Citation Nr: 21062842 Decision Date: 10/12/21 Archive Date: 10/12/21 DOCKET NO. 16-26 607 DATE: October 12, 2021 ORDER Entitlement to a separate disability evaluation for traumatic brain injury (TBI) is denied. FINDING OF FACT For the entire period on appeal, the Veteran's symptoms of his TBI and posttraumatic stress disorder (PTSD) cannot be differentiated between the two disabilities. CONCLUSION OF LAW The criteria for a separate evaluation for TBI from PTSD have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.6, 4.7, 4.14, 4.124a, Diagnostic Codes 9411, 8045 (2021). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from February 2003 to March 2015. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. The Veteran testified before the undersigned Veterans Law Judge (VLJ) in a videoconference hearing in May 2019. A transcript of the hearing is of record. The Board remanded the issue on appeal for additional development in October 2019. The directives having been substantially complied with, the matter again is before the Board. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268 (1998). When a Veteran files a claim for an increased rating, he or she is presumed to be seeking the maximum benefit under any applicable theory, including TDIU. See Rice v. Shinseki, 22 Vet. App. 447, 45354 (2009). In light of this principle, entitlement to special monthly compensation (SMC) has been found to be an inferable issue anytime a veteran is requesting increased benefits. Akles v. Derwinski, 1 Vet. App. 118 (1991). The Board notes that TDIU was previously awarded in an October 2019 Board decision, effective from March 13, 2015, the day following the Veteran's separation from active military service, and as such, no further award of TDIU from an earlier date is legally possible. The Veteran already receives SMC for housebound and loss of a creative organ from March 13, 2015, the day following the Veteran's separation from active service, and there is no further lay or medical evidence the Veteran's disabilities result in loss of use of a limb, blindness or deafness. 38 U.S.C. §§ 1114(s), (l), (k); 38 C.F.R. § § 3.350(a), (b), (i). As such, the Board will not infer the issue of further entitlement to SMC at this time. Veterans Claims Assistance Act of 2000 (VCAA) The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. § §§ 3.102, 3.156(a), 3.159, 3.326(a) (2021). The Veteran in this case has not referred to any deficiencies in either the duties to notify or assist; therefore, the Board may proceed to the merits of the claim. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015, cert. denied, U.S.C. Oct. 3, 2016) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board....to search the record and address procedural arguments when the [appellant] fails to raise them before the Board"); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant's failure to raise a duty to assist argument before the Board). The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000). Background of the Veteran's Appeal for a Separate Evaluation for Traumatic Brain Injury This appeal came to the Board in response to a February 2016 notice of disagreement from a March 2015 rating decision. The Veteran had been granted entitlement to service connection for posttraumatic stress disorder (PTSD), with depressive disorder not otherwise specified (NOS), alcohol dependence in early sustained remission, traumatic brain injury (TBI), and insomnia (also claimed as fatigue, memory lapses or loss due to intracranial brain injury) with a 50 percent evaluation effective from March 13, 2015, the first day after the Veteran ended active service. The Veteran was also granted service connection for headaches with an evaluation of 30 percent effective from March 13, 2015, tinnitus with a 10 percent evaluation from March 13, 2015, bilateral hearing loss with a noncompensable evaluation, and other orthopedic disabilities not directly related to the PTSD or TBI. The Veteran, when still on active duty, had sought medical care for sleeplessness and anxiety in January 2013, and was treated by service mental health providers, to include a hospitalization in October 2013 for PTSD and depression. As a result of his mental health disorders, and to include his TBI, the Veteran was subjected to a medical evaluation board in August and September 2014 to evaluate his continued fitness for service. The Veteran was initially provided a VA general examination in August 2014 prior to his separation from active duty and after his initial claim with VA dated July 2014. The examiner noted insomnia, likely as secondary to PTSD, and recommended the Veteran receive a VA initial PTSD examination. The Veteran received that initial PTSD examination and a separate examination for TBI from VA in late August 2014. Here, the VA psychiatrist examiner diagnosed chronic PTSD and depression NOS secondary to the PTSD. The examiner noted that the two disorders are "coexistent" and that the depression is a progression of the PTSD. The examiner, in a form question, said that "most" symptoms are due to the PTSD, as