Citation Nr: 21003957 Decision Date: 01/25/21 Archive Date: 01/25/21 DOCKET NO. 18-32 598 DATE: January 25, 2021 ORDER Entitlement to service connection for posttraumatic stress disorder (PTSD) is denied. Entitlement to an initial disability rating of 40 percent for service-connected residuals of traumatic brain injury is granted. Entitlement to an initial 10 percent disability rating for scars associated with residuals of TBI is granted. Entitlement to a disability rating in excess of 20 percent for service-connected residuals, left ankle fracture with multiple surgeries and tarsal tunnel release is denied. Entitlement to an effective date prior to April 17, 2018 for the award of an increased 50 percent disability rating for service-connected post-traumatic headaches is denied. Entitlement to special monthly compensation based on the need for regular aid and attendance is denied. Entitlement to special monthly compensation at the housebound level is granted from April 24, 2012 to present. Eligibility for financial assistance in the purchase of one automobile or other conveyance and/or adaptive equipment is denied. REMANDED Entitlement to service connection for a left foot disability is remanded. Entitlement to service connection for a left hip condition is remanded. Entitlement to a compensable disability rating for service-connected hypertension is remanded. FINDINGS OF FACT 1. The preponderance of the evidence of record is against finding that the Veteran has had PTSD at any time during or approximate to the pendency of the claim. 2. Resolving all reasonable doubt in the Veteran’s favor, the Veteran’s TBI residuals have manifested in, at most, objective evidence on testing of mild impairment of memory, attention, concentration, or executive functions resulting in mild functional impairment; prior to April 17, 2018, the evidence does not demonstrate that residual headaches manifested with characteristic prostrating attacks averaging one in 2 months over the past several months; the Veteran is in receipt of a 100 percent disability rating for major depressive disorder for the entirety of the relevant appeal period. 3. Resolving all reasonable doubt in the Veteran’s favor, his tracheotomy scar has resulted in one characteristic of disfigurement throughout the relevant appeal period; the head and neck scars are not painful. 4. The Veteran’s service-connected residuals, left ankle fracture with multiple surgeries and tarsal tunnel release is rated as 20 percent disabling, which is the maximum schedular rating permitted for limited motion of the ankle; the Veteran’s left ankle disability has not resulted in ankylosis of the joint. 5. Prior to April 17, 2018, the evidence does not demonstrate that post-traumatic headaches manifested in characteristic prostrating attacks averaging one in 2 months over the past several months. 6. The Veteran's service-connected disabilities do not render him so helpless as to require the regular aid and attendance of another person to perform personal care functions of everyday living or to protect him from the hazards and dangers incident to his daily environment. 7. After implementation of this decision, the Veteran may be considered to have one service-connected disability rated as total with additional separate service-connected disability rated as 60 percent or more disabling for the entirety of the appeal period. 8. The Veteran’s service-connected disabilities do not result in the physical loss or permanent loss of use of one or both hands or feet, permanent impairment of vision in both eyes with corrected central visual acuity of 20/200 or less in the better eye or central visual acuity of more than 20/200 with a visual field defect of a degree specified by regulation, severe burn injury, amyotrophic lateral sclerosis, or ankylosis of one or both knees or hips. CONCLUSIONS OF LAW 1. The criteria for service connection for PTSD are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for the assignment of an initial 40 percent rating, but no higher, for service-connected TBI residuals, on the basis of Level 2 cognitive impairment, not otherwise classified, have been most nearly approximated since the effective date of the grant of service connection. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 4,1, 4.3, 4.7, 4.124a, Diagnostic Code 8045. 3. The criteria for a disability rating of 10 percent, but no higher, for scars associated with TBI have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.118, Diagnostic Code 7800. 4. The criteria for a rating in excess of 20 percent for service-connected residuals, left ankle fracture with multiple surgeries and tarsal tunnel release have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3. 4.7, 4.45, 4.59, 4.71a, Diagnostic Codes 5270, 5271. 5. The criteria for an effective date prior to April 17, 2018 for the award of an increased 50 percent disability rating for service-connected post-traumatic headaches have not been met. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 3.155, 3.400, 4.1, 4.3, 4.7, 4.124a, Diagnostic Codes 8045, 8100. 6. The criteria for SMC based on the need for regular aid and attendance are not met. 38 U.S.C. §§ 1114; 38 C.F.R. §§ 3.350, 3.352. 7. The criteria for SMC based on statutory housebound status have been met from April 24, 2012. 38 U.S.C. §§ 1114; 38 C.F.R. §§ 3.350, 3.352. 8. The criteria for establishing eligibility for financial assistance in the purchase of an automobile or other conveyance and/or automobile adaptive equipment are not met. 38 U.S.C. §§ 3901, 3902, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.350, 3.808. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from October 1992 to April 2004. These matters come before the Board of Veterans’ Appeals (Board) on appeal from rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). The RO denied the Veteran’s claim for service connection for traumatic brain injury in October 2012. The Veteran appealed, and in a May 2015 decision, the Board denied the claim. The Veteran appealed this denial to the Court of Appeals for Veterans Claims (Court), and in an April 2016 Order, the Court granted the parties’ Joint Motion for Partial Remand (JMPR), vacating the Board’s decision as to the denial of service connection for TBI, and remanded the matter to the Board for action consistent with the JMPR. The Board then remanded the matter in August 2016, before granting service connection for TBI in a September 2017 decision. In a June 2019 decision, the Board denied the Veteran’s claim of entitlement to service connection for a left foot disability. The Veteran appealed this decision, and in a June 2020 Order, the Court granted the parties’ JMPR, vacated the Board’s decision, and remanded the matter to the Board for action consistent with the JMPR. In an April 2018 rating decision, the RO granted service connection for scar on head/scalp and assigned a noncompensable evaluation effective April 24, 2012. The Veteran submitted a Notice of Disagreement with the evaluation in June 2018. In a January 2020 Statement of the Case and rating decision, the RO granted an increased evaluation of 10 percent for scars on the head/scalp effective from January 4, 2020 on the basis of one characteristic of disfigurement of a depressed scar on the anterior neck. While the Veteran’s tracheotomy scar was previously listed as separate from the Veteran’s head/scalp scars, as the RO has considered it as part of the present claim, the Board will do so as well. The issue has been recharacterized above to allow the Veteran the most favorable review of the evidence. 1. Entitlement to service connection for posttraumatic stress disorder (PTSD) is denied. The Veteran asserts that he suffers from PTSD as a result of his military service. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). 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. The Board concludes that the Veteran does not have a current diagnosis of PTSD and has not had one at any time during the pendency of the claim or recent to the filing of the claim. See Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). It is further noted that the Veteran is presently in receipt of service connection benefits and a 100 percent disability rating for major depressive disorder for the span of the appeal period. The Veteran was provided with a VA mental health examination in March 2017. The VA examiner evaluated the Veteran and determined that his psychiatric symptoms warranted diagnoses of panic disorder and major depressive disorder (in partial remission). Of his panic symptoms, the Veteran reported continuing to have digestive issues that cause “panic attack” reactions when eating, reporting a sensation of his chest and heart closing up, racing heart, and shortness of breath. He also reported not taking regular medication for his anxiety, and having anxiety once a day; if his heart flutters, he is afraid he is going into AFib again. The examiner opined that the Veteran had developed another diagnosis since being granted service connection for major depressive disorder. He indicated that the Veteran had developed panic disorder, and that it appears that his anxiety peaks when he is concerned about re-occurrence of potential medical issues such as being in “afib” or having gastrointestinal distress. There is no indication in the examination report that the Veteran asserted that the panic relates to his military history. The claims file additionally includes a VA psychiatric initial assessment treatment record from August 2017. It was noted that the Veteran was referred for ongoing depression, anxiety, and PTSD management. The stressor indicated was relationship problems. The Veteran denied anxiety in open spaces, closed areas, shopping line, public transportation, and being alone outside the home. He reported imagining threats and always staying alert in public. Under PTSD history, the examination report has a box checked indicating that the Veteran denied any significant exposure to traumatic, threatening, or violent incidents, but then includes a narrative addition that “[p]atient has history of exposure to significant traumatic, threatening, and violence incidences in life.” It also notes that he was exposed to repeated stressful traumatic events, described as “ankle injury in service.” Boxes were not checked for the following: symptoms of intrusive thoughts related to traumatic event; persistent avoidance behavior; avoidance of external reminders of traumatic events; negative cognition changes related to traumatic event; detached feelings from others; and alteration in mood and arousal symptoms. The Veteran was provided with a PTSD screen, which was negative; the Veteran denied having a traumatic experience about which he had any nightmares or thought about when he didn’t want to, tried hard not to think about or went out of his way to avoid situations that reminded him of it, was constantly on guard, watchful, or easily startled, or felt numb or detached from others, activities or his surroundings. The Board notes that a November 2006 VA psychiatry individual mental health clinic note indicated that the Veteran had “elements of ptsd/TBI due to a head injury,” but finds the March 2017 and August 2017 reports more probative on the question of whether the Veteran has a current diagnosis of PTSD, as it addressed the criteria necessary for a PTSD diagnosis. That the VA examiner addressed the Veteran’s panic symptoms, and specifically found that they were associated with present health concerns rather than to any in-service stressor is also found to be highly probative. While the Veteran believes he has a current diagnosis of PTSD, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires assessment of the stressors and symptom presentation under the diagnostic criteria laid out in the Diagnostic and Statistical Manual of Mental Disorders (DSM). See Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Further, the Veteran has another diagnosed mental health disability, major depressive disorder, for which service connection has already been awarded. Consequently, the Board gives more probative weight to the competent medical evidence of record. A preponderance of the evidence is thus found to weigh against the Veteran’s claim for service connection for posttraumatic stress disorder. The weight of the evidence being against the claim, there is no reasonable doubt to be resolved in the Veteran’s favor. Increased Ratings Ratings are based on a schedule of reductions in earning capacity from specific injuries or combination of injuries. The ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civilian occupations. 38 U.S.C. § 1155. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 2. Entitlement to an initial disability rating of 40 percent for service-connected residuals of traumatic brain injury (TBI) is granted. In a September 2017 rating decision, the RO implemented the Board’s September 2017 decision granting service connection for residuals of TBI, and assigned a 40 percent evaluation from April 24, 2012 and a noncompensable evaluation from March 7, 2017. The Veteran appealed, seeking a higher initial disability rating. The Veteran’s residuals of TBI are rated under 38 C.F.R. § 4.124a, Diagnostic Code 8045. DC 8045 states that there are three main areas of dysfunction that may result from traumatic brain injuries and have profound effects on functioning: cognitive (which is common in varying degrees after a traumatic brain injury), emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation. Here, in accordance with DC 8045, the Veteran has already been assigned separate evaluations for major depressive disorder, rated as 100 percent disabling throughout the relevant appeal period, and post-traumatic headaches, rated as 50 percent disabling from April 17, 2018. 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 these brain functions may be affected in a given individual with cognitive impairment, and some functions may be affected more severely than others. In an individual, symptoms may fluctuate in severity from day to day. Cognitive impairment is evaluated under the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." 38 C.F.R. § 4.124a, DC 8045. Subjective symptoms may be the only residual of a traumatic brain injury or may be associated with cognitive impairment or other areas of dysfunction. Subjective symptoms that are residuals of a traumatic brain injury, whether or not they are part of cognitive impairment, are evaluated 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, should be rated separately 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. Id. 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 evaluated under the criteria in the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." Id. Physical (including neurological) dysfunction is evaluated 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. Id. The preceding list of types of physical dysfunction does not encompass all possible residuals of a traumatic brain injury; unlisted residuals reported on examination are to be evaluated under the most appropriate diagnostic code. Each condition is evaluated separately, as long as the same signs and symptoms are not used to support more than one evaluation, and combine under 38 C.F.R. § 4.25 the evaluations for each separately rated condition. The evaluation assigned based on the "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" table will be considered the evaluation for a single condition for purposes of combining with other disability rating. Id. Cognitive impairment and subjective symptoms are evaluated using the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" which contains ten important facets of a traumatic brain injury related to cognitive impairment and subjective symptoms. That table provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and a fifth level, the highest level of impairment, and 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, because any level of impaired consciousness would be totally disabling. A 100 percent rating is to be assigned if total is the level of evaluation for one or more facets. If no facet is evaluated as total, the overall percentage rating is based on the level of the highest facet. If the highest is 0, a 0 percent rating is assigned. If the highest is 1, a 10 percent rating is assigned. If the highest is 2, a 40 percent rating is assigned. If the highest is 3, a 70 percent rating is assigned. Id. 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 evaluated under another Diagnostic Code. In such cases, more than one evaluation based on the same manifestations is not to be assigned. If the manifestations of two or more conditions cannot be clearly separated, a single evaluation 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 evaluation is assigned for each condition. Id., Note (1). 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. Id., Note (2). 