Citation Nr: 1621642 Decision Date: 05/31/16 Archive Date: 06/08/16 DOCKET NO. 08-33 849 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to an effective date earlier than August 12, 2004, for the grant of service connection for adjustment disorder with mixed anxiety and depression. 2. Entitlement to an effective date earlier than May 16, 2006, for the grant of service connection for headaches. 3. Entitlement to an initial rating in excess of 50 percent prior to January 9, 2015, for adjustment disorder with mixed anxiety and depression. 4. Entitlement to an initial rating of 50 percent prior to February 12, 2015, for headaches. 5. Entitlement to an increased rating for residuals of a cervical spine injury with degenerative changes, currently rated at 20 percent disabling. 6. Entitlement to an increased rating for degenerative arthritis of the right hand, status post fracture, right middle finger, currently rated at 10 percent disabling. 7. Entitlement to an increased rating for right ankle strain, currently rated at 10 percent disabling. 8. Entitlement to service connection for disequilibrium with impaired hearing, including as secondary to service-connected residuals of a cervical spine injury with degenerative changes. 9. Entitlement to service connection for a dental disability for compensation purposes, to include as secondary to an acquired psychiatric disorder. 10. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). 11. Entitlement to special monthly compensation (SMC) under 38 U.S.C. § 1114(s) for the period from May 16, 2006 to February 11, 2015. WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD L. McCabe, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1982 to January 1994. This case comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of Department of Veterans Affairs (VA) Regional Offices (RO's). A description of the relatively complex procedural history of this case is warranted to clarify the issues on appeal. A June 2008 rating decision of the Cleveland, Ohio RO, in pertinent part, denied service connection for a sinus disorder, an eye disorder, and a dental condition; declined to reopen a service connection claim for disequilibrium; and denied a TDIU. In July 2012, the Veteran testified at a hearing at the RO before the undersigned Veterans Law Judge of the Board (Travel Board hearing) concerning the issues of entitlement to service connection for a psychiatric disorder, a sinus disorder, an eye disorder, a dental condition, headaches, and disequilibrium, as well as the issue of entitlement to a TDIU. A transcript of that hearing is of record. In a November 2014 decision, the Board, in pertinent part, reopened the service connection claim for disequilibrium and remanded the reopened disequilibrium claim, as well as the claims for service connection for sinus disorder, an eye disorder, and a dental condition, and the claim of entitlement to a TDIU, for further development, including to obtain VA examination and to procure additional VA and private treatment records. That development having been accomplished, the claims for service connection for disequilibrium and a dental disability, as well as the claim of entitlement to a TDIU, have returned to the Board. Significantly, as concerning the remanded claims of to service connection for a sinus disorder, to include allergic rhinitis, and entitlement to service connection for an eye disorder, claimed as blurred vision, in a November 2015 communication, the Veteran withdrew his appeals as to these issues. See November 2015 E-mail Correspondence from the Veteran to the RO Titled "Re: FW: [EXTERNAL] Re: RICO Act = NOTICE OF BVA RO Columbia Corruption / EXPEDITE RETURN TO BVA" (explicitly stating that he desired to withdraw his claims for service connection a sinus disorder and a vision disability). Accordingly, these matters are no longer on appeal before the Board. See 38 C.F.R. § 20.204 (2015). That November 2014 Board decision additionally found that, although the Veteran initiated an appeal of the Decatur, Georgia RO's June 2009 rating decision denying his claims of entitlement to increased ratings for his service-connected residuals of a cervical spine injury with degenerative changes, degenerative arthritis of the right hand, and right ankle strain, the RO did not address these claims in a statement of the case (SOC). Manlincon v. West, 12 Vet. App. 238 (1999). Accordingly, the Board remanded these increased rating claims for the issuance of an SOC. See 38 C.F.R. §§ 19.9, 20.200, 20.201 (2015); see also Manlincon, 12 Vet. App. 238. In December 2014, the RO issued the required SOC, which continued to deny higher ratings for the cervical spine, right hand, and right ankle disabilities. The Veteran perfected his appeal concerning these issues in January 2015. See also January 2015 Substantive Appeal (on VA Form 9) (requesting a Board videoconference hearing); January 2015 E-mail Correspondence from the Veteran to the RO Titled "SUPPLEMENT INFORMATION IN SUPPORT OF TERMINATION OF VETERAN-ATTORNEY AGREEMENT" (reflecting that the Veteran wished to withdraw the previous request for a hearing in conjunction with his appeal of the issues of increased ratings for the cervical spine, right hand, and right ankle disabilities); 38 C.F.R. § 20.704(e) (2015) (concerning withdrawals of hearing requests). The Board also awarded service connection for headaches and adjustment disorder with mixed anxiety and depression in that November 2012 decision. The Columbia, South Carolina RO subsequently implemented the Boards decision, assigning the adjustment disorder with mixed anxiety and depression a rating of 50 percent, effective from August 12, 2004, and assigning the headaches a rating of 10 percent, effective from May 16, 2006. See January 2015 Rating Decision (granting service connection for adjustment disorder with mixed anxiety and depression, with a 50 percent evaluation effective from August 12, 2004 to January 8, 2015, and a 100 percent (total) evaluation effective from January 9, 2015 forward; and granting service connection for headaches with an evaluation of 10 percent also effective from August 12, 2004); February 14, 2015 Rating Decision (granting an increased 50 percent rating for the headaches effective from February 12, 2015); February 19, 2015 Rating Decision (finding clear and unmistakable error in the previous January 2015 rating decision, which assigned an effective date for service connection for headaches of August 12, 2004, and instead assigning an effective date of May 16, 2006). The Veteran disagreed with both the effective date and the ratings assigned these service-connected disabilities, and he perfected his appeal as to these issues by a February 2015 Substantive Appeal (VA Form 9). The Board additionally notes that, as concerning the claim of entitlement to a higher initial rating for his headaches, the Veteran specifically limited his appeal to the issue of entitlement to a 50 percent rating. See, e.g., February 2015 Notice of Disagreement (explicitly asserting entitlement to a 50 percent rating for his headaches); February 2015 E-mail Correspondence from the Veteran to the RO Titled "Re: [EXTERNAL] Re: Request for Status Of Final Processing Of VBA-ALJ Favorable Decision Of November 20, 2014" (reflecting the Veteran's satisfaction with the 50 percent rating for his headaches that was assigned in the February 2015 rating decision but asserting that the 50 percent rating was warranted for the entire appellate period, so not just as of February 12, 2015). Although a claimant will generally be presumed to be seeking the maximum benefit allowed by law and regulation, such a claimant may "limit a claim or appeal to the issue of entitlement to a particular disability rating which is less than the maximum disability rating allowed by law" via "clearly expressed intent to limit the appeal to entitlement to a specific disability rating for the service-connected condition." See AB v. Brown, 6 Vet. App. 35, 39 (1993) (citing Hamilton v. Brown, 4 Vet. App. 528, 544 (1993)). Here, the Veteran unequivocally stated on two occasions that the appeal of the rating for his headaches would be satisfied by the grant of an initial 50 percent rating. See also 38 C.F.R. § 4.124a, Diagnostic Code 8100 (reflecting that a 50 percent evaluation is the maximum schedular evaluation available for headaches). Accordingly, given the Veteran's statements and considering the RO's grant of a 50 percent rating for the headaches effective February 12, 2015, the Board finds that the issue on appeal is limited to entitlement to an initial 50 percent rating for headaches prior to February 12, 2015, as reflected on the title page. Finally, as explained below, the issue of entitlement to TDIU also raises the issue of entitlement to special monthly compensation (SMC) under 38 U.S.C. § 1114(s), as the record shows that the criteria for SMC at the (s) rate are satisfied as of May 16, 2006. See Akles v. Derwinski, 1 Vet. App. 118, 121 (1991) (observing that entitlement to SMC is an "inferred issue" in the context of an increased rating claim that must be considered when the record indicates that it may be available, even if the claimant does not place eligibility for this ancillary benefit at issue); Cf. AB, 6 Vet. App. at 38 (holding that a claimant is presumed to be seeking the maximum benefits allowed by law). Given that the Veteran is already in receipt of SMC at the (s) rate for the period February 12, 2015, forward, this issue has been added for appellate consideration as reflected on the cover sheet of this opinion. There is no prejudice to the Veteran in the Board's considering in the first instance entitlement to SMC at the (s) rate for the period from May 16, 2006 to February 11, 2015, as eligibility for this benefit turns solely on the application of law, and the Board's decision is favorable to the extent permitted by law, as discussed below. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993) (holding that where the Board addresses a question that has not been addressed by the AOJ, the Board must consider the potential for prejudice to the appellant). The Board intimates no findings with respect to entitlement to SMC at the (s) rate prior to May 16, 2006; its decision is limited to, and solely based on, the ratings currently assigned and their effective dates. Accordingly, the issues presently before the Board are as reflected on the title page. This appeal was processed using the VBMS paperless claims processing system. The Virtual VA system also contains additional records pertinent to the present appeal. Accordingly, any future consideration of this Veteran's case should take into consideration the existence of this electronic record. The Board additionally notes that the Veteran was previously represented by Kenneth LaVan, Esq. The Veteran has since revoked his power of attorney (POA). As there is no valid POA currently of record, he is proceeding unrepresented. The issues of entitlement to service connection for a dental disability and disequilibrium with impaired hearing, as well as the claims of entitlement to increased ratings for his residuals of a cervical spine injury with degenerative changes, degenerative arthritis of the right hand, and right ankle strain, are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. A claim for service connection for a psychiatric disability, to include adjustment disorder with mixed anxiety and depression, was not received prior to August 12, 2004. 2. The Veteran initially submitted a service connection claim for headaches in August 2004, which was denied in an April 2005 rating decision; he did not submit a notice of disagreement regarding this issue within one year of mailing of notice of the April rating decision, and new and material evidence was not obtained or received by VA within this one-year time period. 3. The Veteran submitted a petition to reopen the service connection claim for headaches on May 16, 2006, which was granted in the November 2014 Board decision and implemented in the January 2015 rating decision. 4. Affording the Veteran the benefit of the doubt, for the period from August 12, 2004 to January 8, 2015, the Veteran's service-connected adjustment disorder with mixed anxiety and depression has been manifested by severe symptoms equivalent in severity to gross impairment in thought processes and communication and grossly inappropriate behavior, resulting in total occupational and social impairment. 5. Affording the Veteran the benefit of the doubt, for the period from May 16, 2006 to February 11, 2015, his service-connected headache disorder is manifested by very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 6. Entitlement to TDIU is moot by virtue of the grant of a 100-percent schedular rating for adjustment disorder with mixed anxiety and depression. 7. Since August 12, 2004, a total rating has been assigned the Veteran's adjustment disorder with mixed anxiety and depression, and since May 16, 2006 other service-connected disabilities involving different anatomical locations or bodily systems have a combined rating of 60 percent or more. CONCLUSIONS OF LAW 1. The criteria are not met for an effective date earlier than August 12, 2004, for the grant of service connection for adjustment disorder with mixed anxiety and depression. 38 U.S.C.A. § 5110 (West 2014); 38 C.F.R. §§ 3.1, 3.151, 3.155, 3.400 (2015). 2. The criteria are not met for an effective date earlier than May 16, 2006, for the grant of service connection for headaches. 38 U.S.C.A. § 5110 (West 2014); 38 C.F.R. §§ 3.1, 3.105, 3.151, 3.155, 3.156, 3.400 (2015). 3. The criteria are met for an initial rating of 100 percent for adjustment disorder with mixed anxiety and depression for the period from August 12, 2004 to January 8, 2015. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.340, 4.1-4.14, 4.21, 4.126, 4.130, Diagnostic Code 9411 (2015). 4. The criteria are met for an initial rating of 50 percent for headaches for the period from May 16, 2006 to February 11, 2015. 38 U.S.C.A. § 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.21, 4.124a, Diagnostic Code 8100 (2015). 5. Entitlement to TDIU is moot. 38 U.S.C.A. § 501 (West 2014); 38 C.F.R. §§ 3.340, 4.16 (2015). 6. Entitlement to SMC at the (s) rate is established as of May 16, 2006. 38 U.S.C.A. § 1114(s) (West 2014); 38 C.F.R. § 3.350(i) (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). Initially, the Board notes that, because the outcome of the Veteran's appeal of the effective dates of service connection for headaches and adjustment disorder with mixed anxiety and depression is determined by applicable law rather than disputed facts, VA's duties to notify and assist under the VCAA do not apply or are moot. See Mason v. Principi, 16 Vet. App. 129, 132 (2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); VAOPGCPREC 5-2004 (June 23, 2004); see also 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. Furthermore, as noted in the introduction above, the Veteran specifically indicated that he was seeking an initial rating of 50 percent for his headaches prior to February 12, 2015. As a 50 percent initial rating for headaches is being granted herein, this award represents a complete grant of the benefit sought on appeal. Additionally, the Board is granting a 100 percent initial schedular rating prior to January 9, 2015, for the adjustment disorder with mixed anxiety and depression, which is a complete grant of the benefit sought on appeal concerning this issue. Finally, also as previously noted, the Board's decision considering entitlement to SMC is fully favorable. Thus, any deficiency in VA's compliance with the duty to notify and assist concerning these claims is deemed to be harmless error, and any further discussion of VA's responsibilities is not necessary. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Earlier Effective Dates The Veteran asserts entitlement to earlier effective dates for service connection for headaches and adjustment disorder with mixed anxiety and depression. Specifically, he asserts that the effective date for service connection for these disabilities should be the day following his discharge from active service, so as of January 14, 1994. See, e.g., March 2016 Memorandum (asserting that service connection is warranted as of January 14, 1994, when he initially sought treatment for his disabilities through the VA healthcare system). Except as otherwise provided, the effective date of an evaluation and award of compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C.A. § 5110; 38 C.F.R. § 3.400. If a claim for disability compensation is received within one year after separation from service, the effective date of entitlement is the day following separation or the date entitlement arose. 38 C.F.R. § 3.400(b)(2). Otherwise, it is the date of receipt of claim or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400. Furthermore, in this contest, the terms "claim" or "application" mean a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1(p). The VA administrative claims process recognizes formal and informal claims. A formal claim is one that has been filed in the form prescribed by VA. 38 C.F.R. § 3.151(a). An informal claim may be any communication or action indicating intent to apply for one or more benefits under VA law. Thomas v. Principi, 16 Vet. App. 197 (2002); see also 38 C.F.R. 3.1(p), 3.155(a) (2015). An informal claim must be written and must identify the benefit being sought. See Rodriguez v. West, 189 F. 3d. 1351 (Fed. Cir. 1999); Brannon v. West, 12 Vet. App. 32, 34-35 (1998). To determine when a claim was received, the Board must review all communications in the claims file that may be construed as an application or claim. See Quarles v. Derwinski, 3 Vet. App. 129, 134 (1992). (A) Adjustment Disorder with Mixed Anxiety and Depression Here, the RO established an effective date of service connection for adjustment disorder with mixed anxiety and depression of August 12, 2004, based on the Board's November 2014 finding that the Veteran has been actively pursuing his claim for an acquired psychiatric disorder since his initial claim [for PTSD] in August 2004." See November 2014 Board Decision (characterizing the Veteran's PTSD claim broadly as one of entitlement to service connection for an acquired psychiatric disorder and granting entitlement to service connection for an acquired psychiatric disability); January 2015 Rating Decision (implementing the Board's grant of service connection for an acquired psychiatric disorder). Significantly, although the Veteran initiated several service connection claims prior to August 2004, these claims were limited to orthopedic disabilities. See February 1994 Formal Claim (on VA Form 21-526, Veteran's Application for Compensation and/or Pension) (asserting entitlement to service connection for disabilities affecting his neck, right knee, right middle finger, and right ankle); July 1994 Rating Decision (granting service connection for cervical strain, residuals of right middle finger fracture, right knee strain, and right ankle strain); August 1994 Notice of Disagreement (reflecting his disagreement with the ratings assigned his service-connected cervical strain and residuals of right middle finger fracture); March 1995 Statement of the Case (denying higher ratings for the cervical strain and residuals of right middle finger fracture). There is thus no claim of record, formal or informal, for service connection for any acquired psychiatric condition prior to this date, or for service connection for any condition that may reasonably relate to his adjustment disorder with mixed anxiety and depression. As discussed in the Board's November 2014 decision, the Veteran's STRs establish the presence of a psychiatric pathology as early as November 1988. See November 2014 Board Decision (reflecting that "the Veteran's service treatment records contain documented evidence of problems with anxiety, stress management, insomnia, and depression" and referencing a "November 1988 mental health clinic consultation reflect[ing] a diagnosis of "Adjustment Disorder with Mixed Emotional Feelings"). His post-service VA treatment records additionally reflect psychiatric diagnoses as early as December 2001. See December 2001 VA Mental Health Note (reflecting a diagnostic impression of "Depression R/O Manic-depressive). However, the mere presence of medical evidence in the record does not establish intent on the part of the Veteran to seek service connection for the benefit in question. See Brannon, 12 Vet. App. at 34-5. As such, the fact that the Veteran's VA treatment records document treatment for his psychiatric disability during the period from January 1994 to August 2004 does not establish an earlier date of claim under any definition of the term. Accordingly, entitlement to an effective date of service connection for adjustment disorder with mixed anxiety and depression earlier than August 12, 2004, is denied. Because the law, and not the facts, is dispositive of the outcome of this issue, the benefit-of-the-doubt rule does not apply. See Sabonis v. West, 6 Vet. App. 426, 430 (1994); see also 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. (B) Headaches As concerning the service-connected headaches, the RO established an effective date of May 16, 2006, following the Board's November 2014 decision that reopened and granted the Veteran's claim for service connection for headaches. See November 2014 Board Decision (reopening and granting the Veteran's previously denied claim of entitlement to service connection for headaches); January 2015 Rating Decision (implementing the Board's grant of service connection for headaches effective from August 12, 2004); February 19, 2015 Rating Decision (finding clear and unmistakable error in the RO's January 2015 assignment of an effective date for service connection for headaches of August 12, 2004, and instead assigning an effective date of May 16, 2006). Here, as discussed in detail in the Board's prior November 2014 decision, the Veteran's August 2004 claim for service connection for headaches was denied on the merits in an April 2005 rating decision, and a letter dated that same month notified the Veteran of the decision and of his appellate rights. See 38 C.F.R. § 19.25 (2015). Although he filed a notice of disagreement (NOD) with this decision, he specifically limited his disagreement to the RO's denial of service connection for a psychiatric disability and of an increased rating for his cervical spine disorder. See April 2005 Correspondence (stating that he wished to "proceed in the appeal proceed to redress [his] service-connected cervical and PTSD claims"). He thus did not submit an NOD with regard to the RO's April 2005 denial of service connection for a headache disability within one year of the date of mailing of that decision. See 38 C.F.R. §§ 20.200, 20.201, 20.302(a) (2015) (setting forth requirements and timeframe for submitting an NOD). Moreover, new and material evidence was not submitted within one year of the date of its mailing. See 38 C.F.R. § 3.156(b); Young v. Shinseki, 22 Vet. App. 461, 466 (2009). Additionally, the Board's November 2014 grant of service connection for headaches was not based on newly obtained service department records, and the Veteran has not moved to revise or reverse the prior April 2005 rating decision on the basis of CUE. See 38 U.S.C.A. § 5109A(a); 38 C.F.R. §§ 3.105(a), 3.156(c). See also November 2014 Board Decision (granting service connection for headaches based primarily upon the Veteran's competent and credible testimony at the July 2012 Board hearing that the headaches began in service and have continued since that time, as supported by post-service VA treatment records). See, generally, Fugo v. Brown, 6 Vet. App. 40 (1993); Oppenheimer v. Derwinski, 1 Vet. App. 370 (1991); Akins v. Derwinski, 1 Vet. App. 228 (1991); Luallen v. Brown, 8 Vet. App. 92 (1995); Elkins v. Brown, 8 Vet. App. 391 (1995);and Cook v. Principi, 318 F.3d 1334 (Fed. Cir. 2002) (reflecting that CUE must be pled with specificity and must involve a contention of the misapplication of a particular law or fact). Accordingly, the April 2005 rating decision is final. See 38 U.S.C.A. § 7105 (West 2014); 38 C.F.R. §§ 3.156(a); 20.1103 (2015). See also November 2014 Board Decision (concluding that "[t]he April 2005 rating decision that denied service connection for headaches . . . is final"). The effective date of an evaluation and an award of compensation based on a reopened claim is the date of receipt of the new claim or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400(q)(2). Thus, once a previous rating decision has become final, the earliest effective date of service connection generally is the date of the petition to reopen rather than the date of the initial claim. See id. Exceptions to this rule include a later grant of service connection based in whole or in part on newly obtained service department records under certain circumstances, as provided in 38 C.F.R. § 3.156(c) (2015), and when the decision is revised or reversed on the basis of clear and unmistakable error (CUE), as provided in 38 U.S.C.A. § 5109A(a) (West 2014) and 38 C.F.R. § 3.105(a) (2015). The Veteran's informal petition to reopen the claim of entitlement to service connection for headaches was received by the RO on May 16, 2006. See May 2006 Statement in Support of Claim (reflecting the Veteran's "wish to reassert for the record [that his] cervical injury prevents [him] from sitting at a computer for any extended period of time without severe headaches occurring"). The evidence of record does not reflect, nor does the Veteran assert, that he filed a claim concerning his asserted headaches during the interim period between his May 2006 claim to reopen and the prior April 2005 denial of service connection. Accordingly, entitlement to an effective date of service connection for headaches earlier than May 16, 2006, is denied. Because the law, and not the facts, is dispositive of the outcome of this issue, the benefit-of-the-doubt rule does not apply. See Sabonis, 6 Vet. App. at 430; see also 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. III. Increased Initial Ratings VA has adopted a Schedule for Rating Disabilities to evaluate service-connected disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. § 3.321; see generally, 38 C.F.R. § Part IV. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10 (2015). The percentage ratings in the Schedule for Rating Disabilities represent, as far as practicably can be determined, the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2015). Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7 (2015). Otherwise, the lower rating will be assigned. Id. All reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3; see also 38 C.F.R. § 3.102. Separate ratings for distinct disabilities resulting from the same injury or disease can be assigned so long as the symptomatology for one condition is not "duplicative or overlapping with the symptomatology" of the other condition. See Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009); Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). However, the evaluation of the same disability or its manifestations under various diagnoses, which is known as pyramiding, is to be avoided. See 38 C.F.R. § 4.14 (2015). Because the level of disability may have varied over the course of the claim, the rating may be "staged" higher or lower for segments of time during the period under review in accordance with such variations, to the extent the evidence shows distinct time periods where the service-connected disability has exhibited signs or symptoms that would warrant different ratings under the rating criteria. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). In initial-rating cases, where the appeal stems from a granted claim of service connection with respect to the initial evaluation assigned, VA assesses the level of disability from the effective date of service connection. See Fenderson, 12 Vet. App. at 125; 38 U.S.C.A. § 5110 (West 2014); 38 C.F.R. § 3.400 (2015). (A) Adjustment Disorder with Mixed Anxiety and Depression The Veteran contends that an initial rating greater than 50 percent is warranted for his adjustment disorder with mixed anxiety and depression. See January 2015 Rating Decision (granting service connection for adjustment disorder with mixed anxiety and depression, with a 50 percent evaluation effective from August 12, 2004 to January 8, 2015, and a 100 percent (total) evaluation effective from January 9, 2015 forward). For the following reasons, the Board finds that entitlement to a 100 percent initial rating is established. The Veteran's adjustment disorder with mixed anxiety and depression is in receipt of a 50 percent initial rating prior to January 9, 2015, under 38 C.F.R. § 4.130, Diagnostic Code (DC) 9440, which pertains to chronic adjustment disorder. Almost all mental health disorders, including adjustment disorders, are evaluated under the General Rating Formula for Mental Disorders (Rating Formula), which assigns ratings based on particular symptoms and the resulting functional impairment. See 38 C.F.R. § 4.130, DC 9440. Under General Rating Formula, as pertinent to the present appeal, a 50 percent rating is warranted where the disorder is manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks (more than once a week); difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9440. A 70 percent rating requires 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 work like setting); and inability to establish and maintain effective relationships. Id. The maximum 100 percent rating requires total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. In evaluating psychiatric disorders, VA also considers a claimant's Global Assessment Functioning (GAF) scores, which are based on a scale set forth in the American Psychiatric Association 's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996); DSM-IV. See, too, 79 Fed. Reg. 45094 (Aug. 4, 2014) (amending the portion of the Rating Schedule dealing with mental disorders so as to replace outdated references to the DSM-IV, with references to the Fifth Edition (DSM-5), applicable to applications for benefits received by VA or pending before the agency of original jurisdiction (AOJ) on or after August 4, 2014). The Board recognizes that VA has amended the Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations; however, while the DSM-5 no longer requires the use of GAF scores to assess quantitive assessment of overall functioning, the Board nonetheless finds that those GAF scores presented in the record assist in illuminating the Veteran's level of disability. According to DSM-IV, a score of 61-70 indicates "[s]ome mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships." A score of 51-60 indicates "[m]oderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning, (e.g., few friends, conflicts with peers or co-workers)." Id. A score of 41-50 indicates "[s]erious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job)." Id. A score of 31-40 indicates "[s]ome impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work)." Id. A GAF score thus may demonstrate a specific level of impairment. See Richard, 8 Vet. App. at 267 (observing that a GAF score of 50 indicates serious impairment); accord Bowling v. Principi, 15 Vet. App. 1, 14-15 (2001). Further, while an examiner's classification of the level of psychiatric impairment as reflected in a GAF score can be probative evidence, such a score is by no means determinative of the rating assigned by VA in evaluating a psychiatric disorder under the rating criteria. See 38 C.F.R. §§ 4.2, 4.126 (2015); VAOPGCPREC 10-95 (March 31, 1995). Rather, VA must take into account all of the Veteran's symptoms and resulting functional impairment as shown by the evidence of record in assigning the appropriate rating, and will not rely solely on the examiner's assessment of the level of disability at the time of examination. See 38 C.F.R. § 4.126. Resolving doubt in the Veteran's favor, the Board finds that, during the period from August 12, 2004 to January 8, 2015, the frequency, severity, and duration of the symptoms of his adjustment disorder with mixed anxiety and depression are equivalent to those required for a 100 percent schedular rating under the Rating Formula, resulting in total social and occupational impairment. See 38 C.F.R. § 4.130, Diagnostic Code 9440. In this regard, the Board notes that, in the January 2015 rating decision, the RO granted a 100 percent schedular rating for the Veteran's psychiatric disability, effective January 9, 2015, the date of a private psychological examination of the Veteran, which found that the Veteran's psychiatric pathology, including his adjustment disorder with mixed anxiety and depression, was productive of total occupational and social impairment due to the severity of symptoms such as depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbance in motivation and mood, difficulty adapting to stressful circumstances, and a history of suicidal behavior. See January 2015 Mental Disorders Disability Benefits Questionnaire (DBQ) from R.L.W., M.D. In finding that the Veteran's psychiatric pathology was productive of total social and occupational impairment, the January 2015 examining physician also noted the Veteran's longstanding inability to maintain employment. See id. Significantly, although the private physician did not endorse symptoms listed in the rating criteria as examples of the type of symptomatology that would warrant a 100 percent rating under 38 C.F.R. § 4.130, Diagnostic Code 9440, the Board emphasizes that the symptoms associated with each evaluation under the General Rating Formula do not 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. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Thus, the evidence considered in determining the appropriate evaluation of a psychiatric disorder is not restricted to the symptoms set forth in the General Rating Formula. See id. Rather, VA must consider all symptoms of a claimant's condition that affect his or her occupational and social impairment, including, if applicable, those identified in the DSM-5. Accordingly, if the evidence demonstrates that the claimant's psychiatric disorder produces symptoms and resulting occupational and social impairment equivalent to that set forth in the criteria for a given rating in the General Rating Formula, then the appropriate, equivalent rating will be assigned. Mauerhan, 16 Vet. App. at 443. In this regard, the Board must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126 (2015); Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013) (noting that the "frequency, severity, and duration" of a veteran's symptoms "play an important role" in determining the disability level and emphasizing that, while VA considers the level of social impairment, it shall not assign an evaluation based solely on social impairment). Here, the evidence supports a finding that the Veteran's adjustment disorder with mixed anxiety and depression was productive of equally severe symptomatology for the period preceding this January 2015 psychological assessment. Specifically, his VA mental health treatment records for the period in question reflect psychiatric symptoms including persistent depression and anxiety; suspiciousness and chronic paranoia; extreme irritability with outbursts of rage; impaired judgement; intermittent homicidal and suicidal ideations; chronic insomnia; recurrent nightmares; impaired concentration and racing thoughts; poor judgment and insight; mania; isolating behaviors; memory problems; and intermittent visual hallucinations. See, e.g., November 2004 VA Mental Health Note (endorsing depression, anxiety, recurring nightmares, chronic sleeplessness; impaired concentration, and racing thoughts); April 2007 VA Mental Health Initial Evaluation (noting homicidal ideation and recurrent thoughts of death and dying; discussing his extreme social isolation, irritability, outbursts of anger, difficulty concentrating, and memory problems; and reflecting that the Veteran experiences intermittent visual hallucinations and has impaired judgment); December 2007 VA Psychiatry Progress Note (reflecting his poor concentration and focus and noting his irritable mood); March 2008 Mental Health Social Work Progress Note (classifying the Veteran's insight and judgment as "poor" and noting his socially isolating behaviors); June 2009 VA Psychological Therapy Note (reflecting severe depression and anxiety and noting that the Veteran presents with "hypo-manic urgency"); September 2008 VA Initial Psychological Assessment (noting that the Veteran's "conversation was extremely difficult to follow" and included "conspiracy theories" and "paranoid thought content about his being arrested and harassed all around the country by police because of his work in exposing government secrets"; noting that the Veteran was "unusually dressed"; and reporting that he presented with circumstantial though processes, rushed and manic speech, and poor insight); January 2010 VA Mental Health Outpatient Note (reporting a suicide attempt 2 months prior). Significantly, this psychiatric pathology was repeatedly classified as severe by various VA treatment providers throughout the appellate period. See, e.g., April 2007 VA Mental Health Initial Evaluation (assigning a GAF of 50, which signifies major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood); August 2007 VA Mental Health Social Work Progress Note (rating the severity of his depression as a 10 out of 10, with 10 being the most severe); December 2007 VA Mental Health Social Work Progress Note (rating the severity of his psychiatric symptomatology, including his anxiety level, as a 10 out of 10, with 10 being the most severe); March 2008 VA Mental Health Social Work Progress Note (rating the severity of his psychiatric symptomatology as a 10 out of 10, with 10 being the most severe); December 2013 VA Mental Health Consultation (categorizing the Veteran's psychiatric symptomatology as "severe" based on his scores on a depression screening test). Furthermore, his VA treatment providers also noted effects of his psychiatric disability including his history of repeated arrests for disorderly conduct, periods of homelessness, and inability to maintain employment. See, e.g., November 2004 VA Mental Health Note (reflecting a history of 4 arrests for disorderly conduct); April 2007 VA Mental Health Initial Evaluation (reporting a history of at least 5 arrests); March 2008 Mental Health Social Work Progress Note (noting the Veteran's his continued unemployment); August 2009 VA Mental Health Outpatient Note (reporting that he is homeless); January 2010 VA Mental Health Outpatient Note (noting multiple arrests including pending charge of "disorderly conduct"). The Board acknowledges that Veteran's psychiatric symptoms do not precisely mirror the symptoms enumerated for a 100 percent rating under Diagnostic Code 9440. For example, there is little or no evidence in the record of disorientation to time or place, memory loss for names of close relatives, own occupation, or own name, or intermittent inability to perform activities of daily living. However, it is apparent that the Veteran's symptoms, especially his suspiciousness and chronic paranoia, extreme irritability with outbursts of rage, thoughts of violence, poor judgment and insight, mania, social isolation and avoidance behavior, impaired concentration and racing thoughts, depression, and anxiety, have been of the frequency, severity, and duration to have rendered the Veteran more nearly totally impaired in his social and occupational functioning throughout this appeal. See Mauerhan, 16 Vet. App. at 443; Vazquez-Claudio, 713 F.3d at 117; 38 C.F.R. § 4.126. In this regard, the Board observes that the Veteran is competent to report on factual matters of which he had firsthand knowledge, e.g., experiencing psychiatric symptoms. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The Board finds that the statements and testimony provided by the Veteran on psychiatric evaluation, during the course of his treatment, and during the pendency of the claim regarding the effects of his current psychiatric symptoms on his daily life, including his occupational impairment and social isolation, are competent and credible. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see, too, Baldwin v. West, 13 Vet. App. 1 (1999) (the Board must analyze the credibility of the evidence). And, as discussed, these symptoms have been medically evaluated as productive of severe symptomatology throughout the appellate period. The Board also notes that there is evidence of record reflecting more moderate symptomatology. However, affording the Veteran the benefit of the doubt, the Board finds that such evidence is reflective of the Veteran's waxing and waning psychiatric symptomatology and thus does reflect sustained improvement. Accordingly, staging the Veteran's rating to reflect these periods of improvement is unwarranted. See Fenderson, 12 Vet. App. at 125. Thus, given the evidence of severe psychiatric symptomatology that has been determined by medical providers to preclude sustained employment, considering the Veteran's competent assertions concerning his profound psychiatric symptoms, and resolving all reasonable doubt in the Veteran's favor, the Board finds that, for the period from August 12, 2004 to January 8, 2015, the Veteran's adjustment disorder with mixed anxiety and depression manifests in symptoms most closely approximating total occupational and social impairment. 38 C.F.R. §§ 4.7, 4.102, 4.130, DC 9440. Accordingly, the criteria for a schedular rating of 100 percent for adjustment disorder with mixed anxiety and depression under Diagnostic Code 9440 are met. 38 C.F.R. §§ 3.102, 4.3, 4.130 (2015). See also 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). As the Veteran has been granted a 100 percent disability rating, the maximum allowable for his adjustment disorder with mixed anxiety and depression, for the entirety of the appeal period, a referral of this disability for extra-schedular consideration is considered moot. See 38 C.F.R. § 3.321. (B) Headaches The Veteran contends that an initial rating of 50 percent is warranted for his headaches for the period prior to February 12, 2015. See January 2015 Rating Decision (granting service connection for headaches with an initial evaluation of 10 percent); February 14, 2015 Rating Decision (granting an increased 50 percent rating for the headaches effective from February 12, 2015); February 19, 2015 Rating Decision (assigning an effective date of May 16, 2006 for the grant of service connection for headaches). The Veteran's headache disorder is in receipt of a 10 percent initial rating from May 16, 2006 to February 11, 2015, under 38 C.F.R. § 4.124a, Diagnostic Code 8100. Under this Code, as pertinent to the present claim, a 10 percent rating is assigned for characteristic prostrating attacks averaging one in 2 months over the last several months; a 30 percent evaluation is assigned for characteristic prostrating attacks occurring on an average once a month over the last several months; and the maximum 50 percent rating is assigned for very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a. Initially, the Board observes that the rating criteria do not define "prostrating," nor has the Court of Appeals for Veterans Claims. See Fenderson, 12 Vet. App. 119 (in which the Court quotes Diagnostic Code 8100 verbatim but does not specifically address the matter of what is a prostrating attack). By way of reference, the Board notes that according to WEBSTER'S NEW WORLD DICTIONARY OF AMERICAN ENGLISH, THIRD COLLEGE EDITION (1986), p. 1080, "prostration" is defined as "utter physical exhaustion or helplessness." A very similar definition is found in DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1530 (32nd Ed. 2012), in which "prostration" is defined as "extreme exhaustion or powerlessness." The rating criteria also do not define "severe economic inadaptability." However, nothing in Diagnostic Code 8100 requires the claimant to be completely unable to work in order to qualify for a 50 percent rating. See Pierce v. Principi, 18 Vet. App. 440 (2004). In evaluating the medical evidence of record, the Board finds that, during the period from May 16, 2006 to February 11, 2015, the symptoms associated with the Veteran's headache disorder more closely approximated the criteria for a 50 percent initial rating under DC 8100, which is the highest schedular rating available under this diagnostic code. See 38 C.F.R. § 4.124(a). The Board notes that most of the Veteran's symptoms associated with his headache disability are subjective; however, the Veteran is competent to state that he has had severe headaches that cause him frequent incapacitation and affected his job performance and attendance. Headaches are a type of disorder that can be easily identified by a lay person who is experiencing this symptomatology. See Jandreau, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Moreover, there is no reason to doubt his credibility when he indicates the severity of the headaches he is experiencing, especially considering that his symptomatology was endorsed by his examining VA physician in February, 2015, who acknowledged that the Veteran experienced very frequent completely prostrating and prolonged attacks of headache pain. In this regard, as previously discussed, in February 2015, the RO granted an increased 50 percent schedular evaluation for the Veteran's headaches, effective February 12, 2015, based on a VA headaches examination finding that the Veteran suffered from "very prostrating and prolonged attacks of headache pain productive of severe economic inadaptability." See February 2015 VA Headaches Disability Benefits Questionnaire (DBQ) (noting symptoms including head pain, nausea, sensitivity to light and sound, and changes in vision). In finding that the Veteran's "frequent" prostrating headache attacks resulted in economic inadaptability, the VA examiner noted that the Veteran has been treated for his headache symptoms throughout the appellate period and that he has been unemployed since 1999, due in part to the manifestations of his headache disability. This finding, then, suggests that the Veteran's headaches have been productive of severe economic inadaptability throughout the appellate period, and not just since the VA examination qualifying his headache condition. Significantly, the Veteran maintains that his headaches have been consistently disabling throughout the time frame on appeal. See, e.g., December 2014 E-mail Correspondence from the Veteran to the RO Titled "EXPEDITING HEADACHE/MIGRAINE SERVICE CONNECTED COMPENSATION - DVA FORM 21-0960C-8" (reporting that he suffers from "migraines which occur daily [headaches] and debilitating migraines on average of two to three times per month"). The Veteran is credible in his reports concerning his headache symptomatology, as discussed. And, as noted by the February 2015 VA examiner, the Veteran has regularly sought treatment for his chronic headaches throughout the time frame on appeal. Accordingly, based on the foregoing, the Board finds that, given the evidence of frequent "debilitating" attacks of headache pain, considering the findings of the VA examiner indicating that the headaches resulted in "severe economic inadaptability" for many years prior, and in the absence of any treatment records or VA examination reports identifying less severe symptomatology, the Board will resolve doubt in the Veteran's favor and find that the evidence more nearly approximates the criteria for an initial 50 percent rating for the entire appellate period, so from May 16, 2006 to February 11, 2015. See 38 C.F.R. § 4.124(a), DC 8100. See also 38 C.F.R. § 3.400(b)(2)(i); Fenderson, 12 Vet. App. at 126. Therefore, the Veteran's claim of entitlement to an initial 50 percent rating for headaches is granted. Given the Veteran's statements that the grant of an initial 50 percent disability rating for his headaches would satisfy his appeal as concerning the increased initial rating issue, and considering that the Board is granting an initial 50 percent rating for his headaches for the entire appellate period, which is the maximum assignable schedular evaluation, the issue of the propriety of referral of this disability for extra-schedular consideration is moot. See 38 C.F.R. § 3.321. Alternatively, a comparison of his symptoms and resulting functional impairment with the schedular criteria does not show "such an exceptional or unusual disability picture . . . as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b). See also Thun v. Peake, 22 Vet. App. 111, 114 (2008). There is no indication that the symptoms and clinical findings are otherwise exceptional or unusual for the Veteran's headache disorder, and the evidence shows that the number of prostrating attacks of headache pain and their effect on his functional ability are adequately compensated by the rating already assigned. See Mauerhan, 16 Vet. App. at 442; see also 38 C.F.R. § 4.21 (2013) (providing that application of the rating schedule requires "coordination of rating with impairment of function"). Accordingly, referral of the Veteran's headaches for extraschedular consideration is not warranted. See 38 C.F.R. § 3.321(b); Thun v. Peake, 22 Vet. App. 111, 114 (2008). IV. TDIU With regard to entitlement to TDIU, this benefit contemplates a schedular rating less than total for the disability or disabilities on which the TDIU would be based. See 38 C.F.R. § 4.16(a). The Board nevertheless recognizes that the Court has held that the receipt of a 100 percent schedular rating for a service-connected disability does not necessarily render moot any pending claim for a TDIU. Bradley v. Peake, 22 Vet. App. 280 (2008). Although no additional disability compensation may be paid when a total schedular disability rating is already in effect, the Court's decision in Bradley recognizes that a separate award of a TDIU predicated on a single disability may form the basis for an award of special monthly compensation. The Bradley case, however, is distinguishable from the instant case. In Bradley, the Court found that TDIU was warranted in addition to a schedular 100 percent evaluation where the TDIU had been granted for a disability other than the disability for which a 100 percent rating was in effect. Under those circumstances, there was no "duplicate counting of disabilities." Bradley, 22 Vet. App. at 293. Here, the evidence reflects that the Veteran is unemployed primarily as a result of his adjustment disorder with mixed anxiety and depression. Importantly, the Veteran does not contend that a TDIU is warranted based solely upon his service-connected disabilities, apart from his psychiatric disorder (e.g. his headaches, rated as 50 percent disabling; his cervical spine disability, rated as 20 percent disabling; his right ankle strain, rated as 10 percent disabling; his degenerative arthritis of the right hand, rated as 10 percent disabling; and his right knee strain, rated as noncompensable (0 percent disabling)). Accordingly, since the Veteran is entitled to a 100-percent rating for adjustment disorder with mixed anxiety and depression on a schedular basis for the entire period under review, entitlement to TDIU is rendered moot. See Vettese v. Brown, 7 Vet App. 31 (1994) (observing that a "claim for TDIU presupposes that the rating for the condition is less than 100 percent"); Holland v. Brown, 6 Vet App. 443 (1994). See also 38 C.F.R. § 4.16(a) (2015) (providing that total disability ratings for compensation may be assigned where the schedular rating is less than 100 percent). V. SMC under 38 U.S.C. § 1114(s) The Board finds that entitlement to SMC under 38 U.S.C.A. § 1114(s) is established as of May 16, 2006. As relevant to this case, special monthly compensation is payable if a veteran has a single service-connected disability rated as total, and has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems. 38 U.S.C.A. § 1114(s); 38 C.F.R. § 3.350(i); see also Bradley, 22 Vet. App. 280. Here, a 100-percent rating has been assigned for a single service-connected disability, namely the Veteran's adjustment disorder with mixed anxiety and depression. Since May 16, 2006, service connection has been in effect for other disabilities involving anatomical segments or bodily systems different from the adjustment disorder with mixed anxiety and depression, and which command a combined rating of at least 60 percent. Specifically, separate evaluations have been assigned for headaches (50 percent from May 16, 2006), a cervical spine disability (10 percent from January 14, 1994 to August 11, 2004, and 20 percent from August 12, 2004), right ankle strain (0 percent from January 14, 1994 to May 15, 2006, and 10 percent from May 16, 2006); degenerative arthritis of the right hand (0 percent from January 14, 1994 to September 22, 2008, and 10 percent from September 23, 2008), and right knee strain (0 percent from January 14, 1994). The ratings for these other service-connected disabilities combine to at least 60-percent under 38 C.F.R. § 4.25 (2015) since May 16, 2006. Accordingly, the criteria for entitlement to special monthly compensation under 38 U.S.C.A. § 1114(s) are satisfied as of May 16, 2006, and therefore SMC at the (s) rate is granted from this date. Prior to May 16, 2006, service connection had not been in effect for the headaches, and the Veteran's service-connected disabilities apart from the adjustment disorder with mixed anxiety and depression did not have a combined rating of 60 percent. The Board's grant of SMC at the (s) rate as of May 16, 2006 is based solely on the fact that the Veteran is entitled to this ancillary benefit as a matter of law as of this date. ORDER Entitlement to an effective date earlier than August 12, 2004, for the grant of service connection for adjustment disorder with mixed anxiety and depression is denied. Entitlement to an effective date earlier than May 16, 2006, for the grant of service connection for headaches is denied. An initial rating of 100 percent for adjustment disorder with mixed anxiety and depression for the period from August 12, 2004 to January 8, 2015, is granted, subject to the laws and regulations government payment of monetary benefits. An initial rating of 50 percent for headaches for the period from May 16, 2006 to February 11, 2015, is granted, subject to the laws and regulations government payment of monetary benefits. Entitlement to a total rating based on individual unemployability (TDIU) is moot. Entitlement to special monthly compensation (SMC) under 38 U.S.C. § 1114(s) is granted as of May 16, 2006, subject to the law governing payment of monetary benefits. REMAND Unfortunately, the remaining claims on appeal must be remanded. While the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the claims so that the Veteran is afforded every possible consideration. 38 U.S.C.A. § 5103A(a) (West 2014); 38 C.F.R. § 3.159(c), (d) (2015). Regarding his claims for higher ratings for his residuals of a cervical spine injury with degenerative changes, degenerative arthritis of the right hand, and right ankle strain, the Board finds that new examinations are warranted to assess the current nature and severity of these disabilities. See 38 C.F.R. § 3.327(a) (2015) (providing that reexaminations will be requested whenever VA needs to determine the current severity of a disability). In this regard, the Veteran was last provided VA examinations concerning these service-connected disabilities in March 2009, so more than six years ago. See March 2009 QTC Orthopedic Examination Report. Given the Veteran's continued assertion that these service-connected disabilities are more severely disabling than reflected in the currently assigned ratings, and in light of the amount of time since his last examination for these disabilities and the possible increase in their severity since, reexamination is needed to fully and fairly evaluate the conditions on appeal. See Palczewski v. Nicholson, 21 Vet. App. 174, 181-82 (2007), citing Caluza v. Brown, 7 Vet. App. 498, 505-06 (1998) ("Where the record does not adequately reveal the current state of the claimant's disability . . . the fulfillment of the statutory duty to assist requires a thorough and contemporaneous medical examination."). See also Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994) (wherein the Court determined the Board should have ordered a contemporaneous examination of the Veteran because a 23-month old examination was too remote in time to adequately support the decision in an appeal for an increased rating); VAOPGCPREC 11-95 (1995). As concerning his claim of entitlement to service connection for disequilibrium with impaired hearing, including as secondary to service-connected residuals of a cervical spine injury with degenerative changes, as noted, the Board remanded the claim in November 2014 so that the Veteran could be afforded a VA examination to determine the nature and etiology of his claimed disequilibrium with hearing impairment. A November 2015 Compensation and Pension Examination Request Inquiry reflects that the request for an examination was still open and that no examination had, as yet, been scheduled. A March 2016 examination detail report reflects that the Veteran failed to "RSVP" for his VA ear conditions examination, and notes that the Veteran failed to respond to an "RSVP letter" in November 2016. Despite this, a review of the record does not reveal that any letter was ever sent to the Veteran concerning this VA examination, and no examination was ever scheduled. See Stegall v. West, 11 Vet. App. 268 (1998) (a remand confers upon the claimant, as a matter of law, the right to compliance with the remand directives); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (noting that Stegall requires substantial compliance with remand orders, rather than absolute compliance). Moreover, the Board notes that the Veteran has consistently reported for repeated medical examinations throughout the appellate period, including for VA dental and audiological examinations in August 2015. Accordingly, given the absence of any evidence suggesting that the Veteran was ever scheduled for, or even notified of, a VA examination for his claimed disequilibrium, the Board finds that remand is required so that the requisite examination can be scheduled and the Veteran provided proper notice of it. The Veteran's claim of entitlement to service connection for a dental disability for compensation purposes, to include as secondary to an acquired psychiatric disorder, was also remanded by the Board in November 2014 for the provision of a VA examination. Specifically, the Board instructed that the dental examiner determine "whether it is at least as likely as not (50 percent or greater probability) that [any identified dental] disorder (1) had its clinical onset during active service or is related to any in-service disease, event, or injury; or (2) was either (a) caused by, or (b) aggravated by a service-connected disability (including specifically his acquired psychiatric disorder)." See November 2014 Board Remand. The Board additionally instructed that the examiner provide a complete rationale for any opinion rendered, "taking into account the Veteran's reports of his history, any reported in-service injuries, exposures, or events, and his current symptomatology." Id. Further, in the event that the examiner determined that a "requested opinion cannot be offered without resorting to speculation," the examiner was instructed to "explain why a non-speculative opinion cannot be offered." Pursuant to the Board's instruction, a VA dental examination was performed in August 2015. The VA dental examiner found that the Veteran was "missing teeth #5,12,18,19,20,28 and all 3rd molars(1,16,17,32)" and additionally diagnosed "moderate chronic generalized adult periodontitis" and identified signs "indicative of chronic bruxism." As to the etiology of these identified conditions, the VA dental examiner stated simply that "[i]t is impossible to determine why the teeth currently missing were lost" and that "[i] It is impossible to determine a specific underlying cause for bruxing." No further explanation or rationale was provided. These conclusory statements are unsupported by adequate rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (noting that most of the probative value of a medical opinion comes from its reasoning); Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007) (holding that "the mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision as to what weight to assign to the doctor's opinion"); 38 C.F.R. § 4.2 (2015) (stating that if the findings on an examination report do not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate for evaluation purposes). In addition, the examiner failed to address the posited relationship between the Veteran's psychiatric disability and his dental disability, as instructed by the Board in the November 2014 remand. See Stegall, 11 Vet. App. at 271. Because VA undertook to provide a VA examination to evaluate the Veteran's dental condition, to include the potential relationship between his psychiatric disability and his dental disability, the Board must ensure that such an examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Accordingly, reexamination is warranted Finally, as the claim is being remanded, the Veteran's updated VA treatment records should also be obtained. Accordingly, the case is REMANDED for the following action: 1. Implement the Board's decision awarding an initial rating of 100 percent for adjustment disorder with mixed anxiety and depression for the period from August 12, 2004 to January 8, 2015; an initial rating of 50 percent for headaches for the period from May 16, 2006 to February 11, 2015; and SMC at the (s) rate as of May 16, 2006. 2. Obtain and associate with the claims folder any outstanding VA treatment records. 3. After the above records have been obtained, schedule the Veteran for appropriate VA examination(s) to assess the nature and current severity of his service-connected residuals of a cervical spine injury with degenerative changes, degenerative arthritis of the right hand, and right ankle strain. A copy of the letter notifying the Veteran of the date, time, and location of the examination(s) should be associated with the claims folder. The entire claims file and a copy of this REMAND must be made available to the examiner(s) prior to the examination(s). The examiner(s) must note in the examination report(s) that the evidence in the claims file has been reviewed. The examination(s) should include any diagnostic testing or evaluation deemed necessary by the examiner(s). The examiner(s) should report in detail all relevant clinical findings, all diagnoses, and all current complaints. The appropriate Disability Benefits Questionnaires (DBQs) should be filled out for this purpose, if possible. 4. Schedule the Veteran for an appropriate VA examination concerning his claimed disequilibrium with hearing impairment. A copy of the letter notifying the Veteran of the date, time, and location of the examination should be associated with the claims folder. The entire claims file and a copy of this REMAND must be made available to the examiner prior to the examination. The examiner must note in the examination report that the evidence in the claims file has been reviewed. The examination should include any diagnostic testing or evaluation deemed necessary by the examiner. The examiner should report in detail all relevant clinical findings, all diagnoses, and all current complaints. After reviewing the claims file, obtaining a complete history from the Veteran, and conducting any necessary physical examination and diagnostic testing, the examiner should diagnose and describe in detail all current disabilities concerning disequilibrium with hearing impairment. As to each identified disorder, the examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any disorder involving disequilibrium with hearing impairment had its clinical onset during active service or is related to any in-service disease, event, or injury, to specifically include the Veteran's November 1993 neck injury. The examiner should also provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any current disorder involving disequilibrium with hearing impairment was either (a) caused by, or (b) aggravated by a service-connected disability (including specifically his acquired psychiatric disorder, headaches, and cervical spine disorder). In providing these opinions, the examiner is must specifically address the Veteran's contention that his service-connected neck disability caused or contributed to his disequilibrium. In this regard, the examiner should note that that the Veteran is competent to report the onset and duration of his symptoms as well as his medical history. The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. All examination findings, along with the complete explanation for all opinions expressed, must be set forth in the examination report. If the examiner is unable to answer any question without a resort to speculation, then he or she should so indicate and provide a rationale for why an answer could not be provided. 5. Schedule the Veteran for a VA dental examination. A copy of the letter notifying the Veteran of the date, time, and location of the examination should be associated with the claims folder. The entire claims file and a copy of this REMAND must be made available to the examiner prior to the examination. The examiner must note in the examination report that the evidence in the claims file has been reviewed. The examination should include any diagnostic testing or evaluation deemed necessary by the examiner. The examiner should report in detail all relevant clinical findings, all diagnoses, and all current complaints, and should provide a detailed overview of the Veteran's mouth, to include documenting missing teeth, existing dental restorations, and outstanding issues. After reviewing the claims file, obtaining a complete dental history from the Veteran, and conducting any necessary physical examination and diagnostic testing, the examiner should identify all current dental disorders, specifically to include any missing teeth, listed by tooth number, and any abnormality(ies) of the mouth. The examiner should also specify whether there is chronic osteomyelitis or osteoradionecrosis of the maxilla or mandible, loss of the mandible, nonunion or malunion of the mandible, temporomandibular articulation or limited jaw motion, loss of the ramus, loss of the condyloid process, loss of the hard palate, loss of the maxilla, or malunion or nonunion of the maxilla (as contemplated by 38 C.F.R. § 4.150). For any diagnosed disorder, to include specifically the previously diagnosed missing teeth and chronic bruxism, the examiner must state whether it is at least as likely as not (50 percent or greater probability) that such disorder (1) had its clinical onset during active service or is related to any in-service disease, event, or injury; or (2) was either (a) caused by, or (b) aggravated by a service-connected disability (including specifically his acquired psychiatric disorder). In providing these opinions, the examiner is must specifically address the Veteran's contention that his service-connected psychiatric disability results in his bruxism and, in turn, loss of teeth. In this regard, the examiner should note that that the Veteran is competent to report the onset and duration of his symptoms as well as his medical history. The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. All examination findings, along with the complete explanation for all opinions expressed, must be set forth in the examination report. If the examiner is unable to answer any question without a resort to speculation, then he or she should so indicate and provide a rationale for why an answer could not be provided. 6. Next, review the claims file and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action must be implemented. If any examination report does not include adequate responses to the specific opinions requested, it must be returned to the providing examiner for corrective action. 7. Finally, after completing the requested actions, and any additional notification and/or development deemed warranted, readjudicate the claim on appeal in light of all pertinent evidence and legal authority. If any benefit sought on appeal remains denied, furnish to the Veteran an appropriate SSOC that includes clear reasons and bases for all determinations, and afford him the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ P.M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs