Citation Nr: 1325365 Decision Date: 08/09/13 Archive Date: 08/13/13 DOCKET NO. 09-32 743 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Providence, Rhode Island THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, claimed as posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for a heart disorder. 3. Entitlement to service connection for a sinus disorder, claimed as left frontal sinus with post nasal drip. 4. Entitlement to a rating in excess of 40 percent for post-fracture status, left supraorbital ridge with headaches. 5. Entitlement to an initial rating in excess of 10 percent for vitreous floaters of the left eye. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D.J. Drucker, Counsel INTRODUCTION The Veteran had active military service from November 1963 to November 1967. This matter initially came to the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Providence, Rhode Island. In that decision, the RO, in pertinent part, denied service connection for heart, eye, and sinus disorders, and further denied a rating in excess of 30 percent for post-fracture status, left supraorbital ridge with headaches. The RO also declined to reopen the Veteran's previously denied claim of service connection for an eye disorder, including vitreous floaters. In May 2011, the Veteran testified during a hearing at the RO before the undersigned Veterans Law Judge. A transcript of the hearing is of record. At that time, the Veteran was represented by The American Legion (AL), his appointed service representative in his case on appeal. However, he later revoked the AL's power of attorney and he has not appointed a new representative in his case. In a January 2013 signed statement, the Veteran stated that he "will not use any other veterans organization" and that he had a list of VA accredited agents and lawyers. As such, the Board finds that all due process requirements were met regarding the Veteran's right to appoint a representative in his case before the Board. In a January 2012 decision, the Board reopened the Veteran's claim for service connection for an eye disorder. At that time, the Board remanded the claims of service connection for eye, sinus, and heart disorders, and PTSD, and an increased rating for post-fracture status, left supraorbital ridge with headaches, to the RO via the Appeals Management Center (AMC) in Washington, D.C., for further evidentiary development. In an October 2012 rating decision, the RO granted service connection for vitreous floaters of the left eye and a scar of the left eyebrow, assigned initial noncompensable and 10 percent ratings, respectively, effective from March 6, 2008. The RO also granted a 40 percent rating for the Veteran's service-connected post-fracture status, left supraorbital ridge with headaches, also effective March 6, 2008. In a January 2013 signed statement, the Veteran expressed disagreement with the October 2012 rating decision and was "gathering data and other material support his reasons for the disagreement." He did not describe the claim(s) with which he disagreed or the specific nature of his disagreement. However, in a February 2013 signed statement, the Veteran said that, as to his scar disability, September 17, 1973 was "the correct date for back payment for this injury." The Board construes the Veteran's February 2013 statement as a new claim for entitlement to an effective date earlier than March 6, 2008 for the award of service connection for a left eyebrow scar. This matter has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. During the pendency of the Veteran's case, the United States Court of Appeals for Veterans Claims (court) held that claims for service connection for PTSD encompass claims for service connection for all psychiatric disabilities. Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009) (the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record). As such, the Board has recharacterized the claim on appeal to more accurately reflect the court's holding in Clemons. The matters of entitlement to service connection for heart and sinus disorders and an initial rating in excess of 10 percent for vitreous floaters in the left eye are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the AMC. FINDINGS OF FACT 1. The evidence of record preponderates against a finding that the Veteran has PTSD or another acquired psychiatric disorder that had its onset or is otherwise related to active military service. 2. The evidence of record shows that the Veteran's post-fracture status, left supraorbital ridge is manifested by symptoms that satisfy the criteria for impairment level 2 for at least one facet of cognitive impairment, but do not satisfy the criteria for impairment of level 3 or greater in any facet. 3. The preponderance of the evidence of record shows that the Veteran experiences a headache disorder related to the service-connected post-fracture status, left supraorbital ridge disability, manifested by prostrating attacks averaging once a month over the past several months that are not shown to cause severe economic adaptability. 4. The preponderance of the evidence shows that the Veteran experiences loss of his left supraorbital sensory nerve secondary to his post-fracture status, left supraorbital ridge disability, productive numbness commensurate with no more than moderate sensory loss. CONCLUSIONS OF LAW 1. The criteria for service connection for an acquired psychiatric disorder, claimed as PTSD, have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2012). 2. The criteria for a rating in excess of 40 percent for post-fracture status, left supraorbital ridge have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107; 38 C.F.R. § 4.124a, Diagnostic Code 8045 (2008) and (2012). 3. The criteria for a separate 30 percent rating, but no higher, for a headache disability related to a post-fracture status, left supraorbital ridge disability, have been met. 38 U.S.C.A. § 1155, 5103A, 5107; 38 C.F.R. §§ 4.124a, Diagnostic Code 8045-8100 (2012). 4. The criteria for a separate 10 percent evaluation, but no higher, for loss of the left supraorbital sensory nerve related to a post-fracture status, left supraorbital ridge disability, have been met. 38 U.S.C.A. § 1155, 5103, 5103A; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 4.124a, Diagnostic Code 8045-8205 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist As provided for by the Veterans Claims Assistance Act (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). In Bryant v. Shinseki, 23 Vet App 488 (2010), the court held that 38 C.F.R. 3.103(c)(2) (2009) requires that the Veterans Law Judge who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, this Veterans Law Judge outlined the issues on appeal and suggested that any evidence tending to show that pertinent disability was related to active duty or a service-connected disability, or worsened in severity, would be helpful in establishing the service connection and increased rating claims. Moreover, the Veteran has not asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2); he has not identified any prejudice in the conduct of the Board hearing. Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, the Veteran was sent letters in March, April and July 2008 and January 2012 that provided information as to what evidence was required to substantiate the claims and of the division of responsibilities between VA and a claimant in developing an appeal. Accordingly, no further development is required with respect to the duty to notify. Next, VA has a duty to assist the Veteran in the development of his claims. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. All reasonably identified and available VA and non-VA medical records were obtained. A review of the Veteran's Virtual VA electronic file reveals VA medical records, dated from May 2008 to January 2012, also considered by the AOJ regarding the service connection and increased rating claims on appeal (see May 9, 2013 supplemental statement of the case, noting that the Veteran's claims were "considered based on all evidence of record", at page 1). In March and May 2008, the Veteran underwent VA neurological and psychological examinations, respectively, and the examination reports are of record. In January 2012, the Board remanded the Veteran's case to the RO for further development that included obtaining records regarding the Veteran's treatment at the Newton-Wellesley Hospital and scheduling him for VA examinations. There has been substantial compliance with the Board's 2013 remand, as he was scheduled for VA examinations in May 2012 and records from the Newton-Wellesley Hospital, dated in December 2001, were obtained. In a January 2012 signed statement, the Veteran reported that he contacted the office of Dr. G. (who treated him in 1997) and was advised that records were only kept for seven years and his records were destroyed. Regarding the May 2012 examination reports, the Board finds them adequate for rating purposes. Indeed, the claims file was reviewed, the examiners reviewed the pertinent history, examined the Veteran, provided clinical findings and diagnoses, and offered etiological opinions with rationales from which the Board can reach a fair determination. The records satisfy 38 C.F.R. § 3.326 (2012). The May 2012 VA examination reports make up for the deficiencies in the March and May 2008 VA examination reports. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records, as well as post-service reports of VA and non-VA treatment and examination. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims. For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Factual Background and Legal Analysis The Board has thoroughly reviewed the record in conjunction with this case that includes the Veteran's service treatment records, VA and non-VA medical records and examination reports, dated from 1973 to 2013, and the Veteran's written statements and oral testimony in support of his claims. Although there is an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). Rather, the analysis below will focus specifically on what the evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant). A. Service Connection Under 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303, a veteran is entitled to disability compensation for disability resulting from personal injury or disease incurred in or aggravated by active military service. To establish a right to compensation for a present disability, a veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service" - the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). This is a direct service connection theory of entitlement. Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by either evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or, when a chronic disease is not present during service, evidence of continuity of symptomatology. However, the theory of continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) As referenced above, certain chronic diseases, including psychoses, may be presumed to have been incurred during service if the disorder becomes manifest to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.307, 3.309 (2012). In addition, secondary service connection may be granted for a disability that is proximately due to, or the result of, a service-connected disease or injury. 38 C.F.R. § 3.310(a). With regard to the matter of establishing service connection for a disability on a secondary basis, the court has held that there must be evidence sufficent to show that a current disability exists and that the current disability was either caused or aggravated by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Additionally, when aggravation of a non-service-connected disability is proximately due to or the result of a service-connected condition, such disability shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Id.; see also 38 C.F.R. § 3.310(b). With regard to a claim for secondary service connection, the record must contain competent evidence that the secondary disability was caused by the service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). A service connection claim must be accompanied by evidence that establishes that the claimant currently has the claimed disability. See Degmetich v. Brown, 104 F. 3d 1328 (1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). See also Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999) (to the effect that complaints of pain alone do not meet the current disability threshold). More recently, the court held that the current disability requirement is satisfied when a claimant has a disability at the time of filing the claim or during the pendency of that claim, even if the disability has since resolved. McClain v. Nicholson, 21 Vet. App. 319 (2007). See also Romanowsky v. Shinseki, No. 11-3272, Vet. App. May 9, 2013 (noting that a diagnosis is "sufficiently proximate to the filing of a claim so as to constitute evidence of a 'current diagnosis' is a factual finding to be made by the Board in the first instance."). Where the determinative issue involves medical causation or a medical diagnosis, there must be competent evidence to the effect that the claim is plausible. Case law has established that lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the appellant's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). However, although the Veteran is competent in certain situations to provide a diagnosis of a simple condition such as a headache, varicose veins, or tinnitus, the Veteran is not competent to provide evidence as to more complex medical questions, such as the etiology of cardiovascular and psychological pathology, as is the case here. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In this case, the Veteran asserts that he has PTSD due to military service, including service-connected disability. Thus, he contends that service connection is warranted for PTSD. Prior to July 13, 2010, service connection for PTSD required that there be (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); (2) a link, established by medical evidence, between current symptoms and an in-service stressor; (3) and credible supporting evidence that the claimed in-service stressor actually occurred. 38 C.F.R. § 3.304(f) (2009); see also Cohen v. Brown, 10 Vet. App. 128, 138 (1997). The diagnosis of a mental disorder must conform to the Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-V) and be supported by the findings of a medical examiner. See 38 C.F.R. § 4.125(a). If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the conditions or hardships of the Veteran's service, the lay testimony alone may establish the occurrence of the in-service stressor. 