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. Id., Note (3). The terms mild, moderate, and severe traumatic brain injury, which may appear in medical records, refer to a classification of traumatic brain injury 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. Id., Note (4). The table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" provides the following evaluations: Impairment of memory, attention, concentration, executive functions are assigned numerical designations of 0 for no complaints of impairment of memory, attention, concentration, or executive functions; 1 for a complaint of mild loss of memory (such as having difficulty following a conversation, recalling recent conversations, remembering names of new acquaintances, or finding words, or often misplacing items), attention, concentration, or executive functions, but without objective evidence on testing; 2 for objective evidence on testing of mild impairment of memory, attention, concentration, or executive functions resulting in mild functional impairment; 3 for objective evidence on testing of moderate impairment of memory, attention, concentration, or executive functions resulting in moderate functional impairment; and total for objective evidence on testing of severe impairment of memory, attention, concentration, or executive functions resulting in severe functional impairment. Impairment of judgment is assigned numerical designations of 0 for normal; 1 for mildly impaired judgment for complex or unfamiliar decisions, occasionally unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision; 2 for moderately impaired judgment, for complex or unfamiliar decisions, usually unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision, although has little difficulty with simple decisions; 3 for moderately severely impaired judgment, for even routine and familiar decisions, occasionally unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision; and total for severely impaired judgment, for even routine and familiar decisions, usually unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision, for example, unable to determine appropriate clothing for current weather conditions or judge when to avoid dangerous situations or activities. Impairment of social interaction is assigned numerical designations of 0 for social interaction is routinely appropriate; 1 for social interaction is occasionally inappropriate; 2 for social interaction is frequently inappropriate; and 3 for social interaction is inappropriate most or all of the time. Impairment of orientation is assigned numerical designations of 0 for always oriented to person, time, place, and situation; 1 for occasionally disoriented to one of the four aspects (person, time, place, situation) of orientation; 2 for occasionally disoriented to two of the four aspects of orientation or often disoriented to one aspect of orientation; 3 for often disoriented to two or more of the four aspects of orientation; and total for consistently disoriented to two or more of the four aspects of orientation. Impairment of motor activity (with intact motor and sensory system) is assigned numerical designations of 0 for motor activity normal; 1 for motor activity normal most of the time, but mildly slowed at times due to apraxia (inability to perform previously learned motor activities, despite normal motor function); 2 for motor activity mildly decreased or with moderate slowing due to apraxia; 3 for motor activity moderately decreased due to apraxia; and total for motor activity severely decreased due to apraxia. Impairment of visual spatial orientation is assigned numerical designations of 1 for mildly impaired, occasionally gets lost in unfamiliar surroundings, has difficulty reading maps or following directions, is able to use assistive devices such as GPS (global positioning system); 2 for moderately impaired, usually gets lost in unfamiliar surroundings, has difficulty reading maps, following directions, and judging distance, has difficulty using assistive devices such as GPS; 3 for moderately severely impaired, gets lost even in familiar surroundings, unable to use assistive devices such as GPS; and total for severely impaired, may be unable to touch or name own body parts when asked by the examiner, identify the relative position in space of two different objects, or find the way from one room to another in a familiar environment. Subjective symptoms are assigned numerical designations 0 for subjective symptoms that do not interfere with work, instrumental activities of daily living, or work, family, or other close relationships, examples are mild or occasional headaches, mild anxiety; 1 for three or more subjective symptoms that mildly interfere with work; instrumental activities of daily living; or work, family, or other close relationships, examples of findings that might be seen at this level of impairment are: intermittent dizziness, daily mild to moderate headaches, tinnitus, frequent insomnia, hypersensitivity to sound, hypersensitivity to light; and 2 for three or more subjective symptoms that moderately interfere with work; instrumental activities of daily living; or work, family, or other close relationships, examples of findings that might be seen at this level of impairment are: marked fatigability, blurred or double vision, headaches requiring rest periods during most days. Neurobehavioral effects are assigned numerical designations of 0 for one or more neurobehavioral effects that do not interfere with workplace interaction or social interaction (examples of neurobehavioral effects are irritability, impulsivity, unpredictability, lack of motivation, verbal aggression, physical aggression, belligerence, apathy, lack of empathy, moodiness, lack of cooperation, inflexibility, and impaired awareness of disability, any of these effects may range from slight to severe, although verbal and physical aggression are likely to have a more serious impact on workplace interaction and social interaction than some of the other effects); 1 for one or more neurobehavioral effects that occasionally interfere with workplace interaction, social interaction, or both but do not preclude them; 2 for one or more neurobehavioral effects that frequently interfere with workplace interaction, social interaction, or both but do not preclude them; and 3 for one or more neurobehavioral effects that interfere with or preclude workplace interaction, social interaction, or both on most days or that occasionally require supervision for safety of self or others. Impairment of communication is assigned numerical designations of 0 for able to communicate by spoken and written language (expressive communication), and to comprehend spoken and written language; 1 for comprehension or expression, or both, of either spoken language or written language is only occasionally impaired, can communicate complex ideas; 2 for inability to communicate either by spoken language, written language, or both, more than occasionally but less than half of the time, or to comprehend spoken language, written language, or both, more than occasionally but less than half of the time, can generally communicate complex ideas; 3 for inability to communicate either by spoken language, written language, or both, at least half of the time but not all of the time, or to comprehend spoken language, written language, or both, at least half of the time but not all of the time, may rely on gestures or other alternative modes of communication, able to communicate basic needs; and total for complete inability to communicate either by spoken language, written language, or both, or to comprehend spoken language, written language, or both, unable to communicate basic needs. Impairment of consciousness is assigned a designation of total for persistently altered state of consciousness, such as vegetative state, minimally responsive state, coma. On VA TBI examination in August 2012, the Veteran was found to have objective evidence on testing of mild impairment of memory, attention, concentration, or executive functions resulting in mild functional impairment. The Veteran was noted as always being oriented to person, time, place, and situation, able to communicate by spoken and written language with normal judgment, visual spatial orientation, motor activity, and consciousness. The Veteran's social interaction was noted as being routinely appropriate. The Veteran was also noted as having subjective symptoms that do not interfere with work; instrumental activities of daily living; or work, family, or other close relationships. The Veteran had no neurobehavioral effects. The Veteran was also noted to have subjective symptoms of headaches. The Veteran's TBI was found not to impact his ability to work. A separate VA headache examination report was completed, and recorded the Veteran’s report of headaches 2-3 times a day which are improved with Motrin. Headache pain was described as pain in the middle of the head and feeling like “brain is about to burst in the middle of the skull,” occasionally making him need to lay down to get relief from headaches. He also reported not seeing any physician regarding his headaches. At a VA TBI examination in March 2017, the Veteran reported mental health problems beginning after his ankle injury in 2002 and when he “admitted to” headaches and complained of memory issues. On examination, the Veteran was found to have no complaints of memory, attention, concentration, or executive functions. The Veteran was noted as always being oriented to person, time, place, and situation, able to communicate by spoken and written language with normal judgment, visual spatial orientation, motor activity, and consciousness. The Veteran's social