Citation Nr: 1754645 Decision Date: 11/29/17 Archive Date: 12/07/17 DOCKET NO. 11-19 193 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to an initial rating in excess of 70 percent for service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to an increased rating for service-connected migraine headaches, in excess of 30 percent prior to April 13, 2017 and 50 percent thereafter. 3. Entitlement to a total disability rating based upon individual unemployability (TDIU) due to service-connected disabilities prior to September 20, 2011. 4. Entitlement to service connection for residuals of a head injury, to include hemangioma. 5. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for residuals of a head injury, to include mood disorder and memory loss. 6. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for facial scars. ATTORNEY FOR THE BOARD K. K. Buckley, Counsel INTRODUCTION The Veteran served on active duty from October 1969 to October 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions dated July 2008, January 2013, and April 2015 of the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. In Board decisions dated April 2015 and March 2016, the claims were remanded for further evidentiary development. As will be described below, a review of the record reflects substantial compliance with the Board's Remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The VA Appeals Management Center (AMC) most recently continued the previous denials in a June 2017 supplemental statement of the case (SSOC). The Veteran's VA claims file has been returned to the Board for further appellate proceedings. In rating decisions dated January 2013 and September 2014, the RO increased the assigned rating for PTSD to 70 percent from the date of service connection, March 1, 2007. Similarly, in rating decisions dated January 2013 and September 2014, the RO increased the assigned rating for headaches to 30 percent from November 6, 2007. A May 2017 rating decision subsequently increased the assigned rating for migraine headaches to 50 percent from April 13, 2017. The Board notes that applicable law mandates that, when a veteran seeks an increased evaluation, it will generally be presumed that the maximum benefit allowed by law and regulation is sought, and it follows that such a claim remains in controversy where less than the maximum benefit available is awarded. See AB v. Brown, 6 Vet. App. 35 (1993). As such, these matters remain on appeal. The Veteran has raised a claim of entitlement to a TDIU based primarily on his PTSD symptomatology. A September 2014 rating decision granted entitlement to a TDIU from September 20, 2011. However, the matter of entitlement to a TDIU prior to September 20, 2011 remains on appeal. The Veteran has asserted entitlement to an earlier effective date for service connection for PTSD and migraine headaches. These issues have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2017). FINDINGS OF FACT 1. From the date of service connection, the Veteran's service-connected PTSD has not more nearly approximated total occupational and social impairment. 2. Throughout the appeal period, the Veteran's migraine headaches have more nearly approximated very frequent completely prostrating and prolonged headache attacks productive of severe economic inadaptability. 3. The evidence of record shows that the Veteran was unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities from March 1, 2007. 4. In a January 2005 decision, the Board denied the Veteran's claims of entitlement to service connection residuals of a head injury to include memory loss and mood disorder. The Veteran did not appeal that decision. 5. The evidence received since the final January 2005 decision includes statements of the Veteran, VA examinations, and private evaluations, as well as treatment records, which relate to unestablished facts necessary to substantiate the matters of entitlement to service connection for residuals of a head injury including memory loss and mood disorder and, if presumed credible, raise a reasonable possibility of substantiating the claim. 6. In a June 2002 rating decision, the RO denied the Veteran's claim to reopen the matter of entitlement to service connection facial scars. The Veteran did not appeal that decision, and new and material evidence was not received within one year of its issuance. 7. Additional evidence received since the June 2002 decision is new to the record, but does not relate to an unestablished fact necessary to substantiate the merits of the claim of service connection for facial scars. 8. A traumatic brain injury clearly and unmistakably existed prior to the Veteran's active duty service; the credible and probative evidence of record shows that the Veteran's disability did not undergo an increase in severity during service. 9. Residuals of a head injury to include memory loss and mood disorder did not have its onset in service and are not otherwise related to the Veteran's active military service. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating in excess of 70 percent for service-connected PTSD have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.130, Diagnostic Codes (DC) 9411 (2017). 2. Resolving all doubt in the Veteran's favor, the criteria for a disability rating of 50 percent, but no higher, for migraine headaches have been met throughout the appeal period. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 3.102, 4.124a, DC 8100 (2017). 3. With reasonable doubt resolved in favor of the Veteran, the criteria for entitlement to a TDIU are met from March 1, 2007. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16 (2017). 4. New and material evidence has been received to warrant reopening of the claim of service connection for residuals of a head injury to include memory loss and mood disorder. 38 U.S.C. §§ 5107, 5108, 7104 (2012); 38 C.F.R. § 3.156 (2017). 5. Since the June 2002 rating decision, new and material evidence has not been received with respect to the claim of entitlement to service connection for facial scars; this claim is not reopened. 38 U.S.C. §§ 5107, 5108, 7105 (2012); 38 C.F.R. § 3.156 (2017). 6. The pre-existing head injury residuals were not aggravated by the Veteran's active military service. 38 U.S.C. §§ 1111, 1153 (2012); 38 C.F.R. § 3.306 (2017). 7. Residuals of a head injury to include memory loss and mood disorder were not incurred in or aggravated by the Veteran's military service. 38 U.S.C. §§ 101, 1101, 1110, 1112, 1113, 1116, 5107 (2012); 38 C.F.R. §§ 3.6, 3.102, 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist As a preliminary matter, the Board finds that no further action is necessary to satisfy VA's duties under the Veteran's Claims Assistance Act of 2000 (VCAA) to notify and assist. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.326(a) (2017). The Veteran has raised no issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Pursuant to the March 2016 Board Remand, the Veteran was afforded VA examinations in April 2017 as to the pending claims. The reports provided by the VA examiners reflect that they thoroughly reviewed the Veteran's past medical history, performed an appropriate examination, and rendered findings that are responsive to the rating criteria. The Board therefore concludes that the April 2017 VA examination reports are sufficient for evaluation purposes. See 38 C.F.R. § 4.2 (2017); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding there was no Stegall violation when the examiner made the ultimate determination required by the Board's remand, because such determination "more than substantially complied with the Board's remand order"). The record does not show, nor has the Veteran contended, that the service-connected disabilities adjudicated herein has increased in severity since he was last examined for VA compensation purposes. Thus, the Board finds that VA does not have a duty to assist that was unmet. II. Increased and initial rating claims Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Board determines the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.10. Where there is a question as to which of two ratings should be applied, the higher rating 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. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, analysis in this decision has therefore been undertaken with consideration of the possibility that different ratings may be warranted for different time periods as to the pending claims. In all cases, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr, at 308 (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). The Board has considered all evidence of record as it bears on the issues before it. See 38 U.S.C. § 7104(a) (2012) ("Decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record"); 38 U.S.C. § 5107(b) ("Secretary shall consider all information and lay and medical evidence of record in a case"). Although the Board has an obligation to provide reasons and bases supporting these decisions, there is no need to discuss, in detail, the extensive evidence of record. The Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the Veteran's appeal. a. PTSD PTSD is evaluated under 38 C.F.R. § 4.130, DC 9411. Under these diagnostic codes, a 30 percent evaluation is assigned when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal, due to such symptoms as depressed mood; anxiety; suspiciousness; panic attacks, weekly or less often; chronic sleep impairment; and mild memory loss, such as forgetting names, directions, recent events. Id. A 50 percent evaluation is for assignment when there is 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; difficulty establishing effective work and social relationships. Id. A 70 percent evaluation is contemplated for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control, such as unprovoked irritability with periods of violence; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, DC 9411. A 100 percent evaluation is warranted when there is evidence of 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 and place; memory loss for names of close relatives, own occupation or name. Id. The GAF is a scale reflecting psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DSM-IV). As will be discussed below, the Veteran has been assigned GAF scores ranging from 50 to 55 as determined by VA examiners. These scores are indicative of moderate to severe impairment. Scores ranging from 41 to 50 reflect serious 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. A GAF score ranging from 51 to 60 reflect more moderate 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. When determining the appropriate disability evaluation to assign, the Board's primary consideration is a veteran's symptoms, but it must also make findings as to how those symptoms impact a veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because the use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran's impairment must be "due to" those symptoms, a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. In this matter, the Veteran was granted service connection for PTSD in an August 2009 rating decision; a 50 percent rating was assigned effective November 6, 2007. The Veteran disagreed with the assigned rating and this appeal followed. As described above, a January 2013 rating decision assigned a higher initial rating of 70 percent, effective from July 16, 2012, for service-connected PTSD. A September 2014 rating decision corrected the assigned effective date for the 70 percent rating to March 1, 2007, which was an earlier date for service connection. For the following reasons, the Board finds that a rating in excess of the assigned 70 percent initial rating is not warranted under the schedular criteria. VA treatment records dated in September 2007 noted the Veteran's report of nightmares, social isolation/withdrawal, insomnia, temper outbursts, and depressed mood. In an October 2007 letter, the Veteran's son, Mr. C.W. described the strain that the Veteran's PTSD symptomatology puts on their relationship. In particular, he reported that the Veteran reacts with great anger to minor problems. In a November 2007 letter, the Veteran's spouse indicated that she has been married the Veteran for 37 years. She described the Veteran's impulsive behavior, anger management problems, social withdrawal, and insomnia. In pertinent part, Mrs. M.W. stated, "I am constantly astounded as I watch the man who was once a clear analytical thinker who was able to audit complex records increasingly become incapable of making fundamentally sound decisions on a consistent basis." She additionally reported that she feels like she is walking on egg shells almost daily wondering when the Veteran will explode next. In a July 2008 letter, licensed clinical social worker, Ms. A.H., detailed the Veteran's depression, sleep disturbances including nightmares, interrupted sleep, night sweats, anxiety, and severe panic attacks. She additionally indicated that the Veteran suffers from recurrent intrusive thoughts, avoidance of crowds and malls, and preference for social isolation. She stated that, when the Veteran does leave his home, he is accompanied by his spouse "because he tends to dissociate frequently and has problems with short-term memory." VA treatment records dated in August 2008 noted the Veteran's explosive outbursts, poor sleep, mood lability, and social isolation. The Veteran was afforded a VA examination in April 2009 at which time he reported that his psychological symptoms are treated with Clonopin and Topiramate. He has been married since 1970 and has six adult children. The Veteran stated that he does not trust other people because he feels that they are out for themselves and want to hurt him. The Veteran reported that he no longer engages in recreational activities he once enjoyed, including golfing and fishing. He endorsed a history of violence/assaultiveness. Specifically, the Veteran reported that he hit a man at a store after he got out of the military service. The examiner described the Veteran as appropriately dressed and groomed. He was well-oriented. The Veteran appeared tense and fatigued. His speech was unremarkable, and his affect was constricted. The Veteran's mood was anxious and depressed. The Veteran endorsed "passive and transient" suicidal and homicidal thoughts. He additionally reported obsessions and safety-related compulsions. The Veteran reported auditory, olfactory hallucinations. He described experiencing panic attacks two to three times per year. He endorsed irritability and outbursts of anger. The examiner noted that the Veteran works part-time, but that his doctor recommended he stop working due to his psychological symptoms. The examiner assigned a GAF of 50, and described the Veteran's PTSD as 'moderate to severe.' He explained that the Veteran's symptoms result in deficiencies in most areas including judgment, thinking, family relations, work, mood, or school. He stated that the Veteran can be reactive, and his "poor anger management, irritability, and anxiety are obstacles to his productivity and reliability." The Veteran was afforded another VA examination in October 2011. The examiner noted the Veteran's report that he has a close relationship with his family; however, he has no close friends. The Veteran retired from his position as an auditor in 2002 and has had several part-time positions since that time. The Veteran reported that his health problems have made it difficult for him to continue working. He attends monthly PTSD groups and sees a psychiatrist for medication management. The Veteran endorsed recurrent thoughts of trauma, avoidance, markedly diminished interest or participation in significant activities, feelings of detachment or estrangement from others, difficulty falling or staying asleep, irritability/outbursts of anger, and hypervigilance. The Veteran additionally described depressed mood, anxiety, panic attacks, chronic sleep impairment, and inability to establish and maintain effective relationships. The examiner indicated that the Veteran's PTSD manifested as "[o]ccupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation." A GAF of 50 was assigned. The Veteran was again afforded a VA examination in August 2012 as to his service-connected PTSD. The examiner noted that the Veteran's attention, memory, and concentration were intact. The Veteran was able to communicate effectively. He denied hallucinations or delusions. The Veteran endorsed avoidance, recurrent thoughts of trauma, markedly diminished interest or participation in significant activities, feelings of detachment or estrangement from others, difficulty falling or staying asleep, and hypervigilance. He also reported depressed mood, anxiety, panic attacks, chronic sleep impairment, and difficulty in adapting to stressful circumstances including work or work-like setting. The examiner stated that the Veteran's PTSD manifests in "[o]ccupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation." The examiner opined that the Veteran's "PTSD alone does not prevent [him] from working." A GAF of 55 was assigned. A private neuropsychological evaluation was performed in October 2013. It was preliminarily noted that the Veteran was on time for the appointment, and was appropriately dressed and groomed. His affect was normal. The examiner stated, "[w]hile very mild inefficiencies were noted in processing speed, verbal memory, and response inhibition, there were no areas of significant impairment." The examiner further reported that the Veteran's present emotional distress including PTSD symptoms "may contribute to and exacerbate areas of cognitive inefficiency." The examiner noted the Veteran's hypervigilance and report of memory loss. He described the Veteran's report of significant anger, frustration, and irritability. The examiner stated that the Veteran is easily overwhelmed and becomes anxious in crowded, hectic spaces, or even when visiting with multiple children and grandchildren. The examiner reported that the Veteran has withdrawn from most social activity and endorses reduced interest and motivation. The Veteran described periods of despondency, but denied active suicidal ideation. In an August 2014 statement, the Veteran's spouse again described the Veteran's outbursts of anger. She reported that the Veteran withdraws from festive family gatherings and becomes almost reclusive. He has difficulty sleeping. In an August 2014 statement, the Veteran described incidents of suicidal ideation in June 2013 and July 2014. He also reported frequent panic attacks and outbursts of anger. He additionally indicated that he frequently smells an "old factory smell." Pursuant to the March 2016 Board Remand, the Veteran was afforded a VA examination in April 2017 at which time the examiner confirmed a diagnosis of PTSD with major depressive disorder (MDD). The examiner stated that the Veteran's psychological symptoms manifested in "[o]ccupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood." The Veteran continues to live with his wife of 54 years. He has six adult children. The Veteran has six living siblings, and his mother is also living; he does not have a good relationship with them. He also reported that he has no friends with whom he socializes. His psychological symptoms are managed with Clonazepam, Sertraline, Bupropion, Busipirone, and Topirimate. He currently experiences depressive-related symptoms including dysphoric mood, irritability/outbursts of anger, crying spells, feelings of hopelessness and worthlessness, low self-esteem, social isolation, and lack of interest in things he once enjoyed. The Veteran denied current suicidal ideation, but then reported that he had previously planned to jump off a four-story building. He denied homicidal ideation. The Veteran additionally endorsed anxiety-related symptoms including excessive apprehension and worry, restlessness, irritability, impaired concentration, impaired short-term memory, sleep disturbance, nightmares, night terrors, flashbacks, intrusive memories, hypervigilance, exaggerated startle response, and avoidance. He also described panic attacks. The examiner noted that the Veteran has disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a work-like setting, as well as an inability to establish and maintain effective relationships. The examiner reported that the Veteran's demeanor and responsiveness to questions was cooperative. He was appropriately dressed and groomed. His speech was clear and coherent. His thought processes were also coherent and goal-directed. There was no evidence of hallucinations, delusions, or paranoia. The Veteran's mood was very angry at first, but he became more relaxed and calm during the examination. His insight and judgment were good. Based on the above, the Board finds that the impact of the Veteran's PTSD symptoms on his social and industrial functioning do not approximate a degree of impairment in excess of the assigned 70 percent rating. As detailed above, the record includes diagnoses of PTSD and MDD, with impaired mood and complaints of memory loss. Significantly, the Veteran's regular psychiatric and psychological treatment providers have not differentiated between such symptoms and have, in fact, repeatedly described the overlapping symptoms of the Veteran's psychiatric diagnoses. As such, the evidence is in equipoise as to whether the Veteran's psychiatric symptoms are attributable to his service-connected PTSD or at least not consistently clearly separable from his service-connected PTSD. Mittleider v. West, 11 Vet. App. 181 (1998). Thus, all psychiatric symptoms are considered part of the service-connected diagnosis. Id. Moreover, while the Veteran's GAF scores have generally reflected levels of moderate to severe impairment, neither GAF scores nor an examiner's characterization of the degree of the disability are dispositive of the legal questions involved in determining the appropriate rating for PTSD. The symptomatology associated with the Veteran's service-connected PTSD have not more nearly approximated total occupational and social impairment at any point from the date of service connection. 38 C.F.R. § 4.7 (2017). Symptoms such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; disorientation to time and place; memory loss for names of close relatives, own occupation or name, have not been shown. The evidence documents the Veteran's report of problems maintaining part-time employment, including due to irritability and outbursts of anger. He is, however, married and maintains a good relationship with his wife and children. Critically, therefore, the evidence does not show total occupational and social impairment due to PTSD. Again, the record establishes that the Veteran is able to maintain social relationships, including with family members. Thus, neither the symptoms nor overall level of impairment meet the criteria for a 100 percent rating under the Rating Schedule, and a rating in excess of 70 percent is therefore not warranted for the Veteran's PTSD. While there may have been day-to-day fluctuations in the manifestations of the Veteran's service-connected PTSD, the evidence shows no distinct periods of time during the appeal period, when the Veteran's service-connected disability varied to such an extent that a higher rating would be warranted. Hart, supra. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). b. Migraine headaches Historically, the Veteran was granted service connection for headaches as a residual of a head injury in a June 2002 rating decision; a 10 percent rating was granted from December 1, 1999. In November 2007, the Veteran asserted a claim of entitlement to an increased rating for service-connected headaches. As indicated above, a January 2013 rating decision increased the assigned rating to 30 percent, effective July 16, 2012. However, a September 2014 rating decision corrected the assigned effective date of the increased rating to November 6, 2007, the date of the increased rating claim. Additionally, a May 2017 rating decision awarded a 50 percent rating for service-connected migraine headaches from April 13, 2017, the date of the most recent VA examination. For the reasons set forth, the Board concludes that a 50 percent evaluation is warranted for the entire appeal period. Thus, a staged rating is not appropriate for the Veteran's service-connected migraine headaches. The Veteran's migraine headaches have been rated under DC 8100. Under DC 8100, which addresses migraines, a 10 percent rating is assigned with characteristic prostrating attacks averaging one in two months, over the last several months. A 30 percent rating is assigned with characteristic prostrating attacks occurring on an average of once a month over the last several months. Finally, a 50 percent rating is assigned when migraines with very frequent, completely prostrating headaches with prolonged attacks that are productive of severe economic inadaptability. 38 C.F.R. § 4.124a, DC 8100. The rating criteria do not define "prostrating." The Board additionally observes that the Court has not undertaken to define "prostrating." See Fenderson v. West, 12 Vet. App. (1999), in which the Court quoted DC 8100 verbatim but did not specifically address the matter of what is a prostrating attack. By way of reference, the Board notes that according to DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1367 (28th Ed. 1994), "prostration" is defined as "extreme exhaustion or powerlessness;" and according to STEDMAN'S MEDICAL DICTIONARY 1461 (27th Ed. 2000), "prostration" is defined as "a marked loss of strength, as in exhaustion." Here, the Veteran filed an increased rating claim for migraine headaches in November 2007. VA treatment records dated in September 2007 noted the Veteran's report of a splitting headache at 8-9/10 in severity with facial grimacing. The Veteran reported that he uses a TENS unit to manage headache pain, with some relief of symptoms. He stated that his headaches occur daily, lasting 3-5 hours. VA treatment records dated in August 2008 noted the Veteran's report of three severe headaches in the past month. The Veteran was afforded a VA examination in August 2012 at which time the examiner confirmed a continuing diagnosis of migraine headaches, including migraine variants. The Veteran reported that his headaches have gotten progressively worse over the years. His headaches are always on the right side of his head with burning pain and dizziness. Headaches occur daily and last a few minutes. However, he also experiences severe headaches three to five times per week, lasting an average of three to six hours. The Veteran takes Indomethacin, Topirimate, and Metoprolol to manage his headache pain. He reported sensitivity to light and sound with his headaches. The examiner reported that the Veteran has characteristic prostrating attacks of migraine headache pain, occurring more frequently than once per year. The examiner indicated that the Veteran does not have 'very frequent' prostrating attacks of headache pain. The examiner further stated that the Veteran's headaches have no impact on his ability to work. An October 2013 private neuropsychological evaluation noted the Veteran's report of significant headaches occurring three to five times per week. In an August 2014 statement, the Veteran's spouse described the Veteran's struggles with debilitating headaches. She stated that, prior to a recent medication change, the Veteran had headaches almost constantly. In an August 2014 statement, the Veteran described severe headache symptoms, which require electrical stimulation for the management of pain. Pursuant to the March 2016 Board Remand, the Veteran was afforded a VA examination in April 2017 as to his service-connected headaches. The examiner confirmed a continuing diagnosis of migraine headaches including migraine variants. The examiner noted that the Veteran reports severe headaches two to three times per week. He stated that, when it rains, he experiences stabbing headache pain. He reported that he also experiences an olfactory odor prior to the stabbing dart to the right side of his head. He continues to treat his headaches with prescription medication and a TENS unit. He reported daily headaches that he can "deal with." He stated that his retirement in 2002 was due in part to his headaches. The Veteran reported that his constant, pulsating or throbbing headache pain worsens with physical activity. He experiences sensitivity to light and sound, as well as the olfactory foul smell. The duration of typical headache pain is less than one day. The examiner indicated that the Veteran does have characteristic prostrating attacks of headache pain, as well as very prostrating and prolonged attacks of headache pain productive of severe economic inadaptability. The examiner stated that the frequency of these prostrating attacks is more than once per month. To this end, the examiner noted the Veteran's report that his treating physician recommended his retirement from work in December 2002 due to severe migraines. The examiner further opined, "[d]espite medication management of migraines, [the Veteran] has very frequent headaches that preclude safe driving of his car during headache[s] nor could he work even in a sedentary capacity." In weighing the clinical and lay evidence of record, the Board finds that, with resolution of doubt in the Veteran's favor, an evaluation of 50 percent for the Veteran's migraine headaches is warranted throughout the appeal period. Although the evidence varies concerning the severity of the Veteran's headaches, the Board notes that the Veteran has reported frequent, severe, and chronic headaches during the appeal period. The Veteran and his spouse have repeatedly asserted that these headaches are prostrating in nature. The Board notes that the frequency, duration, severity, and impairment caused by the disorder are based on lay statements by the Veteran. As corroborated by the VA examiners, the Veteran is competent to report these observable symptoms and their effects, and the Board concludes that his reports are essentially credible because they have been consistent and accepted by VA examiners and treatment providers. Moreover, the Veteran's competent contentions that his migraine headaches are productive of severe economic inadaptability have been documented in the claims file. While there may have been day-to-day fluctuations in the manifestations of the Veteran's service-connected migraine headaches, the evidence shows no distinct periods of time during the appeal period, when his disability varied to such an extent that a rating greater or less than 50 percent assigned herein would be warranted. Hart, supra. Accordingly, for the foregoing reasons, the Board finds that the preponderance of evidence shows that the Veteran's migraine headaches more nearly approximate the schedular criteria for a 50 percent rating throughout the appeal period. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. This is the maximum schedular rating available. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette, supra. III. Entitlement to a TDIU Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. If the total rating is based on a disability or combination of disabilities for which the Rating Schedule provides an evaluation of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age. 38 C.F.R. § 3.341(a). If the schedular rating is less than total, a total disability evaluation can be assigned based on individual unemployability if the Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disability, provided that the Veteran has one service-connected disability rated at 60 percent or higher; or two or more service-connected disabilities, with one disability rated at 40 percent or higher and the combined rating is 70 percent or higher. The existence or degree of nonservice-connected disabilities will be disregarded if the above-stated percentage requirements are met and the evaluator determines that the Veteran's service-connected disabilities render him incapable of substantial gainful employment. 38 C.F.R. § 4.16(a). The central inquiry is "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Neither nonservice-connected disabilities nor advancing age may be considered in the determination. 38 C.F.R. §§ 3.341, 4.19 (2016); Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The Veteran has raised a claim of entitlement to a TDIU based primarily on his psychological and headache symptomatology. As detailed above, the Veteran has been awarded entitlement to a TDIU from September 20, 2011. The Board will herein consider whether a TDIU prior to September 20, 2011 is warranted. The Veteran is assigned a 70 percent rating for service-connected PTSD from the date of service connection, March 1, 2007; and the Veteran's migraine headaches more nearly approximate a 50 percent rating from the date of his increased rating claim, November 6, 2007. The Board notes that the Veteran is also service-connected for tinnitus at 10 percent, residuals of right foot fracture at zero percent, and folliculitis barbae at zero percent. As the Veteran's combined rating is higher than a 70 percent, he therefore meets the schedular criteria. Thus, the question is whether the Veteran's service-connected disabilities preclude gainful employment for which his education and occupational experience would otherwise qualify him. As detailed above, the Veteran's service-connected PTSD and migraine headaches have interfered with his ability to maintain gainful employment. The Veteran has stated that he retired in December 2002 due to PTSD and headache symptomatology, and was unable to maintain even part-time employment due to difficulty managing his psychological symptoms. Significantly, the Veteran's spouse detailed the Veteran's impulsive behavior, significant anger management problems, and social withdrawal. As described above, she opined that the Veteran has "increasingly become incapable of making fundamentally sound decisions on a consistent basis" due to his psychological impairment. This statement is corroborated by the July 2008 letter from Ms. A.H. who described the Veteran's difficulty leaving the home due to dissociation and impaired short term memory. Similarly, with respect to occupational impairment, the April 2009 VA examiner reported that "[t]he Veteran's poor anger management, irritability, and anxiety are obstacles to his productivity and reliability." Moreover, VA examination and treatment records dating from March 2007 consistently documented the Veteran's significant PTSD symptoms including depression, anxiety, social isolation, impaired concentration, hypervigilance, impaired short-term memory, periods of despondency, and difficulty in adapting to stressful circumstances including work or work-like setting. See the VA examination reports dated April 2009, October 2011, August 2012, and April 2017. In addition, the April 2017 VA examiner reported that the Veteran's migraine headaches preclude safe driving of his car during headaches, and the Veteran could not work even in a sedentary capacity. The above evidence thus reflects that the Veteran's PTSD and headache symptomatology have a significant impact on his ability to work. Although some health care professionals have opined that the Veteran's PTSD and headache symptoms do not render him unemployable, the "applicable regulations place responsibility for the ultimate TDIU determination on the VA, not a medical examiner." Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). Whether a veteran could perform the physical and mental acts required by employment at a given time is an issue about which a lay person may provide competent evidence. Id. at 1354. Given the significant effects of the Veteran's psychiatric and headache disabilities and his documented difficulty maintaining gainful employment, as indicated by the lay and medical evidence, the evidence is approximately evenly balanced as to whether his service connected disabilities render him unable to secure and follow substantially gainful employment. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to a TDIU is warranted from March 1, 2007. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. IV. Claims to reopen In general, decisions of the RO and the Board that are not appealed in the prescribed time period are final. 38 U.S.C. §§ 7104, 7105(c) (2012); 38 C.F.R. §§ 20.1100, 20.1103 (2017). Pursuant to 38 U.S.C.A. § 5108, a finally disallowed claim may be reopened when new and material evidence is presented or secured with respect to that claim. For claims such as these, filed on or after August 29, 2001, new evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (2017). To reopen a previously disallowed claim, new and material evidence must be presented or secured since the last final disallowance of the claim on any basis, including on the basis that there was no new and material evidence to reopen the claim since a prior final disallowance. See Evans v. Brown, 9 Vet. App. 273, 285 (1996). For purposes of reopening a claim, the credibility of newly submitted evidence is generally presumed. See Justus v. Principi, 3 Vet. App. 510, 513 (1992) (in determining whether evidence is new and material, the credibility of newly presented evidence is to be presumed unless evidence is inherently incredible or beyond competence of witness). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, in determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, to include by triggering the Secretary's duty to assist. Id. at 118. The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b) (2012); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In a June 2002 decision, the RO denied the Veteran's claim to reopen the matter of entitlement to service connection for residuals of facial scars. The decision also denied the Veteran's original claims of entitlement to service connection for residuals of a head injury to include memory loss and mood disorder. The Veteran filed a timely notice of disagreement (NOD) as to the memory loss and mood disorder claims. Notably, the Veteran did not disagree with the denial of his claim to reopen the issue of service connection for residuals of facial scars. As new and material evidence was not received within one year of the decision, it became final as to the residuals of facial scars claim. See 38 U.S.C. § 7105; 38 C.F.R. § 20.1100; Bond v. Shinseki, 659 F.3d 1362, 1367-68 (Fed. Cir. 2011). Under these circumstances, the RO's June 2002 rating decision is final as to the Veteran's claim to reopen the matter of service connection for residuals of facial scars, and is not subject to revision on the same factual basis. See 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 20.1103. As to the claim of entitlement to residuals of a head injury to include memory loss and mood disorder, a statement of the case (SOC) was issued in December 2002 and the Veteran perfected a timely appeal in December 2002. In a January 2005 decision, the Board denied the claim. The Board decision is final on the date stamped on the face of the decision. 38 C.F.R. § 20.1100(a). The Veteran now seeks to reopen his claims of service connection for residuals of facial scars and residuals of a head injury to include mood disorder and memory loss. As noted above, despite the finality of a prior adverse decision, a claim will be reopened and the former disposition reviewed if new and material evidence is presented or secured with respect to the claim which has been disallowed. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017). Thus, the Board has reviewed the entire record, with particular attention to the additional evidence received since the last final decisions in June 2002 and January 2005. After reviewing the record, the Board finds that the additional evidence received is new and material within the meaning of 38 C.F.R. § 3.156 warranting reopening of the claim of service connection for residuals of a head injury to include memory loss and mood disorder. The Board further finds that new and material within the meaning of 38 C.F.R. § 3.156 has not been received to warrant reopening of the claim of service connection for residuals of facial scars. The evidence associated with the Veteran's claims file at the time of the last final denials in June 2002 and January 2005 included service treatment records (STRs), VA and private treatment records, VA examination reports, and the statements of the Veteran and his spouse. At the time of the last final denials, the Veteran contended that he suffered from a head injury during his military service when his rifle malfunctioned during training and exploded. See, e.g., the Veteran's statement dated September 1990. The Veteran served on active duty from October 1969 to October 1971. Pre-service treatment records dated in August 1957 show that the Veteran fell out of a tree when he was 11 years old and was rendered unconscious. He suffered a laceration to the forehead and concussion at that time. STRs dated in November 1969 document the Veteran's self-reported history that he fell out of a tree when he was age 14 and sustained a laceration of the forehead. STRs are absent any documentation of an in-service head injury resulting from a rifle explosion. However, the Veteran submitted a lay statement dated in October 1991 from his drill instructor, Mr. J.G., who detailed the in-service incident. Mr. J.G. stated that the Veteran's rifle had malfunctioned during training and exploded. The Veteran was taken to the dispensary and later returned to full duty; Mr. J.G. noted that the Veteran had suffered injuries to the head and face at that time. Similarly, in a September 1990 statement, Mr. N.J. reported that he served with the Veteran and was aware of his in-service injury in December 1969 at which time the Veteran suffered a concussion and facial laceration from a rifle explosion. A VA examination dated in June 1992 noted a 0.5 cm. circular scar of the right temple that the Veteran indicated is "so tender to touch as to be unbearable." He was diagnosed with scar residuals due to a facial laceration. The June 1992 examination report also noted the Veteran's memory difficulties and problems with mood and rage. In a September 1992 letter, Dr. A.W. reported that the Veteran suffers from a mood disorder, namely depression. She further reported that the Veteran relates the onset of his problems to an in-service injury in 1969 when his rifle exploded. In an October 1993 letter, Dr. A.W. reported that, at the time of the rifle blast, the Veteran sustained post-concussion symptoms including memory loss. Private treatment records dated in April 1996 indicate that the Veteran has verbal memory loss and attention problems. An August 1999 report from neurologist, Dr. S.A., described the Veteran's report of poor memory since an in-service explosion, along with temper outbursts. The Veteran's memory and mood problems were also noted in a January 2002 VA neurological examination. As described above, the Veteran's claims of entitlement to service connection for residuals of a head injury to include memory loss and mood disorder, and claim to reopen the matter of service connection for a facial laceration were denied in a June 2002 rating decision. The Veteran's appeal of the denials of service connection for residuals of a head injury to include memory loss and mood disorder was denied in a January 2005 Board decision. The Veteran filed claims to reopen, which were denied in an April 2015 rating decision. This appeal follows. a. Residuals of a facial laceration After a review of the entire record, and for the reasons expressed immediately below, the Board concludes that new and material evidence to reopen the claim of entitlement to service connection for residuals of a facial laceration has not been received. The evidence associated with the claims file subsequent to the prior final decision in June 2002 includes, but is not limited to, the Veteran's VA and private treatment records; VA examination reports; and lay statements of the Veteran and his spouse. Medical evidence has been added to the record indicating that the Veteran has continued to report a facial scar due to his in-service injury. In particular, the Board recognizes that an October 2007 VA treatment record noted the Veteran's "[h]istory of service-related facial skull injury secondary to rifle malfunction and explosion occurring [on] 1969 active duty." Critically, this notation is merely a recitation of the Veteran's reported history and does not offer new and material evidence as to outstanding questions of nexus in this matter. The Veteran's report of facial scars due to his in-service injury was well-documented in the record at the time of the last final denial in June 2002. To this end, the Veteran's repeated assertions concerning the incurrence and etiology of his claimed facial laceration, although new, are essentially cumulative of evidence already of record. The Board has considered the holding in Shade v. Shinseki, 24 Vet. App. 110 (2010). In that decision, the Court held that, in determining whether evidence raises a reasonable possibility of substantiating a claim for purposes of reopening a claim, a veteran's testimony regarding having experienced ongoing symptoms since service can be considered relevant as to the issue of nexus. In reaching this conclusion, the Court reaffirmed the notion that a veteran's testimony should not be rejected as not being material solely because he or she is a lay person, or because contemporaneous medical evidence is no longer available to corroborate it. Id; see also Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009) and Jandreau v. Nicholson, 492 F.3d 1372, 1377 (2007). However, as indicated above, in the current appeal the Veteran has not provided evidence in support of nexus between the noted facial laceration and his military service, which was not previously considered in prior decision. Accordingly, his contentions made during the current appeal are cumulative and may not be deemed to be both new and material. Shade, supra. The Veteran has been afforded ample opportunity to submit new and material evidence. 38 U.S.C. § 5107(a). As the additionally received evidence does not tend to establish any point not previously demonstrated, it is cumulative. See 38 C.F.R. § 3.156 (2016). The Board must therefore conclude that new and material evidence has not been received and that the Veteran's claim for service connection for residuals of facial scars is not reopened. b. Residuals of a head injury to include memory loss and mood disorder As described above, the Veteran's petition to reopen the claim of service connection for residuals of a head injury to include memory loss and mood disorder was previously considered and denied in a January 2005 Board decision. Relevant evidence received since the January 2005 decision includes, but is not limited to, the Veteran's VA and private treatment records; VA examination reports; and lay statements of the Veteran and his spouse. Without the need to discuss every piece of newly received evidence in detail, the Board finds that new and material evidence has been received regarding the request to reopen the Veteran's claim of entitlement to service connection for residuals of a head injury to include memory loss and mood disorder. See Shade v. Shinseki, 24 Vet. App. 110, 117-18 (2010). Namely, in a July 2008 letter, licensed clinical social worker, Ms. A.H., noted the Veteran's report of in-service injury, as well as his report of continuing memory loss and impaired mood including dissociation. She then opined, "[t]he symptoms of short term memory loss, frequent dissociation, [and] migraine headaches are usually experienced by veterans involved in explosions such as [improvised explosive devices]." Critically, this statement by Ms. A.H. relates to the previously unestablished element of nexus as to the residuals of head injury to include memory loss and mood disorder claim. Accordingly, the standards under 3.156(a) have been met and the claim is reopened. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); Shade v. Shinseki, 24 Vet. App. 110 (2010). V. Merits of Service Connection Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C. §§ 1110, 1131. Service connection may also be granted for any injury or disease diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). In order to establish direct service connection for the claimed disorder, generally, there must be competent and credible evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Lay evidence can be competent and sufficient to establish the elements of service connection 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. See Jandreau, 492 F.3d at 1377. A veteran is presumed to be in sound condition when examined and accepted into service except for defects or disorders noted at that time. 38 U.S.C. § 1111. The presumption is rebutted where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. "[T]he Government must show clear and unmistakable evidence of both a preexisting condition and a lack of in-service aggravation to overcome the presumption of soundness . . ." Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); see VAOPGCPREC 3-2003 (July 16, 2003) (cited at 69 Fed. Reg. 25,178 (May 5, 2004)). A pre-existing injury or disease is considered to have been aggravated by active service if there is an increase in disability during service, unless there is a specific finding that the increase in disability is due to the natural progression of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(a). VA bears the burden to rebut the presumption of aggravation in service. Laposky v. Brown, 4 Vet. App. 331, 334 (1993); Akins v. Derwinski, 1 Vet. App. 228, 232 (1991). However, aggravation is not conceded where the disability underwent no increase in severity during service based on all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(b); Falzone v. Brown, 8 Vet. App. 398, 402 (1995). Temporary or intermittent flare-ups of a pre-existing injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition, as contrasted with symptoms, has worsened. Jensen v. Brown, 4 Vet. App. 304, 306-307 (1993); Green v. Derwinski, 1 Vet. App. 320, 323 (1991); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). Thus, "a lasting worsening of the condition" - that is, a worsening that existed not only at the time of separation but one that still exists currently is required. Routen v. Brown, 10 Vet. App. 183, 189 (1997); Verdon v. Brown, 8 Vet. App. 529, 538 (1996). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. See 38 U.S.C. § 1153 (West 2012); 38 C.F.R. §§ 3.304, 3.306(b) (2017). In this matter, the Veteran contends that he incurred a head injury during his military service as a result of the in-service rifle malfunction described above. He has further asserted that he suffers from memory loss and mood disorder due to his in-service head injury. For reasons expressed immediately below, the Board finds that the evidence of record establishes that the Veteran had head injury, which pre-existed his active military service. The Veteran served on active duty from October 1969 to October 1971. A neurologic condition was not documented in the Veteran's enlistment examination (October 1969), re-enlistment examination (July 1971), or exit examination (October 1971). Significantly, the Veteran has submitted evidence clearly documenting a pre-service head injury due to falling out of a tree where he lost consciousness and suffered a laceration of the forehead. See private hospital records dated August 30, 1957. Further, STRs reflect that the Veteran reported a history of a head injury with a laceration of the forehead when he was 10 years old upon entry into service. See Report of Medical History dated October 15, 1969. With respect to the question of whether the Veteran had a head injury that pre-existed his military service, the April 2017 VA examiner observed that the Veteran does not have a diagnosis of traumatic brain injury. However, he was diagnosed with hemangioma after his military service, as well as PTSD and migraine headaches. The examiner reviewed the Veteran's medical history and STRs, and reported that the Veteran clearly suffered a concussion and forehead laceration in 1957, prior to his military enlistment. The examiner therefore concluded, "there is evidence of record which clearly and unmistakably shows that the Veteran had a brain condition that existed prior to his entry onto active duty." Based on the above, the Board finds that the Veteran suffered a head injury, which clearly and unmistakably existed prior to service. Under the circumstances of receiving medical care, the related pre-service concussion symptoms and in-service treatment providers noted the condition existed prior to service. The Board accordingly finds that the evidentiary standard for establishing the head injury existed prior to service has been met. Even where the evidence clearly and unmistakably establishes, as it does in this case, that the disorder at issue existed prior to service, to rebut the presumption of soundness, the evidence must also clearly and unmistakably show that the disorder was not aggravated during or by service. Specifically, the evidence must show that the claimed condition was aggravated by service, meaning chronically (i.e., permanently) worsened it beyond its natural progression. 38 U.S.C. § 1153; 38 C.F.R. § 3.306. As described above, although the in-service head injury was not documented in STRs, the Veteran submitted several buddy statements which supported that the incident occurred, which has been conceded by the AOJ. See, e.g., the Veteran's statement dated May 15, 1990 and the lay statements dated September 20, 1990 and October 3, 1991. The Board notes the Veteran was afforded a VA examination in June 1992 which provided him with a diagnosis of a cerebral concussion by record, very mild; completely recovered. The June 1992 examination report also noted the Veteran's memory difficulties and problems with mood and rage. In a September 1992 letter, Dr. A.W. reported that the Veteran suffers from a mood disorder, namely depression. She further reported that the Veteran relates the onset of his problems to an in-service injury in 1969 when his rifle exploded. In an October 1993 letter, Dr. A.W. reported that, at the time of the rifle blast, the Veteran sustained post-concussion symptoms including memory loss. Private treatment records dated in April 1996 indicate that the Veteran has verbal memory loss and attention problems. Magnetic resonance imaging (MRI) of the brain performed in August 1999 noted mild cerebral atrophy and a 1 cm. hemangioma or venous lake. In an August 1999 letter, Dr. S.A. reported that documented brain lesion "is of limited pathological significance and does not seem to be a meningioma, but since this is directly at the site of old trauma had occurred in 1969, it may merely represent a trauma to the alvarium and the venous lake region." Dr. S.A. continued, "[w]hat is more important is the fact that the lesion is unchanged over a two year interval." Dr. S.A. also described the Veteran's report of poor memory since an in-service explosion, along with temper outbursts. A January 2002 neurologic examination found an incidental hemangioma, unrelated to any head injury and not brought on by trauma. The Veteran's memory and mood problems were also noted in a January 2002 VA neurological examination. An MRI performed in October 2007 found a venous hemangioma in the superior right parietal bone. The diagnostic impression was: 1) a history of service-related facial skull injury secondary to rifle malfunction and explosion occurring in 1969 during active duty and 2) headaches syndrome sustained with vascular components, secondary to the facial skull injury. The Veteran was afforded a VA traumatic brain injury (TBI) examination in April 2009 and was diagnosed with a moderate concussion during youth with no evidence to support a diagnosis of a TBI during military service. A June 2011 brain imaging study showed some shrinkage in the deeper portion of the Veteran's brain. It was noted the shrinkage "may be related" to the Veteran's previous brain trauma and a benign abnormality (hemangioma) in the superficial blood vessels on his skull. An October 2011 brain and spinal cord VA examiner provided a negative nexus opinion between a hemangioma and service. Specifically, the examiner opined that "[t]he majority of hemangiomas that involve bone are discovered incidentally in asymptomatic patients. Men are affected twice as often as women, and lesions are usually discovered in the fourth and fifth decades of life." The examiner then concluded that the diagnosed hemangioma was less likely than not incurred in or caused by the claimed in-service injury. A private cognitive evaluation from October 2013 opined that given the duration of the time that had passed since the head injury, the natural process of brain recovery would be expected to have stabilized. Therefore, it was unlikely that a prior brain injury was a major contributing factor to the Veteran's condition. Pursuant to the March 2016 Board Remand, the Veteran was afforded a VA TBI examination in April 2017. The examiner diagnosed the Veteran with a traumatic brain injury, which occurred at the time of the pre-service head injury. The examiner noted objective evidence of mild impairment of memory, attention, concentration, or executive functions resulting in mild functional impairment due to the traumatic brain injury. The examiner additionally reported mildly impaired judgment, and frequently inappropriate social interaction; specifically, the Veteran is socially withdrawn and avoids crowds. In a separate April 2017 medical opinion, the examiner explained that the Veteran suffered a very mild cerebral concussion during his active duty service from which he recovered. The examiner then concluded that the "pre-existing condition was not aggravated by service of that any increase in disability was due to the natural progression of the disease." He additionally explained, "[r]eview of the literature suggests that head trauma which has been previously established as occurring in the service is not likely to influence the development of a hemangioma as noted in a study by the NIH." The examiner continued, "[t]he weight of evidence does not support the association between head trauma either in the service or in fact prior to service, and the subsequent development of a hemangioma." He then concluded that the Veteran's diagnosed hemangioma is less likely than not associated with the in service head injury. When assessing the probative value of a medical opinion, the access to claims files and the thoroughness and detail of the opinion must be considered. The opinion is considered probative if it is definitive and supported by detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). The Court has held that claims file review, as it pertains to obtaining an overview of a claimant's medical history, is not a requirement for private medical opinions. A medical opinion that contains only data and conclusions is not entitled to any weight. Further a review of the claims file cannot compensate for lack of the reasoned analysis required in a medical opinion, which is where most of the probative value of a medical opinion comes from. "It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion." See Nieves-Rodriguez, 22 Vet. App. at 295. The competent medical evidence shows that the diagnosed traumatic brain injury was not aggravated beyond its natural progression by the Veteran's military service. The Board finds the April 2017 VA medical opinion particularly probative as to the question of aggravation, as it appears to have been based upon a thorough review of the record and thoughtful analysis of the Veteran's entire history. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"). The April 2017 VA examiner's rationale was substantial, thorough, and based on the overall record and he addressed each theory of head injury was not incurred in or aggravated by his active military service. The evidence shows that although the Veteran sustained a mild concussion during his military service, it is clear and unmistakable this condition resolved and did not aggravate the previously incurred head injury. Here, there is no evidence to show that the Veteran's disability was aggravated beyond its natural progression by the circumstances of his active duty. There is no competent evidence which contradicts the conclusions of the April 2017 VA examiner. As was explained previously herein, the Veteran has been afforded ample opportunity to present evidence in support of his claim. He has not done so. See 38 U.S.C. § 5107(a) (2012) (it is the claimant's responsibility to support a claim for VA benefits). Significantly, the findings of the April 2017 VA examiner were thoroughly explained and fully supported by the evidence of record, as well as the pertinent medical literature. To this end, the Board notes that the April 2017 medical opinion was based on a review of the record, including the lay statements and evidence submitted by the Veteran, and the examiner explained the reasons for his conclusions based on an accurate characterization of the evidence of record. The Board therefore places significant weight on the findings of the April 2017 VA examiner. See Nieves-Rodriguez, supra; see also Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"). Accordingly, the Board finds that service connection for residuals of a head injury, to include hemangioma, is not warranted. Moreover, with respect to the claimed memory loss and mood disorder, the Board observes that the claimed symptoms of impaired memory and mood have explicitly been considered under the assigned 70 percent rating for service-connected PTSD. The Veteran's treatment providers and examiners have not attempted to differentiate between the symptomatology associated with the pre-existing traumatic brain injury and the service-connected PTSD. See Mittleider, supra. To this end, the Court has interpreted 38 U.S.C. § 1155 as implicitly containing the concept that the rating schedule may not be employed as a vehicle for compensating a claimant twice (or more) for the same symptomatology; such a result would overcompensate the claimant for the actual impairment of his earning capacity and would constitute pyramiding of disabilities, which is cautioned against in 38 C.F.R. § 4.14. Essentially, under the anti-pyramiding provision of 38 C.F.R. § 4.14, the evaluation of the "same disability" or the "same manifestation" under various diagnoses is to be avoided. See Esteban v. Brown, 6 Vet. App. 259 (1994). Accordingly, the Board finds that service connection is not separately warranted for residuals of a head injury to include memory loss and mood disorder. The Board has considered the contentions of the Veteran that the currently diagnosed head injury was aggravated by his military service. To this end, the Board recognizes that lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case by case basis whether a veteran's particular disability is the type of disability for which lay evidence is competent. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Kahana v. Shinseki, 24 Vet. App. 428, 433, n. 4 (2011). In this case, the Veteran's assertions as to aggravation of pre-existing symptomatology concern an internal medical process, which extends beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. Cf. Jandreau, 492 F.3d at 1376 (lay witness capable of diagnosing dislocated shoulder); Barr v. Nicholson, 21 Vet. App. 303, 308-9 (2007); Falzone v. Brown, 8 Vet. App. 398, 403 (1995) (lay person competent to testify to pain and visible flatness of his feet); with Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) ("It is generally the province of medical professionals to diagnose or label a mental condition, not the claimant"); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Jandreau, 492 F.3d at 1377, n. 4 ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). See also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir.2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge). In other words, while the Veteran is competent to describe his symptoms, he lacks the necessary expertise to state that those symptoms represent an aggravation of the underlying disability beyond its natural progression. In addition, the Veteran's contentions are contradicted by the findings of the April 2017 VA examiner who specifically considered the Veteran's lay statements in rendering his negative opinion. In short, the Board finds that the competent evidence, in the form of the service medical records, post-service medical records, and medical opinion evidence, demonstrates that aggravation did not take place. See 38 U.S.C. § 1153 (West 2012); 38 C.F.R. §§ 3.304, 3.306(b) (2017); see also Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002) (the mere occurrence of symptoms, in the absence of a demonstrated increase in the underlying severity, does not constitute aggravation of the disability). For these reasons, the Board finds that the evidence shows that the Veteran's traumatic brain injury pre-existed his active military service, but was not aggravated during such service. Accordingly, entitlement to service connection for residuals of a head injury, to include hemangioma, memory loss, and mood disorder, is not warranted. ORDER Entitlement to an initial rating in excess of 70 percent for service-connected PTSD is denied. A rating of 50 percent, but no higher, for the service-connected migraine headaches is granted throughout the appeal period, subject to controlling regulations applicable to the payment of monetary benefits. Entitlement to a TDIU is granted from March 1, 2007, subject to the laws and regulations governing the payment of monetary benefits. New and material evidence having been received, the application to reopen the claim of service connection for residuals of a head injury to include memory loss and mood disorder is granted. New and material evidence having not been received, the claim of entitlement to service connection for facial scars is denied. Entitlement to service connection for residuals of a head injury, to include hemangioma, is denied. Entitlement to service connection for residuals of a head injury, to include memory loss and mood disorder, is denied. ____________________________________________ K. CONNER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs