Veteran has a combined disability rating of at least 30 percent; consideration of spousal aid and attendance is therefore appropriate. 38 U.S.C. § 1115.

SMC is payable to a veteran by reason of their spouse being in need for aid and attendance. 38 U.S.C. § 1115(1)(E); 38 C.F.R. § 3.351(a)(2). SMC based on the need for aid and attendance of another is payable if, the veteran's spouse is blind or so nearly blind as to have corrected visual acuity of 5/200 or less, in both eyes, or concentric contraction of the visual field to 5 degrees or less; a patient in a nursing home because of mental or physical incapacity; or a factual need for aid and attendance under the criteria set forth in 38 C.F.R. § 3.352(a) is established. 38 C.F.R. § 3.351(c).

Pursuant to 38 C.F.R. § 3.352(a), the following factors will be considered in determining whether regular aid and attendance of another person is needed: inability of claimant to dress or
another is payable if, the veteran's spouse is blind or so nearly blind as to have corrected visual acuity of 5/200 or less, in both eyes, or concentric contraction of the visual field to 5 degrees or less; a patient in a nursing home because of mental or physical incapacity; or a factual need for aid and attendance under the criteria set forth in 38 C.F.R. § 3.352(a) is established. 38 C.F.R. § 3.351(c).

Pursuant to 38 C.F.R. § 3.352(a), the following factors will be considered in determining whether regular aid and attendance of another person is needed: inability of claimant to dress or undress himself (herself), or to keep himself (herself) ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid (this will not include the adjustment of appliances which normal persons would be unable to adjust without aid, such as supports, belts, lacing at the back, etc.); inability of claimant to feed himself (herself) through loss of coordination of upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect the claimant from hazards or dangers incident to his or her daily environment.

It is not required that all of the disabling conditions noted above be found to exist before a favorable rating may be made. Id. The particular personal functions which the veteran's spouse is unable to perform should be considered in connection with his or her condition as a whole. Id. It is only necessary that the evidence establish that the veteran's spouse is so helpless as to need regular aid and attendance, not that there is a constant need. Id.

Factual Background and Analysis

On February 19, 2025, VA received a VA Form 21-526EZ in which the Veteran claimed aid and attendance for his spouse. VA also received a VA Form 21-2680 (examination for housebound status or permanent need for regular aid and attendance) for the Veteran's spouse completed by a private physician. The physician reported that the spouse has a diagnosis of end-stage renal disease (ESRD) that requires dialysis. He checked the respective boxes to indicate she requires assistance with bathing/showering, eating or self-feeding (specifically to cut food), medication management, and additional activities such as housekeeping, laundering, meal preparation, etc. The physician also noted that the spouse has decreased stamina and difficulty with prolonged standing and walking due to fatigue and weakness. She must "sit after just a couple of minutes." This impacts the spouse's ability to stand for grooming and home management. He explained that the spouse requires maximum assistance for home management and for the instrumental activities of daily living (IADLs). He also noted that the spouse goes to dialysis on Monday, Wednesday, and Friday with minimal assistance due to low vision (noting she is legally blind in her right eye). She otherwise only leaves home for medical appointments with assistance from a caregiver. She requires the assistance of a caregiver or cane/brace/crutches to ambulate one block.

In March 2025, VA received private medical records for the Veteran's spouse. A December 2024 treatment record notes the spouse attends dialysis on Monday, Wednesday, and Friday. The assessments include unstable gait, type 2 diabetes mellitus with chronic kidney disease, ESRD on dialysis, essential hypertension, weakness of both lower extremities, pericardial effusion, and chronic diastolic heart failure. A February 2025 treatment record notes that the Veteran's spouse has stage 5 chronic kidney failure.

In a statement received on December 16, 2025, the Veteran's daughter reported that the Veteran's spouse requires assistance with daily tasks because she is blind in one eye, is on dialysis, and has been diagnosed with congestive heart failure. She explained that she cooks, cleans, does laundry, schedules appointments, schedules appointments, and manages medication for the Veteran's spouse. She also explained that the spouse uses a rollator to get around and that she cannot walk far because she becomes easily winded.

Based on the foregoing, the Board finds that the evidence of record sufficiently demonstrates that SMC based on the need for A&A for the Veteran's spouse is warranted. Although the Veteran's spouse is neither blind in both eyes nor a patient in a nursing home, the evidence is at least in approximate or nearly equal balance that she requires assistance with bathing/showering, eating (specifically to cut food), medication management, and additional activities such
diagnosed with congestive heart failure. She explained that she cooks, cleans, does laundry, schedules appointments, schedules appointments, and manages medication for the Veteran's spouse. She also explained that the spouse uses a rollator to get around and that she cannot walk far because she becomes easily winded.

Based on the foregoing, the Board finds that the evidence of record sufficiently demonstrates that SMC based on the need for A&A for the Veteran's spouse is warranted. Although the Veteran's spouse is neither blind in both eyes nor a patient in a nursing home, the evidence is at least in approximate or nearly equal balance that she requires assistance with bathing/showering, eating (specifically to cut food), medication management, and additional activities such as housekeeping, laundering, and meal preparation. She also is unable to ambulate without the assistance of a device or a caregiver, and she requires assistance with her health care needs, including specifically to attend dialysis appointments several times per week. Accordingly, SMC based on the need for regular A&A of the Veteran's spouse is granted.

REASONS FOR REMAND

4. Entitlement to SMC based on the need for A&A for the Veteran.

On February 19, 2025, VA received a VA Form 21-526EZ in which the Veteran claimed aid and attendance for himself. VA also received a VA Form 21-2680 (examination for housebound status or permanent need for regular aid and attendance) completed by a private physician. The physician reported that the Veteran requires assistance with bathing/showering, dressing, ambulating within the home, tending to hygiene needs, transferring in or out of bed/chair, toileting, medication management, and additional activities such as housekeeping, transportation, and meal preparation. The physician identified the diagnosis as subdural hematoma; the Veteran has not established service connection for such disability. The physician related symptoms of impaired mobility and balance, short term memory deficits, weakness, and dizziness / vertigo to the subdural hematoma.

Although the Veteran has not established service connection for subdural hematoma, evidence outlined in the PTSD and TDIU matters above suggests his service-connected disabilities (including PTSD, type 2 diabetes mellitus, and left leg disability) may require the need of regular aid and attendance. Failure to provide the Veteran with a VA examination for A&A based solely on his service-connected disabilities constitutes a pre-decisional duty to assist error.

The matter is REMANDED for the following action:

Schedule the Veteran for a VA examination for housebound status or permanent need for regular aid and attendance.

The examiner should assess the severity of the Veteran's service-connected disabilities and the impact of only his service-connected disabilities on his activities of daily living and whether he can leave his home, including whether his disabilities cause him to be unable to dress or undress, keep ordinarily clean and presentable, adjust of any special prosthetic or orthopedic appliances without aid, feed himself, attend to the wants of nature, or protect himself against the hazards or dangers incident to his daily environment.

The examiner should also address whether the Veteran is considered permanently bedridden by reason of his service-connected disabilities, and whether he requires nursing home/assisted living care.

S. CHARLES NEILL

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board J. Dupont, Counsel

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.

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