separated from symptoms of TBI, to include reexperiencing, hyperarousal, and avoidance behavior. The examiner considered symptoms of memory lapses as due to the TBI, but that other memory problems, difficulty with word finding and other speech issues to be possible due to either the PTSD or the TBI, and he could not distinguish between the two beyond mere speculation. The Board notes that the Veteran's initial TBI injury resulted from his first combat deployment to Iraq in 2004-2005, where he was in a vehicle-based individual explosive device (IED) attack that resulted in him being knocked unconscious. The Veteran's initial VA TBI examination in August 2014 noted the Veteran had been exposed to more than 3 IED blasts from 2004 to 2009. The Veteran also received a VA initial PTSD examination in that same month of August 2014; each of those VA examiners noted on the examination form that it was not possible to distinguish the symptoms of the Veteran's diagnosed TBI from his psychiatric disorders of PTSD and depression. As a result, the Veteran was initially rated in March 2015 with the PTSD and TBI together because of the examiners' statement that the symptoms could not be distinguished and in some instances, overlapped. In the February 2016 notice of disagreement, the Veteran stated that he believed the PTSD and the TBI should be separate disabilities because there were distinct effects from each. Later, in the June 2016 VA Form 9, Substantive Appeal to the Board, the Veteran also stated that he disagreed with the 50 percent evaluation of the PTSD, believing his symptoms were deserving of a higher rating. In October 2019, the Board adjudicated both of those issues, and granted an increased rating of 70 percent for the PTSD and TBI combined disability, effective back to March 13, 2015. The Board also granted a TDIU, effective from the same date of March 13, 2015. However, the Board remanded for another TBI examination and an opinion as to whether the PTSD and TBI could be separately evaluated under their respective diagnostic codes. The Board notes that while the August 2014 VA PTSD examiner had checked a block on his examination form that the symptoms of the PTSD could not be distinguished, that in his comments on the examination he noted that the Veteran's memory lapses are due to his TBI and post-concussive cognitive disorder, distinct from his diagnosed PTSD and its symptoms. The Veteran received another PTSD examination in February 2018 where a civilian service psychiatrist determined that it is possible to differentiate what symptoms in the Veteran are attributable to the TBI versus the PTSD, citing anxiety, depression, panic attacks, and irritability as due to the PTSD. But this February 2018 examiner also noted that a separate TBI evaluation was necessary and did not comment further. Since the Board has already evaluated the Veteran's increased rating claim for his PTSD and TBI and awarded a higher 70 percent rating in its October 2019 decision, the decision will now focus on the TBI symptoms in consideration of whether a separate evaluation for TBI can be awarded. Increased Schedular Ratings - General Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. § Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § §§ 3.321(a), 4.1. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § § 4.7. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § § 4.3. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). That said, higher evaluations may be assigned for separate periods based on the facts found during the appeal period. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). This practice is known as staged ratings. Id. The determination of whether an increased disability rating is warranted is to be based on a review of the entire evidence of record and the application of all pertinent regulations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 38 U.S.C. § 1154(a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability benefits. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). When analyzing lay evidence, the Board should assess the evidence and determine whether the disability claimed is of the type for which lay evidence is competent. See Davidson, 581 F.3d at 1313; Kahana v. Shinseki, 24 Vet. App. 428 (2011). The Board considers not only the criteria of the currently assigned diagnostic codes, but also the criteria of other potentially applicable diagnostic codes. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § § 4.25. However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is not allowed. See 38 C.F.R. § § 4.14. A claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his [or her] earning capacity." See 38 U.S.C. § 1155; Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § § 4.14. However, if a veteran has separate and distinct manifestations attributable to the same injury, they should be compensated under different diagnostic codes. See Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225, 230 (1993). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and the demonstrated symptomatology. Any change in a diagnostic code by VA must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625 (1992). If the evidence for and against a claim is in equipoise, the claim will be granted. 38 C.F.R. § 4.3. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Legal Criteria - TBI The Veteran's combined PTSD and TBI residuals are rated under Diagnostic Codes 9411 and 8045. As noted previously, given the Board already discussed the Veteran's PTSD symptoms in its October 2019 decision, this discussion will focus on the TBI symptomatology and whether such symptoms can be distinguished from the PTSD. Diagnostic Code 8045 provides evaluation for three main areas of dysfunction that may result from traumatic brain injury and have profound effects on functioning: (1) cognitive, which is common in varying degrees after a traumatic brain injury; (2) emotional/behavioral; and (3) physical. Each of those areas of dysfunction may require evaluation. 38 C.F.R. § 4.124a, Diagnostic Code 8045. The Board notes the Veteran is also service-connected for migraine headaches with a 50 percent evaluation from March 13, 2015 under Diagnostic Code 8100. 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, Diagnostic Code 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 evaluated under another diagnostic code, such as migraine headache or Meniere's disease, should be evaluated 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. 38 C.F.R. § 4.124a, Diagnostic Code 8045. Emotional/behavioral dysfunction is evaluated 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." 38 C.F.R. § 4.124a, Diagnostic Code 8045. 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. 38 C.F.R. § 4.124a, Diagnostic Code 8045. The preceding list of types of physical dysfunction does not encompass all possible residuals of a traumatic brain injury. For residuals not listed here that are reported on an examination, evaluate 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 combined under 38 C.F.R. § 4.25 for each separately rated condition. The rating assigned based on the "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" table will be considered the rating for a single condition for purposes of combining with other disability ratings. 38 C.F.R. § 4.124a, Diagnostic Code 8045. The need for special monthly compensation for such problems as loss of use of an extremity, certain sensory impairments, erectile dysfunction, the need for aid and attendance (including for protection from hazards or dangers incident to the daily environment due to cognitive impairment), being housebound, or other reason, must be considered. 38 C.F.R. § 4.124a, Diagnostic Code 8045. 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 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, then a 0 percent rating is assigned. If the highest is 1, then a 10 percent rating is assigned. If the highest is 2, then a 40 percent rating is assigned. If the highest is 3, then a 70 percent rating is assigned. 38 C.F.R. § 4.124a, Diagnostic Code 8045. There may be an overlap of manifestations of conditions evaluated under the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" with manifestations of a comorbid mental or neurologic or other physical disorder that can be separately 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. 38 C.F.R. § 4.124a, Diagnostic Code 8045, 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. 38 C.F.R. § 4.124a, Diagnostic Code 8045, Note (2). Instrumental activities of daily living refer to activities other than self-care that are needed for independent living, such as meal preparation, doing housework and other chores, shopping, traveling, doing laundry, being responsible for one's own medications, and using a telephone. Those activities are distinguished from activities of daily living, which refers to basic self-care and includes bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet. 38 C.F.R. § 4.124a, Diagnostic Code 8045, Note (3). The terms mild, moderate, and severe 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. 38 C.F.R. § 4.124a, Diagnostic Code 8045, 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 (person, time, place, situation) of orientation or often disoriented to one aspect of orientation; 3 for often disoriented to two or more of the four aspects (person, time, place, situation) of orientation; and total for consistently disoriented to two or more of the four aspects (person, time, place, situation) 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. 38 C.F.R. § 4.124a, Diagnostic Code 8045. Evidence and Analysis TBI The Veteran received a VA TBI examination in March 2016. The Veteran was seen in person, and the examiner indicated that they reviewed the Veteran's claims file. For each of the following TBI assessment criteria, the Board will also note the associated severity of that facet, based on the "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" table. On cognitive assessment, the Veteran demonstrated mild memory loss (1), normal judgment (0), social interaction (1), normal orientation (1), normal motor activity (0), normal visual spatial orientation (0), no subjective symptoms that interfere with work (0), one or more neurobehavioral effects that did not interfere with work or social interaction (0), inability to communicate by spoken or written language more than occasionally but less than half the time (0), and normal consciousness (0). For no facets was the Veteran described as having a "total" impairment. Additional residuals included headaches and a mental disorder. The examiner specifically noted neurobehavioral symptoms to include "agitation, irritable mood, verbal aggression, difficulty with concentration, [and] memory impairment." If the TBI were rated separately, an overall evaluation of 10 percent would be appropriate based on the highest level of severity being a "1." The Veteran received another VA examination for his TBI in March 2021. The Veteran was seen in person, and the examiner indicated that they reviewed the Veteran's claims file. For each of the following TBI assessment criteria, the Board will also note the associated severity of that facet, based on the "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" table. On cognitive assessment, the Veteran demonstrated moderate memory loss (3), mildly impaired judgment (1), occasionally inappropriate social interaction (1), normal orientation (0), normal motor activity (0), mildly impaired visual spatial orientation, due to occasionally getting lost in unfamiliar surroundings (1), subjective symptoms that might interfere with work (0), one or more neurobehavioral effects that did not interfere with work or social interaction (1), able to communicate by spoken or written language (0), and normal consciousness (0). For no facets was the Veteran described as having a "total" impairment. Additional residuals included headaches. The examiner specifically noted neurobehavioral symptoms to include "agitation, irritable mood, verbal aggression, difficulty with concentration, [and] memory impairment." Here, if rated separately, the standalone evaluation for the Veteran's TBI would be 70 percent, based on the highest level of severity of "3." A 100 percent evaluation would only be appropriate if "total" is the level of evaluation for one or more facets, and here, no facet is considered to be "total." This March 2021 VA TBI examiner also provided an opinion as to whether the Veteran's TBI symptoms could be separated from his PTSD for the purposes of a separate evaluation. This examiner noted that the Veteran is also service-connected for headaches with a 50 percent evaluation, tinnitus with a 10 percent evaluation, and erectile dysfunction and a vision impairment disorder, each rated as noncompensable, that are expressly related to the Veteran's TBI. The examiner opined that the PTSD and the TBI share numerous symptoms that cannot be distinguished from either disorder. VA also provided a review PTSD examination in May 2021 from a different VA examiner, and as part of the examination, was asked to opine on whether the Veteran's psychiatric disorder symptoms could be distinguished from the co-existing TBI. This examiner noted that the PTSD, unspecified depressive disorder, and TBI share a number of symptoms and are inextricably linked, making differentiation of symptoms and impairment impossible without resorting to speculation. The Board finds all the service and VA examination reports and opinions to be of great probative value, along with the VA treatment notes regarding the Veteran's claimed sleep apnea disability. Indeed, the VA examiners of March 2021 and May 2021 considered the Veteran's contentions, the claims file, and clinical medical evidence before providing a negative opinion regarding a possible separate evaluation for the Veteran's TBI. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (the probative value of a medical opinion is derived from a factually accurate, fully articulated, and soundly reasoned opinion). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The examiners' opinions were supported by a sufficiently clear and well-reasoned medical rationale and was consistent with the verifiable facts regarding the Veteran's contentions. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005). The Board acknowledges that the Veteran is competent to testify as to his belief that his TBI should be evaluated separately from his PTSD. In order for lay evidence to be competent, the individual must have personal knowledge, derived from his/her own senses, of what is being attested; "[c]ompetent testimony is thus limited to that which the witness has actually observed, and is within the realm of [his] personal knowledge." Layno v. Brown, 6 Vet. App. 465, 471 (1994). Here, the Veteran is competent to testify about his symptoms relating to his TBI and PTSD disabilities. However, there is nothing in the record to suggest that the Veteran has the appropriate training, experience, or expertise to render a medical opinion regarding etiological or comorbid relationships of his PTSD and TBI disorders. See 38 C.F.R. § 3.159 (a)(1) (setting forth that competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). While the Veteran is competent to report what he has experienced, he is not competent to ascertain the diagnosis and etiology of any current condition, as the causative factors for such are not readily subject to lay observation. See Layno v. Brown, 6 Vet. App. 465 (1994); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Accordingly, his assertions to that effect are of no probative value. The Board notes the general federal regulations and case law regarding interrelated disabilities, here, the Veteran's service-connected PTSD with TBI, and also migraine headaches, tinnitus, hearing loss, and erectile dysfunction. While this legal guidance does not generally prohibit a Veteran from being service-connected for more than one related condition, 38 C.F.R. § 4.14 prohibits evaluating the same manifestation under different diagnoses. See 38 C.F.R. § 4.14 (noting that "the evaluation of the same manifestation under different diagnoses [is] to be avoided"). In Amberman v. Shinseki, the Federal Circuit recognized that separately diagnosed psychiatric conditions could be service-connected, but could not be separately rated unless they resulted in different manifestations. 570 F.3d 1377, 1381 (Fed. Cir. 2009) ("Section 4.14 clearly contemplates that several separately diagnosed disorders may have a single manifestation, and it clearly prohibits the VA from rating that manifestation for each disorder."). The Federal Circuit found that it was possible evidence could be received that reflected that two conditions resulted in different manifestations, thus allowing the two conditions to be separately rated. Id. For example, in Amberman, the Federal Circuit stated that "bipolar affective disorder and PTSD could have different symptoms and it could therefore be improper in some circumstances for the VA to treat these separately diagnosed conditions as producing only the same disability." Id. Here, multiple VA examiners in March 2016, April 2016, May 2019, March 2021, and May 2021 have all opined that the Veteran's psycho/emotional symptoms cannot be differentiated between the TBI and the PTSD because of the overlap of symptoms. The March 2021 VA psychiatrist went into detail, saying the neurocognitive findings in 2014 of visual construction and attention are connected to the TBI, but the other symptoms cannot be differentiated. The examiner continued, noting the symptoms of the headache are accounted for in the separating 50 percent rating for migraine headaches, and the benign positional vertigo is related to the TBI under the "subjective" category. This examiner also noted that the service-connected erectile dysfunction would be accounted for under the TBI but is separately rated by itself. The May 2021 VA psychologist came to the same opinion, explicitly stating that the TBI and PTSD share a number of symptoms and are inextricably linked, making differentiation of symptoms and impairment impossible without resorting to mere speculation. The criteria for Diagnostic Code 8045, TBI, notes: 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. 38 C.F.R. § 4.124a, Diagnostic Code 8045, Note (1) (emphasis added). Federal regulation in 38 C.F.R. § 4.14 prohibits evaluating the same manifestation under different diagnoses. The United States Court of Appeals for Veterans Claims held that separate ratings could be appropriate if and only if there were distinct symptoms served by distinct and different diagnoses. Esteban v. Brown, 6 Vet. App. 259, 262 (1994) (the critical element is that none of the symptomatology for any one of these conditions is duplicative of or overlapping with the symptomatology of the other conditions). In Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009), the Federal Circuit "agree[d] with the Veterans Court that two defined diagnoses constitute the same disability for purposes of [38 C.F.R. §] 4.14 if they have overlapping symptomatology." Here, all VA examiners have opined that the symptomatology of the Veteran's PTSD and TBI overlap and are inextricably linked, making differentiation of symptoms and impairment impossible without resorting to speculation. There is no medical evidence or medical authority to the contrary in this appeal, and federal regulation and case law provide clear guidance that separate ratings in such a case would amount to pyramiding under Esteban. See 6 Vet. App. 259 at 262; 38 C.F.R. §§ 4.14, 4.124a, Diagnostic Code 8045. Based on the above, the Board finds that the weight of the competent and credible evidence demonstrates that the Veteran's claim for a separate evaluation for his TBI distinct from his PTSD must fail because otherwise separate ratings would constitute a duplication or overlapping of symptomatology of these two diagnoses. For these reasons, the Board finds that a preponderance of the evidence is against the claim of a separate evaluation for the TBI disability, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. MICHAEL A. PAPPAS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Setter, 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.