Citation Nr: 18143699 Decision Date: 10/22/18 Archive Date: 10/19/18 DOCKET NO. 16-02 953 DATE: October 22, 2018 ORDER Entitlement to service connection for residuals of a stroke is denied. New and material evidence has been received and service connection for Hepatitis C is reopened. Entitlement to an initial disability rating greater than 10 percent for residuals of a nose fracture is denied. Entitlement to an initial disability rating of 30 percent for facial scars is granted. Entitlement to an initial compensable disability rating for headaches is denied. Entitlement to an initial disability rating greater than 10 percent for traumatic brain injury (TBI) is denied. Entitlement to an effective date earlier than September 25, 2013 for the award of service connection for facial scars is denied. Entitlement to an effective date earlier than September 25, 2013 for the award of service connection for nasal fracture is denied. Entitlement to an effective date earlier than September 25, 2013 for the award of service connection for post traumatic stress disorder (PTSD) is denied. REMANDED Entitlement to service connection for Hepatitis C is remanded. Entitlement to an initial disability rating greater than 50 percent for PTSD is remanded. Entitlement to a compensable disability rating for residuals of a facial fracture is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran did not have a stroke in active service, and there is no competent evidence of a current stroke or residuals of a stroke. 2. In an unappealed September 2011 rating decision, service connection for Hepatitis C was denied. 3. Evidence received since the September 2011 decision is new and non-cumulative and it relates to unestablished facts necessary to substantiate the claim and raises a reasonable possibility of substantiating the claim of entitlement to service connection for Hepatitis C. 4. The service-connected residuals of the nasal fracture are manifested by 50 percent or less obstruction of the right nasal passage without objective findings of loss of part of the nose, scars or disfigurement exposing the nasal passages, nasal polyps, or sinusitis. 5. The service-connected facial scars are manifested by a temple scar that is at least .6 centimeters wide and a scar on the bridge of the nose that is raised on palpation and there are no objective findings of any other characteristics of disfigurement; the scars are not painful and do not result in visible or palpable tissue loss, gross distortion, asymmetry, or functional limitation. 6. The service-connected headaches occur two to three times a week, but not daily, have lasted up to several hours but less than one day, and have been associated with nausea, sensitivity to light, sensitivity to sound, and occasional vomiting but not by characteristic prostrating attacks of any frequency. 7. The service-connected TBI residuals are manifested by mild impairment in memory, attention, concentration, and executive functions. 8. Service connection for facial scars and a nasal fracture was denied in a September 2011 decision, the Veteran was notified of the decision, and he did not file an appeal. 9. On September 25, 2013, the Veteran’s claim to reopen service connection for facial scars and nasal fracture was received at VA. Service connection for facial scars and nose fracture was ultimately granted in an August 2014 rating decision effective from September 25, 2013. 10. From September 2011 to September 24, 2013, there was no formal claim, informal claim, or written intent to file a claim for service connection for facial scars or a nose fracture. 11. The Veteran first filed a claim seeking entitlement to service connection for PTSD on September 25, 2013 for which service connection was ultimately granted. 12. Prior to September 25, 2013, there was no pending formal claim, informal claim, or written intent to file a claim for service connection for PTSD. CONCLUSIONS OF LAW 1. The criteria for service connection for residuals of a stroke are not met. 38 U.S.C. §§ 1112, 1113, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2018). 2. The evidence received subsequent to the September 2011 rating decision is new and material, and the criteria to reopen the claim for service connection for Hepatitis C have been met. 38 U.S.C. §§ 5108, 7104(b), 7105(c) (2012); 38.F.R. §§ 3.102, 3.156(a) (2018). 3. The criteria for an initial rating in excess of 10 percent for residuals of a nose fracture have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.21, 4.97, Diagnostic Code 6502 (2018). 4. The criteria for a 30 percent initial disability rating for facial scars have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.118, Diagnostic Codes 7800, 7804 (2018). 5. The criteria for an initial compensable rating for headaches have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8100 (2018). 6. The criteria for an initial rating in excess of 10 percent for TBI have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8045 (2018). 7. The criteria for an effective date earlier than September 25, 2013 for the grant of service connection for residuals of a nasal fracture have not been met. 38 U.S.C. §§ 5110, 5107 (2012); 38 C.F.R. 3.400 (2018). 8. The criteria for an effective date earlier than September 25, 2013 for the grant of service connection for facial scars have not been met. 38 U.S.C. §§ 5110, 5107 (2012); 38 C.F.R. 3.400 (2018). 9. The criteria for an effective date earlier than September 25, 2013 for the grant of service connection for PTSD have not been met. 38 U.S.C. §§ 5110, 5107 (2012); 38 C.F.R. 3.400 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1977 to January 1978. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from rating decisions dated in August 2014, October 2014, and March 2017 of the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan. In November 2016, the Veteran submitted a waiver of agency of original jurisdiction (AOJ) consideration of new evidence pursuant to 38 C.F.R. § 20.1304 (2018). 1. New and material evidence has been received and the claim for service connection for Hepatitis C is reopened. Service connection may be granted for disability or injury incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). Service connection may also be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred in service. 38 C.F.R. § 3.303 (d) (2018). In order to establish service connection for the claimed disorder, generally, there must be (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Rating actions from which an appeal is not perfected become final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. The governing regulations provide that an appeal consists of a timely filed notice of disagreement in writing, and after a statement of the case has been furnished, a timely filed substantive appeal. 38 C.F.R. § 20.200. In order to reopen a claim which has been denied by a final decision, new and material evidence must be received. 38 U.S.C. § 5108. New and material evidence means evidence not previously submitted to agency decisionmakers; which relates, either by itself or when considered with previous evidence of record, to an unestablished fact necessary to substantiate the claim; which is 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 which raises a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a). To reopen a previously disallowed claim, new and material evidence must be presented or secured since the last final disallowance of the claim on any basis, including on the basis that there was no new and material evidence to reopen the claim since a prior final disallowance. See Evans v. Brown, 9 Vet. App. 273, 285 (1996). For purposes of reopening a claim, the credibility of newly submitted evidence is generally presumed. See Justus v. Principi, 3 Vet. App. 510, 513 (1992) (in determining whether evidence is new and material, “credibility” of newly presented evidence is to be presumed unless evidence is inherently incredible or beyond competence of witness). The Board is required to give consideration to all of the evidence received since the first denial of the claim in light of the totality of the record. See Hickson v. West, 12 Vet. App. 247, 251 (1999). In this regard, the Court in Shade v. Shinseki, 24 Vet. App. 110 (2010) held that the language of 38 C.F.R. § 3.156 (a) created a low threshold, and viewed the phrase “raises a reasonable possibility of substantiating the claim” as “enabling rather than precluding reopening.” Further, in determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering VA’s duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. In a September 2011 rating decision, service connection for Hepatitis C was denied. The Veteran was notified of the decision and he did not appeal. The September 2011 rating decision is final. The evidence of record at the time of the September 2011 decision included service treatment records, an October 2009 questionnaire about the Hepatitis C risk factor completed by the Veteran, and VA treatment records dated November 2009 to December 2009. The claim for service connection for Hepatitis C was denied because this disease was not incurred in or caused by active service. The rating decision indicates that the Veteran failed to report to the VA examination that was scheduled for the claim. In September 2013, the Veteran applied to reopen his previously denied claim for service connection for Hepatitis C. The additional evidence received in support of his claim includes an August 2014 VA examination report and medical opinion as to the Hepatitis C and the possible etiology. The Board concludes there is sufficient evidentiary basis to reopen the Veteran’s claim on appeal. This evidence is new since this evidence is neither cumulative nor redundant of the evidence that was of record in September 2011. This evidence is also material because this medical evidence shows that the Veteran has a diagnosis of Hepatitis C. This evidence addresses the Veteran’s medical history and risk factors pertinent to Hepatitis C. This evidence could reasonably substantiate the claim were the claim to be reopened by triggering VA’s duty to assist. As discussed in the remand below, an additional VA medical opinion should be obtained in this matter as to the Hepatitis C risk factors. Thus, the Board finds that this evidence is new and material and the claim for service connection is reopened. 2. Service Connection for residuals of a stroke is denied. Service connection will be granted for disability resulting from a disease or injury incurred in or aggravated by military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Service connection requires competent evidence showing, (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Where a veteran served ninety days or more of active service, and certain chronic diseases, such as an organic disease of the nervous system or a cardiovascular disorder, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). 38 C.F.R. § 3.303 (b) applies to the “chronic diseases” under 38 C.F.R. § 3.309 (a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Once the evidence has been assembled, it is the Board’s responsibility to evaluate the evidence. 38 U.S.C. § 7104 (a). The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.102, 4.3. The Veteran has contended that service connection is warranted for a stroke. Based upon a review of all the lay and medical evidence, the Board finds the weight of the competent and credible evidence shows that the Veteran does not have a stroke or residuals of a stroke that is related to injury, disease, or other event in active service. Service treatment records show no treatment or diagnosis of a stroke. A current diagnosis of a stroke or residuals of a stroke are not currently shown by the evidence of record. The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997) (holding that section 1110 of the statute requires the existence of a present disability for VA compensation purposes); see also Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998). The Board acknowledges that the Veteran is competent to report his symptoms and observations. However, the Board finds that the identification of specific disabilities and the determination as to a specific diagnosis are essentially medical questions, and as such are beyond the Veteran’s competence to evaluate based upon his own knowledge and expertise. Further, the record does not indicate that the Veteran has medical expertise or training. Thus, the Veteran’s determination that he has a stroke is not competent evidence. See Jandreau v. Nicholson, 492 F.3d 1372 (2007); Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). A VA medical opinion was not provided for the issue of service connection for a stroke. VA does not have a duty to provide an examination in every case. See Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010). Rather, the Secretary’s obligation under 38 U.S.C. § 5103A (d) to provide the Veteran with a medical examination or to obtain a medical opinion is not triggered unless there is an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran’s service or with another service-connected disability. See McLendon, 20 Vet. App.at 81. The record in this case is negative for any indication that the Veteran currently has a stroke or residuals of a stroke that is associated to service. The record in this case is negative for any indication, other than the Veteran’s own general assertion, that he has this disability. The Veteran did not provide lay or medical evidence of this disorder in active service or symptoms or disease in active service. The service treatment records do not document a stroke. The post-service evidence does not document a stroke. The Veteran’s sole assertion that he wants service connection for stroke is insufficient to trigger VA’s duty to provide an examination with an opinion. There is no evidence of the claimed disability in active service or any indication of an association to service. There is sufficient competent evidence on file for the Board to make a decision on the claim. As such, VA’s duty to provide an examination with an opinion is not triggered. Accordingly, on this record, the evidence is found to preponderate against the claim for service connection for a stroke or residuals of a stroke. Therefore, service connection is denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. 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 evaluations (ratings) shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 4.3, 4.7. While a veteran’s entire history is reviewed when assigning a disability rating, where service connection has already been established and an increase in the rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). In determining the present level of a disability for any increased rating claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). VA should interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability. 38 C.F.R. § 4.2. Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. 4. Entitlement to an initial disability rating greater than 10 percent for residuals of a nose fracture is denied. By way of history, an August 2014 rating decision granted service connection for residuals of a nasal fracture and assigned a 10 percent rating from September 25, 2013 under Diagnostic Code 6502, deviation of nasal septum. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the assignment of a disability evaluation in excess of 10 percent for the service-connected nasal fracture. Diagnostic Code 6502, deviation of nasal septum, provides a maximum 10 percent rating for traumatic deviation of the nasal septum with 50 percent obstruction of the nasal passage on both sides or complete obstruction on one side. Under this diagnostic code, there is no allowable higher rating. The August 2014 VA examination report indicates that the Veteran reported that the right side of his nose was bigger and he had difficulty breathing through it. It was noted that he has less than 50 percent occlusion of the right nares. The other pertinent finding is an asymptomatic transverse scar on the bridge of the nose. The Board notes that the Veteran is assigned a separate rating for this scar. The Veteran did not have loss of part of the nose or scars exposing the nasal passages. The VA treatment records do not show any treatment for the nasal fracture. As noted above, a 10 percent rating represents the maximum schedular rating for traumatic deviation of the nasal septum under Diagnostic Code 6502. The medical evidence is negative for chronic sinusitis or rhinitis that could warrant an additional rating or a higher rating under a separate diagnostic code. The Veteran has no loss of part of the nose, or a scar or disfigurement exposing the nasal passages. He has no nasal polyps, and he does not assert his disability causes pain or discharge. Thus, a higher schedular rating for the Veteran’s deviated septum disability is unavailable under Diagnostic Codes 6502 to 6514 and 6522. In sum, the preponderance of the evidence is against a disability rating in excess of 10 percent for the residuals of a nasal fracture throughout the entire appeal period. As the preponderance of evidence weighs against the claim, the benefit of the doubt rule is not applicable and the appeal is denied. 5. Entitlement to an initial 30 percent disability rating for facial scars is granted. By way of history, an August 2014 rating decision granted service connection for facial scars and assigned a 10 percent rating from September 25, 2013 under Diagnostic Code 7800, burn scars of the head, face, or neck; scars of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck. 38 C.F.R. § 4.118. The Board has carefully reviewed the evidence of record and finds that the evidence supports the assignment of a 30 percent disability evaluation and no higher for the service-connected facial scars. On July 13, 2018, VA issued a final rule amending its regulations on skin disabilities. The effective date of this final rule is August 13, 2018. For this final rule, VA’s intent is that the claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. For applications filed on or after the effective date, only the new criteria will be applied. 83 Fed. Reg. 32592-32601 (July 13, 2018). The Board notes that the new regulations did not amend the provisions of Diagnostic Codes 7800 and 7804 which are the pertinent diagnostic codes in this appeal. See 38 C.F.R. § 4.118. The Board notes that the provisions of Diagnostic Code 7805 were not substantively changed. Id. Diagnostic Code 7800, applicable to burn scars of the head, face, or neck; scars of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck, provides the following ratings: 10 percent: With one characteristic of disfigurement. 30 percent: 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 two or three characteristics of disfigurement. 50 percent: Visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips); or with four or five characteristics of disfigurement. 80 percent: Visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement. 38 C.F.R. § 4.118, Diagnostic Code 7800. The eight characteristics of disfigurement are as follows: (1) Scar 5 or more inches (13 or more cm) in length; (2) Scar at least one quarter inch (0.6 cm) wide at its widest part; (3) Surface contour of scar elevated or depressed on palpation; (4) Scar adherent to underlying tissue; (5) Skin hypo or hyperpigmented in an area exceeding six square inches (39 sq. cm.); (6) Skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm); (7) Underlying soft tissue missing in an area exceeding six square inches (39 sq. cm); and (8) Skin indurated and inflexible in an area exceeding six square inches (39 sq. cm). Id., Note 1. The August 2014 VA examination report indicates that the Veteran has two facial scars: an asymptomatic scar on the nose and an asymptomatic scar to the left temple area. The scar on the nose was transverse and was .1 centimeters by .5 centimeters. The scar on the temple was .2 centimeters by 2.5 centimeters. The 10 percent rating was assigned to the facial scars based upon the finding that the temple scar was 2.5 centimeters wide, which is one characteristic of disfigurement. The Board finds that the evidence supports the assignment of a 30 percent disability evaluation and no higher for the service-connected facial scars. The service-connected facial scars meet two characteristics of disfigurement. The service-connected facial scars are manifested by a temple scar that is at least.6 centimeters wide and the scar on the nose is manifested by a raised area to palpation across the bridge of the nose which approximates elevated surface contour of the scar. See the August 2014 VA examination report. Thus, a 30 percent rating is warranted under Diagnostic Code 7800 based upon the findings of two characteristics of disfigurement for the entire period of the appeal. A disability rating in excess of 30 percent is not warranted for the facial scars under Diagnostic Code 7800. There are no objective findings of more than two characteristics of disfigurement. The scars are not more than 13 centimeters in length, the surface contour of the scars is not depressed on palpation, the scars are not adherent to the underlying tissue, and the total area of hypo- or hyperpigmentation is not more than 39 square centimeters. The scars are not manifested by abnormal skin texture, missing underlying soft tissue, or indurated or inflexible skin in an area more than 39 square centimeters. See the August 2014 VA examination findings. The service-connected facial scars do not result in visible or palpable tissue loss or gross distortion or asymmetry of one feature or a paired set of features. The VA treatment records do not show any treatment of or pertinent findings for the facial scars. Thus, the Board finds that the preponderance of the evidence weighs against the claim for a disability rating in excess of 30 percent for the facial scars under Diagnostic Code 7800. Diagnostic Codes 7801 and 7802 do not apply because those Diagnostic Codes apply to scarring affecting parts of the body other than the face. A higher or separate rating under Diagnostic Code 7804, scars, unstable or painful, is not warranted because the service-connected facial scars are not shown to be painful or unstable on examination. A higher or separate rating under Diagnostic Code 7805 is not warranted. Diagnostic Code 7805 provides that other scars and other effects of scars evaluated under Diagnostic Codes 7800, 7801, 7802 and 7804, any disabling effects not considered in a rating provided under diagnostic codes 7800-04 may be evaluated under an appropriate diagnostic code. See 38 C.F.R. § 4.118, Diagnostic Code 7805 (in effect before and after August 13, 2018). The weight of the competent and credible evidence shows that the facial scars do not cause any other disabling effects. The August 2014 VA examination report indicates that the facial scars do not cause or result in a limitation of function. Thus, the Board finds that the evidence supports the assignment of a 30 percent disability evaluation and no higher for the service-connected facial scars. The claim for a higher initial rating is granted to that extent. 6. Entitlement to an initial compensable disability rating for headaches is denied. By way of history, an August 2014 rating decision granted service connection for headaches and assigned a zero percent rating from September 25, 2013 under Diagnostic Code 8100, migraines. 38 C.F.R. § 4.124a. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the assignment of a compensable disability evaluation for the service-connected headaches. Diagnostic Code 8100 provides that migraine headaches with less frequent attacks than the criteria for a 10 percent rating are rated as non-compensable (0 percent). Migraine headaches with characteristic prostrating attacks averaging one in 2 months over the last several months are rated 10 percent disabling. A 30 percent evaluation is warranted with characteristic prostrating attacks occurring on an average once a month, over the preceding several months. A 50 percent rating is warranted for very frequent, completely prostrating, and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a, Diagnostic Code 8100. The Board notes that the rating criteria for Diagnostic Code 8100 link the ratings for migraine headaches to two elements: severity and frequency. It is not sufficient to demonstrate the existence of a particular frequency of headaches; the headaches must be of a specific prostrating character. See 38 C.F.R. § 4.124a. The rating criteria and the Court do not define “prostrating.” Fenderson v. West, 12 Vet. App. 119 (1999) (wherein the Court quotes Diagnostic Code 8100 verbatim but does not specifically address the matter of what is a prostrating attack). For reference, according to Merriam Webster ‘s Collegiate Dictionary 999 (11th Ed. 2007), “prostration” is defined as “complete physical or mental exhaustion.” A similar definition is found in Dorland’s Illustrated Medical Dictionary 1554 (31st Ed. 2007), in which “prostration” is defined as “extreme exhaustion or powerlessness.” Review of the record shows that the Veteran underwent VA examination in August 2014. The diagnosis in pertinent part was post traumatic headaches. The Veteran reported that he had headaches two to three times a week and the duration was five minutes to an hour. It was noted that the typical duration of headache pain was less than 1 day. The headache went from his temple to his forehead and eyes and was associated with some nausea, occasional vomiting, and sensitivity to light and sound. He reported that he sometimes saw flashing lights. He stated that he last had a headache 4 days ago and he took aspirin or ibuprofen for the headaches. The Veteran did not have any characteristic prostrating attacks of headache pain. The VA examiner indicated that the headaches did not impact the Veteran’s ability to work. The VA treatment records do not show any treatment of or pertinent findings for the headaches. The Veteran’s headaches occur two to three times a week, but not daily, have lasted up to several hours but less than one day, and have been associated with nausea, sensitivity to light, sensitivity to sound, and occasional vomiting but not by characteristic prostrating attacks of any frequency. After considering the record on appeal, the Board concludes that a 10 percent rating is not warranted for the Veteran’s headaches. In that regard, the Board notes that, while the record shows that while the Veteran reported he had headaches several times a week, the competent evidence of record did not show that he has suffered from prostrating attacks averaging one in two months over a period of several months, or for any several-month period, as is required for a 10 percent rating. While the record shows that he suffers several headaches a week, of varying intensity, that lasted up to several hours, along with nausea, sensitivity to light, sensitivity to sound, and occasional vomiting associated with headaches, the record does not show that he suffers from prostrating attacks or show the extreme exhaustion or powerlessness that is contemplated by the regulations. The criteria for a 10 percent rating for the Veteran’s service-connected headaches have not been approximated at any time. 38 C.F.R. § 4.7. Accordingly, the preponderance of the evidence is against the assignment of a compensable rating for headaches. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 7. Entitlement to an initial disability rating greater than 10 percent for TBI is denied. By way of history, an August 2011 rating decision granted service connection for TBI and assigned a 10 percent rating from November 6, 2009 under Diagnostic Code 8045, residuals of traumatic brain injury (TBI). 38 C.F.R. § 4.124a. The Veteran filed a claim for an increased rating in September 2013. The rating criteria for TBI is set forth in Diagnostic Code 8045. A Veteran is evaluated based on three main areas of functioning: cognitive (which is common in varying degrees after a TBI), emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation. 38 C.F.R. § 4.124a, Diagnostic Code 8045 (2018). Each of these main areas has up to 10 subsets of criteria. Cognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain. Executive functions are goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive. Not all of those brain functions may be affected in a given individual with cognitive impairment, and some functions may be affected more severely than others. In a given individual, symptoms may fluctuate in severity from day to day. Cognitive functions are evaluated under the table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.” 38 C.F.R. § 4.124a, Diagnostic Code 8045. Subjective symptoms may be the only residual of TBI or may be associated with cognitive impairment or other areas of dysfunction. Subjective symptoms that are residuals of TBI, whether or not they are part of cognitive impairment, are rated under the subjective symptoms facet in the table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.” However, any residual with a distinct diagnosis that may be rated under another diagnostic code, such as migraine headache or Meniere’s disease, is separately rated, even if that diagnosis is based on subjective symptoms, rather than under the “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified” table. 38 C.F.R. § 4.124a , Diagnostic Code 8045. Emotional/behavioral dysfunction is rated under 38 C.F.R. § 4.130, the schedule of ratings for mental disorders when there is a diagnosis of a mental disorder. When there is no diagnosis of a mental disorder, emotional/behavioral symptoms are rated under the criteria in the table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.” 38 C.F.R. § 4.124a, Diagnostic Code 8045. Physical, including neurological, dysfunction is rated based on the following list, under an appropriate diagnostic code: Motor and sensory dysfunction, including pain, of the extremities and face; visual impairment; hearing loss and tinnitus; loss of sense of smell and taste; seizures; gait, coordination, and balance problems; speech and other communication difficulties, including aphasia and related disorders, and dysarthria; neurogenic bladder; neurogenic bowel; cranial nerve dysfunctions; autonomic nerve dysfunctions; and endocrine dysfunctions. 38 C.F.R. § 4.124a, Diagnostic Code 8045. The preceding list of types of physical dysfunction does not encompass all possible residuals of TBI. For residuals not listed that are reported on an examination, they are rated under the most appropriate diagnostic code. Each condition should be rated separately, as long as the same signs and symptoms are not used to support more than one rating, and the ratings are combined. The rating assigned based on the “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified” table will be considered the rating for a single condition for purposes of combining with other disability evaluations. 38 C.F.R. § 4.124a, Diagnostic Code 8045. The rater should consider the need for special monthly compensation for such problems as loss of use of an extremity, certain sensory impairments, erectile dysfunction, the need for aid and attendance (including for protection from hazards or dangers incident to the daily environment due to cognitive impairment), or being housebound. 38 C.F.R. § 4.124a, Diagnostic Code 8045. The table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified” contains 10 important facets of TBI related to cognitive impairment and subjective symptoms. It provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and a 5th level, the highest level of impairment, labeled “total.” However, not every facet has every level of severity. The Consciousness facet, for example, does not provide for an impairment level other than “total,” since any level of impaired consciousness would be totally disabling. A 100-percent rating is assigned if “total” is the level of evaluation for one or more facets. If no facet is evaluated as “total,” assign the overall percentage rating based on the level of the highest facet as follows: 0 warrants a 0 percent rating; 1 warrants a 10 percent rating; 2 warrants a 40 percent rating; and 3 warrants a 70 percent rating. For example, a 70 percent rating is assigned if 3 is the highest level of evaluation for any facet. 38 C.F.R. § 4.124a, Diagnostic Code 8045. There may be an overlap of manifestations of conditions evaluated under the table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified” with manifestations of a comorbid mental or neurologic or other physical disorder that can be separately rated under another diagnostic code. In such cases, more than one rating based on the same manifestations is not to be assigned. If the manifestations of two or more conditions cannot be clearly separated, a single rating is assigned under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning due to both conditions. However, if the manifestations are clearly separable, a separate rating is assigned for each condition. 38 C.F.R. § 4.124a, Diagnostic Code 8045, Note (1) (2018). Symptoms listed as examples at certain evaluation levels in the table are only examples and are not symptoms that must be present in order to assign a particular evaluation. 38 C.F.R. § 4.124a, Diagnostic Code 8045, Note (2) (2018). Instrumental activities of daily living refers to activities other than self-care that are needed for independent living, such as meal preparation, doing housework and other chores, shopping, traveling, doing laundry, being responsible for one’s own medications, and using a telephone. Those activities are distinguished from activities of daily living, which refers to basic self-care and includes bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet. 38 C.F.R. § 4.124a, Diagnostic Code 8045, Note (3). The terms mild, moderate, and severe TBI, which may appear in medical records, refer to a classification of TBI made at, or close to, the time of injury rather than to the current level of functioning. That classification does not affect the rating assigned under diagnostic code 8045. 38 C.F.R. § 4.124a, Diagnostic Code 8045, Note (4) (2018). The 10 important facets of cognitive impairment and other residuals of TBI not otherwise classified are as follows: (1) Memory, attention, concentration, executive functions; (2) Judgment; (3) Social interaction; (4) Orientation; (5) Motor activity; (6) Visual spatial orientation; (7) Subjective symptoms; (8) Neurobehavioral effects; (9) Communication; and (10) Consciousness. 38 C.F.R. § 4.124a, Diagnostic Code 8045 (2018). Applying the criteria set forth above to the facts in this case, the Board finds that the preponderance of the evidence is against assignment of a disability rating in excess of 10 percent for TBI at any time during the period on appeal. In August 2014, the Veteran underwent a VA TBI examination. With regard to cognitive impairment, the VA examiner reported that there was objective evidence on testing of mild impairment of memory, attention, concentration, or executive functions. The veteran reported difficulty with remembering appointments. The Montreal Cognitive assessment (MOCA) score was 25/30 and 26 or greater was ormal for high school graduates. It was noted that the Veteran had variable attention during the course of the screening examination. Judgment was normal, social interaction was routinely appropriate, and the Veteran was always oriented to person, time, place, and situation. Motor activity and visual spatial orientation were normal. The examiner stated that the Veteran’s subjective symptoms did not interfere with work, instrumental activities of daily living, or family or other close relationships. Examples were identified as mild or occasional headaches and mild anxiety. The examiner remarked that the Veteran demonstrated one or more neurobehavioral effects that did not interfere with workplace interaction or social interaction. The VA examiner noted that the neurobehavioral effects were secondary to PTSD. The Veteran was able to communicate by spoken and written language and to comprehend spoken and written language. Consciousness was normal. The examiner reported that the Veteran’s headaches were residuals attributable to TBI. Additionally, there was a scar associated with the Veteran’s TBI, but the examiner indicated that the scar was not painful and/or unstable, and the total area of the scar was not greater than 39 square centimeters (6 square inches). The diagnosis was TBI and reported that none of the Veteran’s residual conditions attributable to a TBI impacted his ability to work. The VA treatment records do not show any treatment of or pertinent findings for the TBI. Applying the criteria set forth above to the facts in this case, the Board finds that the preponderance of the evidence is against assignment of an initial rating in excess of 10 percent for TBI at any time during the period on appeal. The Board notes that the Veteran’s PTSD, headaches, facials scars, facial fracture, and nose fracture have been evaluated separately. In this regard, the Board has considered the 10 facets discussed above. The Veteran’s disability has been manifested by no greater than level 1 impairment for any of the facets under the Cognitive Table. As noted, during the August 2014 VA examination, the VA examiner reported that there was mild impairment of memory, attention, concentration, or executive functions. Therefore, the Board finds that the evidence of record is indicative of level 1 impairment for memory, attention, concentration and executive functions. With regard to judgment, the August 2014 VA examiner concluded that the Veteran’s judgment was normal, indicative of level 0 impairment. Additionally, social interaction was routinely appropriate, indicative of level 0 impairment. As for orientation, it was determined that the Veteran was always oriented to person, time, place, and situation, suggestive of level 0 impairment. As for motor activity, the August 2014 VA examiner found the Veteran’s motor activity to be normal, indicative of level 0 impairment. The August 2014 VA examiner noted that the Veteran’s visual space orientation was normal, indicative of level 0 impairment. With regard to subjective symptoms, the August 2014 VA examiner found that the Veteran’s subjective symptoms did not interfere with work, instrumental activities of daily living, or family or other close relationships, which equates to level 0 impairment of relating to subjective symptoms. As for neurobehavioral symptoms, the August 2014 VA examiner reported that the Veteran demonstrated one or more neurobehavioral effects that did not interfere with workplace interaction or social interaction, which equates to level 0 impairment for neurobehavioral effects. With regard to communication, at the August 2014 VA examination, the Veteran was able to communicate by spoken and written language and to comprehend spoken and written language, indicative of level 0 impairment for communication. Additionally, the August 2014 VA examiner reported that the Veteran’s consciousness was normal. Accordingly, based on the evidence of record, a disability rating greater than 10 percent for TBI is not warranted. 38 C.F.R. § 4.124a, Diagnostic Code 8045. The Board observes that the Veteran’s neurobehavioral symptoms have been contemplated in the rating assigned for the Veteran’s service-connected PTSD and that some subjective symptoms have included headaches. To increase his compensation for these symptoms which are contemplated by his service-connected psychiatric disorder and headaches would be unlawful pyramiding. 38 C.F.R. § 4.14. In finding against the next-higher 40 percent rating, the Board notes that the record does not support a finding of impairment at a level of 2, 3, or total impairment in any of the remaining 10 facets in the table of “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified” as to warrant a higher disability rating at any time throughout the duration of the appeal. The Board has also considered Diagnostic Code 8045’s instruction to consider the Veteran’s entitlement to special monthly compensation (SMC). The medical evidence of record does not show that the Veteran is in need of regular aid and attendance of another person or is housebound. Accordingly, the preponderance of the evidence is against the assignment of a disability rating higher than 10 percent for TBI and any residuals thereof. The claim is denied. 8. Entitlement to an effective date earlier than September 25, 2013 for the award of service connection for facial scars, nasal fracture, and PTSD is denied. Under 38 C.F.R. § 3.400 (b)(2)(i), the effective date for a grant of direct service connection will be the day following separation from active service or the date entitlement arose if the claim is received within one year after separation from service. Otherwise, the effective date is the date of receipt of claim, or date entitlement arose, whichever is later. The effective date for presumptive service connection will be the date entitlement arose, if a claim is received within one year after separation from active service. Otherwise, the effective date will be the date of receipt of the claim, or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400 (b)(2). “Date of receipt” generally means the date on which a claim, information or evidence was received by VA. 38 C.F.R. § 3.1 (r). Effective on March 24, 2015, VA amended its regulations as to what constitutes a claim for benefits. Such now requires that claims be made on standard form prescribed by the Secretary, effectively eliminating informal claims. See 79 Fed. Reg. 57660 (Sept. 25, 2014). The amendments, however, are only effective for claims and appeals filed on or after March 24, 2015. As the claim in this case was filed prior to that date, the amendments are not applicable in this instance and the regulations in effect prior to March 24, 2015, will be applied. Prior to March 24, 2015, which is the time relevant time period in this appeal, the VA administrative claims process recognized formal and informal claims. A claim is a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1 (p). Any communication or action, indicating intent to apply for one or more benefits under the laws administered by VA, from a claimant, a duly authorized representative, or a person acting as next friend who is not sui juris may be considered an informal claim. 38 C.F.R. § 3.155. VA is required to identify and act on informal claims for benefits. 38 U.S.C. § 5110 (b)(3) (2012); 38 C.F.R. §§ 3.1 (p), 3.155(a); Servello v. Derwinski, 3 Vet. App. 196 (1992). Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. If received within one year from the date it was sent to the claimant, it will be considered filed as of the date of receipt of the informal claim. In the present case, the Veteran asserts that an effective date for the award of service connection for facial scars, nasal fracture and PTSD should be earlier than the date assigned. The Veteran and his attorney do not make a specific argument for the basis of this contention. Review of the record shows that in November 2009, the Veteran’s initial claim for service connection for a nasal fracture and facial scars was received at VA. Service connection for a nasal fracture and facial scars was denied in a September 2011 rating decision. The Veteran was notified of this decision and did not appeal. The September 2011 rating decision is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 20.302, 20.1103 (2018). On September 25, 2013, a claim to reopen service connection for a nasal fracture and the facial scars was received at the RO. The initial claim for service connection for PTSD was received at the RO on that date as well. Service connection for a nasal fracture, facial scars, and PTSD was ultimately granted in an August 2014 rating decision effective from September 25, 2013. Under VA laws and regulations, the effective date following a prior denial based on new and material evidence, other than service department records, is the date of receipt of a new claim, or date entitlement arose, whichever is later. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400 (q)(1)(ii), (r). It is settled law that the effective date for the grant of service connection following a final decision is the date of the reopened claim. See Sears v. Principi, 16 Vet. App. 244, 248 (2002) (“the Court thus holds that the effective date statute, 38 U.S.C. § 5110 (a), is clear on its face with respect to granting an effective date for an award of VA periodic monthly benefits no earlier than the date that the claim for reopening was filed”). In the Sears case, the Court explained that the statutory framework did not allow for the Board to reach back to the date of the original claim as a possible effective date for an award of service-connected benefits that is predicated upon a reopened claim. The Court explained that the term, new claim, as it appeared in 38 C.F.R. § 3.400 (q), means a claim to reopen a previously and finally decided claim. In order for a veteran to be awarded an effective date based on an earlier claim, he or she has to show clear and unmistakable error (CUE) in the prior denial of the claim. 38 C.F.R. §§ 3.104 (b), 3.105(a); Flash v. Brown, 8 Vet. App. 332, 340 (1995). The date of receipt of the claims to reopen service connection for nasal fracture and facial scars is September 25, 2013. The Board has reviewed whether there is any evidence of an intent to file a claim for benefits prior to September 25, 2013. In this regard, the last final decision declining to reopen service connection for a nasal fracture and facial scars was the September 2011 rating decision and the Veteran was notified of this decision by letter dated September 28, 2011. The record does not contain any claims formal or informal revealing an intent to file a claim for service connection for a nasal fracture and facial scars after September 28, 2011 and before September 25, 2013. Therefore, the Board concludes that the proper effective date for the award of service connection for nasal fracture and facial scars is September 25, 2013, the date of receipt of the claim to reopen and no earlier. The appeal is denied. Upon review of the record, the Board finds that entitlement to an effective date earlier than September 25, 2013 for the grant of service connection for PTSD is not warranted. The Veteran was granted entitlement to service connection for PTSD effective the date his claim was received by VA, September 25, 2013, which was more than one year following the date of the Veteran’s separation from service. There was no formal claim, informal claim, or written intent to file a claim for PTSD prior to that date. The governing regulations dictate that the effective date will be the date of receipt of the claim or the date entitlement arose, whichever is the later, and the Board is bound by that authority. 38 U.S.C. § 5110a (2012); 38 C.F.R. § 3.400. Under the facts of the case, the effective date of service connection for PTSD can be no earlier than September 25, 2013, the date the Veteran’s claim was received by VA. Therefore, the Board concludes that the proper effective date for the award of service connection for PTSD is September 25, 2013, the date of receipt of the claim for service connection and no earlier. The preponderance of the evidence is against the claim for an earlier effective date and the appeal is denied. 9. Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. 5103, 5103A (2012); 38 C.F.R. 3.159 (2018). The Veteran filed the claims through VA’s fully developed claim program. The Board finds that the content requirements of a duty-to-assist notice letter have been fully satisfied as the Veteran was provided all of the relevant notice requirements in his September 2013 VA 21-526 EZ Fully Developed Claim forms (EZ Claim). He has had representation throughout the entire appeal period. VA provided the Veteran with 38 U.S.C. 5103 (a)-compliant notice in April 2014. Therefore, additional notice is not required. VA has fulfilled its obligation to assist the Veteran in developing these claims. Neither the Veteran nor his representative has identified any deficiency in VA’s notice or assistance duties. REASONS FOR REMAND VA’s duty to assist a claimant includes providing a medical examination or obtaining a medical opinion when an examination or opinion is necessary to make a decision on the claim. 38 U.S.C. § 5103A (d)(1) (2012). 10. Entitlement to service connection for Hepatitis C is remanded. The Board finds that another VA medical opinion is necessary as to the etiology of the Hepatitis C. The Board notes that the Veteran’s history of multiple risk factors for Hepatitis C is precisely the reason why the Board requires a medical opinion based on the evidence of record and a reviewing physician’s best judgment. A medical opinion was obtained in August 2014 but the VA examiner did not rank the documented risk factors relative to the probability that any Hepatitis C infection is etiologically related to the risk factor. The VA examiner opined that it was less likely than not that the Hepatitis C was related to the events (risk factors) that took place in service and noted that the Veteran had other risk factors including imprisonment and alcohol abuse. Entitlement to an initial disability rating in excess of 50 percent for PTSD is remanded. The Veteran underwent an examination of the service-connected PTSD in August 2014. Evidence added to the record since the exam reflects a possible worsening. See the November 2016 PTSD Disability Benefits Questionnaire. Thus, a new examination is needed to determine the current level of severity of the PTSD. 11. Entitlement to a compensable disability rating for residuals of a facial fracture is remanded. The Board will remand the appeal so that the Veteran may be afforded one more opportunity to report for a VA examination to ascertain the current severity and manifestations of the service-connected residuals of a facial fracture. 12. Entitlement to TDIU is remanded. In a statement received in December 2016, the Veteran’s attorney raised the issue of entitlement to TDIU due to the service-connected PTSD. The claim for entitlement to a TDIU will be considered “part and parcel” of the claim for a higher rating for PTSD. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). As the AOJ has not developed or adjudicated the matter of whether the Veteran is entitled to a TDIU rating, under Rice, the Board must remand for such action. 38 C.F.R. § 4.16. The Board also finds that the claim for TDIU is inextricably intertwined with the pending claims for increased ratings and service connection. Because adjudication of the Veteran’s claim of entitlement to an increased rating and service connection for hepatitis C will potentially affect his TDIU claim, adjudication of the Veteran’s TDIU claim is deferred until these claims have been decided. The matter is REMANDED for the following action: 1. Schedule the Veteran for a VA examination by an appropriate clinician, preferably one with expertise in infectious diseases, to obtain evidence as to the etiology and onset of the Hepatitis C. A history of all of the Veteran’s potential risk factors of Hepatitis C infection should be detailed in full and the examiner must list and discuss all documented and reported pre-service, in-service, and post-service risk factors. The examiner should then rank the documented risk factors relative to the probability that any Hepatitis C infection is etiologically related to the risk factor. The examiner is then requested to provide an opinion as to whether it is at least as likely as not that any diagnosed Hepatitis C is related to the Veteran’s active military service. The bases for the opinion provided should be explained in detail. If the examiner determines that he/she cannot provide an opinion on the issue at hand without resorting to speculation, the examiner should explain the inability to provide an opinion, identifying precisely what facts could not be determined. In particular, he/she should comment on whether an opinion could not be rendered because the limits of medical knowledge have been exhausted regarding the etiology of the diagnosed disorder or whether additional testing or information could be obtained that would lead to a conclusive opinion. (The AOJ should ensure that any additional evidentiary development suggested by the examiner should be undertaken so that a definitive opinion can be obtained.) 2. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of the service-connected PTSD. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms. To the extent possible, the examiner should identify any symptoms and social and occupational impairment due to the service-connected PTSD alone. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of the service-connected facial fracture. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner should report the range of motion of the temporomandibular articulation to include the range of lateral excursion and inter-incisal range of motion. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. To the extent possible, the examiner should identify any symptoms and functional impairments due to facial fracture alone and discuss the effect of the Veteran’s disability on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 5. Provide to the Veteran a VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability and ask him to complete and return the form. THOMAS H. O'SHAY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C.L. Krasinski, Counsel