Citation Nr: 18158234 Decision Date: 12/14/18 Archive Date: 12/14/18 DOCKET NO. 15-33 965 DATE: December 14, 2018 ORDER Service connection for anxiety disorder is granted. For the initial rating period from April 1, 2015, forward, a disability rating in excess of 60 for mitral valve prolapse, status post mitral valve replacement with pericarditis (mitral valve prolapse) is denied. For the initial rating period from January 12, 2015, forward, a disability rating of 30 percent, but no higher, for headaches is granted. For the initial rating period from October 1, 2013, forward, a disability rating of 10 percent, but no higher, for a gastrointestinal disorder, to include status post appendectomy (gastrointestinal disorder), is granted. A 10 percent rating based upon multiple noncompensable service-connected disabilities is denied. REMANDED Service connection for a traumatic brain injury (TBI) is remanded. For the initial rating period from April 4, 2014, a disability rating in excess of 0 percent for scars status post appendectomy is remanded. An earlier effective date than January 12, 2015 for service connection for mitral valve prolapse is remanded. A total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran has a current diagnosis of anxiety disorder; the anxiety disorder is etiologically related to service, to include deployment during service. 2. For the entire initial rating period from April 1, 2015, mitral valve prolapse did not manifest as hospital admission for valve replacement; chronic congestive heart failure; a workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope; or, left ventricular dysfunction with an ejection fraction of less than 30 percent. 3. For the entire initial rating period from January 12, 2015, the service-connected headaches has more nearly approximated prostrating attacks averaging once a month over the last several months. 4. For the entire initial rating period from October 1, 2013, the gastrointestinal disorder has more nearly approximated moderate symptoms of bowel disturbance with abdominal distress. 5. At no time during the pendency of the appeal has the Veteran had multiple noncompensable service-connected disabilities in combination with no other service-connected disabilities that have a compensable disability rating. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran’s favor, the criteria for service connection for anxiety disorder have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. 2. For the entire initial rating period from April 1, 2015, an initial disability rating in excess of 60 for mitral valve prolapse have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.3, 4.7, 4.104, Diagnostic Code 7016. 3. For the entire initial rating period from January 12, 2015, the criteria for a disability rating of 30 percent, but no higher, for headaches have been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.321, 4.3, 4.7, 4.124a, Diagnostic Code 8100. 4. For the entire initial rating period from October 1, 2013, the criteria for a 10 percent rating, but no higher, for gastrointestinal disorder have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.114, Diagnostic Code 7399-7319. 5. The criteria for a 10 percent rating based on multiple noncompensable service-connected disabilities have not been met as a matter of law. 38 U.S.C. § 1155; 38 C.F.R. § 3.324. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the Appellant, served on active duty from May 2008 to February 2009, January 2011 to January 2012, and April 2013 to September 2013. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2014 rating decision from the Regional Office (RO), which, in pertinent part, granted service connection for a gastrointestinal disorder, assigning a 0 percent initial disability rating effective October 1, 2013; granted service connection for three scars status post appendectomy, assigning a 0 percent initial disability rating effective April 4, 2014; denied service connection for an anxiety disorder; and denied a 10 percent disability rating based on multiple noncompensable service-connected disabilities under 38 C.F.R. § 3.324. This matter also comes on appeal from an August 2015 rating decision that granted service connection for mitral valve prolapse, assigning staged initial ratings of 100 percent (effective January 12, 2015) and a 60 percent (effective April 1, 2015); granted service connection for headaches, assigning a 0 percent initial rating (effective January 12, 2015), and denied service connection for a traumatic brain injury. Because a 100 percent rating is assigned for mitral valve prolapse from January 12, 2015 (date of claim) to April 1, 2015, the relevant rating period for mitral valve prolapse is from April 1, 2015, the date a 60 percent initial rating is assigned, to present. June 2018 and October 2018 rating decisions granted staged initial disability ratings of 10 percent (effective March 9, 2018) and 30 percent (effective June 27, 2018) for the service-connected headaches. As the Veteran has not expressed satisfaction with the assigned ratings, his claim remains before the Board. See AB v. Brown, 6 Vet. App. 35, 38 (1993). During the pendency of the appeal for a higher initial disability rating for a gastrointestinal disorder, the Veteran submitted a claim for TDIU that attached to the claim for a higher initial disability rating for a gastrointestinal disorder for the rating period from October 1, 2013. August 2018 TDIU Claim (VA Form 21-8940). See Rice v. Shinseki, 22 Vet. App. 447, 453-4 (2009). As such, the TDIU rating period on appeal is from October 1, 2013, the effective date for the service-connected gastrointestinal disorder. As to the issue of service connection for an anxiety disorder, the Board finds that the duties to notify and assist the appellant have been rendered moot by the grant of service connection for an anxiety disorder, which is a full grant of the benefits sought on appeal. Additional VA treatment records and VA examination reports, have been received by the Board, for which the Veteran has requested a remand for RO consideration of the additional evidence. See October 2018 Correspondence. The RO considered additional evidence regarding the appeals for increase rating for a gastrointestinal disorder, mitral valve prolapse, headaches, and TDIU, as evidenced by readjudication of these issues in the October 2018 rating decision. Moreover, the additional records do not reflect evidence that is relevant and pertinent to the issue of a 10 percent rating based on multiple noncompensable service-connected disabilities under 38 C.F.R. § 3.324. As such, a remand is not warranted for RO consideration of the additional evidence regarding the appeals for a gastrointestinal disorder, mitral valve prolapse, headaches, TDIU, and a 10 rating under 38 C.F.R. § 3.324. 38 U.S.C. § 7105(e); 38 C.F.R. § 20.1304. With regard to the appeals for increase rating for headaches, mitral valve prolapse, and a gastrointestinal disorder, the Board finds that the duties to notify and assist the appellant in this case have been fulfilled. Neither the appellant nor the evidence has raised any specific contentions regarding the duties to notify or assist. The Board need not address the duties to notify and assist the Veteran regarding the appeals for service connection for a traumatic brain injury, increase rating for scars status post appendectomy, an earlier effective date for mitral valve prolapse, a and TDIU, as these issues are being remanded for further development. 1. Service Connection for Anxiety Disorder The Veteran generally contends that service connection is warranted for an anxiety disorder, as he was anxious and depressed post-deployment. See June 2015 Notice of Disagreement (NOD). Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Generally, service connection for a disability requires evidence of: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated by service. Initially, the Board finds that the Veteran has a current diagnosis of anxiety disorder, as reflected in the July 2014, August 2016, and July 2018 VA examination reports. After reviewing all the medical and lay evidence, the Board finds that the evidence is at least in equipoise on the question of whether the current anxiety disorder is causally or etiologically related to service. The May 2007 service entrance examination reflects that psychiatric evaluation was normal; the Veteran denied any history of anxiety, nervousness, panic attacks, depression, and poor sleep; and no mental health disorders were noted by the military physician at service induction. The April 2012 post-deployment health assessment reflects that the Veteran endorsed emotional problems that made it difficult to work and get along with others since returning from deployment in Bosnia. See May 2007, April 2012 service treatment records. Anxiety disorder, not otherwise specified (NOS) and depressive disorder, NOS were first diagnosed in July 2012. See July 2012 VA treatment record. Post-service records reflect continued treatment for anxiety disorder since service separation. See January 2014, June 2014, May 2015, September 2017 VA treatment records. The VA examiner in July 2018 opined that the anxiety disorder was less than likely related to service because it clearly and unmistakably pre-existed service. See July 2018 VA examination report. The Board gives this opinion no probative weight, as the no psychiatric disorder was noted at service entrance, therefore, the Veteran is presumed sound with no pre-existing anxiety disorder at service entrance. 38 U.S.C. §§ 1111, 1153; 38 C.F.R § 3.306. Moreover, the VA examiner in July 2014 assessed that the anxiety disorder worsened due to deployment. The August 2016 VA examiner also opined that the anxiety disorder was likely related to service, reasoning that the Veteran was deemed fit to serve at service entrance, service treatment record document a reduction in capability during service and ongoing mental health treatment post service, and clinical interview indicates that the anxiety disorder is due to service. For these reasons, and resolving reasonable doubt in the Veteran’s favor, the Board finds that the criteria for service connection for anxiety disorder have been met. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. Where there is a question as to which of two disability ratings shall 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. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. The Veteran has appealed from the initial ratings assigned for mitral valve prolapse, headaches, and gastrointestinal disorder. In an appeal for a higher initial rating after a grant of service connection, all evidence submitted in support of a veteran’s claim is to be considered. Separate ratings may be assigned for separate periods of time based on the facts found, a practice known as “staged” ratings. 38 C.F.R. § 4.2; Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). The Board does not find staged ratings to be warranted in this appeal. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the rating of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran’s service-connected disabilities. 38 C.F.R. § 4.14. It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits compensating a veteran twice for the same symptoms or functional impairment). 2. Rating Mitral Valve Prolapse from April 1, 2015. A 60 percent initial disability rating is assigned for mitral valve prolapse for the entire initial rating period from April 1, 2015, pursuant to Diagnostic Code 7016. 38 C.F.R. § 4.104. The Veteran generally, contends that a 100 percent disability rating should be assigned for an indefinite period following hospital admission for valve replacement. See November 2015 NOD. The service-connected mitral valve prolapse is rated pursuant to Diagnostic Code 7016. 38 C.F.R. § 4.104. Under Diagnostic Code 7016, a 60 percent rating is warranted for more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is warranted for chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. Id. A 100 percent rating is also warranted for indefinite period following date of hospital admission for valve replacement. A rating of 100 percent shall be assigned as of the date of hospital admission for valve replacement, six months following discharge the appropriate rating shall be determined by mandatory VA examination. 38 C.F.R. § 4.104, Diagnostic Code 7016, Note. After reviewing all the evidence, lay and medical, the Board finds that from April 1, 2015 the service-connected mitral valve prolapse has not met or more nearly approximated the criteria for a higher 100 percent rating, that is, chronic congestive heart failure, or; a workload of three METs or less that results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent, or; hospital admission for valve replacement. VA treatment records reflect that an undetected heart murmur was diagnosed in July 2014, and a follow up echocardiogram revealed mitral valve myxomatous degeneration and prolapse with severe mitral regurgitation and an ejection fraction of 60 to 65 percent. The Veteran was admitted for mitral valve replacement on September 4, 2014 and subsequently discharged September 11, 2014. See July 2014, August 2014, September 2014 VA treatment records. The evidence of record does not reflect any additional hospital admissions for valve replacement since discharge in September 2014; therefore, the criteria for a 100 percent rating based on hospital admission for valve replacement have not been met or more nearly approximated for the rating period from April 1, 2015, six months following discharge. Additionally, while private and VA treatment records post discharge reflect post-operation complaints of persistent symptoms intermittent of palpitations, chest pain, fatigability and dyspnea, an October 2015 echocardiogram revealed and ejection fraction of 55 percent without evidence of cardiac hypertrophy or dilatation. Moreover, mitral valve prolapse has been managed with chronic anticoagulation therapy with Warfarin since 2015 without evidence of any episodes of congestive heart failure. See April 2015, October 2015, November 2015 private treatment records; VA May 2015, October 2017, October 2018 VA treatment records. VA examinations were provided in April 2015, August 2016, and August 2018. The VA examinations reflect continued treatment of mitral valve prolapse with medications such as Warfarin, Metoprolol, and Colchicine. Echocardiograms showed an ejection fraction of 50 to 55 percent without evidence of congestive heart failure or cardiac hypertrophy or dilatation. The April 2015 and August 2016 VA examiners assessed that mitral valve prolapse manifested as a workload of greater than five but less than seven METs with dyspnea and fatigue. The August 2018 VA examiner assessed an overall workload of greater than three but less than five METs, but assessed that the mitral valve prolapse alone only resulted in a workload of greater than seven but less than 10 METs, noting that the additional decrease in METs is due to deconditioning. See April 2015, August 2016, and August 2018 VA examination reports. Overall, the evidence of record for the initial rating period April 1, 2015 to present does not reflect that mitral valve prolapse has more nearly approximated chronic congestive heart failure, a workload of three METs or less, an ejection fraction of less than 30 percent, or additional hospital admission for valve replacement since April 1, 2015. As the preponderance of the evidence is against the appeal for an initial disability rating in excess of 60 percent for mitral valve prolapse from April 1, 2015 to present, the appeal for a higher initial rating must be denied. 38 C.F.R. §§ 4.3, 4.7, 4.104, Diagnostic Code 7016. 3. Rating Headaches from January 12, 2015. The service-connected headaches are assigned a 0 percent rating from January 12, 2015 to March 9, 2018, a 10 percent rating from March 9, 2018 to June 27, 2018, and a 30 percent rating from June 27, 2018 pursuant to Diagnostic Code 8100. 38 C.F.R. § 4.124a. Migraine headaches are rated under 38 C.F.R. § 4.124a, Diagnostic Code 8100, which provides a 0 percent rating with evidence of less frequent attacks. A 10 percent rating is warranted for prostrating attacks averaging one in two months over the last several months. A 30 percent rating is warranted for migraine headaches with characteristic prostrating attacks occurring on an average once a month over the last several months. A 50 percent rating is warranted for migraine headaches with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. Although prostrating attacks are not defined in the rating criteria, medical guidance used by the VA Compensation Service indicates that such an attack causes one a lack of strength to the point of exhaustion. See VA Compensation Service’s Medical Electronic Performance Support System. The Board has considered whether higher or separate ratings are warranted under the other Diagnostic Codes used to rate headaches, but finds that none apply. Therefore, higher or separate ratings under other Diagnostic Codes are not warranted. See 38 C.F.R. § 4.124a, Diagnostic Codes 8103-8108. After reviewing all the lay and medical evidence, the Board finds that for the entire initial rating period from January 12, 2015 to present, the service-connected headaches have more nearly approximated the criteria for a higher 30 percent rating, that is, prostrating attacks occurring on average once a month over the last several months. The evidence of record reflects that the Veteran reported almost daily headaches over a three-month period between November 2015 and January 2016, which he described as sharp and dull achy pain that sometimes caused nausea, lightheadedness, and dizziness. The headaches ranged from mild to severe, lasted as little as a couple hours to a couple days, and were treated with over the counter Tylenol. The Veteran reported missing six days of work between December 2015 and January 2016 due to headaches. However, the Veteran reported improvement in headaches in February 2017, indicating that headaches had decreased from occurring daily to occurring weekly. See January 2016 Correspondence; see also February 2016, February 2017, May 2017 VA treatment records; April 2015 private treatment record. VA examinations were provided in April 2015, August 2016, and May 2018. In April 2015, the Veteran endorsed constant head pain bilaterally of a typical duration of less than a day, but the VA examiner assessed no evidence of prostrating attacks. In August 2016, the Veteran endorsed sharp pain in both temples occurring every two to three days with light sensitivity that could last for up to one day and sometimes interfered with concentration at work, but no prostrating attacks were evidenced. In May 2018, the VA examiner assessed prostrating attacks occurring once in two months, but did not assess evidence of very prostrating and prolonged attacks productive of severe economic inadaptability. See April 2015, August 2016, and May 2018 VA examination reports. Given lay evidence of headaches that are mild to severe, can last anywhere from a few hours to a couple days, that were severe enough to require taking leave from work six times over the course of a three-month period, the Board has resolved reasonable doubt in the Veteran’s favor in finding that the service-connected headaches more nearly approximated prostrating attacks averaging once a month for the entire initial rating period from January 12, 2015, as required for a higher 30 percent rating. 38 C.F.R. §§ 4.3, 4.7, 4.124a, Diagnostic Code 8100 The headaches have not more nearly approximated prostrating and prolonged attacks productive of severe economic inadaptability since January 12, 2015, as required for a higher 50 percent rating. While the evidence reflects that the Veteran has reported that headaches sometimes interfere with concentration at work and that he has missed some days of work due to the service-connected headaches, the Veteran also reported the ability to work through headaches while at work. See January 2016 Correspondence, August 2016 VA examination report; May 2017 VA treatment record. The Veteran reported working full time as a database administrator and endorsed the ability to meet expectations at work “fairly well.” See September 2017 and January 2018 VA treatment records. Moreover, the Veteran reported improvement in headaches in February 2017 and reported that he recently resigned from his job in July 2018 due to feeling “pressure” and overwhelmed, not due to the service-connected headaches. See February 2017, August 2018 VA treatment records. As such, the evidence does not reflect that headaches have more nearly approximated severe economic inadaptability, as required for a higher 50 percent (the maximum) rating from January 12, 2015. As the preponderance of the evidence is against the appeal for an initial disability rating in excess of 30 percent for headaches for the initial rating period from January 12, 2015 to present, the appeal for a higher initial rating must be denied. 38 C.F.R. §§ 4.3, 4.7, 4.124a, Diagnostic Code 8100. 4. Rating Gastrointestinal Disorder from October 1, 2013. The service-connected gastrointestinal disorder, to include status post appendectomy, is assigned a 0 percent initial disability rating for the entire rating period from October 1, 2013 pursuant to Diagnostic Code 7399-7319, indicating the condition has been rated by analogy to Diagnostic Code 7319. 38 C.F.R. §§ 4.20, 4.114. The Veteran contends a 10 percent rating is warranted for the gastrointestinal disorder due to intermittent symptoms of sharp, stabbing lower abdominal pain. See June 2015 NOD. Diagnostic Code 7319 provides ratings for irritable colon syndrome (spastic colitis, mucous colitis, etc.). Mild irritable colon syndrome, with disturbances of bowel function with occasional episodes of abdominal distress, is rated noncompensable (0 percent) disabling. Moderate irritable colon syndrome, with frequent episodes of bowel disturbance with abdominal distress, is rated 10 percent disabling. Severe irritable colon syndrome, with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress, is rated 30 percent disabling. 38 C.F.R. § 4.114. With regard to coexisting abdominal conditions, VA regulation recognizes that there are diseases of the digestive system, particularly within the abdomen, which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia and disturbances in nutrition. 38 C.F.R. § 4.113. Consequently, certain coexisting diseases in this area do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in § 4.14. Id. Rather, a single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. The Board also notes that, with regard to the schedule of ratings for the digestive system, section 4.114 expressly prohibits, in pertinent part, the combination of ratings under Diagnostic Codes 7301 to 7329, inclusive, which include the schedular criteria for irritable colon syndrome (Diagnostic Code 7319). After reviewing all the evidence, lay and medical, and resolving reasonable doubt in the Veteran’s favor, the Board finds that for the entire initial rating period from October 1, 2013 to present, the gastrointestinal disorder more nearly approximated the criteria for a 10 percent rating, that is, moderate symptoms with episodes of bowel disturbance and abdominal distress. The March 2014 service treatment records reflect complaints of sharp, crampy lower abdominal pain, constipation, nausea, and vomiting. Objective findings of diffuses tenderness and pain with palpitation were noted on examination; however, an abdominal CT, x-ray, and colonoscopy were unremarkable with no evidence of inflammation or bowel obstruction. The Veteran underwent an appendectomy in April 2014, but no pathology was noted. The Veteran endorsed continued abdominal pain post-surgery with bowels alternating between constipation and diarrhea. See March 2014, April 2014 service treatment records, July 2014 VA treatment record. VA examinations were provided in July 2014 and April 2015. In July 2014, the VA examiner assessed symptoms of intermittent sharp abdominal pain and constipation. In April 2015, the Veteran reported resolution of abdominal pain after undergoing mitral valve replacement. See July 2014 and April 2015 VA examination reports. Treatment records dated 2015 to 2017 generally reflect no complaints or treatment of gastrointestinal symptoms including abdominal pain or tenderness, nausea, vomiting, or diarrhea; however, a recurrence of mild diarrhea was reported in March 2018. See November 2015 private treatment record, March 2018 VA treatment record. Given the history of complaints of intermittent sharp abdominal pain with constipation and diarrhea that initially did not resolve following appendectomy, the Board has resolved reasonable doubt in the Veteran’s favor in finding that the service-connected gastrointestinal disorder more nearly approximated a higher 10 percent rating due to moderate symptoms with bowel disturbance and abdominal distress for the entire initial rating period October 1, 2013. A higher 30 percent rating (the maximum), is not warranted for the gastrointestinal disorder, as the gastrointestinal disorder has not approximated severe irritable colon syndrome with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress since October 1, 2013. The evidence shows that the Veteran generally endorsed resolution of gastrointestinal complaints, including abdominal pain and diarrhea in 2015, following heart surgery. The has endorsed no more than intermittent symptoms during the course of the appeal, and no more than mild diarrhea in 2018. See June 2015 NOD; April 2015 VA examination report, November 2015 private treatment record, March 2018 VA treatment record. As the preponderance of the evidence is against the appeal for an initial disability rating in excess of 10 percent for the gastrointestinal disorder for the entire initial rating period from January 12, 2015 to present, the appeal for a higher initial rating must be denied. 38 C.F.R. §§ 4.3, 4.7, 4.124a, Diagnostic Code 8100. Extraschedular Referral Consideration The Board has considered whether the Veteran or the record has raised the question of referral for an extraschedular rating adjudication under 38 C.F.R. § 3.321(b) for any period for the initial rating issue on appeal. See Thun v. Peake, 22 Vet. App. 111 (2008). After review of the lay and medical evidence of record, the Board finds that the question of an extraschedular rating has not been made by the Veteran or raised by the record as to the issue on appeal. 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); Yancy v. McDonald, 27 Vet. App. 484, 494 (2016), citing Dingess v. Nicholson, 19 Vet. App. 473, 499 (2006), aff’d, 226 Fed. Appx. 1004 (Fed. Cir. 2007) (holding that when 38 C.F.R. § 3.321(b)(1) is not “specifically sought by the claimant nor reasonably raised by the facts found by the Board, the Board is not required to discuss whether referral is warranted”). 5. 10 Percent Rating under 38 C.F.R. § 3.324 A veteran with two or more separate, permanent, service-connected disabilities of such character as clearly to interfere with normal employability, even though none of the disabilities may be of compensable degree under the Rating Schedule, shall be awarded a 10 percent rating, but not in combination with any other rating. 38 C.F.R. § 3.324. Pursuant to this Board decision, compensable ratings disability ratings have been assigned for service-connected disabilities, with effective dates from the date of October 1, 2013, the date after separation from service. Accordingly, as there will be at least a 10 percent (compensable) rating in effect from October 1, 2013, the provisions of 38 C.F.R. § 3.324 cannot be met as a matter of law. Sabonis v. Brown, 6 Vet. App. 426 (1994). Accordingly, a 10 percent rating under 38 C.F.R. § 3.324 is denied. REASONS FOR REMAND 1. RO consideration of additional evidenced. The record reflects that additional VA treatment records and VA examination reports have been received by the Board, for which the Veteran has requested a remand for RO consideration of the additional evidence. See October 2018 Correspondence. RO consideration of the additional evidence with regard to the appeals for increase rating for mitral valve prolapse, headaches, gastrointestinal disorder, and TDIU is evidenced by readjudication of the issues in the October 2018 rating decision; however, the record does not indicate that the RO has considered the additional evidence and readjudicated the appeals for service connection for traumatic brain injury or increase rating for scars status post appendectomy. As such a remand, is warranted for the RO to consider additional evidence and readjudicate service connection for traumatic brain injury and increase rating for scars status post appendectomy. 2. Service Connection for TBI is remanded. The Veteran contends that service connection for TBI is warranted due to trauma during service. Specifically, the Veteran contends that he sustained a severe head injury due to a motor vehicle accident (MVA) during service, that has caused trouble focusing, memory problems, and headaches since service. See January 2015 Claim, January 2016 lay statements. The VA examiner in April 2015 opined that it was less than likely that the Veteran sustained a mild TBI during service, reasoning that there was no evidence of loss of consciousness at the time of impact or post traumatic amnesia. See April 2015 VA examination report. VA examination reports in August 2016 and July 2018 also reflect that TBI is not shown in the record. See August 2016 and July 2018 VA examination reports. However, the service treatment records reflect that brief loss of consciousness was noted following the May 2009 motor vehicle accident, and the Veteran was seen for observation and diagnosed with concussion with post-concussive symptoms following the MVA. Additionally, a February 2016 TBI screening reflects an assessment of mild TBI/concussion, and a June 2018 treatment reflects that concussion with less than one hour of loss of consciousness is an active problem. See February 2016, June 2018 VA treatment records. Therefore, a new VA examination and medical opinion is warranted clarify whether the Veteran has a current TBI or and residuals disorders of a TBI, to include post-concussive syndrome, and if so, whether any current TBI or residuals of TBI are causally or etiologically related to service. 3. TDIU is remanded. During the pendency of the appeals for an increased disability rating for scars status post appendectomy, among other service-connected disorders, the Veteran submitted a claim for TDIU that attached to the claim for an increased disability rating for gastrointestinal disorder from October 1, 2013. August 2018 TDIU Claim (VA Form 21-8940). See Rice v. Shinseki, 22 Vet. App. 447, 453-4 (2009). Additionally, as the Board has granted service connection for anxiety disorder, the rating assigned for an acquired psychiatric disorder, to include major depressive disorder and the now service-connected anxiety disorder, may be relevant to the question of whether the combined rating criteria for TDIU are met for the entire rating period on appeal from October 1, 2013. Appellate review of the issue of TDIU must be deferred because the above-mentioned service connection issues are inextricably intertwined and must be addressed by the AOJ first. 4. Earlier Effective Date for Service Connection for Mitral Valve Prolapse The Court has directed that, where a veteran has submitted a timely Notice of Disagreement (NOD) with an adverse decision and the RO has not subsequently issued a SOC addressing the issue, the Board should remand the issue(s) to the RO for issuance of a SOC. Manlincon v. West, 12 Vet. App. 238, 240-241 (1999). The record reflects that an August 2015 rating decision granted service connection for mitral valve prolapse, effective January 12, 2015, the date the claim for service connection for mitral valve prolapse was received. The Veteran submitted a timely February 2016 NOD with the effective date assigned for the service-connected mitral valve prolapse. A review of the record reflects that the RO has not acknowledged the February 2016 NOD or issued a SOC regarding the issue of an earlier effective date for the service-connected mitral valve prolapse; therefore, the issue must be remanded for the issuance of a SOC. See 38 C.F.R. § 19.9(c), codifying Manlincon, 12 Vet. App. 238 The service connection for TBI, increase rating for scars status post appendectomy, a 10 percent rating under 38 C.F.R. § 3.324, and TDIU are REMANDED for the following action: 1. Schedule the appropriate VA TBI examination. The relevant documents in the record should be reviewed by the examiner and a detailed history of relevant symptoms should be obtained from the Veteran. All indicated studies should be performed. A rationale for all opinions and a discussion of the facts and medical principles involved should be provided. 2. The examiner should provide the following opinion: a. Does the Veteran have a current diagnosis of a TBI or any residuals of an TBI, other than the service-connected headaches, to include post-concussive syndrome, and if so, is it at least as likely as not (50 percent or higher degree of probability) that any currently diagnosed TBI or residuals of TBI, to include post-concussive syndrome, was incurred in or is etiologically related to active service, to include the MVA with trauma to the head during service? 3. Readjudicate the issues of service connection for TBI, increase rating for scars status post appendectomy, and TDIU. If the benefit sought on appeal remains denied, the Veteran and representative should be provided a Supplemental Statement of the Case. Thereafter, return the case to the Board for further appellate consideration, if in order.   4. Issue a statement of the case addressing the issue of an earlier effective date than January 12, 2015 for service connection for mitral valve prolapse. The Veteran and representative should be given the appropriate opportunity to respond to the SOC. The RO should advise the Veteran that the claims file will not be returned to the Board for appellate consideration of this issue following the issuance of the SOC unless the appeal is perfected by a substantive appeal. J. PARKER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Moore, Associate Counsel