Citation Nr: A21020308 Decision Date: 12/21/21 Archive Date: 12/21/21 DOCKET NO. 190302-11834 DATE: December 21, 2021 ORDER A separate, initial disability rating of 50 percent for service-connected migraine headaches (a diagnosed residual of service-connected traumatic brain injury), effective March 27, 2013, is granted. From March 27, 2013, to January 23, 2017, a separate, initial disability rating of 10 percent, but no higher, for service-connected traumatic brain injury residuals (not otherwise encompassed by the rating for migraine headaches) is granted. From January 23, 2017, an increased disability rating in excess of 70 percent for service-connected traumatic brain injury residuals (rated with other trauma and stressor related disorder, and not otherwise encompassed by the rating for migraine headaches) is denied. Entitlement to an effective date earlier than January 23, 2017, for the 70 percent disability rating for service-connected traumatic brain injury (rated with other trauma and stressor related disorder, and not otherwise encompassed by the rating for migraine headaches) is denied. REMANDED Service connection for posttraumatic stress disorder is remanded. Service connection for a back disability is remanded. Service connection for a bilateral foot/ankle disability is remanded. Prior to January 23, 2017, entitlement to a total disability rating based on individual unemployability is remanded. FINDINGS OF FACT 1. The Veteran's service-connected traumatic brain injury resulted in migraine headaches, which are a separate and distinct diagnosed disability. 2. From March 27, 2013, the Veteran's migraine headaches most closely resulted in very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 3. From March 27, 2013, to January 23, 2017, the Veteran's traumatic brain injury residuals (not otherwise encompassed by the rating for migraine headaches) consisted of mild loss of memory, decreased attention, decreased concentration, or decreased executive functions, but without objective evidence on testing; and did not result in more severe symptoms. 4. From January 23, 2017, the Veteran's traumatic brain injury residuals (rated with other trauma and stressor related disorder, and not otherwise encompassed by the rating for migraine headaches) resulted in objective evidence on testing of moderate impairment of memory, attention, concentration, or executive functions resulting in moderate functional impairment; and did not result in more severe symptoms. 5. The earliest date for which an increased disability rating of 70 percent for traumatic brain injury residuals (rated with other trauma and stressor related disorder, and not otherwise encompassed by the rating for migraine headaches) can be granted is January 23, 2017, the date the Veteran filed his notice of intent to file a claim. CONCLUSIONS OF LAW 1. From March 27, 2013, the criteria for an initial disability rating of 50 percent, the highest allowed, for migraine headaches are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Codes 8045, 8100. 2. From March 27, 2013, to January 23, 2017, the criteria for an initial disability rating of 10 percent, but no higher, for traumatic brain injury residuals (not otherwise encompassed by the rating for migraine headaches) are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8045. 3. From January 23, 2017, the criteria for an increased disability rating in excess of 70 percent for traumatic brain injury residuals (rated with other trauma and stressor related disorder, and not otherwise encompassed by the rating for migraine headaches) have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8045, 4.130, Diagnostic Code 9410. 4. The criteria for entitlement to an effective date earlier than January 23, 2017, for the award of an increased disability rating of 70 percent for traumatic brain injury residuals (rated with other trauma and stressor related disorder, and not otherwise encompassed by the rating for migraine headaches) have not been met. 38 U.S.C. §§ 1155, 5110; 38 C.F.R. § 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from April 1978 until his discharge under honorable conditions in March 1984. This appeal has been advanced on the Board of Veterans' Appeals' (Board) docket pursuant to 38 U.S.C. § 7107(b); 38 C.F.R. § 20.902(c). On October 25, 2018, VA received the Veteran's filing to opt into the Rapid Appeals Modernization Program (RAMP) under the VA Claims and Appeals Modernization Act (AMA), 84 Fed. Reg. 2449 (Feb. 7, 2019). He elected to have all eligible issues that were currently on appeal reviewed in the higher-level review process. The VA Regional Office issued a RAMP decision February 7, 2019, which is the decision on appeal. The Board received VA Form 10182 Decision Review Request: Board Appeal (Notice of Disagreement) on February 27, 2019, from the Veteran as to the February 7, 2019, decision on appeal, wherein he elected the Board Hearing docket. The Board Hearing docket provides the Veteran the opportunity to testify before the Board and submit additional evidence within 90 days of the Board hearing. In August 2020, the Veteran testified at a Board hearing before a Veterans Law Judge. The requisite 90-day period has expired, and the Board may proceed to adjudicate the claim. Procedural Background The Board finds it necessary to discuss the procedural history related to his migraines, traumatic brain injury, and psychiatric disorders claims because they are intertwined. The procedural history is relatively complicated and doing so will hopefully provide clarity to the Veteran and the VA Regional Office on remand, and it will also provide clarity for the Board's decisions. The Board does not address the procedural history related to his claims for service connection for a back disability and bilateral foot/ankle disability as those do not require special attention. On March 27, 2013, the Veteran filed a claim for service connection for posttraumatic stress disorder (PTSD), which necessarily include related psychiatric disorders. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009) (finding that the scope of a claim may include any disorder that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and other information of record). On June 28, 2013, he filed a claim for migraine headaches. A March 26, 2014, VA Regional Office decision denied service connection for PTSD and migraine headaches. The Veteran filed a timely notice of disagreement only with respect to the denial of service connection for migraine headaches. Following the filing of his notice of disagreement, the Veteran filed a new claim for service connection for PTSD on September 4, 2014. In a December 12, 2014, decision, the VA Regional Office confirmed denial of service connection for PTSD, which became final. In December 2014, the VA Regional Office obtained a VA examination addressing whether the Veteran had a traumatic brain injury based on his military service. This examination was done in connection with his claim for service connection for migraine headaches. In a February 2015 opinion, an examiner opined that the Veteran's migraine headaches were due to his traumatic brain injury in military service (based on a motor vehicle accident). On October 31, 2016, the Veteran filed a claim for service connection for depression. On December 22, 2016, he filed a new claim for service connection for PTSD. And on March 16, 2017, he filed a claim for service connection for traumatic brain injury (with blackouts, seizures, headaches, memory loss, and hallucinations). The VA Regional Office obtained examinations addressing these claimed disabilities. A July 2017 VA-contracted examiner opined that the Veteran did not have a medical diagnosis of PTSD, but he did have "other trauma and stressor related disorder." An August 2017 VA-contracted examiner opined that the Veteran had migraines that were at least as likely as not caused by his traumatic brain injury. In a September 5, 2017, decision, the VA Regional Office granted service connection for "traumatic brain injury (also claimed as post-concussion syndrome and to include claimed symptoms of blackouts, memory loss, syncope, and hallucinations) with an evaluation of 70 percent effective January 23, 2017"; denied service connection for depression; and denied service connection for PTSD. The Veteran filed a notice of disagreement as to the denial of service connection for PTSD. Not until November 10, 2018, did the VA Regional Office grant the Veteran service connection for migraine headaches, assigning him a disability rating of 30 percent effective March 27, 2013. By that time, however, the Veteran had already filed his RAMP opt in notice on October 25, 2018. And on February 7, 2019, the VA Regional Office issued a higher-level review RAMP decision in which it determined the following: Service connection for migraines (diagnosed as traumatic brain injury, post concussive disorder with posttraumatic headaches (claimed as migraines, head injury)) (also claimed as postconcussion syndrome to include symptoms of blackouts, memory loss, syncope, and hallucinations) is granted. A 10 percent evaluation is effective March 27, 2013. The 70 percent evaluation effective January 23, 2017 is continued. Service connection for other trauma and stressor related disorder (also claimed as posttraumatic stress disorder) is granted effective January 23, 2017 and will be evaluated with the traumatic brain injury with posttraumatic headaches (claimed as migraines, head injury) (also claimed as post-concussion syndrome and to include claimed symptoms of blackouts, memory loss, syncope and hallucinations) as 70 percent disabling. The previous denial of service connection for posttraumatic stress disorder (PTSD) (formerly post traumatic stress disorder, other trauma and stressor related disorder) is confirmed and continued. From what the Board gathers, the VA Regional Office determined that the Veteran's migraine headaches were part of his claim for service connection for a traumatic brain injury and, thus, were to be rated only under the rating criteria for a traumatic brain injury. Hence, the VA Regional Office did not provide the Veteran a separate disability rating for his migraine headaches apart from his traumatic brain injury. It also appears that the VA Regional Office found the Veteran's "other trauma and stressor related disorder" symptoms, while constituting a separate disability, overlapped with his traumatic brain injury symptoms such that they were rated together to avoid pyramiding. See 38 C.F.R. § 4.14 (VA cannot rate symptoms twice). In his VA Form 10182 (Notice of Disagreement), the Veteran specifically appealed the effective date and combined ratings for his "combined injuries, migraine as traumatic brain injury, post-concussive disorder with posttraumatic headaches"; service connection for PTSD, as well as service connection for a back disability and bilateral foot/ankle disability that were also decided as part of the February 7, 2019, RAMP decision. He did not specifically appeal any part of the VA Regional Office's decision related to service connection for "other trauma and stressor related disorder." Evidentiary Standards Under the AMA system, the Board's review of the record is limited to the evidence of record at the time the Veteran filed his RAMP opt-in form on October 25, 2018, and the evidence submitted within the 90-day period following the Veteran's Board hearing. 38 C.F.R. §§ 20.300, 20.302; see also 38 C.F.R. § 3.2400(d) ("Once an eligible claimant elects the modernized review system with respect to a particular claim, the provisions of 38 C.F.R. Parts 3, 19, and 20 applicable only to legacy claims and appeals no longer apply to that claim."). Any findings favorable to the Veteran made by the VA Regional Office in notification of a decision are binding on the Board unless rebutted by evidence that identifies a clear and unmistakable error in the favorable finding. 38 C.F.R. § 20.801(a). "Findings" means "conclusions on questions of fact and application of law to facts made by an adjudicator concerning the issue under review." Id. In deciding claims, it is the Board's responsibility to evaluate the entire record on appeal. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits and when rating disabilities. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b) (service connection); 38 C.F.R. § 4.3 (disability rating). To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The law requires the Board address its reasons for rejecting evidence favorable to the Veteran. Timberlake v. Gober, 14 Vet. App. 122, 12829 (2000). The Board must review the entire record but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1381 (Fed. Cir. 2000). The analysis below focuses on the most salient and relevant evidence within the period on appeal and on what this evidence shows, or fails to show, on the claims. New and Relevant Evidence Before addressing the merits of each claim, the Board believes it is proper to recognize that in the February 7, 2019, higher-level review RAMP decision, the VA Regional Office found new and relevant evidence had been received in relation to the Veteran's claims for service connection for PTSD and bilateral foot/ankle disability. Generally, a claim that has been denied in a final, unappealed rating decision may not thereafter be readjudicated and allowed. 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. An exception to this rule is found in 38 U.S.C. § 5108 and provides that if "new and relevant" evidence is presented or secured with respect to a supplemental claim, VA shall readjudicate the claim, taking into consideration all of the evidence of record, limited by the particular docket selected by the claimant. "New" evidence is "evidence not previously part of the actual record before agency adjudicators." 38 C.F.R. § 3.2501(a)(1). "Relevant" evidence "is information that tends to prove or disprove a matter at issue in a claim. Relevant evidence includes evidence that raises a theory of entitlement that was not previously addressed." Id. Here, a May 1990 decision, which denied service connection for bilateral foot/ankle disabilities, and a December 2014 decision that denied service connection for PTSD, were each final as the Veteran did not submit new and material evidence (the standard that governed under the Legacy Appeal process at that time, Pub. L. No. 115-55, 131 Stat. 1105 (2017)) within one-year of the respective decisions, and he did not timely appeal those decisions. The VA Regional Office's finding that new and relevant evidence has been received is a favorable finding by which the Board is bound. 38 C.F.R. § 20.801(a). Thus, readjudication of the claims is properly before the Board. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities found in 38 C.F.R. Part 4. The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Diagnostic codes are assigned to individual disabilities. Diagnostic codes provide rating criteria specific to a particular disability. If two diagnostic codes are applicable to the same disability, the diagnostic code that allows for the higher disability rating applies. 38 C.F.R. § 4.7. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Id. Rating Criteria Traumatic Brain Injury The Veteran has appealed the effective dates and ratings assigned for his migraine headaches, which are part of his service-connected traumatic brain injury. In order to analyze his claim properly, the Board must start with the rating criteria for a traumatic brain injury. Residuals associated traumatic brain injuries (TBI) are rated under 38 C.F.R. § 4.124a, Diagnostic Code 8045. The rules for rating TBI residuals are relatively complicated. The applicable rating criteria for TBI residuals outline three main areas of dysfunction: (1) cognitive, (2) emotional/behavioral, and (3) physical. Each area of dysfunction has particular rules associated with it, which are outlined next. Cognitive dysfunction "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." Id. Adjudicators must "[e]valuate cognitive impairment[, including subjective symptoms that are residuals of TBI, whether or not they are part of cognitive impairment,] under the table titled 'Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified (TBI Table).'" Id. The TBI table is provided later. Diagnostic Code 8045 specifically instructs adjudicators to evaluate any residual with a distinct diagnosis under an appropriate diagnostic code separately, "such as migraine headache or Meniere's disease, even if that diagnosis is based on subjective symptoms, rather than under" the TBI Table. Id. Emotional/Behavioral dysfunction When a mental disorder is diagnosed as a TBI residual, an adjudicator is required to evaluate the disorder under 38 C.F.R. § 4.130 (Schedule of ratings mental disorders). 38 C.F.R. § 4.124a, Diagnostic Code 8045. When there is no diagnosis of a mental disorder, adjudicators must rate emotional/behavioral TBI residual symptoms under the TBI Table. Id. Physical dysfunction Diagnostic Code 8045 specifically instructs adjudicators to evaluate physical dysfunction (to include neurologic dysfunction) under appropriate diagnostic codes other than 8045. Diagnostic Code 8045 provides a detailed list of symptoms that are to be considered, which are: 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 endocrine dysfunctions. For residuals not listed above, but that are reported on an examination, adjudicators must evaluate them under the most appropriate diagnostic code. Each physical dysfunction is evaluated separately and combined under 38 C.F.R. § 4.25, as long as the same signs and symptoms are not used to support more than one evaluation. TBI Table The TBI Table contains 10 important facets of a TBI related to cognitive impairment and subjective symptoms. It provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and a 5th level, the highest level of impairment, labeled "total." Not every facet has every level of severity. The "Consciousness" facet, for example, does not provide for an impairment level other than "total," since any level of impaired consciousness would be totally disabling. A 100 percent evaluation 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 evaluation based on the level of the highest facet is to be assigned as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent. The regulation provides the following example: "assign a 70 percent evaluation if 3 is the highest level of evaluation for any facet." Id. In other words, one rating for a TBI is to be assigned based upon the highest level of severity for any of the 10 facets of cognitive impairment apart from any separately diagnosed disability. Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified (TBI Table) Facets of cognitive impairment and other residuals of TBI not otherwise classified Level of impairment Criteria Memory, attention, concentration, executive functions 0 No complaints of impairment of memory, attention, concentration, or executive functions. 1 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 Objective evidence on testing of mild impairment of memory, attention, concentration, or executive functions resulting in mild functional impairment. 3 Objective evidence on testing of moderate impairment of memory, attention, concentration, or executive functions resulting in moderate functional impairment. Total Objective evidence on testing of severe impairment of memory, attention, concentration, or executive functions resulting in severe functional impairment. Judgment 0 Normal. 1 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 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 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. Total 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. Social interaction 0 Social interaction is routinely appropriate. 1 Social interaction is occasionally inappropriate. 2 Social interaction is frequently inappropriate. 3 Social interaction is inappropriate most or all of the time. Orientation 0 Always oriented to person, time, place, and situation. 1 Occasionally disoriented to one of the four aspects (person, time, place, situation) of orientation. 2 Occasionally disoriented to two of the four aspects (person, time, place, situation) of orientation or often disoriented to one aspect of orientation. 3 Often disoriented to two or more of the four aspects (person, time, place, situation) of orientation. Total Consistently disoriented to two or more of the four aspects (person, time, place, situation) of orientation. Motor activity (with intact motor and sensory system) 0 Motor activity normal. 1 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 Motor activity mildly decreased or with moderate slowing due to apraxia. 3 Motor activity moderately decreased due to apraxia. Total Motor activity severely decreased due to apraxia. Visual spatial orientation 0 Normal. 1 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 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 (global positioning system). 3 Moderately severely impaired. Gets lost even in familiar surroundings, unable to use assistive devices such as GPS (global positioning system). Total 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 0 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 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. 2 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 0 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 One or more neurobehavioral effects that occasionally interfere with workplace interaction, social interaction, or both but do not preclude them. 2 One or more neurobehavioral effects that frequently interfere with workplace interaction, social interaction, or both but do not preclude them. 3 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. Communication 0 Able to communicate by spoken and written language (expressive communication), and to comprehend spoken and written language. 1 Comprehension or expression, or both, of either spoken language or written language is only occasionally impaired. Can communicate complex ideas. 2 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 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. Total 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. Consciousness Total Persistently altered state of consciousness, such as vegetative state, minimally responsive state, coma. There are five notes that accompany Diagnostic Code 8045. In this case, only the first four are relevant, which are: Note (1): There may be an overlap of manifestations of conditions evaluated under the TBI table with manifestations of a comorbid mental or neurologic or other physical disorder that can be separately evaluated under another diagnostic code. In such cases, do not assign more than one evaluation based on the same manifestations. If the manifestations of two or more conditions cannot be clearly separated, assign a single evaluation 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, assign a separate evaluation for each condition. Note (2): Symptoms listed as examples at certain evaluation levels in the TBI table are only examples and are not symptoms that must be present in order to assign a particular evaluation. Note (3): "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. These 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. Note (4): The terms "mild," "moderate," and "severe" TBI, which may appear in medical records, refer to a classification of TBI made at, or close to, the time of injury rather than to the current level of functioning. This classification does not affect the rating assigned under Diagnostic Code 8045. Analysis 1. A separate, initial disability rating of 50 percent for service-connected migraine headaches (a diagnosed residual of service-connected traumatic brain injury), effective March 27, 2013, is granted. The VA Regional Office assigned a 10 percent disability rating for the Veteran's migraine headaches under Diagnostic Code 8045 from March 27, 2013, to January 23, 2017. The Board finds that the VA Regional Office erred in doing so because it did not interpret the text of Diagnostic Code 8045 appropriately. The Veteran is correct, he is entitled to a separate disability rating for his migraine headaches, a distinct diagnosed physical residual disability of his TBI, which are to be rated separately according to Diagnostic Code 8045. Migraine headaches are rated under 38 C.F.R. § 4.124a, DC 8100 ("Migraine"). Holmes v. Wilkie, 33 Vet. App. 67, 72 (2020) ("migraine is a broader term than headache"). Diagnostic Code 8100 provides: Rating (%) Migraine: With very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability 50 With characteristic prostrating attacks occurring on an average once a month over last several months 30 With characteristic prostrating attacks averaging one in 2 months over last several months 10 With less frequent attacks 0 Diagnostic Code 8100's criteria are successive, meaning that each level requires that the veteran also satisfy the lower levels. Johnson v. Wilkie, 30 Vet. App. 245, 247 (2018). Diagnostic Code 8100 focuses on "attacks." "It is the frequency, duration, severity, and economic impact of these attacks that differentiate the levels of disability in DC 8100." Holmes, 33 Vet. App. at 73. "Prostrating" means "lacking in vitality or will: powerless to rise: laid low." Johnson, 30 Vet. App. at 252 (citing Webster's Third New International Dictionary of the English Language Unabridged 1822 (1966)). The phrase "characteristic prostrating attacks" plainly describes "migraine attacks that typically produce powerlessness or a lack of vitality." Id. at 252. The modifier "completely," as used before "prostrating" in the 50 percent criteria, means that the veteran must be rendered "entirely powerless," and "productive of severe economic inadaptability" means either "producing or capable of producing severe economic inadaptability." Id. at 253. Thus, a 50 percent rating for migraines is appropriate "with very frequent, prolonged attacks that render the veteran entirely powerless and either cause or can cause severe economic inadaptability." Holmes, 33 Vet. App. at 7071. Diagnostic Code 8100 "contemplates more than just headache symptoms and requires that VA consider all the symptoms the veteran experiences as a result of migraine attacks, and then rate those symptoms based on the frequency, duration, severity, and economic impact of the attacks." Id. at 73. In other words, whatever symptoms the veteran experiences associated with migraine attacks, VA must consider when assigning a schedular disability rating." Id. The Veteran has received two VA-contracted examinations addressing the severity of his migraine headaches, one in August 2017 and another in October 2017. During the August 2017 examination, the Veteran reported he experienced three types of headaches: (1) at the back of head, which felts like it is going to "blowup," and it was accompanied by a pressure-type pain, during which he was unable to function; (2) in the middle of his head and behind his face, which made his eyes hurt, and which were associated with light sensitivity and sound sensitivity; and (3) headaches all over his head. The examiner endorsed general symptoms of pain on both sides of the head, nausea, and light and sound sensitivity. The symptoms worsened with activity. The Veteran reported that he experienced headaches two to three times week that last for an entire day. The examiner characterized the Veteran's headaches as prostrating, about two times per week, which resulted in severe economic inadaptability. During the October 2017 VA examination, the Veteran reported, and the examiner endorsed, symptoms associated with his migraine headaches to include pulsating or throbbing head pain; pain on both sides of the head, which worsened with physical activity; nausea; vomiting; sensitivity to light; and changes in vision, such as scotoma, flashes of light, and tunnel vision. The examiner endorsed that the Veteran's head pain lasted less than a day, and that his migraines were prostrating but did not result in severe economic inadaptability. The Board finds it odd that the examinations, which were conducted about two months apart, provided different results. Namely, the August 2017 examiner characterized the Veteran's headaches as prostrating, about two times per week, which resulted in severe economic inadaptability, whereas the October 2017 examiner did not characterize the Veteran's migraines as resulting in severe economic inadaptability. The Board notes that each examination was conducted by a neurologist, thus making each examination equally credible and probative in that respect. Of note, during his August 2017 examination, the Veteran reported his migraine headache symptoms fluctuated. Thus, the Board finds it reasonable to conclude that his August 2017 examination and October 2017 examination were conducted during different periods of "fluctuation," not that the Veteran's symptoms had become better two months later. Moreover, the Board finds the August 2017 examiner elicited more information from the Veteran about his symptoms, to include his medical history, onset, and treatment, making that examination more probative. The Secretary is required to maximize benefits. See AB v. Brown 6 Vet. App. 35, 38 (1993) (presuming that a claimant is seeking the maximum benefits allowed by law and regulation); 38 C.F.R. § 3.103(a) (noting VA's obligation to "render a decision which grants every benefit that can be supported in law"). Here, the Board finds the August 2017 examination is more probative than the October 2017 examination. As such, the Board finds that the Veteran's migraines (a residual of his TBI in service) most closely resembled very frequent, completely prostrating and prolonged attacks productive of severe economic inadaptability, which is consistent with the 50 percent rating criteria. 38 C.F.R. § 4.124a, Diagnostic Code 8100. The highest rating available under Diagnostic Code 8100 is 50 percent. The Board finds the Veteran's migraine headache symptomatology are adequately captured by the 50 percent rating criteria. Thus, consideration on an extraschedular basis is not warranted. As to the appropriate effective date for the award of a 50 percent disability rating, the Board finds the Veteran is entitled to an effective date of March 27, 2013. On March 27, 2013, the Veteran contacted VA and requested to file a claim for service connection for PTSD, which he clarified was to include a request for service connection for migraines in a June 2013 correspondence. As the Veteran's claim for service connection for migraines was pending since March 27, 2013, that is the appropriate effective date for the award of a 50 percent disability rating. 38 U.S.C. § 5110; 38 C.F.R. § 3.400(o). 2. From March 27, 2013, to January 23, 2017, a separate, initial disability rating of 10 percent, but no higher, for service-connected traumatic brain injury residuals (not otherwise encompassed by the rating for migraine headaches) is granted. While the Board has assigned the Veteran a separate disability rating for his migraine headaches (as residual of his TBI), this is not the end of the analysis. Diagnostic Code 8045 instructs adjudicators to assign a disability rating for any residual TBI symptoms not part of a diagnosed disability under the "facet" criteria of the TBI Table. In this case, the Veteran is entitled to a separate 10 percent disability rating under Diagnostic Code 8045 from March 27, 2013, to January 23, 2017, for additional residual TBI symptoms not encompassed by his migraine headache disability rating. Of record, between March 27, 2013, and January 23, 2017, is a VA examination addressing the Veteran's TBI residuals. Based on the examination, the examiner endorsed the following symptoms associated with the Veteran's TBI residuals. In addition, the Board provides the associated facet rating with each symptom endorsed under the TBI Table. 1. A complaint of mild memory loss (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. The Veteran reported mild difficulty with attention, concentration, and short-term memory. He occasionally used adaptive strategies. a. The Board finds the level of impairment for the facet of memory, attention, concentration, and executive function corresponds with 1. 2. Judgment was normal. a. The Board finds the level of impairment for the facet of judgment corresponds with 0. 3. Social interaction was routinely appropriate. a. The Board finds the level of impairment for the facet of social interaction corresponds with 0. 4. He was always oriented to person, time, place, and situation. a. The Board finds the level of impairment for the facet of orientation corresponds with 0. 5. Motor activity was normal. a. The Board finds the level of impairment for the facet of motor activity corresponds with 0. 6. The facet of visual spatial orientation was not applicable to the Veteran. a. The Board finds the level of impairment for the facet of visual spatial orientation corresponds with 0. 7. Subjective symptoms included headaches localized to the occipital region, frontal/facial region, stabbing/throbbing in character, intensity ranged from 7-9/10 with no preceding aura. His headaches were associated with blurred vision, photophobia, phonophobia, anxiety, and neck pain. They lasted between two to three hours, three to four times a week, and resulted in disabling episodes about two times a month. Overall, the examiner opined, his subjective symptoms did not interfere with work; instrumental activities of daily living; or work, family, or other close relationships. a. Although the examiner's endorsement is the equivalent of facet level 0 for subjective symptoms, the Board finds the Veteran's headaches that resulted in hypersensitivity to sound and light, and which resulted in incapacitation monthly, most closely align with the facet level 1. 8. The neurobehavioral effects included irritability and anxiety during that time, which were attributed to his military service and head injury. Those symptoms were moderate in intensity. The examiner also noted that he suffered from PTSD for which he was under treatment. There was no evidence of suicidal or homicidal ideation. The examiner endorsed one or more neurobehavioral effects that did not interfere with workplace interaction or social interaction. a. As of December 12, 2014, the date of the examination, the Veteran did not have a service-connected psychiatric disorder. Despite the examiner's statement that the Veteran had PTSD, there was insufficient evidence that his PTSD was related to his military service at the time or that it was a residual of his TBI. Therefore, at this time, the Veteran is not entitled to a separate disability rating for a psychiatric disorder as a residual of his TBI. As discussed later, the Board is remanding the claim for service connection for PTSD, but that claim is not premised on the Veteran's PTSD being a residual of his TBI, but rather based on a separate incident. That claim does not prevent the Board from adjudicating the current claim for TBI residuals on appeal. b. The Board finds the level of impairment for the facet of neurobehavioral effects corresponds with 0. 9. The Veteran was able to communicate by spoken and written language (expressive communication) and to comprehend spoken and written language. a. The Board finds the level of impairment for the facet of communication corresponds with 0. 10. Consciousness was normal. a. The Board finds the level of impairment for the facet of consciousness is not "total," the only available rating. Frist, the Board finds the highest facet level received is 1 for the facets of memory, attention, concentration, and executive functions; and subjective symptoms, based on headaches and mental symptoms. The Veteran's migraine headaches, and accompanying symptoms, are separately rated at 50 percent. Therefore, the only reason to rate his migraine headaches under Diagnostic Code under 8045 would be if it offered a higher rating, which it does not. Here, the evidence shows his migraine headaches and associated symptoms would be rated at 10 percent based on a facet level of 1. As VA's duty is to maximize benefits, the Veteran is awarded a higher rating under Diagnostic Code 8100, and his migraine headaches will not be rated under Diagnostic Code 8045 in order to avoid pyramiding. See 38 C.F.R. § 4.14; 38 C.F.R. § 4.124a, Diagnostic Code 8045, Note (1). Nonetheless, the Veteran's migraine headaches do not include the symptoms of mild memory loss, and decreased attention, concentration, or executive functions. Nor do his migraine headaches include symptoms of irritability or anxiety. Because the 50 percent rating under Diagnostic Code 8100 for the Veteran's migraine headaches is not premised on these foregoing symptoms, he is entitled to a separate initial 10 percent rating for these TBI residual symptoms under Diagnostic Code 8045 from March 27, 2013, to January 23, 2017, as the highest facet level is 1, which corresponds with a 10 percent rating. 38 C.F.R. § 4.124a, Diagnostic Code 8045. A rating in excess of 10 percent for these TBI residuals is not warranted prior to January 23, 2017, because the evidence does not support facet-level ratings higher than 10 percent, nor are they distinct diagnosed disabilities during that timeframe. The effective date for this award is based on the sympathetic interpretation of the Veteran's March 27, 2013, claim for benefits seeking service connection for migraine headaches, which the Board finds encompasses a claim for TBI residuals. Szemraj v. Principi, 357 F.3d 1370, 1373 (Fed. Cir. 2004) (the Board is required to read a veteran's filings sympathetically); Clemons, 23 Vet. App. at 5; 38 U.S.C. § 5110; 38 C.F.R. § 3.400(o). 3. From January 23, 2017, an increased disability rating in excess of 70 percent for service-connected traumatic brain injury residuals (rated with other trauma and stressor related disorder, and not otherwise encompassed by the rating for migraine headaches) is denied. To the extent the Veteran's VA Form 10182 can be reasonably interpreted as seeking a disability rating in excess of 70 percent from January 23, 2017, for his service-connected other trauma and stressor related disorder (a residual of his TBI), the evidence weighs against a higher rating. Since the Veteran's diagnosed other trauma and stressor related disorder is an emotional/behavioral residual of his TBI, adjudicators are required to rate the psychiatric disorder separately. 38 C.F.R. § 4.124a, Diagnostic Code 8045 ("Evaluate emotional/behavioral dysfunction under § 4.130 (Schedule of ratings - mental disorders)"). Nevertheless, if the evaluation of the criteria under 38 C.F.R. § 4.130 results in a lower rating than that under 38 C.F.R. § 4.124a, Diagnostic Code 8045, then the adjudicator should use the higher rating. Under the General Formula for Mental Disorders (General Formula), 38 C.F.R. § 4.130, the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017). The symptoms listed in the VA's general rating formula for mental disorders are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, which would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 11418 (Fed. Cir. 2013). The General Formula, 38 C.F.R. § 4.130, Diagnostic Code 9410 ("Other specified anxiety disorder"), provides as follows: Rating (%) Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 100 Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. 70 Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 50 Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 30 Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. 10 A mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. 0 Considerations in rating a mental disorder include the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating must be based on all evidence of record that bears on occupational and social impairment rather than solely on an examiner's assessment of the level of disability at the moment of the examination. Id. Although the extent of social impairment is a consideration in determining the level of disability, the rating may not be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The United States Court of Appeals for the Federal Circuit held that evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating." Vazquez-Claudio, 713 F.3d at 11617. The Veteran received a psychiatric VA-contracted examination in July 2017 at which time the examiner diagnosed him with "other trauma stressor related disorder." Based on the recorded symptoms, the examiner opined that the Veteran's other trauma and stressor related disorder resulted in occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication. The examiner was unable to differentiate the symptoms associated with the Veteran's TBI residual and psychiatric disorder; that is, they were comorbid and overlapped. The examiner's opinion corresponds with a disability rating of 10 percent under Diagnostic Code 9410, which is significantly less than that assigned by the VA Regional Office under Diagnostic Code 8045. Turning to Diagnostic Code 8045, the VA Regional Office relied on an August 2017 VA-contract examination assessing the Veterans' TBI residuals when assigning a disability rating for his other trauma and stressor related disorder. Of significance, the examiner endorsed that the Veteran displayed objective evidence on testing of moderate impairment of memory, attention, concentration, or executive functions resulting in moderate functional impairment. This corresponds with a facet level of 3 and a rating of 70 percent. The examiner also endorsed occasionally inappropriate social interaction, which corresponds with a facet level of 1 and a rating of 10 percent; mildly impaired visual spatial orientation, which corresponds with a facet level of 1 and a rating of 10 percent; three or more subjective symptoms that mildly interfere with work, which the examiner attributed to the Veteran's migraine headaches and associated symptoms, which corresponds with a facet level of 1 and a rating of 10 percent; one or more neurobehavioral effects that occasionally interfere with workplace interaction, social interaction, or both but do not preclude them, which corresponds with a facet level of 1 and a rating of 10 percent; comprehension or expression, or both, of either spoken language or written language is only occasionally impaired, which corresponds with a facet level of 1 and a rating of 10 percent. Otherwise, the remaining facets were either not applicable or the Veteran's symptoms were normal such that a noncompensable rating applied. The examiner opined that the Veteran's psychiatric disorder symptoms could not be separated from his TBI symptoms. Based on the evidence, the highest facet level was 3, which corresponds to a 70 percent rating, for the Veteran's decreased memory, attention, concentration, executive function. As these symptoms could not be separated between his psychiatric disorder and his TBI, they overlap with respect to each disability. Because the Veteran is entitled to only one rating for these symptoms in order to avoid pyramiding, he is properly rated under Diagnostic Code 8045 because he has received a 70 percent disability rating, whereas he would only receive a 10 percent rating under Diagnostic Code 9410 for these symptoms. In order to receive a 100 percent disability rating under Diagnostic Code 9410, the Veteran's psychiatric symptoms would have to show total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The evidence of record from January 23, 2017, to include VA examinations, lay statements, and VA medical records do not establish such symptoms. In addition, none of the evidence of record sufficiently establishes that the Veteran's TBI residuals at any of the facet levels meets the "total" facet level rating of 100 percent from January 23, 2017. Importantly, the Board notes that the Veteran's migraine headaches are a separately diagnosed disability. His 70 percent rating for his TBI residuals, to include other trauma related stressor disorder, is not premised on his migraine headaches as they are not part of his psychiatric disorder. Accordingly, the Veteran is still entitled to a separate 50 percent disability rating for his migraine headaches from March 27, 2013. He is also entitled to a separate 10 percent disability rating for his TBI residuals not encompassed by his migraine headaches from March 27, 2013, to January 23, 2017, and then a 70 percent disability rating thereafter as those TBI residuals worsened. 4. Entitlement to an effective date earlier than January 23, 2017, for the 70 percent disability rating for service-connected traumatic brain injury (rated with other trauma and stressor related disorder, and not otherwise encompassed by the rating for migraine headaches) is denied. At his August 2020 Board hearing, the Veteran explained that he believed his 70 percent disability rating should extend back to his initial claim for service connection filed on March 27, 2013. Unfortunately, the Board finds the evidence is against his claim. Generally, the effective date of an initial rating is the date of receipt of the claim/request or the date entitlement arose, whichever is later. 38 U.S.C.§ 5110(a); 38 C.F.R. § 3.400(o)(1); see Sutton v. Nicholson, 20 Vet. App. 419, 422 (2006). Here, the Board has awarded the Veteran an initial disability rating of 10 percent effective March 27, 2013, for his TBI residuals not otherwise encompassed by his separately rated migraine headaches. The general rule under 38 U.S.C. § 5110(a) and 38 C.F.R. § 3.400 is that the effective date of an increase in a veteran's disability compensation shall be fixed in accordance with the facts found but shall not be earlier than the date of receipt of application therefor. 38 U.S.C. § 5110(b)(2) provides an exception to this general rule: "The effective date of an award of increased compensation shall be the earliest date as of which it is ascertainable that an increase in disability had occurred, if application is received within one year from such date." See also 38 C.F.R. § 3.400(o)(2). Thus, "the plain language of [section] 5110(b)(2) . . . only permits an earlier effective date for increased disability compensation if that disability increased during the one-year period before the filing of the claim." Gaston v. Shinseki, 605 F.3d 979, 983 (Fed. Cir. 2010). Thus, three possible dates may be assigned depending on the facts: (1) If an increase in disability occurs after the claim is filed, then the date that the increase is shown to have occurred, whichever is later (date entitlement arose) (38 C.F.R. § 3.400(o)(1)); (2) If an increase in disability precedes the claim by a year or less, then the date that the increase is factually shown to have occurred (factually ascertainable) (38 C.F.R. § 3.400(o)(2)); or (3) If an increase in disability precedes the claim by more than a year, and it is not factually ascertainable that the disability increased within the year prior to the filing of the claim, then the date that the claim is received (date of claim) (38 C.F.R. § 3.400(o)(2)). The Board first finds that the Veteran's other trauma and stressor disorder was not formally diagnosed until the July 2017 VA-contracted examination. That is the point it became factually ascertainable that he had the disorder. Second, the symptoms identified by the August 2017 VA-contracted examiner in association with the Veteran's TBI residuals were not present in prior medical examinations, nor did his VA medical records sufficiently document symptoms of similar severity prior to January 23, 2017, although they did document symptoms that were consistent with the 10 percent rating prior to January 23, 2017, such as anxiety and irritability. Finally, the VA Regional Office assigned the effective date of January 23, 2017, because it found that was the date the Veteran filed an intent to file a claim for benefits. Thereafter, the Veteran submitted a claim for benefits for his TBI. Thus, the earliest date that the Veteran's increased rating can be awarded is January 23, 2017, as there is no evidence within the year preceding that date that the criteria for an increased rating in excess of 10 percent for TBI residuals were satisfied. Accordingly, an effective date prior to January 23, 2017, for the 70 percent disability rating for service-connected traumatic brain injury (rated with other trauma and stressor related disorder, and not otherwise encompassed by the rating for migraine headaches) is not warranted. REASONS FOR REMAND In the context of an appeal under the AMA, if the Board identifies a duty-to-assist error that existed at the time of the rating decision on appeal and cannot grant the maximum benefit for the claim, the Board "shall remand the claim to the agency of original jurisdiction for correction of such error and readjudication." 38 U.S.C. § 5103A(f)(2)(A); 38 C.F.R. § 3.2601(g); see also 38 C.F.R. § 20.802(a) (Board's duty to remand for error correction). 1. Service connection for posttraumatic stress disorder is remanded. On December 2, 2014, the Veteran submitted VA Form 21-0781, Statement in Support of Claim for PTSD. In that form, he identified two stressors. The first stressor was an incident at Camp Pendleton, California, between December 1983 and March 1984. He described, with detail, being part of a motor vehicle accident in which he was a passenger with two other service members that went off a mountain hillside and ejected them. The second identified stressor occurred at Camp Pendleton between May and June of 1978 at which time he witnessed a fellow service member accidently kill himself at a rifle range due to improper use of a rifle. The Veteran has consistently repeated these stressors throughout the pendency of his claim. The VA Regional Office denied service connection because it was unable to corroborate his stressors. In a December 8, 2014, memorandum, the VA Regional Office reported that the Veteran failed to provide sufficient information to send to the "U.S. Army and JSRRC and/or insufficient to allow for meaningful research of Marine Corps or National Archives and Records Administration (NARA) records." The memorandum, however, failed to identify what additional information was necessary and failed to inform the Veteran of the same. Based on the Board's review of the evidence, the Veteran has identified specific locations, specific people involved, relatively specific timeframes, and has given detailed accounts of the claimed stressors. The Board finds the VA Regional Office's failure to identify what additional information was necessary to corroborate the stressors, and to inform the Veteran of such, constitutes a pre-decisional duty to assist error. In addition, the Veteran has submitted medical evidence from his VA psychiatric professionals that he has a diagnosis of PTSD. See January 29, 2014, VA Mental Health Counseling Note (submitted to VA September 4, 2014). The VA examiners who evaluated the Veteran for a medical diagnosis of PTSD prior to the decision on appeal made no reference of this diagnosis when determining that he did not have PTSD. Given the conflict of information, a pre-decisional duty to assist error exists that requires remand for a new VA examination addressing the Veteran's PTSD. 2. Service connection for a back disability is remanded. The Veteran claims he has a back disability as a result of his motor vehicle accident in service. The Board finds no VA examination has been offered to the Veteran to address this claim. Instead, in June 2017, the VA Regional Office obtained an opinion from a VA examiner on an unrelated back disability claim, where the Veteran claimed he received medical treatment at a VA medical center that resulted in back disabilities. Thus, the opinion only addressed potential for service connection under 38 U.S.C. § 1151 and did not address direct service connection as due his motor vehicle accident. Furthermore, the Board notes that within the February 7, 2019, higher-level review RAMP decision denying service connection, the VA Regional Office relied on a statement made by the Veteran in a March 1990 VA examination addressing his feet conditions that he suffered a motor vehicle accident in 1987 after his military. The VA Regional Office completely ignored the next paragraph in that examination report that states the Veteran experienced a motor vehicle accident in 1984 while in service. Thus, as the evidence of record prior to the October 2018 RAMP opt-in sufficiently indicates competent evidence that the Veteran had a current back disability, or persistent or recurrent symptoms of back disability; an event in service; indication that the back disability or persistent or recurrent symptoms of the back disability may be associated with his service; and the lack of sufficient competent medical evidence on file for VA to decide the claim, remand is required to obtain a VA examination and opinion addressing the etiology of the Veteran's back disability. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); Waters v. Shinseki, 601 F.3d 1274, 1277 (Fed. Cir. 2010); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The failure to obtain a VA examination and opinion constitutes a pre-decisional duty-to-assist error. 3. Service connection for a bilateral foot/ankle disability is remanded. The Veteran claims he suffered bilateral foot/ankle disabilities in service because of his in-service training. He testified he experienced clicking and popping in service. He received a VA examination in 1990 that documented he injured his foot during a 1984 motor vehicle accident. Again, the Board notes that the VA Regional Office's February 7, 2019, decision only relied on the statement about a 1987 motor vehicle accident after service, ignoring the statement about the 1984 in-service accident. The Board finds no VA examination has been offered to the Veteran to address this claim. Thus, as the evidence of record prior to the October 2018 RAMP opt-in sufficiently indicates competent evidence that the Veteran had a current foot/ankle disability, or persistent or recurrent symptoms of such disability; an event in service; indication that the disability or persistent or recurrent symptoms of the disability may be associated with the veteran's service; and the lack of sufficient competent medical evidence on file for VA to decide the claim, remand is required to obtain a VA examination and opinion addressing the etiology of the Veteran's bilateral foot/ankle disability. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); Waters, 601 F.3d at 1277; McLendon, 20 Vet. App. 79. The failure to obtain a VA examination and opinion constitutes a pre-decisional duty-to-assist error. 4. Prior to January 23, 2017, entitlement to a total disability rating based on individual unemployability is remanded. The Veteran has been awarded a total disability rating based on individual unemployability (TDIU) from January 23, 2017. A request for TDIU benefits is "part and parcel" of a claim for an increased disability rating and is not a separate freestanding claim itself but rather an alternate way to obtain a total disability rating without being rated 100 percent disabled under the Rating Schedule. Rice v. Shinseki, 22 Vet. App. 447, 45355 (2009) (TDIU is implicitly raised whenever a veteran, who presents cogent evidence of unemployability, seeks to obtain a higher disability rating). Because the Board has awarded increased disability ratings for the Veteran's migraine headaches and TBI residuals, and due the potential for additional service connection of the claims being remanded, TDIU is properly raised by the record and is inextricably intertwined with this decision and the claims being remanded. In light of the Board's decisions in this appeal and depending on the development on remand, the VA Regional Office will need to readjudicate whether the Veteran is entitled to TDIU benefits prior to January 23, 2017. Accordingly, the matters are REMANDED for the following actions: 1. Based on the December 8, 2014, VA memorandum stating that the information provided by the Veteran in his December 2, 2014, VA Form 21-0718, Statement in Support of Claim for PTSD, is insufficient, the VA Regional Office is directed to send the Veteran proper correspondence, to include the stressor verification form, identifying and requesting specifically what information is necessary to submit his identified stressors for corroboration to the appropriate agencies; that is, if the VA Regional Office continues to deem the provided information already of record insufficient. Following receipt of any response, including lay statements of record and review of medical and military records, appropriate action should be taken to attempt to verify any reported stressors that are capable of verification to include contacting appropriate sources. If the search for corroborating records leads to negative results, the VA Regional Office must notify the Veteran and her representative of this fact, explaining the efforts taken, describing further action, if any, to be taken, and affording them the opportunity to respond. The VA Regional Office should also follow up on any additional action suggested by each appropriate source contacted. 2. After any additional records are associated with the claims file, obtain a VA examination from an appropriately qualified clinician to provide an opinion addressing the onset and etiology of the posttraumatic stress disorder (PTSD). The entire claims file must be made available to and be reviewed by the examiner, including a copy of this REMAND order. The examiner is asked to provide an opinion regarding the following: (a.) During the pendency of his claim, since approximately 2014, has the Veteran ever been diagnosed with PTSD, and does he have a current diagnosis of PTSD in accordance with standards of the DSM-5? The examiner is directed to consider the Veteran's VA medical records, particularly the January 29, 2014, VA Mental Health Counseling Note (submitted to VA September 4, 2014) documenting a PTSD diagnosis. (b.) If yes, are the symptoms of such distinguishable from symptoms of his other trauma and stressor related disorder for which service-connected is already in effect? Why do you say so? (c.) If the Veteran has had or currently has a diagnosis of PTSD, whether it is at least as likely as not (50 percent probability or more) that the Veteran's PTSD had its onset in or is otherwise etiologically related to an in-service event, injury, or disease, to include the identified stressors within the December 2, 2014, VA Form 21-0781, Statement in Support of Claim for PTSD. A clear and detailed rationale for the opinion(s), including a discussion of the facts and medical principles involved, should be provided as it will be of considerable assistance to the Board. Please do not simply list the facts on which you relied. If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). 3. After any additional records are associated with the claims file, obtain a VA examination from an appropriately qualified clinician to provide an opinion addressing the onset and etiology of the Veteran's back disability. The entire claims file must be made available to and be reviewed by the examiner, including a copy of this REMAND order. The examiner is asked to provide an opinion regarding the following: (a.) Please identify any back disabilities that the Veteran currently has and has had since the pendency of his claim, from about 2013. (b.) For each identified back disability, is it at least as likely as not (50 percent probability or more) that such disability had its onset in or is otherwise etiologically related to an in-service event, injury, or disease, to include a motor vehicle accident in 1984? The examiner is informed that pain alone can qualify as a disability where it diminishes the body's ability to function under the ordinary conditions of daily life including employment, even where it is not diagnosed as connected to a current underlying condition. Saunders v. Wilkie, 886 F.3d 1356 (2018) The examiner is reminded to consider the Veteran's lay statements regarding the nature and onset of his back disability, including any evidence concerning continuity of symptomatology, as he is legally permitted to report his symptoms, past medical history, and experiences. The examiner must not opine on the credibility of the Veteran. The examiner may, however, discuss whether there is any medical reason to accept or reject the Veteran's assertion of a back disability in service or the assertion that an in-service event, injury, or illness led to a back disability. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). A clear and detailed rationale for the opinion(s), including a discussion of the facts and medical principles involved, should be provided as it will be of considerable assistance to the Board. Please do not simply list the facts on which you relied. The examiner is informed that reliance on a lack of treatment and/or gap between discharge from military service and diagnosis of a disability, without explaining why such evidence is significant, is an insufficient rationale. The examiner is informed that the absence of contemporaneous service treatment records or medical records in general, standing alone, without explaining why such evidence is significant, is an insufficient rationale. If the examiner determines a disability was acute rather than chronic, the examiner should explain how he or she arrived at that conclusion rather than providing a conclusory opinion. For example, what evidence led to that conclusion, what would the examiner expect to see if a condition was chronic, how do the Veteran's lay statements, if any, affect the conclusion? If the examiner relies on medical treatises, the examiner should identify the treatises. If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). 4. After any additional records are associated with the claims file, obtain a VA examination from an appropriately qualified clinician to provide an opinion addressing the onset and etiology of the Veteran's bilateral foot/ankle disability. The entire claims file must be made available to and be reviewed by the examiner, including a copy of this REMAND order. The examiner is asked to provide an opinion regarding the following: (a.) Please identify any bilateral foot/ankle disabilities that the Veteran currently has and has had since the pendency of his claim, from about 2013. (b.) For each identified foot/ankle disability, is it at least as likely as not (50 percent probability or more) that such disability had its onset in or is otherwise etiologically related to an in-service event, injury, or disease, to include a motor vehicle accident in 1984; and/or training in service, to include running? The examiner is informed that pain alone can qualify as a disability where it diminishes the body's ability to function under the ordinary conditions of daily life including employment, even where it is not diagnosed as connected to a current underlying condition. Saunders v. Wilkie, 886 F.3d 1356 (2018) The examiner is reminded to consider the Veteran's lay statements regarding the nature and onset of any foot/ankle disability, including any evidence concerning continuity of symptomatology, as he is legally permitted to report his symptoms, past medical history, and experiences. The examiner must not opine on the credibility of the Veteran. The examiner may, however, discuss whether there is any medical reason to accept or reject the Veteran's assertion of a foot/ankle disability in service or the assertion that an in-service event, injury, or illness led to a foot/ankle disability. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). A clear and detailed rationale for the opinion(s), including a discussion of the facts and medical principles involved, should be provided as it will be of considerable assistance to the Board. Please do not simply list the facts on which you relied. The examiner is informed that reliance on a lack of treatment and/or gap between discharge from military service and diagnosis of a disability, without explaining why such evidence is significant, is an insufficient rationale. The examiner is informed that the absence of contemporaneous service treatment records or medical records in general, standing alone, without explaining why such evidence is significant, is an insufficient rationale. If the examiner determines a disability was acute rather than chronic, the examiner should explain how he or she arrived at that conclusion rather than providing a conclusory opinion. For example, what evidence led to that conclusion, what would the examiner expect to see if a condition was chronic, how do the Veteran's lay statements, if any, affect the conclusion? If the examiner relies on medical treatises, the examiner should identify the treatises. If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). M. Tenner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. F. Sawka, Associate 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.