Citation Nr: 18152213
Decision Date: 11/21/18	Archive Date: 11/21/18

DOCKET NO. 18-20 502
DATE:	November 21, 2018
ORDER
New and material evidence not having been received, the Veteran’s application to reopen the claim for entitlement to service connection for a back condition is denied.
New and material evidence not having been received, the Veteran’s application to reopen the claim for entitlement to service connection for sleep apnea is denied. 
Entitlement to an initial compensable rating for bilateral hearing loss is denied.
Entitlement to a compensable rating for hemorrhoids is denied.
Entitlement to a rating in excess of 10 percent for laceration scar of the forehead is denied.
Entitlement to a rating in excess of 10 percent for laceration scar of the left wrist is denied.
Entitlement to a rating in excess of 30 percent for post-traumatic headaches is denied.
Entitlement to a rating in excess of 50 percent for post-traumatic stress disorder (PTSD) is denied.
REMANDED
Entitlement to service connection for hypertension, to include as secondary to post-traumatic stress disorder (PTSD), is remanded.
FINDINGS OF FACT
1. A May 2004 rating decision denied service connection for a back condition; the Veteran did not perfect a timely appeal of that decision and the decision became final.
2. The evidence received since the May 2004 rating decision is cumulative and redundant of the evidence of record at the time of that decision, does not relate to an unestablished fact necessary to substantiate the claim for service connection for a back condition, and does not raise a reasonable possibility of substantiating the claim.
3.  An April 2008 rating decision denied service connection for sleep apnea. The Veteran did not perfect a timely appeal of that decision and the decision became final.
4. The evidence received since the April 2008 rating decision is cumulative and redundant of the evidence of record at the time of that decision, does not relate to an unestablished fact necessary to substantiate the claim for service connection for sleep apnea, and does not raise a reasonable possibility of substantiating the claim.
5. The Veteran's bilateral hearing loss is manifested by pure tone threshold averages and speech recognition scores that corresponded to no more than a level "I" hearing acuity in the right and a level "III" hearing acuity in the left ear.
6. The Veteran's hemorrhoids are not shown to be large, thrombotic, or irreducible, with excessive redundant tissue, evidencing frequent recurrences; and there is no persistent bleeding with secondary anemia, or with fissures.
7. The Veteran's laceration scars of the forehead display one characteristic of disfigurement for VA purposes, with no evidence of visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features; scars do not result in functional limitation, and do not impact the Veteran’s ability to work.
8. The Veteran's laceration scar of the left wrist results in pain; there is no evidence of three or more scars that are unstable or painful. 
9. For the entire appeal period, the Veteran's post-traumatic headaches have not been productive of severe economic inadaptability. 
10. For the entire appeal period, the Veteran’s PTSD has not manifested by symptoms that more nearly approximate occupational and social impairment with deficiencies in most areas. 
CONCLUSIONS OF LAW
1. The May 2004 rating decision denying service connection for a back condition is final. 38 U.S.C. §§ 5108, 7105(c) (West 2012); 38 C.F.R. § 20.1103 (2017).
2. The evidence received since the May 2004 rating decision is not new and material and the Veteran's claim for service connection for a back condition is not reopened. 38 U.S.C. §§ 5108, 7105 (West 2012); 38 C.F.R. § 3.156 (2017).
3. The April 2008 rating decision denying service connection for sleep apnea is final. 38 U.S.C. §§ 5108, 7105(c) (West 2012); 38 C.F.R. § 20.1103 (2017).
4. The evidence received since the April 2008 rating decision is not new and material and the Veteran's claim for service connection for sleep apnea is not reopened. 38 U.S.C. §§ 5108, 7105 (West 2012); 38 C.F.R. § 3.156 (2017).
5. The criteria for an initial compensable rating for bilateral hearing loss have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.85, 4.86 Diagnostic Code 6100 (2018).
6. The criteria for a compensable evaluation for hemorrhoids have not been met. 38 U.S.C. §§ 1155, 5107(b) (West 2012); 38 C.F.R. §§ 3.321 (b)(1), 4.2, 4.7, 4.10, 4.21, 4.31, Diagnostic Code 7336 (2017).
7. The criteria for a rating in excess of 10 percent for laceration scars of the forehead have not been met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.118, Diagnostic Code 7800 (2017).
8. The criteria for a rating in excess of 10 percent for a laceration scar of the left wrist have not been met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.118, Diagnostic Code 7805 (2017).
9. The criteria for a rating in excess of 30 percent for post-traumatic headaches have not been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8100 (2017).
10. The criteria for a rating in excess of 50 percent for PTSD have not been met. 38 U.S.C. §§1110, 1155, 5107 (West 2012); 38 C.F.R. §§ 4.7, 4.22, 4.130, Diagnostic Code 9411 (2017).
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
The Veteran served on active duty in the U.S. Army from February 1962 to February 1965. This appeal to the Board of Veterans' Appeals (Board) arose from Department of Veterans Affairs (VA) Regional Office (RO) rating decisions in September 2010, June 2016, and August 2017. The Veteran perfected an appeal.  See October 2010 Notice of Disagreement (NOD); July 2016 NOD; September 2017 NOD; May 2018 Statement of the Case (SOC); June 2018 VA Form-9. 
The Board notes that in his June 2018 substantive appeal (contained in two separate VA-Form-9s), the Veteran asserted that VA failed to assist in the development of his claim, never reviewed medical evidence that he submitted, and did not properly consider evidence contained within the claims file. See June 21, 2018 VA Form-9; June 22, 2018 VA Form-9.
The Board notes that VA has a duty to provide assistance to substantiate a claim. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159 (c). Relevant to the duty to assist, the AOJ obtained and considered the Veteran's service treatment records as well as post-service VA, and private treatment records. To the extent that the Veteran contends that VA failed to assist in development, the Veteran has not identified any additional, outstanding records that have not been requested or obtained. Additionally, the Veteran has not specified which pieces of evidence he believes that VA has failed to review or consider. Therefore, the Board finds that VA has met its duty to assist the Veteran in obtaining relevant records. Additionally, the Veteran was provided a number of VA medical examinations in relation to his claims. These examination reports are adequate for rating purposes because they are based upon consideration of the relevant facts particular to this Veteran's medical history, describe the disability in sufficient detail so that the Board's evaluation is a fully informed one, and contain reasoned explanations. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-04 (2008). 
Further, the Veteran was afforded a Board hearing before the undersigned Veteran’s Law Judge (VLJ), during which time he was afforded the opportunity to provide testimony relevant to his claims. At his hearing, the Veteran made no contentions as to the record being incomplete. Additionally, the Board has conducted a de novo review of the Veteran’s claims which included a complete and thorough review of all evidence in the Veteran’s claims file. Thus, the Board finds that VA's duty to assist has been met.
New and Material Evidence
The Veteran seeks to reopen his previously denied claims for entitlement to service connection for a back condition and obstructive sleep apnea.
Notwithstanding determinations by the RO that new and material evidence has or has not been received to reopen the Veteran's claims, it is noted that on its own, the Board is required to determine whether new and material evidence has been presented. Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001) (holding that the Board has a legal duty under 38 U.S.C. §§ 5108 and 7105, to address the question of whether new and material evidence has been presented to reopen a previously denied claim); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996).
In general, rating decisions that are not timely appealed are final and binding based on all of the evidence then of record. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.104, 20.1103 (2017). A claim which has been denied in an unappealed rating decision may not thereafter be reopened and allowed. 38 U.S.C. § 7105 (c) (2012). The exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented with respect to a claim that has been disallowed, the claim may be reopened. 38 U.S.C. § 5108 (2012); see Manio v. Derwinski, 1 Vet. App. 140, 145 (1991). 

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 (a) (2017). 

VA must review all of the evidence submitted since the last final rating decision in order to determine whether the claim may be reopened. See Hickson v. West, 12 Vet. App. 247, 251 (1999). For purposes of determining whether new and material evidence has been received to reopen a finally adjudicated claim, the recently submitted evidence will be presumed credible. See Kutscherousky v. West, 12 Vet. App. 369, 371 (1999) (per curium) (holding that the "presumption of credibility" doctrine continues to be precedent). 

The Court of Appeals for Veterans Claims has held that the determination of whether newly submitted evidence raises a reasonable possibility of substantiating the claim should be considered a component of the question of what is new and material evidence, rather than a separate determination to be made after the Board has found that evidence is new and material. Shade v. Shinseki, 24 Vet. App. 110 (2010). The Court further held that new evidence would raise a reasonable possibility of substantiating the claim if, when considered with the old evidence, it would at least trigger the Secretary's duty to assist. Id. 

The Veteran need not present evidence as to each element that was a specified basis for the last disallowance, but merely new and material evidence as to at least one of the bases of the prior disallowance. Id. (holding that it would be illogical to require that a claimant submit medical nexus evidence when he has provided new and material evidence as to another missing element).

For the purpose of establishing whether new and material evidence has been submitted, the evidence is presumed credible unless it is inherently false or untrue, or it is beyond the competence of the person making the assertion. Justus v. Principi, 3 Vet. App. 510, 513 (1992).
1. Back Condition
The Veteran filed a claim for service connection for a back condition in November 2003. The claim was denied in a May 2004 rating decision. The RO notified the Veteran of its decision and of his appellate rights, but he did not initiate an appeal of the RO’s decision within the one-year appeal period. Therefore, the May 2004 rating decision became final. 38 U.S.C. § 7105 (West 2002) [(West 2012)]; 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2010) [(2017)]. Accordingly, the claim may now be considered on the merits only if new and material evidence has been received since the time of the prior adjudication. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a) (2017); Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001).
In this instance, the May 2004 rating decision denied the claim on the basis that the Veteran’s back condition was not the result of military service, but rather was shown to have resulted from a back injury sustained on a work site in 2003. Accordingly, the Board finds that new and material evidence would consist of evidence that the Veteran’s current back condition is related to service.  
The Veteran submitted a request to reopen the previously denied claim in January 2010. Evidence received since the May 2004 rating decision consists of medical records documenting ongoing treatment for a back condition, lay statements, and the Veteran’s testimony before the undersigned Veteran’s Law Judge (VLJ) at an August 2018 hearing.  
At his Board hearing, the Veteran repeated his contention that his back condition stemmed from a documented in-service motor vehicle accident. He also reported that he sought treatment at the West Roxbury VAMC after service, as well as from a private chiropractor. However, he indicated his belief that the chiropractor had passed away and any records were unavailable. The Veteran reported that although he continued to experience back pain, he did not see an orthopedist until having back surgery at age 60.
Although the Veteran has submitted various treatment records, there is no evidence of a link to service or to a service-connected disability. To the extent that the Veteran has reported treatment right after service, the Board notes that this information was previously of record as the Veteran’s claim for a back condition was first denied in a November 1966 rating decision. Further, the Veteran’s reports of seeing an orthopedist leading up to having back surgery are cumulative of the evidence available at the time of the May 2004 rating decision. The RO considered this evidence and such evidence was also considered by a VA examiner during a December 2003 back examination. 
As such, the Board is unable to conclude that the evidence received since the May 2004 rating decision constitutes new and material evidence to reopen the claim, as there is no evidence that the Veteran has a back condition as a result of service or secondary to a service-connected disability. 
The Board has considered the holding in Shade v. Shinseki, 24 Vet. App. 110 (2010). 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 layperson, 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); 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 a nexus that was not already previously considered in prior decisions. Accordingly, his contentions made during the current appeal may not be deemed both new and material. Shade, supra.

Since the evidence submitted after May 2004 is not new and material, the claim for service connection for a back condition is not reopened. The benefit sought is denied. As the Veteran has not fulfilled his threshold burden of submitting new and material evidence to reopen the finally disallowed claim, the benefit-of-the-doubt doctrine is not applicable. See Annoni v. Brown, 5 Vet. App. 463, 467 (1993).
2. Sleep apnea
The Veteran filed a claim for service connection for sleep apnea in September 2007. The claim was denied in an April 2008 rating decision. The RO notified the Veteran of its decision and of his appellate rights, but he did not initiate an appeal of the RO’s decision within the one-year appeal period. Therefore, the April 2008 rating decision became final. 38 U.S.C. § 7105 (West 2002) [(West 2012)]; 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2010) [(2017)]. Accordingly, the claim may now be considered on the merits only if new and material evidence has been received since the time of the prior adjudication. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a) (2017); Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001).
In this instance, the April 2008 rating decision denied the claim on the basis that the evidence did not show that the Veteran’s sleep apnea was related to his service-connected headaches, nor any evidence of the disability during military service. Accordingly, the Board finds that new and material evidence would consist of evidence that the Veteran’s sleep apnea condition is related to his service-connected post-traumatic headaches, or otherwise related to service.  
The Veteran submitted a request to reopen the previously denied claim in January 2010. Evidence received since the April 2008 rating decision consists of medical records documenting ongoing treatment for sleep apnea, lay statements, and the Veteran’s testimony before the undersigned VLJ at an August 2018 hearing.  
At his hearing, the Veteran described symptoms of his sleep apnea and reported that he had been told by a doctor that his sleep apnea was related to his service-connected headaches. The Board notes that this information was previously of record at the time of the April 2008 rating decision. In this regard, the Veteran stated his contention that he was told by a doctor his sleep apnea was likely due to his service connected head injury in his September 2007 claim for service connection. Further, he was afforded a VA examination in December 2007, which noted the symptoms described by the Veteran and specifically addressed his contention that his sleep apnea was caused by his post-traumatic headaches. The examiner provided a negative nexus opinion, on both a direct and secondary basis, with a supporting rationale. To date, the Veteran has offered no other medical evidence linking his sleep apnea to service or a service-connected disability. 
As such, the Board is unable to conclude that the evidence received since the April 2008 rating decision constitutes new and material evidence to reopen the claim, as there is no evidence that the Veteran’s sleep apnea is the result of service or secondary to a service-connected disability. 
The Board has considered the holding in Shade v. Shinseki, 24 Vet. App. 110 (2010). 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 layperson, 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); 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 a nexus that was not already previously considered in prior decisions. Accordingly, his contentions made during the current appeal may not be deemed both new and material. Shade, supra.

Since the evidence submitted after April 2008 is not new and material, the claim for service connection for sleep apnea is not reopened. The benefit sought is denied. As the Veteran has not fulfilled his threshold burden of submitting new and material evidence to reopen the finally disallowed claim, the benefit-of-the-doubt doctrine is not applicable. See Annoni v. Brown, 5 Vet. App. 463, 467 (1993).
Increased Rating
Disability ratings are determined by the application of VA's Schedule for Rating Disabilities. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155 (2012); 38 C.F.R. § Part 4 (2017). Ratings for service-connected disabilities are determined by comparing the Veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. 

The veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and 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). Here, the relevant evidentiary window begins one year before the Veteran filed his claim for an increased rating, and continues to the present time. The Board will also consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). 

When there is a question as to which of two ratings to apply, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating, otherwise the lower rating shall be assigned. 38 C.F.R. § 4.7. 

After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2017).
1. Hearing Loss
The Veteran seeks entitlement to an initial compensable rating for bilateral hearing loss. Service connection for bilateral hearing loss was established by a June 2016 rating decision, at which time a noncompensable rating was assigned, effective from March 31, 2016. The Veteran submitted a notice of disagreement with the rating assigned.
The basis for evaluating defective hearing is the impairment of auditory acuity as measured by pure tone threshold averages, within the range of 1000 to 4000 Hertz and speech discrimination using the Maryland CNC word recognition test. 38 C.F.R. § 4.85. 
Section 4.85(a) requires that an examination for hearing loss be conducted by a state-licensed audiologist, and must include both a controlled speech discrimination test (Maryland CNC test) and a pure tone audiometry test. 
Examinations must be conducted without the use of hearing aids. Pure tone threshold averages are derived by dividing the sum of the pure tone thresholds at 1000, 2000, 3000, and 4000 by four. Id. The pure tone threshold averages and the Maryland CNC test scores are given a numeric designation, which are then used to determine the current level of disability based upon a pre-designated schedule. Tables VI and VII in 38 C.F.R. § 4.85. Under these criteria, the assignment of a disability rating is a "mechanical" process of comparing the audiometric evaluation to the numeric designations in the rating schedule. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1993). 
In addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in the final report. See Martinak v. Nicholson, 21 Vet. App. 447 (2007).  Here, VA reports of record reflect the Veteran's account of the functional impact of his hearing loss. These notations indicate that the examiners did elicit information from the Veteran concerning the functional effects of his disability as required by 38 C.F.R. § 4.1, 4.2, 4.10.
The Veteran was afforded a VA examination in May 2016. On the authorized audiological evaluation in May 2016, pure tone thresholds, in decibels, were as follows:
 	 	 	HERTZ	 	 
 	500	1000	2000	3000	4000
RIGHT	 25	20 	 35	50 	75 
LEFT	 35	30	 40	70	80
The examination shows a pure tone threshold average of 44 in the right ear and 55 in left ear. Speech audiometry revealed speech recognition ability of 94 percent in the right ear and of 92 percent in the left ear. This corresponds to a numeric designation of “I” in the right ear and “I” in the left ear. Table VI in 38 C.F.R. § 4.85. These combined numeric designations then result in a rating of 0 percent under Table VII. 38 C.F.R. § 4.85, Table VII. The examiner described the functional impact of the Veteran’s hearing loss as difficulty hearing his wife and hearing the television.  
The Veteran was afforded a VA examination in February 2018. On the authorized audiological evaluation in February 2018, pure tone thresholds, in decibels, were as follows:
 	 	 	HERTZ	 	 
 	500	1000	2000	3000	4000
RIGHT	 25	25 	 40	55 	75 
LEFT	 35	40	 50	75	75
The examination shows a pure tone threshold average of 49 in the right ear and 60 in left ear. Speech audiometry revealed speech recognition ability of 96 percent in the right ear and of 88 percent in the left ear. This corresponds to a numeric designation of “I” in the right ear and “III” in the left ear. Table VI in 38 C.F.R. § 4.85. These combined numeric designations then result in a rating of 0 percent under Table VII. 38 C.F.R. § 4.85, Table VII. The examiner described the functional impact of the Veteran’s hearing loss as difficulty understanding conversations, especially on the television.  
Based on these objective findings, the Veteran's bilateral hearing loss does not meet the requirements for a higher rating based on 38 C.F.R. §§ 4.85, 4.86(b). A noncompensable rating is warranted and reflective of the Veteran’s hearing acuity for the entirety of the appeal period.
The Board has considered the Veteran's statements regarding the severity of his hearing loss and how it has affected his daily activities. In this regard, at his VA examinations and in testimony at an August 2018 Board hearing, the Veteran has reported difficulty hearing conversations and television and indicated that experiences trouble with speech recognition, despite receiving hearing aids. See May 2016 VA Examination; February 2018 VA Examination; August 2018 Hearing Transcript. 
The Board acknowledges the Veteran’s statements and contentions about the degree of his bilateral hearing loss. Lay persons are competent to provide opinions on some medical issues. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). However, in this case, such an opinion falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). To the extent that the Veteran contends that his hearing loss is more severe than currently evaluated, while he is competent to report symptoms such as difficulty hearing and understanding speech, he is not competent to report that his hearing acuity is of sufficient severity to warrant a certain percent evaluation under VA's tables for rating hearing loss disabilities because such an opinion requires medical expertise (training in evaluating hearing impairment) which he does not possess. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau, 492 F.3d at 1377; Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Charles v. Principi, 16 Vet. App. 370 (2002); Woehlaert v. Nicholson, 21 Vet. App. 456 (2007).
However, as noted above, disability ratings for hearing impairment are to be derived by the mechanical application of the Rating Schedule to the numeric designations assigned based on audiometric evaluations. While the Board is sympathetic to the Veteran's assertions that he has difficulty hearing, the VA rating criteria are definitive and provide for a precise result based on audiometric test results. His subjective report of difficulty hearing and understanding speech, unfortunately cannot be the basis for an evaluative rating. The Board is bound to apply the VA rating schedule, under which the rating criteria are defined by audiometric test findings involving hearing acuity in a controlled laboratory environment.
As such, the Board finds that the more probative evidence concerning the level of severity of this disorder consists of the audiometric testing results of record, as documented in the May 2016 and February 2018 VA examination reports. These reports outweigh any lay subjective reports of a more severe degree of disability, because they directly address the rating criteria for hearing loss. Thus, the Board finds that a compensable rating is not warranted. See 38 C.F.R. §§ 4.85, 4.86, Diagnostic Code 6100.
In sum, the preponderance of the evidence is against an initial compensable rating for the Veteran's service-connected bilateral hearing loss. Therefore, reasonable doubt does not arise, and the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990).
2. External Hemorrhoids
The Veteran is service connected for external hemorrhoids, evaluated as noncompensable from July 15, 1966. He seeks a compensable rating.  
The Veteran's external hemorrhoids are rated under 38 C.F.R. § 4.114, Diagnostic Code 7336. 

Diagnostic Code 7336 is applicable to both external and internal hemorrhoids. Under this diagnostic code, a noncompensable rating is assigned if the hemorrhoids are mild or moderate. A 10 percent rating is warranted for hemorrhoids that are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. A maximum 20 percent rating is warranted for hemorrhoids "[w]ith persistent bleeding and with secondary anemia, or with fissures." See 38 C.F.R. § 4.114, Diagnostic Code 7336.
Turning to the evidence of record, the Veteran filed a claim for an increased rating in January 2010. A VA rectum and anus examination was performed in February 2010. The examiner noted that although the Veteran had been referred for evaluation of his rectum and anus, he denied any symptoms in respect to his bowels, rectum or anus. There were however, prior service treatment notes for hemorrhoids. The examiner noted that this void in the Veteran’s memory may have represented a memory lapse secondary to his established head trauma. However, at the time of the examination, the Veteran denied abdominal pain, diarrhea, constipation, blood in the stools, pain on moving his bowels, or any other bowel symptoms whatsoever. He had never had incontinence of stool or urine. See February 2010 VA Rectum and Anus examination. 
The Veteran reported that he had a colonoscopy approximately six years prior with normal findings. On physical examination, anal inspection was normal. Digital examination was normal with normal anal sphincter tone and with the ability to contract voluntarily on the examining finger. There was no abnormality of the rectal vault. The Veteran’s prostate was normal in size and consistency and there was no blood on the examining finger. Stool examination for occult blood was negative. An anoscopy to 5cm above the pectinate line showed normal rectal mucosa and no evidence of bleeding. There were enlarged internal hemorrhoids at five o’clock and at seven o’clock (lithotomy position), but without prolapse. There was no evidence of erosion or bleeding from these hemorrhoids and no evidence of anal fissure. The impression was grade II internal hemorrhoids. The examiner remarked that there appeared to be no rectal or anal problems at present. Id.
The Veteran underwent a VA rectum and anus examination in December 2015. The Veteran denied problems with hemorrhoids and stated, “I told the doctor a hundred times I don’t have no problems with that.” He denied blood in his stool or pain with bowel movements. He noted that he had frequent constipation but denied abdominal, rectal, or anal pain with bowel movements. The examiner did not conduct an examination of the rectal/anal area because the Veteran denied any problems with hemorrhoids, rectum, or anus and deferred examination. The examiner noted the findings of the 2010 anoscopy and reported that there were no other significant diagnostic test findings or results. The condition did not impact the Veteran’s ability to work. In his remarks, the examiner reported that there was no active hemorrhoid issue. See December 2015 VA Rectum and Anus Conditions Disability Benefits Questionnaire.  
A Rectum and anus examination was performed in February 2018. The examiner noted the diagnosis of internal or external hemorrhoids. A diagnosis of internal hemorrhoids was confirmed on anoscopy in February 2010. The Veteran denied bright red blood in the stool, painful bowel movements or other GI-related problems. He used no medications for the condition. An examination was not performed as the Veteran had no symptoms and declined examination. See February 2018 VA Rectum and Anus Conditions Disability Benefits Questionnaire.  

At his Board hearing in August 2018, the Veteran testified that he had good and bad days in respect to his hemorrhoids. He reported using Preparation H up to a few times a month, depending on what he had been doing. He reported flare-ups that occurred twice a month, which he treated with over-the-counter medications. See August 2018 Hearing Transcript. 
The Board finds that the preponderance of the evidence is against concluding that the Veteran’s service-connected hemorrhoids have been of such severity as to warrant a compensable disability rating at any time during this appeal.
In this regard, the record demonstrates that the Veteran has repeatedly denied any symptoms associated with his hemorrhoids and declined physical examination on both the December 2015 and February 2018 examinations. Physical examination on the February 2010 VA examination revealed internal hemorrhoids, with no symptoms. The Board notes that the February 2010 VA examiner suggested that the Veteran’s memory problems may have contributed to a void in memory regarding his hemorrhoid condition. Even considering this possibility, there is nothing in the evidence of record to suggest that the Veteran has more than mild or moderate hemorrhoids. 
The Board acknowledges the Veteran’s hearing testimony describing hemorrhoidal flare-ups up to twice a month, and the use of over-the-counter medications such as Preparation H. However, the Veteran’s testimony did not indicate the presence of irreducible large or thrombotic hemorrhoids with excessive redundant tissue, evidencing frequent recurrences, nor any symptoms which might more nearly approximate the criteria for a compensable rating. Rather, the Veteran’s description of occasional flare-ups of hemorrhoids with symptoms relieved by over-the-counter medication suggests no more than a mild or moderate condition, especially taken in conjunction with his consistent denial of symptoms throughout the appeal periods. As such, a compensable rating is not warranted. 
3. Laceration Scars of the Forehead
The Veteran is service connected for a laceration scar of the forehead, currently evaluated as 10 percent disabling, under Diagnostic Code 7800. He contends that the current rating does not adequately reflect the severity of his disability.  
Diagnostic Code 7800 provides ratings for disfigurement of the head, face, or neck. 38 C.F.R. § 4.118. A 10 percent rating is assigned under DC 7800 for scars of the head, face, or neck with one characteristic of disfigurement. A 30 percent rating is assigned for scars of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips) or with 2 or 3 characteristics of disfigurement. A 50 percent rating is assigned for scars of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of 2 features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips) or with 4 or 5 characteristics of disfigurement. A maximum 80 percent rating is assigned under DC 7800 for scars of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of 3 or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips) or with 6 or more characteristics of disfigurement. Id.
Note (1) to DC 7800 lists the 8 characteristics of disfigurement. They are: (1) scar 5 or more inches (13 or more centimeters (cm) in length, (2) scar at least 1/4 inch (0.6 cm) wide at widest part, (3) surface contour of scar elevated or depressed on palpation, (4) scar adherent to underlying tissue, (5) skin hypo- or hyper-pigmented in an area exceeding 6 square inches (39 square cm), (6) skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding 6 square inches (39 square cm), (7) underlying soft tissue missing in an area exceeding 6 square inches (39 square cm), and (8) skin indurated and inflexible in an area exceeding 6 square inches (39 square cm). See 38 C.F.R. § 4.118, DC 7800, Note (1) (2017).
A November 1966 rating decision granted service connection for forehead laceration wounds sustained in service, and assigned a noncompensable rating. The Veteran submitted a request for an increased rating in January 2010. 
The Veteran was afforded a VA examination in February 2010. Examination revealed the following scars on the Veteran’s forehead: a 2.0 x .02 cm transverse scar above the outer end of the right eyebrow that was without keloid, not tethered, superficial and non-tender; an L-shaped scar on the forehead, just to the left of the midline, extending longitudinally for 2 cm and laterally over the left eyebrow for an additional 2.0 cm. This scar was .03 at its greatest width and was nontender, without keloid, superficial and non-tender; an area of de-pigmentation over the central forehead which measured 5 x 3.5 cm (17.5 square cm) and appeared to represent an area of deep abrasion and healing. This scar was not tethered, tender, nor superficial; lastly, there was a 4.0 x 0.3 cm scar (1.2 square cm) extending from the left upper forehead into the scalp. This scar was not tethered, without keloid, nontender, and superficial. The examiner noted that the scars, in themselves did not make a significant contribution to the Veteran’s disability and in and of themselves did not cause significant disability. See February 2010 VA Examination. 
The Veteran underwent a VA scars examination in October 2010 by the same examiner who provided the February 2010 examination. In the left upper forehead, there was a 4.0 x 2.0 cm (8.0 square cm) slightly depigmented area of superficial skin scar, which appeared to be the result of an abrasion. Above the left eyebrow, there was a 1.0 x 1.0 cm (1.0 square cm) slight depigmentation, probably secondary to an old abrasion. Over the right eyebrow, there was a 1.0 x 0.1 cm (0.1 square cm) superficial oblique scar without tethering, tenderness of keloid. The examiner noted that there was no significant change in the elicited history and he provided an impression of scars, as described. See October 2010 VA Scars Examination. 
A VA scar examination in December 2015. Examination revealed a 1 cm scar of the forehead. There was no elevation, depression, adherence to underlying tissue, or missing underlying soft tissue. Further, there was no abnormal pigmentation or texture of the head, face, or neck, nor evidence of gross distortion or asymmetry of facial features or visible palpable tissue loss. The scar did not result in limitation of function and did not affect the Veteran’s ability to work. See December 2015 VA Scars Examination. 
A VA scar examination was provided in February 2018. The examiner identified a scar on the left forehead measuring 1 x 1.2 cm. There was no elevation, depression, adherence to underlying tissue, or missing underlying soft tissues, nor any abnormal pigmentation or texture of the head, face, or neck. There was no gross distortion or asymmetry of facial features or visible or palpable tissue loss. The scars did not result in limitation of function or impact the Veteran’s ability to work. See February 2018 VA Scar Examination. 
During an August 2018 Board hearing, the Veteran testified that he had scar tissue on his forehead which became blotchy and inflamed whenever he got in the sun or experienced a sunburn. The Veteran reported that his forehead scarring was not painful. See August 2018 Hearing Transcript. 
The Board finds that for the entire period of appeal, the record does not demonstrate the requisite manifestations for a rating in excess of 10 percent for the forehead laceration scar(s) under Diagnostic Code 7800. A higher evaluation of 30 percent is not warranted for scar(s) of the head, face, or neck unless the evidence shows two or three characteristics of disfigurement or visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks or lips).
Based on the evidence of record, the Board finds that the Veteran’s forehead laceration scars are appropriately rated as 10 percent disabling under Diagnostic Code 7800. The Veteran displays one characteristic of disfigurement as outlined in Note 1, warranting a 10 percent rating. In this regard, the evidence shows scars at least ¼ inch (0.6 cm) wide at widest point as documented on the VA examinations. However, the Veteran displayed no other characteristics of disfigurement. There was no evidence that the surface contour of the scars was elevated or depressed on palpation; adherent to underlying tissue; there was no abnormal skin texture in an area exceeding 6 square inches (39 square cm); no underlying soft tissue missing; and no evidence that the skin was indurated and inflexible. Although the examiner noted depigmentation over the central forehead, such depigmentation was measured as 17.5 square cm, well below the requirement of hypo- or hyperpigmented skin in an are exceeding 39 square cm necessary to be considered a characteristic of disfigurement. Additionally, there was no evidence of visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features.   
The Board acknowledges the Veteran's contentions that his forehead scars warrant a higher rating. However, the Board notes that scarring must meet the defined rating criteria to be compensated. As the Veteran's forehead scars display only one characteristic of disfigurement, with no evidence of visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features, a higher rating is not warranted. 
The Board notes that the evidence of record does not reflect that the Veteran's forehead scars are unstable or painful and the Veteran himself has denied pain associated with his forehead scars. See Hearing Transcript. Accordingly, the assignment of a separate rating under DC 7804 for the Veteran's forehead scars is not warranted. Diagnostic Codes 7801 and 7802 apply to scars that are not of the head, face, or neck and are thus inapplicable in this instance.
The Board finds that Diagnostic Code 7800 is the most appropriate Diagnostic Code because it specifically pertains to the service-connected disability in this case: scars of the face or head. The Board finds that no other diagnostic code would be more appropriate than Diagnostic Code 7800. The Board notes that neither the Veteran nor his representative has requested that another diagnostic code be used to evaluate his service-connected disability. Accordingly, the Board concludes that the Veteran is appropriately rated under DC 7800.
In summary, the Board finds that a rating in excess of 10 percent for a laceration scar of the forehead is not warranted at any point during the appeal period.
4. Laceration Scar of the Left Wrist
The Veteran is service connected for a laceration scar of the left wrist, currently evaluated as 10 percent disabling, under Diagnostic Code 7804. He contends that the current rating does not adequately reflect the severity of his disability.  
Diagnostic Code 7804 provides a 10 percent rating for one or two scars that are unstable or painful. A 20 percent evaluation is warranted for three or four scars that are unstable or painful. A 30 percent evaluation is warranted for five or more scars that are unstable or painful. 38 C.F.R. § 4.118, Diagnostic Code 7804 (2017). Note (1) states that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provides that if one or more scars are both unstable and painful, 10 percent will be added to the evaluation that is based on the total number of unstable or painful scars.
The Veteran was afforded a VA examination in February 2010. Physical findings showed a 4.0 x .05cm (2.0 square cm) scar on the radial-volar aspect of the left wrist with slight keloid and slight tethering. The scar appeared to be superficial, was non-tender, and did not appear to limit motion. There was no denervation of the skin or light touch of pain distal to this scar. The examiner noted that the scars, in themselves did not make a significant contribution to the Veteran’s disability and in and of themselves did not cause significant disability. See February 2010 VA Examination. 
The Veteran underwent a VA scars examination in October 2010. The examiner noted that there was no significant change in the elicited history. He noted that the Veteran had pain in the left wrist and left thumb, especially exaggerated during cold weather when he is required to wear gloves constantly for comfort. Physical examination showed a painful scar over the radial volar aspect of the left wrist measuring 3.0 x .02 cm (0.6 cm). The scar had some keloid but no tethering and was described as a deep scar. There was no identifiable sensory loss or loss of motion of the left thumb in relation to the scar, but there was a sensation of pain and radiation of pain into the thumb on palpation of the scar. The examiner rendered an impression of scars, as describe, with neuropathy in the left thumb with cold sensitivity. See October 2010 VA Examination. 
A VA scar examination was provided in December 2015. The examiner noted a painful scar on the left wrist which could hurt in cold weather if the Veteran was working outside. The Veteran reported wearing a glove to keep it warm. Upon physical examination, the examiner noted that the scars were not unstable, with frequent loss of covering of skin. The examiner noted scars on the left wrist and left thumb, measuring 4 cm and 1 cm, respectively. The scars did not result in limitation of function, or impact the Veteran’s ability to work. See December 2015 VA Scars Examination.
A February 2018 VA examination documented linear scars located on the left wrist and left thumb which measured 4.1 cm and 1.1 cm, respectively. The left wrist scar was painful when exposed to cold. The scars were stable, without frequent loss of covering of skin. The scars did not result in limitation of function, or impact the Veteran’s ability to work. See February 2018 VA Scars Examination.  
In lay statements and testimony before the undersigned VLJ, the Veteran has reported that his left wrist scar has always bothered him. He reported that the scar bothered him more in cold weather and caused him to experience stiffness and discomfort most of the time. He reported that in winter, the scar becomes painful and bothers his left thumb. The Veteran also indicated that he had trouble holding, grabbing, and grasping things due to pain in his thumb, when it is cold outside. He indicated sensations of weakness and numbness when this happens. See October 2010 NOD; August 2018 Hearing Transcript. 
The Board finds that that for the entire period of appeal, the record does not demonstrate the requisite manifestations for rating in excess of 10 percent for the left wrist scar under Diagnostic Code 7804. For a 20 percent rating, there must be three or four scars that are unstable or painful. 38 C.F.R. § 4.71a, Diagnostic Code 7804.

Based on the evidence of record the Board finds that the Veteran's left wrist laceration scar is appropriately rated as 10 percent disabling under Diagnostic Code 7804. The Veteran is not entitled to a higher rating under Diagnostic Code 7804 because while the Veteran does have more than one scar, none of the Veteran's scars is unstable and there is no indication from the Veteran or the record that he experiences pain from the other scars. The record fails to show that any of the Veteran's scars experience a loss of skin, and therefore they are not unstable. The Veteran's lay statements of pain to his left wrist scar are deemed credible, and are of significant weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Thus, the Veteran's complaints of pain to his left wrist scar throughout the appeal period warrants a 10 percent disability rating.
The Board has considered the applicability of other relevant diagnostic codes. Although Diagnostic Codes 7801 and 7802 apply to scars that are not of the head, face, or neck, the extent of the Veteran’s scarring does not involve a total area of involvement of even the 6 square inches (39 square cm) which would warrant a compensable rating under these diagnostic codes. Further, as described above, Diagnostic Code 7800 applies to scars of the head, face, and neck, and is thus inapplicable in this instance.
Thus, the Board finds that Diagnostic Code 7804 is the most appropriate Diagnostic Code because it specifically pertains to the service-connected disability in this case: unstable or painful scars. The Board finds that no other diagnostic code would be more appropriate than Diagnostic Code 7804. The Board notes that neither the Veteran nor his representative has requested that another diagnostic code be used to evaluate his service-connected disability. Accordingly, the Board concludes that the Veteran is appropriately rated under DC 7804.
In summary, the Board finds that a rating in excess of 10 percent for a laceration scar of the left wrist is not warranted at any point during the appeal period.
5. Post-traumatic headaches
The Veteran is service connected for post-traumatic headaches, currently evaluated as 30 percent disabling, under Diagnostic Code 8100. He contends that his post-traumatic headaches are more severe than reflected in his current disability rating.  

The Veteran’s post-traumatic headaches (formerly rated under Diagnostic Code 8045-9304) are rated under 38 C.F.R. § 4.124a, Diagnostic Code 8100 for migraines. Under diagnostic code 8100, a 30 percent rating is warranted for headaches with characteristic prostrating attacks occurring on an average once a month over the last several months. A 50 percent rating is warranted for headaches with very frequently completely prostrating and prolonged attacks productive of severe economic inadaptability. See 38 C.F.R. § 4.124a, Diagnostic Code 8100 (2017).
The term "prostrating attack" is not defined in regulation or case law. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999) (quoting Diagnostic Code 8100 verbatim but not specifically addressing the definition of a prostrating attack). However, prostration can be defined as "extreme exhaustion or powerlessness." Dorland's Illustrated Medical Dictionary 1531 (32nd ed. 2012).

As to the term "productive of economic inadaptability", such term could have either the meaning of "producing" or "capable of producing" economic inadaptability. Pierce v. Principi, 18 Vet. App. 440, 445 (2004).
A November 2009 VA neurology consult documents that the Veteran had migraines behind both eyes which lasted for hours to days with no nausea or vomiting. The Veteran reported photophobia and mild phonophobia which improved with time and laying down in a dark room. The Veteran initially experienced these headaches once per week but noted that they had become less frequent and now occurred every couple of months. The Veteran was referred to neurology because headaches had increased in frequency over the past year. The Veteran was prescribed propranolol for headache control, but reported fatigue from the medication. See November 2009 VA Neurology Consultation. 
A VA traumatic brain injury (TBI) examination was performed in February 2010. The Veteran reported that he had a history of headaches for more than 40 years, following an in-service motor vehicle accident. The Veteran indicated that headaches started approximately one to two months after the accident and have continued since that time. At the examination, the Veteran reported headaches that appeared on an average of twice per month, lasting from two hours up to two days. Headaches had an aura characterized by a feeling of pressure in the occipital region and throbbing. The Veteran reported that when the aura begins, he would avoid strong lights and stay in his bedroom with no lights and no sounds. He reported treating the headaches with Advil to decrease the length and intensity of headaches. See February 2010 VA TBI Examination. 
The Veteran reported that the frequency and intensity of his headaches had been stable for the past several years, but noted that the intensity was 9 on a 1-10 pain scale. Headaches were often accompanied by nausea. The Veteran also reported a history of episodic slurring of speech lasting for seconds or minutes. The examiner noted that an August 2004 CT scan of the brain was normal. A December 2009 MRI showed a single focus of susceptibility artifact in the posterior left frontal lobe, which the examiner indicated raised the possibility of a cavernoma or post-traumatic change. The examiner stated that the Veteran had a well-documented history and examination findings consistent with post-traumatic headaches. Id. 
April 2010 VA treatment records document that the Veteran was seen for a neurology consultation. It was noted that the Veteran had post-traumatic migraines that had increased in intensity over the past year. The doctor noted that headaches were not frequent enough to warrant prophylactic medication. The Veteran seemed to be able to control headaches with Advil and a dark, quiet room. It was noted that the increase in frequency was probably related to an increase in stress in the Veteran’s life. There was an additional indication that headaches had increased since the Veteran began taking propranolol. It was noted that he would be switched back to his original medication as he was not tolerating propranolol. Headaches typically lasted for one to two hours and on very rare occasions lasted for a day. It was noted that the Veteran might experience a bad headache with tearing approximately every other month. See April 2010 VA Neurology Consultation. 
The Veteran underwent a TBI examination in July 2010. The examiner did not offer an opinion as to whether the Veteran warranted a separate diagnosis of TBI in addition to post-traumatic headaches, so an addendum opinion was requested. In an August 2010 addendum, the examiner reported that the Veteran had post-traumatic headaches with no other evidence of sequelae of TBI. See August 2010 Addendum Opinion.  
The Veteran was afforded a VA examination in December 2015. The Veteran described headaches for as long as he could recall. Pain was located behind the eyes and at the back of the head. The Veteran reported headache frequency three to four times per month, lasting one to one and a half days. It was noted that the Veteran takes Advil for his headaches and will turn the lights out. Symptoms included pulsating or throbbing head pain on both sides of the head and sensitivity to light. Non-headache symptoms associated with headaches included a visual aura of fortification spectrum. Headaches 1-2 days, less than a day on both sides of the head. The examiner noted characteristic prostrating attacks of migraine/non-migraine headache pain, with a prostrating attack once in 2 months. The Veteran’s treatment plan included medications, including gabapentin. The Veteran did not have very prostrating and prolonged attacks of migraines/non-migraine pain productive of severe economic inadaptability, and the condition did not impact his ability to work. See December 2015 Headaches Disability Benefits Questionnaire. 
The Veteran also underwent an evaluation of residuals of traumatic brain injury (TBI) in December 2015. The examiner reported the Veteran’s history of TBI stemming from his 1963 motor vehicle accident in-service. In pertinent part, the examiner noted that the Veteran experienced subjective symptoms of headaches, including migraine headaches, which were attributable to TBI. Findings relevant to the headache condition were detailed in the VA examination described above. See December 2015 TBI Disability Benefits Questionnaire.   
The Veteran was afforded another VA exanimation in February 2018. The Veteran described headaches that were posterior and behind the eyes and occurred about once per week to once per month. It was noted that they were prostrating once per month. The Veteran reported dull pain with associated nausea, sensitivity to light and sound and occasional visual aura. It was noted that the Veteran took Advil to help the pain and that this would limit the headache to a day if taken early. The Veteran keeps Advil with him always but avoids prophylactic medications for headaches, although he tried gabapentin in the past. See February 2018 Headaches Disability Benefits Questionnaire. 
The examiner noted symptoms of pulsating or throbbing head pain; localized pain to one side of the head; nausea; sensitivity to light and sound; and changes to vision. Typical duration was from one to two days with pain located on both sides of the head. The examiner noted characteristic prostrating attacks which occurred once every moth. These attacks were not productive of severe economic inadaptability. Id.
An associated evaluation of TBI residuals was performed in February 2018. The examiner noted frequent headaches, associated with TBI, for which the Veteran had to alter his activities once per month. All other findings pertinent to the Veteran’s headache condition were detailed in the headaches DBQ described above. See February 2018 TBI Disability Benefits Questionnaire. 
In an August 2018 Board hearing, the Veteran testified that he had headaches consistently since service. He reported that he can tell every morning whether he’s going to have a good or a bad day. On bad days, he indicated that headache pain was bad and he would take Advil and go to a dark room. He indicated that on such occasions, he will spend his day in the room and cannot watch television as noise bothers him tremendously. He reported two to three “bad” days in a month and indicated that on occasion he will have up to two bad days in a row. See August 2018 Hearing Transcript. 
Based on the above, the Board finds that a rating in excess of 30 percent for post-traumatic headaches is not warranted. 

In this regard, the Board finds that the evidence does not show that the Veteran suffers from headaches with very frequent completely prostrating and prolonged attacks producing, or capable of producing, severe economic inadaptability as required for the next higher rating. The Board acknowledges that the Veteran reports experiencing severe headaches up to two to three times a month. The evidence of record indicates that the Veteran’s headaches have fluctuated in frequency and intensity throughout the appeal period. However, the evidence indicates that they have averaged 1-3 times per month, and although the Veteran has reported that he must remain in a dark, quiet room during severe headaches, he has not indicated that his headaches cause severe economic inadaptability. Further, both the December 2015 and February 2018 VA examiners clearly found that the Veteran did not have headaches with very frequently completely prostrating and prolonged attacks productive of severe economic inadaptability. The Board thus finds that the Veteran's symptoms do not more closely approximate the criteria contemplated in the next higher rating. As such, a higher rating is not warranted. 

The Board has also considered whether staged ratings are appropriate; however, the Board finds that his symptomatology has been stable throughout the appeal period. Therefore, assigning staged ratings for such disability is not warranted.  

The Board has carefully reviewed and considered the Veteran's lay statements regarding the severity of his service-connected post-traumatic headaches. However, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms.

Additionally, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (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).

In reaching these conclusions the Board has considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the claim, the doctrine is not for application. Gilbert, supra.
Entitlement to a rating in excess of 50 percent for PTSD
Service connection for post-traumatic stress disorder was granted in an August 2017 rating decision, at which time an initial rating of 50 percent was assigned, effective January 12, 2017. An April 2018 rating decision granted an earlier effective date of December 14, 2016. The Veteran contends that the initial rating assigned does not adequately reflect the severity of his psychiatric symptomatology.  
The Veteran's PTSD is evaluated under Diagnostic Code 9411, which is evaluated under the General Rating Formula For Mental Disorders. 38 C.F.R. § 4.130.

Under this formula, a 50 percent rating is assigned 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 in establishing and maintaining effective work and social relationships. Id.

A 70 percent evaluation is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical obscure, or irrelevant speech; 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. Id.
A 100 percent evaluation is warranted where there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. 

Consideration is given to the frequency, severity, and duration of psychiatric symptoms, the length of remission, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. See 38 C.F.R. § 4.126 (a). Furthermore, when evaluating the level of disability arising from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126 (b). It is necessary to evaluate a disability from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2 (2017).
The symptoms associated with the psychiatric rating criteria are not intended to constitute exhaustive lists, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436, 443 (2002). Thus, the Board will consider whether "the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, "and, if so, the "equivalent rating will be assigned." Id. In Vazquez-Claudio v. Shinseki, the Federal Circuit held that a Veteran may only qualify for a given disability rating "by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." 713 F.3d 112, 117 (Fed. Cir. 2013) ("Reading [38 C.F.R. §§ 4.126 and 4.130] together, it is evident that the 'frequency, severity, and duration' of a Veteran's symptoms must play an important role in determining his disability level.").
Factual Background and Analysis

The Veteran underwent an initial PTSD evaluation in August 2017. Diagnoses of PTSD and traumatic brain injury (TBI) were rendered. The examiner noted that it was possible to differentiate which symptoms were attributable to each diagnosis. In this regard, the examiner noted that migraine headaches, amnesia, and memory problems were attributable to the TBI condition. Intrusive reexperiencing, avoidance, negative cognitions, and hyperarousal were attributed to the PTSD. See August 2017 Initial PTSD Disability Benefits Questionnaire. 
The examiner found that the Veteran demonstrated occupational 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 stated that it was possible to differentiate what portion of the occupational and social impairment was caused by the Veteran’s TBI. In this regard, she noted that the majority of impairment was attributed to the Veteran’s PTSD. Id. 
The Veteran had symptoms of depressed mood; anxiety; chronic sleep impairment; mild memory loss, such as forgetting names, directions, or recent events; impairment of short- and long-term memory, for example, retention of only highly learned material, while forgetting to complete tasks. Id.
The Veteran arrived on time and unaccompanied for his examination. He was alert and oriented to person place and time. The Veteran’s thinking was logical and goal-oriented and his speech was fluent and of normal rate and volume. Auditory comprehension was within normal limits. The Veteran presented as casually dressed, neatly groomed, pleasant, and cooperative. His mood was anxious, and affect was constricted in range. He exhibited no signs of hallucinations or delusions and denied homicidal or suicidal ideation. The examiner noted that the Veteran was capable of managing his financial affairs. Id.  
A PTSD evaluation was performed in February 2018. The examiner noted the diagnosed PTSD and TBI conditions and indicated that all the noted symptoms and impairment in her report were attributable to PTSD. In this regard she noted that neuropsychiatric sequelae of a mild TBI are unlikely to persist beyond several months post injury. The examiner noted that the Veteran has had a variety of neuropsychological and neurological exams that had all concluded that the Veteran’s memory function was within normal limits. His memory complaints have been attributed to PTSD and mood symptoms rather than an underlying neurologic condition such as TBI or Alzheimer’s disease. See February 2018 Review PTSD Disability Benefits Questionnaire. 

The examiner found that the Veteran demonstrated occupational 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. Id.
The examiner noted that the Veteran indicated healthy relationships with his spouse and adult children. He reported that he could complete his regular household chores and was able to complete self-care (e.g. dressing, showering) independently and regularly. He described enjoying watching tv and occasionally reading a book in his free time. The Veteran indicated that his mental health remained about the same as it had been during his previous examination in August 2017. Id. 
The Veteran had symptoms of depressed mood; anxiety; panic attacks that occurred weekly or less often; chronic sleep impairment; disturbances of motivation and mood; and difficulty in adapting to stressful circumstances, including work or a worklike setting. Id.
The Veteran reported early to his scheduled appointment on time, well groomed, and dressed casually. His behaviour was calm and pleasant with good eye contact. Speech was at a normal rate, rhythm, and volume. The Veteran displayed linear and organized thought processes with no flight of ideas, obsessions, or preoccupations. He denied suicidal or homicidal ideation as well as auditory and visual hallucinations. The Veteran’s mood was stable and euthymic with affect congruent to mood and content of speech. His insight and judgment were intact. Id. 
In her remarks, the examiner noted that the Veteran reported ongoing symptoms of PTSD including re-experiencing, avoidance, negative alterations in mood and cognition, and arousal symptoms. The Veteran indicated that since the previous examination, his wife had noted increased depression and that he had been less interested in engaging in activities that he enjoys. The Veteran reported he became anxious particularly when driving and experienced panic attacks. He endorsed poor sleep and distressing dreams as well. The examiner stated that the Veteran’s mental health symptomatology resulted in moderate functional impairment in areas such as ability to concentrate, cope with stress, and maintain stable mood/motivation. The Veteran’s symptoms were not likely to impact his ability to function in an employment setting given that he was able to maintain work for many years without any notable difficulties until his retirement in 2011. The Veteran had not worked since he retired but engaged in household activities as well as socially. The examiner concluded by stating that the Veteran’s current level of disability appeared to be consistent relative to what was noted in his prior C&P examination in 2017. Id.  
At his August 2018 Board hearing, the Veteran testified that he will not drive with another person and always hears the sound of crushing metal when he gets into his vehicle as a result of his PTSD. He further reported that he cannot drive with the radio on or other distractions. The Veteran described symptoms of paranoia and memory loss. In regard to memory loss, he described instances of long-term and short-term memory issues. The Veteran stated that he could not concentrate, and noted that he struggled to stay with a movie or a book he was reading. He indicated that he gets frustrated easily and experienced anxiety attacks. See August 2018 Hearing Transcript.    
Having carefully considered the Veteran's contentions in light of the evidence of record and the applicable law, the Board finds that the Veteran's PTSD is appropriately rated as 50 percent disabling for the entirety of the appeal period. 
As outlined above, the evidence shows that the Veteran's PTSD has resulted in occupational and social impairment with reduced reliability and productivity due to symptoms. In that regard, the evidence shows that during appeal period, the constellation of symptoms associated with the Veteran's disability were broad and included: depressed mood; disturbances of motivation and mood; anxiety; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; impairment of short and long-term memory; retention of only highly learned material, while forgetting to complete tasks; panic attacks less than weekly; difficulty in adapting to stressful circumstances (including work or a worklike setting); and 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). 
However, the Veteran has not exhibited symptoms indicating occupational and social impairment with deficiencies in most areas. Instead, the evidence consistently shows that the Veteran's symptoms are not manifested by suicidal ideation, obsessional rituals, intermittently illogical speech, near-continuous panic or depression affecting the ability to function independently, or neglect of personal appearance. Indeed, the Veteran was consistently found to be oriented in all spheres and to have no evidence of impairment of thought. He did not report suicidal ideation. He was appropriately dressed and groomed and did not report near-continuous panic or depression. The Board realizes that the symptoms noted in the rating criteria are not intended to be an exhaustive list, but are examples of the types and severity of symptoms that indicate a certain level of disability. 

In reaching this conclusion, the Board has considered the Veteran's and his wife's statements regarding the severity of his psychiatric disorder. They are competent to report the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1154 (a); 38 C.F.R. § 3.159 (a)(2); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). However, in weighing this evidence against the other relevant evidence of record (to include the aforementioned VA examination reports), the Board finds that the effects of the Veteran's symptoms were not described to be of a type, frequency, and severity that are in accord with the level of impairment contemplated by the criteria for a 70 percent schedular rating. 

The Board concludes that the symptomatology noted in the medical and lay evidence has been adequately addressed by the evaluations assigned and do not more nearly approximate the criteria for higher evaluations at any time during all relevant periods on appeal. See 38 C.F.R. § 4.130, Diagnostic Code 9411; see also Fenderson, supra. 

In reaching the conclusions above, the Board has considered the applicability of the benefit of the doubt doctrine. See 38 U.S.C. § 5107 (b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990).
REASONS FOR REMAND
Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. 38 U.S.C. § 5103A (West 2012); 38 C.F.R. § 3.159 (2017).
1. Hypertension, as secondary to PTSD
The Veteran has claimed entitlement to service connection for hypertension as secondary to his service-connected PTSD. It is the Veteran's contention that his PTSD caused or aggravated his hypertension. 
The Veteran was afforded a VA examination in August 2017 to determine whether his hypertension was proximately due to or the result of his service-connected PTSD. The August 2017 VA examiner opined that the Veteran's hypertension was less likely than not (less than 50 percent probability) proximately due to or the result of his service connected condition. The examiner noted that at the Veteran’s enlistment examination in January 1962, his blood pressure was recorded as 120/80. At his separation examination in December 1964, his blood pressure was recorded as 110/78. The examiner stated that he found no other blood pressure readings in the service treatment records. Thus, he opined, that it could be confidently inferred that the Veteran did not manifest hypertension during service. See August 2017 VA Disability Benefits Questionnaire and Medical Opinion.
The examiner reported that he could not find clear evidence in the VA clinical records or in records of outside care that indicated the onset of hypertension. He noted that the Veteran’s BP had been normal on VA office visits from 2005 to the present, with the Veteran being treated with lisinopril and atenolol. He stated that it was reasonable to infer that the Veteran’s PTSD and hypertension had both been active problems for quite some time. The examiner noted that almost any emotional disorder can be associated with anxiety and in turn, the anxiety can cause an elevated blood pressure. However, the examiner stated that hypertension is so common at the Veteran’s age, that the association was most likely coincidental rather than causal. He noted that this was especially true in the absence of any evidence in available records that supported a causal relationship. The examiner stated that in his opinion, it was less likely than not that the Veteran’s hypertension is caused by PTSD. Id.
The Board finds that the August 2017 VA opinion is inadequate to the extent that the examiner did not specifically address whether the Veteran's hypertension was aggravated by his service-connected PTSD. An opinion that something "is not caused by or a result of" does not answer the question of aggravation. See El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013) (noting that an inquiry request requiring that the examiner state his conclusion using one of the listed legally recognized phrases that included "is caused by or a result of" did not permit the examiner to opine on any question other than one of direct causation). In the instant case, the Board notes that the examination request directed the VA examiner to provide an opinion as to whether the Veteran’s hypertension was proximately due to or the result of PTSD. The examiner was not asked to provide an opinion as to aggravation. Although the examiner has provided a clear basis for his opinion that the Veteran’s hypertension did not manifest in service and was not due to or the result of his PTSD, the Board finds that an addendum opinion is necessary to address whether the Veteran’s hypertension is aggravated by his service-connected PTSD. 
Accordingly, the matter is REMANDED for the following action:
1. Return the claims file to the VA examiner who conducted the August 2017 VA examination for an addendum opinion regarding the Veteran’s hypertension. If that examiner is no longer available, forward the claims file to an examiner of like experience and training to proffer an addendum opinion. The need for an examination is left to the discretion of the medical professional offering the addendum opinion. 
The claims file and a copy of this remand must be made available to the reviewing examiner, and the examiner should indicate in the addendum report that the claims file was reviewed.

The examiner is requested to provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's hypertension was AGGRAVATED (i.e., permanently worsened beyond the natural progress of the disorder) by his service-connected PTSD. If aggravation is shown, the examiner should quantify the degree of aggravation, if possible.

All opinions should be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an opinion cannot be offered without resort to mere speculation, the examiner should fully discuss why this is the case.
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2. Thereafter, readjudicate the claim on appeal. If the claim remains denied, provide the Veteran and his representative with a supplemental statement of the case, and after they have had an adequate opportunity to respond, return the appeal to the Board for further appellate review, if otherwise in order.
 
DEBORAH W. SINGLETON
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	B. Lewis