interaction was noted as being routinely appropriate. The Veteran was further noted as not having subjective symptoms or other pertinent physical findings. The examiner noted that neuropsychological testing had been performed, and that the Veteran scored 28/30- Normal Mini-Mental Status Exam (MMSE). The Veteran's TBI was found not to impact his ability to work. The examiner concluded that “there is no absolute convincing evidence that his actual brain was injured,” and indicated that there were no residuals of a speculative TBI. On VA TBI examination in October 2018, the Veteran reported current symptoms including frequent daily headaches of varying degrees of intensity, memory problems, inattentiveness, and photosensitivity. On examination, the Veteran was found to have objective evidence on testing of mild impairment of memory, attention, concentration, or executive functions resulting in mild functional impairment. The Veteran was noted as occasionally being disoriented to one of the four aspects (person, time, place, and situation), able to communicate by spoken and written language with normal judgment, visual spatial orientation, motor activity, and consciousness. The Veteran's social interaction was noted as being routinely appropriate. The Veteran was also noted as having three or more subjective symptoms, specified as frequent headaches most days, memory problems, inattentiveness, and photosensitivity, that moderately interfere with work; instrumental activities of daily living; or work, family, or other close relationships. The Veteran had no neurobehavioral effects. The Veteran’s subjective symptoms were also noted to be related to residuals of headaches and mental disorder attributable to a TBI. The examiner noted that both 2012 and 2017 VA examinations utilized MMSE testing, with score of 28/30, but explained that MMSE is more sensitive for picking up dementia, while other tests are better at assessing mild neurocognitive disorder. He stated that mild neurocognitive disorder was found at the time of the October 2018 examination utilizing one of these other tests, with a score of 22/30. The Veteran was noted to struggle most in the areas of delayed recall, language, and orientation, which the examiner commented were all essential functions for many occupations. The examiner stated that these impairments have the potential to negatively impact communication and work efficiency. A separate VA headache examination report was completed in September 2018, which noted very prostrating and prolonged attacks of migraines/non-migraine pain productive of severe economic inadaptability. On VA TBI examination in March 2020, the Veteran reported memory problems such that he cannot follow movies and forgets what is being discussed in conversations. On examination, the Veteran was found to have objective evidence on testing of mild impairment of memory, attention, concentration, or executive functions resulting in mild functional impairment. The Veteran was noted as always oriented to person, time, place, and situation, able to communicate by spoken and written language with normal judgment, visual spatial orientation, motor activity, and consciousness. The Veteran's social interaction was noted as being routinely appropriate. The Veteran was noted as having no subjective symptoms and no neurobehavioral effects. The Veteran was noted as having memory issues as residual of TBI but also as related to behavioral health. The functional impact of his TBI was an expected 2-4 weeks lost work time over the past 12 months, and that memory issues would impact his ability to work. The Board finds that when resolving all reasonable doubt in the Veteran’s favor, the record supports the assignment of a 40 percent evaluation under DC 8045 for residuals of TBI for the duration of the relevant appeal period, April 2012 to present. Considering the 10 facets discussed under the pertinent diagnostic code, the Veteran will be assigned a 40 percent rating which is commensurate with a severity of “2,” on the basis of objective evidence on testing of mild impairment of memory, attention, concentration, or executive functions resulting in mild functional impairment. Such was found at TBI examinations in August 2012, October 2018, and March 2020. While the March 2017 examination report indicates that there was no complaint of memory problems and normal MMSE, this appears to disregard the Veteran’s lay statements of memory impairment, and the October 2018 examination report includes a persuasive explanation for why MMSE testing may appear normal while not adequately reflecting mild neurocognitive disorder. A higher 70 percent evaluation under DC 8045 is not found warranted. During the appeal period, the evidence of record does not show that the Veteran had abnormal communication, consciousness, judgment, motor activity, neurobehavioral symptoms, inappropriate social interaction, or disorientation that was more than occasional. Thus, the Board finds that the competent medical evidence, when consider against all relevant evidence, weighs against a finding that the Veteran's level of impairment was severe enough to warrant an impairment of level 3 or higher. Thus, the evidence of record does not support a rating in excess of 40 percent at any time during the relevant appeal period. Consideration has also been given to whether higher separate evaluations are warranted under other diagnostic codes for subjective, emotional, and/or physical symptoms associated with TBI. As noted above, the Veteran is presently in receipt of a 100 percent disability rating for major depressive disorder, which is the maximum available, throughout the relevant appeal period. As will be discussed in greater detail below, a separate compensable disability rating for post-traumatic headaches prior to April 17, 2018 has been considered, but is not found warranted. No other relevant diagnostic codes are indicated by the evidence of record. In summation, the weight of the evidence supports the award of an initial 40 percent evaluation, but no higher, for TBI residuals under DC 8045 for the entirety of the appeal period. A preponderance of the evidence weighing against the assignment of an even higher, 70 percent disability rating, there is no reasonable doubt to resolve in the Veteran’s favor. 3. Entitlement to an initial 10 percent disability rating, but no higher for residual scars associated with TBI is granted throughout the relevant appeal period. The Veteran contends that he is entitled to a higher initial disability rating for his residual scars associated with TBI “head scars” because he asserts that the scars on his scalp are painful. The Veteran’s head scars are currently rated under 38 C.F.R. § 4.118, Diagnostic Code 7800, for 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. VA amended the criteria for rating skin disabilities effective from August 13, 2018. However, diagnostic code 7800 was not changed by the August 13, 2018, amendments. Under Diagnostic Code 7800, one characteristic of disfigurement warrants a 10 percent rating. A scar with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement warrants a 30 percent rating. A scar with 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 warrants a 50 percent rating. A scar with visible or palpable tissue loss and either gross distortion 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 warrants an 80 percent rating. 38 C.F.R. § 4.118. Note 1 to Diagnostic Code 7800 lists the eight characteristics of disfigurement: a scar 5 or more inches in length; a scar at least one-quarter inch wide at widest part; surface contour of scar elevated or depressed on palpation; scar adherent to underlying tissue; skin hypo- or hyper-pigmented in an area exceeding six square inches; skin texture abnormal in an area exceeding six square inches; underlying soft tissue missing in an area exceeding six square inches; and, skin indurated and inflexible in an area exceeding six square inches. Id. Note 5 specifies that the characteristics of disfigurement may be caused by one scar or by multiple scars, and need not be caused by a single scar to qualify for that evaluation. When resolving all reasonable doubt in the Veteran’s favor, the Board finds that a 10 percent disability rating is warranted for the entirety of the appeal period (April 24, 2012 to present) on the basis of scars of the head, face or neck resulting in one characteristic of disfigurement. Specifically, a January 2020 VA examination report documents one scar at the anterior neck from trachea placement which is slightly indented. While prior examination reports do not indicate that this scar was depressed or had missing underlying soft tissue, the Board finds it at least as likely as not that the minor depression of the scar noted by the January 2020 examiner was present throughout the appeal period. The Board finds that the preponderance of the evidence is against the assignment of a rating in excess of 10 percent under Diagnostic Code 7800 because the Veteran does not have visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features, or; two or three characteristics of disfigurement. At VA examinations performed in August 2012, September 2018, and January 2020, the Veteran’s individual scars were found, at most, to have a length of 7 cms and a width of 0.2 cm, and none were found to adhere to the underling tissue or result in hypo- or hyper-pigmented skin in an area exceeding 6 square inches of hypo- or hyper-pigmented skin, missing underlying soft tissue, or indurated and inflexible skin. A preponderance of the evidence is thus against an award of a disability rating in excess of 10 percent under DC 7800. The Board has also considered the other diagnostic codes pertaining to scars. However, the Veteran’s scars are not deep and non-linear and are not associated with underlying soft tissue damage. Although superficial and not associated with underlying soft tissue damage, they do not cover an area or areas of 144 square inches or greater. Therefore, Diagnostic Codes 7801, 7802, both prior to and from August 13, 2018, are inapplicable. Finally, the evidence of record shows there are no other disabling effects not considered in a rating provided under Diagnostic Codes 7800-04 as contemplated under both pre- and post-August 13, 2018, Diagnostic Code 7805. The Board has specifically considered whether a higher initial disability rating may be available under DC 7804, on the basis of unstable or painful scar(s). Note (1) states that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (3) states that scars evaluated under DCs 7800, 7801, 7802, or 7805 may also receive an evaluation under DC 7804, when applicable. The Veteran submitted a statement in May 2018 indicating that the scars on the top of his head are very painful, especially when washing or touching his scalp. At the September 2018 VA contract examination, the examiner indicated that the Veteran had 5 or more scars of the head, face, or neck which were painful and unstable, recording the Veteran’s reports of pain when combing his hair which prevent him from wearing hats and flaking of the scar that looks like dandruff. Despite checking the boxes for 5 or more scars that were painful and unstable, the examiner only identified the measurements and location of one scar, at the posterior scalp. At the January 2020 VA examination, the examiner noted that the Veteran reported that his scalp scars are tender, and painful if using a hairbrush, shampooing, or wearing hats. The Veteran also reported that his skin is dry, and he has a lot of flaking on the scars. In addressing the findings of the September 2018 examiner, the January 2020 examiner noted that the posterior scalp scar specified at that examination is found to be the skin in the posterior, proximal neck area that folds when the Veteran extends his head; and the Veteran self-reported that this “is not a scar from the TBI.” The January 2020 examiner further noted that there was no tenderness on palpation of the scalp scars on examination. The scars were all found to be well-healed, and the scalp skin flaking was not limited to the scarred areas. The examiner opined that it is less likely as not that the skin flaking is due to or related to the Veteran’s scalp scars, and are more likely due to an unrelated skin condition, i.e. tinea capitus/dandruff. The Board finds the January 2020 examination report to carry significant probative weight, as it provides a detailed description of each of the Veteran’s four scars, of the scalp and neck, considers the Veteran’s lay statements concerning his symptoms, and clearly explains the basis of the examiner’s findings as well as the inconsistencies from the September 2018 examination. While the Veteran reports that he has scalp pain when brushing or shampooing his hair and wearing hats, as well as flaking of the scar tissue, the Board considers the findings of the January 2020 examiner to be more probative, as they are the result of direct observation on manipulation of the scar tissue and explain that the flaking of the scalp is not limited to the scar tissue. While the Veteran is competent to report observable symptoms, such as pain, the evidence does not demonstrate that such symptoms are related to his scars, as opposed to an unrelated scalp condition. The Veteran’s treatment records are also silent as to any reported scar pain, somewhat lessening the credibility of the Veteran’s lay reports of pain. See Fed. R. Evid. 803 (4) (noting that statements made to physicians for the purposes of diagnosis and treatment are exceptionally trustworthy, and not excluded by the hearsay rule because the declarant has a strong motive to tell the truth in order to receive proper care); Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (“[R]ecourse to the [Federal] Rules [of Evidence] is appropriate where they will assist in the articulation of the Board’s reasons.”)). As the most probative evidence of record is found to weigh against a finding that the Veteran’s head and/or neck scars are unstable or painful, a separate compensable award under DC 7804 is not warranted. As a preponderance of the evidence is against such an award, there is no reasonable doubt to be resolved in the Veteran’s favor. In summation, the evidence of record is found to support an award of 10 percent under DC 7800, for scars with one characteristic of disfigurement, but no higher, throughout the relevant appeal period. 4. Entitlement to an effective date prior to April 17, 2018 for the award of an increased 50 percent disability rating for service-connected post-traumatic headaches is denied. In an October 2018 rating decision, the RO granted an increased 50 percent disability rating for service-connected post-traumatic headache, effective from April 17, 2018. The RO indicated that the effective date was assigned based on the date of an “intent to file,” as his completed claim was received within one year of that date. The Veteran’s post-traumatic headaches are considered to be a residual of his in-service TBI. The Veteran’s claim for a higher initial disability rating for TBI is thus also found to encompass an inferred claim for a higher evaluation on the basis of the separately-rated residuals. The Board will thus consider the severity and manifestations of the Veteran’s headaches from the date the Veteran filed his claim for service connection for TBI, April 2012, to the present. The Veteran’s headaches are rated by analogy under 38 C.F.R. § 4.124a, DC 8100. Under DC 8100, a noncompensable rating is warranted for migraine headaches with less frequent attacks. A 10 percent rating is warranted for headaches with characteristic prostrating attacks averaging one in 2 months over the last several months. A 30 percent rating is warranted for headaches with characteristic prostrating attacks occurring on average once a month over the last several months. A 50 percent rating is warranted for headaches with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. The rating criteria of DC 8100 are considered successive, meaning that a claimant cannot fulfill the criteria of the higher rating without fulfilling those of the next lower rating. Johnson v. Wilkie, 30 Vet. App. 245, 252 (2018). This renders 38 C.F.R. §§ 4.7 and 4.21 inapplicable. Johnson, 30 Vet. App. at 252. The phrase “characteristic prostrating attacks” is used in the criteria corresponding to 10 percent and 30 percent ratings under DC 8100 to describe the nature and severity of migraines, but it is not defined in the regulation. Pursuant to Dorland’s Illustrated Medical Dictionary 1531 (32d ed. 2012), prostration is defined as “extreme exhaustion or powerlessness.” Thus, the phrase “characteristic prostrating attacks” is understood to describe migraine attacks that typically produce extreme exhaustion or powerlessness. The Board concludes that, prior to April 2018, the Veteran’s post-traumatic headaches have resulting in prostrating attacks occurring less frequently than one in 2 months on average over the last several months, corresponding to the criteria for a noncompensable rating under DC 8100. At the August 2012 VA TBI examination, the Veteran reported headaches several times per day, which were later qualified by the examiner as mild or occasional headaches. They were not found to interfere with work or activities of daily living. An August 2012 VA headaches examination noted the Veteran experiences tension headaches, which he reported experiencing 2-3 times per day, each lasting for several hours which were improved with Motrin. He stated that he occasionally had to lay down to get relief from the headaches and had not seen any physician regarding his headaches. The report indicates that the Veteran did not have characteristic prostrating attacks of migraine or non-migraine type pain, and that there was no impact on his ability to work. In VA treatment records during this time, the Veteran largely denied experiencing headaches, except in July 2015, where a report of systems is notable for “+ headaches.” There does not appear to be any treatment focusing on complaints of headaches prior to April 2018. The Veteran is competent to report his readily observable symptoms, such as daily headaches. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, the lack of treatment sought for headache pain as well as the VA examiner’s finding that the Veteran did not have characteristic prostrating attacks, along with the Veteran’s statement that he only occasionally had to lay down to get relief from headaches seems to describe a severity and frequency of headaches that is closer to the disability picture contemplated by a noncompensable, rather than a 10 percent level under DC 8100. Accordingly, the Board concludes that a preponderance of the evidence demonstrates that the Veteran’s headaches occurred with prostrating attacks occurring less frequently than one every two months, on average, corresponding to the criteria for a noncompensable rating under DC 8100. Thus, a compensable rating under DC 8100 is not warranted prior to April 17, 2018. From April 17, 2018, the Veteran is in receipt of a 50 percent disability rating under DC 8100, which contemplates headaches with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. This is the highest rating available under this diagnostic code. 5. Entitlement to a disability rating in excess of 20 percent for service-connected residuals, left ankle fracture with multiple surgeries and tarsal tunnel release is denied. The Veteran’s service-connected residuals, left ankle fracture with multiple surgeries and tarsal tunnel release is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5271, for limitation of motion of the ankle. Under Diagnostic Code 5271, a maximum 20 percent rating is warranted for marked limited motion of the ankle. 38 C.F.R. § 4.71a, Diagnostic Code 5271. The Veteran was provided with VA examination of the left ankle in October 2017 and September 2018. At the October 2017 examination, the Veteran reported current symptoms including extreme swelling, difficulty walking long distances, increased pain with weather changes, and pinching sensation. He denied pain at rest and reported he can only walk a very short distance as pain starts as soon as he puts weight on his foot and subsides once he is off his feet. He further stated that when lying in bed, putting one foot on top of the other causes pain and wakes him up. Range of motion testing of the left ankle demonstrated dorsiflexion limited to 0 to 10 degrees and plantar flexion limited to 0 to 35 degrees, with pain noted on both movements which did not result in/cause functional loss. There was evidence of pain with weight bearing and facial grimacing with palpation of the joint. Repetitive motion testing did not result in further limitation of motion, and the examiner stated that he was unable to say without mere speculation whether pain, weakness, fatiguability, or incoordination could significantly limit functional ability during flare ups or when the joint is used repeatedly over time. The Veteran demonstrated normal (5/5) strength for left ankle plantar flexion and dorsiflexion, and there was no ankylosis. The examiner indicated that instability was suspected, but that both anterior drawer and talar tilt tests were negative for laxity when compared with the right ankle. The Veteran was noted to occasionally use a cane as an assistive device. The Veteran reported that his left ankle disability interferes with chores/activities around his home. At the September 2018 examination, the Veteran reported that his condition had gotten worse: that he could not walk or run for prolonged time and that his ankle felt like it had no cushion. He indicated that he experienced flare-ups as an increase in symptoms with changes in temperature or the weather. He stated that at times the pain is so bad he cannot walk. Range of motion testing for the left ankle demonstrated dorsiflexion from 0 to 15 degrees and plantar flexion from 0 to 30 degrees, with pain noted on both movements but not resulting in/causing functional loss. There was additionally pain with weight bearing and objective evidence of mild tenderness at the medial malleolus. There was no further limitation of motion following repetitive use testing. The examiner indicated that pain, weakness, fatigability, or incoordination significantly limit functional ability with repeated use over time and with flare-ups, but indicated that the range of motion would be dorsiflexion limited to 15 degrees and plantar flexion limited to 30 degrees, the same as was demonstrated at the time of the examination. The Veteran demonstrated normal (5/5) strength for left ankle plantar flexion and dorsiflexion and no ankylosis. The examiner indicated that ankle instability or dislocation was not suspected. The Veteran was noted to make occasional use of an ankle brace. The examination report states that the Veteran’s pain and decreased range of motion of the left ankle interferes with prolonged standing, walking, running, climbing, and jumping. As the Veteran is in receipt of a 20 percent disability rating based on “marked” limitation of motion of the left ankle, the highest schedular rating for limited motion of the ankle, there is no basis upon which to award a higher rating. The Veteran has asserted that his left ankle disability has led to left foot and left hip disabilities, which are being considered for service connection on a secondary basis and remanded, below. The Board has considered whether any other diagnostic codes related to disabilities of the ankle would provide for a higher disability rating. However, the evidence does not reflect that the symptoms would warrant a higher rating under a different diagnostic code. See 38 C.F.R. § 4.71a. In that respect, no os calcis or astragalus malunion or astragalectomy was noted at VA examinations of the ankle conducted in October 2017 and September 2018, and both examinations further indicated that there was no ankylosis of the ankle, or subastragalar or tarsal joint. There was further no indication of related neurological symptoms. As the Veteran already has the maximum schedular disability rating for limited motion of the left ankle joint, in the absence of ankylosis, the appeal is denied. 6. Entitlement to special monthly compensation based on the need for regular aid and attendance is denied. Special Monthly Compensation (SMC) is payable at a specified rate if a veteran, as the result of service-connected disability, is permanently bedridden or is so helpless as to need the regular aid and attendance of another person. 38 U.S.C. § 1114(l); 38 C.F.R. § 3.350(b). The following will be accorded consideration in determining the need for regular aid and attendance: inability of the veteran to dress or undress himself, or to keep himself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid (this will not include the adjustment of appliances which normal persons would be unable to adjust without aid, such as supports, belts, lacing at the back, etc.); inability of veteran to feed himself through loss of coordination of upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect the veteran from hazards or dangers incident to his daily environment. It is not required that all the disabling conditions enumerated in 38 C.F.R. § 3.352(a) be found to exist before a favorable rating may be made. The particular personal functions which the veteran is unable to perform should be considered in connection with his condition as a whole. It is only necessary that the evidence establish that the veteran is so helpless as to need regular aid and attendance, not that there is a constant need. 38 C.F.R. § 3.352(a); see also Turco v. Brown, 9 Vet. App. 222, 224 (1996) (noting that at least one factor listed in § 3.352(a) must be present for a grant of special monthly pension based on need for aid and attendance). For the purposes of 38 C.F.R. § 3.352(a), “bedridden” will be a proper basis for the determination of whether a veteran needs the regular aid and attendance of another person. “Bedridden” will be that condition which, through its essential character, requires that the Veteran remain in bed. The fact that the Veteran has voluntarily taken to bed or that a physician has prescribed rest in bed for the greater or lesser part of the day to promote convalescence or cure will not suffice. 38 C.F.R. § 3.352(a). The Veteran is presently in receipt of service-connection benefits for a number of disabilities including, but not limited to major depressive disorder, post-traumatic headache, residuals of traumatic brain injury, and left ankle, lumbar, cervical spine, hypertension, and scar disabilities. When considering the evidence of record, a preponderance of the evidence is found to demonstrate that despite the Veteran’s impairment from his service-connected disabilities, he has not been rendered so helpless as to require the regular aid and attendance of another person. In this regard, the Veteran has not asserted that he requires regular assistance in dressing or undressing himself, bathing and grooming, feeding himself, attending to the wants of nature, or to protect himself from hazards or dangers of his daily environment. While the Board notes that the Veteran is in receipt of a total disability rating for his major depressive disorder partially based on a history of suicide attempts and problems with self-medicating, excessive drinking, and abuse of pain medications with two DUIs, these dangers are not of a type or experienced with such frequency that supervision is required in order to protect against them. The Veteran has not alleged and the record does not otherwise demonstrate that he requires regular supervision to prevent him from hurting himself. Thus, a preponderance of the evidence weighs against a finding that the combined functional impairment from his service-connected disabilities have led to any of the functional impairments listed in 38 C.F.R. § 3.352(a) or any of comparable severity as to render the Veteran in need for regular aid and attendance, and the evidence does not show that the Veteran is bedridden. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply, and the claim of entitlement to SMC based on the need for aid and attendance is denied. See 38 U.S.C. § 5107. 7. Entitlement to special monthly compensation at the housebound level from April 24, 2012 to present is granted. Special monthly compensation may also be payable at a specified rate if a veteran, as the result of service-connected disability, has one service-connected disability rated as 100 percent disabling and separate disability rated at 60 percent or higher or is permanently housebound. The veteran will be found to be permanently housebound if, due to service-connected disabilities, he is substantially confined to his home or the immediate premises or, if institutionalized, to the ward or clinical areas, and it is reasonably certain that such confinement will continue throughout the veteran’s lifetime. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). There is no evidence of record indicating that the Veteran is permanently housebound. At the present, the Veteran is in receipt of SMC at the housebound rate from April 24, 2012 to March 7, 2017 and from April 17, 2018 to the present on the basis of major depressive disorder rated as 100 percent disabling and additional service-connected disabilities independently ratable at 60 percent or more. After implementation of this decision granting higher initial disability ratings for residuals of traumatic brain injury and associated scars, the Veteran will have one service-connected disability rated as 100 percent disabling and additional service-connected disabilities independently ratable at a combined 60 percent or more throughout the relevant appeal period. Therefore, SMC at the housebound level is warranted for the pendency of the claim period seeking a higher initial disability rating for residuals of traumatic brain injury, from the date service connection was claimed and from which the grant of service connection was made effective, April 24, 2012. 8. Eligibility for financial assistance in the purchase of one automobile or other conveyance and/or adaptive equipment is denied. Financial assistance may be provided to an “eligible person” in acquiring an automobile or other conveyance and adaptive equipment, or automobile adaptive equipment only. 38 U.S.C. § 3902(a)(b). Eligibility for financial assistance in the purchase of a vehicle or other conveyance and adaptive equipment is warranted where one of the following exists as the result of injury or disease incurred or aggravated during active service: (1) loss or permanent loss of use of one or both feet; (2) loss or permanent loss of use of one or both hands; (3) permanent impairment of vision of both eyes, meaning central visual acuity of 20/200 or less in the better eye, with corrective glasses, or central visual acuity of more than 20/200 if there is a field defect in which the peripheral field has contracted to such an extent that the widest diameter of visual field subtends an angular distance no greater than 20 degrees in the better eye; (4) severe burn injury precluding effective operation of an automobile; (5) amyotrophic lateral sclerosis; or, (6) for adaptive equipment only, ankylosis of one or both knees or one or both hips. 38 C.F.R. § 3.808. In chapter 39 of title 38 of the U.S. Code, Congress established the program authorizing funding for automobiles and adaptive equipment for veterans with certain service-connected disabilities. 38 U.S.C. §§ 3901-04. Pursuant to the authority established in 38 U.S.C. § 3902, the Secretary promulgated 38 C.F.R. § 3.808, which reiterates the § 3901(a) requirement that entitlement to automobile and adaptive equipment is warranted for "the loss or permanent loss of use” of one or both feet or one or both hands. 38 C.F.R. § 3.808(b)(i), (ii). The regulation does not further define the phrase "loss or permanent loss of use." Under the applicable eligibility criteria for financial assistance in the purchase of an automobile or other conveyance and adaptive equipment, found in statutory § 3901 and regulatory § 3.808, the appellant must show that they lost their foot or hand or permanently lost the use of a foot or hand as a result of service-connected disability. It is noted that "loss of use" is used in several places in the rating schedule. In the context of special monthly compensation under 38 C.F.R. § 3.350(a)(2)(i), loss of use of a hand or a foot will be held to exist when no effective function remains other than that which would be equally well served by an amputation stump at the site of election below elbow or knee with use of a suitable prosthetic appliance. A less restrictive definition is written into 38 U.S.C. § 2101 and 38 C.F.R. § 3.809 regarding specially adapted housing; that regulation specifies that “loss of use” was defined by the adjacent modifier, “such as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair.” See Jensen v. Shulkin, 29 Vet. App. 66, 78-79 (2017). However, this modifier is noticeably absent from 38 U.S.C. § 3901 and 38 C.F.R. § 3.808, and had Congress or the Secretary of VA wished for such a definition to apply to these sections, it presumably would have been included. As such, loss of use under 38 C.F.R. § 3.808 will be taken to mean actual loss of functional use of the body part(s), with any need of assistive devices being relevant to, but not dispositive of the question of whether the Veteran has permanent loss of use. In relevant part, the Veteran is presently in receipt of VA service connection benefits for the following: post-traumatic headache; residuals, left ankle fracture with multiple surgeries and tarsal tunnel release; shin splints, bilateral; anterior labral repair, versus superior labrum anterior and posterior repair, left shoulder; residuals of traumatic brain injury; and scars of the left forearm and left ankle. The Veteran has not been granted service connection benefits for disabilities involving visual impairment, burn injuries, or amyotrophic lateral sclerosis. Additionally, while the Veteran’s claim for service connection for a left hip disability is being remanded for further development, he has not asserted, and the evidence of record does not otherwise demonstrate, that the claimed disability results in fixation of the joint/ankylosis. The evidence of record further does not indicate that the Veteran has ankylosis of his knees, and he is not service-connected for a disability of the knees. Eligibility for financial assistance in the purchase of an automobile or other conveyance and/or adaptive equipment is therefore unavailable on these bases. In considering the evidence of record, the Board finds that the Veteran’s service-connected disabilities do not result in such a severe degree of functional impairment as to approximate “loss of use” of a foot or hand. The Veteran has not asserted, and the evidence of record does not otherwise indicate that he has experienced loss of use of a hand. In a September 2017 addendum to the Veteran’s notice of disagreement, the Veteran’s representative stated that the Veteran sought special monthly compensation based on factors including loss of use of the left foot. However, VA treatment records from September 2017 and earlier noted that the Veteran had a “normal gait,” or sometimes noted that he ambulated with a cane. At a September 2018 examination of the left ankle, the Veteran reported that he cannot walk or run for a prolonged time, and that the ankle feels like it has no cushion. He further described flare-ups of left ankle pain with changes in temperature or weather, which at times is so bad that he is unable to walk. As to his need to use assistive devices as a normal mode of locomotion, the Veteran was noted to occasionally use an ankle brace. The examiner opined that due to the Veteran’s ankle condition, there was not functional impairment of an extremity such that no effective functions remain other than that which would be equally well served by an amputation with prosthesis. The examiner opined that the disability interferes with prolonged running, climbing, and jumping. A preponderance of the evidence is found to demonstrate that while the Veteran likely suffers and/or has suffered from some degree of gait abnormality as a result of his service-connected left ankle disability, he retains the ability to walk and make use of his foot. In that respect, the evidence from the September 2018 VA ankle examination is found to be particularly probative, as it includes the Veteran’s lay report as to the limitations from his service-connected disability in general and during flare-ups of symptoms as well as the opinion of the examiner as to the overall functional impact of the disability. The Veteran’s report that he cannot walk or run for a prolonged time implies that he is still able to walk or run for a shorter duration. Therefore, the weight of the evidence is against a finding that the Veteran has permanent loss of use of a foot due to service-connected disability. The Board acknowledges that the appeal of the denial of service connection for a left foot disability is being remanded, below. However, as explained above, the evidence does not demonstrate that the Veteran presently experiences functional impairment resulting in effective loss of use of his foot, whether or not considering only presently service-connected disabilities. Eligibility for the benefit sought in this case requires the Veteran to meet at least one of the six criteria enumerated under 38 C.F.R. § 3.808. Because the Veteran does not have service-connected disability resulting in the loss or permanent loss of use of one or both hands or feet, does not have ankylosis of his knees or hips, and does not have any of the other physical disabilities listed among the relevant criteria, he does not qualify for eligibility for financial assistance in the purchase of an automobile or other conveyance and/or adaptive equipment under 38 C.F.R. § 3.808. As such, the claim must be denied. REASONS FOR REMAND 1. Entitlement to service connection for a left foot disability is remanded. In the June 2020 JMPR, the parties agreed that the Board previously provided an inadequate rationale for its finding that the Veteran did not have a current left foot disability, as it failed to address the Veteran’s September 2017 statement in which he argued that he had current left foot disability including callouses on the bottom of the foot that sometimes split, rough skin, ingrown toenails, and a great toenail that has turned black. The April 2018 VA foot examination report lists “no response provided” concerning whether the Veteran had callouses or tenderness, under the subsection for flatfoot. Although the examination report indicates that the Veteran reported “no” as to whether he had any ongoing foot issues, the need for a current disability is met if the Veteran had such disability at any time during the appeal period, even if it subsequently resolved. On remand, an additional VA examination of the left foot should be provided which specifically addresses the skin and nails of the left foot. 2. Entitlement to service connection for a left hip condition is remanded. The Veteran was provided with a VA examination regarding his claimed left hip disability in October 2017. The VA examiner diagnosed the Veteran with femoroacetabular impingement (FAI) with severe cam deformity and acetabular retroversion with large labral tear status post surgical repair, and stated a conclusion that FAI is a congenital condition, and that it is at least as likely as not that the Veteran would have developed this left hip condition without a previous left ankle injury. However, no opinion was provided as to whether the Veteran’s service-connected left ankle disability and any resulting gait abnormality aggravated his left hip condition beyond its natural progression. On remand, a supplemental medical opinion should be obtained. 3. Entitlement to a compensable disability rating for service-connected hypertension is remanded. The Veteran seeks a higher, compensable disability rating for his service-connected hypertension. His claim form was received by VA in September 2018. At present, the most recent blood pressure reading for the Veteran is from a May 2018 VA dental treatment record. VA treatment records between September 2018 and January 2019 indicate that the Veteran had received treatment through the Community Care program, and that medical documentation had been scanned into VistAImaging. Unfortunately, these scanned documents are not accessible by the Board, and are not part of the official record. While the Veteran was provided with a VA examination pertaining to the severity of his hypertension in September 2018, the examiner specifically indicated that no records were reviewed in the preparation of the examination report. On remand, the AOJ should associate any relevant scanned medical records with the claims file and provide the Veteran with an opportunity to identify any private medical records he wishes VA to obtain on his behalf. While in remand status, the AOJ should ensure that all updated/outstanding VA treatment records are associated with the claims file. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records from January 2020 to the present and associate them with the claims file. To the extent that there are relevant community care records that have been scanned into VA systems (such as VistaImaging) from April 2012 to the present that have not yet been associated with the claims file, such should be produced and added to the record. 2. Ask the Veteran to complete a VA Form 21-4142 for any relevant outstanding private treatment records he wishes VA to obtain on his behalf. Make two requests for the authorized records from the private physicians/facilities, unless it is clear after the first request that a second request would be futile. 3. After associating all responsive records with the claims file, schedule the Veteran for an additional VA examination for his left foot with a suitably qualified medical professional. The examiner must review the claims file. After interviewing the Veteran and considering the evidence of record, including the medical evidence in the file, the Veteran’s lay statements, and any observations made at the examination, the examiner should address the following: a. Provide a diagnosis for any disability of the left foot, or the toes or toenails of the left foot, present at any point during the relevant appeal period (February 2014 to present). If a diagnosis cannot be provided but the Veteran’s condition manifests in symptoms that cause functional impairment, then the examiner should consider them a “disability” for the purpose of providing the requested opinion(s) below. The examiner’s attention is directed to a statement from the Veteran made at a September 2017 teleconference, indicating that his prior tarsal tunnel release resulted in his left foot being flat (previously described as fallen arch), that he had callouses on the bottom of his left foot that sometimes split, with very rough skin in the area. He further asserted that he had ingrown toenails which he believed were from his altered gait due to his left ankle problems, and that his great toenail had turned black. b. For any left foot disability identified, is it: i) at least as likely as not related to service; ii) at least as likely as not proximately due to his service-connected left ankle disability (and any resulting gait abnormality); and/or iii) at least as likely as not aggravated, i.e., worsened beyond its natural progression, by his service-connected left ankle disability (and any resulting gait abnormality)? A clear rationale must be provided for any and all opinions/conclusions provided. 4. After associating all records responsive to remand directives # 1 and 2 with the claims file, obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s left hip disability is at least as likely as not aggravated beyond its natural progression by his service-connected left ankle disability (and any resulting gait abnormality). (Continued on the next page)   5. A clear rationale must be provided for any and all opinions and conclusions stated. MICHAEL MARTIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Solomon, Counsel 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.