38 U.S.C.A. § 1154(b) (West 2002 and Supp. 2012). Where a current diagnosis of PTSD exists, the sufficiency of the claimed in-service stressor is presumed. Cohen v. Brown, 10 Vet. App. 128, 144 (1997). Nevertheless, credible evidence that the claimed in-service stressor actually occurred is also required. 38 C.F.R. § 3.304(f). See Anglin v. West, 11 Vet. App. 361, 367 (1998); Gaines v. West, 11 Vet. App. 353, 357 (1998), Cohen v. Brown, 10 Vet. App. at 138; Suozzi v. Brown, 10 Vet. App. 307 (1997). Effective July 13, 2010, VA amended 38 C.F.R. § 3.304(f) by liberalizing, in certain circumstances, the evidentiary standards for establishing the occurrence of an in-service stressor for non-combat Veterans. See 75 Fed. Reg. 39,843-39,852 (effective July 13, 2010) (codified at 38 C.F.R. § 3.304(f)) (2012). Section 3.304 (f) was amended to include a new paragraph (f)(3) that reads as follows, in pertinent part: (f)(3) If a stressor claimed by a veteran is related to the veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of [PTSD] and the veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. See 75 Fed. Reg. 3984 -51 (July 13, 2010) and corrective notice at 75 Fed. Reg. 41092 (July 15, 2010). During the course of his appeal, the Veteran reported stressors associated with his service in Turkey and Greece, including that he was exposed to an anti-American riot in Turkey and citizen rebellion in Greece. The Veteran reported that, in August 1964, he was at an International Trade Fair in Turkey, when a mob of several thousand people rampaged through the fairgrounds. During his May 2011 Board hearing, he characterized this incident as an "anti-American riot." See Board hearing transcript at page 10. The Veteran also contends that, in April 1967, he was in Athens, Greece, in a crowd of Greek civilians who suddenly rebelled against Greek soldiers enforcing martial law. Shots were fired and his life was in danger. Service personnel records show that the Veteran was at Cigli Air Base, Turkey, from April 1964 to November 1965, and at Athinai Airport, Greece, from November 1965 until November 1967. In support of his stressors, the Veteran provided two articles from the New York Times that describe the events noted above in detail, consistent with his assertions. As noted in the Board's January 2013 remand, while the evidence does not expressly establish that the Veteran was involved in either event, his May 2011 hearing testimony was credible and the claimed stressors were consistent with the circumstances of his service. Accordingly, the Board found that the Veteran's claimed stressors were sufficiently corroborated. Thus, the remaining question for consideration is whether the Veteran has a confirmed diagnosis of PTSD, or another psychiatric disorder, that was incurred during active service. Service treatment records do not reflect complaints, diagnosis, or treatment for a psychiatric disorder. On a Report of Medical History completed in September 1967, the Veteran denied having depression, or excessive worry, nightmares, or nervous trouble of any sort. When examined for separation at that time, a psychiatric abnormality was not noted. Post service, a September 1973 VA examination report does not discuss a psychiatric disorder. A May 1980 VA examination report notes the Veteran's report of episodes of tension all over, not associated with head pain. A psychiatric disorder was not diagnosed. An August 1982 VA examination report does not discuss a psychiatric disorder. In May 2008, the Veteran underwent a VA psychological examination. The examiner reviewed the medical records and performed a clinical evaluation. The Veteran's verified stressor of being in a riot in Turkey was noted. When asked to describe any emotional or psychiatric complaints, the Veteran stated that he felt "okay." He denied nightmares and did not have sleep difficulty. The VA examiner found that the Veteran did not meet the DSM-IV criteria necessary to support a diagnosis of PTSD and did not diagnose another mental disorder. The VA examiner commented that, while the Veteran did not meet full criteria for the diagnosis of PTSD, he may well have cognitive and personality deficits resulting from his three traumatic brain injuries. Further evaluation was recommended. In May 2012, the Veteran underwent another VA psychological examination for PTSD. He gave a history of working as a software engineer and, more recently, on home renovation projects for his house and his mother's home. He had problems concentrating at work when he had headaches, approximately 3 to 4 times a month. Due to those symptoms he no longer wished to continue with computer work and quit his job in 2001. He then worked as a consultant for two years, and fully retired in the early 2000s. The Veteran described his two stressful events in service. He reported experiencing discomfort and a racing heart, which occurred, for example, in large stores. This happened once or twice a month and he associated it with the rioting experience. He did not have anxiety in crowds or other public places. The Veteran had mild irritability while driving and some concentration difficulties that he attributed at times to headaches. He denied all other psychiatric symtoms and never took prescribed psychiatric medications. Upon examination, the VA examiner concluded that the Veteran's symtoms did not meet the diagnostic criteria for PTSD or another diagnosed mental disorder that conformed to DSM-IV criteria. There is no medical opinion of record to refute the May 2012 VA examiner's conclusion, which is entirely consistent with that of the March 2008 VA examiner. In sum, the evidence fails to show that the Veteran exhibits PTSD or another diagnosed psychiatric disorder. Despite some reported symptoms, they have not been deemed sufficient to warrant a psychiatric diagnosis, following two VA mental health examinations. No other medical evidence of record enables a finding that the Veteran has a chronic psychiatric disorder currently or at any time during the appeal period. The Board notes that, in the absence of proof of a present disability or any complaints related to chronic or recurrent symptoms, there can be no valid claim. See 38 C.F.R. § 3.304; Brammer v. Derwinski, 3 Vet. App. at, 225. Thus, service connection is not warranted for an acquired psychiatric disorder, claimed as PTSD. Moreover, in so finding, the Board notes that the Veteran, as a layperson, lacks the expertise to diagnose a disorder as complex as PTSD. Indeed, such diagnosis requires knowledge beyond that observable to the senses. B. Increased Rating The Veteran claims that the severity of his service-connected post-fracture status, left supraorbital ridge with headaches warrants a higher disability rating. Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27 (2012). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). See also 38 C.F.R. §§ 4.1, 4.2. Additionally, although regulations require that a disability be viewed in relation to its recorded history, 38 C.F.R. §§ 4.1, 4.2, when assigning a disability rating, it is the present level of disability which is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Regulations require that where there is a question as to which of two evaluations is to be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). The Veteran's statements describing the symptoms of his service-connected disability are deemed competent evidence. However, these statements must be considered with the clinical evidence of record and in conjunction with the pertinent rating criteria. When the RO received the Veteran's current increased rating claim in March 2008, his traumatic brain injury (TBI) disability (then characterized as post-fracture status, left supra-orbital ridge with headaches) was evaluated as 30 percent disabling under Diagnostic Code 8305-8100. In the assignment of diagnostic code numbers, hyphenated diagnostic codes may be used. Injuries will generally be represented by the number assigned to the residual condition on the basis of which the rating is determined. Diseases will be identified by the number assigned to the disease itself, with the residual condition added, preceded by a hyphen. 38 C.F.R. § 4.27 (2012). Diagnostic Code 8305 evaluates neuritis and Diagnostic Code 8100 evaluates migraine headaches. 38 C.F.R. § 4.124a (2012). The October 2012 rating decision assigned a 40 percent rating under Diagnostic Code 8045, effective from March 6, 2008. Effective October 23, 2008, the protocol for evaluating TBI was revised. See 73 Fed. Reg. 54,693 (Sept. 23, 2008). See 38 C.F.R. § 4.124a, Note (5) (2012). A veteran whose residuals of TBI are rated under a version of § 4.124a, Diagnostic Code 8045, may request review under Diagnostic Code 8045, irrespective of whether his disability worsened since the last review. Id. Where a law or regulation (particularly those pertaining to the Rating Schedule) changes after a claim has been filed, but before the administrative and/or appeal process has been concluded, both the old and new versions must be considered. See VAOPGCPREC 7-2003 (Nov. 19, 2003). The effective date rule established by 38 U.S.C.A. § 5110(g) (West 2002), however, prohibits the application of any liberalizing rule to a claim prior to the effective date of such law or regulation. The Veteran does get the benefit of having both the old regulation and the new regulation considered for the period before and after the change was made. See Rhodan v. West, 12 Vet. App. 55 (1998), appeal dismissed, No. 99-7041 (Fed. Cir. Oct. 28, 1999) (unpublished opinion) (VA may not apply revised schedular criteria to a claim prior to the effective date of the pertinent amended regulations). Again, the October 2012 rating decision effectuated the 40 percent rating for the Veteran's disability under Diagnostic Code 8045 from March 6, 2008. Prior to October 23, 2008, Diagnostic Code 8045 provided that purely neurological disabilities such as hemiplegia, epileptiform seizures, facial nerve paralysis, etc., following trauma to the brain, will be rated under the diagnostic codes specifically dealing with such disabilities, with citation of a hyphenated diagnostic code (e.g., 8045-8911). Purely subjective complaints such as headache, dizziness, insomnia, etc., recognized as symptomatic of brain trauma, will be rated 10 percent and no more under Diagnostic Code 9304. This 10 percent rating will not be combined with any other rating for a disability due to brain trauma. Ratings in excess of 10 percent for brain disease due to trauma under Diagnostic Code 9304 are not assignable in the absence of a diagnosis of multi-infarct dementia associated with brain trauma. 38 C.F.R. § 4.124a, Diagnostic Code 8045 (effective prior to October 23, 2008). Under the revised Diagnostic Code 8045, effective October 23, 2008, there are three main areas of dysfunction that may result from TBI and have profound effects on functioning: cognitive (which is common in varying degrees after TBI), emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation. 38 C.F.R. § 4.124a, Diagnostic Code 8045 (2012). Cognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain. Executive functions are goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive. 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. Evaluate cognitive impairment under the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." Id. Subjective symptoms may be the only residual of TBI or may be associated with cognitive impairment or other areas of dysfunction. Evaluate subjective symptoms that are residuals of TBI, whether or not they are part of cognitive impairment, under the subjective symptoms facet in the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." However, separately evaluate any residual with a distinct diagnosis that may be evaluated under another diagnostic code, such as migraine headache or Meniere's disease, even if that diagnosis is based on subjective symptoms, rather than under the "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" table. Id. The rater is to evaluate emotional/behavioral dysfunction under § 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 TBI Not Otherwise Classified." Id. The rater is to evaluate physical (including neurological) dysfunction based on the following list, under an appropriate diagnostic 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. Id. The preceding list of types of physical dysfunction does not encompass all possible residuals of TBI. For residuals not listed here that are reported on an examination, evaluate under the most appropriate diagnostic code. Evaluate each condition separately, as long as the same signs and symptoms are not used to support more than one evaluation, and combine under 38 C.F.R. § 4.25 the evaluations for each separately rated condition. The evaluation assigned based on the "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" table will be considered the evaluation for a single condition for purposes of combining with other disability evaluations. Id. Also for consideration is the need for special monthly compensation for such problems as loss of use of an extremity, certain sensory impairments, erectile dysfunction, the need for aid and attendance (including for protection from hazards or dangers incident to the daily environment due to cognitive impairment), being housebound, etc. Evaluation of Cognitive Impairment and Subjective Symptoms: The table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" contains 10 important facets of TBI 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, and 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. Assign a 100- percent evaluation if "total" is the level of evaluation for one or more facets. If no facet is evaluated as "total," assign the overall percentage evaluation 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, assign a 70 percent rating if 3 is the highest level of evaluation for any facet. 