Citation Nr: A22004457 Decision Date: 03/14/22 Archive Date: 03/14/22 DOCKET NO. 210218-142558 DATE: March 14, 2022 ORDER 1. An effective date prior to September 1, 2016, for the award of a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) rating, is denied. 2. An effective date prior to September 1, 2016, for the award of special monthly compensation (SMC) at the housebound rate, is denied. 3. A 100 percent rating for posttraumatic stress disorder (PTSD) with major depressive disorder, panic disorder, major neurocognitive disorder, traumatic brain injury (TBI), and colloid cyst at foramen of Monro, from the earlier date of September 1, 2016, is granted, subject to the regulations governing payment of monetary awards. 4. Entitlement to special monthly compensation based on aid and attendance under 38 U.S.C. § 1114(t) [SMC(t)] for a TBI is denied. FINDINGS OF FACT 1. The Veteran's initial claim of service connection for PTSD was filed in service. 2. The Veteran separated from service on August 31, 2016. 3. A September 2016 rating decision awarded service connection for PTSD with major depressive disorder, panic disorder, major neurocognitive disorder, TBI, and colloid cyst at foramen of Monro, rated 70 percent effective September 1, 2016. 4. An August 2017 rating decision continued the evaluation for PTSD. 5. Additional evidence relevant to determining the evaluation for PTSD was received in May 2017 and February 2018, within a one-year appeal period following the September 2016 and August 2017 rating decisions, respectively. The Agency of Original Jurisdiction (AOJ) did not determine whether the February 2018 evidence was new and material as to the evaluation of his PTSD. 6. An October 2020 rating decision awarded a TDIU rating and SMC at the housebound rate from the earlier effective date of September 1, 2016. 7. It is reasonably shown by the evidence in the record that from September 1, 2016 (the earlier effective date), the Veteran's PTSD had manifested symptoms indicating total occupational and total social impairment. 8. The Veteran's service-connected TBI does not require the need for personal healthcare services provided on a daily basis in the Veteran's home by a person who is licensed to provide such services or who provides such services under the regular supervision of a licensed healthcare professional. 9. The effects of the Veteran's service-connected disabilities do not meet the requirements necessary to warrant special monthly compensation at the "(m)," "(n)," "(o)," "(p)," "(r)," rates or intermediate rates higher than the "(l)" rate. CONCLUSIONS OF LAW 1. An effective date prior to September 1, 2016, for the award of a TDIU rating, is not warranted. 38 U.S.C. §§ 5101, 5110; 38 C.F.R. §§ 3.151, 3.155, 3.156, 3.400. 2. An effective date prior to September 1, 2016, for the award of SMC at the housebound rate, is not warranted. 38 U.S.C. §§ 5101, 5110; 38 C.F.R. §§ 3.151, 3.155, 3.156, 3.400. 3. An earlier effective date of September 1, 2016 is warranted for the award of a 100 percent rating for PTSD. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 3.151, 3.400(o)(2), 4.1, 4.3, 4.130, Diagnostic Code (Code) 9411. 4. The criteria to establish eligibility for SMC(t) have not been met. 38 U.S.C. § 1114(t); 38 C.F.R. §§ 3.350(j), 3.352. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 2000 to August 2016. These matters are before the Board of Veterans' Appeals (Board) on appeal of October 2020 Department of Veterans Affairs (VA) rating decisions. A September 2017 rating decision under the legacy system denied eligibility for SMC(t) and the Veteran submitted a timely notice of disagreement (NOD). In June 2020, the AOJ issued a statement of the case (SOC). In June 2020, the Veteran submitted a VA Form 20-0996, Decision Review Request: Higher-Level Review (HLR), and opted this issue into the Appeals Modernization Act (AMA), from the June 2020 SOC. In October 2020, the AOJ issued the HLR decision on appeal, which considered the evidence of record at the time of the June 2020 SOC and continued the denial of eligibility for SMC(t). An August 2018 rating decision under the legacy system continued the 70 percent rating for PTSD and he submitted a timely NOD, also raising entitlement to a TDIU rating as part and parcel to his claim for an increased rating for PTSD. An April 2020 rating decision awarded an increased rating (to 100 percent) for PTSD as well as SMC at the housebound criteria, both effective February 26, 2020. Also in April 2020, the AOJ issued a SOC. In May 2020, the Veteran submitted a VA Form 20-0096, Decision Review Request: HLR, and opted the issues into the AMA from the April 2020 SOC. In the October 2020 HLR rating decision, the AOJ awarded an increased rating (to 100 percent) for PTSD from an earlier effective date of May 10, 2018, and also awarded a TDIU rating and SMC at the housebound rate from an earlier effective date of September 1, 2016. The Veteran timely appealed these October 2020 rating decisions to the Board and requested the submission of additional evidence lane. Therefore, in the matter of eligibility for SMC(t), the Board's review is limited to evidence on record at the time of the June 5, 2020 SOC and evidence submitted by the appellant or his representative within 90 days following the receipt of VA Form 10182 (received February 18, 2021). In the matters of entitlement to a 100 percent rating for PTSD prior to May 2018, and entitlement to a TDIU rating and SMC at the housebound criteria prior to September 1, 2016, the Board's review is limited to evidence on the record at the time of the April 30, 2020 SOC and evidence submitted by the appellant or his representative within 90 days following the receipt of VA Form 10182 (received February 18, 2021). The appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C. § 7107(a)(2). Earlier Effective Date Except as otherwise provided, the effective date of an award of compensation based on an original claim or a claim to reopen will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. If a claim is received within one year following separation the effective date of an award of compensation shall be the day following separation from service or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(b); 38 C.F.R. § 3.400(b)(2). An appeal in the legacy system consists of a timely-filed NOD in writing and, after an SOC has been furnished, a timely-filed substantive appeal. To perfect an appeal to the Board, a substantive appeal must be filed within 60 days from the date the AOJ mails a claimant a SOC or within the remainder of the one-year period from the date of mailing of the rating decision being appealed, whichever period ends later. 38C.F.R. § 19.52. Otherwise, the rating decision becomes final. 38 C.F.R. § 20.1103. However, under the legacy system, new and material evidence received within a one-year period following issuance of a rating decision is to be considered as having been received in connection with the claim pending at the beginning of the appeal period. See 38 C.F.R. § 3.156 (b); Beraud v. McDonald, 766 F.3d 1402, 1407 (Fed. Cir. 2014); Bond v. Shinseki, 659 F.3d 1362, 1367 (Fed. Cir. 2011); Mitchell v. McDonald, 27 Vet. App. 431, 436 (2015). If VA receives new and material evidence within the one-year appeal period following a rating decision, it must be considered in accordance to 38 C.F.R. § 3.156(b); if this evidence is not considered, the underlying claim does not become final and remains pending. Beraud, 766 F.3d at 1407. In such situation, the applicable rating action will not become final, and any subsequent decision based on such evidence will be considered to be on the original claim. Id. at 1406-07. The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). 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, No. 2020-2067, 2021 U.S. App. LEXIS 37307 (Fed. Cir., Dec. 17, 2021) (en banc). The Veteran filed an initial claim of service connection for PTSD while in service. A March 2016 rating decision proposed to establish service connection for PTSD with major depressive disorder, TBI, and colloid cyst at foramen of Monro with a 70 percent evaluation. The Veteran separated from service on August 31, 2016. A September 2016 rating decision awarded service connection for PTSD with major depressive disorder, panic disorder, major neurocognitive disorder, TBI, and colloid cyst at foramen of Monro, rated 70 percent effective September 1, 2016. Here, the Veteran did not submit a NOD with the September 2016 rating decision, but new and material evidence was received within a year of the rating decision (i.e., a May 2017 VA examination documenting symptoms consistent with an increased rating for his PTSD). An August 2017 rating decision readjudicated the claim in light of the evidence of record, to include the May 2017 VA examination, and continued the 70 percent rating for PTSD. The Veteran did not submit a NOD with the August 2017 rating decision; however, new and material evidence was received within a year of the rating decision. In February 2018, the Veteran submitted a private PTSD disability benefits questionnaire (DBQ) documenting symptoms consistent with an increased rating for his PTSD. Because this evidence was received within the appeal period of the August 2017 rating decision and is reasonably related to his claim for an increased rating for PTSD, VA had an obligation to consider the evidence as having been filed in connection with his original claim for evaluation of PTSD, and then determine whether it was new and material. 38 C.F.R. § 3.156 (b); Beraud, 766 F.3d at 1406-07. The AOJ, however, never determined whether this evidence was new and material under 38 C.F.R. § 3.156(b), and so the claim remained unadjudicated. Accordingly, the August 2017 rating decision did not become final and the original claim remains open. See 38 C.F.R. § 3.156(b); Beraud, 766 F.3d at 1407). On May 10, 2018, VA received a formal claim for an increased rating for PTSD. As discussed above, he timely appealed the subsequent August 2018 rating decision and opted the matters into AMA. 1. 2. An effective date prior to September 1, 2016, for the award of a TDIU rating and SMC at the housebound rate, is denied. A claim for entitlement to a TDIU rating is considered part and parcel of the increased rating claim. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Additionally, VA has a "well-established" duty to maximize a claimant's benefits. See Buie v. Shinseki, 24 Vet. App. 242 (2011); AB v. Brown, 6 Vet. App. 35, 38 (1993). This duty to maximize benefits requires VA to assess all of a claimant's disabilities to determine whether any combination of disabilities establishes entitlement to SMC under 38 U.S.C. § 1114. See Bradley v. Peake, 22 Vet. App. 280, 294 (2008). The October 2020 rating decision found TDIU was reasonably raised while the evaluation for his service-connected PTSD remained pending and had not been finally adjudicated. The Board is bound by this favorable finding. 38 C.F.R. § 3.104(c). As noted above, the Veteran first filed a claim of service connection for PTSD while still in service. The AOJ awarded entitlement to a TDIU rating and to SMC at the housebound rate from September 1, 2016, the day after following separation. The Board is bound by governing law and regulations, and has no authority to awards benefits not authorized by governing law. Because the Veteran separated from service on August 31, 2016, VA is precluded from granting an effective date prior to September 1, 2016 for the award of a TDIU rating and SMC at the housebound rate. As the AOJ has already assigned the earliest possible effective date under governing law given the undisputed facts in this case, the law is dispositive in this matter. Sabonis v. Brown, 6 Vet. App. 426 (1994). Considering the foregoing, the Board finds that an effective date prior to September 1, 2016 for the award of a TDIU rating and SMC at the housebound rate is not warranted and this portion of the appeal must be denied. Increased Rating Disability evaluations are determined by the application of a schedule of rating, which is based on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Where the appeal is from the initial rating decision assigned with an award of service connection, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). If there is a question as to which of two ratings shall be assigned, the higher criteria will be assigned if the disability more closely approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 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 claimant 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, No. 2020-2067, 2021 U.S. App. LEXIS 37307 (Fed. Cir., Dec. 17, 2021) (en banc). 3. A 100 percent rating for PTSD from September 1, 2016 is granted. PTSD is rated under Code 9411 (and the general rating criteria for mental disorders). A 70 percent rating is warranted for 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); and inability to establish and maintain effective relationships. A 100 percent (maximum schedular) rating for PTSD is warranted when there is total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintaining 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. VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). The use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms listed after that phrase are not intended to constitute an exhaustive list, but rather 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). Nevertheless, all ratings in the general rating formula are also associated with objectively-observable symptomatology and the plain language of the regulation makes it clear that a veteran's impairment must be "due to" those symptoms; a veteran may only qualify for a given disability rating by demonstrating the particular symptoms result in functional impairment associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. Thus, while certain symptoms might be present on isolated occasions, such symptoms must also produce the contemplated level of occupational and social impairment to provide a basis for increased rating assignments in any particular period. When evaluating the level of disability from a mental disorder, the rating agency shall consider the extent of social impairment, but shall not assign an evaluation based solely on social impairment. The focus of the rating process is on industrial impairment from the service-connected psychiatric disorder, and social impairment is significant only insofar as it affects earning capacity. 38 C.F.R. §§ 4.126, 4.130. For residuals of TBI under Code 8045, there are three main areas that may result from a TBI and have profound effects on functioning: cognitive (which is common in varying degrees after a traumatic brain injury), emotional/behavioral, and physical. Each of these areas may require evaluation. Cognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain. Executive functions include goal setting, speed of information processing, planning, prioritizing, self-monitoring, decision making, spontaneity, and flexibility in changing unproductive actions. Not all of these brain functions may be affected in a given individual with cognitive impairment, and some functions may be affected more severely than others. In a given individual, symptoms may fluctuate in severity from day to day. Cognitive impairment is to be evaluated under the table titled "Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified." Subjective symptoms may be the only residual of a TBI or may be associated with cognitive impairment or other areas of dysfunction. Subjective symptoms that are residuals of a TBI, whether or not they are part of cognitive impairment, should be evaluated under the subjective symptoms facet in the table titled "Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified". However, VA is to separately evaluate any residual with a distinct diagnosis that may be evaluated under another code, such as migraine headache, even if that diagnosis is based on subjective symptoms, rather than under the "Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified" table. Emotional/behavioral dysfunction is evaluated under 38 C.F.R. § 4.130 (Schedule of ratings - mental disorders) when there is a diagnosis of a mental disorder. When there is no diagnosis of a mental disorder, evaluate emotional/behavioral symptoms under the criteria in the table titled "Evaluation of Cognitive Impairment and Other Residuals of Traumatic Brain Injury Not Otherwise Classified". Physical (including neurological) dysfunction is evaluated based on the following list, under an appropriate code: Motor and sensory dysfunction, including pain, of the extremities and face; visual impairment; hearing loss and tinnitus; loss of sense of smell and taste; seizures; gait, coordination, and balance problems; speech and other communication difficulties, including aphasia and related disorders, and dysarthria; neurogenic bladder; neurogenic bowel; cranial nerve dysfunctions; autonomic nerve dysfunctions; and endocrine dysfunctions. The preceding list of types of physical dysfunction does not encompass all possible residuals of a TBI. Residuals not listed in 38 C.F.R. § 4.124a, Code 8045 that are reported on an examination, are to be evaluated under the most appropriate code. Each condition is to be evaluated separately (as long as the same signs and symptoms are not used to support more than one evaluation), and the evaluations for each separately rated condition are combined under 38 C.F.R. § 4.25. The evaluation assigned based on the "Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified" table will be considered the evaluation for a single condition for purposes of combining with other disability evaluations. The table titled "Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified" contains 10 important facets of a traumatic brain injury related to cognitive impairment and subjective symptoms. It provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and a 5th level, the highest level of impairment, labeled "total". However, not every facet has every level of severity. The consciousness facet, for example, does not provide for an impairment level other than "total", since any level of impaired consciousness would be totally disabling. A 100 percent evaluation is assigned if "total" is the level of evaluation for one or more facets. If no facet is evaluated as "total", the overall percentage evaluation is assigned based on the level of the highest facet as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent. For example, a 70 percent evaluation is assigned if 3 is the highest level of evaluation for any facet. The following note is pertinent for this case: (1) There may be an overlap of manifestations of conditions evaluated under the table titled "Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified" with manifestations of a comorbid mental or neurologic or other physical disorder that can be separately evaluated under another diagnostic code. In such cases, do not assign more than one evaluation based on the same manifestations. If the manifestations of two or more conditions cannot be clearly separated, assign a single evaluation under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning due to both conditions. However, if the manifestations are clearly separable, assign a separate evaluation for each condition. In a November 2015 VA PTSD examination (conducted before separation from service), PTSD, major depressive disorder, and TBI were diagnosed. Symptoms included: depressed mood, anxiety, suspiciousness, panic attacks more than once per week, near continuous panic or depression affecting the ability to function independently, appropriately and effectively, memory loss for names of close relatives, own occupation, and own name, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances including work or a worklike setting. The examiner attributed the anxiety, nightmares, and intrusive thoughts to PTSD; the depressed mood, loss of interest, and social withdrawal to depression; and the memory impairment to TBI. The examiner opined the psychiatric diagnosis would result in occupational and social impairment with reduced reliability and productivity. The examiner opined it is not possible to differentiate what portion of the occupational and social impairment is caused by the TBI, noting symptoms are comorbid and mutually aggravating. In a November 2015 VA TBI examination, there was objective testing of mild impairment of memory, attention, concentration, or executive functions resulting in mild impairment. The Veteran's judgment was normal. His social interaction was routinely appropriate. He was oriented to person, time, place, and situation. His motor activity was normal. His visual spatial orientation was normal. He reported three or more subjective symptoms that moderately interfere with work, instrumental activities of daily living, or work, family or other close relationships (marked fatiguability, blurred or double vision, and headaches). He reported one or more neurobehavioral effects that do not interfere with workplace interaction, social interaction, or both but do not preclude them. He was able to communicate by spoken and written language and to comprehend spoken and written language. His consciousness was normal. The examiner opined his memory, vision, hearing, and vestibular deficits are associated with the service-related concussion. A December 2016 VA treatment record notes the Veteran does not provide independent care for his three children due to high anxiety, especially with the youngest, who was four years old. A December 2016 VA treatment record notes the Veteran reported worsening memory problems and worsening anxiety, which he said affected his independence. He reported an increase in daily anxiety triggers and an incident where he did not set a timer when trying to cook on the stove, causing a small fire (so he no longer cooks meals). The provider opined the worsening cognitive concerns are likely a result of his increasing mental health problems and continued lack of sleep. The provider noted that until the Veteran could control his anxiety, he would be likely unable to consistently implement strategies to compensate for cognitive concerns. In a February 2017 VA treatment record, the Veteran reported he becomes extremely anxious when left alone and requires assistance from his wife to compensate for his memory loss and physical impairments. In a May 2017 VA PTSD examination, PTSD, major depressive disorder, and TBI were assessed. Symptoms of his psychiatric disability included: depressed mood, anxiety, panic attacks that occur weekly or less often, chronic sleep impairment, flattened affect, suicidal ideation, impaired impulse control (including unprovoked irritability with periods of violence), and intermittent inability to perform activities of daily living (including minimal personal hygiene). The examiner opined the diagnoses would result in occupational and social impairment with reduced reliability and productivity; he was not able to differentiate what symptoms are attributable to each diagnosis or what portion of the occupational and social impairment is caused by the TBI, noting the significant overlap of symptoms. On May 2017 VA TBI examination, the Veteran reported mood symptoms, anxiety, irritability, tinnitus, memory problems, chronic headaches, stutters when he gets nervous, sensitivity, hearing loss, dizziness, feeling off balance, and chronic pain. There was objective testing of moderate impairment of memory, attention, concentration, or executive functions resulting in moderate impairment, noting he has difficulty remembering names, dates, and topics of previous discussion, has short term memory loss, relies on his phone for calendar and scheduling, and misplaces items frequently. His judgment was normal. His social interaction was frequently inappropriate, noting he isolates and avoids social interaction. He was always oriented to person, time, place, and situation. His motor activity was normal. His visual spatial orientation was normal. He reported three or more subjective symptoms that moderately interfere with work, instrumental activities of daily living, or work, family or other close relationships (sensitivity to light, tinnitus, and memory problems). He reported one or more neurobehavioral effects that frequently interfere with workplace interaction, social interaction, or both but do not preclude them (irritability and impulsivity). He was able to communicate by spoken and written language and to comprehend spoken and written language. His consciousness was normal. The examiner noted residuals of TBI include tinnitus; gait, coordination, and balance; headaches; and mood disorder. The examiner opined there was significant overlap of symptoms and each diagnosis (TBI and PTSD) can cause isolation, irritability, mood changes, aggression, memory/concentration problems, anxiety, depression, and insomnia. The examiner opined these symptoms can make it difficult to interact with others, can decrease productivity, may lead to increase sick days and disciplinary action due to mood, irritability, impulsivity, and oversights due to memory problems. In February 2018, the Veteran submitted a private disability benefits questionnaire by a private psychologist (Dr. B.V.). PTSD, severe recurrent major depressive disorder, and TBI were diagnosed. Symptoms of his psychiatric/TBI disability included: depressed mood, anxiety, suspiciousness, panic attacks more than once per week, near continuous panic or depression affecting the ability to function independently, chronic sleep impairment, impaired judgement, impaired abstract thinking, gross impairment in thought process or communication, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, suicidal ideation, persistent danger of hurting self or others, neglect of personal appearance and hygiene, and intermittent inability to perform activities of daily living (including minimal personal hygiene). The provider opined he was able to distinguish the symptoms attributed to the depressive disorder, PTSD, and TBI. Notably, he attributed chronic sleep impairment and inability to perform activities of daily living, including maintenance of minimal personal hygiene to PTSD and attributed memory loss and attention deficits in more complex learning and memory for both verbal and nonverbal material to his TBI. The provider opined that the disability results in total occupational and social impairment. Additionally, the provider opined that it is more likely than not that the Veteran suffers from a total impairment in one or more categories of executive function since the Veteran has great difficulty with memory, concentration, processing, planning, organizing, and prioritizing, self-monitoring or problem solving. He noted the Veteran forgets dates, topics of previous discussions of his TBI, relies upon his telephone for calendar and scheduling of appointments, and misplaces items frequently. He reported the Veteran scored a 0 on the MOCA Delayed Recall (0/5), and opined his executive function of memory, processing, planning, organizing, prioritizing, and flexibility are severely impaired rendering him with a total level of impairment. The provider found the Veteran's TBI impairment has caused the Veteran to have complete inability to work in any profession and he must be taught proper self-care and proper sleep hygiene on a regular basis due to his inability to remember, process, plan, organize, or prioritize. He noted the Veteran requires assistance or supervision from others more than 75 percent of the time. In an October 2018 statement, the Veteran reported that he still has residuals of his TBI. He noted that his short-term memory is poor. He reports he routinely forgets conversations and misplaces items. He reported that his wife is his primary caregiver. She has to remind him to brush his teeth or groom, gives him medications, tells him when to shower, and help him put on socks. The Veteran apparently failed to report for an examination scheduled in August 2018. The rescheduled examination was ultimately conducted in February 2020. In the February 2020 VA PTSD examination, the Veteran reported he was unable to work, unable to be alone in his house without his wife or mother there to prevent him from having a panic or anxiety attack, unable to be out in public around people, and unable to have the kind of relationship he wants to have with his wife and children. PTSD, major depressive disorder, major neurocognitive disorder due to multiple etiologies with behavioral disturbance were diagnosed. The examiner opined that the disability results in total occupational and social impairment. Symptoms of his psychiatric disability include: depressed mood, anxiety, suspiciousness, near continuous panic affecting his ability to function (requiring his mother or his wife to be with him at all times), chronic sleep impairment (affecting short and long-term memory, forgetting to complete tasks, and forgetting where he is going), disturbance of motivation and mood, difficulty establishing and maintaining work and social relationships, difficulty adapting to stressful circumstances, inability to establish and maintain effective relationships, and daily suicidal ideation. The examiner opined it is not possible to differentiate symptoms attributable to each diagnosis, noting those more likely due to his TBI include headache, dizziness, slurred speech, nausea, vomiting, and diplopia while those that are caused by the overlapping diagnoses and cannot be differentiated include cognitive function mood fluctuation. The examiner found the Veteran did not appear competent to manage his own financial affairs and his wife therefore has a power of attorney. On February 2020 VA TBI examination, there was objective testing of moderate impairment of memory, attention, concentration, or executive functions resulting in moderate impairment. The Veteran reported he experiences difficulty in remembering and following conversation, difficulty with concentration, he no longer remembers the creeds and pledge of allegiance, he easily forgets appointments, and must rely on others texting him and reminding him if they are not present. His judgment was normal. His social interaction was frequently inappropriate, noting he no longer goes to college due to difficulty interacting with others, he stays to himself, and sometimes has a sense of fear but trust his wife and mother. He is occasionally disoriented to two of the four aspects or is often disoriented to one aspect of orientation. He reports he sometimes experiences a sense of loss of location and his sense of time is off. His motor activity was normal most of the time but mildly slowed at times due to apraxia. His visual spatial orientation was moderately impaired, noting he can get lost in familiar surroundings or forget where he is. He reported three or more subjective symptoms that moderately interfere with work, instrumental activities of daily living, or work, family or other close relationships (constant headaches and tinnitus, depression, fatigue, sensitivity to light, and visual disturbances). He reported one or more neurobehavioral effects that frequently interfere with workplace interaction or social interaction (or both) but do not prevent him for interactions (irritability, lack of motivation, verbal aggression, and sometimes physical aggression). Comprehension or expression (or both) of either spoken language or written language is only occasionally impaired and he could communicate complex ideas. His consciousness was normal. The examiner opined his TBI precludes gainful employment. In the February 2021 VA Form 10182, the Veteran, via his attorney, request an earlier effective date for the 100 percent rating for PTSD, arguing that the report from Dr. R.T. is new and relevant evidence (the applicable standard under AMA). The Veteran's PTSD with major depressive disorder, panic disorder, major neurocognitive disorder, TBI, and colloid cyst at foramen of Monro has been rated 70 percent under Code 8045-9411 from September 1, 2016 and 100 percent from May 10, 2018. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. The hyphenated diagnostic code indicates that the TBI disability is rated by analogy under the criteria for PTSD. As the Board found above that the September 2016 and August 2017 rating decisions have been rendered nonfinal by the receipt of new and material evidence within a year of each of the rating decisions, the critical question remaining is whether, at any time from September 1, 2016 (the day following his separation from service) to May 10, 2018, the Veteran's PTSD symptoms and their impact on occupational and social functioning approximated total occupational and total social impairment, warranting a 100 percent schedular rating. The Board finds that the evidence reasonably supports the award of a 100 percent rating for PTSD with major depressive disorder, panic disorder, major neurocognitive disorder, TBI, and colloid cyst at foramen of Monro symptoms from the earlier effective date of September 1, 2016. An April 2020 rating decision increased the rating for PTSD from 70 percent to 100 percent based on symptomology found on the February 2020 VA examination, including findings of forgetting names, forgetting recent events, near continuous depression and panic affecting the ability to function independently, appropriately, and effectively, difficulty understanding complex commands, impairment of short- and long-term memory, and total occupational and social impairment. Importantly, the October 2020 rating decision awarded the 100 percent rating from the earlier effective date of May 10, 2018 based on his claim for increased evaluation on May 10, 2018; the AOJ found good cause for the failure to report to the 2018 VA examination and that it was no fault of the Veteran that the rescheduled examination did not occur until 2020. While the November 2015 and May 2017 VA examiners declined to endorse that his psychiatric symptoms were severe enough to produce total occupational and social impairment, the Veteran's symptoms reported to the examiners (notably memory loss for names of close relatives, own occupation, or own name and intermittent inability to perform activities of daily living) and symptoms reported to VA treating providers are consistent with the subsequent private DBQ and VA examination, which found total occupational and social impairment. Although he remains married to his wife and his mother lives with him, he rarely leaves his home, requires significant assistance from them, and is unable to perform activities of daily living such as preparing his own food. Additionally, the Board notes the Veteran has not been able engage in any employment activities since he separated from service. In sum, the Veteran's PTSD has resulted in symptoms of similar severity, frequency, and duration to the symptoms associated with a 100 percent rating and have more nearly approximated total occupational and social impairment from September 1, 2016. Resolving any remaining reasonable doubt in the Veteran's favor (as required under 38 C.F.R. § 4.3), the Board finds that an earlier effective date of September 1, 2016 is warranted for a 100 percent rating for PTSD. The Board has considered whether a separate rating under Code 8045 for rating TBI is warranted and finds that it is not. November 2015, May 2017, and February 2020 VA examiners found the symptoms of the Veteran's TBI and diagnosed psychiatric disabilities are indistinguishable, opining that symptom and resulting impairment overlap significantly. While the private provider in February 2018 was able to distinguish which symptoms are attributable to which diagnoses, it is notable that the memory loss the private provider attributed solely to his TBI has also been associated to his mental health and the related sleep impairment by his VA provider. See December 2016 VA treatment record. If symptoms for a comorbid diagnosis (here PTSD) overlap with those under Code 8045, then a determination must be made as to which Code allows for the highest rating. 38 C.F.R. § 4.124a, Code 8045, Note (1). As the same symptoms may not be separately rated under two separate diagnostic codes (see 38 C.F.R. § 4.14) and the maximum (100 percent) rating is being awarded under Code 9411, the Veteran is adequately compensated under Code 9411 because this provides him with the highest rating for the overall level of impaired functioning due to both conditions. 4. Entitlement to special monthly compensation based on aid and attendance under SMC(t) for a TBI is denied. During the pendency of the appeal for an increased rating for PTSD and entitlement to eligibility to SMC at the T rate, the Veteran, via his attorney, raised entitlement to SMC under the (l) through (r)(2) criteria. October 2017 NOD. The attorney provided no argument for why the Veteran would be entitled the SMC under the (l) through (r)(2) criteria. The Veteran is already in receipt of SMC under 38 U.S.C. § 1114(s), based on the statutory housebound status. The Veteran states he needs supervision of healthcare providers and for other personal functions in daily living. February 2018 statement. In addition to regular levels of compensation for aid and attendance as authorized by 38 U.S.C. § 1114(l), 38 U.S.C. § 1114(r) provides for a higher level of benefit called "special aid and attendance" in certain circumstances. A veteran receiving the maximum rate under 38 U.S.C. § 1114(o), who is in need of regular aid and attendance or a higher level of care, is entitled to an additional allowance during periods he or she is not hospitalized at government expense. 38 U.S.C. § 1114(r)(1)-(2). A still higher-level aid and attendance allowance is authorized by 38 U.S.C. § 1114(r)(2), and is payable in lieu of the regular aid and attendance allowance authorized by 38 U.S.C. § 1114(r)(1). In addition, this higher level of aid and attendance allowance is payable whether or not the need for regular aid and attendance or a higher level of care was a partial basis for entitlement to the maximum rate under 38 U.S.C. § 1114 (o), or was based on an independent factual determination. The SMC provided by 38 U.S.C. § 1114(t) is payable to a Veteran who, as the result of service-connected disability, needs regular aid and attendance for the residuals of a TBI, is not eligible for compensation under 38 U.S.C. § 1114(r)(2), and in the absence of such regular aid and attendance would require hospitalization, nursing home care, or other residential institutional care. Determination of this need is subject to the criteria of § 3.352. 38 C.F.R. § 3.350(j). Section 3.352(b)(2) provides that a veteran is entitled to the higher level aid and attendance allowance authorized by § 3.350(j) when all of the following conditions are met: (i) As a result of service-connected residuals of TBI, the veteran meets the requirements for entitlement to regular aid and attendance allowance in paragraph (a); and (ii) As a result of service-connected TBI residuals, the veteran needs a "higher level of care" than is required to establish entitlement to the regular aid and attendance allowance, and without receiving such care, the veteran would need hospitalization, nursing home care, or other residential institutional care. In addition, 38 C.F.R. §§ 3.350 and 3.352 further explain criteria for granting aid and attendance benefits. These regulations also provide criteria as to when an R1 rate is to be granted and when an R2 rate is to be granted. The following criteria are used for determining the need for regular aid and attendance: (1) Inability of the claimant to dress or undress him or herself or to keep him or herself ordinarily clean and presentable; (2) Frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without assistance; (3) Inability of the claimant to feed him or herself through loss of coordination of upper extremities or through extreme weakness; (4) Inability to attend to the wants of nature; or (5) Incapacity, either physical or mental, that 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 enumerated in this paragraph be found to exist before a favorable rating may be made. The particular personal functions which the veteran is unable to perform should be considered in connection with his or her condition as a whole. It is only necessary that the evidence establish that the veteran is so helpless as to need regular aid and attendance, not that there be a constant need. Determinations that the veteran is in need of regular aid and attendance will not be based solely upon an opinion that the claimant's condition is such as would require him or her to be in bed. They must be based on the actual requirement of personal assistance from others. If any veteran, as the result of service-connected disability, is in need of regular aid and attendance for the residuals of TBI and in the absence of such a higher level of care would require hospitalization, nursing home care, or other residential institutional care, the veteran shall be paid, in addition to any other compensation under this section, a monthly aid and attendance allowance equal to the rate described in 38 U.S.C. § 1114(r)(2). 38 U.S.C. § 1114(t). Relevant to this inquiry is the question of whether the Veteran meets the requirements for (and is entitled to) a "higher rate of aid and attendance" under 38 U.S.C. § 1114(r)(2); this provision addresses the need for personal healthcare services provided on a daily basis at home by a licensed healthcare professional (or a caregiver under the regular supervision of a licensed provider). 38 C.F.R. § 3.352 (b)(2). Personal healthcare services include (but are not limited to) physical therapy, administration of injections, placement of indwelling catheters, and changing of sterile dressings, or like functions which require professional healthcare training or the supervision of a trained health care professional. A licensed healthcare professional includes (but is not limited to) a doctor of medicine or osteopathy, registered nurse, licensed practical nurse, or licensed physical therapist. 38 C.F.R. § 3.352(b)(3). If the Veteran were eligible for such a benefit under 38 U.S.C. § 1114(r)(2), he would not be entitled to SMC under 38 U.S.C. § 1114(t). The evidence demonstrates, however, that the Veteran is not eligible for this benefit under 38 U.S.C. § 1114(r)(2) because he does not meet the criteria of the other lower levels that are required for the (r)(2) rate. A December 2016 VA treatment record notes the Veteran underwent an initial eligibility assessment for the Program of Comprehensive Assistance for Family Caregivers and his wife, as his caregiver, was interviewed. His wife reported his care needs relate to PTSD, migraines, and TBI. She reported he is a safety risk related to falling and/or passing out, forgetting his medications, or leaving on electrical devices. A February 2017 VA treatment record notes the Veteran was not eligible for the Program of Comprehensive Assistance. The Veteran and his wife reported care needs related to back pain, migraines, colloid cyst, PTSD, and TBI. The determination found another person is not required to assist with the management of personal care functions required in everyday life, noting a recent evaluation found the Veteran to be independent or modified in all areas with the exception of bathing, in which a minimum of assistance was needed. Additionally, it was determined that there was no evidence that the Veteran would be unsafe in his home without a caregiver and he does not exhibit the risk factors for a higher level of care such as long term placement in an alternative care facility. In a July 2017 statement appealing the Caregiver determination (received in February 2018), the Veteran's wife reported that the Veteran requires constant supervision as it gives him moral support to keep him from being hospitalized for anxiety, PTSD, depression, and TBI conditions. She reports because the caregiver is not constant, he is unable to make the required VA appointments or remember his prescribed medications. She reported he suffers as she is unable to drive him to care during normal business hours and he needs a stable environment in which he has one caregiver that knows all of his needs and offers all forms of care. A July 2017 VA Caregiver Program support note, upholding the February 2017 determination, recommended the Veteran seek Homemaker/Home Health Aid for bathing assistance if desired and continuing mental health services. In the February 2018 private DBQ, the private provider noted the Veteran must be taught proper self-care and proper sleep hygiene on a regular basis due to his inability to remember, process, plan, organize, or prioritize. He remarked the Veteran requires assistance or supervision from others more than 75 percent of the time rendering him to have complete inability to care for himself. In the October 2018 statements, the Veteran and his wife said that if he did not have his wife or mother to take care of him, he would have to be in a mental hospital or care facility. In a June 2020 VA aid and attendance examination, a self-care deficit was diagnosed. The examiner noted that the Veteran was not permanently bedridden or hospitalized, he was not unable to travel beyond his current home, and does not require nursing home care. The examiner opined the TBI affects food preparation and cognitive impairment; the TBI with residual vestibulopathy affects memory impairment, headaches, and photophobia; the cystic lesion in the brain affects dizziness and cognitive impairment; PTSD limits him in going to public places and leaving the home except for doctor's appointments; and musculoskeletal disabilities affect his range of motion, ability to ambulate more than a block, and his ability to reach his back during a shower. The examiner marked the Veteran is able to feed himself but is not able to prepare his own meals, noting his spouse and mother help with food preparation due to a fall risk and short term memory problems from TBI. The examiner noted he requires mild to moderate assistance dressing, bathing, keeping himself ordinarily clean and presentable, and toileting. He reported the Veteran needs assistance with medication set up and is able to manage his own finances. The examiner noted the Veteran is able to walk a block with the assistance of an ambulation device. In a February 2021 statement in support of the claim, a private provider (Dr. R.T.) opined that it is more than likely than not that the Veteran is in need of regular aid and attendance due to solely to service-connected residuals of TBI and that in the absence of such regular aid and attendance, the Veteran requires hospitalization, nursing home care, or other residential institutional care due to his TBI. The provider noted the Veteran has been unable to live independently and, due to his TBI, needs assistance from his wife to perform normal daily activities. In addition, the Veteran's wife helps him with various activities of daily living including basic hygiene, reminders for daily tasks, and supervision to protect him from hazards or dangers incident to his daily environment. The provider asserts that while the Veteran's TBI is rated in multiple ratings for several symptoms and secondary diagnoses, the overlaps between PTSD, major depressive disorder, and TBI have not been properly accounted for in the current and separate ratings. The provider asserts the lay statements and medical records demonstrate that issues involving balance, dizziness, impaired coordination, memory deficits, changes in mood, irritability, anxiety, depression, and chronic migraine are the primary issues that cause the need for aid and attendance and they are all due to TBI. Additionally, he asserts depressed mood, anxiety, chronic sleep impairment, and memory impairment are typical of both PTSD and TBI and that all mental health conditions are aggravated by his TBI. The provider concludes that without assistance from his wife, the Veteran would need nursing home care or hospitalization due to his TBI impairments and would pose a severe danger to himself. The provider did not address the June 2020 VA aid and attendance examination or the July 2017 VA Caregiver Program negative determination. As noted above, qualifying for SMC(t) requires both a showing of aid and attendance under 38 C.F.R. § 3.352(a) and the need for higher level care under 38 C.F.R. § 3.352 (b)(3). If either requirement is not met, SMC(t) cannot be awarded. Here, the evidence does not support that the Veteran's service connected TBI residuals result in the need for higher level care. The Veteran's overall treatment record does not indicate that he needs any specific healthcare service. Significantly, VA found him ineligible for the Program of Comprehensive Assistance for Family Caregivers. The 2017 determination recommended that he seek bathing assistance but the record does not indicate they sought the recommended service. Nevertheless, while the type of care that his wife has said she provides defines aid and attendance in 38 C.F.R. § 3.352 (a), it does not demonstrate the need for higher level care defined in 38 C.F.R. § 3.352(b)(3); it is not hospital, nursing home care or other residential institutional care. The Board observes the VA received a private assessment from a private provider in support of the claim. However, while the provider indicated that he would require hospitalization, nursing home car, or other residential institutional care in the absence of the aid and attendance of his wife, there is no indication that she is a doctor of medicine or osteopathy, a registered nurse, a licensed practical nurse, or a licensed physical therapist who can provide a higher level of care or that she provides such services under the regular supervision of a licensed healthcare professional (as required by SMC(t)). 38 C.F.R. § 3.352(b)(3). The Veteran's condition does not require that he be provided healthcare services on a daily basis that are performed by a healthcare professional or the supervision of a healthcare professional. Based on the examples of the healthcare services provided in 38 C.F.R. § 3.352 (b)(2), these are not the type of services that the Veteran requires as a result of his TBI. Instead, he reportedly needs services that do not require a healthcare professional or the supervision of a healthcare professional. Transportation, food preparation, assistance with dressing, reminders, and providing for the Veteran's hygiene are services that can and, in practice, are being performed by people without healthcare training. While this may seem to be an unnecessarily strict interpretation, the provisions of 38 C.F.R. § 3.352 (b) provide that it must be strictly construed, and that SMC(t) may only be granted when the Veteran's need is clearly established. 38 C.F.R. § 3.352 (b)(6). The weight of the evidence is against establishing that need. Entitlement to SMC(t) has not been established and the claim must be denied. The Board has considered whether the Veteran is eligible for any additional SMC (beyond his current award) and finds he is not. The Board notes that in adjudicating a claim, the competence and credibility of the Veteran must be considered. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). The Board acknowledges that the Veteran is competent to give evidence about what he observes or experiences. For example, he is competent to report that he experiences certain symptoms, such as pain, and he is credible in this regard. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). However, the Veteran's competent and credible belief that his service-connected disabilities warrant a higher SMC rate are outweighed by the competent and credible medical examinations that evaluated the true extent of impairment based on objective data coupled with the lay complaints. The VA examiners have the training and expertise necessary to administer the appropriate testing for a determination of the type and degree of the impairment associated with the Veteran's complaints. For these reasons, greater evidentiary weight is placed on the physical examination findings than the Veteran's lay statements. The rate amounts increase the later in the alphabet the letter appears (except for the (s) rate). SMC under subsections (k) through (r) are rates that are paid in addition to any other SMC rates, with certain monetary limits. Initially, the Board notes that a number of the provisions under 38 U.S.C. § 1114 are inapplicable. For example, there is no evidence or assertion that any of the Veteran's service-connected disabilities have resulted in or are manifested by loss of use, paralysis, anatomical loss, or amputation of any extremity; loss of vision or blindness in one or both eyes; deafness; aphonia (inability to communicate by speech); or tuberculosis. 38 U.S.C. §§ 1114(k), (l), (m), (n), and (o); 38 C.F.R. § 3.350(a), (b), (c), (d), (e), (f), (g). Accordingly, the Board will not further address the criteria for the assignment of SMC on the basis of these manifestations. Additionally, as discussed above, at the time of the award of the 100 percent evaluation, the Veteran was already in receipt of SMC at the (s) or "housebound" rate based on the statutory housebound criteria, which requires a single service-connected disability rated as total (here, TDIU based on the single disability of PTSD with major depressive disorder, panic disorder, major neurocognitive disorder, TBI, and colloid cyst at foramen of Monro) with additional service-connected disabilities independently rated at 60 percent or more, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems. Notably, the law does not provide any avenue for separating 100 percent disabilities and allocating additional service-connected disabilities so as to produce distinct awards of SMC at the statutory housebound rate. See 38 U.S.C. § 1114(s), 38 C.F.R. § 3.350(i). Nor is there any provision that allows for "stacking" separate awards of SMC at the (s) rate based upon the Veteran satisfying the statutory housebound criteria and being housebound "in fact" by virtue of being permanently housebound by reason of service-connected disability. Id. SMC at the (l) rate is warranted when a Veteran's service-connected disability or disabilities cause the anatomical loss or loss of use of both feet or one hand and one foot, cause the Veteran to be blind in both eyes, or renders the Veteran permanently bedridden or with such significant disabilities as to be in need of regular aid and attendance. 38 U.S.C. § 1114 (l); 38 C.F.R. § 3.350 (b). While the evidence does show that he requires aide and attendance for this TBI, the Veteran is already in receipt for Housebound status at the (s) rate based on PTSD with major depressive disorder, panic disorder, major neurocognitive disorder, TBI, and colloid cyst at foramen of Monro and additional service-connected disabilities. The Veteran is not entitled to separate payments at the (s) and (l) rates unless the disability or disabilities which render the Veteran eligible for aid and attendance are separate and distinct from that or those which entitle him to SMC(s). 38 U.S.C. § 1114(k) and (s). SMC at the (o) rate is warranted for combinations and is payable when a veteran, as the result of service-connected disability, has suffered disability under conditions which would entitle such veteran to two or more of the rates provided in one or more subsections (l) through (n) of 38 U.S.C. § 1114, no condition being considered twice in the determination. See 38 U.S.C. § 1114(o); 38 C.F.R. § 3.350(e)(3). A veteran who is in receipt of SMC at a rate under 38 U.S.C. § 1114(l) through (n) cannot establish entitlement to a second rate under subsection (l) based on the need for aid and attendance, which would result in a higher payment of SMC at the rate under 38 U.S.C. § 1114(o), unless the need for aid and attendance arises from a disability other than that for which the veteran is already in receipt of SMC. Breniser v. Shinseki, 25 Vet. App. 64, 65 (2011). Additionally, an SMC(p) rating will be awarded when the Veteran is in receipt of an SMC rate between (l) and (o) and also has additional service-connected disabilities that combine independently to 50 or 100 percent. See 38 U.S.C. § 1114(p); 38 C.F.R. § 3.350(f). Such an award creates "entitlement to the next higher intermediate rate or if already entitled to an intermediate rate to the next higher statutory rate under 38 U.S.C. § 1114." 38 C.F.R. § 3.350(f)(3). Put another way, SMC(p) affords "a half-step" or "full step" increase in the level of compensation. The disability or disabilities independently ratable at 50 percent or more must be separate and distinct and involve different anatomical segments or bodily systems from the conditions establishing entitlement under 38 U.S.C. §§ 1114(l) through (n). Here, the evidence does not establish that the Veteran meets the criteria for an award of SMC under §§ 1114(l) through (n), as discussed above. Accordingly, a higher rate of SMC under 38 U.S.C. § 1114(o) or (p) is not warranted. See 38 U.S.C. §§ 1114(o), (p); 38 C.F.R. §§ 3.350(e), (f). Finally, SMC at the (r) rate concerns special aid and attendance and is divided between (r)(1) and (r)(2), each with separate criteria. 38 U.S.C. § 1114(r); 38 C.F.R. § 3.350(h). To qualify under the (r)(1) or the (r)(2) rate, receipt of the (o) rate, the maximum rate under (p), or an intermediate rate between the (n) and (o) rates plus a (k) rate is required. Id. In this case, as detailed above, the evidence does not establish entitlement to SMC at the (l) rate based on aid and attendance or under 38 U.S.C. §§ 1114(k), (n), (o), or (p). As such, the threshold requirements for SMC at the (r) rate are not met. Accordingly, the Board finds that the evidence of record does not establish that the Veteran meets the criteria for an award of additional SMC in excess of the amount paid pursuant to 38 U.S.C. § 1114(s). In reaching this decision, the Board has considered the benefit-of-the-doubt doctrine. However, as the evidence is persuasively against the Veteran's claim, the doctrine is not applicable, and his claim must be denied. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. S. CHARLES NEILL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Naumovich, Associate 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.