Citation Nr: 19155477 Decision Date: 07/18/19 Archive Date: 07/17/19 DOCKET NO. 18-28 822 DATE: July 18, 2019 ORDER Service connection for obstructive sleep apnea (OSA) is granted. Service connection for hypertension secondary to posttraumatic stress disorder (PTSD) is granted. Service connection for migraine headaches secondary to PTSD is granted. From July 21, 2016, a 100 percent disability rating for PTSD is granted. Prior to July 21, 2016, a total disability rating based on individual unemployability (a TDIU rating) is granted. Service connection for tinnitus is denied. Prior to July 21, 2016, an increased disability rating (greater than 70 percent) for PTSD is denied. The appeal for an effective date prior to July 13, 2010 for service connection for PTSD is dismissed. From July 21, 2016, the appeal for a TDIU rating is dismissed. FINDINGS OF FACT 1. The preponderance of the medical evidence, including a December 2018 sleep disorder Disability Benefits Questionnaire (DBQ), establishes that it is at least as likely as not that the Veteran’s OSA was proximately aggravated by his PTSD symptoms. 2. The preponderance of the medical evidence, including a June 2013 private treatment note, establishes that it is at least as likely as not that the Veteran’s hypertension was proximately aggravated by his PTSD symptoms. 3. The preponderance of the medical evidence, including a December 2018 disability benefits questionnaire (DBQ), establishes that it is at least as likely as not that the Veteran’s migraine headaches were proximately aggravated by his PTSD symptoms. 4. From July 21, 2016, the Veteran’s PTSD symptoms include flattened affect, near-continuous panic or depression affecting the ability to function independently, variable concentration, difficulty with short and long-term memory including struggles to remember basic information; these worsening symptoms resulted in total occupational and social impairment. 5. Prior to July 21, 2016, the impairment caused by the Veteran’s service-connected PTSD symptoms (including mood swings, anxiety, difficulty in adapting to stressful circumstances such as work or a worklike setting, and inability to establish and maintain effective relationships), prevented him from obtaining or maintaining substantially gainful employment consistent with his high school education and post-service work experience. 6. The Veteran first reported tinnitus symptoms more than thirty-five years after service; based on this fact and on a negative VA linkage opinion, the preponderance of the evidence is against a finding that the Veteran’s tinnitus is due to acoustic trauma during service. 7. Prior to July 21, 2016, the Veteran’s PTSD symptoms more nearly approximated occupational and social impairment with deficiencies in most areas (for example, depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, difficulty maintaining effective work and social relationships and difficulty adapting to stressful circumstances, including work or a work-like setting) and not total occupational and social impairment because the evidence does not show that the symptoms noted above were sufficiently severe and frequent as to warrant a finding of total occupational and social impairment during this period. 8. The October 2010 rating decision granting service connection for PTSD with an effective date of July 13, 2010 was not appealed and thus became final; the claim for an earlier effective date for service connection for PTSD was “freestanding” and did not allege clear and unmistakable error (CUE) in a prior final rating decision. 9. From July 21, 2016, the Veteran has been granted a 100 percent schedular rating for PTSD. CONCLUSIONS OF LAW 1. The criteria for service connection for sleep apnea have been met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 38 C.F.R. § 3.310 (a) (2017). 2. The criteria for service connection for hypertension secondary to PTSD have been met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 38 C.F.R. § 3.310 (a) (2017). 3. The criteria for service connection for migraine headaches secondary to PTSD have been met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 38 C.F.R. § 3.310 (a) (2017). 4. From July 21, 2016, the criteria for a 100 percent rating for PTSD are met. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 9411. 5. Prior to July 21, 2016, the criteria for a TDIU rating are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 4.16(b) (2016). 6. The criteria for service connection for tinnitus have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385 (2017). 7. Prior to July 21, 2016, the criteria for rating greater than 70 percent for PTSD have not been met. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 9411. 8. The appeal seeking an effective date prior to July 13, 2010 for the grant of service connection for PTSD is dismissed. 38 U.S.C. §§ 5110, 7104 (2012); 38 C.F.R. §§ 3.302, 3.400, 20.101 (2017). 9. From July 21, 2016, the appeal for a TDIU rating is dismissed as moot. 38 U.S.C. § 7105; 38 C.F.R. § 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran honorably served from December 1966 to July 1969. This matter is before the Board of Veterans Appeals (Board) on appeal from April 2014 and April 2015 rating decisions. Pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009), a claim for a TDIU either expressly raised by the Veteran or reasonably raised by the record involves an attempt to obtain an appropriate rating for a disability and is part of any claim for an increased rating where unemployability is raised. In this case, the issue was raised by the Veteran through submission of a July 2016 mental status examination in which the clinician opined that the Veteran’s PTSD symptoms are preventing him from maintaining substantially gainful employment. See July 2016 DBQ (and attached mental status examination). Thus, the Board finds that a claim for TDIU was raised by the record as part of the Veteran’s appeal for an increased rating with respect to his service-connected PTSD. See Rice, 22 Vet. App. at 448. However, the Board will only consider to TDIU prior to July 21, 2016 because, pursuant to the 100 percent rating granted for PTSD from that date discussed herein, the issue of TDIU is moot from July 21, 2016. 38 U.S.C. § 7105; 38 C.F.R. § 4.16. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131. Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). An alternative method of establishing the second and third element is by establishing continuity of symptoms, if the disability is listed as a “chronic disease” in relevant VA regulations. 38 C.F.R. § 3.309(a); 38 C.F.R. § 3.303(b). Tinnitus is a qualifying chronic disease. Fountain v. McDonald, 27 Vet. App. 258 (2015). Service connection may be established on a secondary basis for a disability that is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310 (a). Establishing service connection on a secondary basis requires evidence to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. El-Amin v. Shinseki, 26 Vet. App. 136, 138 (2013); Allen v. Brown, 7 Vet. App. 439, 448 (1995). 1. Obstructive Sleep Apnea Factual Background The Veteran contends that he currently has OSA that is proximately caused and aggravated his service-connected PTSD. A June 2016 sleep study showed a current diagnosis for OSA with the need for sleep apnea therapy. December 2018 sleep disorder DBQ with an accompanying nexus opinion completed by a qualified clinician noted that the Veteran’s OSA is both precipitated and aggravated by his service. The opinion cited to a recent medical study that found an arousal-based mechanism initiated by PTSD that promotes the development of OSA. The opinion further stated that the Veteran informed her that he has difficulty using his CPAP machine due to his PTSD symptoms which cause heightened anxiety. Ultimately, the clinician concluded that the Veteran’s inability to use his CPAP greatly aggravates the effects of his OSA. Analysis As there are no negative medical opinions of record, the Board finds that the December 2018 DBQ is the most probative evidence of record. Accordingly, the preponderance of the evidence is in favor of finding that the Veteran’s OSA is proximately aggravated by his service-connected PTSD and a grant of service connection on a secondary basis is warranted. 2. Hypertension Factual Background A June 2013 private treatment note affirms that the Veteran currently has hypertension. This same treatment note assessed that the Veteran’s PTSD is “worsening and aggravating [the Veteran’s] underlying hypertension.” Moreover, the treating physician stated that the Veteran’s hypertension treatment plan must include controlling his PTSD symptoms because they are “aggravating his hypertension.” The record also contains VA examination reports from April 2012 and March 2014. Both examiners opined that the Veteran’s hypertension was not proximately due to or the result of his service-connected PTSD based the lack of an established medical link between PTSD and hypertension. The April 2014 examination report acknowledged a 2009 study finding that Veterans with PTSD may have an increased rate of hypertension but noted that the study had limitations. Analysis Upon careful review of the evidence of record, the Board finds that the positive and negative evidence regarding the Veteran’s claim for service connection for hypertension secondary to PTSD on an aggravation basis is at least in relative equipoise. Despite the VA examiners rendering negative nexus opinions generally, they were based on a lack of established link between PTSD and hypertension. These examinations did not consider the possibility of whether individual symptoms caused by the Veteran’s PTSD such as stress or anxiety could proximately cause or aggravate his hypertension. Moreover, the standard for determining whether service connection is warranted on a secondary basis is whether it is at least as likely as not that this particular Veteran’s hypertension was proximately caused or aggravated by a service-connected disability, not whether there is a definitively established link between two conditions in the medical field generally. In sum, resolving reasonable doubt in the Veteran’s favor, service connection for hypertension secondary to PTSD is warranted. 3. Migraine headaches Factual Background A January 2003 neurology consult note affirms that the Veteran has a diagnosis of chronic headaches. A December 2018 DBQ with an accompanying nexus opinion completed by a qualified clinician notes that the Veteran’s headaches began during service while stationed in Germany and have increased in both frequency and severity since that time. The clinician opined that the Veteran’s migraine headaches were precipitated and aggravated by his service-connected PTSD. The clinician cited to a study which shows that depression and anxiety disorders are associated with migraine headaches. Further, the study notes that stress can be a predisposing factor that contributes to a headache disorder’s onset and can accelerate the progression of a headache disorder into a chronic condition while also exacerbating it. Analysis As there are no conflicting medical opinions of record the Board finds that the December 2018 DBQ is the most probative evidence of record. The clinician’s findings were supported by peer-reviewed studies and demonstrated significant familiarity with the Veteran’s medical history. Accordingly, the preponderance of the evidence is in favor of finding that the Veteran’s migraine headaches are proximately aggravated by his service-connected PTSD and a grant of service connection on a secondary basis is warranted. 4. Tinnitus Factual Background The Veteran contends generally that his tinnitus was caused by noise exposure in service. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. Certain chronic diseases, including tinnitus, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from service, even though there is no evidence of the disease during service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309(a); Fountain v. McDonald, 27 Vet. App. 258 (2015). An April 2015 VA audiological examination reflects that the Veteran has a current diagnosis of tinnitus. The examiner concluded that the Veteran’s tinnitus was less likely than not caused by or a result of military noise exposure because the Veteran reported its onset as ten years prior to the examination, over thirty-five years after separation from service. The examiner explained that tinnitus usually has its onset immediately or shortly after traumatic noise exposure. Analysis The Board finds that the preponderance of evidence weighs against the claim for service connection for tinnitus. At the outset, the Board notes that the preponderance of evidence is against a finding that the Veteran’s tinnitus manifested itself to a degree of disability of 10 percent or more within a year of his discharge from service in 1969. The one-year presumption for tinnitus under 38 C.F.R. §§ 3.307 and 3.309 is therefore not helpful. As noted, the Veteran did not report tinnitus symptoms until many years after service. This is probative evidence against presumptive service connection for tinnitus. Although the presumptive paths for establishing service connection are not available for the Veteran’s tinnitus, the claim could be granted if the three elements of direct service connection are shown by an equipoise standard of evidence. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). As for service connection on a direct basis, the April 2015 VA examiner’s opinion is the most probative evidence of record as to whether the Veteran’s current tinnitus is related to active duty. The examiner’s rationale is logical, well-reasoned and based on consideration of the entire record, including the history of the condition as reported by the Veteran himself, as well as the STRs. The examiner’s opinion that the Veteran’s tinnitus is not caused by his active service is consistent with the many years between when his active service ended and when tinnitus symptoms were first reported. Further, there are no contradictory medical opinions of record. The Board is satisfied that the VA examiner’s opinion is adequate for deciding this appeal. In this case, the Board must conclude that the weight of the evidence is against the claim of service connection for tinnitus. The preponderance of the evidence is against the Veteran’s claim and, thus, the benefit-of-the-doubt provision does not apply. Accordingly, service connection for tinnitus is not warranted. Increased Ratings Legal Criteria – Increased Ratings Generally Disability ratings are based on average impairment in earning capacity resulting from a particular disability and are determined by comparing symptoms shown with criteria in VA’s Schedule for Rating Disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. When there is a question as to which of two ratings to apply, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating, otherwise the lower rating shall be assigned. 38 C.F.R. § 4.7. The Board has reviewed all evidence in the claims file, with an emphasis on the evidence relevant to these appeals. Although the Board must provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The Board will summarize the relevant evidence as appropriate and the analysis will focus on what the evidence shows, or fails to show, as to the claims. Consideration will be given to “staged ratings” since service connection was made effective. See Fenderson v. West, 12 Vet. App. 119 (1999). In other words, where the evidence contains factual findings demonstrating distinct periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of a staged rating would be necessary. Id. 6. Increased Rating for PTSD Rating Criteria for PTSD Psychiatric disorders are rated under 38 C.F.R. § 4.130, Diagnostic Code 9411. A 30 percent evaluation is warranted for occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal) due to such symptoms as: depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran’s capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. The use of the term “such as” in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The DSM-5 applies to claims certified to the Board on and after August 4, 2014. 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). The RO certified the Veteran’s appeal to the Board after that date; thus, DSM-5 is the governing directive and Global Assessment of Functioning (GAF) scores have not been considered; instead, the Board has considered the symptoms underlying such scores as opposed to the scores themselves. See Golden v. Shulkin, No. 16-1208, 2018 U.S. App. Vet. Claims LEXIS 202 (Vet. App. Feb. 23, 2018). Factual Background The Veteran is in receipt of a 30 percent rating from July 13, 2010 and a 70 percent rating from August 29, 2014 for his service-connected PTSD. The appeal period is from August 29, 2013, the date of his increased rating claim, plus the one-year “look back” period. Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010). A June 2015 VA psychological examination documented that the Veteran has a 48-year-old daughter that doesn’t speak to him because she “thinks he’s crazy.” He has several friends who he sees once a month, he has been living with a female friend for the past eight years. The Veteran noted that he last worked in 2007 and had to stop because he lost his wife and “couldn’t function anymore.” He further stated that he spends his time isolated at home, talking to himself and taking walks. The Veteran stated that he manages his symptoms by smoking marijuana and that he has dreams that someone is trying to kill him. He avoids people because he is “pissed off” and afraid of hurting them. The Veteran’s symptoms were noted as depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, difficulty maintaining effective work and social relationships and difficulty adapting to stressful circumstances, including work or a work-like setting. The Veteran was noted to be alert, cooperative and well-groomed. The examiner state that his PTSD had not changed in severity since his last evaluation in 2010. A July 2016 DBQ completed in conjunction with a mental status examination noted that the Veteran’s PTSD causes total occupational and social impairment. The Veteran had diminished interest or participation in significant activities, feelings of detachment or estrangement from others, restricted range of affection and a sense of foreshortened future. He also had difficulty falling asleep, irritability with outbursts of anger, difficulty concentrating, hypervigilance and exaggerated startle response. The Veteran also now was noted to suffer from near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, mild memory loss and flattened affect. The Veteran stated to the clinician that he no longer enjoyed the simplest of activities. A mental status examination revealed variable concentration with difficulties in short and long-term memory with struggles to remember basic information. The Veteran’s judgment was noted to be below average. The Veteran was noted to be hypervigilant and suspicious during the interview. The examiner opined that his PTSD and social impairment and emotionally debilitating. Analysis A. Prior to July 21, 2016 Upon careful review and consideration of the evidence of record the Board finds that, prior to July 21, 2016, the Veteran’s service-connected PTSD caused social and occupational impairment with deficiencies in most areas, such as work (he last worked in 2007 and stated he “couldn’t function anymore), family relations (he is estranged from his daughter), thinking (he has intrusive thoughts and short-term memory problems), and mood (he experiences depression and anger). However, the Board finds that the Veteran’s acquired psychiatric disorder symptoms exhibited during this period do not meet the criteria for a 100 percent disability rating. Although the Veteran’s symptoms are certainly severe, the evidence of record does not establish that they rise to the level of total occupational and social impairment during this period. The July 2015 VA examination indicated that he was able to interact with a few other people and was generally able to perform activities of daily living, manage his household, and care for himself. Although the Board acknowledges the Veteran’s symptoms and their significant effect on his life, they did not, at this time, rise to the level of total social and occupational impairment. Therefore, the Board finds that prior to July 21, 2016, the Veteran’s service-connected acquired psychiatric disorder symptoms did not meet the criteria for a 100 percent disability rating. B. From July 21, 2016 During the July 2016 mental status examination, the clinician noted that the Veteran’s PTSD symptoms caused total occupational and social impairment. In addition to the symptoms discussed above, the Veteran’s PTSD was characterized as causing flattened affect and near-continuous panic or depression affecting the ability to function independently. The mental status examination also revealed variable concentration with difficulties in short and long-term memory with struggles to remember basic information, showing an increase in severity in thinking impairment from the July 2015 VA examination. The Veteran’s judgment was now noted to be below average, indicating that his symptoms had worsened to the point of causing impaired judgment. It was noted that the Veteran was still able to perform most activities of daily living including managing his household and maintaining appropriate personal hygiene. However, the Veteran was noted to be completely socially isolated and unable to sustain the stress from a competitive work environment or be expected to engage in gainful activity due to his PTSD symptoms. Resolving reasonable doubt in the Veteran’s favor, the medical evidence of record as of July 21, 2016 established that the Veteran’s PTSD symptoms had worsened to the point of causing total occupational and social impairment warranting a 100 percent disability rating. 6. TDIU prior to July 21, 2016 A TDIU rating is warranted when, due to service-connected disabilities, a Veteran is unable to obtain or maintain a substantially gainful occupation. See 38 C.F.R. §§ 3.340, 3.341, 4.16. The central inquiry is whether the Veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability. See Hatlestad v. Brown, 5 Vet. App. 524 (1993). Consideration may be given to the Veteran’s level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.340, 3.341, 4.16; Van Hoose v. Brown, 4 Vet. App. 361 (1993). To meet the criteria for a schedular TDIU rating, the Veteran must have either: (i) one disability rated at 60 percent or more; or (ii) two or more disabilities, with at least one disability rated at 40 percent or more and sufficient additional disability bringing the combined rating to at least 70 percent. 38 C.F.R. § 4.16(a). Factual Background The Veteran was assigned a 70 percent rating for PTSD from August 29, 2014. Thus, the percentage criteria are met for a schedular TDIU rating and the only question is whether a TDIU rating is substantively warranted. The Veteran’s post-service work history indicates that the Veteran last worked full-time running a hot dog vending business out of his driveway in 2007. The Veteran stated that he could no longer maintain this occupation because he could no longer function normally. See 2015 VA examination report. During a May 2015 VA psychological examination, the Veteran’s PTSD symptoms were assessed as causing occupational and social deficiencies in most areas including work, judgment and thinking or mood. The Veteran stated that he does not talk to anyone and that he actively avoids people. It was noted, among other symptoms, that the Veteran would have difficulty in adapting to stressful circumstances, including work or a worklike setting. An inability to establish and maintain effective relationships was also indicated. An “Employability Review” section of a July 2016 mental status examination found that the Veteran could not sustain the stress from a competitive work environment or be expected to engage in gainful activity due to his PTSD. Mood swings were noted to be a potential issue in establishing a healthy work life. The Veteran stated that would be unable to establish meaningful occupational relationships because he is unable to trust others. Ongoing anxiety issues were noted to be a potential safety hazard on the job. The examining clinician cited to peer-reviewed studies finding a connection between PTSD and unemployment related to the presence of a sense of foreshortened future, a symptom the Veteran was noted to have. In sum, the clinician opined that the Veteran’s PTSD symptoms prevent him from maintaining substantially gainful employment. Analysis In light of the above, the Board finds that the evidence reasonably shows that the Veteran’s service-connected PTSD precludes obtaining or following substantially gainful employment. Therefore, the Board finds that a TDIU rating is warranted for the period prior to July 21, 2016. Regarding entitlement to a TDIU rating from July 21, 2016, a TDIU rating is provided where the combined schedular evaluation for service-connected diseases and disabilities is less than total, that is, less than 100 percent. 38 C.F.R. § 4.16 (a). A 100 percent rating under the Schedule for Rating Disabilities means that a Veteran is totally disabled. Holland v. Brown, 6 Vet. App. 443, 446 (1994), citing Swan v. Derwinski, 1 Vet. App. 20, 22 (1990). Thus, if VA has found a Veteran to be totally disabled as a result of a particular service-connected disability or combination of disabilities pursuant to the rating schedule, there is no need, and no authority, to rate that Veteran totally disabled on any other basis. See Herlehy v. Principi, 15 Vet. App. 33, 35 (2001) (finding request for TDIU moot where 100 percent schedular rating was awarded for the same period). Thus, entitlement to a TDIU rating is moot from July 21, 2016 because a 100 percent schedular evaluation is being assigned for the service-connected PTSD for that period. 7. An effective date prior to July 13, 2010 for service connection for PTSD The Board acknowledges that the Veteran raised the issue of an earlier effective date for service connection for PTSD in a May 2015 NOD in response to an April 2015 rating decision that denied the Veteran’s increased rating claim. This matter was then addressed in a May 2018 SOC. The Veteran submitted a substantive appeal indicating that he wished to appeal his current evaluation for PTSD and the effective date of the grant of service connection. The October 2010 rating decision granting service connection for PTSD with an effective date of July 13, 2010 became final because it was not timely appealed. Once the decision assigning an effective date has become final, the effective date cannot be challenged with a “freestanding” earlier effective date claim. Rudd v. Nicholson, 20 Vet. App. 296 (2006). Rather, if a claimant believes he is entitled to an effective date earlier than that assigned in a RO decision, the claimant must file a timely appeal to that decision in which the effective date was assigned or submit new and material evidence within the one-year appeal period. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156 (b), 20.201, 20.302. Otherwise, once the decision has become final, the only way to challenge the effective date is to submit a motion to revise the decision on the basis of clear and unmistakable error (CUE) in the decision assigning the effective date, the revision of that decision would result in an earlier effective date. 38 U.S.C. § 5109A; 38 C.F.R. § 3.105; Rudd, 20 Vet. App. 296 at 299. A freestanding claim for an earlier effective date vitiates the rule of finality and must be dismissed. Rudd, 20 Vet. App. 296 at 299-300. In this case, the Veteran did not file a timely appeal or submit new and material evidence within a year of the October 2010 rating decision. The Veteran has not submitted a motion alleging CUE in the decision assigning the effective date. As such, the Veteran’s freestanding claim for an earlier effective date for the grant of service connection for PTSD must be dismissed. VICTORIA MOSHIASHWILI Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. McKone, Attorney for the Board The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.