38 C.F.R. § 4.124a, Diagnostic Code 8045. Note (1): There may be an overlap of manifestations of conditions evaluated under the table titled "Evaluation Of Cognitive Impairment And Other Residuals Of TBI Not Otherwise Classified" with manifestations of a co-morbid 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. Id. Note (2): Symptoms listed as examples at certain evaluation levels in the table are only examples and are not symptoms that must be present in order to assign a particular evaluation. Id. Note (3): "Instrumental activities of daily living" refers to activities other than self-care that are needed for independent living, such as meal preparation, doing housework and other chores, shopping, traveling, doing laundry, being responsible for one's own medications, and using a telephone. These activities are distinguished from "Activities of daily living," which refers to basic self-care and includes bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet. Id. Note (4): The terms "mild," "moderate," and "severe" TBI, which may appear in medical records, refer to a classification of TBI made at, or close to, the time of injury rather than to the current level of functioning. This classification does not affect the rating assigned under Diagnostic Code 8045. Id. Facts In a March 2008 signed statement, the Veteran's mother noted that he had painful headaches. The Veteran underwent VA neurological examination in March 2008. He complained of having periodic headaches, a "very quick temper" and difficulty dealing with stress. He reported sustaining two closed head injuries. The first was in 1964 when he was thrown from a horse and lost consciousness. After that injury, he started to see stars in his left eye. The headaches began after his second injury in 1966 when his skull was fractured in a fight for which he underwent surgery. The Veteran reported that he developed severe headaches after his second head injury, as well as a sensation of numbness and tightness in the forehead. The Veteran also complained of being irritable and having a "quick temper," and difficulty coping with any emotional stress. Objectively, the Veteran was tense and irritable, but was cooperative and a good historian. He had high integration of functions that were intact. There was a small, well-healed scar in the left eyebrow area. Motor examination showed normal muscle tone, bulk, and strength in all muscle groups. Deep tendon reflexes were 1 and symmetrical. Plantar reflexes were flexor. Sensory examination was intact to pinprick and light touch. Cerebellar examination was normal. The Veteran reported no change in his headache pattern ever since 1966. He was able to work as a manager all his life with no interference and no disability due to the periodic headaches. The diagnosis was chronic posttraumatic headaches, mild to moderate, unchanged for years. In the VA examiner's opinion, the Veteran's chronic posttraumatic headaches, that were present since 1966, have not caused any significant disability. However, the Veteran claimed to have been subjected to severe psychological stresses during his military service that, according to him, led to his inability to cope with emotional stresses. The examiner recommended that he be evaluated for possible PTSD. During his May 2011 Board hearing, the Veteran complained of having severe headaches and a quick temper since his discharge. See Board hearing transcript at page 3. He had headaches, numbness, and tightness in the area of his left supraorbital fracture. Id. at 4. The Veteran stated that he had severe headaches that interfered with his ability to work. Id. at 7-8. His headaches and loss of concentration made it hard for him to work and led him to stop working in 2001. Id at 7. Further, the Veteran indicated that he told the March 2008 VA examiner that there were times when he had 2 or 3 headaches in one week and then went for two weeks without a headache. Id. at 8. The Veteran had approximately 3 to 4 headaches a week, and had two headaches that week. Id. at 13-14. His headaches varied in intensity, and at their worst they rendered him unable to do anything all day. Id. at 14. He did not take prescribed medication for his headaches. Id. at 15. In May 2012, the Veteran underwent VA examination for residuals of TBI. The Veteran's history of two significant head injuries in service was noted. The Veteran subsequently developed headaches, bifrontal in location, throbbing, photophobic, 3 to 4 times a month, for which he had no special therapy, that lasted 45 minutes, and were at times prostrating. He further reported that in the same year he was inadvertently thrown into a wall with no loss of consciousness, but was dazed and a little dizzy. When he returned home, his family said that he changed. The Veteran, himself, noted his short temper, frequent inappropriate outbursts, and irritability, and that he was a loner, never married, and had trouble being with anyone. He avoided seeing doctors and had a myocardial infarction in 1997. The Veteran had panic attacks and now avoided those settings that induced them. Regarding the 10 facets of TBI-cognitive impairment and subjective symtoms, it was noted that there was a complaint of mild memory loss, attention, concentration, or executive functions, but without objective evidence on testing. The Veteran had mildly impaired judgment and his social interaction was frequently inappropriate. He was a loner in all things. He was always oriented to person, place, time, and situation. His motor activity and visual spatial orientation were both normal. The Veteran had subjective symtoms that did not interfere with work, instrumental activities of daily living, or work, family or other close relationships. It was noted that the Veteran had one or more neurobehavioral effects of TBI that occasionally interfere with workplace interaction, social interaction, or both but do not preclude them including poor temper control, panic attacks, irritability, and social isolation. The Veteran was able to communicate by spoken and written language (expressive communication) and to comprehend spoken and written language. The Veteran's consciousness was normal. The Veteran also had subjective symtoms attributable to his TBI that were migraine headache, that were fairly frequent, photophobic with behavioral symtoms as noted above. The VA examiner also noted that the Veteran had a 2-3 centimeter (cm) left supraorbital scar with hypothesia of about 3 to 5 cm consistent with nerve dysfunction. The other cranial nerves I to XII were intact, pupils were round, equal, and reactive to light, there was full extra ocular movement, his face was symmetric, his tongue and palate midline, and he was able to smell cloves. The VA examiner reported that the Veteran's residual conditions attributable to TBI impacted his ability to work. It was noted that the Veteran was retired for over 10 years and had cardiac and temper control and stress that made his headaches worse. The VA examiner further remarked that the Veteran had TBI with cognitive, executive, and behavioral dysfunction of moderate to severe degree, migraine headache, and loss of the left supraorbital sensory nerve secondary to fracture and surgery. Analysis TBI The Veteran has some memory loss, the manifestations of which have been described as mild and non-confirmed on objective testing. On VA examination in May 2008, there was no evidence of memory problems and the examiner reported that he was attentive and focused during his interview. On objective evaluation during his VA examination in May 2012, there was evidence of mild memory loss, attention, concentration, or executive functions, without objective evidence on testing. Hence, his level of impairment in this facet is no more than 1. Judgment and insight were considered intact on VA examination in March 2008. On objective evaluation during his VA examination in May 2012, there was evidence of mildly impaired judgment, but no evidence of impaired motor activity or visual or spatial orientation. Hence, his level of impairment in this facet is no more than 1. The Veteran has always been oriented to person, time, place, and situation on examination, and there is no evidence of any dysfunction of his communication skills. He has acknowledged irritability and volatility associated with his TBI, as reported by the March 2008 VA examiner and the May 2012 VA examiner reported that the Veteran's social interaction was frequently inappropriate. Hence, his level of impairment in this facet is no more than 2. The Veteran has reported stress and moderate to severe headaches, several times a month. The May 2012 VA examiner reported that the Veteran's subjective symtoms did not interfere with work, instrumental activities of daily living, or work, family, or other close relationships. Hence, his level of impairment in this facet is no more than 1. The Veteran has repeatedly complained of irritability and the May 2012 VA examiner noted his reported poor temper control, panic attacks and social isolation. Hence, his level of impairment in this facet is no more than 2. Accordingly, as the Veteran's level of impairment for all of the categories listed in the current version of Diagnostic Code 8045 does not exceed level 2, a rating in excess of the currently assigned 40 percent rating under the new version of Diagnostic Code 8045. The preponderance of the objective and credible evidence of record is against a rating in excess of 40 percent for post-fracture status, left supraorbital ridge. Headaches The medical evidence of record also shows that the Veteran has consistently complained of headaches throughout the entire period on appeal. The March 2008 VA examiner noted that the Veteran had mild to moderate headaches that did not cause any significant disability. The examiner also noted that the Veteran reported that he was able to work as a manager with no interference and no disability due to his periodic headaches. However, during his May 2011 Board hearing, the Veteran maintained that he had severe headaches that interfered with his ability to work. His headaches occurred 2 to 3 times a week and varied in intensity, and he argued that he had at least 3 to 4 headaches a month. The May 2012 VA TBI examiner reported that the Veteran had fairly frequent, photophobic migraine headaches attributable to his TBI. There is no medical evidence of record stating that the Veteran's recurrent headaches are not related to his TBI. The Rating Schedule specifically states that any residual with a distinct diagnostic code, such as migraine headaches, should be separately rated even if that diagnosis is based on subjective symptoms. 38 C.F.R. § 4.124a, Diagnostic Code 8045 (2012). The evidence of record shows that the Veteran experiences a headache disability related to his service-connected TBI. Accordingly, the Board finds that a separate rating is warranted for the Veteran's headaches. 38 C.F.R. § 4.124a, Diagnostic Code 8100. Migraine headaches are rated in accordance with 38 C.F.R. § 4.124a, Diagnostic Code 8100. A 10 percent rating is warranted for characteristic prostrating attacks averaging one in 2 months over last several months. Id. A 30 percent rating is warranted for characteristic prostrating attacks occurring on an average once a month over last several months. A 50 percent rating is warranted for very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. Id. The rating criteria do not define "prostrating," nor has the Court. By way of reference, the Board notes that according to Webster's New World Dictionary of American English, Third College (1986), p. 1080, "prostration" is defined as "utter physical exhaustion or helplessness." A similar definition is found in Dorland's Illustrated Medical Dictionary 1523 (30th ed. 2003), in which "prostration" is defined as "extreme exhaustion or powerlessness. The Veteran has testified that he had severe headaches that occurred 2 or 3 times a week although he could then go 2 weeks without a headache, but they occurred at least 3 to 4 times a month. He asserts that the headaches interfered with his ability to work. In the March 2008 VA neurological examination, the examiner noted that the Veteran had mild to moderate headaches that periodically occurred and did not cause any significant disability. In May 2012, the VA examiner noted that the Veteran has fairly frequent migraine headaches that are photophobic. After considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is entitled to a separate rating of 30 percent, but no higher, for migraine headaches under hyphenated Diagnostic Code 8045-8100, effective from March 6, 2008. A higher 50 percent rating is not warranted as there is no evidence of headaches manifested by frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. The Board notes that, while the Veteran has maintained that his headaches interfered with his ability to work and led to his retirement in 2001, he did not file his current increased rating claim until March 2008, nearly eight years later. Given this, and in light of the objective VA examination findings did not describe the headaches as prolonged or frequently prostrating, the disability picture appears to most nearly approximate the 30 percent rating. Indeed, there is simply no objective evidence of record of frequent completely prostrating headaches productive of severe economic inadaptability. In sum, a separation 30 percent evaluation is warranted for the Veteran's headaches, separate and apart from his TBI rating. The benefit of the doubt has been resolved in the Veteran's favor to this extent. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski. Left Supraorbital Sensory Nerve The October 2012 rating decision granted service connection for a left eyebrow scar and assigned an initial 10 percent rating under 38 C.F.R. § 4.118, DC 7800 (2012) that governs disfigurement of the head, face, or neck. However, during his May 2011 Board hearing, the Veteran testified that he experienced numbness and tightness in the area of his left supraorbital fracture. See Board hearing transcript at page 4. The medical evidence shows that the Veteran experienced loss of his left supraorbital sensory nerve due to his post-fracture status, left supraorbital ridge. In May 2012, the VA examiner reported that the Veteran had a 2-3 cm. left supraorbital scar with hypoesthesia of about 3-5 cm. consistent with nerve dysfunction. Other cranial nerves I-XII were intact. Pupils were round, equal, reactive to light and accommodation. Extraocular muscles were full, his face was symmetric, his tongue and palate midline, and he was able to smell cloves. The diagnosis included loss of the left supraorbital sensory nerve secondary to fracture and surgery. The supraorbital nerve is a branch of the trigeminal nerve (or fifth cranial nerve), and supplies sensation to the skin of the upper eyelid, forehead, anterior scalp, and muscosa of the frontal sinus, all of the places where the Veteran is complaining of constant, throbbing pain. See Dorland's Illustrated Medical Dictionary, 1242 (30th ed. 2003). The evidence of record shows that the Veteran experiences numbness associated with his TBI disability, for which a separate compensable rating may be assigned. See 38 C.F.R. § 4.124a, Diagnostic Code 8045 (2012). Under 38 C.F.R. § 4.124a, Diagnostic Code 8205, paralysis of the fifth trigeminal cranial nerve warrants a 10 percent evaluation if incomplete and moderate, 30 percent if incomplete and severe, and 50 percent if complete. The term "incomplete paralysis" indicates impairment of function of a degree substantially less than the type pictured for complete paralysis. When the involvement is wholly sensory, the rating should be for the mild, or, at most, the moderate degree. 38 C.F.R. § 4.124a. Applying the above criteria to the facts of this case, the Board finds that the evidence warrants a separate 10 percent rating, but no higher, for the Veteran's nerve dysfunction, but the preponderance of the evidence is against an evaluation in excess of 10 percent for residuals of injury to the supraorbital nerve. The totality of the medical evidence shows that the Veteran's residuals consist of sensory loss in the area of the left supraorbital scar. No other sensory or motor deficit of the fifth cranial nerve is present. Accordingly, the Board finds that the overall disability picture attributable to the residuals of injury to the supraorbital nerve consists of no more than moderate and incomplete paralysis. As such, a separate 10 percent rating, but no higher, is warranted for loss of the left supraorbital sensory nerve secondary to service-connected post-fracture status, left supraorbital ridge since March 6, 2008. 38 C.F.R. § 4.124a, Diagnostic Code 8045-8205. The benefit of the doubt has been resolved in the Veteran's favor to this extent. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, supra. Extraschedular Considerations The Board has also considered whether the Veteran's TBI disability presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of an extra-schedular rating is warranted. See 38 C.F.R. § 3.321(b)(1) (2012); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). Pursuant to § 3.321(b)(1), the Under Secretary for Benefits or the Director, Compensation and Pension Service, is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1) (2012). The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). When it is not possible to separate the effects of a non-service-connected condition from those of a service-connected disorder, reasonable doubt should be resolved in the claimant's favor with regard to the question of whether certain signs and symptoms can be attributed to the service- connected disability. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). Here the Board has considered Mittleider and attributed all potentially service-connected symtoms to his service-connected foot disabiity before considering if the Veteran is entitled to an extra-schedular rating. If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). The manifestations of the Veteran's disability are headaches, numbness, irritability and panic attacks. The rating schedule contemplates these symptoms. Diagnostic Codes 8045, 8100, 8205. Thus, the Board finds that the threshold test is not met for referral for extraschedular consideration. Id.; see also Thun v. Peake, 22 Vet. App. at 111. In sum, the preponderance of the evidence is against a rating in excess of 40 percent for the Veteran's post-fracture status, left supraorbital ridge. However, a separate 30 percent rating, but no higher, is warranted for migraine headaches, and a separate 10 percent rating, but no higher, is warranted for left supraorbital sensory nerve dysfunction, since March 6, 2008. The benefit of the doubt has been resolved in the Veteran's favor to this limited extent. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. at 49. Further, the Board notes that, if the claimant or the record reasonably raises the question of whether the Veteran is unemployable due to the disability for which an increased rating is sought, then part and parcel to that claim for a higher rating is whether a TDIU as a result of that disability is warranted. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case the Veteran has repeatedly told VA examiners in 2008 and 2012 that he stopped working in 2001. In written statements and oral testimony, he argued that the headaches and loss of concentration associated with his service-connected TBI rendered him unable to work and led to his 2001 retirement. However, in the March 2008 rating decision, the RO denied the Veteran's claim of entitlement to a TDIU. He did not perfect an appeal as to that determination and it was not certified for appellate consideration by the Board. Thus, any further consideration of entitlement to a TDIU is not warranted at this time. ORDER Service connection for an acquired psychiatric disorder, claimed as PTSD, is denied. A rating in excess of 40 percent for post-fracture status, left supraorbital ridge, is denied. A separate 30 percent rating, but no higher, is granted for residuals of post-fracture status, left supraorbital ridge-migraine headaches, from March 6, 2008, subject to the laws and regulations governing the award of monetary benefits. A separate 10 percent rating, but no higher, is granted for loss of the left supraorbital sensory nerve related to a post-fracture status, left supraorbital ridge disability, from March 6, 2008, subject to the laws and regulations governing the award of monetary benefits. REMAND Pursuant to the Board's January 2012 remand, the Veteran underwent VA ear, nose, and throat (ENT) and heart examinations in May 2012 with respect to his claims of service connection for sinus and heart disorders. The Board asked the examiners if it was at least as likely as not that a sinus or heart disorder had its onset in service or was otherwise causally related to any event in service including documented head injuries. Further, the Board asked if was at least as likely as not that a sinus or heart disorder was proximately due to, or caused by service connected disability, to particularly include the post-fracture status left supraorbital ridge with headaches. If so, the examiner was requested to address whether it was as likely as not that the sinus or heart disorder was aggravated (made permanently worse beyond the natural progression) by the service-connected disability. If so, the examiner was asked to state the baseline level of disability prior to aggravation. The May 2012 VA examination for sinusitis, rhinitis, and other conditions of the nose, throat, larynx, and pharynx shows a diagnosis of chronic vasomotor rhinitis. The nurse practitioner who performed the examination observed that it was "possible that this type of injury could cause chronic rhinitis but due to lack of evidence of when this condition began, and because there are many causes of rhinitis medication, endocrine, allergic), it is not possible to definitively state that his injury caused his rhinitis. Rhinitis is less likely than not service related." The May 2012 VA examiner failed to address all of the Board's questions, particularly those regarding secondary service connection, see 38 C.F.R. § 3.310 (2012). Thus, the medical evidence of record is inadequate for appellate review as to the Veteran's claim for service connection for a sinus disorder. Moreover, the examiner appeared to believe that, to offer a favorable response, the evidence would need to show a "definitive" relationship, which is not the correct legal standard for application. For the above reasons, the Board concludes that a new VA medical opinion should be obtained from a physician with expertise to assess the etiology of any chronic sinus/rhinitis disorder found present. The Veteran also asserts that he has a heart disorder due to military service. He also appears to contend that his heart disorder may be related to Darvon that was prescribed for his headaches and anxiety associated with his service-connected post-fracture of the left supraorbital ridge. During his May 2011 Board hearing, the Veteran testified that his 1997 heart attack was the first he learned that he had a cardiovascular problem. See Board hearing transcript at page 18. In May 2012, the Veteran underwent VA examination for ischemic heart disease. The physician-examiner reviewed the medical records, performed a clinical evaluation, and found that the Veteran had ischemic heart disease and coronary heart disease. In a May 2013 Addendum, a VA nurse practitioner reviewed the Veteran's medical records and opined that the claimed heart disorder was less likely than not (less than a 50 percent probability) incurred in or caused by an in-service injury, event, or illness. According to this examiner, the Veteran developed ischemic heart disease decades after his discharge from military service. There was no documentation in his claims file to indicate that the Veteran had any heart condition/complaints while in military service. The VA examiner also opined that the Veteran's claimed condition was less likely than not proximately due to or the result of his service-connected disability. The examiner stated that there was no documentation in the Veteran's claims file to indicate a link between his service-connected disabilities and his heart disorder diagnosed in 1997. The examiner noted that the Veteran's lay statement referenced his stress from service-connected disabilities as a cause for his heart condition, as well as the use of Darvon. According to the VA examiner, three decades passed since the Veteran was in military service, and the onset of his heart condition, and many other everyday life factors could have equally caused his stress. The examiner indicated that stress was a constant in everyone's day to day life, (but) not everyone developed heart conditions. The examiner noted that, according to the Federal Drug Administration, Darvon was removed from the market due to electrical changes that it may cause in one's heart. Electrical changes in one's heart may lead to an arrhythmia. However, arrhythmia was not the same condition as coronary artery disease. According to the VA examiner, there was no link currently identified connecting the Veteran's service-connected disabilities and his heart disorder. There was no recent documentation for one to establish aggravation. It was less likely than not that the Veteran's service-connected disabilities led to aggravation of his ischemic heart disease. However, here, too, the May 2013 VA examiner failed to address all of the Board's questions, particularly those regarding secondary service connection, see 38 C.F.R. § 3.310. Thus, the medical evidence of record is inadequate for appellate review as to the Veteran's claim for service connection for a heart disorder. A new VA medical opinion should be obtained from a physician with expertise to assess the etiology of any chronic heart disorder found present. The October 2012 rating decision granted service connection an initial 10 percent rating for vitreous floater in the left eye. In his February 2013 signed statement, the Veteran expressed disagreement with a May 2012 VA eye examination report and reported that the floaters were always visible in his left eye field of vision and constantly interfered with his ability to see anything clearly without distraction. He indicated that bright light caused him to close his left eye and interfered with his ability to drive safely. The Board construes the Veteran's statement as a notice of disagreement for an initial rating in excess of 10 percent for vitreous floaters in the left eye. Since the appellant filed a timely notice of disagreement with respect to the assigned rating, the Board's jurisdiction has been triggered. At this point, the issue must be REMANDED, per Manlincon v. West, 12 Vet. App. 238 (1999), so that the RO can issue a statement of the case on the underlying claim. Accordingly, the case is REMANDED for the following action: 1. The RO/AMC should issue a statement of the case regarding the matter of entitlement to an initial rating in excess of 10 percent for vitreous floaters of the left eye. If, and only if, the Veteran timely perfects an appeal as to the matter, should this claim be returned to the Board. 2. Refer the Veteran's claims file and a copy of this Remand to a VA otolaryngologist (ear, nose, and throat (ENT) physician). A physician must respond- it is insufficient that a physician merely be consulted in a report written by a physician assistant. (A clinical evaluation should be scheduled only if deemed necessary by the examiner.) The examiner is requested to review the claims file, including any post service private medical records added to the claims file, and address the following: a. whether it is at least as likely as not that (a 50 percent probability) that any post service sinus disorder including chronic rhinitis is related to service. b. If any post service sinus disorder including chronic rhinitis is unrelated to service, is it at least as likely as not that it is due to or aggravated (permanently worsened beyond its natural progression) by service-connected post-fracture status, left supraorbital ridge with headaches? c. If aggravated, what is the baseline level of sinus disability and what is the permanent, measurable increase in current sinus pathology attributable to the post-fracture status, left supraorbital ridge with headache disorder? d. All opinions and conclusions expressed must be supported by a complete rationale in a report. 3. Refer the Veteran's claims file and a copy of this Remand to a VA cardiologist. A physician must respond- it is insufficient that a physician merely be consulted in a report written by a physician assistant. (A clinical evaluation should be scheduled only if deemed necessary by the examiner.) The examiner is requested to review the claims file, including any post service private medical records added to the claims file, and address the following: a. whether it is at least as likely as not that (a 50 percent probability) that any post service heart disorder including ischemic or coronary heart disease is related to service. b. If any chronic coronary or ischemic heart disease is unrelated to service, is it at least as likely as not that it is due to or aggravated (permanently worsened beyond its natural progression) by service-connected post-fracture status, left supraorbital ridge with headaches? c. If aggravated, what is the baseline level of heart disability and what is the permanent, measurable increase in current heart pathology attributable to the post-fracture status, left supraorbital ridge with headache disorder? d. All opinions and conclusions expressed must be supported by a complete rationale in a report. 4. After completion of the above, the RO/AMC should review the expanded record and determine if any of the benefits sought can be granted. If any benefit sought is not granted in full, the Veteran should be furnished an appropriate supplemental statement of the case and be afforded an opportunity to respond. Thereafter, the case should be returned to the Board for appellate review. The appellant 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 Supp. 2012). ______________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs